Every finding on record at Park View Home

Based on observation, interview and record review, the facility did not ensure that 2 of 2 residents (R) reviewed for pressure injuries (PI) (R4 and R7) received care consistently with professional standards of practice to prevent further deterioration and promote healing of an existing PI.The facility did not complete weekly comprehensive skin assessments with staging of the PI for R4 and R7. This is evidenced by Facility's policy titled Skin Management with review date of 06/22/26 documented, Assessment/Treatment/Documentation: ~The nurse will complete and document a skin assessment weekly. ~Skin injury, or signs of impaired skin integrity, will be reported promptly to the Director of Nursing, or designee, and documented accordingly.~A wound assessment will be completed and documented by the nurse (i.e. wound type, tissue type with description, granulation tissue, epithelialization, necrotic tissue, location, stage, size, depth, appearance, exudate, current treatment, effect on ADL's pressure relieving devices used, nutritional support, etc.)~Nurses will refer to the facility Wound Care Guide Manual [clinically-based guidelines per The National Pressure Injury Advisory Panel{NPIAP} for skin injury, wound assessment and treatment guidance and notify the residents' primary healthcare provider; or request a referral to the local wound clinic for further assessment and treatment.~The nurse will routinely assess wound for progress in healing, risks to healing, plan, timeline, and supply/equipment needs to promote healing.~The nurse will document assessment of wound weekly and consult the residents' primary healthcare provider for treatment change if no signs of healing are present within 14 days or sooner if worsening of wound. Example 1 R4 was admitted to the facility on [DATE]. R4's current diagnosis includes fracture of neck of left femur, type 2 diabetes mellitus, acquired absence of right foot, and dementia. On 06/12/26, the Minimum Data Set (MDS) assessment documented R4's Brief Interview for Mental Status (BIMS) score of 10/15, meaning moderately impaired cognition. On 05/20/26, Braden Scale for Predicting Pressure Ulcer Risk Braden Evaluation: Results: Not at Risk Score: 19.0. R4's progress notes documented on 05/25/2026 at 1:24 PM, Skin/Wound Note Note Text: Resident's mom / POA asked writer to look at left heel. Left heel has skin peeling, but is not open at this time. D/T (due to) history of open areas on feet, foam dressing was applied. Order entered to change every 3 days and prn until resolved. Fax sent to PHCP. R4 was admitted to the hospital on [DATE] and returned to the facility on [DATE]. Facility's readmission skin assessment did not document the left heel having skin issues. On 06/10/2026 at 10:14 AM, Orders - Administration Note, Note Text: change foam dressing to left heel for peeling skin until resolved as needed as neededdressing was not intact on left heel. Revealed open area of4.6 x 2.4 cm open area surrounded by soft tissue of 7 x 6 cm. Appears to be an open blister. No surrounding redness. Educated resident he needs to keep heel elevated. The facility did not complete a comprehensive assessment to include description of wound bed, drainage, and staging. On 06/11/2026 at 10:24 AM, COMMUNICATION - with Physician Situation: Fax returned from NP regarding resident has open area on left heel that was just a dried patch previously. Will continue foam dressing. Ok for 30ml of Prosource or equivalent daily to promote wound healing.Recommendations: Per NP: 1) OK for foam dressing to left heel until resolved. 2) OK for 30ml Prosource or equivalent daily. On 06/13/2026 at 1:40 PM, Skin/Wound Note, Note Text: . Heel has new foam pad applied, area is bright red where it is open and skin of blister is turning yellow around this. Weeping and filled foam from yesterday. The facility did not complete a weekly comprehensive assessment to include description of wound bed, measurements, drainage, and staging. On 06/21/2026 at 7:12 AM, Orders - General Note from eRecordNote Text: heel area has dried edges of blister, center is open measure 3 x 4 cm red base, moist, weeping. Edges are dried and hard. Entire area measures 4 x 6 cm. On 06/24/2026 at 7:28 AM, Orders - General Note from eRecordNote Text.Heel blister has a 5 x 4 cm open center which is red and moist. The edges are soft and macerated and fourth edge is stiff dried skin. The entire area measures 8.5 x 6 cm. The facility did not complete a comprehensive assessment to include description of wound bed, drainage, and staging. On 06/24/2026 at 2:23 PM, Orders - Administration Note, Note Text: change foam dressing to left heel for peeling skin until resolved, as needed as needed, Resident with therapy stood up x two. This caused bleeding from site on heel. Area cleansed and redressed. Measurements at this time are a black center of 1 x 1 cm, surrounded by a red base of 2.1 x 3.5 cm. Surrounded by open area of 3 x 6.5 cm. Around this is a macerated area of 2 to 4 cm with slough skin/old blister on three sides with a fourth side of vulnerable pink area which was still covered with skin layer, this was superior to open area measuring 2.5 cm. Note that this area was not there this a/m. POA was present and took pictures of wound and shared them with DON, appointment for wound clinic is on the eighth of July. On 06/24/2026 14:57COMMUNICATION - with Physician Situation: Left heel wound, Background: resident had blister that opened, Assessment (RN)/Appearance (LPN): wound has deteriorated with current dressing orders. New orders received from NP has wound clinic appointment 7/6/2026 soonest he can get in; is on wait list for earlier appointment, Recommendations: d/c foam dressing, apply hydrofera blue today into wound bed apply under flap if able; cover with foam. Remove on Friday 6/26 and call on the status and for further wound care orders. POA updated by NP and new dressing applied by RN. On 06/25/2026 at 1:55 PM, Braden Scale for Predicting Pressure Ulcer Risk Braden Evaluation: Result: High Risk Score: 12.0. On 07/01/2026 at 3:16 PM, Orders - Administration NoteNote Text: Wound measurements: Left heel and buttocks area. Complete wound documentation on areas of concerns in SKIN assessment every day shift every Wed. The facility did not complete a weekly comprehensive assessment to include description of wound bed, measurements, drainage, and staging. On 07/03/2026 at 10:52 AM, Orders - General Note from eRecordNote Text: wound open area measures 3 x 2.5 cm with active bleeding in lower aspect of approx. size of 1 cm. at 1200 skin is macerated 2 x 3 cm and above this is a dry discolored area. Two areas within the open area, one is white 1 x 1 cm and next to it is 0.5 cm area that is red in center and white edges. Area cleansed and redressed. The facility did not complete a weekly comprehensive assessment to include description of wound bed, measurements, drainage, and staging. On 07/17/2026 at 11:34 AM, Orders - Administration NoteNote Text: Complete MED A charting for resident: include status of resident and any changes in condition or treatment plan. every day shift, resident refusing heel protectors due to how hot it is and they are. Did allow elevation of leg and heels off edge of pillow. On 07/17/2026 at 11:36 AM, Orders - General Note from eRecordNote Text: heel measurement of open area is 2.5 x 1.3 cm and base is shiny red, not surrounding redness but shows healing pink tissue. another open area is 1.5 cm with half of that being a scabbed area. On 07/20/2026 at 2:10 PM, Orders - Administration NoteNote Text: Left heel Treatment1) Cleanse with Vashe wound cleanser2) Skin prep to peri-wound3) Apply Hydofera Blue Ready with slits in the middle and on the outside to overlap wound and conform correctly4) Cover with bordered foam and secure with tape.every day shift every Mon, Wed, Fri for Skin concern. On 07/22/2026 at 2:38 PM, Orders - General Note from eRecordNote Text: area on heel measures 5 cm by 5 cm and has a pink healed base with two open areas within it. Open area measures 1 cm with bleeding and red base. Open area measures 0.5 x 1cm with half base red and half base white. There was seeping of clear fluid from this area. The two open areas are two cm apart with pink healed area between. Cleansed and redressed as ordered. On 07/28/2026 at 9:56 AM, Surveyor interviewed Licensed Practical Nurse (LPN) C about wound assessments. LPN C stated everyone will look at the wound and document in the progress notes. Director of Nursing (DON) B will look at the wound and contact the physician when needed. Will send the resident to the wound clinic when needed. Will chart in the nurse's notes of the measurements, observation of the wound and if worsened. Will let DON B or charge nurse know if there are any changes. Surveyor asked at what stage the wounds were. LPN C stated she can't stage the wound because of being an LPN. Surveyor asked what stage the heel was documented. LPN C stated can't fully recall the stage believes it was stage 3 for the heel. The buttocks was a small open area between buttocks and is healed now with some dry skin. On 07/28/2026 at 11:38 AM, Surveyor interviewed DON B asking about R4's weekly PI assessments. DON B stated R4 returned to the facility on [DATE] and a skin assessment was completed and found no skin issues with the heel. On 05/25/26, R4's Power of Attorney (POA) found the left heel was peeling. R4 has a history of diabetic ulcers. Surveyor asked if R4 had a history of PI to the left heel. DON B stated R4 did not have a history of PI to the left heel. Weekly skin checks are completed. R4 can be non-compliant with positioning. Surveyor asked how often are PI assessments completed. DON B states it should be charting measurement and status of the wound. Facility nurses will not stage a wound and will have the wound clinic or the Nurse Practitioner stage a wound. The wound clinic had staged the left heel as an unstageable deep tissue injury. On 06/10/26, staff notified DON B of the open are to the left heel. When the area gets worse would contact the physician and consult. On 07/06/26, was the first time R4 went to the wound clinic. Can say for certainty that the wound was not a stage 3 and the area had progressed to a stage 2. Weekly diabetic foot checks are completed with weekly skin checks. Per Surveyor findings, the facility does not have any additional wound documentation and only has the weekly narrative charting. Surveyor reviewed with DON B of the charting not being comprehensive with description of the wound and wound bed, type of drainage, consistent measurements, and staging of the wound. DON B stated they don't disagree, the charting could be better. Example 2 R7 admitted to the facility on [DATE], with diagnoses including dementia, pressure ulcer of unspecified buttock stage 2, and type 2 diabetes mellitus. Staff assessment of R7's cognition indicated severe cognitive impairment. R7 was dependent on staff for all Activities of Daily Living (ADLs). R7's Power of Attorney (POA) was activated to assist with decision making. R7's care plan included: -The resident has potential/actual impairment to skin integrity of the face and buttocks related to (r/t) contact dermatitis, fragile skin. Date Initiated: 01/28/2026, revision on: 04/03/2026. - The resident's Skin injury/shearing of the buttocks will be healed by review date. Date Initiated: 01/28/2026, revision on: 01/28/2026, target Date: 10/14/2026. - Follow facility protocols for treatment of injury. Date Initiated: 01/28/2026. - Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs/symptoms (s/sx) of infection, maceration etc. to MD. Date Initiated: 01/28/2026. - The resident needs a ROHO cushion for pressure relief to protect the skin while up in chair. Date Initiated: 01/28/2026, revision on: 01/28/2026. - The resident needs pressure reducing air mattress to protect the skin while in bariatric bed. Date Initiated: 01/28/2026, revision on: 01/28/2026. - Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Date Initiated: 01/28/2026. - Use a draw sheet or lifting device to move resident. Date Initiated: 01/28/2026. R7's progress notes and physician orders included: - 01/19/26-02/24/26, Physician order: Apply bordered foam dressing to buttocks (interdry under foam) change every (q) 3 days and as needed (PRN) one time a day every 3 day(s). -04/16/26, Progress note: Skin/Wound Note Text: small abrasion noted on right buttock, area cleansed, and foam dressing applied. -6/10/2026, Progress note: Skin/Wound Note-Resident with 3cm x 1cm area that is purple in color, was area of shear on right buttock, no open areas or drainage noted, area cleansed with wound cleanser, and foam dressing applied, fax left for providers. -06/10/26-Current, Physician order: Change foam dressing to right buttock every 3 days and PRN for shear area until resolved. -06/11/26, Progress note: Nurse Practitioner (NP) returned fax: Resident has r/t (related to) buttock 3 cm round area that had been a sheer area. We are placing a foam patch on it to change q 3 days. Background: Assessment Registered Nurse (RN)/Appearance Licensed Practical Nurse (LPN): Recommendations: Per NP: OK for foam and update for lack of improvement. - July 2026, Treatment Administration Record (TAR): Routine weekly skin checks every evening shift every Thursday. Measure and document buttock area until resolved -Start Date 03/05/2026. On 07/27/26 at 11:35 AM, Surveyor observed R7 in an exercise activity. Surveyor observed R7 seated in wheelchair with Roho cushion in place. Surveyor interviewed R7's POA (Power of Attorney), with no concern expressed. On 07/27/26, Surveyor noted R7's progress notes read on 06/10/26, resident with 3cm x 1cm area that is purple in color, was area of shear on right buttock, no open areas or drainage noted, area cleansed with wound cleanser, and foam dressing applied, fax left for providers. Surveyor was unable to find weekly wound assessments for R7. On 07/27/26 at approximately 12:30 PM, Surveyor asked licensed nursing staff where weekly wound assessments would be found in a resident's electronic record. Staff replied that Director of Nursing (DON) B would complete weekly wound assessments. On 07/27/26 at 3:15 PM, Surveyor interviewed DON B. DON B reported the facility does not have a wound care nurse and that licensed nursing staff monitors and provides wound care unless directed by provider to be sent to wound clinic for care. DON B stated nurses should be monitoring all wounds with every treatment change in a resident's progress notes. DON B stated R7 has an order to measure and document buttock area until resolved. DON B stated R7's wound started on 03/05/26 and is chronic. DON B stated on 06/10/26, area was not open but discolored. DON B looked in R7's record and read to Surveyor, On 06/10/26, documentation states purple/shearing, not open, no drainage. DON B reported on 06/11/26 that foam dressing was changed but did not state a description or measurements of the wound at that time. DON B stated she would expect staff to be looking at wound when changing preventative foam dressing and to chart any concerns in progress notes. DON B stated she would not expect weekly documentation if wound was not open. DON B stated the shearing was from R7 moving around in bed. DON B looked in R7's record and stated there is documentation in progress notes on R7's wound on 09/09/25, 11/11/25, 11/17/25, and 11/20/25, and stated to Surveyor R7's wound was present on admission. On 07/28/2026 at 9:50 AM, DON B came to Surveyor and stated R7 had the same area since admission on [DATE]. DON B stated they do not think the area has healed since admission. DON B stated the facility does foam treatment as an intervention, so it doesn't open. DON B stated the area is just discoloration, and skin discoloration is monitored with treatments. Surveyor asked DON B what type of injury R7's wound was, DON B stated it is not a wound because it is not open. DON B stated they are not a wound care nurse. Surveyor stated the documentation indicated area was caused by shearing. DON B stated they do not think the area is shearing and that would be the nurse's perception, who documented it as shearing. On 07/28/2026 at 11:56 AM, Surveyor interviewed Certified Nursing Assistant (CNA) D. CNA D stated R7 does have an area on their buttock that is oval in shape, (held up her fingers to show approximate size). CNA D stated they do not know what R7's wound is but thinks it is skin breakdown from R7 sitting on their butt. CNA D stated R7 does sit in their chair a lot. CNA D stated nurses change dressing to R7's buttock. On 07/28/2026 at 12:14 PM, Surveyor interviewed Registered Nurse (RN) E. RN E stated R7 has had the area on their buttock for a while. RN E stated staff would document measurements and description of wound when it is more open. RN E stated R7's wound opens and closes but stated they are not sure what R7's wound looked like currently. RN E stated they were not sure if the area was from pressure, but staff get an order for foam border treatment when it is more open, like a few layers of the epidermis. Due to lack of weekly comprehensive skin assessments, type of wound was undetermined, if the wound was present on admission, if R7 had consistent treatments, or if R7's wound healed and re-opened.

Based on interview, record review and facility policy review, the facility failed to ensure a complete and accurate medical record for 2 of 3 residents (R) reviewed. (R4 and R2)The facility failed to completely describe an accurate description of a fall and document immediate interventions to protect R4 and R2. This is evidenced by: Facility's policy titled Fall Assessment for Injury with review date of 07/09/26 documented: Document the incident and outcome in the resident's EMAR including all relevant post-fall clinical findings, such as vital signs, pain, swelling, bruising, body positioning, environmental surroundings, possible cause and changes in function or cognitive status. Update a fall risk assessment and the residents care plan with intervention[s] to prevent reoccurrence. Example 1 R4 was admitted to the facility on [DATE]. R4's current diagnosis includes fracture of neck of left femur, type 2 diabetes mellitus, acquired absence of right foot, and dementia. On 06/12/26, the Minimum Data Set (MDS) assessment documented R4's Brief Interview for Mental Status (BIMS) score of 10/15, meaning moderately impaired cognition. R4's progress notes documented on 03/31/2026 at 09:23, COMMUNICATION - with Physician Situation: Resident slid out of bed this morning, no noted injury. Dr. [Name] here on rounds. Updated MD. OK to d/c (discontinue) neuro checks. Progress notes on 05/12/2026 at 11:00, Order Note Text: ok to d/c (discontinue) neuros d/t (due to) fall by sliding off side of bed. Progress notes on 05/12/26 at 12:50 PM and on 05/13/26 at 12:44 PM documented fall risk evaluations were completed with no documentation to when falls occurred or descriptions of the event. Progress notes on 06/2/2026 at 07:23 AM, Orders - General Note from eRecord, Note Text: no s/s (signs/symptoms) of pain. noted resident lying in bed on back with left leg extended off bottom of bed and right leg pulled up on the bed. Asked if he had pain and response was yes 7 all over left hip. Refused offer of going to hospital to be checked out. Stated yes when asked if he would please call for assist if he wanted to stand or go to bathroom. Stated I tripped when asked what happened causing him to fall. There appears to be no items misplaced in room at this time which would cause a tripping hazard. Call light in place. Progress notes on 06/02/2026 at 10:15 AM, Orders - General Note from eRecord Note Text: resident continues to say no to going to doctors and yes to pain. Had a fall on noc shift. Progress notes on 06/05/26 at 10:53 AM, 06/11/26 at 3:28 PM, and on 06/28/26 at 1:19 AM documented fall risk evaluations were completed with no documentation about when falls occurred or descriptions of the event. On 07/27/26 at 1:36 PM, Surveyor requested R4's fall investigations from Director of Nursing (DON) B. On 07/27/26 at 2:30 PM, DON B provided copies of the fall investigation and stated the investigations are not part of the resident's medical record, they are part of risk management and are to be returned to the facility. Review of the risk management fall investigations documented falls occurring on 05/12/26 at 7:45 AM, 06/02/26 at 4:44 AM, 06/02/26 at 4:44 AM, 06/27/26 at 9:30 AM. On 07/28/2026 at 9:56 AM, Surveyor interviewed Licensed Practical Nurse (LPN) C asking where fall process of charting is located. LPN C stated when called to a resident's room nurse will assess the resident and do an assessment of the room. Nurses will obtain vitals, assess for pain, and assess the resident's skin. We ask the resident what happened. If the resident hit their head, we do neuro checks for 24 hours or until the physician discontinues. LPN C stated we notify the physician and Power of Attorney (POA) and/or family. The fall is charted in risk management not in the progress notes. LPN C stated we monitor the resident for 3 days every shift and check vital signs and skin. The Certified Nursing Assistant (CNA) writes a statement on paper and gives the statement to DON B. On 07/28/26 at 12:10 PM, Surveyor interviewed DON B asking if the risk management fall investigation is part of the resident's medical record. DON B stated the fall investigation is only risk management and does not go into the resident's medical record. Staff are to document the fall in the computer under risk management. Surveyor asked if the R4's progress notes document a full description of the fall event with the date, time, location, possible causes, position of resident, injuries, assessment, and interventions. DON B stated when a new intervention is put into place, we notify staff and update the care plan. DON B stated the management team, every day in morning meeting, talk about the residents. Surveyor asked if this is documented in the resident's medical record. DON B stated no but we have notes on what the staff talked about. Surveyor asked if those notes were put in the resident's medical record. DON B stated no. Surveyor asked if R4's medical record is complete and accurate if the fall events are not recorded in R4's medical record, for example on 06/27/26, R4's medical record does not document a fall occurred. DON B stated they are working on a new computer system and now are being penalized for not putting things in the right place. DON B stated in the old system we did not document everything about the fall in the medical record. Surveyor explained that the resident's medical record is to be complete and accurate to the events that occurred while residing in the facility. Example 2 R2 was admitted to the facility on [DATE], after hospitalization for fall with hip fracture requiring surgical intervention. R2 scored 07/15 during Brief Interview for Mental Status (BIMS) which indicated severe cognitive impairment. R2's care plan included: -03/26/26, the resident is high risk for falls r/t confusion. Interventions: Ensure that the resident is wearing appropriate footwear/non-skid socks when. Follow facility fall protocol. PT (Physical Therapy) evaluation and treat as ordered. - 03/30/26, the resident has had an actual fall. Interventions: Continue interventions on the at-risk plan. Monitor/document /report PRN (as needed) x 72h to MD for s/sx (signs/symptoms) Pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation. PT (Physical Therapy) consult for strength and mobility. Surveyor was unable to find documentation in R2's record of fall on 03/28/26. Surveyor requested documentation of R2's fall on 03/28/26. DON B provided the facility's fall investigation. DON B stated the document was in risk management, and in the past, Surveyors have not taken fall risk investigations from the facility. Note, the document states on the bottom, Privileged and confidential. Not part of the medical record, do not copy test. On 03/28/26, facility fall investigation states: responded to resident's call light. Resident was sitting on the floor with back against the bed and walker nearby, stated slipped off the bed while trying to get up and go to the BR (bathroom) Resident denied pain and denied hitting head, stating I barely even hit the floor. Immediate action: Writer and two CNAs used Hoyer lift to transfer resident to bed. No bruising noted to right hip or bottom or head. Resident was reminded to wait for staff to assist before attempting to get out of bed or walk. Resident repeatedly stated they would not attempt to walk anymore. Neuro checks were WNL (within normal limits) and VSS (vital signs stable). Reminded to wait for staff. Other info: New admission, poor cognition. Statements: No statements found. On 03/30/26, R2's care plan was updated: Monitor/document /report PRN x 72h to MD for s/sx: Pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation. Surveyor noted a progress note in R2's record on 04/19/26. Progress note: Notified RN on call of resident's fall at 05:25. Updated [son] on fall and transfer to ER, for evaluation of Rt. (right) hip hematoma and pain. He will notify his brothers. Surveyor requested documentation of R2's fall on 04/19/26. DON B provided facility's fall investigation. DON B stated document was in risk management, and in the past, Surveyors have not taken fall risk investigations from the facility. Note, the document states on the bottom, Privileged and confidential. Not part of the medical record, do not copy test. -04/19/26, Facility fall investigation: 4/19/26 at 5:15 AM, found resident sitting on the floor next to bed, had unplugged bed alarm and tried to get up. Denies hitting head, stated fell on R (right) hip, large swollen area to previous incision site. C/o (complained of) of increased pain, stated, I was trying to go to the BR (bathroom). Immediate action: Transferred back to bed via Hoyer lift. ER physician notified, to transport to ER for evaluation. Sent to ER for evaluation. Injuries: Hematoma right hip Other info: R unplugged alarm. Statements: No statements found. ER X-ray determined no fx (fracture). On 04/20/26, R2's care plan was updated: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Has reminder sign in room to use call light. Surveyor noted a progress note in R2's record on 05/02/26. Progress note: 05/02/26, Returned from ER; no acute fracture, per X-rays. Having increased pain Rt. hip with transfer to the bathroom, clutching leg, having difficulty standing. PRN pain medication given. Surveyor requested documentation of R2's fall on 05/02/26. DON B provided facility's fall investigation. DON B stated document was in risk management, and in the past, Surveyors have not taken fall risk investigations from the facility. Note, the document states on the bottom, Privileged and confidential. Not part of the medical record, do not copy test. 05/02/26, Facility fall investigation: CNA heard crash and moaning, resident found on floor in room, in front of BR. Bed and chair alarm were both plugged in and on but not sounding. Resident admits to turning them off at times. Resident appeared angry, stating, I can't do anything by myself, it doesn't matter, I can't do anything by myself, I can't even go to the bathroom. Immediate action: States hip hurt but declined to go to the hospital. Resident stated hip always hurts. Neuro checks and VS WNL. Resident was assisted into bed with Hoyer lift and two staff. On call hospitalist and POA contacted and requested that resident be sent to ER. Post Incident injuries: Fracture, r hip. Notes, resident was sent back to ER d/t continued uncontrolled pain, CT scan completed this ER visit shows acute fracture x-ray did not show on last ER visit. Other info: Resident turned off alarm. ER, X-ray determined no fracture. On 05/04/26, R2's care plan was updated: The resident uses chair/bed electronic alarm. Ensure the device is placed in a location where resident cannot reach them and turn them off. Surveyor noted progress note on 05/04/26, Progress note: message left for POA to update that resident is being brought to ER again for another evaluation given ongoing right hip pain from fall over weekend. Waiting for return call back. ER phoned nursing home to provide update on resident. They were currently loading resident into ambulance to transfer to hospital due to right femur fracture. On 07/27/2026 at 3:15 PM, Surveyor interviewed DON B. DON B stated the documents she provided were the falls investigation. Note, DON B provided paper documents but stated in the past Surveyors have not taken these documents from the facility, therefore she did not want to provide copies. DON B stated the facility switched electronic health record systems on 03/01/26, DON B stated she has started adding information to the falls investigations later and not right away as she is still learning the new system. DON B reported that she updated the care plan after each fall. DON B reported the facility IDT (Interdisciplinary team) meets every morning M-F (Monday - Friday) to discuss any concerns, and any fall would be included in that meeting. The team would discuss appropriate interventions and root cause analysis. DON B did not provide further evidence of investigating falls.

Based on observation, policy review and interview, the facility did not ensure food was stored, prepared, and served with proper food handling practices to prevent the outbreak of foodborne illness. This has the potential to affect all 44 residents (R) residing in the facility. 1. Staff did not follow safe food cooling protocols. Staff did not monitor and document cooling temperatures. Hot food was mixed with cool food, increasing risk for harmful bacteria growth in the leftovers.2. The dry storage area and kitchen cooler contained multiple food items not labeled with open or use-by dates. Bulk food removed from original packaging and not labeled with date or use by dates. 3. An employee walked through the kitchen with no hairnet4. Staff did not follow accepted standards of practice for taking food temperatures consistently and documenting cooked food temperatures, ensuring food is held safe temperatures while being served.5. Staff did not ensure cross contamination was prevented. Staff handled clean dishes with contaminated clothes.Findings include:According to Wisconsin Food Code, section 3-501.16, It is prohibited to mix hot food with cooled leftovers in a single container for storage. The primary reason for this rule is to prevent the temperature of the cold leftovers from rising back into the temperature danger zone (41-135 F), where harmful bacteria can multiply rapidly. The facility policy, titled Leftover, reviewed last 4/18/25, states: To store leftover food properly under sanitary conditions to prevent food borne illness.-Refrigerate or Freeze leftover within 2 hours .-Leftover can be kept in the refrigerator for 7 days at 41 and then must be eaten or placed in freezer.The facility policy, titled Food Temperatures, reviewed last 1/21/25, states .Acceptable Holding Temperatures.-Foods must be cooled for 135 F to 70 F within 2 hours; from 70 F to 41 F within 4 hours; the total time for cooling from 134 F to 41 F and should not exceed 6 hours; temperatures must be documented.Example 1On 9/22/25 at 8:19 AM, during initial tour, Surveyor observed multiple containers of leftovers. Dietary Manager (DM) D stated cooks would not use food without looking at dates. DM D started pulling things off the shelf and taking food out of the cooler. DM D stated DM D typically has cooks use food in 2-3 days or food is discarded. The following items fall outside the facility's date range for left-over use policy of 7 days. (9/15/25) -Mashed potatoes 9/14/25-Corn - no label (on menu 9/10/25)-Baked potatoes - no label (on menu 9/14/25) -Red noodle mixture - no label - DM called it casserole - unable to identify what its date is per menu calendar.On 09/23/25 at 12:50 PM, Surveyor observed [NAME] (CK) G put away leftovers. CK G brought food back from the kitchenette 1 on a 3 tier open non-heated cart. Surveyor observed CK G pull tall see through plastic containers from the cooler with food already in them. They were labeled with the item and today's date, from another kitchenette not identified on the label. CK G proceeded to add food just taken from kitchenette 1's steamless heating table, with the food already cooling in the containers. After observing CK G put the veggies and meat gravy main course into containers with their like food, Surveyor asked CK G to temp the rice from kitchenette 1 and the rice from the cooler. The rice from kitchenette 1 was 139 F and the rice from the cooler in the storage container was 124 F. After taking the rice's temperature, CK G put the warmer rice with the rice from the cooler and put containers back in the cooler with lid ajar (tented). CK G only temped the rice and did not record this temp on a log. On 9/23/25 at 12:53 PM, Surveyor interviewed CK G who stated they put food in containers as it comes back and place in the cooler. The container is tented, and the night shift covers them completely when it is cool.On 9/23/25 at 12:55 PM, the final kitchenette's food was brought back into the kitchen via the 3 tier open non-heated cart. CK G pulled the containers back out of the cooler and proceeded to mix the food that just came back from the warming steamless tables with food from the cooler. CK G combined the rice and then veggies without getting a temperature. Surveyor asked if CK G would get the temperature of the meat and gravy before CK G mixed them. The meat and gravy returning to the kitchen was 161 F and the meat and gravy from the cooler was 124 F. CK G proceeded to add the meat together and put all items back in the cooler with lids ajar. No other temperatures were taken. The temperatures the Surveyor asked to be taken were not recorded or logged. Surveyor observed the container was 1/3 to 1/2 full. On 9/24/25 at 10:23 AM, Surveyor interviewed DM D who stated we follow Wisconsin Food Code. DM D stated that after we serve lunch, we will try to save what we can, put in a container, label and date. Let it cool down in the cooler. DM D stated leftovers are used within 2-3 days, if possible; leftovers are used for the PM snack. Surveyor asked if leftovers from each kitchen should be put in one container. DM D stated no they should be put in separate containers labeled kitchenette (K) K1, K2, K3. DM D stated if you mix it all together there is risk of a food borne illness. If K1 is a different temperature and it is put together there could be a food borne illness and it contaminates the whole batch. Example 2 According to Food Code and Federal regulations CMS F812, foods in nursing home storage needs to be labeled with a received date or a similar date like a use by or made on date.The facility policy, titled Food Storage, reviewed 4/18/25, states: Policy: to store, prepare, distribute and serve food under sanitary conditions to prevent food borne illness.Procedure: .-Food items will be dated when opened and discarded when expired.-Food items removed from original container will be labeled (identified), dated, and discarded when expired.On 9/22/25 during the initial kitchen tour that began at 8:16 AM, Surveyor observed the following undated items:In kitchen cooler there were:-Chicken patties - open, not labeled with open date or use by date.-Commercial size BBQ sauce, no open date or use by date.-Commercial size French dressing, no open date or use by date.-Frozen bag of food on bottom shelf, not open but no manufacturer food label or dates. No label of when taken out of freezer on product or bin it was being kept in. DM D stated it was chicken soup.-Square tube of meat, not open but no manufacturer food label or dates. DM D stated it was precooked ham patties.-None of the manufacturer packaging or the shipping/bulk box, had a label on when it was received or placed in the cooler, or visual identifier in what order to use what.In kitchen cook's area there was:-Oatmeal container, not labeled with open date or use by date.In cook's cooler there was:-Frosted crackers, not labeled or dated. DM D stated they are for snack today. In downstairs dry storage there was:-Cereal in waxy plastic bags lying on the shelves, no manufacturer's food label, dates or lot. DM D identified the bags as Chex and [NAME] Krispies. DM D stated, I used to keep in box, but it took up so much room. Bags were not labeled with received date either.-5 bins with Chef's Brand 24 oz size foil like bags of blueberry gelatin, orange gelatin, cherry gelatin, whipped topping mix, chocolate pudding. DM D stated it was removed from bulk packaging and put in bins for storage purposes. Food bags had a manufacturer's label identifying what the food product was. Surveyor asked DM D to find an expiration date or lot number. DM could not find a date or lot number on any of the food bags. There was no facility created label with date of receipt or a use by date. On 9/23/25 at 7:25 AM, Surveyor made the following observation during kitchen follow up tour,In kitchen cooler:-Frozen meat in tub on bottom shelf with no manufacturer's label, no label on container with date removed from freezer or use by date. DM D stated it was hamburger.On 9/22/25 at 8:32 AM, Surveyor interviewed DM D who stated we followed the manufacturer's dates on their labels. Surveyor asked how do you know what to use first if they do not have dates. DM D stated we can also look up lot numbers for dates. DM D stated all items are used first come first use or old is placed in front and new in the back when put away. DM D stated we go through food so quickly. 9/24/25 at 10:21 AM, DM D stated DM D's expectation is that staff label anything they prepare and put in the fridge for leftovers, and to follow the expiration dates.Example 3According to Section 2-402.11 of the FDA Food Code, Food employees are required to wear hair restraints such as hats, hair coverings, nets, beard restraints, and clothing that covers all body hair to prevent hair from contacting exposed food, clean equipment, and utensils. Per Wisconsin Food Code [NAME] restraint rule: Unlike head hair, the code is specific about facial hair Effective restraints must be worn for beards longer than 1/2 inch in food processing areas. On 09/23/25 at 1:26 PM, Surveyor observed Maintenance Supervisor (MS) E walk into the main kitchen with MS E's hair net on MS E's head like a beanie. MS E also had a full beard, greater than a 1/2 inch in length and no beard net. CK G noticed MS E's hair net and told him to straighten it. MS E stated he had no hair back there but adjusted his hair net to cover to the nape of his neck, and his entire head of hair. MS E turned to go back to MS E's task. Surveyor asked MS E if he had any other hair to cover. MS E said Oh and pulled the hair net completely over his head, face and beard. MS E then walked back to the entry way open door and looked at wall. MS E said MS E did not think we (the facility) had anything for MS E 's beard. MS E stated MS E does not usually come in here, his coworker does, and his coworker doesn't have a beard. MS E came back into the kitchen, straightened MS E's hair net on MS E's head so it was no longer covering MS E's face and beard and continued tour with Life Safety Surveyor. On 9/24/25 at 10:08 AM, Surveyor interviewed DM D who stated yes, we have beard nets. Surveyor informed DM D about MS E entering kitchen without a beard net on yesterday. DM D stated MS E does not come through the kitchen often. DM D stated MS E knows MS E should wear a hair and beard net. DM D stated everyone that comes into the kitchen should have a hair net on most definitely. We have a ton of beard nets and MS E knows it.Example 4According to Food and Drug Administration Food Code, section 3-401.12 Records, Creation, and Retention: Records must be maintained to verify that the critical limits required for food safety are being met. It is standard practice to maintain temperature logs to document when food temperatures are checked and to ensure compliance with federal and state regulations, State 483.60.The facility policy, titled Food Temperatures, reviewed last 1/21/25, states: -Dietary staff will be trained in food safety practice and preparation to ensure that food is palatable, attractive and at the proper temperature. The Dietary manager will monitor this protocol, review temperature logs and report any negative findings to the facility Quality and Assurance Performance Improvement Committee. -Before taking food out of the main kitchen to the household hot well dining rooms, the cook will use a calibrated thermometer to check whether meat has reached a safe internal temperature.-This process will be repeated prior to serving from the hot wells in each household for all meals to ensure appropriate holding temperature.-Staff will record each food item temperature on the appropriate log.On 9/23/25 at 11:31 AM, Surveyor observed kitchen staff prepare to take food temperatures for lunch meal. CK G stated CK G already took temperatures when food came out of the oven. All food was in metal pans, covered and sitting on stove top. CK G said CK G has to take food temperatures before food leaves the kitchen. Surveyor observed food temperatures taken and food being placed on a 3 tier open non heated cart used to bring food to kitchenettes. All food for K1, K3 and then K2 had its temperature taken and placed on its kitchenette's cart. When asked,CK G stated she already took the temperature of food when it came out of the oven. CK G did not record any temperatures taken with Surveyor before leaving kitchen at 11:49 AM. On 9/23/25 at 11:50 AM, Surveyor observed the kitchen temperature log with CK F. CK F showed how the log was split into sections, breakfast, lunch, dinner and that only one set of temperatures were recorded in each section. CK F stated we record the temperature of the food when it comes out of the oven only. Temperatures for 9/23/25 lunch was on log. CK F stated CK F takes temperatures of food when it comes out of the oven and before it leaves the kitchen; this is often the same time. CK F says CK F takes it again before CK F serves the food in the dining room.On 9/23/25 at 12:21 PM, Surveyor observed CK G serving food in Kitchenette #1. Surveyor asked CK G if CK G took the temperature of the food before CK G served it. CK G said CK G did not take temperatures again before serving. CK G stated CK G has done it enough to know it will hold the temperature. CK G stated CK G does not need to take temperature again if it is the right temperature when it leaves the kitchen. CK G stated the steamless warming table will hold the temperature. On 9/23/25 at 12:21 PM, Surveyor asked to see the temperature log for the kitchenette #1. CK G said there are no food temperature logs on the kitchenettes. On 9/23/25 at 12:21 PM, Surveyor observe staff struggle with finding a thermometer in kitchenette 1 where all residents were already eating food. Surveyor asked CK G to get the temperature of the meat and gravy before CK G served it. CK G stated CK G did not think there were thermometers in the kitchenettes. CK G had to open 4 drawers before CK G found a thermometer in the back of the drawer. CK G did not wipe the thermometer before taking the temperature. Meat and gravy temperature was 150 F. Surveyor had observed meat and gravy's temperature at 178 F when it left the kitchen.On 9/23/25 at12:33 PM, Surveyor observed CK F serve in kitchenette #2. Prior to CK F serving food, CK F looked for a thermometer in all the drawers. No thermometer in kitchenette, CK F went back to kitchen to get one. CK F came back to kitchenette with thermometer, took food temperatures, did not write any down. CK F stated the only temperature log is in the kitchen.On 9/24/25 at 10:22 AM, Surveyor interviewed DM D who stated food is to be temped before it leaves the kitchen and before it is served. DM stated there are thermometers in the kitchenettes. Food temps should be taken before serving and at end to make sure it held temperature the whole time. DM D stated all temperatures should be recorded but they haven't been. DM D stated DM D needs to come up with a new form so they (the cooks) can record temps when they get temps for food served and before it leaves the kitchenette.Example 5 The facility policy, title Food Serving, last reviewed 4/23/25, states: 8. Be mindful that the last plate served should be the same quality as the first.Food Code, section 2-304.11 states, Food employees shall wear clean outer clothing to prevent contamination of food, equipment, utensils, linens, and single-service and single-use articles .On 9/23/25 at 8:58 AM, Surveyor observed Dietary Aide (DA) H in kitchenette # 1 begin to clean up after breakfast. DA H was leaning over sink, soaking utensils in a bucket. When DA H stood up DA H's shirt showed wet spots and food debris. DA H stated DA H wore gloves to rinse dirty dishes before they were put in the dishwasher. DA H stated DA H does not wear anything else while doing dirty dishes. DA H stated DA H washes DA H's hands before DA H puts the clean dishes away. DA H stated when DA H is done cleaning up, DA H will go back to the kitchen to put together the dessert cart.On 9/23/25 at 9:12 AM, Surveyor observed DA H put clean dishes away wearing the same contaminated clothing DA H washed dishes with. No barrier between clean and dirty. On 9/23/25 at 10:15 AM when Surveyor entered the kitchen, Surveyor observed DA H was putting desserts on a cart with the same contaminated clothing and no apron to cover. On 9/23/25 at 1:24 PM, Surveyor observed CK G do dishes in the kitchen. CK G was only wearing gloves as CK G rinsed a pan with gravy. Surveyor observed the dirty rinse water spray up onto CK G's shirt. CK G put together a rack of dirty dishes and tried to push it into the dishwasher. The rack would not budge as the aisle was full and there was no room for dishes to move. CK G washed CK G's hands and went to the clean side to empty a rack of clean dishes to the drying cart. CK G did not have an apron while cleaning dirty dishes, nor did she put a clean one on before handling the clean dishes. CK G touched clean dishes with contaminated clothing.On 9/23/25 at 1:25 PM, Surveyor interviewed CK G who stated CK G has gloves for when CK G cleans dirty dishes. CK G stated CK G just need to wash CK G's hands before putting clean dishes away. On 9/24/25 at 10:22 AM, Surveyor interviewed DM D who stated when doing dishes there should be a clean side and a dirty side. Staff should wash hands before they take clean dishes out of the dishwasher; it should be same with kitchenettes. DM D stated one person should not be doing both washing of dishes and putting clean away at the same time; it might cause cross contamination. DM D stated DM D's expectation is that staff do not have to wear gloves when doing dirty dishes; they must wash their hands before they handle clean dishes and wear a hair net obviously. DM D stated yes, DM guesses there would be risk for cross contamination if clothes got dirty doing dishes and then you went and cooked or put away clean dishes.

Based on observation, interview and record review, the facility did not ensure its medication error rate was less than 5%. The facility medication error rate was 5.88%.Licensed Practical Nurse (LPN) C administered insulin in deltoid muscle instead of subcutaneous tissue per physician order.According to Diabetes Strong article, dated 07/02/24, indicated, Why it matters where you inject your insulin. Insulin is designed to be injected (or delivered via an insulin pump) into body fat - also known as subcutaneous tissue. The rate at which your insulin is absorbed is largely based on the assumption that it's being injected into fat, rather than muscle. When a pharmaceutical company tells you that the onset of your Novolog or Humalog insulin is 15 minutes, for example, that is based on when it is injected into body fat. The peak of its efficacy and the duration of it staying in your bloodstream also depends on it being injected into body fat - not muscle. R17 was admitted to the facility on [DATE] with diagnoses that include type 2 diabetes mellitus. R17's physician's orders stated, Insulin Glargine 100/UNIT/ML 14 units sub-Q daily and Novolog (Aspart) 100 unit/ml inject variable doses (per sliding scale) sub-Q three times a day. On 09/23/25 at 7:19 AM, Surveyor observed LPN C administer Lantus (glargine) insulin 14 units in the left deltoid muscle and Aspart insulin 2 units into the right deltoid muscle of R17. On 09/23/2025 at 11:46 AM, Surveyor interviewed Director of Nursing (DON) B and asked where on the body staff would be expected to administer insulin. DON B stated it should be in the fattier subcutaneous areas. DON B was informed of the observation and stated, It is not our typical practice to administer insulin in the deltoid region. The nurse did not follow standards of practice.

Based on interview and record review, the facility did not ensure a thorough investigation was conducted to prevent further abuse for 1 of 3 residents (R) R2 reviewed for abuse. -The facility did not thoroughly investigate to rule out abuse to other residents. No interviews were conducted with other residents to ensure there had been no further incidents of abuse. Findings include: The facility policy titled, Abuse Prevention/ Resident Safety that was reviewed on 04/15/24, states, in part: Response Upon receiving information concerning a report of abuse, the administrator, or designee, will immediately initiate a thorough investigation to include the following details of the incident: In the event of a Resident-to-Resident altercation, staff will implement the following: 3. Conduct an internal investigation to include investigating the situation, including identification of witnesses, interviewing people involved or with knowledge of the situation. R2 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's, anxiety, and localized edema. R2 was not considered their own person and had an activated POA. The facility determined that R2 was no longer able to consent for sexual interactions. R2's most recent MDS performed on 12/17/24 indicated that R2 had a brief interview for mental status (BIMS) score of 4 out of 15, which indicates cognitive impairment. R1 is a member of the assisted living community that is attached to the skilled nursing facility. Members of the assisted living community utilize a dining area that is located on the skilled nursing side of the building. Members of the assisted living community also attend activities on the skilled nursing facility community areas. Surveyor reviewed the facility's investigation, completed on 01/10/25, into the sexual abuse of R1 to R2. On 01/06/25, R1 kissed R2 on the mouth without proper consent. The facility did not have any documentation in which other residents that R1 would have had access to were interviewed. There was no evidence in the report that the facility had ensured other residents had no contact with R1. On 01/23/24 at 11:07 AM, Surveyor interviewed R3 and asked if the facility had approached them in the last month and done any type of interviewing regarding other residents. R3 said they had not. On 01/23/24 at 11:07 AM, Surveyor interviewed R4 and asked if the facility had approached them in the last month and done any type of interviewing regarding other residents. R4 said they had not. On 01/23/24 at 12:32 PM, Surveyor interviewed Director of Nursing (DON) B regarding the investigation into R1 kissing R2 on the mouth. DOB B explained that R1 had a history with another resident and during that relationship R1 and the other resident needed to stop seeing each other due to a reduction in cognition level of the other resident. R1 understood and then sometime later the relationship with R2 started and they believed that they knew R1's patterns and that R1 gave no indication that they needed to investigate other residents. They had never seen R1 in another resident's room although he did visit a male friend from time to time who lived in the skilled nursing facility. DON B believed that R1 was not left alone in the long-term care, and they had not seen R1 entering other female residents' rooms. On 01/23/24 at 12:45 PM, Surveyor interviewed Nursing Home Administrator (NHA) A regarding the investigation and missing resident interviews. When asked if the facility interviewed residents to ensure no one else was affected or targeted, NHA A said no they didn't. NHA A reiterated they did not feel it was necessary in this situation. They removed R1 immediately and did not allow them back to the skilled nursing facility. NHA A also said they knew R1's history and tendencies, and due to that they felt the residents were safe.

Based on observation, interview and record review, the facility did not prepare, distribute, and serve food in accordance with professional standards for food service safety. Staff touched ready-to-eat foods with bare hands and did not perform hand hygiene. This affected 5 of 21 residents (R) served meals from the 100-hall dining room. (R94, R32, R21, R35, and R31). Staff touched ready-to-eat biscuits with contaminated bare hands and served to residents on the 100-hall. Staff performed inadequate hand hygiene during breakfast service and clean up in the dining room on the 100-hall. Findings include: FDA Food Code 2022 states in part, 3-301.11 Preventing Contamination from Hands. In November 1999, the National Advisory Committee on Microbiological Criteria for Foods (NACMCF) concluded that bare hand contact with ready-to-eat foods can contribute to the transmission of foodborne illness and agreed that the transmission could be interrupted .The three interdependent critical factors in reducing foodborne illness transmitted through the fecal-oral route, identified by the NACMCF, include exclusion/restriction of ill food workers; proper handwashing; and no bare hand contact with ready-to-eat foods. Facility policy entitled, Bare Hand Contact with Food and Use of Plastic Gloves, states in part: Single-use gloves will be worn when handling food directly with hands to assure that bacteria are not transferred from the food handlers' hands to the food product being served. Bare hand contact with food is prohibited . Facility policy entitled, Hand Hygiene Policy and Procedure, states in part, .Procedure: 1. Hand washing with soap: a. Push up long sleeves. b. Wet hands with running water. c. Apply hand-washing agent and thoroughly disperse over hands. d. Vigorously rub hands together for 15-20 seconds generating friction on all surfaces including under fingernails. e. Rinse thoroughly with arms extended downward. f. Pat dry thoroughly with a paper towel to shut off the faucet . On 06/19/24 at 8:33 AM, Surveyor observed Dietary Aide (DA) C serve breakfast in the 100-hall dining room. Surveyor observed DA C pick up a biscuit with bare hands, cut it in half, and place on a plate. DA C ladled gravy over the biscuit and served it to R94. At 8:35 AM, Surveyor observed DA C wipe hands on the sides of uniform top and take two pieces of toast out of the toaster with bare hands. DA C held the toast in the palm of one hand to butter it. DA C placed the toast on a plate, held the pieces with one bare hand and cut the slices. DA C then served to the toast to R32. DA C picked up some dirty dishes from the table and placed them on the counter by the sink. DA C did not wash hands after handling dirty dishes. DA C wiped hands on the side of uniform top, reached into a bread bag with bare hands, and took out two pieces of bread. DA C placed the bread in the toaster. At 8:44 AM, DA C took the toast out of the toaster with bare hands and held the toast to put butter and jelly on it. DA C held the toast with one bare hand and cut the slices. DA C served the toast to R94. On 06/19/24 at 8:47 AM, Surveyor observed DA C take a cart and pick up dirty dishes from tables in the dining room. DA C rinsed the dishes in the sink and placed them in the dishwasher. DA C did not wash hands after handling dirty dishes. DA C then put food and beverage containers back in the refrigerator. DA C took a cloth out of a blue bucket and wiped counters and a cart. DA C placed the cloth back in the blue bucket. DA C did not wash hands. DA C placed two trays on the cart. DA C took bread out of a bag with bare hands and put it in the toaster. DA C took two plates out of the cupboard and placed on the counter. DA C took pitchers out of the refrigerator, poured milk and orange juice in cups, placed covers on the cups, and placed them on the trays. DA C picked up a biscuit with bare hands, cut it, placed it on the plate, ladled gravy over it, and placed it on a tray on the cart. DA C took toast out of the toaster with bare hands, held it to put butter and jelly on, cut it, and placed it on a plate. DA C wiped hands on shirt. DA C washed hands in the sink for 2 seconds, turned off the faucet with bare hands, and dried hands on a cloth towel that was lying on the counter. DA C took the cart with covered trays and served to R21 and R35 in their rooms. On 06/19/24 at 9:11 AM, Surveyor observed DA C wiping tables in the 100-hall dining room with a cloth from a blue bucket. DA C picked up dirty dishes from the tables and placed them on the counter in the kitchen. DA C did not wash hands after wiping tables and handling dirty dishes. DA C then took a clean plate out of the cupboard, picked up a biscuit with bare hands, cut it, and placed it on the plate. DA C put gravy on the biscuit, poured milk and juice in cups and served the food to R31 in the 100 hall dining room. DA C picked up dirty dishes from a table and placed them on the counter. DA C did not wash hands after touching dirty dishes. DA C took a clean cup and filled with coffee. DA C opened a sugar packet and poured into the coffee cup. DA C stirred with a spoon and served the coffee to R31. On 06/19/24 at 9:22 AM, Surveyor interviewed DA C and asked their normal procedure for handling ready-to-eat foods such as biscuits or toast. DA C stated we use tongs to pick those up. Surveyor asked DA C if they did that today during breakfast service. DA C stated they did when first starting service, but when it got so busy they didn't use the tongs and just picked up the toast and biscuits with bare hands. On 06/19/24 at 9:25 AM, Surveyor observed DA C place dirty dishes from the tables on the counter. DA C did not wash hands after handling dirty dishes. DA C then began taking clean dishes out of the dishwasher and stacking them in the cupboard. On 06/19/24 at 10:42 AM, Surveyor interviewed Dietary Manager (DM) E and described the above observations and interview with DA C. Surveyor asked DM E if DA C was following facility policy or FDA Food Code for safe handling of food. DM E stated DA C had been educated about hand hygiene and no bare hand touching of ready-to-eat foods, but DA C did not follow policy on the above observations. DM E stated they would expect staff to wash hands when moving from dirty tasks to clean tasks. DM E stated they would expect staff to use tongs to touch ready-to-eat foods.

Based on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Staff did not perform hand hygiene between glove changes during wound care and during bathing observations for 2 of 2 observations. (R25 and R11) Findings include: Facility policy and procedure entitled, Hand Hygiene Policy and Procedure, states in part, .Hand hygiene must be performed .immediately after gloves are removed . On 06/18/24 at 9:25 AM, Registered Nurse (RN) D stated R25 had chronic Moisture Associated Skin Damage (MASD) to buttocks, and they would be doing wound care after a bath today. On 06/18/24 at 1:46 PM, Surveyor observed RN D perform wound care on R25's bottom after a bath. RN D used hand sanitizer and entered R25's room. RN D put on a gown and gloves and stated R25 was on enhanced barrier precautions due to chronic open wounds. RN D gathered supplies from the closet and placed on a waterproof barrier at the bedside. Two Certified Nursing Assistants (CNAs) lifted R25 to a standing position with a mechanical lift. RN D removed the old dressing from the back of R25's right upper thigh. RN D cleaned the area with wound cleanser and gauze and patted dry. RN D removed their gloves and put on clean gloves without using hand sanitizer or washing hands. RN D applied a new dressing to the back of the right thigh. RN D removed their gloves and put on clean gloves without washing hands or using hand sanitizer. RN D applied skin barrier powder to excoriated areas on buttocks and left thigh and then sprayed with skin barrier spray to create a crust over the excoriated areas. One of the CNAs informed RN D they had observed a new red area in a crease on the right side of R25's neck during bath. RN D removed old gloves and put on clean gloves without using hand sanitizer or washing hands. RN D then assessed the area on the right side of R25's neck and patted the area with a dry gauze. When the procedure was complete, RN D disposed of used supplies, removed gown and gloves, and washed hands. On 06/19/24 at 2:35 PM, Surveyor interviewed Director of Nursing (DON) B and reviewed the observation of RN D providing wound care to R25's bottom. Surveyor informed DON B that RN D did not perform hand hygiene after each glove change during the procedure. DON B stated RN D did not follow the facility policy. DON B stated RN D should have performed hand hygiene after each glove removal. 49353 Example 2: On 06/19/24 at 9:24 AM, Surveyor observed CNA F complete bathing cares for R11 in facility spa room. CNA F completed R11's bath and cares and removed gloves and did not complete hand hygiene. Then CNA F took a lotion bottle with R11's name written on it and applied the lotion into CNA F's bare hand and applied to R11's bare skin. On 06/19/24 at 12:47 PM, Surveyor interviewed CNA F. Surveyor asked CNA F why hand hygiene or gloves were not used while applying lotion to R11. CNA F stated that R11 had just come out of tub, so they are clean, and gloves wouldn't be necessary. CNA F added that she had just given R11 the bath, so her hands were also considered clean to put the lotion on.

Based on observation and interview, the facility did not ensure that resident identifiable information was kept confidential. This affected 5 of 42 residents. (R5, R6, R244, R8, and R193) During the three-day survey, Surveyors had 6 observations of computer screens left open and unattended on medication carts with resident (R) identifiable information visible. Findings include: Facility Compliance and Ethics Program document states in part, .All individuals working at Park View Community Campus are expected to .practice good ethics in abiding the following principles: Respecting and maintain the privacy and confidentiality of residents . Facility document entitled Workplace Expectations stated in part, .When residents enter Park View Community Campus, we assume a professional obligation to keep in confidence all information pertaining to the resident and their affairs .Information concerning the care, treatment or condition of the resident must be held in strict confidence . On 06/12/23 at 12:17 PM, Surveyor observed Med Tech (MT) C walk away from the medication cart to administer medications in the dining room on the 300 hallway. MT C left the computer screen up with R5's information visible. On 06/13/23 at 7:08 AM, Surveyor observed Licensed Practical Nurse (LPN) D enter a resident room to administer medications. LPN D left the medication cart unattended in the 200 hallway. The computer screen was open on the medication cart with R6's information visible. On 06/13/23 at 8:05 AM, Surveyor observed Registered Nurse (RN) E walk away from the medication cart to administer medications to a resident. The medication cart was left unattended on the 200 hallway. Surveyor observed the computer screen open with R244's information visible. On 06/13/23 at 8:10 AM, Surveyor observed RN E walk away from the medication cart to administer medications to R5. Surveyor observed the computer screen was open on the unattended medication cart with R5's information visible. On 06/14/23 at 7:30 AM, Surveyor observed LPN D walk away from the medication cart to administer medications to R8 in the 100 unit dining room. Surveyor observed the computer screen was open with R8's information visible on the unattended cart. When LPN D returned to the medication cart, Surveyor interviewed LPN D about the facility expectation for keeping resident's medical information private when leaving the medication cart. LPN D stated they were supposed to close the computer screen so resident information was not visible. LPN D stated they did not close the screen because their hands were full. On 06/14/23 at 7:42 AM, Surveyor interviewed Director of Nursing (DON) B about the observations of staff leaving the computer screen open so resident information was visible during medication administration. DON B stated they should have closed the computer screen to protect resident privacy. DON B provided a copy of facility Compliance and Ethics Program document and facility Workplace Expectations Resident Relations Confidential Information document. 43352 On 06/13/23 at 10:05 AM, Surveyor observed LPN D leave the medication cart unattended in hall by the kitchen. The computer screen is open with R193's information visible; anyone walking by could see the information.

Based on observation and interview, the facility did not ensure safe and secure storage for controlled substances in 2 of 2 medication rooms. Resident (R)144's liquid Lorazepam concentration (schedule IV medication) was stored in an unlocked medication refrigerator in the locked medication room on the 300 unit. R22's liquid Lorazepam concentration was stored in an unlocked medication refrigerator in the locked medication room on the 100 unit. Findings include: On 06/13/23 at 11:02 AM, Surveyor reviewed medication storage room on 300 unit with Registered Nurse (RN) E. Surveyor observed a bottle of liquid Lorazepam in a plastic bag labeled for R144 in the medication refrigerator. The refrigerator was not locked. RN E stated they always kept the liquid Lorazepam in the unlocked refrigerator in the medication room. RN E stated the medication room was kept locked when no one was in the room and the nurses on duty for each shift were the only staff who had keys to access the medication room. RN E stated they had no mechanism to lock the medication refrigerator. On 06/13/23 at 11:25 AM, Surveyor reviewed the medication room on 100 unit with Licensed Practical Nurse (LPN) D. Surveyor observed two bottles of liquid Lorazepam in plastic bags labeled for R22 in the medication refrigerator. The medication refrigerator was not locked and did not have a locking mechanism. On 06/14/23 at 2:11 PM, Surveyor interviewed Director of Nursing (DON) B about the facility practice for storage of liquid Lorazepam. DON B stated they had always kept the liquid Lorazepam in the unlocked medication refrigerators in the locked medication storage rooms. Surveyor informed DON B that schedule IV medications were required to be in a separately locked container in a locked room or container. DON B was not aware that was a requirement and will obtain locking devices for the medication refrigerators.

Based on interview and record review, the facility did not ensure a resident having a mental illness was screened through the Pre-Admission Screen and Resident Review (PASRR) level II process to determine if nursing home placement was appropriate and if specialized services were required for 1 of 1 sampled residents (R) (R24). The facility did not complete a PASRR level II screen as indicated by the PASRR Level I upon R24's admission to the facility. Findings include: On 06/12/23 at 1:00 PM, Surveyor reviewed R24's medical record. R24 was admitted to the facility on [DATE] with a diagnosis of schizoaffective disorder (a mental health condition that includes features of both schizophrenia and a mood disorder) and taking the medication risperidone (an antipsychotic medicine that works by changing the effects of chemicals in the brain). A PASRR level I screen was completed on 04/20/21. The PASRR Level I determined that the documentation supported the criteria for an Abbreviated Level II screen to be completed. On 06/12/23 at 1:05 PM, Surveyor asked Director of Nursing (DON) B for a copy of R24's Abbreviated PASRR level II. On 06/12/23 at 1:15 PM, DON B gave Surveyor a copy of R24's PASRR Level I screen indicating that R24 meets the qualification for a Level II screen based on R24's diagnosis and medication. DON B asked Social Services (SS) F to check and see if there was a PASRR Level II done. On 06/12/23 at 1:29 PM, Surveyor interviewed SS F regarding no PASRR level II found on R24's chart. SS F replied that this Level I screen was done before she was hired a year and a half ago and agreed that a PASRR Level II should have been done then. On 06/12/23 at 2:30 PM, SS F advised Surveyor that a PASRR level II had just been submitted and is waiting to hear back. SS F is now doing audits on all the residents that were admitted before SS F started to make sure that all PASRR's are done on every resident. On 06/14/23 at 8:25 AM, SS F informed Surveyor that R24's PASRR Level II is complete and now in the chart. On 06/14/23 at 8:51 AM, Facility provided Surveyor with PASRR Level II completed and signed 06/13/23.

Based on observation, interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to help prevent the development and transmission of disease and infection, such as COVID-19, which had the potential to affect all residents of the facility. 1. The facility did not ensure staff wore appropriate Personal Protective Equipment (PPE)/eye protection in resident care areas when the community transmission rate for COVID-19 was high. This had the potential to affect all 39 Residents (R) in the facility. 2. The facility did not ensure visitors were wearing facemasks when visiting residents in common areas with other residents present for 2 of 2 observations of visitors in common areas. 3. The facility did not ensure staff wore well-fitting facemasks covering the mouth and nose during food service 1 of 3 days of survey. Findings include: Example 1: According to Centers for Disease Control and Prevention (CDC) guidance for Responding to COVID-19 in Long-Term Care Facilities (LTCFs), health care personnel (HCP) working in facilities located in counties with substantial or high transmission: .eye protection (i.e., goggles or a face shield that covers the front and sides of the face) should be worn during all patient care encounters. According to the Center for Disease Control (CDC) COVID Data Tracker, the Community Transmission rate for the facility's county, for the date range 05/08/22 through 05/14/22 was High. Surveyor reviewed the facility Policy titled Infection Control-COVID-19 Prevention, Identification and Response Plan, last revised 04/13/22. The policy stated in part, .Protocol: the facility administrator and IPCO [Infection prevention and control officer] will routinely consult the guidance put forth by CMS [Centers for Medicare and Medicaid] and CDC for preventing the transmission of COVID-19, and follow state and local health department direction, including data from https://covid.cdc.gov/covid-data-tracker/#county-view?list_select_state=Wisconsin&data-type=Risk&list_select_county+ to monitor community transmission levels and implement facility protocols to help prevent and or control spread of COVID-19 to residents and staff . For the first 2 and 1/2 days of survey, Surveyors observed all staff not wearing eye protection in all resident care areas of the building. On 05/17/22, at 10:03 AM, Surveyor interviewed Director of Nursing (DON) B, who verified it was the facility's policy to follow CDC guidance for staff PPE use while working in the facility. DON B stated staff should wear eye protection while in resident care areas if the Community Level was high. DON B stated she checked the CDC Data Tracker daily and the current Community Level for COVID-19 for the facility's county was medium, so the staff was not required to wear eye protection. Surveyor clarified Community Level versus Community Transmission Level on the CDC Data Tracker website with DON B. Surveyor showed DON B the current Community Transmission Level for the facility's county was high. DON B stated she had been checking the Community Level instead of the Community Transmission Level. DON B stated if the Community Transmission Level was high staff should be wearing eye protection. Surveyors observed all staff not wearing eye protection in resident care areas the remainder of the day on 05/17/22. On the morning of 05/18/22, Surveyors observed all staff in resident care areas not wearing eye protection. On 05/18/22, at 10:20 AM, Surveyor interviewed Nursing Home Administrator (NHA) A about staff wearing eye protection, if according to CDC guidance, all staff should wear eye protection for resident encounters if county Community Transmission Level was high. NHA A stated they had not been requiring staff to wear eye protection because the Community Transmission for their county had been medium up until today. Surveyor looked at the CDC data tracker information with NHA A, which showed the Community Transmission Level was high today. NHA A stated the Community Transmission Level for their county had been medium until today. Surveyor showed NHA A how to look back at the history of Community Transmission, which showed the facility's Community Transmission Level had been high since April. NHA A agreed based on that data staff should have been wearing eye protection. Example 2: According to CDC guidance for Responding to COVID-19 in Long-Term Care Facilities, visitors should wear source control when around other residents or HCP, regardless of vaccination status. The CDC defines source control as a well-fitting surgical, medical procedure, dental, or isolation mask that is FDA cleared. On 05/16/22, at 12:04 PM, Surveyor observed a visitor with R30 in the dining room. The visitor was not wearing a face mask and was squatted down beside the table between R30 and R35. The visitor was visiting with both residents within 6 feet. Multiple staff members were walking past the visitor during this time. None of the staff members asked the visitor to put on a face mask. At 12:15 PM, DON B walked past the visitor and asked her to put on a mask. The visitor then put on a leopard print cloth mask. On 05/16/22, at 1:00 PM, Surveyor observed two visitors seated at a table with a resident in the dining room. Neither of the visitors were wearing a face mask. There were multiple other residents in the dining room at the time. Surveyor observed multiple staff members walk through the dining room during this time. None of the staff members asked the visitors to put on a face mask. On 05/18/22, at 11:34 AM, Surveyor interviewed DON B about observations of visitors not wearing face masks in common areas with multiple other residents present. Surveyor informed DON B of observations of multiple staff walking past the visitors without requesting them to put on a mask. DON B stated staff had been trained to instruct visitors to put on face masks when in common areas of the building, but the staff possibly did not feel comfortable telling visitors to do that. On 05/16/22 at 12:12 PM, Surveyor observed Dietary Cook (DC) G in the 100-kitchenette serving food. At this time until the end of serving food to residents DC G had the face mask positioned below her nose and did not adjust the face mask to cover her nose. Surveyor observed DC H assisting with meal service to residents wearing the face mask positioned below her nose. On 05/17/22 at 09:55 AM, Surveyor interviewed Dietary Supervisor (DS) D asking about proper face mask positioning. DS D indicated masks are to be worn to cover nose and mouth. Surveyor reviewed with DS D the observation of DC G and DC H wearing face masks below their nose during food service.

Based on observation and interviews, the facility failed to ensure food was handled and served in accordance with professional standards for food service safety. Kitchen staff were observed touching ready to eat foods (buns, cheese, and curly fries) with gloves that had touched multiple potentially contaminated surfaces during meal service. This has the potential to affect residents who received ready to eat foods in 2 of 2 dining rooms and could result in an outbreak of a foodborne illness. Findings include: Example 1: On 05/16/22, from 12:03 PM to 12:25 PM, Surveyor observed Dietary Aide (DA) C serving food in the #2 dining room. DA C put on a pair of gloves and proceeded to touch multiple potentially contaminated surfaces with those gloves while serving meals. Surveyor observed DA C reach into the bag and pull out a bun to put on a resident's plate while wearing those same gloves. Surveyor observed DA C pick up a piece of cheese to put on the bun with the same gloves. Surveyor observed DA C repeat this same process multiple times throughout the serving process without changing gloves, or washing hands. On 05/16/22, at 12:28 PM, Surveyor observed DA C remove the gloves, wash hands, and serve a resident a cup of coffee. DA C then returned to the serving area and put on clean gloves without washing hands. DA C began putting food from the steam table into the food cart. DA C removed serving utensils from the food containers and placed them in the sink. DA C touched multiple surfaces in the serving area during this process. Surveyor observed DA C reach into a bag and pull out a bun and place on a resident's plate without changing gloves or washing hands. DA C opened a drawer, pulled out a serving utensil, and put meat on the bun. Then with the same gloves, DA C picked up a piece of cheese to place on the bun. DA C opened the door of the food cart, took a serving container out of the cart, took the cover off the container, and with the same gloves grabbed a handful of curly fries and placed on the resident's plate. On 05/16/22, at 12:35 PM, Surveyor interviewed DA C about touching the buns and cheese with the gloves that had touched multiple surfaces in the serving area. DA C stated it would be very difficult and wasteful to change gloves every time she went to pick up a bun and a piece of cheese. DA C stated it would be very difficult to use tongs to get a bun out of a bag, or pick up a piece of cheese. Surveyor asked DA C if after touching multiple surfaces with those gloves, should they be considered contaminated, and then should not touch ready to eat foods. DA C stated probably, but didn't know any other way to do it. Surveyor asked DA C about picking up a handful of curly fries to place on a resident's plate with gloves that had touched the food cart, and multiple other potentially contaminated surfaces. DA C stated she had already put the serving tongs in the sink, so just used the gloved hand to serve the fries. Surveyor asked DA C if that glove was probably contaminated. DA C stated yes probably. On 05/18/22, at 8:55 AM, Surveyor interviewed Dietary Supervisor (DS) D about the above observations. DS D was aware of the observations. DS D stated it was not appropriate for DA C to touch the buns, cheese, and curly fries with gloves that had touched multiple other surfaces during the serving process. On 05/16/22 at 12:12 PM, Surveyor observed in the 100 kitchenette, Dietary Cook (DC) G serving food with gloved hands and touching resident food request slips. Theses slips were brought to the kitchen by staff after the staff went room to room asking residents of their food choice. DC G then, with the same gloved hands, touched the buns and opened the buns and touched the sliced cheese and placed the cheese on the bun. With the same gloved hands, DC G touched the ladle to place the meat on the buns and with the same gloved hands touched the bun to hold and place the meat on the bun. DC G touched the cabinet handle to get a bowl out for the creamed corn. DC G touched the plastic bowl of salad that was sitting on the counter and placed on the plate. DC G opened another bag of buns with the same gloved hands, and took out buns and opened and touched the cheese slices and put onto bun. DC G started to use tongs to get the buns out of the bag and split the bun open then started to hold bun with same gloved hands. DC G continued touching cabinet door handles to get out plate covers and continued to touch buns and cheese. A total of 18 residents in the dining room received the meal served by DC G using the same contaminated gloved hands. On 05/17/22 at 09:55 AM, Surveyor interviewed DS D asking about the observation with DC G and handling the buns and cheese with the same gloves. DS D indicated staff were educated yesterday about glove use. This meal was a new meal served and DS D will make adjustments to prepare in the main kitchen.

Based on interview, observation, and record review, the facility did not ensure a resident (R), with a wound received the necessary care and treatment in accordance with professional standards of practice for 1 of 1 resident reviewed (R5). R5 had an open lesion on chest wall that was not thoroughly assessed weekly. This is evidenced by: R5 was admitted to facility on 02/09/2018, and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's most recent Minimum Data Set (MDS) assessment, dated 02/09/2022, indicated a Brief Interview for Mental Status (BIMS) score of 00, meaning R5 had severe cognitive impairment. R5 had an activated Power of Attorney for Health Care (POA-HC). R5's Advance Directives indicated goals were for comfort-based care and to avoid any hospitalization s. Physician notification facsimile dated 08/10/2021, read in part: .CONCERNS: Resident's open chest area/mole appears to be getting worse. The size is 1.4cm width and 0.8cm in height. Area is still raised, asymmetrical, variable coloring. The size appears to have grown since I saw it last .RESPONSE: This area most likely is skin cancer. Area was assessed on 6/17/2021 with dx (diagnosis) of probable [CONDITION(S)]. POA (Power of Attorney) aware. No new orders unless area is causing pain, draining/appears infected etc. Also assessed 7/26 w/o (without) new concern at that time. R5's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Pat dry with gauze. Bordered foam dressing to cover for protection/comfort. Change every three days. *****DOCUMENT MEASUREMENTS OF AREA*****AM first date: 6/18/2021 Ordered by (Nurse Practitioner) R5's medical record contained multiple nursing and physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's Care Plan related to, I NEED: extra protection to prevent skin injury and to reposition frequently, last revised 3/3/2022, identified, .blanching discoloration(s) on my buttocks, s/sx (signs/symptoms) of a topical yeast infection in my groin . and addresses multiple interventions to prevent pressure related skin breakdown. R5's Care Plan did not identify open lesion to chest wall, nor did it indicate what was needed to care for area. On 05/17/22 at 10:35 AM, Surveyor observed Registered Nurse (RN) F perform wound care for R5's chest wall lesion. Cleansing and dressing change of wound was performed using good technique without any breaks in infection control practices. However, RN F did not perform or document any measurements of wound as indicated in R5's Skin Treatment Orders. On 05/18/2022, Surveyor requested to view all wound assessments for R5's chest wall lesion from past 3 months. No measurements of area had been documented in past 3 months. Last note indicating a numerical size of wound was dated 1/17/2022 and read: Area on chest approx. (approximately) 4 cm diameter . All subsequent wound/skin assessment notes indicated no new areas, no changes, no new problems; occasional notes document the amount and characteristic of drainage from lesion. On 05/18/22 at 9:31 AM, Surveyor interviewed RN E and asked how often wounds were assessed and measured? RN E stated at least weekly, sometimes more often depending on the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN E looked on computer for wound measurements for R5. RN E stated she looked back a month and didn't see that any measurements had been recorded. On 5/18/22 at 9:47 AM, Surveyor interviewed Director of Nursing (DON) B regarding assessments of wounds. DON B stated the expectation was all open wounds were to be thoroughly measured and assessed weekly and documented in the medical record. Surveyor asked if there was any reason why R5's wound had not been measured weekly? DON B stated she was not sure of the reason. DON B stated the order in R5's medical record that read *****DOCUMENT MEASUREMENTS OF AREA***** was a nursing order, not a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview and record review, the facility failed to prevent the spread of infection such as COVID 19 as evidenced by failure to disinfect glucometer (blood sugar testing device) according to the manufacturer's recommendation. This failure had the potential to affect five residents (R1, R2, R3, R4, and R5) who shared the use of glucometer in Unit 1. The facility census was 22. Findings include: Observation on 7/8/2020 at 12:27pm revealed Licensed Practical Nurse 1 (LPN1) performed glucose check using Assure Prism, a glucometer for Resident1 (R1). After the glucose check, LPN1 returned to her cart and used the alcohol wipes to clean the glucometer. When asked if this was the facility's policy for glucometer cleaning and disinfection, LPN1 responded, Yes. LPN1 confirmed that the glucometer was multi-use glucose device except when residents were on isolation. Review of the list of residents with blood sugar (BS) check revealed: R1 BS check four times a day R2 BS check four times a day R3 BS check five times a day R4 BS check three times a day R5 BS check AM/PM Monday and Friday Review of R1's electronic record revealed [DIAGNOSES REDACTED]. Review of R2's electronic record revealed [DIAGNOSES REDACTED]. Review of R3's electronic record revealed [DIAGNOSES REDACTED]. Review of R4's electronic record revealed [DIAGNOSES REDACTED]. Review of R5's electronic record revealed [DIAGNOSES REDACTED]. During an interview with the Administrator and Director of Nursing (DON) on 7/8/20 at 1:40pm, the DON stated that alcohol was acceptable and provided a printed document from Centers for Disease Control and Prevention (CDC) titled Infection Control Chemical Disinfectants Guideline for Disinfection and Sterilization in Healthcare Facilities (2008). During this interview the surveyor indicated that she would review the document provided and would follow up with the facility. During the same day on 7/8/2020 at 8:50pm, the surveyor provided the facility the most recent guidelines related to the cleaning and disinfection of point of care testing. Review of Assure Prism Multi Blood Glucose Monitoring System Reference Manual under Cleaning and Disinfecting Meter revealed: To minimize the risk of transmitting blood-borne pathogens, the cleaning and disinfection procedure should be performed as recommended in the instructions below. The meter should be cleaned and disinfected after use on each patient. The Assure Prism multi Blood Glucose Monitoring System may only be used for testing multiple patients when standard precautions and the manufacturer's disinfection procedures are followed. Cleaning and Disinfection The cleaning procedure is needed to clean dirt, blood and other bodily fluids off the exterior of the meter before performing the disinfection procedure.The disinfection procedure is needed to prevent the transmission of blood-borne pathogens.A variety of the most commonly used EPA-registered wipes have been tested and approved for cleaning and disinfecting of the Assure Prism multi Blood Glucose Monitoring System.The disinfectant wipes listed below have been shown to be safe for use with this meter. Please read the manufacturer's instructions before using their wipes on the meter. Manufacturer Brand Name EPA# Clorox® Professional Products Company- Clorox® Germicidal Wipes -12 Dispatch® Hospital Cleaner Disinfectant Towels and Bleach -7 Professional Disposables International, Inc. (PDI)-PDI® Super Sani-Cloth® Germicidal Disposable Wipe 9480-4 Metrex® Research CaviWipes1 (Trademark) -13 . Disinfecting (The meter should be cleaned prior to disinfection.) Step 5: Open the towelette container and pull out 1 towelette and close the lid. Step 6: Wipe the entire surface of the meter 3 times horizontally and 3 times vertically to remove blood-borne pathogens. Step 7: Dispose of the used towelette in a trash bin. Step 8: Allow exteriors to remain wet for the appropriate contact time and then wipe the meter using a dry cloth. Disinfectant Brand Name Contact Time Clorox Germicidal Wipes 1 minute Dispatch Hospital Cleaner Disinfectant Towels and Bleach 1 minute Super Sani-Cloth Germicidal Disposable Wipe 2 minutes CaviWipes1 2 minutes . On 7/10/2020 at 12:45pm during a telephone interview with the Administrator, the Administrator acknowledged that the use of alcohol for glucometer cleaning was not consistent with the current CDC guidelines and with the manufacturer's recommendation. According to: https://www.cdc.gov/infectioncontrol/guidelines/disinfection/ Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 Update: May 2019 .Uses. Alcohols are not recommended for sterilizing medical and surgical materials principally because they lack sporicidal action and they cannot penetrate protein-rich materials .

Based upon observation and interview, the facility did not store, prepare and distribute food in a sanitary manner on 2 of 3 days of survey. This had the potential to affect 4 residents served bread, and 8 residents served water on 12/19/16, and a potential for some residents who would possibly be served cookies on 12/20/16. The cooks touched other items with gloved hands, and then touched food items. The dietary aide touched the tops of the water glasses, after touching other objects. This is evidenced by: On 12/19/16 at 12:15 p.m., Surveyor was observing tray line in dining room #3. Dietary Cook (DC) B was putting food onto plates. The main course being served was turkey and gravy over bread. Surveyor observed DC B use ladles to dish up the meat and gravy and the mashed potatoes. Then DC B used her gloved hands to reach into the bread bag, take a piece of bread and put it on the next plate. DC B went to the table, set the plate down, then back to the steam table and touched the steam table, ladles, and plates. DC B went to a drawer and opened it to get another utensil. DC B then continued to use the contaminated gloves to take bread out of the bread bag. Surveyor observed four plates served in this manner and then stopped DC B. DC B acknowledged she had touched other items, and then took off her gloves, washed her hands and then got a tongs to use for the bread. On 12/19/16 at 12:25 p.m., Surveyor observed Dietary Aide (DA) A serving drinks to residents. DA A had gloves on her hands. DA A picked up a drink glass by the rim of the glass, then touched the table, and then pushed the drink cart forward and served another glass of water, again touching the top rim of the glass with her contaminated hands. DA A did this with eight glasses of water. At this time, Surveyor interviewed DA A to ask if she was aware of the unsanitary way in which the glasses were being handled. DA A then took off her gloves and washed her hands. On 12/20/16 at 9:00 a.m., Surveyor was inspecting the kitchen and observed DC C making cookies. DC C took the cookies off the tray, dumping them onto waxed paper on the counter. DC C then moved the cookies with her gloved hand; no utensils were used. DC C then touched the food cart with her gloved hands and went over to get trays for the cookies from storage area. DC C then came back to the counter and moved the can opener, which was visibly soiled, to the back of the counter. DC C then took another cookie sheet of cookies and guided them onto the waxed paper, touching the cookies. Surveyor stopped DC C to inform her of the contamination. DC C then removed her gloves and washed her hands. On 12/20/16 at 1:45 p.m., Surveyor interviewed Dietary Manager (DM) D about the above observations. DM D acknowledged that tongs should have been used for the bread.

Based on observation, interview and record review, the facility did not store, prepare, and serve food under sanitary conditions. This has the ability to affect all of the facility's 44 residents. The facility did not use test stripes in the high temperature dish machine to ensure the surface temperature of items reached appropriate temperatures for sanitization. The facility staff does not routinely monitor the parts per million (ppm) Quat-base sanitizer in the kitchen sanitization bucket. The facility staff, with contaminated gloves, touched the toast and served it to residents. The facility did not utilize temperature strips to monitor the internal temperature of the dishwashers in 2 of 3 of the facility kitchenettes. This is evidenced by: According to the 2013 Food Code, When using a hot water mechanical dish machine, procedures must be in place to ensure items ran through the dishwasher achieve a surface temperature of 160 degrees Fahrenheit as measured by an irreversible registering temperature indicator. On 01/04/16 at 6:15 p.m., Surveyor conducted a tour of the facility kitchen with Dietary Cook (DC) H. Surveyor observed a high temperature dish machine and asked DC H if the facility uses a testing strip to check the surface temperature of the items running through the dish machine. DC H indicated the supplier tests everything, but they do have strips to use if there is a problem. Surveyor asked DC H when the sanitization bucket ppm is monitored. DC H indicated when the supplier checks. On 01/05/16 at 7:19 a.m., Surveyor observed Dietary Assistant (DA) I prepare a breakfast tray. With gloved hands, DA I touch the lid and the scoop of the cream of wheat. With the same gloved hands, DA I touched the toast and held the toast on the plate with her thumb and served to Resident #4. On 01/05/16 at 2:30 p.m., Surveyor asked Dietary Manager (DM) B for a facility policy regarding the dish machine operation, appropriate sanitizing temperatures, or checking the surface temperatures. DM B indicated the supplier comes into the facility and tests everything. DM B indicated that if the dishwasher did not reach temperature the machine would continue to run and the staff would call maintenance to check the machine. DM B indicated the sanitization bucket is not checked daily; the strips are used only if it seems off. DM B indicated DA I should have used tongs to serve the toast. On 01/06/16 at 12:30 p.m., Surveyor observed and interviewed DA G while loading the dishwasher on the Wing I kitchenette. Surveyor asked DA G if he used the temperature monitoring strips that were available on the unit. DA G stated, No I do not use those. I go by the outside gauge on the dishwasher. Surveyor asked DA G if he tested the internal temperature of the dishwasher. DA G stated, We do if we think the outside temperature gauge is broke. On 01/06/15 at 1:45 p.m., Surveyor observed and interviewed DA G while loading the dishwasher on the Wing II kitchenette. DA G stated he does not use the temperature monitoring strips on this unit unless the outside gauge is not working.

Based on observation, record review and interview, the facility staff did not provide a sanitary environment to help prevent the spread, development or transmission of infection during 2 of 5 (Resident #4 and #3) observations of staff assistance during hygiene cares. This is evidenced by: 1. Resident #4's [DIAGNOSES REDACTED]. Resident #4 requires staff assistance during hygiene cares. On 01/06/15 at 8:00 a.m., Surveyor observed Certified Nursing Assistants (CNAs) C and D assist Resident #4 with hygiene cares. After performed hand hygiene, CNA C gathered supplies from a closet, and filled a gray basin with warm water. CNA D gathered several washcloths and two towels. After CNA D assisted the resident with washing his face and upper torso, CNA D placed the used washcloth and towels directly onto the arm of a blue cloth recliner, which was next to the resident's bed. After changing gloves and performing hand hygiene, the CNA's assisted the resident into a standing position. Then CNA D completed frontal peri care. After drying the penal area, CNA D placed the used washcloth and towel directly on the arm of the cloth recliner. CNA D, then cleansed the resident's buttock and rectal areas with a clean washcloth and towel. After performing rectal hygiene cares, CNA D directly placed the used washcloth and towel on the arm of the recliner. The CNA's then removed their gloves, performed hand hygiene and then assisted the resident with dressing. After assisting the resident to dress, CNA D removed her gloves and performed hand hygiene. After donning a fresh pair of gloves, CNA D obtained plastic garbage bags from the residents closet and placed the soiled linen that had been placed on the arm of the recliner into a plastic bag. CNA D then carried the bag to the soiled utility room and disposed of it in the receptacle. CNA D removed her gloves and performed hand hygiene. 2. Resident #3's [DIAGNOSES REDACTED]. On 01/06/15 at 7:30 a.m., Surveyor observed CNA D assist Resident #3 with hygiene cares. Upon entering the room, CNA D performed hand hygiene and donned a pair of vinyl gloves. After donning the gloves, CNA D assisted the resident into an adjacent bathroom next to a sink, using the resident's walker for assistance. After assisting the resident unto the commode, CNA D performed hand hygiene and donned a fresh pair of gloves. CNA D then gathered clean clothes and supplies from the resident's closet. After gathering the clean clothes and supplies, CNA D filled the sink with water and added clean washcloths. CNA D then assisted Resident #3 with upper torso cleaning and dressing. CNA D then placed the used linen on the floor next to the commode. CNA D then removed her gloves and performed hand hygiene. After donning a fresh pair of gloves, CNA D, using a clean washcloth, cleansed the resident's labial area, using a front to back motion, and folding the washcloth into clean sections. CNA D placed the used linen directly on the floor next to the commode. CNA D then performed hand hygiene and donned a fresh pair of gloves. After donning a fresh pair of gloves, CNA D assisted the resident with rectal cares. CNA D initially used three disposable cloths to cleanse the rectal area, then used a washcloth. All of the cloths became contaminated with stool. CNA D placed the disposable cloths into a garbage can. Then, using the same washcloth stained with fecal matter, cleansed the resident's outer buttock area. CNA D then placed the fecal stained washcloth directly onto the bathroom floor. CNA D then dried the area, from outer to inner buttock, and placed the used towel directly onto the floor. CNA D then removed her gloves and performed hand hygiene. After performing hand hygiene and donning a fresh pair of gloves, CNA D assisted the resident with dressing and into her wheelchair. CNA D then obtained a garbage bag from the closet and placed the soiled items from the floor into the garbage bag. After placing the items into the bag, CNA D took the bag into the soiled utility room and placed it in a receptacle. CNA D then removed her gloves and performed hand hygiene. At 2:30 p.m., Surveyor interviewed the Nursing Home Administrator (NHA) about the observations above. The NHA stated, .used linen should be placed into garbage bags and not directly onto the floor. The NHA also informed Surveyor that the CNAs receive training regarding how to perform proper peri/rectal cares during the facility's infection control training and intermittently throughout the year.

Based on observation, record review and interview, the facility did not ensure that a resident's environment was as free from potential accident hazards as is possible for 1 of 12 sampled residents whose environment was reviewed for safety. Resident #4 used a modified car seatbelt in his wheelchair. The facility did not care plan for or assess the seatbelt for safety of use. This is evidenced by: Resident #4's [DIAGNOSES REDACTED]. On 01/05/16 at 7:15 a.m., Surveyor observed Resident #4, who was seated in his wheelchair with a seatbelt on, brushing his teeth. Surveyor observed Resident #4 at 9:15 a.m., 10:15 a.m., 12:00 p.m., and 3:00 p.m. Resident #4 had the seatbelt on at each observation. On 01/06/16, Resident #4 was observed several times in his wheelchair, including observations during hygiene assistance provided by the staff. Resident #4's seatbelt was observed in his chair unlatched. On 01/07/16 at 8:20 a.m., Surveyor observed Resident #4. Resident #4 was up in his wheelchair in the dining room, waiting for the morning meal. Resident #4 told Surveyor that the seatbelt in his wheelchair was devised and modified for his wheelchair by his son-in-law. Resident #4 stated, He put it on when I was living in my apartment because I fell on my face three times. Resident #4 proceeded to demonstrate the use of the seatbelt twice, by latching and unlatching the device. Resident #4 then stated, This is from a car. Surveyor interviewed Registered Nurse (RN) A, who serves as the Resident Care Coordinator. When asked if she was aware that Resident #4 had a modified seatbelt on his wheelchair, RN A stated, No. Surveyor reviewed Resident #4's clinical record. The clinical record, including the resident's care plan, did not show the presence of the modified seatbelt. Under the heading Muscle Weakness the subtitle which included Equipment stated, .Nurse Aide--Equiptment: Wheelchair. No other durable medical equipment was listed. Surveyor interviewed Certified Nursing Assistant (CNA) E. CNA E indicated that Resident #4 has had that seatbelt on his wheelchair for years. He had it on when he used to come over here for help with his showers when he was living in the Assisted Living area. The CNAs don't put it on, Resident #4 puts it on and takes it off himself. Surveyor interviewed CNA F. CNA F stated, I have seen him with it on coming down the hall. Surveyor interviewed CNA D. CNA D stated, He puts that seatbelt on and takes it off when he wants to. Surveyor interviewed the Nursing Home Administrator (NHA) about the above observations and interviews. The NHA stated, We talked to the Occupational Therapist who saw him. The Occupational Therapist did not inform the staff of the seatbelt or document the seatbelt since Resident #4 was was not using it at the time.

Based on observation and interview, the facility did not ensure that residents remained free of accidents for 1 of 2 spa rooms observed for unlocked chemicals. As evidenced by: On 12/10/14 at 9:45 a.m., Surveyor , while completing the required facility tour, observed the spa room located on the 300 hall to have the door open. Surveyor walked into the spa room and noted a large brown cabinet which had a key in the door. Surveyor noted the cabinet to be unlocked and easily accessible. Surveyor opened the cabinet door and noted, on the bottom shelf below knee level, the following items: - One 128 ounce container of bleach which contained approximately 1/4 of bleach liquid. Surveyor noted a child proof lid on the container of bleach. Surveyor noted a warning label on the container stated to contact poison control if ingested. - One Clorox Bleach Germicidal Cleaner spray bottle (32 ounces) containing approximately 3/4 full of liquid. Surveyor noted the spray bottle nozzle to be in the "ON" position and no child proof closure was noted. Surveyor noted a warning label on the container stated to contact poison control if ingested. - One "Turbo Clean" pre-disinfectant chelating detergent bottle, 128 ounce container, which was approximately 1/2 full. Surveyor noted no child proof lid on this container. Surveyor noted a label on container stated, "Caution: If ingested, contact physician, drink plenty of water and induce vomiting." On 12/10/14 at approximately 9:47 a.m., Surveyor interviewed Certified Nursing Assistant (CNA) A in regard to residents residing on the 300 hall and 200 hall. CNA A stated that both 300 hall and 200 hall, which had access to the above noted spa room, had multiple residents who had dementia and some residents did wander throughout the facility. On 12/10/14 at approximately 9:50 a.m., Surveyor interviewed Registered Nurse (RN) B in regard to the unlocked cabinet in the spa room. RN B stated the cabinet should have been locked due to storage of harmful chemicals and agreed that most residents residing in the facility and near the spa room did have dementia and some of those residents were at risk for wandering. Surveyor observed RN B close the large cabinet in the spa room and lock it. On 12/11/14 at 7:10 a.m., Surveyor interviewed the Director of Nursing (DON) in regard to the above noted observation of unlocked chemicals. The DON stated the facility staff should have ensured the cabinet was locked so chemicals were not accessible to residents.

Based on interview, clinical record review, and policy review, the facility did not ensure that 4 of 12 (#4, #3, #8, and #10) residents whose medications were reviewed were free from unnecessary drugs and not given medication without adequate indication for their use. * Resident #4 has received Bactrim Single Strength (SS) as a [MEDICATION NAME] antibiotic for Urinary Tract Infections (UTIs) since admission to the facility in June 2013. The antibiotic does not have adequate indications for use. Resident #4 was placed on antibiotics prior to urine culture results being obtained. * Resident #3 was started on an antibiotic for treatment of [REDACTED]. When the results of the UC (urine culture) were known, the antibiotic was discontinued due to resistance of the organism and a new antibiotic was ordered. * Resident #8 has been taking Trazadone for [MEDICAL CONDITION]. The facility did not complete a sleep assessment or sleep monitoring/tracking for the use of the medication. *Resident #10 has been taking [MEDICATION NAME] for [MEDICAL CONDITION]. The facility did not complete a sleep assessment, sleep monitoring/tracking, or a sleep hygiene care plan for the use of the medication. This is evidenced by: Antibiotic Use: The facility's [MEDICATION NAME] Antibiotic Policy and Procedure states. "1. Residents will only receive [MEDICATION NAME] antibiotics when necessary to treat specific conditions such as but not limited to the following:" "Documented history of urosepsis with three or more UTI's in past 12 months." The facility's Policy and Procedure for Antibiotic Use states, "4. If a prescriber chooses to NOT follow the minimum criteria for antibiotic use, nursing will educate the prescriber on McGeer's criteria, document education in the resident's chart and the Director of Nursing will discuss at the QA (Quality Assurance) meeting with the facility Medical Director." 1. On 05/28/14, Resident #4's admission information contained secondary [DIAGNOSES REDACTED]. Resident #4 has received Bactrim SS daily as a [MEDICATION NAME] antibiotic for recurrent UTIs. On 06/25/14, Resident #4's physician responded to the pharmacist's request of the extended treatment with an antimicrobial agent to suppress bacterial dose and prevent clinical urinary tract infections. The physician documented, "Documented to have a history of urosepsis with three of more UTIs's in past 12 months. Patient on antibiotic [MEDICATION NAME] for uncertain length of time, will review with family." On 12/03/14, Resident #4's physician progress notes [REDACTED]." The Assessment included, "4. hospitalization [DATE] for Urinary Tract Infection [MEDICAL CONDITION] with a history of recurrent urinary tract infection. The patient continues on [MEDICATION NAME] antibiotics and her son is in agreement." Resident #4's medical record identified she did not have any UTIs from admission to 12/06/14. On 12/06/14, Resident #4 slid out of her chair onto the floor. The incident report identified Resident #4 was disoriented and lethargic at the time of the fall. Resident #4's Power of Attorney for Health Care (POA-HC) was contacted related to the fall. The POA-HC stated this was how Resident #4 acted the last time she had a UTI. The POA-HC stated he wanted the facility to collect a urine sample. On 12/06/14, the facility contacted Resident #4's physician and received orders to collect a urinalysis and urine culture (UA/UC). Resident #4's nurses' notes on 12/07/14 at 1:38 a.m. included, "Left message for (physician's name): Regarding UA results appear to be negative. Result: returned call at 11:00 p.m. and stated no new orders, await UC." On 12/07/14 at 2:11 p.m., the nurses' notes included, "(Physician's name) called and lpn (licensed practical nurse) updated him to resident condition and we do not have culture returned yet." "Received order [MEDICATION NAME] start her on something and to give two doses today." No orders were received related to the use of the [MEDICATION NAME] antibiotic while on the Cipro. Resident #4's medical record did not contain documentation of Resident #4's physician being asked about the continued use of the Bactrim SS while on the Cipro. On 12/07/14 at 4:10 p.m., Resident #4's nurses' notes stated, "Urinary Findings: no problem noted." Resident #4's nurses' notes did not contain documentation related to signs or symptoms of a UTI prior to this entry. Resident #4's nurses' notes on 12/10/14 at 6:20 a.m. identified Resident #4's urine was dark. All other entries related to her urinary status from 12/07 - 12/11/14 identified "Urinary Findings: no problem noted." On 12/09/14, the UC results identified "Coalase Negative Staph, No Further Workup." No antibiotics were identified in the sensitivity analysis section. No organism was identified. The UC results were faxed to Resident #4's physician for review. The physician responded, "Has patient returned to baseline function? Please update on Wednesday. No new orders at this time." On 12/10/14, a fax was sent to the physician identifying Resident #4 had returned back to her baseline. No lethargy was noted, no increase of behaviors, afebrile and no complaints of pain. On 12/11/14 at 12:42 p.m., Resident #4's physician faxed orders to the facility, "OK to d/c (discontinue) after today's 2 doses." Review of Resident #4's Medication Administration Record [REDACTED] On 12/15/14 at 2:40 p.m., Surveyor interviewed the Director of Nurses (DON) related to the use of the [MEDICATION NAME] antibiotic since admission and starting [MEDICATION NAME] to the UC results being known and without indications of a UTI. The DON stated the Bactrim was not placed on hold while Resident #4 received the Cipro. The DON stated the nurses had updated the physician that the UC had not returned and updated him on Resident #4's condition. The physician gave orders to start something (Cipro). On 12/16/14 at 12:40 p.m., Surveyor interviewed LPN E who stated usually the facility does not start antibiotics until the UC results are received. LPN R stated that orders prior to the UC results depended on the residents' physicians. LPN R stated Resident #4's son had stated she had lived with him for [AGE] years and this was how Resident #4 acted when she had an UTI (lethargic, falls and did not respond well). LPN R stated Resident #4 did not have UTIs since admission. On 12/16/14 at 1:23 p.m., Surveyor interviewed Registered Nurse (RN) I related to [MEDICATION NAME] antibiotic use and procedure for antibiotic use prior to the UC results being known. RN I stated the pharmacist reviews the use of the antibiotics and she knew he had left notes for Resident #4's physician related to the antibiotic use. RN Iinformed Surveyor Resident #4 had not had a UTI from admission until 12/07/14. 2. Resident #3 has a history of UTIs and poor fluid intake at times. Resident #3's nurses' notes identified the following: -On 12/01/14,Resident #3 demonstrated increased confusion, her urine was concentrated and she had painful urination. A UA/UC was sent to the lab. A fax was sent to Resident #3's physician which stated, "See attached UA results. Many bacteria present with leukocyte esterase 3+ (plus). Any new orders? The physician responded, "If NKA (no known allergies [REDACTED]. Check UC (urine culture)." No nurses' notes contained documentation of signs/symptoms of an UTI from 12/01/14 at 2:24 p.m. to 12/03/14 at 10:03 a.m. when the nurse's note identified Resident #3's urine was cloudy and her temperature was 97.4 tympanic. On 12/03/14, Resident #3's UC results were received. The Microbiology Report identified there were less than 100,000 of gram negative negative organism, ID/Sen (Identification/Sensitivity) pending and 50,000 CFU/MI gran positive organism, ID/ pending. The UC identified the organism Escherichia Coli was resistant to Cipro. On 12/03/14, a fax was sent to Resident #3's physician related to the lab results (UA/UC). New orders were received to stop [MEDICATION NAME] begin [MEDICATION NAME] 500/125 mg twice daily for ten days. On 12/15/14 at 2:40 p.m., Surveyor interviewed the DON related to Resident #3's physician [MEDICATION NAME] to the UC being completed and the need to change antibiotics related to [MEDICATION NAME] resistant to the organism. The DON stated the nurses had called the physician and he gave them orders to start [MEDICATION NAME] to the UC results being back. On 12/16/14 at 12:40 p.m., Surveyor interviewed LPN E who stated usually the facility does not start antibiotics until the UC results are received. LPN R stated that orders prior to the UC results depended on the residents' physician. On 12/16/14 at 1:23 p.m., Surveyor interviewed RN I related to starting antibiotics prior to the UC results being known. RN I stated the nurses do at times discuss with the physician antibiotics are not to be ordered until after the UC is returned. The conversation with the physician should be documented in the resident's nurses' notes. RN I stated it was the physicians who make the determination if they want to start an antibiotic before the UC results are back. Hypnotic Use: 1. Resident #8 was re-admitted to the facility on [DATE] with orders for Trazadone 100 mg at bedtime and Trazadone 50 mg at bedtime as needed (prn) for [MEDICAL CONDITION]. The orders identified the Trazadone 50 mg prn was to be given before 3:00 a.m. if the scheduled dose was ineffective. No sleep assessment or sleep monitoring/tracking for the use of the medication were found in Resident #8's medical record. On 12/16/14 at 8:30 a.m., Surveyor interviewed the DON related to sleep assessments and sleep monitoring/tracking for residents on medications used for [MEDICAL CONDITION]. The DON informed Surveyor the Trazadone was a new order upon re-admission and the facility did not have a sleep assessment for Resident #8 yet. The DON stated the nurses had been documenting every night in the nurses' notes on how Resident #8 sleeps. The DON stated no care plan had been developed for [MEDICAL CONDITION] as the significant change Minimum Data Set (MDS) was not due until the end of the week. On 12/16/14 at 10:45 a.m., the DON provided Surveyor with Resident #8's nurses' notes since re-admission on 11/28/14. The nurses' notes contained no documentation of sleep monitoring/tracking. Resident #8's behavior monitoring entries by the night staff did not identify the hours Resident #8 slept or was awake on the night shift. On 12/16/14 at 1:03 p.m., Surveyor interviewed the DON who stated the Certified Nursing Assistants (CNAs) were not monitoring Resident #8's sleep as Resident #8 was still in the assessment period for his significant change MDS. The DON stated Resident #8 had not used any sleep medications prior to his hospitalization . Surveyor reviewed with the DON Resident #8's nurses' notes related to documentation sleep monitoring. The DON verified the nurses' notes did not address Resident #8's sleep patterns. 2. On 12/15/14 at 9:15 a.m., Surveyor reviewed the medical record for Resident #10 and noted the following: - Resident #10 was currently receiving the medication [MEDICATION NAME] 30 mg (milligrams) at bedtime for [MEDICAL CONDITION]. - Physician order, dated 04/01/14, stated, "[MEDICATION NAME] 15 mg PO (oral) qhs (at night)" for "[MEDICAL CONDITION], agitation." Resident #10's medical record later indicated [MEDICATION NAME] was increased to 30 mgs. - Surveyor was unable to identify a comprehensive sleep assessment for Resident #10. On 12/16/14 at 10:55 a.m., Surveyor interviewed the DON in regard to a comprehensive sleep assessment for Resident #10. The DON stated the facility did not complete a sleep assessment for Resident #10 and agreed that a sleep assessment should have been completed due to the resident currently taking a hypnotic medication. No further information was provided.