Every finding on record at Morningside Health Services

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 more than 4 of the 30 residents residing in the facility.Staff did not complete proper hand hygiene prior to donning/doffing gloves, while preparing and serving food, and during dish washing.Findings include:On 2/10/26 at 1:09 PM, Culinary Manager (CM)-F stated the facility follows the Wisconsin Food Code.The Wisconsin Food Code documents at Chapter 2 Personal Cleanliness 2-301.14 titled When to Wash: Food employees shall clean their hands and exposed portions of their arms as specified under 2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms .(E) After handling soiled equipment or utensils; (F) During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (H) Before putting on gloves to initiate a task that involves working with food; and after engaging in other activities that contaminate the hands.The facility's undated Hand Washing Policy & Procedure Manual indicates: .1. When to wash hands: a. When entering the kitchen at the start of a shift. b. After touching bare human body parts other than clean hands and wrists. c. After using the restroom. d. After caring for or handling service animals or aquatic animals. e. After coughing, sneezing, using a tissue, using tobacco, eating, or drinking. f. After handling soiled equipment or utensils. g. During food preparation, as often as necessary to remove soil or contamination and to prevent cross-contamination when changing tasks. h. When switching between working with raw food and working with ready-to-eat food. i. Before donning disposable gloves for working with food and after gloves are removed. j. After engaging in other activities that contaminate the hands. 2. How to Wash Hands: a. Turn on the faucet using a paper towel to avoid contaminating the faucet. b. Wet hands and forearms with warm water and apply an antibacterial soap. c. Scrub well with soap and additional water as needed, scrubbing all areas thoroughly. Pay close attention to the fingernails using a brush as needed. Scrub for a minimum of 10 to 15 seconds within the 20-second hand washing procedure. Apply vigorous friction between fingers and fingertips. Rinse with clean, running warm water. d. Rinse thoroughly. e. Dry hands with paper towel or use a hand blow dryer .4. Each hand washing sink will post the hand washing procedure.During breakfast service on 2/10/26 at 7:56 AM, Surveyor observed [NAME] (CK)-G cook French toast on a grill with gloved hands. CK-G dipped bread in an egg mixture and put the bread on the grill. CK-G then removed and disposed of CK-G's gloves. Without completing hand hygiene, CK-G continued to prepare breakfast and continued to cook French toast and remove it from the grill.On 2/10/26 at 8:10 AM, Surveyor observed CK-G don a clean pair of gloves without completing hand hygiene. Surveyor observed CK-G prepare another batch of [NAME] toast by dipping bread into an egg mixture and placing the bread on the grill.On 2/10/26 at 8:13 AM, Surveyor observed CK-G remove gloves and obtain temperatures for two items on the steam table. CK-G did not wash hands after removing gloves and obtaining food temperatures. On 2/10/26 at 8:15 AM, Surveyor observed CK-G walk to the handwashing sink near the dishwashing area and wash hands. Surveyor heard the water turn on and walked for appoximately four seconds toward the sink. When CK-G was in sight, Surveyor observed CK-G dry CK-G's hands with paper towel. CK-G continued to cook, prepare, and serve food from the steam table. Surveyor observed CK-G leave the serving line two more times and wash hands at the sink. Both times Surveyor walked to the service area, CK-G was drying hands within 4 seconds.On 2/10/26 at 9:17 AM Surveyor observed CK-G wash dishes and then wash hands at a nearby sink. Surveyor noted CK-G completed hand hygiene (including drying CK-G's hands) in 10 seconds.On 2/10/26 at 9:29 AM, Surveyor observed CK-G in the clean dish area. CK-G washed hands in the nearby sink and completed hand hygiene (including drying CK-G's hands) in 9 seconds.On 2/10/26, Surveyor requested certification for kitchen staff and the facility's Hand Washing policy.On 2/10/26 at 10:24 AM, Regional Dietary Manager (RDM)-E provided the facility's hand washing policy and signed education that was completed. RDM-E indicated RDM-E observed an issue during food service and provided education to CM-F and CK-G. RDM-E provided Surveyor with a form, dated 2/10/26 at 10:00 AM and signed by CM-F and CK-G, that indicated RDM-E reviewed the handwashing policy with CM-F and CK-G.On 2/10/26 at 1:04 PM, Surveyor interviewed CK-G who indicated CK-G received handwashing education earlier that day. When Surveyor asked when hand hygiene should be completed, CK-G provided appropriate instances for handwashing. When asked about missed hand hygiene opportunities and instances observed by Surveyor when CK-G did not meet the 20 second minimum for handwashing in accordance with the facility's policy, CK-G stated CK-G must have been having an off day.On 2/10/26 at 1:09 PM, Surveyor interviewed CM-F who stated all kitchen staff, including CM-F, were familiar with the facility's Hand Washing policy.On 2/11/26 at 2:01 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated kitchen staff should be aware of and follow the Wisconsin Food Code and the facility's Hand Washing policy.

Based on observation, staff and resident interview, and record review, the facility did not ensure nail care was provided for 1 resident (R) (R23) of 15 sampled residents.R23 was not provided nail care on a regular basis.Findings include:The facility's Nail Care policy, revised 4/20/23, indicates: The purpose of this procedure is to provide guidelines for the provision of care to a resident's nails for good grooming and health .3. Routine cleaning and inspection of nails will be provided during activities of daily living (ADL) care on an ongoing basis. 4. Routine nail care, to include trimming and filing, will be provided on a regular schedule (such as weekly on Wednesday 3-11 shift or shower day). Nail care will be provided between scheduled occasions as the need arises.From 2/9/26 to 2/11/26, Surveyor reviewed R23's medical record. R23 had diagnoses including dementia, depression, and anxiety. R23's Minimum Data Set (MDS) assessment, dated 12/22/25, had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated R23 had moderate cognitive impairment. R23 had an activated Power of Attorney (POA) who assisted with healthcare decisions.A care plan indicated R23 had an ADL self-care deficit related to weakness and Huntington's disease and was non-diabetic. The care plan contained an intervention (initiated 6/16/25) for Certified Nursing Assistants (CNAs) to provide nail care.On 2/9/26 at 10:48 AM, Surveyor observed R23 in a wheelchair near the nurses' station. R23's fingernails were yellow and curved around the fingertip, longer than a 1/4 inch, and contained dark colored debris underneath them. On 2/10/26 at 3:25 PM, Surveyor noted R23's nails were in the same condition. Surveyor interviewed R23 who acknowledged R23's nails were long.On 2/10/26 at 3:29 PM, Surveyor interviewed Director of Nursing (DON)-B who reviewed R23's electronic medical record and did not see any refusals for nail care. DON-B stated R23 should receive nail care weekly on Friday which was R23's shower day and staff should clean under R23's nails more frequently if needed. Surveyor requested R23's past four months of nail care documentation, including whether nail care was offered and completed.On 2/10/26 at 3:33 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-D who attempted to review R23's shower sheets to see if nail care was documented. ADON-D indicated there were no shower sheets entered into R23's medical record after 2024.On 2/10/26 at 3:49 PM, Surveyor interviewed Senior [NAME] President of Success (SVPS)-C who indicated the facility did not have shower sheets for R23 because they do not keep them. SVPS-C was unsure when R23's nails were last cut or cared for. SVPS-C indicated R23's nails were long and were being cleaned and cut that day. On 2/11/26 at 9:47 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-I who stated CNAs should complete nail care for residents on shower days or whenever they need care. CNA-I stated nail care should be documented in task charting in the resident's medical record and shower sheets should indicate if nail care was provided or refused. When asked what staff should do if they notice nail care was not completed, CNA-I stated CNA-I would provide nail care and notify a nurse of any issues. CNA-I stated nurses do weekly skin checks on shower days and should also note if there is an issue with nail care.On 2/11/26 at 9:59 AM, Surveyor noted R23's nails were trimmed and cleaned. R23 indicated R23 was happy that nail care was provided and stated R23 felt better.On 2/11/26 at 10:56 AM, Surveyor interviewed Registered Nurse (RN)-H who indicated nail care should be documented in the Treatment Administration Record (TAR) and is also documented on shower sheets. RN-H stated refusals should be documented in the TAR or a progress note. RN-H stated CNAs and nurses should notice if nail care is not being done with weekly showers.On 2/11/26, Surveyor reviewed R23's TAR which indicated R23 was scheduled for a weekly shower on Fridays. The TAR did not indicate whether R23's shower on 2/6/26 was completed or refused.On 2/11/26 at 11:14 AM, Surveyor interviewed ADON-D who indicated nail care does not need to be documented and is part of weekly shower care. When Surveyor asked ADON-D why some residents had nail care documented on their TARs but R23 did not, ADON-D stated Surveyor should ask SVPS-C.On 2/11/26 at 2:05 PM, Surveyor interviewed SVPS-C who indicated staff do not typically document nail care for non-diabetic residents; however, nail care should be consistent for non-diabetic residents and should be completed weekly with showers.

Based on staff interview and record review, the facility did not ensure Pre-admission Screening and Resident Review (PASRR) requirements were met for 1 resident (R) (R24) of 5 sampled residents. R24 had diagnoses including anxiety disorder and major depressive disorder. The facility did not ensure R24's PASRR Level I Screen was completed timely or accurately. Findings include: The facility's admission of a Resident policy, dated 2/2/26, indicates: As part of the pre-admission preparation .c. Facility designated staff member(s) may be needed to assist in the admission process in gathering of information such as mental retardation (MR) and mental illness (MI) screening forms, mental health diagnoses, and background information, etc. From 2/9/26 to 2/11/26, Surveyor reviewed R24's medical record. R24 was admitted to the facility on [DATE] and had diagnoses including anxiety disorder and major depressive disorder. R24's Minimum Data Set (MDS) assessment, dated 2/3/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R24 had intact cognition. R24 was responsible for R24's healthcare decisions. R24's medical record did not include a PASRR Level I Screen following R24's 11/21/25 admission. R24's medical record indicated R24 was transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. R24's PASRR Level I Screen, dated 12/31/25, did not indicate R24 had a serious mental illness. R24's medical record did not include a PASRR Level II Screen. On 2/11/26 at 1:59 PM, Surveyor interviewed Social Services Designee (SSD)-M who was responsible for PASRR completion. SSD-M stated a PASRR Level I Screen is completed any time a resident admits to the facility. SSD-M indicated SSD-M was not aware of the requirements for when to send a referral for a PASRR Level II Screen and only sent them in when the state mental health authority sent SSD-M an email that a Level II Screen was due. SSD-M confirmed a PASRR Level I Screen was not completed for R24's 11/21/25 admission. On 2/11/26 at 2:42 PM, Surveyor interviewed Senior [NAME] President of Success (SVPS)-C who confirmed PASRR Level I and Level II Screens should have been completed timely and accurately for R24.

Based on staff interview and record review, the facility did not ensure Minimum Data Set (MDS) assessments were accurate for 2 residents (R) (R8 and R6) of 15 sampled residents. R8 had diagnoses including anxiety disorder and delusional disorder. R8's MDS assessment, dated 1/21/26, indicated R8 did not have a mental illness. R6 had diagnoses including post-traumatic stress disorder (PTSD), bipolar disorder, major depressive disorder, and schizoaffective disorder. R6's MDS assessment, dated 11/20/25, indicated R6 did not have a mental illness. Findings include: The facility's Conducting an Accurate Resident Assessment policy, dated 4/28/25, indicates: The purpose of the policy is to assure all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas .3. The appropriate, qualified health professional will correctly document the resident's medical, functional, and psychosocial problems and identify residents' strengths to maintain or improve medical status, functional abilities, and psychosocial status. 1. From 2/9/26 to 2/11/26, Surveyor reviewed R8's medical record. R8 was admitted to the facility on [DATE] and had diagnoses including anxiety disorder and delusional disorder. R8's MDS assessment, dated 1/21/26, had a Brief Interview for Mental Status (BIMS) score of 5 out of 15 which indicated R8 had severely impaired cognition. R8 had an activated Power of Attorney for Healthcare (POAHC) who assisted R8 with healthcare decisions. R8's medical record included a Pre-admission Screening and Resident Review (PASRR) Level II Screen, dated 1/17/24, that indicated R8 had a serious mental illness. R8's MDS assessment, dated 1/21/26, indicated R8 was not considered by the PASRR Level II process to have a serious mental illness (Section A1500). On 2/11/26 at 2:42 PM, Surveyor interviewed Social Services Designee (SSD)-M. After reviewing R8's Level II PASRR Screen, SSD-M indicated Section A1500 of the assessment should have indicated a PASRR Level II Screen confirmed the presence of a mental illness. 2. From 2/9/26 to 2/11/26, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] and had diagnoses including post-traumatic stress disorder (PTSD), bipolar disorder, major depressive disorder, and schizoaffective disorder. R6's MDS assessment, dated 11/20/25, had a BIMS score of 15 out of 15 which indicated R6 had intact cognition. R6 was responsible for R6's healthcare decisions. R6's medical record included a PASRR Level II Screen, dated 4/10/23, that indicated R6 had a serious mental illness. R6's MDS assessment, dated 11/20/25, indicated R6 was not considered by the PASRR Level II process to have a serious mental illness (Section A1500). On 2/11/26 at 2:42 PM, Surveyor interviewed SSD-M. After reviewing R6's Level II Screen, SSD-M indicated Section A1500 of the assessment should have indicated a PASRR Level II Screen confirmed the presence of a mental illness.

Based on staff and resident representative interview and record review, the facility did not ensure a bed-hold and transfer/discharge notice and/or a discharge summary was provided for 3 residents (R) (R24, R1, and R39) of 4 sampled residents. R24 was transferred to the Emergency Department (ED) on 1/18/26 and 2/6/26. Neither R24 or 24's representative were provided with a bed-hold or transfer/discharge notice. R1 was transferred to the hospital on [DATE]. Neither R1 or R1's representative were provided with a bed-hold or transfer/discharge notice.R39 was not provided with an accurate discharge summary. R39 discharged home on [DATE] with a blister pack of R41's medication which was accidentally administered to R39. Findings include: The facility's Transfer and Discharge policy, dated 7/15/22, indicates: It is the policy of this facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility except as initiated by the resident, as necessary for the health and safety of residents or other individuals are endangered, or as otherwise permitted by applicable law .7. Emergency Transfers/Discharges - initiated by the facility for medical reasons .I. Provide a notice of the facility's bed-hold policy to the resident and representative at the time of transfer, as soon as possible but no later than 24 hours after the transfer. J. Provide a transfer notice as soon as practicable to the resident and the resident's representative .9. Anticipated Transfers or Discharges .b. A member of the Interdisciplinary Team completes relevant sections of the discharge summary. The nurse caring for the resident at the time of discharge is responsible for ensuring the discharge summary is complete and includes .iii. Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter). iv. A post-discharge plan of care that is developed with the participation of the resident and the resident's representative(s) which will assist the resident to adjust to a new living environment. The facility's Discharge Medication Policy indicates: Medications are sent with the resident upon discharge on ly under conditions that protect the resident and assure compliance with applicable state laws .2. The labels of discharge medications are verified for completeness and accuracy by checking them against the most recent prescriber's orders. 3. Directions for use are reviewed with the resident or responsible party. If current directions for use are not the same as those on a prescription label, the medication name, strength, and correct directions for use are written on a separate piece of paper. The correct directions are given to the resident or responsible party, not affixed to the container .6. Discharge medication information is entered on the discharge instruction form, continuity form, or facility designated form. 1. From 2/9/26 to 2/11/26, Surveyor reviewed R24's medical record. R24 was admitted to the facility on [DATE] and had a diagnosis of left above-the-knee amputation. R24's Minimum Data Set (MDS) assessment, dated 2/3/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R24 had intact cognition. R24 was responsible for R24's healthcare decisions. R24's medical record indicated R24 was transferred to the ED on 1/18/26 and on 2/6/26. R1's medical record did not include documentation that R24 or R24's representative received a bed-hold or transfer/discharge notice. On 2/11/26 at 2:42 PM, Surveyor interviewed Senior [NAME] President of Success (SVPS)-C who confirmed the facility did not complete bed-hold or transfer/discharge notices for R24's hospital transfers. 2. From 2/9/26 to 2/11/26, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had a diagnosis of personal history of urinary tract infections. R1's MDS assessment, dated 12/14/25, had a BIMS score of 15 out of 15 which indicated R1 had intact cognition. R1 was responsible for R1's healthcare decisions. R1's medical record indicated R1 was transferred to the hospital on [DATE] and returned to the facility on [DATE]. R1's medical record did not include documentation that R1 or R1's representative received a written bed-hold or transfer/discharge notice. On 2/11/26 at 2:42 PM, Surveyor interviewed SVPS-C who confirmed the facility did not complete a bed-hold or transfer/discharge notice for R1's 12/7/25 hospital transfer. 3. From 2/9/26 to 2/11/26, Surveyor reviewed R39's medical record. R39 was admitted to the facility on [DATE] and had diagnoses including diabetes, transient ischemic attack, dysphagia, cognitive communication deficit, congestive heart failure, anxiety disorder, and hallucinations. R39's MDS assessment, dated 11/25/25, had a BIMS score of 15 out of 15 which indicated R39 had intact cognition. R39 had an activated Power of Attorney (POA) and was discharged home on [DATE]. Surveyor reviewed R39's discharge medications which did not include a medication of R41's that was sent with R39 upon discharge. A discharge nursing note, dated 12/4/25, indicated R39 was discharged home with belongings and all medications. The note indicated Family Member (FM)-L signed the discharge paperwork and took R39 home. On 2/10/26 at 12:16 PM, Surveyor interviewed FM-L who stated (R41's) medication was sent home with R39 when R39 discharged on 12/4/25 and was accidentally administered to R39 by FM-L's sibling. FM-L called the facility on 12/5/25 to report the error and an unknown staff told FM-L to send the medication back. When FM-L stated the facility was incompetent, the staff member hung up on FM-L. FM-L stated one medication was in a blister pack that contained R41's name and the dosage. Surveyor verified that R41 discharged from the facility on 12/31/25 and was prescribed the medication that FM-L described. On 2/10/26 at 2:36 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who was not aware that R39 was discharged with R41's medication. NHA-A indicated R39 and R41 were discharged on different dates in December (2025). NHA-A stated it is the discharge nurse's responsibility to reconcile discharge medications with the resident or the resident's resposible party. On 2/10/26 and 2/11/26, Surveyor left messages for FM-L's sibling but did not receive a return call.

Based on staff and resident representative interview and record review, the facility did not maintain privacy of medication and healthcare information for 1 resident (R) (R41) of 15 sampled residents. R39 was discharged home with a blister pack of R41's medication.Findings include:The facility's Discharge Medication Policy indicates: Medications are sent with the resident upon discharge on ly under conditions that protect the resident and assure compliance with applicable state laws .2. The labels of discharge medications are verified for completeness and accuracy by checking them against the most recent prescriber's orders. 3. Directions for use are reviewed with the resident or responsible party. If current directions for use are not the same as those on a prescription label, the medication name, strength, and correct directions for use are written on a separate piece of paper. The correct directions are given to the resident or responsible party, not affixed to the container .6. Discharge medication information is entered on the discharge instruction form, continuity form, or facility designated form. From 2/9/26 to 2/11/26, Surveyor reviewed R39's medical record. R39 was admitted to facility on 11/21/25 and had diagnoses including diabetes, transient ischemic attack, dysphagia, cognitive communication deficit, congestive heart failure, chronic kidney disease, anxiety disorder, and hallucinations. R39's Minimum Data Set (MDS) assessment, dated 11/25/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R39 had intact cognition. R39 had an activated Power of Attorney (POA). On 2/10/26 at 12:16 PM, Surveyor interviewed Family Member (FM)-L who stated when R39 was discharged on 12/4/25, another resident's medications were sent home with R39 and FM-L's sibling accidentally administered the medication to R39. FM-L stated FM-L called the facility on 12/5/25 to report the error and was told by an unknown staff to send the medication back. When FM-L stated the facility was incompetent, the staff member hung up on FM-L. FM-L stated one medication was in a blister pack and provided the name of the resident (R41) and the dosage. Surveyor verified that R41 discharged from the facility on 12/31/25 and was prescribed the medication that FM-L described.On 2/10/26 at 2:36 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who was not aware that R39 received R41's medication upon discharge. NHA-A indicated R39 and R41 were discharged on different dates in December (2025). NHA-A stated it is the responsibility of the discharge nurse to reconcile discharge medications with the resident or the resident's resposible party.

Based on observation, staff and resident interview, and record review, the facility did not ensure the accurate and safe administration of medication for 1 resident (R) (R13) of 15 sampled residents.Containers of Mentholatum Original Ointment (decongestant, analgesic ointment), Biofreeze (pain relieving gel), and Equate Vaporizing Rub (cough suppressant, topical analgesic) were observed on R13's bedside table. The medications did not contain pharmacy labels and only one of the medications had a physician's order. In addition, R13 did not have a self-administration of medication assessment that indicated R13 could safely and accurately self-administer medication and/or store medication at the bedside.Findings include: The facility's Self-Administration of Medication policy, dated 5/19/25, indicates: The Center will ensure that a resident can self-administer medication if the resident wants to do so and is determined to be able to do so safely. 1. The Executive Director/designee will inform residents on admission that they have the right to self-administer medication unless the resident has been found incompetent or does not have the physical or mental capacity to self-administer as determined by the resident's physician. 2. The Executive Director/designee will complete a medication self-administration evaluation on admission, annually, and with any significant change of condition for all residents who desire to self-administer medication and do not meet the exemption criteria listed in #1 .5. Staff will assume responsibility for administering medication for residents who are not capable of self-administering medication or who choose to have their medication managed and administered by staff. 6. The Executive Director/designee will ensure written orders are in the resident's record for all medication that the resident self-administers. 7. The Executive Director/designee will incorporate the plan for a resident to self-administer medication on the ISP. 8. The Executive Director/designee will ensure there is a secure location in the resident's room for storing medication, including a locked refrigerator if needed .On 2/9/26, Surveyor reviewed R13's medical record. R13 was admitted to the facility on [DATE] and had diagnoses including alcoholic polyneuropathy, chronic pulmonary disease with acute exacerbation, solitary pulmonary nodule, and edema. R13's Minimum Data Set (MDS) assessment, dated 2/5/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R13 had intact cognition. R13 was R13's own decision maker.On 2/9/26 at 2:09 PM, Surveyor interviewed R13 and observed three containers of medication on R13's bedside table, including Mentholatum Original Ointment, Biofreeze, and Equate Vaporizing Rub. None of the medications contained a pharmacy label or indicated they were prescribed to R13. R13 stated R13 applied the medications when R13 needed them. R13 stated R13 brought the medications from home when R13 was admitted to the facility approximately a year ago and the medications have been in R13's room ever since.Surveyor reviewed R13's physician orders and noted R13 did not have orders for Mentholatum Original Ointment and Equate Vaporizing Rub. R13 had a physician's order, dated 8/11/25, for Biofreeze External Cream 10% (menthol topical analgesic). Apply a thin layer to both knees topically every 8 hours as needed for pain control. R13 did not have an order to keep Biofreeze at the bedside.R13's care plan did not indicate R13 could store medication at the bedside or self-administer medication.R13's medical record did not contain a self-administration of medication assessment.On 2/10/26 at 2:19 PM, Surveyor observed the same medications in R13's room.On 2/11/26 at 9:47 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-I who stated residents should not have medication in their rooms and indicated residents cannot bring medication from home to keep in their rooms.On 2/11/26 at 10:03 AM, Surveyor interviewed R13 who stated R13 was not told that R13 cannot apply medication or store medication in R13's room. Surveyor noted the three medications were still on R13's bedside table.On 2/11/26 at 10:56 AM, Surveyor interviewed Registered Nurse (RN)-H who indicated a resident can have medication in their room if they have an approved self-administration of medication assessment and can safely self-administer medication. RN-H stated if there is medication in a resident's room, the resident should have an order for bedside storage and it should be reflected in the resident's care plan.On 2/11/26 at 11:14 AM, Surveyor interviewed Assistant Director of Nursing (ADON)-D who indicated a resident can have medication at the bedside if they have a self-administration of medication assessment, a risk versus benefits form, and a physician's order to keep medication at the bedside. ADON-D indicated bedside medication storage should be included in a resident's care plan and the medication should be locked up. ADON-D also indicated medication stored in a resident's room should contain a pharmacy label. ADON-D indicated the facility does not allow residents to bring medication from home and stated if a resident brings medication from home, the medication is locked up until they can be taken back home. On 2/11/26, Surveyor requested a bedside medication storage order for R13 and R13's most recent self-administration of medication assessment.On 2/11/26, Senior [NAME] President of Success (SVPS)-C approached Surveyor and indicated R13 did not have an order to store medication at the bedside or a self-administration of medication assessment. On 2/11/26 at 2:01 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated there should be an order for all medication in a resident's room and a bedside storage order. NHA-A indicated the resident should also have a self-administration of medication assessment that indicates the resident can safely and accurately administer medication.

Based on staff interview and record review, the facility did not ensure a Power of Attorney for Healthcare (POAHC) was notified regarding an allegation of abuse for 1 resident (R) (R2) of 3 sampled residents. On 11/23/24, Certified Nursing Assistant (CNA)-D reported that CNA-D witnessed CNA-C be aggressive and use vulgar language during cares for R2 on 11/19/24. The facility did not notify R2's POAHC of the alleged abuse. Findings include: The facility's Change in Condition of the Resident policy, dated 9/20/22, indicates: A facility should immediately inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident's representative when there is an accident involving the resident which results in an injury and has a potential for requiring physician intervention, a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status and either life-threatening conditions or clinical complications), or a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) .4. Notify the resident and/or family/responsible party as applicable and in accordance with the resident's wishes .Documentation needs to include but is not limited to the following .4. Notification of responsible party - include date, time, what was conveyed, any comments (each time notified). On 1/27/25, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including Huntington's disease, depression, dysphagia, and weakness. R2's Minimum Data Set (MDS) assessment, dated 12/18/24, had a Brief Interview for Mental Status (BIMS) score of 00 out of 15 which indicated R2 had impaired cognition. R2 had an activated POAHC who was responsible for R2's medical decisions. On 1/27/25, Surveyor reviewed a facility-reported incident (FRI) that indicated on 11/19/24, CNA-D witnessed CNA-C use excessive force while changing R2's brief and witnessed CNA-C grab and yank R2 aggressively toward CNA-C. CNA-D also reported that CNA-C used vulgar language while completing cares. CNA-D did not report the allegation of abuse to administration until 11/23/24. The investigation did not indicate R2's POAHC was notified of the alleged abuse. On 1/27/25 at 11:37 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who verified R2's medical record did not contain documentation that R2's POAHC was notified of the allegation of abuse. NHA-A stated NHA-A would expect NHA-A or a staff delegated by NHA-A to contact R2's POAHC within hours of the reported incident on 11/23/24.

Based on observation, staff interview, and record review, the facility did not ensure all drugs and biological were stored and disposed of in accordance with the facility's policy. This had the potential to affect more than 4 of the 26 residents residing in the facility. On [DATE], a medication cart was left unlocked and unattended. On [DATE], an expired bottle of ProSource (a protein supplement) was observed in the medication cart. Findings include: The facility's Medication Administration General Guidelines policy, dated ,d+[DATE], indicates: .8. Check expiration date on package/container. No expired medication will be administered to a resident. b. The nurse shall place a 'date opened' sticker on the medication .17. During administration of medications, the medication cart is kept closed and locked when out of sight of medication nurse .The cart must be clearly visible to the personnel administering medications when unlocked. Medication Cart: On [DATE] at 8:21 AM, Surveyor noted a medication cart was unlocked in the hallway while Registered Nurse (RN)-E administered medication in R1's room with the door closed. Expired Medication: On [DATE] at 9:26 AM, Surveyor observed a bottle of ProSource in the medication cart labeled with an open date of [DATE]. Per the manufacturer's label on the bottle, ProSource expires 60 days after opening. On [DATE] at 10:35 AM and on [DATE] at 9:22 AM, Surveyor interviewed Director of Nursing (DON)-B and Assistant Director of Nursing (ADON)-J. ADON-J indicated when staff step away from the medication cart, the cart should be locked. ADON-J also confirmed the bottle of ProSource was expired.

Based on observation, staff and resident interview, and record review, the facility did not ensure nutritional needs were met for 5 residents (R) (R5, R12, R15, R14 and R6) of 5 residents who had orders for carbohydrate-controlled diets. Staff did not follow physician-ordered carbohydrate-controlled diets for R5, R12, R15, R14, and R6 when they served full servings of dessert during the 10/7/24 lunch meal and did not offer diet desserts or half-servings as indicated. Findings include: The facility's Available Diets document, with a review date of 7/13/22, indicates: When necessary, the facility will provide a therapeutic diet that is individualized to meet the clinical needs and desires of a patient/resident to achieve outcomes/goals of care. Available therapeutic diets should coincide with the therapeutic diets on the facility's menu extensions .Diets will be offered as ordered by the physician or his/her designee .The therapeutic diet orders that will be offered are: .Consistent Carbohydrate (CCHO) .The nutrition manual will be available in the food and nutrition services department for staff use .Individuals may be granted a diet holiday from their therapeutic diet for special holidays and events .Individuals on carbohydrate-controlled diets will continue to receive smaller portions of sweet desserts, snacks and low calorie beverages. On 10/6/24 at 9:00 AM, Surveyor interviewed R5 who indicated the facility did not monitor diabetic diets and R5 was concerned that the choices and portions offered to diabetics were not appropriate. R5 indicated R5 counted carbohydrates and the meals were not healthy or carbohydrate-appropriate for someone with diabetes. On 10/7/24, Surveyor reviewed R5's medical record. R5 had diagnoses including type 2 diabetes mellitus, history of urinary tract infections (UTIs), congestive heart failure (CHF), and chronic kidney disease (CKD) stage 3. R5's Minimum Data Set (MDS) assessment, dated 9/16/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R5 had intact cognition. R5's care plan indicated R5 was at risk for nutritional status change related to morbid obesity, type 2 diabetes, and cardiovascular dysfunction and contained an intervention to provide diet as ordered. R5 had a physician order for a consistent-controlled carbohydrate (CCHO) cardiac diet with regular texture, regular/thin consistency. On 10/7/24, Surveyor reviewed R12, R15, R14, and R6's medical records and noted the following: ~ R12 had a diagnosis of type 2 diabetes mellitus and an order for a CCHO diet (dated 3/13/24). ~ R15 had a diagnosis of type 2 diabetes mellitus and an order for a CCHO diet (dated 9/11/24). ~ R14 had a diagnosis of type 2 diabetes mellitus and an order for a CCHO diet (dated 11/29/23). ~ R6 had a diagnosis of type 2 diabetes mellitus and an order for a CCHO diet (dated 7/3/24). During a continuous kitchen observation that began at 11:48 AM on 10/7/24, Surveyor observed lunch service at the steam table. Surveyor noted the dessert was strawberry shortcake and R5's meal ticket indicated R5 should receive a half serving of strawberry shortcake. Surveyor noted there was no variation in size of the strawberry shortcake servings during the lunch meal. Surveyor interviewed [NAME] (CK)-G who indicated all of the strawberry shortcake servings on the cart were the same size. CK-G stated diabetic residents on CCHO diets should have a half piece but I didn't want to waste the cake so I cut them all the same size. On 10/7/24 at 1:44 PM, Surveyor interviewed Regional Food Director (RFD)-F who confirmed residents on CCHO diets should have received a half serving of dessert for lunch. RFD-F provided Surveyor with a meal ticket that indicated R5 should have received a half serving of strawberry shortcake and also provided Surveyor with the names of all residents on CCHO diets. Surveyor noted R12, R15, R14, and R6 were also on CCHO diets and were not served the correct dessert portion during the lunch meal.

Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 6 residents (R) (R5, R1, R22, R18, R20, and R24) of 6 sampled residents. R5 was on enhanced barrier precautions (EBP). On 10/7/24, Certified Nursing Assistant (CNA)-C and CNA-D did not wear gowns during high-contact care for R5. In addition, RN-E did not cleanse hands between glove changes or wear a gown during wound care for R5. R1 was on EBP. On 10/7/24, Registered Nurse (RN)-E exited R1's room before removing personal protective equipment (PPE). RN-E removed RN-E's gown and gloves in the hallway, disposed of the PPE in the medication cart garbage, and performed hand hygiene at the medication cart. In addition, on 10/8/24, RN-I did not perform appropriate hand hygiene during peri-care for R1. On 10/6/24, RN-H did not follow perform appropriate hand hygiene during medication administration for R22, R18, R20, and R24. Findings include: The facility's Enhanced Barrier Precautions policy, with a revised date of 8/8/24, indicates: It is the policy of this facility to implement enhanced barrier precautions (EBP) for the prevention of transmission of multidrug-resistant organisms (MDROs) .3. Implementation of Enhanced Barrier Precautions: .Position a trash can inside the resident room and near the exit for discarding personal protective equipment (PPE) after removal, prior to exit of the room, or before providing care for another resident in the same room. The Centers for Disease Control and Prevention's (CDC's) Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions (EBP) in Nursing Homes document, updated 6/28/24, indicates: .EBP expand the use of gown and gloves beyond anticipated blood and body fluid exposures. They focus on use of gown and gloves during high-contact resident care activities that have been demonstrated to result in transfer of multidrug-resistant organisms (MDROs) to hands and clothing of healthcare personnel, even if blood and body fluid exposure is not anticipated. EBP are recommended for residents known to be colonized or infected with an MDRO. The CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings document, updated 4/12/24, indicates: .5a. Hand Hygiene References and resources .1. Require healthcare personnel to perform hand hygiene in accordance with CDC recommendations .2. Use an alcohol-based hand rub or wash with soap and water for the following clinical indications: .immediately after glove removal. The facility's General Guidelines policy under Medication Administration, dated 1/2023, indicates: .11. Hands are washed with soap and water and gloves applied before administration of topical, ophthalmic, otic, parenteral, enteral, rectal, and vaginal medications. Hands are washed with soap and water again after administration and with any resident contact. Antimicrobial sanitizer may be used in place of soap and water as allowed per state nursing regulations and facility policy. The facility's Infection Prevention and Control Program, with a revision date of 7/23/24, indicates under Equipment Protocol: a. All reusable items and equipment requiring special cleaning or disinfection shall be cleaned in accordance with our current procedures governing the cleaning of soiled or contaminated equipment. 1. On 10/7/24, Surveyor reviewed R5's care plan (with a review date of 9/5/24) which indicated R5 was at risk for infection related to colonization with MDRO pseudomonas, Klebsiella. The care plan contained an intervention for staff to use EBP when performing high-contact care activities. On 10/7/24 at 10:46 AM, Surveyor noted an EBP sign on R5's door and a PPE cart next to the door. On 10/7/24 at 10:49 AM, Surveyor observed CNA-C and CNA-D perform hand hygiene and don gloves prior to transferring R5 from wheelchair to bed via Hoyer lift. CNA-C and CNA-D rolled and tucked the Hoyer sling under R5, rolled R5 back to remove the sling, and provided a urinal for R5. After R5 finished urinating, CNA-C and CNA-D performed hand hygiene, donned gloves, and provided hygiene care for R5. During the provision of care, neither CNA-C nor CNA-D wore a gown. On 10/7/24 at 11:09 AM, Surveyor observed RN-E enter R5's room and don gloves without completing hand hygiene. RN-E assessed an open area in R5's upper inner groin which CNA-C and CNA-D noted was bleeding during peri-care. RN-E picked up a tube of zinc oxide and changed gloves without completing hand hygiene. RN-E wiped R5's inner groin area with a washcloth, applied zinc oxide, and removed gloves. Without completing hand hygiene, RN-E donned clean gloves and applied non-adherent gauze to the area. RN-E then removed gloves, washed hands with soap and water, and exited R5's room. On 10/7/24 at 11:20 AM, Surveyor interviewed CNA-C and CNA-D. When asked about the EBP sign on R5's door, CNA-D stated, They were supposed to take that down. When Surveyor asked why R5 was on EBP, CNA-D indicated CNA-D did not know. When Surveyor asked if CNA-C and CNA-D should have worn a gown during cares, CNA-D stated, Yes, we should have or asked the nurse. CNA-C agreed. On 10/7/24 at 11:32 AM, Surveyor interviewed RN-E. When asked if RN-E was aware that R5 was on EBP, RN-E indicated RN-E should have worn a gown and gloves during wound care. On 10/7/24 at 11:34 AM, Surveyor interviewed Director of Nursing (DON)-B. When asked if R5 was on EBP, DON-B stated, Yes, (R5) has MDROs. When asked when staff should use EBP during the provision of care, DON-B indicated staff should use EBP when they have close contact with residents or body fluids. DON-B verified staff should wear gowns while providing hygiene care and transferring R5. DON-B also indicated DON-B expects staff to complete hand hygiene prior to donning gloves and in between glove changes. 50467 2. On 10/7/24 at 8:24 AM, Surveyor observed RN-E exit R1's room wearing a gown and gloves and remove the PPE outside R1's door. RN-E disposed of RN-E's gown and gloves in the medication cart garbage and performed hand hygiene at the mediation cart. Surveyor noted R1 was on EBP. Surveyor interviewed RN-E who indicated the garbage can was on the other side of R1's room and not near the door. RN-E indicated RN-E should have brought the garbage can over to the door prior to leaving R1's room and removing PPE. On 10/8/24 at 8:35 AM, Surveyor observed RN-I provide peri-care for R1. RN-I completed anterior peri-care. Without removing gloves and cleansing hands, RN-I rolled R1 to the side and completed posterior peri-care. Without removing gloves and cleansing hands, RN-I applied powder and cream to R1's backside, positioned R1 on R1's back, and removed gloves. Without cleansing hands, RN-I donned new gloves, applied cream to R1's folds, put a clean brief on R1, and removed gloves. Without completing hand hygiene, RN-I replaced R1's right sock and boot, covered R1 with a blanket, lowered R1's bed, picked up the cream and powder, and exited R1's room. Immediately following the observation, Surveyor interviewed RN-I who indicated RN-I should have changed gloves when going from dirty to clean and should have performed hand hygiene when RN-I removed gloves. 3. On 10/6/24 at 8:57 AM, Surveyor observed RN-H take R22's pulse and blood pressure with a manual blood pressure cuff and pulse oximeter during the AM medication pass. RN-H did not sanitize the equipment after use. On 10/6/24 at 9:07 AM, Surveyor observed RN-H prepare medication for R18. RN-H did not perform hand hygiene prior to preparing R18's medication. On 10/6/24 at 9:20 AM, Surveyor observed RN-H return to the medication cart and prepare medication for R20. RN-H did not perform hand hygiene prior to preparing R20's medication. On 10/6/24 at 9:41 AM, Surveyor observed RN-H prepare medication for R24 without performing hand hygiene. RN-H then administered R24's medication, returned to the medication cart, and prepared another medication for R24 without performing hand hygiene. On 10/7/24 at 10:35 AM and on 10/8/24 at 9:22 AM, Surveyor interviewed DON-B and Assistant Director of Nursing (ADON)-J. ADON-J indicated hand hygiene should be performed before and after medication administration. ADON-J indicated staff should remove and dispose of PPE inside a resident's room and complete hand hygiene before exiting the room. ADON-J also indicated equipment such as blood pressure cuffs and pulse oximeters should be sanitized and air dried between uses. DON-B indicated staff should remove gloves and complete hand hygiene when going from dirty to clean during the provision of peri-care, when the task is completed, and when gloves are removed. DON-B also indicated hand hygiene should be performed when staff enter a resident's room, before the application of gloves, and after glove removal following the application of topical creams and powder.

Based on staff interview and record review, the facility did not ensure 2 Certified Nursing Assistants (CNAs) (CNA-G, and CNA-H) of 18 CNAs reviewed had a valid Certified Nursing Assistant certification. This practice had the potential to affect multiple residents in the facility. CNA-G and CNA-H did not have active nurse aide certification and were not on the Wisconsin Nurse Aide Registry. Findings include: The facility's Abuse, Neglect and exploitation policy, with a review date of 7/15/22, indicated: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .I. Screening .Background, reference, and credential checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers and consultants. Background checks, including re-checks, will be completed consistent with applicable state laws and regulations. On 8/8/23, Surveyor requested background check and Nurse Aide Registry information for CNA-H. On 8/9/23, Surveyor reviewed CNA-H's background check and Nurse Aide Registry information. Surveyor noted a copy of CNA-H's Certificate of Successful Completion of Nurse Aide Program, dated December 20, 2022; however, Wisconsin Nurse Aide Registry information was not provided for CNA-H. Surveyor reviewed CNA-H's Certified Nursing Assistant Certification from https://wi.tmuniverse.com which indicated CNA-H was not on the Wisconsin Nurse Aide Registry. Surveyor reviewed staff schedules and noted CNA-H worked in the facility as a CNA on 7/2/223. On 8/9/23 at 8:30 AM, Surveyor interviewed Business Office Manager (BOM)-F regarding Nurse Aide Registry information for CNA-H. BOM-F indicated BOM-F would contact the facility's corporate office, request information, and follow up with Surveyor. On 8/9/23 at 9:28 AM, BOM-F approached Surveyor and indicated the background check and Certified Nursing Assistant Certification information provided for CNA-H was the only information the facility had. BOM-F indicated BOM-F would contact the contracted company to inquire about Nurse Aide Registry information for CNA-H and follow up with Surveyor. On 8/9/23 at 11:00 AM, Surveyor reviewed staff schedules and a staff list of direct hire and contracted CNAs. Surveyor reviewed the Wisconsin Nurse Aide Registry for all CNAs who worked in the facility from https://wi.tmuniverse.com. Surveyor was unable to locate Nurse Aide Registry information for CNA-G. On 8/9/23 at 12:30 PM, Surveyor interviewed BOM-F and Director of Nursing (DON)-B. DON-B indicated DON-B followed up with the contracted company and there was no documentation CNA-H was on the Wisconsin Nurse Aide Registry, on the waitlist for the Wisconsin Nurse Aide Registry or completed an examination for the Certified Nurse Aide Certification. BOM-F verified CNA-H worked in the facility as a CNA on 7/2/23. DON-B indicated the person responsible to ensure background check and license/certification information provided from contracted companies is accurate and thorough should probably be DON-B. Surveyor requested information from BOM-F and DON-B regarding whether or not CNA-G had an active Nurse Aide Certification. On 8/9/23 at 1:19 PM, DON-B approached Surveyor and indicated there was no documentation to indicate CNA-G completed a state approved Certified Nursing Assistant Program or was on the Wisconsin Nurse Aide Registry. DON-B verified CNA-G worked as a CNA in the facility on 2/23/23.

Based on staff interview and record review, the facility did not implement its policy and procedure to prohibit abuse, neglect and mistreatment of residents for 1 staff (Registered Nurse (RN)-E) of 8 staff reviewed during the caregiver program compliance check. The facility did not ensure an out-of-state background check was completed for RN-E. Findings include: The facility's Abuse, Neglect and Exploitation policy, last reviewed 7/15/22, contained the following information: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .I. Screening .Background, reference, and credential checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers and consultants. Background checks, including re-checks, will be completed consistent with applicable state laws and regulations. On 8/8/23, Surveyor requested staff schedules and a list of direct hire and contracted staff. Surveyor selected a sample of employees to review for background check compliance, including RN-E, who was employed through a contracted nurse staffing agency and began working at the facility on 8/26/22. On 8/9/23, Surveyor reviewed RN-E's Background Information Disclosure (BID) form, dated 7/19/22, and noted RN-E indicated RN-E resided in the state of Indiana within the past 3 years prior to working at the facility. Surveyor reviewed RN-E's background check information and noted an out-of-state background check was not included. On 8/9/23, Surveyor reviewed staff schedules and noted RN-E worked in the facility an average 15 shifts per month from January 2023 through July 2023. Surveyor noted RN-E was scheduled and worked on 8/7/23. On 8/9/23 at 8:30 AM, Surveyor interviewed Business Office Manager (BOM)-F regarding RN-E's out-of-state background check. BOM-F indicated BOM-F would contact the facility's corporate office and the staffing agency, request information, and follow up with Surveyor. On 8/9/23 at 1:19 PM, Director of Nursing (DON)-B approached Surveyor and indicated neither the staffing agency that employed RN-E or the facility's corporate office had record of an out-of-state background check for RN-E. On 8/9/23 at 1:30 PM, Surveyor interviewed BOM-F who indicated the staffing agency is responsible for conducting background and license checks and the facility is able to contact the staffing agency and request the files. On 8/9/23 at 1:46 PM, Surveyor interviewed [NAME] President of Success (VPS)-D who indicated there is supposed to be a process conducted by the facility for checking all background information for accuracy and thoroughness prior to staff working in the facility.

Based on observation, staff interview, and record review, the facility did not ensure 1 Resident (R) (R11) of 4 residents observed during medication administration was free of a medication error. Licensed Practical Nurse (LPN)-C administered 50 milligrams (mg) of Metoprolol Succinate Extended Release (ER) (blood pressure reducing medication) to R11 prior to obtaining R11's pulse. Findings include: The facility's medication administration policy titled Medication Administration General Guidelines 01/23 contained the following information: .1. Medications are administered in accordance with written orders of the prescriber .2. Obtain and record any vital signs as necessary prior to medication administration. On 8/8/23, Surveyor reviewed R11's medical record. R11 was admitted to the facility on [DATE] with diagnoses to include hypertensive heart and chronic kidney disease with heart failure. R11's most recent Minimum Data Set (MDS) assessment contained a Brief Interview for Mental Status (BIMS) score of 8 out of 15 which indicated R11 had moderately impaired cognition. On 8/8/23 at 7:48 AM, Surveyor observed LPN-C administer medications to R11. LPN-C administered R11's Metoprolol Succinate ER 50 mg tablet prior to obtaining R11's pulse. At 7:52 AM, Surveyor observed LPN-C obtain R11's vital signs. R11's pulse was 50. On 8/8/23, Surveyor reviewed R11's medical record, including R11's physician orders. R11 had a physician order for Metoprolol Succinate ER oral tablet ER 24-hour 50 mg; give 50 mg by mouth one time a day for hypertension (high blood pressure), hold if pulse less than 50. On 8/8/23 at 1:02 PM, Surveyor interviewed LPN-C regarding R11's metoprolol order. LPN-C verified LPN-C should have obtained R11's pulse prior to metoprolol administration per R11's physician order. On 8/8/23 at 1:16 PM, Surveyor interviewed Director of Nursing (DON)-B who verified LPN-C should have checked R11's pulse prior to administering the medication per the physician order.

Based on staff interview and record review, the facility did not ensure 3 Residents (R) (R14, R7, and R20) of 3 sampled residents reviewed for hospitalization received written information of the duration of the bed hold policy, the reserve bed payment and the right to return to the facility. R14 was transferred to the hospital on 4/21/23 and did not receive a written bed hold notice. R7 was transferred to the hospital on 6/26/23 and did not receive a written bed hold notice. R20 was transferred to the hospital on 7/10/23 and 7/14/23. R20 did not receive a written bed hold notice for either transfer. Findings include: The facility's Transfer and Discharge policy, dated 7/15/22, indicates: It is the policy of this facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility except as initiated by resident, necessary for the health and safety of resident or other individuals are endangered, or as otherwise permitted by applicable law. Emergency Transfer/Discharges- Initiated by the facility for medical reasons, or for the immediate safety and welfare of a resident (nursing responsibilities unless otherwise specified). b. Notify resident and/or resident representative i. Provide a notice of the bed hold policy to the resident and representative at the time of transfer, as possible, but no later than 24 hours after the transfer. 1. On 8/8/23, Surveyor reviewed R14's medical record. R14 was transferred to the hospital on 4/21/23 for a urinary tract infection (UTI). R14's medical record did not contain a signed bed hold notice for the hospital transfer. 45942 2. On 8/8/23, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] with diagnoses that included diabetes, heart failure, obesity and high blood pressure. R7's Minimum Data Set (MDS) assessment, dated 7/6/23, contained a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R7 had intact cognition. R7 was transferred to the emergency roiagnom on [DATE] due to pain and shortness of breath and was admitted to the hospital with a diagnosis of severe sepsis. R7's medical record did not contain a signed bed hold notice for the hospital transfer. 3. On 8/8/23, Surveyor reviewed R20's medical record. R20 was admitted to the facility on [DATE] with diagnoses that included aphasia (comprehension and communication disorder due to brain trauma), dysphagia (difficulty eating/swallowing food/liquid) following cerebral infarction (stroke), and chronic kidney disease. R20 was transferred to the emergency roiagnom on [DATE] for a UTI and on 7/14/23 for altered mental status and hypotension (low blood pressure). R20's medical record did not contain a signed bed hold notice for either transfer. On 8/8/23 at 12:25 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated the facility recognizes they did not provide bed hold notices. DON-B verified residents who are transferred to the hospital should be informed of the facility's bed hold policy in writing and have the policy signed.

Based on staff and resident interview, and record review, the facility did not investigate, resolve, and record resolution of a grievance for 1 Resident (R) (R17) of 2 residents reviewed for grievances. The facility did not thoroughly document and investigate a grievance expressed by R17. Findings include: The facility's Grievance policy, with a reviewed/revised date of 7/22, contained the following information:.The facility will seek to resolve concerns, complaints or grievances and provide residents, responsible parties, staff and others feedback and resolution in a timely manner per S483.10 (J)(1), The resident has a right to voice grievances without fear or retaliation. Procedure: The Grievance Officer for the facility is the Administrator/Executive Director. In his/her absence, the Director of Social Services will execute the duties of the Grievance Officer. Residents, residents' families and responsible parties, facility staff and facility contractors will be in-serviced on the grievance procedure, how to initiate a grievance, who the Grievance Officer is and how resolutions will be communicated. Residents will be in-serviced through Resident Council Meetings and on admission that they can access and initiate a concern form and that staff members, the resident's family members/friends can assist them in completing the form upon request. When a Complaint/Grievance Report is initiated: A copy of the initiated concern form will be placed in the Grievance Notebook as a reminder that the grievance is still being investigated and resolved. The original form will then be forwarded to the department head for which the grievance pertains to (i.e., Dietary Manager for food and dining related issues, Director of Nursing for any nursing or clinical related issues, Laundry Supervisor for missing clothing issues, etc.) The Department Head that is assigned the concern form is responsible for investigating the issue and following up to provide a resolution within 72 hours of being assigned the grievance. R17 was admitted to the facility on [DATE] with diagnoses that included high blood pressure, arthritis, and depression. R17's Minimum Data Set (MDS) assessment, dated 5/21/23, contained a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R17 had intact cognition. R17 did not have an activated power of attorney. On 8/7/23 at 10:31 AM, Surveyor interviewed R17 who indicated R17 lost two nightgowns (one was white flannel and the other had cardinals). R17 informed staff of the missing nightgowns a couple of months ago (unsure of the exact dates); however, there was no follow-up thus far. R17 also indicated R17 informed Life Enrichment Specialist (LES)-I of the missing nightgowns a couple of months ago. On 8/7/23, Surveyor reviewed the facility's written grievances and did not see a grievance regarding R17's missing nightgowns. Surveyor also reviewed R17's medical record which did not contain documentation regarding the missing nightgowns. On 8/8/23 at 11:19 AM, Surveyor interviewed Social Worker (SW)-M regarding R17's missing nightgowns. SW-M indicated SW-M was not aware of R17's missing nightgowns. SW-M indicated if SW-M was aware, SW-M would have written a grievance, investigated and followed up with R17. SW-M agreed a grievance should have been filed. On 8/8/23 at 2:03 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-J who indicated CNA-J was aware of R17's missing nightgowns. Per CNA-J, R17 informed CNA-J of the missing nightgowns several weeks ago. CNA-J did not fill out a grievance form and did not inform anyone else. On 8/8/23 at 2:19 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who confirmed NHA-A is the facility's Grievance Officer. NHA-A indicated NHA-A started at the facility a week ago and was not aware of R17's missing nightgowns. NHA-A indicated the facility's process for missing items is that staff report resident concerns immediately to administration, a grievance is written up and an investigation is initiated. If the facility is unable to find the missing items, the facility replaces the missing items. NHA-A indicated NHA-A would follow up with the resident promptly with the results of the investigation. NHA-A confirmed a grievance should have been filled out by staff who had knowledge of R17's missing nightgowns. On 8/8/23 at 2:26 PM, Surveyor interviewed LES-I who indicated LES-I was not aware of R17's missing nightgowns. On 8/8/23 at 2:35 PM, Surveyor interviewed DON-B, who indicated DON-B was not aware of R17's missing nightgowns. DON-B indicated the process for missing clothing is to fill out a grievance form, ask for a description of the missing item, search the resident's room, call the resident's family and search the laundry room. Per DON-B, if the facility was unable to find the missing items, an investigation would start by speaking with staff and residents. If the items were still missing after an investigation was conducted, the facility would replace the items and DON-B would follow-up with the resident as soon as possible. DON-B agreed a grievance should have been filed, investigated and follow up should have occurred with R17. On 8/8/23 at 2:45 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-C who indicated LPN-C was not aware of R17's missing nightgowns. LPN-C indicated if LPN-C was aware, LPN-C would have filled out a grievance form and informed Director of Nursing (DON)-B. On 8/8/23 at 3:00 PM, Surveyor interviewed CNA-K who indicted CNA-K was aware of R17's missing nightgowns when R17 informed CNA-K about the missing nightgowns a few weeks ago. CNA-K did not fill out a grievance form and did not inform anyone else. CNA-K indicated CNA-K should have informed the nurse. On 8/9/23 at 10:14 AM, Surveyor interviewed Laundry Attendant (LA)-L who indicated LA-L was made aware of R17's missing nightgowns approximately six months ago. LA-L indicated LA-L did not inform anybody other than an ex-staff member and did not fill out a grievance form. Per LA-L, R17 continued to inquire about the missing nightgowns and was able to describe the nightgowns. LA-L indicated LA-L continued to look for the nightgowns and was unable to find them. LA-L confirmed if items are missing, administration should be informed immediately.

Based on staff interview and record review, the facility did not ensure a written notification of transfer, including the reason for the transfer, location of the transfer, appeal rights, and contact information for the State Long-Term Care Ombudsman was provided for 3 Residents (R) (R14, R7, and R20) of 3 residents reviewed for hospitalization . R14 was transferred to the hospital on 4/21/23 and was not provided a written transfer notice. R7 was transferred to the hospital on 6/26/23 and was not provided a written transfer notice. R20 was transferred to the hospital on 7/10/23 and 7/14/23. R20 was not provided a written transfer notice for either transfer. Findings include: The facility's Transfer and Discharge policy, dated 7/15/22 indicates: It is the policy of this facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility except as initiated by the resident, necessary for the health and safety of the resident or other individuals are endangered, or as otherwise permitted by applicable law. Emergency Transfer/Discharges - Initiated by the facility for medical reasons, or for the immediate safety and welfare of a resident (nursing responsibilities unless otherwise specified). b. Notify resident and/or resident representative. d. Complete and send with the resident (or provide as soon as practicable) a Transfer form. f. The original copies of the Transfer form and Advance Directive accompany the resident. Copies are retained in the medical record. j. Provide Transfer form as soon as practicable to resident and representative. 1. On 8/8/23, Surveyor reviewed R14's medical record. R14 was transferred to the hospital on 4/21/23 for a UTI (urinary tract infection.) R14's medical record did not contain a written notice for the hospital transfer. 45942 2. On 8/8/23, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] with diagnoses that included diabetes, heart failure, obesity, and high blood pressure. R7's Minimum Data Set (MDS) assessment, dated 7/6/23, contained a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R7 had intact cognition. R7 was transferred to the emergency roiagnom on [DATE] due to pain and shortness of breath and admitted to the hospital with a diagnosis of severe sepsis. R7's medical record did not contain a written notice for the hospital transfer. 3. On 8/8/23, Surveyor reviewed R20's medical record. R20 was admitted to the facility on [DATE] with diagnoses that included aphasia (comprehension and communication disorder due to brain trauma,) dysphagia (difficulty eating/swallowing) following cerebral infarction (stroke), and chronic kidney disease. R20 was transferred to the emergency roiagnom on [DATE] for a UTI and on 7/14/23 for altered mental status and hypotension (low blood pressure). R20's medical record did not contain a written notice for either hospital transfer. On 8/8/23 at 12:25 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated the facility recognizes they do not provide transfer notices. DON-B indicated residents who are transferred to the hospital should be informed of the facility's transfer notice policy and should be provided a written notice of transfer.

Based on observation and resident and staff interview, the facility did not ensure incontinence care and a transfer were provided timely for 1 Resident (R) (R1) of 4 sampled residents. R1's call light was shut off and assistance was not provided timely when R1 requested incontinence care and to be transferred out of bed. Findings include: 1. On 2/13/23, Surveyor reviewed R1's medical record. R1 was admitted to the facility with diagnoses to include muscle weakness and morbid obesity. R1's five (5) day Minimum Data Set (MDS), dated [DATE], indicated R1's cognition was 15 out of 15 (the higher the score, the more cognizant). R1 required extensive staff assistance for personal hygiene and was dependent on staff for transfers. On 2/13/23 at 11:28 AM, Surveyor observed R1 activate R1's call light for the provision of incontinence care and to be transferred out of bed. At 11:37 AM, Certified Nursing Assistant (CNA)-C answered R1's call light. R1 asked to be changed because R1 was incontinent of urine. R1 also stated R1 wanted to get out of bed and go to the dining room. CNA-C shut off R1's call light and advised R1 the wound doctor was coming. R1 stated the wound doctor was not coming and CNA-C left R1's room to check. At 12:17 PM, R1 stated CNA-C still had not come back to R1's room and the wait was getting ridiculous. Lunch will be soon. At 12:28 PM, Surveyor noted R1 had been waiting for one (1) hour for incontinence care and stated, sad, no excuse for waiting that long. At 12:33 PM, R1 activated the call light again. At 12:36 PM, Registered Nurse (RN)-D answered R1's call light. R1 stated R1 needed to be changed and wanted to get out of bed for lunch. RN-D stated, I have to wait for a couple other people to help get R1 out of bed. At 12:39 PM, CNA-C, CNA-E and RN-D provided incontinence care and transferred R1 out of bed for lunch. R1 was provided assistance 1 hour and 11 minutes after R1 requested assistance. On 2/13/23 at 1:08 PM, Surveyor interviewed CNA-C regarding the observation. CNA-C verified R1's call light was shut off and stated not everyone can be first. CNA-C verified it was not acceptable for R1 to wait 1 hour and 11 minutes for assistance.

Based on observation, resident and staff interview and record review, the facility did not provide services to prevent a urinary tract infection (UTI) for 1 R (Resident) (R1) of 4 sampled residents. R1 was not provided perineal cleansing after an episode of urinary incontinence. Findings include: The facility's Perineal Care policy, with a reviewed/revised date of 8/9/22, stated it is the practice of the facility to provide perineal care to all incontinent residents as needed to promote cleanliness and comfort, and prevent infection to the extent possible. 1. R1's five (5) day Minimum Data Set (MDS) assessment, dated 1/20/23, documented R1's cognition was 15 out of 15 (the higher the score, the more cognizant). The MDS documented R1 was always incontinent of bladder, required extensive assistance from staff for personal hygiene and had a UTI in the last 30 days. On 2/13/23 at 12:39 PM, Surveyor observed Certified Nursing Assistant (CNA)-C, CNA-E and Registered Nurse (RN)-D assist R1 with changing R1's incontinence brief after R1 was incontinent of a large amount of urine. CNA-C removed R1's wet brief and verified R1 was incontinent of urine. CNA-C and CNA-E placed a clean incontinence brief on R1 without cleansing R1's perineal area, groin or buttocks and then transferred R1 from bed to an electric wheelchair. On 2/13/23 at 12:55 PM, R1 stated to Surveyor that incontinence cares were not provided after R1 was incontinent of a large amount of urine and R1 had a history of UTIs. On 2/13/23 at 1:08 PM, Surveyor interviewed CNA-C regarding the observation. CNA-C stated incontinence cares were not completed after R1 was incontinent of a large amount of urine because R1 gets antsy to get to the dining room, so CNA-C wanted to hurry and get it done.

Based on observation and staff interview, the facility did not maintain an infection control program designed to prevent the development and transmission of disease and infection during a care observation for 1 Resident (R) (R1) of 4 sampled residents. Staff did not cleanse hands during an observation of wound and incontinence care for R1. Findings include: The facility's Hand Hygiene policy, with a reviewed/revised date of 11/2/22, stated all staff will perform proper hand hygiene procedures to prevent the spread of infection. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. Hand hygiene will be performed after handling contaminated objects and after removing gloves. The Morbidity and Mortality Weekly Report, dated 10/25/02 and published by the Centers for Disease Control and Prevention (CDC), titled Guideline for Hand Hygiene in Health Care Settings contains recommendations to wash hands after removing gloves and to decontaminate hands after contact with body fluids or excretions and when moving from a contaminated body site to a clean body site during patient care. The above information can also be found at: https://www.cdc.gov/handhygiene/providers/index.html with the page last reviewed on January 8, 2021. 1. On 2/13/23 at 12:39 PM, Surveyor observed Certified Nursing Assistant (CNA)-C, CNA-E and Registered Nurse (RN)-D provide care for R1. CNA-C, CNA-E and RN-D washed hands and donned gloves. CNA-C removed R1's wet incontinence brief. Without removing gloves and cleansing hands, CNA-C placed a clean brief underneath R1. RN-D then cleansed R1's leg wound with normal saline. Without removing gloves and cleansing hands, RN-D placed a clean border foam dressing on R1's leg wound. With the same soiled gloves CNA-C used to remove R1's wet incontinence brief, CNA-C pulled up R1's clean incontinence brief, placed a sling underneath R1, applied R1's belly band and straightened R1's clothing. CNA-C then removed gloves and sanitized hands. RN-D removed gloves and washed hands. On 2/13/23 at 12:57 PM, Surveyor interviewed RN-D regarding hand hygiene during wound care for R1. RN-D verified the above observation and stated RN-D should have removed gloves and washed or sanitized hands after cleansing R1's leg wound prior to applying a clean dressing. On 2/13/23 at 1:08 PM, the Surveyor interviewed CNA-C regarding hand hygiene during incontinence care for R1. CNA-C verified CNA-C did not remove gloves and wash or sanitize hands when going from dirty to clean during the provision of care.

Based on observation, staff interview, and record review, the facility did not ensure the resident environment remained free of accident hazards for 1 Resident (R) (R1) of 3 residents reviewed for safety. On 3/29/22, R1 sustained 2nd and 3rd degree [CONDITION(S)] from a radiator heater next to R1's bed. Facility failure to assess the resident's proximity to the hot surface and the risk for burn injury related to this surface, created a finding of immediate jeopardy that began on 3/29/22. Regional Field Operations Director notified NHA (Nursing Home Adminhistrator)-A of the immediate jeopardy on 5/31/22 at 11:19 AM. The immediate jeopardy was removed on 3/29/22 and corrected on 4/4/22. This is being cited as past noncompliance. Findings Include: According to John Hopkins University (https://www.hopkinsmedicine.org/health/conditions-and-diseases/[CONDITION(S)]), Both infants and the older adults are at the greatest risk for burn injury .First-degree [CONDITION(S)] affect only the epidermis, or outer layer of skin. The burn site is red, painful, dry, and with no blisters. Mild sunburn is an example. Long-term tissue damage is rare and usually involves an increase or decrease in the skin color. Second-degree [CONDITION(S)] involve the epidermis and part of the dermis layer of skin. The burn site appears red, blistered, and may be swollen and painful. Third-degree [CONDITION(S)] destroy the epidermis and dermis. Third-degree [CONDITION(S)] may also damage the underlying bones, muscles, and tendons. When bones, muscles, or tendons are also burned, this may be referred to as a fourth-degree burn. The burn site appears white or charred. There is no feeling in the area since the nerve endings are destroyed. R1 was admitted to the facility on [DATE] with diagnoses to include Type II diabetes, Dementia, [CONDITION(S)] (impaired blood flow), hypertension (high blood pressure), [CONDITION(S)] (nerve damage resulting in numbness or tingling) and anxiety. R1's Minimum Data Set (MDS) assessment, dated 1/10/22, indicated R1's cognition to be severely impaired and that R1 required staff assistance with bed mobility and transfers. R1's care plan, revised 4/5/22, states Thermal injury to LLE (Left Lower Extremity) r/t [CONDITION(S)] with interventions to adminster analgesia (pain relief) and treatments per MD orders, encourage and asisst as needed to turn and reposition, follow up care with MD as ordered, and report evidence of infection such as purulent drainage, swelling, localized heat, increased pain, etc. Notify MD PRN (as needed). R1's bed was next to the wall and up against the radiant heater on the wall. On 5/31/22 at 2:55 P.M., the Surveyor interviewed Licensed Practical Nurse (LPN) - Q, who confirmed that R1 was able to lift R1's legs and that R1 would be able to slide R1's legs over the edge of the bed. On 6/1/22 at 9:05 A.M., the Surveyor interviewed Doctor (MD) - F, who verified that R1 could move R1's legs and feet a little bit. On 5/31/22 at 2:45 P.M., the Surveyor interviewed Consultant (C) - C, who verified that the facility had not recently assessed R1's sensation in the lower extremities or R1's risk for [CONDITION(S)] related to the radiant heater next to R1's bed . On 5/31/22, the Surveyor reviewed R1's medical record to include progress notes and wound assessments. R1's medical record contained a progress note, dated 3/29/22 at 5:43 A.M., which stated: [R1] found with left leg over the side of the bed on the heater. [R1] has two new open areas to area. A wound care note, dated 3/29/22, states: ~Burn wound of the left lower leg (full thickness), 21.5 cm x 8 cm x <1 cm, light serous drainage. A wound care note, dated 4/1/22 states: Asked to return today as new areas have opened on [R1's] left foot and one of [R1's] toes probably from deeper thermal injury ~Burn wound of the left lower lateral leg (full thickness), 21.2 cm x 7.5 cm x <1 cm, light sero-sanguineous (blood tinged) drainage, 70% slough (dying tissue). R1's leg wound underwent excisional debridement (removal of dying tissue with surgical tools), removing 111.3 cm of devitalized tissue, including slough, biofilm (microbial mix of bacteria, fungi, yeast, and other microbes that can inhibit healing), and non-viable subcutaenous fat and surrounding connective tissues at a depth of 0.1 cm. ~Burn wound of the left foot (full thickness), 6 cm x 4.5 cm x <1 cm, red peri-wound (skin around the wound bed), 10% necrotic (dead) tissue, 90% slough. This wound underwent excisional debridement, removing 27 cm of devitalized tissue and necrotic subcutaneous fat an surrounding connective tissues along with slough and biofilm. ~ Burn wound of the left second toe (full thickness), 3.0 cm x 7.0 cm x 0.1 cm. Additional wound assessments and excisional debridements were conducted on 4/4/22, 4/11/22, and 4/18/22. Hospital notes, dated 4/19/22, indicate that R1 underwent sedated surgical debridement with a plastic surgeon. Hospital note states [R1] .sustained third degree [CONDITION(S)] to left lower extremity and foot .despite dressings [R1] has non viable tissue The risks of the procedure were explained to the [POAHC] including but not limited to risks associated with general anesthesia, pulmonary embolism (blood clot in the lung), death, infection, bleeding, wound healing complications, hematoma (bruising), damage to nearby structures, and need for possible skin graft in future. The procedure note states sharply debrided the lateral foot down to bleeding tissue with a scalpel and scissors. [R1's] peroneal brevis tendon (tendon on outside of ankle that allows the foot to rotate outwardly away from the rest of the leg) appeared dried and not viable and this was debrided the left lateral lower leg burn was sharply debrided with a scalpel until bleeding tissue .chose not to skin graft as .given [R1's] status this would lead to further pain .high risk of graft failure .immobility of the leg may be challenging. R1's left toe burn was noted as resolved on 4/25/22. Additional wound assessments and excisional debridements were conducted on 5/2/22, and 5/9/22 A wound care note, dated 5/16/22, states: ~Burn wound of the left lower lateral leg (full thickness), 14 cm x 2 cm x <1 cm ~Burn wound of the left foot (full thickness), 4cm x 2.2 cm x 0.2 cm, 30% necrotic tissue, 10% slough. This wound is in an [CONDITION(S)] stage and is unable to progress to a healing phase because of the presence of biofilm. This wound underwent excisional debridement. A wound care note, dated 5/23/22, states: .foot wound looks worse . ~Burn wound of the left lateral leg, 14 cm x 2 cm x <1 cm, no change in wound progress. Wound culture done .ESR (Erythrocyte Sedimentation Rate) (lab test for inflammation and infection), CRP (c-reactive protein) (lab test for inflammation), and WBC (white blood cell count) to check for infection. X-ray of left foot orderd to look for [CONDITION(S)] (infection of the bone). Consider Infectious Disease consult and empiric antibiotics. ~Burn wound of the left foot, 3.3 cm x 3 cm x 0.3 cm, red peri-wound, moderate sero-sanguinous drainage, 20% necrotic tissue, 30% slough. This wound is in an [CONDITION(S)] stage and is unable to progress to a healing phase because of the presence of biofilm. This wound underwent excisional debridement. Wound progress is noted as deteriorated. This wound underwent excisional debridement. On 6/1/22 at 9:05 A.M., the Surveyor interviewed MD - F, who verified that the x-ray results had been negative but that MD-F was ordering an MRI (magnetic resonance imaging) to ensure no infection of the bone. MD-F also stated that MD-F had concerns related to R1 because the [CONDITION(S)] seemed severe and that due to R1's age and comorbidities that [CONDITION(S)] could happen very quickly. MD-F also verified that R1 had the ability to move R1's legs a little bit. The failure to assess and monitor risk for [CONDITION(S)] created a finding of immediate jeopardy. The facility had removed the jeopardy on 3/29/22 when all beds were moved 18 inches from heat radiators. The facility corrected the non-compliance on 4/4/22 when all staff were trained on bed placement. This was cited as past noncompliance based on the facility's response to remove the immediacy and to correct the deficient practice.