Every finding on record at Sheboygan Senior Community Inc

Based on observation, interview, record review, and policy review, the facility did not ensure 4 residents (R) (R1, R2, R3, and R4) of 4 sampled residents who self-administered medications had an assessment that indicated it was clinically appropriate to do so. R1 was observed self-administering Flonase in the dining room. R1 did not have a self-administration of medication assessment that indicated they could safely and accurately self-administer medication. Staff placed medication next to R2, R3, and R4 in the dining room and walked away. Staff did not instruct R2, R3, or R4 to take the medication or watch them do so. R2, R3, and R4 did not have self-administration of medication assessments that indicated they could safely and accurately self-administer medication. Findings include: Review of the facility's Self-Administration of Medication policy, dated December 2025, revealed: Residents have the right to self-administer medications if the interdisciplinary team (IDT) has determined that it is clinically appropriate and safe for the resident to do so .1. As part of the evaluation/comprehensive assessment, the IDT assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident .3. If it is deemed safe and appropriate for a resident to self-administer medications, it is documented in the medical record and care plan. The decision that a resident can safely self-administer medications is re-assessed periodically based on changes in the resident's medical and/or decison-making status .5. Residents who are identified as being able to self-administer medications are asked whether they wish to do so. 6. Residents who are able to self-administer medications will be care planned. 1. Review of R1's admission Record, located in the electronic medical record (EMR) under the Resident Information tab, revealed a current admission date of 8/14/25 and diagnoses including end stage renal disease (ESRD) on hemodialysis and diabetes. Review of R1's Quarterly Minimum Data Set (MDS) assessment, dated 7/9/26 and located under the Resident Assessment tab, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Review of R1's 8/2026 physician orders, located under the Physician's Orders tab of the EMR, revealed an order dated 8/14/25 for fluticasone propionate (Flonase) spray two sprays to each nostril once daily. Review of R1's EMR revealed an assessment had not been completed for R1 to use the nasal spray without nursing supervision. During an observation on 8/3/26 at 12:20 PM, R1 was in the dining room with the nasal spray on the table. R1 used the nasal spray without staff supervision. (See interview under example 4.) 2. Review of R2's admission Record, located in the EMR under the Resident Information tab, revealed a current admission date of 8/18/23 with a diagnosis of Alzheimer's disease without behavioral disturbance. Review of R2's Quarterly MDS assessment, dated 7/8/26 and located under the Resident Assessment tab, revealed R2 had a BIMS score of 15 out of 15, indicating intact cognition. Review of R2's 8/2026 physician orders, located under the Physician's Orders tab, revealed an order dated 11/20/23 for acetaminophen (Tylenol) 500 milligrams (mg), two tabs to equal 1000 mg, by mouth three times daily. Review of R2's EMR revealed an assessment had not been completed for R2 to self-administer medications without nursing supervision. During an observation on 8/3/26 at 12:25 PM, Licensed Practical Nurse (LPN) 2 set 2 tablets of Tylenol beside R2's plate in the dining room and walked away. LPN2 did not instruct R2 to take the medication or watch them take it. (See interview under example 4.) 3. Review of R3's admission Record, located in the EMR under the Resident Information tab, revealed a current admission date of 4/22/24 with diagnoses including Parkinson's disease and dementia without behavioral disturbance. Review of R3's Quarterly MDS assessment, dated 8/1/26 and located under the Resident Assessment tab, revealed R3 had a BIMS score of 14 out of 15, indicating intact cognition. Review of R3's 8/2026 physician orders, located under the Physician's Orders tab, revealed an order dated 4/22/24 for acetaminophen (Tylenol) 325 mg, two tabs to equal 650 mg, by mouth three times daily. Review of R3's EMR revealed an assessment had not been completed for R3 to self-administer medications without nursing supervision. During an observation on 8/3/26 at 12:25 PM, LPN2 set two tablets of Tylenol beside R3's plate in the dining room and walked away. LPN2 did not instruct R3 to take the medication or watch them take it. (See interview under example 4.) 4. Review of R4's admission Record, located in the EMR under the Resident Information tab, revealed a current admission date of 3/24/22 with diagnoses including multiple sclerosis and neuromuscular dysfunction of the bladder. Review of R4's Quarterly MDS assessment, dated 7/27/26 and located under the Resident Assessment tab, revealed R4 had a BIMS score of 15 out of 15, indicating intact cogniton. Review of R4's 8/2026 physician orders, located under the Physician's Orders tab, revealed an order dated 10/14/24 for baclofen (aids with bladder spams) 20 mg, two tabs to equal 40 mg, by mouth three times daily. Review of R4's EMR revealed an assessment had not been completed for R4 to self-administer medications without nursing supervision. During an observation on 8/3/26 at 12:25 PM, LPN2 set two baclofen tablets beside R4's plate in the dining room and walked away. LPN2 did not instruct R4 to take the medication or watch them take it. On 8/3/26 at 12:33 PM, Surveyor interviewed LPN2 who stated they leave medications with R2, R3, and R4 because they are alert and oriented and take them. LPN2 was not sure if R2, R3, or R4 were assessed as able to self-administer medications. On 8/3/26 at 12:45 PM, Surveyor interviewed Director of Nursing (DON)-B who verified medications should not be left with residents who have not been assessed as able to self-administer and stated staff should observe the residents take them. DON-B indicated LPN2 had been talked to about leaving medications unattended with residents.

Based on staff and resident interview and record review, the facility did not ensure care was provided in accordance with a physician order for 1 resident (R) (R9) of 16 sampled residents.R9 had a diabetic heel ulcer. An Apligraf (a bioengineered, bi-layered skin substitute that contains living human keratinocytes, fibroblasts, and bovine collagen commonly used to treat diabetic foot ulcers) was applied at a podiatry appointment on 11/3/25 with an order not to remove the graft. Staff removed the graft on 11/4/25 and did not inform the podiatry clinic. During a podiatry appointment on 11/11/25, it was noted that the Apligraf was missing and R9's ulcer had worsened. R9 was hospitalized for nine days and diagnosed with osteomyelitis (a bone infection). R9 required surgical debridement and both intravenous (IV) and oral antibiotics. The facility's lack of order entry process along with not following current orders/not clarifying orders with the physician resulted in the Apligraf being removed between 11/3/25 and 11/11/25. This resulted in R9 being admitted to the hospital for surgical debridement, IV antibiotics, insertion of a peripherally inserted central catheter (PICC) line (a thin tube inserted into a peripheral vein in the upper arm and threaded to a large vein near the heart for long-term intravenous access), and hospitalized for nine days. There was no sign of infection at the time the Apligraf was applied on 11/3/25.Findings include: The facility's Medication Orders policy, dated February 2025, indicates: The purpose of this procedure is to establish uniform guidelines in receiving and recording medication orders .Recording Orders: .6. Treatment Orders: When recording treatment orders, specify the treatment, frequency, and duration of the treatment .From 1/12/26 to 1/20/26, Surveyor reviewed R9's medical record. R9 was admitted to the facility on [DATE] and had diagnoses including diabetes with polyneuropathy, peripheral artery disease, status post right below-the-knee amputation (BKA) (7/16/25), and chronic left posterior ankle diabetic ulcer with visible tendon. R9's Minimum Data Set (MDS) assessment, dated 1/7/26, had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R9 had intact cognition. R9 made R9's own healthcare decisions.R9 had a diabetic ulcer on the left foot. Surveyor reviewed wound care notes and physician visit notes. (Of note: The location was referred to as heel and posterior ankle interchangeably.) A wound care note, dated 9/25/25, indicated R9's right BKA surgical stump wound was healed and the left heel wound included visible tendon.A note from a podiatry visit with Doctor of Podiatric Medicine (DPM)-P on 10/16/25 indicated: Cleanse wound with saline and gauze. Apply gentian (antiseptic dye that helps promote healing) to peri-wound and Adaptic (non-adherent wound dressing that protects regenerating tissue) to wound bed. Cover with ABD (gauze dressing that absorbs fluid from draining wounds). Secure with Kerlix (gauze bandage). Change three times weekly and as needed. R9 was being treated under an advanced wound care plan and with a plan to apply a graft.On 10/20/25, podiatry applied an Apligraf to R9's left heel. A wound care note, dated 10/27/25, indicated: Apligraf applied last week. Okay to remove Apligraf today. DPM-P plans to apply every other week with a one week break between applications. Will alternate wound care and podiatry appointments with wound care to remove graft and podiatry to apply. Will apply Hydrofera blue (antibacterial foam wound dressing) today. Left posterior ankle: Cleanse wound with saline and gauze. Apply saline-moistened Hydrofera blue to wound bed. Cover with ABD. Secure with Kerlix. Change 3 times weekly and as needed (PRN). On 11/3/25, podiatry applied Apligraf #2 to R9's left heel ulcer. A progress note by DPM-P indicated: The total wound surface area has continued to improve and is 11 centimeters squared (cm2). Apligraf application was discussed to help promote healing. Verbal consent was obtained. Home health will change the dressing once this week. They are not to disturb the Steri-Strips or Adaptic so as not to disturb the graft. R9 should follow-up with DPM-P next week. Apligraf 11 cm2 graft application #2 was applied to the wound. Adaptic was applied over the graft followed by Steri-Strips, a 4 x 4 (gauze), and an ABD. Kerlix and Coban (self-adherent plastic wrap used in wound care) were applied over the Steri-Strips and Adaptic. The graft should not be disturbed until R9 follows-up with wound care the following week. A new graft should be applied in 2 weeks. A progress note, dated 11/3/25 at 2:05 PM and written by Licensed Practical Nurse (LPN)-F, indicated R9 had a podiatry appointment with treatment: Wound graft #2 placed on left foot. DO NOT REMOVE. (Of note: The order (written on 11/3/25) was not entered into R9's Treatment Administration Record (TAR) until 11/4/25. A wound care note, dated 11/11/25, indicated when R9's heel dressing was removed, the Apligraf was gone. The left heel contained a significant amount of boggy, non-viable, hypergranulation tissue (excessive growth of friable, bright red or dark tissue that extends above the wound margin, often signaling stalled healing, infection, or chronic irritation). The wound edges were cauterized (a medical technique using heat chemicals (electrocautery), or cold (cryocautery) to seal blood vessels, stop bleeding, and remove abnormal tissue). R9 was admitted to the hospital for surgical debridement (a medical procedure that uses sterile instruments like scalpels or scissors to remove necrotic (dead), damaged, or infected tissue and foreign debris from a wound, facilitating faster healing) and IV antibiotics. (Of note: R9 reported to the wound care provider during the visit that a nurse removed the Apligraf a day after it was applied and later applied Adaptic and gauze. R9 did not inform anyone until the wound clinic visit on 11/11/25.) On 11/13/25, R9 was diagnosed with calcaneus (heel bone) osteomyelitis status post partial calcanectomy (removal of heel bone) and debridement and had a bone biopsy. R9 was diagnosed with Achilles tendon and calcaneus with abscess, calcaneal avulsion fracture (a rare heel bone injury where the Achilles tendon pulls a piece of the heel bone away) and a partial thickness tear of the Achilles tendon.On 11/20/25, R9 returned to the facility on IV antibiotics (vancomycin and ceftriaxone) and had orders for wound care.A vascular surgery note, dated 11/24/25, indicated R9 had adequate perfusion to the left heel wound and required surgical intervention for carotid stenosis (narrowing of the carotid arteries in the neck, usually from plaque buildup, which restricts blood flow and oxygen to the brain, significantly increasing stroke risk) to decrease the risk of stroke when there were no further signs of infection. R9 was cleared to wear a prosthetic and follow-up with a carotid duplex in 2 months.An Infectious Disease note, dated 12/2/25, indicated R9's surgical culture was positive for Proteus and diptheroids. The wound was closed with no signs of infection. R9 was to continue IV vancomycin until 12/25/25, complete a vancomycin trough (a lab to measure vancomycin levels) and weekly labs, and start Cefdinir (an antibiotic) 300 milligrams (mg) by mouth twice daily for 2 months starting 12/26/25.A podiatry note, dated 12/4/25, indicated R9's heel wound sutures were removed with no signs of infection. R9's foot was dressed with a dry sterile dressing. The note indicated to keep the dressing clean, dry, and intact and continue elevating. R9 could weight bear as tolerated with the prosthetic and progress with physical therapy.A wound care note, dated 12/30/25, indicated the wound was healed. It was recommended to cover the wound for protection for 2 weeks. R9 could weight bear and wear proper footwear. The note contained the following wound care order: Left posterior ankle: Cleanse with saline; pat dry; cover newly healed area with ABD and Kerlix padding the heel well. Change 3 times weekly and as needed. Continue pressure relief to the left heel and prevent friction to the area to prevent reopening.Surveyor reviewed R9's medical record and TAR for wound care orders for the left posterior ankle/heel and noted the following:~ Dressing change for left lower extremity (LLE): Per podiatry: Change outer bandage cautiously with gauze, ABD, Kerlix, and tape twice weekly. Once daily on Tuesday and Saturday. Special Instructions: ***DO NOT REMOVE ADAPTIC AND STERI-STRIPS*** SKIN GRAFT TO REMAIN IN PLACE. (Start date: 10/20/25; End date: 10/28/25). (The order was documented as completed on 10/21/25 and 10/25/25.) ~ Cleanse wound with saline and gauze. Apply saline-moistened Hydrofera blue to wound bed. Cover with ABD. Secure with Kerlix. Once daily on Tuesday, Thursday, and Saturday (Start date: 10/28/25; End date: 11/4/25).~ Left posterior ankle: Cleanse wound with saline and gauze. Apply saline-moistened Hydrofera blue to wound bed. Cover with ABD. Secure with Kerlix. Once a day on Tuesday, Thursday, and Saturday. DO NOT REMOVE SKIN GRAFT (under special instructions) (ordered by Medical Doctor (MD)-Q and created by LPN-F). (Start date: 11/4/25; End date: 11/6/25). (The order was documented as completed by LPN-F on 11/4/25 and LPN-G on 11/6/25).~ DO NOT REMOVE DRESSING AT LEFT ANKLE UNTIL SEEN AT WOUND CLINIC. NEW GRAFT PLACED 11/3/25. Frequency every shift. (Start date: 11/6/25; End date: 11/20/25). (The order was documented as completed on the 11/6/25 AM shift through the 11/11/25 AM shift.) ~ DO NOT REMOVE DRESSING AT LEFT ANKLE UNTIL SEEN AT WOUND CLINIC. NEW GRAFT PLACED 11/5/25. Frequency every shift. (Start date: 11/6/25; End date: 11/6/25). (The order was documented as not completed on 11/6/25 at 3:14 PM by LPN-G with a reason of other.) On 1/15/26 at 10:58 AM, Surveyor interviewed R9 regarding the left heel skin grafts. R9 stated the day after the second graft was applied, a nurse (who R9 described) looked at R9's left heel and stated, Eww. What's that? The nurse left the room, returned with supplies, wet the wound, and pulled pieces of the skin graft off. R9 did not have feeling in the left foot. R9 did not say anything but wondered why the nurse did that. R9 stated the same nurse came back later that day with another nurse. They unwrapped R9's left foot and re-did the dressing. R9 informed the provider at a wound clinic appointment on 11/11/25. R9 stated the provider verified the skin graft was gone. On 1/20/26 at 10:45 AM, Surveyor interviewed Wound Care Registered Nurse (WCRN)-J via telephone who worked with Wound Care Nurse Practitioner (WCNP)-K at the wound clinic. RN-J verified R9's 11/11/25 appointment was pre-scheduled and stated the wound clinic did not have any documented calls from the facility except notification that R9 had an X-ray on 11/11/25. WCRN-J stated WCRN-J was available for further information via fax request. On 1/20/26 at 10:55 AM, Surveyor interviewed Podiatry Registered Nurse (PRN)-O from the office where R9 received the heel skin grafts. PRN-O verified R9's medical record did not contain telephone encounters or questions from the facility.On 1/20/26 at 11:29 AM, WCRN-J called Surveyor and stated WCRN-J spoke with the nurse and provider who worked with R9 on 11/11/25. WCRN-J stated the facility did not contact the wound clinic prior to R9's visit on 11/11/25. WCRN-J stated R9 told DPM-P that staff removed the Apligraf, applied Hydrofera blue, and then came back and removed the Hydrofera blue. WCRN-J stated wound clinic staff removed an Adaptic dressing from R9's left heel on 11/11/25 which was the only dressing on the heel. WCRN-J stated the Apligraf was not on long enough to adhere and indicated it takes 48 hours to adhere to the wound and begin working. R9 reported that staff removed the graft (on 11/4/25) the day after it was applied (on 11/3/25). WCRN-J stated R9's left heel wound became infected and required surgical debridement. R9 was admitted to the hospital on [DATE] for surgical intervention and IV antibiotics. WCRN-J stated the skin graft looked like a non-transparent gelatinous, white, shiny tissue paper with a thick consistency and was visible on the wound. WCRN-J stated when a skin graft is applied, the ordered dressing change usually includes Adaptic and Steri-Strips. WCRN-J stated if a nurse removed the skin graft, the nurse would have noticed something different and would have had to remove the ABD and Steri-Strips to remove the graft. WCRN-J verified R9's graft should not have been removed and verified R9's 11/3/25 order stated no dressing changes. WCRN-J stated the provider sends new orders back to the facility with the resident. On 1/20/26 at 12:49 PM, Surveyor interviewed LPN-F via phone. LPN-F indicated the facility received orders to change R9's left heel wound outer dressing every other or every third day and not to remove the inner dressing, unless it was saturated and they contacted the provider. LPN-F stated LPN-F did not contact the provider. LPN-F also recalled a standing order to change the outer dressing, but nothing else. LPN-F denied removing the inner dressing and stated LPN-F only changed the outer Kerlix or ace bandage once but not because it was saturated. LPN-F denied changing or removing Steri-Strips or Hydrofera blue. LPN-F thought staff said one of the nurses removed the skin graft between 11/3/25 and 11/11/25 after the second graft was applied. LPN-F stated there was no oversight of wound care at the facility. Nurses entered orders when they received them and Director of Nursing (DON)-B usually verified new orders the next day. LPN-F stated DON-B asks staff at the start of their shift to verify DON-B's work as a third check. LPN-F stated if nurses have questions regarding order entry, they ask an RN from another unit to verify the order. LPN-F verified LPN-F wrote 11/3/25 progress note regarding Apligraf #2 and not to remove it which was the order sent back from R9's 11/3/25 appointment. (Of note: The order was not entered on R9's TAR on 11/3/25.) On 1/20/26 at 1:55 PM, Surveyor interviewed Scheduler (SCH)-H who stated a nurse told SCH-H that another nurse removed R9's Apligraf because the nurse did not see the new order. SCH-H thought LPN-G (who resigned from the facility before the end of November 2025) was the one who removed the graft. SCH-H was unsure if LPN-G knew what LPN-G had done because there was confusion with R9's orders. SCH-H stated the facility's former wound nurse may have known about the graft removal but no longer worked at the facility. SCH-H stated SCH-H may have been told about the graft removal on 11/6/25 but did not tell anyone and had not heard anything since. SCH-H was unsure if DON-B was aware but assumed the nurse who informed SCH-H informed DON-B. (Of note: SCH-H's description of the nurse who allegedly removed the Apligraf matched R9's description of the nurse.) On 1/20/26 at 2:14 PM, Surveyor interviewed Rehab Manager (RM)-I who stated LPN-G called RM-I to help figure out R9's wound care orders. RM-I reviewed R9's wound care orders and noticed R9's podiatry notes indicated R9 had a graft in place for one week. When RM-I observed R9's left heel with LPN-G, the graft was intact. RM-I stated an envelope with a progress note and medication list is sent back with the resident and usually contains new orders or the wound clinic sends new orders via fax. An RN or LPN enters a progress note with the new order, enters the order in the system, and initials and dates the paper order. RM-I stated the facility does not have a policy for second checks to ensure orders are entered correctly. RM-I stated the Health Unit Coordinator (HUC) thins charts and may remove orders from a resident's paper chart. On 1/20/26 at 2:39 PM, Surveyor interviewed LPN-G via phone who worked at the facility through November 2025. LPN-G recalled R9's TAR and stated LPN-G wrote R9's orders on a sticky note prior to entering R9's room to complete a dressing change. LPN-G stated R9's left heel contained Hydrofera blue and LPN-G applied Hydrofera blue. LPN-G stated if LPN-G signed the TAR, LPN-G completed the order. When Surveyor asked if LPN-G remembered changing R9's dressing on 11/6/25, LPN-G did not recall the exact date. When Surveyor asked if LPN-G remembered a skin graft on R9's left heel, LPN-G recalled two skin grafts with Steri-Strips. LPN-G stated LPN-G did not remove the Steri-Strips from R9's left heel because the instructions stated not to. LPN-G recalled confusion with R9's wound care orders but did not recall the date or what the confusion was about. LPN-G verified RM-I reviewed the orders and stated LPN-G had not heard that the Apligraf was removed.On 1/20/26 at 3:00 PM, Surveyor interviewed DON-B who was not aware that a nurse removed R9's Apligraf. DON-B verified a progress note stated not to remove the graft. DON-B stated unless DON-B notices something out of the ordinary with an order, DON-B does not double or triple check newly entered orders and it is not necessary for the oncoming nurse to do so either. DON-B reviewed the 11/3/25 entry on R9's TAR, the 11/3/25 paper order, and the 11/3/25 provider note in R9's medical record. DON-B also reviewed orders from the provider after the first graft was applied on 10/20/25. DON-B indicated R9's wound care orders were ambiguous. When Surveyor noted the 11/11/25 wound care note stated the Apligraf was missing when the dressing was removed and R9 required wound debridement, IV antibiotics, and hospitalization, DON-B indicated there was room for improvement. DON-B stated if DON-B was aware the graft was removed, DON-B would have initiated an investigation and sent R9 back to podiatry for a graft replacement. DON-B would have also provided education regarding order entry, transcription, double checks, and skin grafts. DON-B stated new orders sometimes go to the HUC who sends the orders to DON-B, RM-I, or the Hickory unit nurse. The orders are entered by an LPN. When a resident returns from an appointment, the orders are written on paper and the unit nurse enters them in the resident's medical record and writes a progress note. The nurse puts the paper order in the resident's chart. The process is the same for faxed orders. Phone orders are written on order sheets and saved for the physician to sign. DON-B verified the facility's policy for order entry did not cover verifying or double-checking orders.On 1/21/26, Surveyor faxed DPM-P with questions per the clinic's request. Surveyor did not receive a response as of this writing.

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 57 residents residing in the facility. The microwaves on all three households contained dried food debris. Food items in the dry storage area were not label with use-by dates. Equipment in the main kitchen was not stored to prevent contamination. Findings include: On 1/13/26 at 2:09 PM, Surveyor interviewed Dietary Manager (DM)-R who stated the facility follows the Wisconsin Food Code. Microwave Cleanliness: The Wisconsin Food Code documents at 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils: (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. The Wisconsin Food Code documents at 4-602.12 Cooking and Baking Equipment: (B) The cavities and door seals of microwave ovens shall be cleaned at least every 24 hours by using the manufacturer's recommended cleaning procedure. The facility's Cleaning Instructions: Microwave Oven procedure, dated 2013, states the microwave will be kept clean, sanitized, and odor free. The microwave interior should be cleaned after each use as needed, and at a minimum, after each meal service. On 1/12/26 at 6:26 PM, Surveyor conducted an initial tour of the kitchen and 3 separate household kitchens with Assistant Dietary Manager (ADM)-S. During a tour of the household kitchens, Surveyor noted the microwaves in all three kitchens contained dried food debris on the interior ceiling. ADM-S acknowledged the debris and stated microwaves should be cleaned after each use and at the end of the day. Dating: The facility's undated Food Dating Policy indicates the facility should date everything that is opened with a prepared date and/or use-by-date .5. Dry storage is checked bi-weekly. During the initial kitchen tour that began at 6:26 PM on 1/12/26, Surveyor observed the following: ~ Elbow macaroni noodles, not in the original container, with an open date of 12/4/25 and no use-by date~ Rice, not in the original container, with an open date of 12/12/25 and no use-by date~ Halved walnuts, in the original container, with an open date of 12/24/25 and no use-by date~ Halved walnuts, in the original container, with an open date of 11/18/25 and no use-by date On 1/13/26 at 2:09 PM, Surveyor interviewed DM-R who stated staff refer to a sheet that contains foods and their use-by dates for direction on when to discard items. DM-R stated the facility's policy is to label items with open and discard dates if the item is not in its original packaging. DM-R confirmed the items observed by Surveyor should contain open and use-by dates. On 1/20/26, Surveyor reviewed the facility's Produce Storage Cheat Sheet. Items listed on the sheet included fruits and vegetables. Surveyor noted the cheat sheet did not include dry foods. Kitchen Equipment:The Wisconsin Food Code documents at 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles: .B) Clean equipment and utensils shall be stored .(2) Covered or inverted.During the initial kitchen tour that began at 6:26 PM on 1/12/26, Surveyor and ADM-S observed two mixers and a slicer that were uncovered. ADM-S stated the slicer was used daily. The mixers were not used daily. ADM-S stated the equipment is not covered when not in use. On 1/15/26 at 9:45 AM, Surveyor interviewed DM-R who was not aware kitchen equipment should be covered when not in use.

Based on staff interview and record review, the facility did not ensure 3 residents (R) (R36, R37 and R63) of 5 sampled residents reviewed for unnecessary medication had documentation that indicated the resident and/or their legal representative were thoroughly informed of the risks and benefits of prescribed psychotropic medication. R36 was prescribed duloxetine (antidepressant medication). The facility did not ensure an Informed Consent for Medication form was thoroughly reviewed and completed with R36. R37 was prescribed lorazepam (antianxiety medication) and desipramine (antidepressant medication). The facility did not ensure Informed Consent for Medication forms were thoroughly reviewed and completed with R37. R63 was prescribed buspirone (antianxiety medication) and citalopram (antidepressant medication). The facility did not ensure Informed Consent for Medication forms were thoroughly reviewed and completed with R63. Findings include: The facility's undated Psychotropic Medication policy indicates: .1. The facility will make every effort to comply with state and federal regulations related to the use of psychopharmacological medications in the long-term care facility to include regular review for .side effects, risks and/or benefits .3. Document discussion with the resident and/or responsible party regarding the risks versus benefits of the use of these medications. Included in the discussion and documentation must be the presence of any black box warning or off label use of the medication affecting the prescribing of the medication to the resident. 1. From 1/12/26 to 1/20/26, Surveyor reviewed R36's medical record. R36 was admitted to the facility on [DATE] and had diagnoses including vascular dementia with mood disturbance and anxiety disorder. R36's Minimum Data Set (MDS) assessment, dated 1/2/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R36 had intact cognition. R36 was responsible for R36's healthcare decisions. Review of R36's Informed Consent for Medication form for duloxetine indicated the medication was prescribed for depression. Surveyor noted that R36 only initialed and dated page 1. Pages 2 and 3 did not contain R36's initials, signature, or a date. In addition, questions 2 and 3 on page 1 were left blank. (See interviews under example 3) 2. From 1/12/26 to 1/20/26, Surveyor reviewed R37's medical record. R37 was admitted to the facility on [DATE] and had diagnoses including anxiety disorder and depression. R37's MDS assessment, dated 10/21/25, had a BIMS score of 15 out of 15 which indicated R37 had intact cognition. R37 was responsible for R37's healthcare decisions. Surveyor reviewed R37's Informed Consent for Medication forms for Ativan and desipramine and noted R37 only signed and dated the last page of both forms. Pages 1, 2, and 3 did not contain initials or dates. In addition, questions 2 and 3 on page 1 were left blank. (See interviews under example 3) 3. On 1/14/26, Surveyor reviewed R63's medical record. R63 was admitted to the facility on [DATE] and had diagnoses including anxiety and depression. R63's MDS assessment, dated 1/14/26, had a BIMS score of 13 out of 15 which indicated R63 had intact cognition. R63 made R63's own healthcare decisions. R63's medication orders included buspirone for anxiety and citalopram for depression. On 1/15/26 at 11:14 AM, Surveyor reviewed R63's Informed Consent for Medication forms for buspirone and citalopram. Surveyor noted R63 signed and dated the last page of both forms; however, all pages did not contain initials or dates. In addition, questions 2 and 3 on page 1 were left blank on both forms. On 1/20/26 at 12:30 PM, Surveyor interviewed Registered Nurse (RN)-M regarding the process of filling out Informed Consent for Medication forms. RN-M stated not all nurses have residents initial and date every page. RN-M indicated RN-M usually just has the resident sign and date the last page but should have residents initial and date all pages. On 1/20/26 at 12:35 PM, Surveyor interviewed Director of Nursing (DON)-B who stated it would be nice if all pages were initialed, dated, and completed; however, it was fine as long as the last page was signed and dated.

Based on staff interview and record review, the facility did not notify the State Long-Term Care Ombudsman of an emergent hospital transfer for 1 resident (R) (R10) of 6 sampled residents.R10 was transferred to the Emergency Department (ED) on 11/25/25 for evaluation. The Ombudsman was not notified of the transfer. In addition, Social Worker (SW)-L was not aware of the need to notify the Ombudsman of hospital transfers if the resident returned to the facility.Findings include:The facility's undated Discharge policy did not include Ombudsman notification of hospital transfers.From 1/12/26 to 1/15/26, Surveyor reviewed R10's medical record. R10 was admitted to the facility on [DATE] and had diagnoses including type 2 diabetes mellitus and peripheral artery disease. R10's Minimum Data Set (MDS) assessment, dated 1/5/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R10 had intact cognition.R10's medical record indicated R10 was transferred to the ED on 11/25/25 for evaluation.On 1/14/26 at 10:04 AM, Surveyor reviewed Ombudsman notification for 11/1/25 to 11/30/25 and noted R10's 11/25/25 ED transfer was not included on the list.On 1/15/26 at 11:42 AM, Surveyor interviewed SW-L who verified R10 was transferred to the ED and returned to the facility. SW-L stated since R10 was not discharged , SW-L did not notify the Ombudsman of the transfer. SW-L stated SW-L thought Ombudsman notification was only necessary when residents were discharged from the facility.

Based on observation, staff interview, and record review, the facility did not ensure Minimum Data Set (MDS) assessments were accurate for 3 residents (R) (R36, R1, and R28) of 16 sampled residents.R36's MDS assessments, dated 1/2/26 and 12/3/25, indicated R36 received hypnotic medication. R36 was not prescribed a hypnotic medication.R1's MDS assessment, dated 10/13/25, indicated R1 received parenteral feeding. R1 did not receive parenteral feeding. R28's MDS assessment, dated 11/20/25, did not indicate R28 was on dialysis. R28 was on dialysis since admission to the facility on 8/14/25. Findings include: The facility's Minimum Data Set (MDS)/Health Information Process policy, dated September 2025, indicates: .3. (Named Company) will upload all relevant information including the resident's history and physical, hospital discharge summary, medical visits, imaging, and labs. (Named Company) completes authorizations, updates, audits, and coding .6. Section K is completed by the Registered Dietitian .8. Sections H, I, J, M, N, O, and P are input by (Named Company) and reviewed/signed by the Director of Nursing (DON) .9. The DON will sign verify that the MDS is completed. 1. From 1/12/26 to 1/20/26, Surveyor reviewed R36's medical record. R36 was admitted to the facility on [DATE] and had diagnoses including vascular dementia with mood disturbance and anxiety disorder. R36's MDS assessment, dated 1/2/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R36 had intact cognition. R36 was responsible for R36's healthcare decisions. On 1/13/26, Surveyor reviewed the facility's matrix for providers which indicated R36 was prescribed a hypnotic medication. R36's Quarterly MDS assessment, dated 1/2/26, and Significant Change MDS assessment, dated 12/3/25, indicated R36 received hypnotic medication. R36's physician's orders did not include hypnotic medication. On 1/14/26 at 9:42 AM, Surveyor interviewed Minimum Data Set Coordinator (MDSC)-N who was responsible for coding Section N of the MDS assessments. MDSC-N was unsure why the MDS assessments indicated R36 received hypnotic medication. MDSC-N stated the assessments may have been coded in error. On 1/15/26 at 2:33 PM, Surveyor interviewed DON-B who stated R36 was prescribed Remeron (antidepressant medication); however, the indications for use had changed since admission. DON-B stated R36 received Remeron for appetite stimulation, depression, and insomnia. DON-B stated Remeron should be coded as an antidepressant medication and not a hypnotic medication on the MDS assessments and confirmed R36's MDS assessments were coded in error. 2. From 1/12/26 to 1/15/26, Surveyor reviewed R1's medical record. R1 was admitted to facility on 8/4/21 and had diagnoses including dementia, cognitive impairment, delusional disorder, and communication deficit. R1's MDS assessment, dated 10/13/25. had a BIMS score of 10 out of 15 which indicated R1 had moderate cognitive impairment. R1 had an activated Power of Attorney (POA) since 1/30/24. On 1/12/26 ,Surveyor reviewed the facility's matrix which indicated R1 received parenteral feeding. Surveyor noted R1's 10/13/25 MDS assessment also indicated R1 received parenteral feeding. On 1/14/26 at 12:02 PM, Surveyor observing R1 eating at a table in the dining room. When Surveyor asked Licensed Practical Nurse (LPN)-F if R1 also received parenteral feeding, LPN-F indicated R1 never received parenteral feeding. On 1/15/26 at 2:32 PM, Surveyor interviewed DON-B who verified that R1 did not receive parenteral nutrition and R1's MDS assessment was coded in error. 3. From 1/12/26 to 1/15/26, Surveyor reviewed R28's medical record. R28 was admitted to the facility on [DATE] and had diagnoses including end stage renal disease and dependence on renal dialysis. R28 received hemodialysis related to renal failure at an outside dialysis center 3 times weekly (Monday, Wednesday, and Friday). R28's MDS assessment, dated 11/20/25, had a BIMS score of 13 out of 15 which indicated R28 had intact cognition. R28's MDS assessment, dated 11/20/25, did not indicate R28 received dialysis. On 1/14/26 at 9:43 AM, Surveyor interviewed MDSC-N who confirmed R28's 11/20/25 MDS assessment did not indicate R28 received dialysis. MDSC-N indicated dialysis was also missed on the 11/20/24 MDS assessment. MDSC-N was unsure why it was missed and confirmed R28 had been on dialysis since admission.

Based on staff interview and record review, the facility did not ensure care and services to prevent pressure injuries from developing and/or promote healing was provided for 2 residents (R) (R8 and R36) of 6 sampled residents.On 11/20/25, R8 was noted to have a stage 1 pressure injury on top of the head. The facility did not ensure preventative measures were implemented to prevent further skin breakdown which resulted in a stage 2 pressure injury on top of R8's head.On 12/26/25, R36 was re-admitted to the facility from an acute hospital stay with a stage 2 pressure injury on the left buttock. On 1/3/26, the facility documented that R36 developed a stage 2 pressure injury on the right buttock. The facility did not ensure initial evaluations and/or wound assessments were completed to monitor R36's pressure injuries.Findings include:The facility's undated Pressure Injuries Overview/Staging policy indicates avoidable means the resident developed a pressure ulcer/injury and that one or more of the following was not completed: Evaluation of the resident's clinical condition and risk factors; Definition or implementation of interventions consistent with resident needs, resident goals, and professional standards of practice; Monitoring or evaluation of the impact of the interventions; or Revision of the interventions as appropriate.1. From 1/12/26 to 1/20/26, Surveyor reviewed R8's medical record. R8 was admitted to the facility on [DATE] and had diagnoses including dementia, Parkinson's disease, abnormal involuntary movements, and abnormal posture. R8's Minimum Data Set (MDS) assessment, dated 11/1/25, indicated R8 was rarely to never understood/understands. A staff interview for mental status indicated R8 had severe cognitive impairment. R8 had an activated Power of Attorney for Healthcare (POAHC) who assisted with healthcare decisions.A pressure injury care plan, dated 7/26/23, indicated R8 had the potential for alteration in skin integrity secondary to decreased functional mobility and frequent involuntary movements from Parkinson's disease. A progress note, dated 11/20/25, stated staff notified nursing that when they got R8 up for the day, R8 was sleeping with R8's head against the wall. R8 had a reddened area on the top back of the head with a small abrasion. The physician was notified and directed staff to treat the area as a stage 1 pressure injury. (Of note: R8's alteration in skin integrity care plan was not updated following the discovery of the stage 1 pressure injury.) A physician order, dated 11/20/25 through 1/4/26, indicated to monitor the stage 1 pressure injury on top of R8's head related to leaning R8's head against the wall while sleeping. A progress note, dated 12/13/25 at 2:23 PM and written by Licensed Practical Nurse (LPN)-F, indicated Certified Nursing Assistant (CNA)-T informed LPN-F that R8's head was against wall when CNA-T got R8 up for the day. LPN-F indicated the area on top of R8's head was the same area that had previously healed. The area included a small bump that was approximately 0.5 inches (length) x 0.5 inches (width) with the top layer of skin peeled off. The area was cleaned and bandaged. LPN-F initiated an intervention to add padding between the wall and bed to prevent R8's head from rubbing the wall.A Therapy Screen, dated 12/16/25, contained a safety measure to place 2 foam wedges between the bed and the wall to prevent R8's head from rubbing against the wall.An admission Skin Assessment, dated 12/17/25, indicated R8 had a pressure wound on the top of the scalp that measured approximately 2.5 centimeters (cm) x 3.0 cm with a red abrased area, shallow. yellow crater areas, and dried red scabs. The area was open to air and covered with Aquaphor.R8's Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not include treatment orders for the stage 2 pressure injury.On 1/14/26 at 12:14 PM, Surveyor interviewed CNA-T who confirmed CNA-T got R8 up on 12/13/25. CNA-T stated R8's head was against the wall and skin from R8's head was on the wall when CNA-T repositioned R8. CNA-T notified LPN-F. CNA-T stated pillows and wedge cushions were put between the wall and bed to prevent R8 from rubbing R8's head. CNA-T was aware that R8 had a previous area on top of the head but was uncertain how the injury occurred or if there were any interventions in place.On 1/14/26 at 3:23 PM, Surveyor interviewed LPN-F who assessed R8's wound on 12/13/25. LPN-F verified CNA-T reported that skin on the top of R8's head rubbed off on the wall. LPN-F stated the area had reopened and resulted from R8 resting R8's head against the wall. LPN-F completed the necessary treatment, entered a nursing order, and sent a fax to the physician. LPN-F stated the facility did not have a standardized wound assessment to complete and indicated nursing would monitor the area and document if it worsened. LPN-F stated LPN-F does not chart if the wound improves/heals and only documents if it worsens.On 1/15/26 at 8:19 AM, Surveyor interviewed Director of Nursing (DON)-B who was aware that wound care was an issue in the facility. DON-B stated the facility's previous wound nurse was no longer with the facility and a new wound provider was not scheduled to start rounds until 1/22/26. DON-B stated nurses only document wounds in progress notes. DON-B verified the facility did not have a standardized tool to assess wounds. DON-B stated Rehab Manager (RM)-I had more information related to R8's wound care.On 1/20/26 at 12:42 PM, Surveyor interviewed RM-I who stated RM-I became aware on 12/15/25 that R8 had an open area on top of the head from resting R8's head against the wall. RM-I was unsure why R8's head was against the wall and stated R8 had a severe left lean at times and head jerking movements related to RM-I's diagnosis. RM-I stated the facility's Interdisciplinary Team decided to place a mat next to the wall until therapy could screen R8. RM-I stated the open area was a new area on top of R8's head, but acknowledged R8 had a similar area prior. RM-I stated RM-I managed wounds on R8's unit only and did not know if an intervention was implemented following R8's first pressure injury on 11/20/25. RM-I stated if a safety measure was implemented on 11/20/25, it should have been on R8's care plan. RM-I confirmed R8's care plan did not include foam wedges or a wall mat.2. From 1/12/26 to 1/20/26, Surveyor reviewed R36's medical record. R36 was admitted to the facility on [DATE] and had diagnoses including vascular dementia and cerebral infarction affecting the right dominant side. R36's MDS assessment, dated 1/2/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R36 had intact cognition. R36 was responsible for R36's healthcare decisions.A progress note, dated 12/26/25, indicated R36 was readmitted to the facility with a stage 2 pressure injury on the left buttock that was treated with barrier cream. (Of note: R36's medical record did not include a full nursing assessment or measurement of the area.) A progress note, dated 1/3/26, indicated R36 had a 1 cm x 0.7 cm x 0.1 cm open area on the right buttock. R36 had an order to clean the wound with normal saline and apply a Mepilex dressing. (Of note: R36's medical record did not contain ongoing assessments or monitoring of the area.)On 1/20/26 at 12:35 AM, Surveyor interviewed RM-I who stated when a new area is discovered, nurses should assess and measure the area and send a fax to the physician for orders. RM-I stated the facility did not have a specific procedure for ongoing wound assessments. RM-I stated some nurses document the status of the wound with each treatment or dressing change and others only document if the wound worsens. RM-I stated nurses should document an assessment of the wound every time they provide treatment to the area.On 1/20/26 at 10:48 AM, Surveyor interviewed DON-B who confirmed the only documentation of R36's wounds was in R36's progress notes. DON-B was aware of concerns regarding wound care and stated a new provider was starting on 1/22/26 and would complete weekly wound rounds. DON-B confirmed staff education was not completed regarding wound care concerns.

Based on staff interview and record review, the facility did not complete a fall report to determine the root cause of a fall, update a care plan, or implement post-fall monitoring for 1 resident (R) (R8) of 1 sampled resident. R8 had an unwitnessed fall on 1/8/26. The facility did not complete a fall incident report or post-fall neurological checks. In addition, the facility did not update R8's care plan with a preventative safety intervention.Findings include:The facility's undated Assessing Falls policy indicates: .6. Observe for delayed complications of a fall for approximately seventy-two hours after a fall and document findings in the medical record .8. Complete an incident report for a resident fall no later than 24 hours after the fall occurs. The incident report should be completed by the nursing supervisor on duty and submitted to the Director of Nursing (DON) .When a resident falls, the following information should be recorded in the resident's medical record . 2. Assessment data, including vital signs and injuries. 3. Interventions, first aid, or treatment administration.The facility's undated Neurological Assessment procedure indicates routine neurological assessments are conducted to evaluate the resident for small changes over time or from a fall that may be indicative of neurological injury.The facility's undated Neurological Flow Sheet indicates staff should complete vital signs and neurological checks as follows: Every 15 minutes x 1 hour; Every 30 minutes x 1 hour; Every 1 hour x 4 hours; Every 4 hours x 24 hours.From 1/12/26 to 1/20/26, Surveyor reviewed R8's medical record. R8 was admitted to the facility on [DATE] and had diagnoses including dementia, Parkinson's disease, abnormal involuntary movements, and history of repeated falls. R8's Minimum Data Set (MDS) assessment, dated 11/1/25, indicated R8 was rarely to never understood/understands. A staff interview for mental status indicated R8 had severe cognitive impairment. R8 had an activated Power of Attorney for HealthCare (POAHC) to assist with healthcare decisions.A progress note, dated 1/8/26 at 3:38 PM, indicated staff discovered R8 on the floor lying on the left side. R8's medical record did not include a fall report, a preventative safety intervention implemented post-fall, or neurological checks completed post-fall.On 1/20/26 at 12:44 PM, Surveyor interviewed Rehab Manager (RM)-I who confirmed R8's care plan was not updated with a safety intervention following the fall. RM-I confirmed R8's care plan should have been updated.On 1/20/26 at 11:47 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-E who stated if a resident has an unwitnessed fall, neurological checks should be completed using a paper flowsheet. The checks should be documented in the resident's medical record.On 1/20/26 at 10:47 AM, Surveyor interviewed Director of Nursing (DON)-B who verified an incident report, care plan revision, and neurological checks were not completed for R8 following R8's fall on 1/8/26. DON-B verified an incident report should have been completed to determine the root cause of the fall and appropriate safety interventions should have been implemented. DON-B also confirmed neurological checks should have been completed.

Based on observation, staff and resident interview, and record review, the facility did not provide the necessary respiratory care and services for 3 residents (R) (R10, R15, and R62) of 3 sampled residents.R10, R15, and R62 did not have orders or care plans for nebulizer (a medical device that turns liquid medicine into a fine mist allowing it to be inhaled directly into the lungs to treat respiratory conditions) cleaning.Findings include:The facility's undated Administering Medications Through a Small Volume Nebulizer policy indicates: .Steps in the Procedure: .26. Rinse and disinfect the nebulizer equipment according to facility protocol, or: a. Wash pieces with warm, soapy water; b. Rinse with hot water; c. Place all pieces in a bowl and cover with isopropyl (rubbing) alcohol. Soak for five minutes; d. Rinse all pieces with sterile water (not tap, bottled, or distilled); and e. Allow to air dry on a paper towel .28. When equipment is completely dry, store in a plastic bag with the resident's name and date. 29. Change equipment and tubing every seven days, or according to facility protocol .1.From 1/12/26 to 1/15/26, Surveyor reviewed R10's medical record. R10 was admitted to the facility on [DATE] and had diagnoses including type 2 diabetes mellitus and chronic obstructive pulmonary disease (COPD). R10's Minimum Data Set (MDS) assessment, dated 1/5/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R10 had intact cognition.R10 had the following physician orders:~ Budesonide (used to treat respiratory conditions) suspension for nebulization; 0.5 milligrams (mg)/2 milliliters (ml); 1 vial via inhalation once daily.~ Ipratropium-albuterol (used to treat respiratory conditions) solution for nebulization; 0.5 mg-3 mg (2.5 mg base)/3 ml; 1 ampule via inhalation four times daily.On 1/12/26 at 7:30 PM, Surveyor interviewed R10 and observed a nebulizer on the nightstand with a mouthpiece stained with what appeared to be red lipstick. R10 thought staff cleaned the nebulizer and stated R10 used the nebulizer a couple days ago. Surveyor also interviewed Registered Nurse (RN)-C who entered R10's room during the interview. RN-C confirmed the mouthpiece contained red lipstick and indicated it was from that day because R10 had nebulizer treatments scheduled four times daily. RN-E stated nursing staff usually rinse the nebulizer.On 1/12/26 at 8:56 PM, Surveyor interviewed RN-C regarding nebulizer cleaning. RN-C stated nebulizers should be rinsed after each use, placed in the bathroom to dry, and should be dated and changed every 3 days.2. From 1/12/26 to 1/15/26, Surveyor reviewed R15's medical record. R15 was admitted to the facility on [DATE] and had diagnoses including shortness or breath, chronic cough, and other COPD. R15's MDS assessment, dated 10/30/25, had a BIMS score of 12 out of 15 which indicated R15 had moderate cognitive impairment. R15 had an activated Power of Attorney for Healthcare (POAHC).R15 had the following physician order:~ Budesonide suspension for nebulization 0.5 mg/2 ml; 1 dose via inhalation twice daily.On 1/12/26 at 7:44 PM, Surveyor interviewed R15 and observed a nebulizer on the nightstand. The tubing was not dated and the nebulizer chamber contained liquid. R15 stated the nebulizer was not cleaned that day after use.3. From 1/12/26 to 1/15/26, Surveyor reviewed R62's medical record. R62 was admitted to the facility on [DATE] and had diagnoses including acute bronchospasm (sudden tightening of airway muscles) and influenza. R62's MDS assessment, dated 1/13/26, had a BIMS score of 13 out of 15 which indicated R62 had intact cognition.R62 had the following physician order:~ Albuterol sulfate (used to treat respiratory conditions) solution for nebulization 2.5 mg/3 ml; 1 vial via inhalation.On 1/12/26 at 7:20 PM, Surveyor interviewed R62 and observed a nebulizer on the nightstand. The nebulizer tubing and equipment were not dated and the nebulizer chamber contained drops of liquid. R62 stated R62 had not seen anybody rinse the nebulizer chamber. R62 used the nebulizer twice daily.On 1/13/26 at 2:38 PM, Surveyor interviewed RN-C and Licensed Practical Nurse (LPN)-E who both indicated nebulizer equipment should be taken apart and rinsed under tap water then dried on a paper towel after each use. RN-C and LPN-E confirmed R10, R15, and R62's medical records did not contain orders for nebulizer cleaning. RN-C and LPN-E also indicated nurses clean nebulizers after nebulizer treatments but there was no documentation for cleaning.On 1/13/26 at 3:05 PM, Surveyor interviewed Director of Nursing (DON)-B regarding nebulizer cleaning. DON-B indicated nebulizer chambers/parts should be rinsed with sterile water after each use and cleaning should be documented in the resident's Medication Administration Record (MAR) or Treatment Administration Record (TAR).

Based on staff and resident interview and record review, the facility did not ensure vital signs, weight, and monitoring of the fistula site were completed before and after dialysis for 1 resident (R) (R28) of 1 sampled resident.R28's medical record did not contain orders to obtain vital signs or weight or monitor the fistula site pre- or post-dialysis. Findings include: The facility's Dialysis policy, dated October 2025, indicates: This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan .to meet the medical needs of the resident receiving hemodialysis .Compliance Guidelines: .4. The licensed nurse will communicate to the dialysis facility via .dialysis communication form or other form, that will include but not limit itself to: .b. Vital signs .d. Nutritional/fluid management including documentation of weights .7. The nurse will monitor and document the status of the resident's access site upon return from the dialysis treatment to observe for bleeding or other complications .11. The nurse will ensure the dialysis access site is checked before and after dialysis treatments and every shift for patency by auscultating for a bruit and palpating for a thrill. If absent, the nurse will immediately notify the attending physician, dialysis facility, and/or nephrologist. From 1/12/26 to 1/15/26, Surveyor reviewed R28's medical record. R28 was admitted to the facility on [DATE] and had diagnoses including end stage renal disease and dependence on renal dialysis. R28 received hemodialysis related to renal failure at an outside dialysis center 3 times weekly (Monday, Wednesday, and Friday). R28's Minimum Data Set (MDS) assessment, dated 8/20/25, had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R28 had intact cognition. R28's medical record did not contain documentation of fistula site assessment for bleeding, thrills, or bruits or documentations of vital signs obtained by facility staff. Vital signs recorded in R28's medical record were vital signs obtained by dialysis staff. On 1/12/26 at 7:59 PM, Surveyor interviewed R28 regarding assessments done before and after dialysis. R28 indicated staff do not obtain R28's vital signs or weight prior to or after dialysis treatments. R28 stated the dialysis center obtains R28's vital signs and weight when R28 arrives. R28 stated facility staff check R28's fistula for bleeding. On 1/13/26 at 2:41 PM, Surveyor interviewed Registered Nurse (RN)-C and Licensed Practical Nurse (LPN)-E regarding assessments completed for R28 pre- and post-dialysis. RN-C stated RN-C ensures R28's fistula is assessed and not bleeding. When Surveyor asked if RN-C documents the assessment, RN-C could not provide documentation and stated RN-C might have missed some assessments. LPN-E confirmed R28 did not have an order to check for bruit and thrill. LPN-E verified vital signs are not obtained by facility staff pre- or post-dialysis but stated they are obtained at the dialysis center. On 1/13/26 at 2:55 PM, Surveyor interviewed Director of Nursing (DON)-B who stated nurses should check a resident's fistula for bruit and thrill and confirmed R28 did not have an order to do so. DON-B also stated nurses should obtain a resident's vital signs pre- and post-dialysis and check the fistula site for bleeding. DON-B verified monitoring and assessments should be documented in R28's medical record.

Based on staff interview and record review, the facility did not ensure allegations of abuse were reported to the State Agency (SA) for 2 residents (R) (R4 and R6) of 7 sampled residents. On 11/22/24, R7 notified staff that R1 was physically aggressive toward R4 on 11/21/24. The facility did not report the allegation of abuse to the SA. On 11/22/24, R1 initiated a resident-to-resident altercation with R6. The facility did not report the allegation of abuse to the SA. Findings include: The facility's Abuse, Neglect, Mistreatment and Misappropriation of Resident Property and Exploitation policy, revised 5/2023, indicates: It is the policy of the facility to encourage and support all residents, staff, families, visitors, volunteers, and resident representatives in reporting any suspected acts of abuse .Residents will not be subjected to abuse by anyone, including but not limited to, facility staff, other residents .Any nursing home employee or volunteer who becomes aware of abuse, mistreatment, neglect, exploitation or misappropriation shall immediately report to the Nursing Home Administrator. The Nursing Home Administrator or designee will report abuse to the State Agency per state and federal requirements . On 2/27/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had a diagnosis of Alzheimer's disease. R1's Minimum Data Set (MDS) assessment, dated 9/13/24, had a Brief Interview for Mental Status (BIMS) score of 5 out of 15 which indicated R1 had severe cognitive impairment. R1's medical record indicated R1 had a Power of Attorney for Healthcare (POAHC) who was responsible for R1's healthcare decisions. R1 passed away at the facility on 12/1/24. R1's medical record contained a note, dated 11/22/24, that indicated R1 was yelling in the dining room. After staff redirected R1 to R1's room, R1 re-entered the dining room, grabbed the handles of another resident's wheelchair, shook the wheelchair and yelled, Come on let's go. Staff redirected R1 out of the dining room. On 2/27/25, Surveyor reviewed a grievance investigation, dated 11/22/24, that indicated R7 (whose MDS assessment, dated 12/23/24, indicated R7 was not cognitively impaired) reported to staff that R1 attempted to stab R4 but missed and threw a knife or a fork at R4 on 11/21/24. The investigation indicated staff reported the allegation of abuse to Nursing Home Administrator (NHA)-A and placed R1 on 1:1 supervision at all times. On 2/27/25, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] and had diagnoses including heart failure and major depressive disorder. R4's MDS assessment, dated 2/18/25, had a BIMS score of 9 out of 15 which indicated R4 had moderate cognitive impairment. R4's medical record indicated R4 had a POAHC who was responsible for R4's healthcare decisions. On 2/27/25 at 12:26 PM and 1:09 PM, Surveyor interviewed Director of Nursing (DON)-B and Social Worker (SW)-C. SW-C indicated the facility was informed that the incident involving R4 occurred in the evening on 11/21/24. SW-C indicated R6 was the resident in the wheelchair mentioned in the 11/22/24 note in R1's medical record. SW-C indicated R6 told SW-C that R1 swung out at (R6) but (R6) was able to move away. SW-C indicated decisions regarding reporting involve a group discussion with NHA-A who makes the final decision whether or not to report to the SA. SW-C indicated NHA-A chose not to report the above incidents. SW-C indicated the above incidents should have been reported to the SA from a regulation standpoint.DON-B indicated DON-B verbally re-educated staff regarding reporting requirements but did not document the education or which staff received the education. On 2/27/25, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] and had diagnoses including congestive heart failure and asthma. R6's MDS assessment, dated 1/26/25, had a BIMS score of 13 out of 15 which indicated R6 was not cognitively impaired. R6's medical record indicated R6 had a POAHC who was responsible for R6's healthcare decisions. On 2/27/25, Surveyor reviewed handwritten notes that indicated SW-C reported R1's 11/22/24 incident of aggression toward R6 to NHA-A on 11/22/24. On 2/27/25 at 1:42 PM, Surveyor interviewed DON-B who indicated R4 and R6 were not physically harmed. DON-B indicated DON-B spoke with R4 a couple days after the 11/21/24 incident. DON-B indicated R4 told DON-B that R4 felt a little shaken up at the time (of the incident) but felt fine at the time of the discussion with DON-B.

Based on staff interview and record review, the facility did not ensure allegations of abuse were thoroughly investigated for 2 residents (R) (R4 and R6) of 7 sampled residents. On 11/22/24, R7 notified staff that R1 was physically aggressive toward R4 on 11/21/24. The facility did not thoroughly investigate the allegation of abuse. On 11/22/24, R1 was physically aggressive toward R6. The facility did not thoroughly investigate the allegation of abuse. Findings include: The facility's Abuse, Neglect, Mistreatment and Misappropriation of Resident Property and Exploitation policy, revised 5/2023, indicates: The facility will immediately begin a thorough investigation of any reported incident, collect information that corroborates or disproves the incident and document the findings for the incident .A root cause investigation and analysis will be completed. A thorough investigation is an investigation that adequately addresses the circumstances of the allegation. The investigation will include the facts necessary to form a reasonable conclusion as to what happened. The facility will document the investigation and the reasons for the conclusion. The information gathered is given to Administration and the Grievance Officer . On 2/27/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had a diagnosis of Alzheimer's disease. R1's Minimum Data Set (MDS) assessment, dated 9/13/24, had a Brief Interview for Mental Status (BIMS) score of 5 out of 15 which indicated R1 had severe cognitive impairment. R1's medical record indicated R1 had a Power of Attorney for Healthcare (POAHC) who was responsible for R1's healthcare decisions. R1 passed away at the facility on 12/1/24. R1's medical record contained a note, dated 11/22/24, that indicated R1 was yelling in the dining room. After staff redirected R1 to R1's room, R1 re-entered the dining room, grabbed the handles of another resident's wheelchair, shook the wheelchair, and yelled, Come on let's go. Staff redirected R1 out of the dining room. On 2/27/25, Surveyor reviewed a grievance investigation, dated 11/22/24, that indicated R7 (whose MDS assessment, dated 12/23/24, indicated R7 did not have impaired cognition) reported to staff that R1 attempted to stab R4 but missed and threw a knife or fork at R4 on 11/21/24. The investigation indicated staff reported the allegation to Nursing Home Administrator (NHA)-A and placed R1 on 1:1 supervision at all times. On 2/27/25, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] and had diagnoses including heart failure and major depressive disorder. R4's MDS assessment, dated 2/18/25, had a BIMS score of 9 out of 15 which indicated R4 had moderate cognitive impairment. R4's medical record indicated R4 had a POAHC who was responsible for R4's healthcare decisions. On 2/27/25 at 12:26 PM and 1:09 PM, Surveyor interviewed Director of Nursing (DON)-B and Social Worker (SW)-C. SW-C indicated the facility was informed on 11/22/24 that the incident involving R4 occurred in the evening on 11/21/24. SW-C indicated the facility was not aware of the 11/21/22 incident until R7 reported it to staff on 11/22/24. When asked about the 11/22/24 note in R1's medical record, SW-C indicated the facility did not have an investigation aside from SW-C's handwritten notes. DON-B indicated DON-B thought a Dietary Aide witnessed the 11/21/24 incident and reported it to a nurse. SW-C indicated R6 was the resident in the wheelchair mentioned in the 11/22/24 note in R1's medical record. SW-C indicated R6 told SW-C that R1 swung out at (R6) but (R6) was able to move away. On 2/27/25, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] and had diagnoses including congestive heart failure and asthma. R6's MDS assessment, dated 1/26/25, had a BIMS score of 13 out of 15 which indicated R6 was not cognitively impaired. R6's medical record indicated R6 had a POAHC who was responsible for R6's healthcare decisions. On 2/27/25, Surveyor reviewed five pages of handwritten notes that indicated SW-C reported R1's 11/22/24 incident of aggression toward R6 to NHA-A on 11/22/24. The handwritten notes contained a few dates and times. On the page that mentioned the stabbing attempt between R1 and R4, the word sobbing was written. The note did not indicate who was sobbing. On the page that mentioned R6, the words swung out and move away were written next to R6's name. On 2/27/25, Surveyor reviewed a grievance investigation, dated 11/22/24, that indicated R6 reported R1 swinging out but (R6) was not hurt and able to move away from (R1). The investigation was started on 11/25/24. On 2/27/25 at 1:42 PM, Surveyor interviewed DON-B and SW-C. DON-B indicated the forms used to document R1's 1:1 intervention were not filed in R1's medical record. DON-B stated, I assume staff threw the forms away. SW-C verified SW-C completed the grievance investigation, dated 11/22/24, regarding the incident against R6 on 2/27/25 and backdated the form to 11/22/24. SW-C stated, I had my notes, just put it in grievance format today. When asked about the 11/25/24 investigation start date on the grievance investigation, SW-C thought the 11/25/24 date was written in error by SW-C. Surveyor observed SW-C review SW-C's handwritten notes. SW-C indicated SW-C was confused regarding the dates and times. SW-C stated, I think we were called over the weekend. When asked if a thorough investigation was completed, SW-C indicated the documents did not contain details and timeframes. When asked if an investigation was not started until 11/25/24, SW-C indicated the incidents were reported to NHA-A on 11/22/24.

Based on staff interview and record review, the facility did not ensure the individual designated as the food and nutritional services director met the minimum qualifications for the role. This had the potential to affect all 55 residents residing in the facility. Dietary Manager (DM)-H did not complete an approved dietary manager or food service manager certification course or other related education. Findings include: On [DATE] at 9:04 AM, Surveyor interviewed DM-H who indicated DM-H worked in the facility for several years and had been the Dietary Manager for 3 to 4 years. DM-H indicated DM-H was ServSafe certified; however, DM-H's certification expired in August and DM-H had not renewed it. DM-H indicated DM-H was not currently enrolled in a dietary or food service manager certification course. On [DATE] at 3:40 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who confirmed DM-H was not certified or enrolled in a certified training program. NHA-A stated it was not in the facility's budget to get DM-H certified.

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect 54 of 55 residents residing in the facility. Cooling temperature logs were not completed for leftover and pre-made food. Staff did not consistently monitor or document cooked food temperatures or hot/cold holding temperatures. Staff did not consistently test or document parts per million (PPM) of the quaternary sanitizing solution per manufacturer's instructions. Staff did not monitor and document dishwasher and surface temperatures. Staff did not follow procedures for reheating food in a microwave. Staff did not wear hair restraints when entering the kitchen where resident food was prepared. Staff did not perform appropriate hand hygiene and safe food handling practices when serving food. Findings include: On 9/23/24 at 9:04 AM, Surveyor completed an initial tour of the kitchen with Dietary Manager (DM)-H who stated the facility followed the Federal Food Code. Cooling Temperatures: The 2022 Federal Food and Drug Administration (FDA) Food Code documents at 3-501.14 Cooling: (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 57 Celsius (C) (135 Fahrenheit (F)) to 21 C (70 F); and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less. (B) Time/temperature control for safety food shall be cooled within 4 hours to 5 C (41 F) or less. The 2022 FDA Food Code section 3-501.15 documents at Cooling Methods: (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under S 3-501.14 by using one or more of the following methods based on the type of food being cooled: (1) Placing the food in shallow pans; (2) Separating the food into smaller or thinner portions; (3) Using rapid cooling equipment; (4) Stirring the food in a container placed in an ice water bath; (5) Using containers that facilitate heat transfer; (6) Adding ice as an ingredient; or (7) Other effective methods. The facility's undated Food Preparation and Service policy indicates: Food and nutrition services employees prepare, distribute, and serve food in a manner that complies with safe food handling practices .1. Potentially hazardous foods are cooled rapidly. This is defined as cooling from 135 degrees F to 70 degrees F within two hours and then to a temperature of 41 degrees F or below within the next 4 hours. The total cooling time between 135 degrees F to 41 degrees F is not to exceed 6 hours .2. Large or dense foods are cooled using special interventions in order to meet the time and temperature requirements for cooling. During an initial tour of the kitchen that began at 9:04 AM on 9/23/24, Surveyor observed multiple containers in the cooler, including sauerkraut, tuna salad, stuffing, and chili. DM-H confirmed the contents were leftover meals or pre-made meals for resident consumption. DM-H stated the facility did not maintain a cooling log to ensure appropriate cooling methods were followed for leftover or pre-made food. Food Holding Temperatures: The 2022 FDA Food Code documents at section 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding .Time/Temperature Control for Safety Food shall be maintained: (1) At 57 Celsius (C) (135 Fahrenheit (F)) or above, except that roast cooked to a temperature and for a time specified in 3-401.11 (B) or reheated as specified in 3-403.11 (E) may be held at a temperature of 54 C (130 F) or above; (2) At 5 C (41 F) or less. In a January 2001 report, the National Advisory Committee on Microbiological Criteria for Foods (NACMCF) recommended the minimum hot holding temperature specified in the Food Code: Be greater than the upper limit of the range of temperatures at which Clostridium perfringens (C. perfringens) and Bacillus cereus (B. cereus) may grow; and provide a margin of safety that accounts for variations in food matrices, variations in temperature throughout a food product, and the capability of hot holding equipment to consistently maintain product at a desired target temperature. C. perfringens have been reported to grow at temperatures up to 52 C (126 F). Growth at this upper limit requires anaerobic conditions and follows a lag phase of at least several hours. The literature shows that lag phase duration and generation times are shorter at incubation temperatures below 49 C (120 F) than at 52 C (125 F). Studies also suggest that temperatures that preclude the growth of C. perfringens also preclude the growth of B. cereus. The Centers for Disease Control and Prevention (CDC) estimates that approximately 250,000 foodborne illness cases can be attributed to C. perfringens and B. cereus each year in the United States. These spore-forming pathogens have been implicated in foodborne illness outbreaks associated with foods held at improper temperatures. This suggests that preventing the growth of these organisms in food by maintaining adequate hot holding temperatures is an important public health intervention. Taking into consideration the recommendations of NACMCF and the 2002 Conference for Food Protection meeting, the FDA believes maintaining food at a temperature of 57 C (135 F) or greater during hot holding is sufficient to prevent the growth of pathogens and is therefore an effective measure in the prevention of foodborne illness. The 2022 FDA Food Code documents at section 3-401.11 Raw Animal Foods: (A) Except as specified under (B) and in (C) and (D) of this section, raw animal foods such as eggs, fish, meat, poultry, and food containing these raw animal foods, shall be cooked to heat all parts of the food to a temperature and for a time that complies with one of the following methods based on the food that is being cooked .Internal Cooking Temperature Specifications for Raw Animal Foods .Raw eggs cooked for immediate service, fish, intact meat, except whole meat roasts and whole muscle intact beef steak at 145 F for 15 seconds .Commercially raised game animals, rabbits at 155 F for 17 seconds .Non-intact meats and raw eggs not for immediate service, wild game animals, poultry, stuffed fish, meat, pork, pasta, ratites, stuffing containing fish, meat, ratites, and poultry at 165 F for greater than 1 second. The 2022 FDA Food Code documents at section 3-403.11: .(C) and (D) Food that is taken from a commercially processed, hermetically sealed container or intact package cooked to a temperature of 135 F. From 9/23/24 through 9/25/24, Surveyor reviewed cooking logs for breakfast, lunch, and dinner from 9/1/24 through 9/22/24. Surveyor noted staff did not consistently document cooking temperatures for 43 of 66 meals served. On 9/23/24 at 11:54 AM, Surveyor observed dining service on the Hickory household. Surveyor noted staff did not check the temperature of the food prior to serving. Surveyor also noted a hot holding cart that contained food near the steam table was not plugged in. On 9/23/24 at 12:29 PM, Surveyor interviewed Dietary Aide (DA)-I and DA-J. DA-J stated the facility used to check hot and cold holding temperatures but staff were told they no longer needed to. DA-J and DA-I were unable to state why the facility stopped checking holding temperatures. On 9/23/24 at 11:45 AM, Surveyor observed dining service on the Maple household. Surveyor noted staff did not check the temperature of the food prior to serving. At 12:37 PM (which was the end of dining service), Surveyor asked DA-L to check the food temperatures of two trays and noted the following: ~ Mashed potatoes -126.1 degrees F ~ Three bean salad - 49.6 degrees F ~ Banana pudding - 48 degrees F ~ Cabbage roll - 125.1 degrees F ~ Cheesy potatoes- 130 degrees F ~ Carrots - 115.7 degrees F At 12:44 PM, Surveyor interviewed DA-L who stated DA-L did not know if the temperatures were within standards for food safety. DA-L stated DA-L had never temped food before and had not received training on checking temperatures. During an initial tour of the kitchen that began at 9:04 AM on 9/23/24, Surveyor reviewed food cooking and holding temperature logs with DM-H and noted missing entries. DM-H acknowledged the missing temperatures and indicated temperatures should be documented by the cook when the food is removed from the oven. DM-H stated staff do not complete holding temperatures because all food goes directly from the oven to the hot holder and is sent to the households to be served. Sanitizing Solution: The 2022 FDA Food Code documents at 4-501.116 Warewashing Equipment, Determining Chemical Sanitizer Concentration: Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device. The facility's undated Sanitization policy indicates: The food service area is maintained in a clean and sanitary manner .6. Manual washing and sanitizing is a three-step process for washing, rinsing and sanitizing .c. Sanitize with hot water (at least 171 degrees F for 30 seconds) or chemical sanitizing solution. Chemical sanitizing solutions are used according to manufacturer's instructions. During an initial tour of the kitchen that began at 9:04 AM on 9/23/24, Surveyor reviewed the sanitization logs for the three-compartment sink with DM-H. The logs contained 10 entries for July 2024, 4 entries for August 2024, and 4 entries for September 2024. DM-H acknowledged the inconsistencies and stated the log should be completed each time the sink is filled which should be prior to each meal or when the water is dirty. Dishwasher/Surface Temperature Monitoring: The 2022 FDA Food Code documents at Section 4-501.110 Mechanical Warewashing Equipment, Wash Solution Temperature: (A) The temperature of the wash solution in spray type warewashers that use hot water to sanitize may not be less than: (1) For a stationary rack, single temperature machine, 74 C (165 F); (2) For a stationary rack, dual temperature machine, 66 C (160 F); (3) For a single tank, conveyor, dual temperature machine, 71 C (160 F) or (4) For a multi-tank, conveyor, multi-temperature machine, 66 C (150 F). The 2022 FDA Food Code documents at 4-302.13 Temperature Measuring Devices, Manual Warewashing: Water temperature is critical to sanitization in warewashing operations. This is particularly true if the sanitizer being used is hot water. The effectiveness of cleaners and chemical sanitizers is also determined by the temperature of the water used. A temperature measuring device is essential to monitor manual warewashing and ensure sanitization. Effective mechanical hot water sanitization occurs when the surface temperatures of utensils passing through the warewashing machine meet or exceed the required 71 C (160 F). Parameters such as water temperature, rinse pressure, and time determine whether the appropriate surface temperature is achieved. Although the Food Code requires integral temperature measuring devices and a pressure gauge for hot water mechanical warewashers, the measurements displayed by these devices may not always be sufficient to determine that the surface temperatures of utensils are reaching 71 C (160 F). The regular use of irreversible registering temperature indicators provides a simple method to verify that the hot water mechanical sanitizing operation is effective in achieving a utensil surface temperature of 71 C (160 F). The facility's undated Sanitization policy indicates: The food service area is maintained in a clean and sanitary manner .5. Dishwashing machines are operated according to manufacturer's instructions. General recommendations for heat and chemical sanitization are: High-Temperature Dishwasher (Heat Sanitization): (1) Wash temperature (150F -165F); and (2) Rinse temperature (180F) (160F at the rack level/dish surface reflects 180F at the manifold which is the area just before the final rinse nozzle where the temperature of the dish machine is measured); or 165F for a stationary rack, single temperature machine. During an initial tour of the kitchen that began at 9:04 AM on 9/23/24, Surveyor reviewed surface temperature logs and noted 10 entries for August 2024 and 5 entries for September 2024. DM-H stated test strips should be run through the dishwasher once per day. From 9/23/24 to 9/25/24, Surveyor requested to review dishwasher temperature logs for the main kitchen and the household dishwashers. The logs were not provided. Microwave Heating: The 2022 FDA Food Code documents at 3-403.11 Reheating for Hot Holding: (A) Except as specified under (B) and (C) and in (E) of this section, Time/Temperature Control for Safety food that is cooked, cooled, and reheated for hot holding shall be reheated so that all parts of the food reach a temperature of at least 165 degrees for 15 seconds. (B) Except as specified under (C) of this section, Time/Temperature Control for Safety food reheated in a microwave oven for hot holding shall be reheated so that all parts of the food reach a temperature of at least 165 degrees Fahrenheit and the food is rotated or stirred, covered, and allowed to stand covered for 2 minutes after reheating. The facility's undated Food Preparation and Service policy indicates: Previously cooked food is reheated to an internal temperature of 165F for at least 15 seconds before holding for hot service. On 9/23/24 at 11:54 AM, Surveyor observing dining service in the Hickory household. Surveyor observed DA-I reheat soup for a resident. DA-I reheated the soup for 30 seconds, stirred the soup, and reheated the soup for another 30 seconds. DA-I then served the soup to the resident without checking the temperature. On 9/23/24 at 12:29 PM, Surveyor interviewed DA-I who acknowledged DA-I did not check the temperature of the soup before serving. DA-I stated staff used to temp check all reheated items, but no longer do that. Hair Restraints: The 2022 FDA Food Code documents at 2-402.11: Food Employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively to keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. The facility's undated Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices policy indicates: Food and nutritional services employees follow appropriate hygiene and sanitary procedures to prevent the spread of food borne illness .All employees who handle, prepare or serve food are trained in the practice of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents .Hairnets or caps and/or beard restraints are worn when cooking, preparing, or assembling food to keep hair from contacting exposed food, clean equipment, utensils and linens. On 9/24/24 at 8:14 AM, Surveyor observed Certified Nursing Assistant (CNA)-M in the kitchen without a hair restraint where food for resident consumption was being prepared. On 9/24/24 at 8:16 AM, Surveyor observed Nursing Home Administrator (NHA)-A in the main kitchen without a hair restraint. Surveyor observed NHA-A walk through the dish area into the cooking area past the hairnet station and stand approximately 3 feet into the cooking area where food for resident consumption was being prepared. On 9/24/24 at 8:30 AM, Surveyor interviewed CNA-M who stated CNA-M usually tried to get the attention of staff in the kitchen and did not enter the kitchen. CNA-M confirmed CNA-M should have donned a hair restraint when entering the kitchen. On 9/24/24 at 9:03 AM, Surveyor interviewed NHA-A who stated NHA-A was not required to wear a hairnet because NHA-A stood in the doorway and was not all the way into the kitchen. Hand Hygiene: The 2022 FDA Food Code documents at 2-301.14: Food Employees shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles. The 2022 FDA Food Code documents at 3-301.11 Preventing Contamination from Hands: (A) Food Employees shall wash their hands as specified under S 2-301.12. (B) Except when washing fruits and vegetables as specified under S3-302.15 or as specified in (D) and (E) of this section, Food Employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. The facility's undated Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices policy indicates: Food and nutritional services employees follow appropriate hygiene and sanitary procedures to prevent the spread of food borne illness .All employees who handle, prepare or serve food are trained in the practice of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents .Gloves are considered single-use items and must be discarded after completing the task for which they are used. Gloves are removed, hands washed and gloves are replaced: .a. after direct contact with residents; b. after assisting medical treatments; c. between handling raw meats and ready-to-eat-foods; and d. between handling soiled and clean dishes .The use of disposable gloves does not substitute for proper handwashing .Food service employees are trained in the proper use of utensils such as tongs, gloves, deli paper and spatulas as tools to prevent foodborne illness. On 9/23/24 at 11:54 AM, Surveyor observed dining service on the Hickory household. Surveyor observed DA-J don gloves without completing hand hygiene. DA-J touched a hot dog bun and a baked bread roll and plated three plated with gloved hands. DA-J then removed gloves and donned new gloves without completing hand hygiene. DA-J touched baked bread rolls, cut breaded chicken with a knife, and picked up a hamburger bun with gloved hands. DA-J then removed gloves and donned new gloves without completing hand hygiene. DA-J opened the hot holding door with a gloved hand and touched a hamburger bun with the same gloved hand. DA-J also plated food and touched breaded chicken, a baked bread roll, and another breaded chicken breast with the same gloved hands. DA-J then removed gloves and donned new gloves without completing hand hygiene. DA-J touched a breaded chicken breast, DA-J's glasses, serving cards, and a grilled cheese sandwich with gloved hands. DA-J then removed gloves and did not complete hand hygiene. On 9/23/24 at 12:29 PM, Surveyor interviewed DA-J who stated proper hand hygiene is to perform hand hygiene between glove changes. DA-J confirmed DA-J did not wash DA-J's hands during dining service.

Based on staff interview and record review, the facility did not ensure minimum required members of the Quality Assessment and Assurance (QAA) committee met at least quarterly. The facility did not have documentation that indicated the minimum required members of the QAA committee met at least quarterly. As of 9/25/24, the facility's most recent QAA committee meeting with all required members in attendance was on 6/12/23. Findings include: On 9/24/24, Surveyor requested the facility's policy and procedure for Quality Assurance and Performance Improvement (QAPI). Director of Nursing (DON)-B provided Surveyor with an undated QAPI Plan which was worded in the style of a template and did not describe the facility's specific QAPI policy and procedure. The QAPI Plan did not designate staff (including the DON, Medical Director or designee, the Infection Preventionist, and at least 3 other staff members one of whom was the Nursing Home Administrator (NHA), owner, board member, or other individual in a leadership role) required to participate in the QAPI committee and did not establish the frequency of QAPI committee meetings. The QAPI Plan also did not outline how the facility developed, monitored, or evaluated quality indicators. On 9/24/24 at 8:49 AM, Surveyor reviewed the facility's QAA committee meeting sign in sheets and noted the following: ~ The 2023 2nd quarter meeting, dated 6/12/23, had all required members in attendance. ~ The QAA committee did not meet for the 3rd quarter (July, August, and September) of 2023. ~ The 2023 4th quarter meeting, dated 11/2/23, did not include the Medical Director or designee. ~ The 2024 1st quarter meeting, dated 3/29/24, did not include sufficient staff members. ~ The QAA committee did not meet for the 2nd quarter (April, May, and June) of 2024. ~ The 2024 3rd quarter meeting, dated 8/8/24, did not include the Infection Preventionist. On 9/25/24 at 10:14 AM, Surveyor interviewed NHA-A who confirmed the QAA committee meeting sign in sheets accurately reflected the committee's meeting dates and attendance.

Based on staff interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe and sanitary environment and prevent the transmission of communicable disease and infection. This practice had the potential to affect all 55 residents residing in the facility. The facility did not appropriately monitor residents and staff for infections and outbreaks. Findings include: The facility's Surveillance for Infections policy, dated 9/2017, indicates: The Infection Preventionist (IP) will conduct ongoing surveillance for healthcare-associated infections (HAIs) and other epidemiological significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions .1. The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiological significant organisms and HAIs to guide appropriate interventions and prevent future infections .4. For targeted surveillance using facility-created tools, follow these guidelines. a. Daily (as indicated): record detailed information about the resident and infection on an individual infection report form; b. Monthly: Collect information from individual resident reports and enter line listing of infections by resident for the entire month; c. Monthly: Summarize monthly data for each nursing unit by site and by pathogen; d. Monthly/Quarterly: Identify predominant pathogens or sites of infection among residents in the facility or in particular units by recording them month to month and observing trends. Calculating Infection Rates: 1. Obtain the month's total resident days from the business office. The following days is used as the denominator to calculate the monthly infection rate: Total resident days (daily census of each day in the designated time period added together). 2. To determine the incidence of infection per 1000 residents days, divide the number of new HAIs for the month by total resident days for the month x 1000. From 9/23/24 to 9/25/24, Surveyor reviewed the facility's infection line lists for residents and staff. The facility provided Surveyor with a partial line list for residents with random dates and months for infections from February 2024 to September 2024. The line list did not include symptoms, labs, and dose or duration of antibiotics used. The line list also did not track and trend infections or contain monthly infection rates or percentages. In addition, the facility provided a staff illness line list for August 2024. The line list contained two staff and no return to work dates. On 9/25/24 at 9:12 AM, Surveyor interviewed Director of Nursing (DON)-B who verified the line lists and antibiotic tracking were incomplete. DON-B indicated DON-B started at the facility on 7/8/24 and was assigned the IP role along with another Registered Nurse (RN). DON-B indicated DON-B looked at previous line lists which also contained gaps but did not provide the line lists to Surveyor. DON-B indicated DON-B just started infection control training and had only completed two modules so far.

Based on staff interview and record review, the facility did not ensure a staff person designated as the Infection Preventionist (IP) completed specialized training in infection prevention and control. This practice had the potential to affect all 55 residents residing in the facility. Director of Nursing (DON)-B and Registered Nurse (RN)-E were the facility's designated IPs and did not complete specialized training in infection prevention and control. Findings include: The facility's Infection Preventionist policy, dated 9/2017, indicates: The IP is responsible for coordinating the implementation and updating of the infection control program. Qualifications: 1. The IP is qualified by education, training, experience and/or certification and has sufficient knowledge to perform the role 2. The IP remains current with infection prevention and control issues and is aware of national organizations guidelines as well as those from national/state/local and public health authorities. 3. Evidence of training is provided through a certificate(s) of completion or equivalent documentation. On 9/25/24 at 9:12 AM, Surveyor interviewed DON-B who indicated DON-B started at the facility on 7/8/24 and was assigned the IP role. DON-B indicated DON-B started IP training recently and had only finished 2 modules. DON-B indicated another nurse would also be completing the training. DON-B indicated the other nurse would assume the IP role and DON-B would oversee the program. On 9/25/24 at 9:20 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who verified the facility did not have a qualified IP. NHA-A indicated the former DON and IP submitted a 30-day notice and ended employment with the facility on 6/30/24. NHA-A indicated NHA-A hired DON-B and planned to have a consultant monitor DON-B. NHA-A indicated DON-B should have been on board sooner with the infection prevention and control program and stated the facility had a plan moving forward to have DON-B and another nurse maintain the program.

Based on observation and resident and staff interview, the facility did not maintain the dignity of 3 residents (R) (R18, R23, and R50) in the dining room during meal time with the potential to affect more than 4 of 55 residents residing in the facility. R18's vital signs were obtained at the dining table during the lunch meal on 9/24/24. Medications were administered to residents at the dining table, including R23. Residents who sat at the same table were not served at the same time, including R50. Findings include: On 9/23/24 at 11:49 AM, Surveyor observed lunch service in the Oak dining room. There were thirteen residents in the dining room. Surveyor witnessed the following: ~ On 9/23/24 at 11:49 AM, staff obtained R18's blood pressure at the table with other residents present. Dining service had already started. ~ On 9/23/24 at 11:57 AM, staff administered medication to multiple residents while eating, including R23. ~ On 9/23/24 at 12:10 PM, four residents were served and 9 residents were without food. ~ On 9/23/24 at 12:35 PM, the last resident's food was served. All residents at the table had already finished eating. Dessert had not yet been served. On 9/24/24 at 7:45 AM, Surveyor observed breakfast service in the Maple dining room. There were seventeen residents in the dining room. Surveyor witnessed the following: ~ On 9/24/24 at 7:54 AM, five residents had food (three had yogurt, one had a sliced banana, and one had Cheerios). The other residents had drinks. ~ On 9/24/24 at 7:55 AM, staff administered medication to a resident. Medication pass continued throughout breakfast for multiple residents in the dining room. ~ On 9/24/24 at 7:55 AM, Surveyor observed Dietary Aide (DA)-N cook and serve breakfast alone in the Maple dining room. DA-N prepared meals one by one while residents waited and watched each resident get served. ~ On 9/24/24 at 8:00 AM, one resident was served the first full breakfast. There were seventeen residents in the dining room waiting to eat. ~ On 9/24/24 at 8:44 AM, the last full breakfast was served. There were seven residents in the dining room. Ten residents had already eaten and left the dining room. On 9/24/24 at 1:11 PM, Surveyor observed the Oak dining room during lunch service and witnessed the following: On 9/24/24 at 1:11 PM, Surveyor observed Licensed Practical Nurse (LPN)-D obtain R18's vital signs at the dining table. First LPN-D took R18's blood pressure and then checked R18's oxygen level. While LPN-D took R18's vital signs, R18 had food on R18's plate and was unable to eat. On 9/24/24 at 8:25 AM, Surveyor interviewed DA-N who confirmed DA-N cooked and served residents one by one and often went table by table which took awhile. DA-N stated the cooking process was typically relaxed and confirmed taking an hour to serve the meal was typical. On 9/24/24 at 8:37 AM, Surveyor interviewed Anonymous Staff (AS)-Q who stated AS-Q heard complaints from residents that food took too long because it was served one table at a time. AS-Q stated it could take fifteen minutes between residents at the same table and it was typical for the meal service to take an hour in the dining room. On 9/24/24 at 1:14 PM, Surveyor interviewed LPN-D who confirmed LPN-D checked R18's blood pressure and oxygen level prior to administering R18's medication. LPN-D stated R18 was not in distress or ill. LPN-D conceded LPN-D shouldn't obtain residents' vital signs at the dining table. On 9/24/24 at 2:21 PM, Surveyor interviewed R18 who indicated R18 was unable to eat while staff checked R18's vital signs at meals. On 9/24/24 at 2:49 PM, Surveyor interviewed R50 who indicated R50 often waited for food. R50 indicated it felt awkward when one resident received their food and the others did not get theirs. R50 indicated R50 would like it if everyone received their meals at the same time. R50 stated R50 waited a half hour that morning for a toaster waffle and a banana. On 9/24/24 at 2:58 PM, Surveyor interviewed R23 who stated meals took awhile and R23 felt R23 waited too long. R23 stated receiving medication in the dining room made the facility feel more like a hospital than a home. On 9/25/24 at 9:35 AM, Surveyor interviewed Director of Nursing (DON)-B who stated vital signs should be obtained in a resident's room and not at the dining table, unless the resident is in distress. On 9/25/24 at 12:35 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-O who indicated when residents get antsy while waiting for food and other residents have food, CNA-O tells the cook to hurry up. On 9/25/24 at 12:58 PM, Surveyor interviewed CNA-P who indicated sometimes residents gets anxious if their table partners don't receive their food at the same time and don't want to eat if others don't have food. CNA-P stated it can take awhile in between serving each resident their food and staff have to occupy residents while they wait. CNA-P indicated CNA-P sometimes asks kitchen staff to get a specific resident their meal because the resident has waited awhile and the other residents at the table have their food. On 9/25/24 at 1:11 PM, Surveyor interviewed LPN-G who indicated sometimes residents don't understand why one resident gets their food and others have to wait. LPN-G stated a resident mentioned to LPN-G that other residents received their food ten minutes prior and wondered why they didn't have their food. LPN-G stated LPN-G explained to the resident that the kitchen was working on making their meal.

Based on record review and staff interview, the facility did not ensure 4 residents (R) (R17, R45, R46, and R6) of 5 sampled residents who received psychotropic medication were monitored for adverse reactions or side effects of the medication. R17 was prescribed lorazepam (an antianxiety medication), sertraline (an antidepressant medication), and quetiapine (Seroquel) (an antipsychotic medication). R17's plan of care did not indicate R17 was monitored for adverse reactions or side effects of the medications. R45 was prescribed Seroquel. R45's plan of care did not indicate R45 was monitored for adverse reactions or side effects of the medication. R46 was prescribed lorazepam, sertraline, and quetiapine (Seroquel). R46's plan of care did not indicate R46 was monitored for adverse reactions or side effects of the medications. R6 was prescribed lorazepam, sertraline, and mirtazapine (an antidepressant medication also used for appetite). R6's plan of care did not indicate R6 was monitored for adverse reactions or side effects of the medications. Findings include: The facility's Medication Utilization and Prescribing-Clinical Protocol policy, dated 2001, indicates: The staff and physician will identify and address unexpected, unintended, undesirable, or excessive responses to a medication based on the severity of underlying conditions, the seriousness of any adverse drug reactions, risk of worsening of medical conditions, and other factors .The staff and physician will periodically re-evaluate the conditions and symptoms for which each resident is receiving medications to ensure the medication and dosage are still relevant and not causing undesired complications. The facility's Antipsychotic Medication Use policy, dated July 2022, indicates: .17. Nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the attending physician: a. General/anticholinergic: Constipation, blurred vision, dry mouth, urinary retention, sedation; b. Cardiovascular: orthostatic hypotension, arrhythmias; c. Metabolic: increase in total cholesterol/triglycerides, unstable or poorly controlled blood sugar, weight gain; d. Neurologic: akathisia, dystonia, extrapyramidal effects, akinesia; or tardive dyskinesia, stroke or TIA. The Abnormal Involuntary Movement Scale (AIMS) is a 12 item clinician-rated scale widely used to assess for the presence and severity of dyskinesias in residents taking antipsychotic medication. According to Medlineplus.gov: lorazepam may cause side effects including, but not limited to: Drowsiness, dizziness, weakness, unsteadiness, diarrhea, nausea, changes in appetite, restlessness or excitement, constipation, blurred vision, ringing in your ears, anxiety, memory problems, difficulty concentrating, sleep problems, seizures, shaking, muscle twitching, changes in mental health, aggression, depression, burning or prickling feeling in your hands, arms, legs or feet, seeing or hearing things that others do not see or hear, thoughts of harming or killing yourself or others, overexcitement, or losing touch with reality. According to Medlineplus.gov: mirtazapine may cause side effects including, but not limited to: Drowsiness, dizziness, anxiousness, confusion, increased weight and appetite, dry mouth, constipation, nausea, vomiting, flu-like symptoms (fever, chills, sore throat, mouth sores, other signs of infection), chest pain, fast heartbeat, seizures, new or worsening depression, thinking about harming or killing yourself or planning or trying to do so, extreme worry, agitation, panic attacks, difficulty falling asleep or staying asleep, aggressive behavior, acting without thinking, severe restlessness, and frenzied abnormal excitement. According to Medlineplus.gov: sertraline may cause side effects including, but not limited to: Nausea, diarrhea, constipation, vomiting, dry mouth, heartburn, loss of appetite, weight changes, dizziness, excessive tiredness, nervousness, uncontrollable shaking of a part of the body, excessive sweating, seizures, abnormal bleeding or bruising, hallucinations, fever, confusion, fast heartbeat, shivering, severe muscle stiffness or twitching, loss of coordination, rash, hives, swelling, difficulty breathing, new or worsening depression, thinking about harming or killing yourself or planning or trying to do so, extreme worry, agitation, panic attacks, difficulty falling asleep or staying asleep, aggressive behavior, irritability, acting without thinking, severe restlessness, and frenzied abnormal excitement. According to Medlineplus.gov, Seroquel may cause side effects, including but not limited to: Dizziness, feeling unsteady, or having trouble keeping your balance, pain in the joints, back, neck, or ears, dry mouth, vomiting, constipation, stomach pain or swelling, increased appetite, excessive weight gain, irritability, difficulty thinking or concentrating, difficulty speaking or using language, unusual dreams, numbness, burning, or tingling in the arms or legs, fainting, seizures, changes in vision, uncontrollable movements of your arms, legs, tongue, face, or lips, painful erection of the penis that lasts for hours, excess sweating, fast or irregular heartbeat, unusual bleeding or bruising, difficult or painful urination, or other signs of infection, hives, rash, blisters, tightening of the neck muscles or the throat, tongue sticking out, difficulty breathing, or swallowing. 1. From 9/23/24 to 9/25/24, Surveyor reviewed R17's medical record. R17 was admitted to the facility on [DATE] and had a diagnosis of Alzheimer's disease. R17's Minimum Data Set (MDS) assessment, dated 6/11/24, indicated R17 had severe cognitive impairment. R17 had an activated Power of Attorney for Healthcare (POAHC). R17's medical record contained the following physician orders: ~ Quetiapine 25 milligrams (mg) twice daily (dated 3/4/24) ~ Sertraline 75 mg once daily (dated 11/1/23) ~ Lorazepam 0.5 mg at bedtime (dated 6/14/24) ~ Lorazepam 0.5 mg one to two tablets as needed (PRN): one tablet for mild to moderate anxiety or terminal restlessness; two tablets for severe anxiety or terminal restlessness (dated 6/24/24) R17's care plan, dated 2/26/24, indicated R17 received psychotropic medication for Alzheimer's disease, anxiety, and depression and required ongoing monitoring for effectiveness and adverse effects of the medications. R17's medical record did not contain monitoring interventions for adverse reactions or side effects of quetiapine, sertraline, or lorazepam. In addition, R17 did not have a baseline or ongoing assessments for the medications. On 9/24/24 at 1:39 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated staff and providers monitor residents for side effects of psychotropic medication, but it is not routinely documented in residents' medical records. On 9/25/24 at 9:36 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-G who indicated psychotropic medication monitoring was completed by observing the resident's behavior and monitoring for sleepiness. LPN-G indicated psychotropic medication monitoring was focused on behavior rather than potential adverse drug reactions. LPN-G indicated residents' medical records had an automatic notification that prompted nursing staff to document behaviors every shift if the resident received antipsychotic medication. LPN-G showed Surveyor the prompt which read, Behavior charting every shift, please document refusals and aggressive behaviors. (Of note, R17 did not have the prompt in R17's medical record.) LPN-G indicated it was not routine practice to document monitoring for adverse drug reactions of antipsychotic medication and stated if an adverse drug reaction was identified, it would be documented in the resident's progress notes. LPN-G was unaware of any place in the medical record where potential adverse reactions to medication were listed for nursing staff to reference. LPN-G indicated if LPN-G needed to know potential medication side effects, LPN-G searched the Internet or used a reference book. 45942 2. On 9/24/24, Surveyor reviewed R46's medical record. R46 was admitted to the facility on [DATE] with diagnoses including Alzheimer disease, depression, agitation, and restlessness. R46's MDS assessment, dated 9/13/24, had a BIMS score of 5 out of 15 which indicated R46 had severe cognitive impairment. R46 had an activated Power Of Attorney (POA). R46's medical record contained the following physician orders: ~ Lorazepam oral tablet 0.5 mg give 0.25 mg twice daily ~ Sertraline oral tablet 50 mg once daily ~ Quetiapine oral tablet 50 mg twice daily R46's plan of care did not contain monitoring interventions for adverse reactions or side effects of lorazepam, sertraline, or quetiapine. R46's medical record also did not contain a baseline or ongoing assessments. On 9/24/24 at 11:32 AM, Surveyor interviewed DON-B confirmed DON-B was unable to locate assessments for R46. 48794 3. Between 9/23/24 and 9/25/24, Surveyor reviewed R45's medical record. R45 was admitted to the facility on [DATE] and had diagnoses including dysphagia following cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting unspecified side, panic disorder, adjustment disorder with mixed and anxiety and depressed mood, anxiety disorder, and cognitive communication deficit. R45's MDS assessment, dated 9/10/24, had a BIMS score of 15 out of 15 which indicated R45 had intact cognition. R45 had a physician order for Seroquel 25 mg once daily for visual hallucinations (dated 7/23/24). R45's medical record did not contain monitoring interventions for adverse reactions or side effects of Seroquel. On 9/25/24 at 9:00 AM, Surveyor interviewed DON-B who confirmed the facility did not have side effect monitoring in place for R45. DON-B stated R45's medical record should contain interventions for staff to monitor and be aware of adverse reactions and side effects of the antipsychotic medication. 49010 4. Between 9/23/24 and 925/24, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] and had diagnoses including anxiety, major depression, heart failure, atrial fibrillation, abnormal weight loss, and anorexia. R6's MDS assessment, dated 6/17/24, had a BIMS score of 15 out of 15 which indicated R6 had intact cognition. R6's medical record contained the following physician orders: ~ Lorazepam 0.5 mg by mouth at bedtime ~ Mirtazapine 30 mg by mouth at bedtime ~ Sertraline 50 mg by mouth once daily. R6's plan of care indicated staff were to monitor for side effects of medication, but did not indicate what side effects were possible and what specifically to monitor for. R6's Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not include information for staff to monitor R6 for adverse reactions or side effects of the medications.

Based on staff and resident representative interview, and record review, the facility did not ensure 1 resident (R) (R31) of 18 sampled residents and their activated Power of Attorney (POA) were offered care conferences and involved in continued care planning. R31's only care conference was completed on 9/17/21. Social Worker (SW)-C verified care conferences should be held yearly, when there is a change in a resident's condition, or if requested by a resident's family. Findings include: On 9/23/24, Surveyor reviewed R31's medical record. R31 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke), epilepsy, and cognitive communication deficit. R31's Minimum Data Set (MDS) assessment, dated 7/31/24, indicated R31 had severely impaired cognition. R31 had an activated POA. R31's medical record did not indicate care conferences were offered or declined by R31's POA. On 9/23/24 at 11:58 AM, Surveyor interviewed R31's POA who indicated they were not involved with R31's plan of care and had not attended any care conferences since R31 was first admitted . R31's POA indicated they would like to have care conferences and did not know why the facility didn't have them. R31's POA stated they lived farther away, could not visit R31 daily, and needed time to set up appointments to work around their schedule. R31's POA indicated they would like to be a part of decision making for R31's care prior to the implementation of cares and goals by the facility. On 9/24/24 at 11:08 AM, Surveyor interviewed SW-C who confirmed R31 had only one care conference since R31 was admitted on [DATE]. SW-C indicated R31's POA was involved with communication on a regular basis and SW-C was waiting for R31's POA to return a message. SW-C indicated R31's POA didn't come to the facility often and was not interested in an official conference. SW-C indicated care conferences were held yearly, with a change in condition, or if requested by a resident's family. Surveyor requested the facility's care conference policy from SW-C. SW-C indicated SW-C did not think R31 should have gone 3 years without a care conference. SW-C confirmed there was no documentation to indicate care conferences were offered or decined. SW-C indicated the facility did not have a process for tracking care conferences but set up care conferences annually. SW-C indicated residents' care plans were updated when MDS assessments were completed. Surveyor did not receive a care conference policy from the facility as of this writing.

Based on a policy and record review, staff and resident interviews, the facility did not ensure staff acknowledged and honored resident #1's right to refuse treatment out of a sample of four residents. Resident #1 refused a suppository that was administered by LPN (Licensed Practical Nurse)-A. CNA (Certified Nursing Assistant)-C was assisting LPN-A and heard the resident refuse. LPN-A stated she did not hear the refusal. CNA-C stated she did not alert LPN-A because she was unaware residents could refuse medication or treatment. Findings include: The facility's policy Resident Abuse, Neglect, Mistreatment, Misappropriation or Injury of Unknown Etiology dated 3/15/10 states: Resident Rights and Abuse training is provided to all employees upon hire and at least yearly...All new employees will receive training regarding abuse during their initial orientation and at least yearly. Annual training will include but is not limited to:...Resident rights. All facility staff will receive additional education if any portion of this policy is not followed during an investigation. The facility's policy Resident Rights dated 4/24/98 states: It is the policy of The Sheboygan Retirement Home and Beach Health Care Center, Inc. to provide the residents with the right to dignified existence, self-determination and communication as designated in state and federal guidelines. The facility will protect and promote the rights of all residents...The resident has the right to refuse treatment. The facility's Bowel Training Program dated 11/04 details a protocol to be followed to prevent constipation and impactions. The protocol states: Second day of no BM: Give MOM (Milk of Magnesia). Small or no results from MOM, give suppository by the next day (Day 3). Small or no results from MOM and suppository, give enema by the next day (Day 4). Small or no results from MOM, suppository and enema, call the MD for further instruction (Day 4). Fiber and fluid intake will be monitored. Dietary will be alerted when increase in fiber is necessary. Increase fluid intake unless contraindicated. Monitor effectiveness of bowel medications. Update nursing care plan as needed. On 6/14/13 surveyor # investigated a self-report submitted to the State agency that alleged resident #1 received a suppository against the resident's will. According to the resident's facesheet, resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent MDS dated [DATE] indicated the resident was continent of bowel and bladder and required extensive assistance of staff for transfers, personal hygiene and toileting. The resident was assessed to be 12 out of 15 from BIMs (Brief Interview for Mental Status, this score indicates the resident is reliable for interviews and most decisions). According to the facility's investigation, on 4/24/13 shortly after 6:00 a.m., resident #1 approached CNA (Certified Nursing Assistant)-F and indicated he had a "bad night." Upon further inquiry, the resident also indicated "the nurse aide held him down and gave him an enema. Resident #1 had told them 'no' and they did it anyway." CNA-F informed nursing staff and RN (Registered Nurse)-D followed up with resident #1 regarding the allegation. RN-D indicated in a written statement, "(Resident #1) was upset that they had forced him into getting a suppository at 6:00 a.m. (Resident #1) told them (resident #1) had a bowel movement yesterday but the nurse told (resident #1) that (resident #1) was on her bowel list and needed to have one. CNA (CNA-C) was spoken to this morning and she did say that (resident #1) told him (sic) (resident #1) didn't want one but the nurse gave it to (resident #1) anyway." SW (Social Worker)-G was informed by DON (Director of Nursing)-E of resident #1's allegation. SW-G spoke with resident #1 and her statement contained the following information: "This worker asked (resident #1) how the morning is going and (resident #1) stated, 'terrible'. This worker asked why and (resident #1) stated that (resident #1) cannot remember how it all started but the women (sic) from the night shift with blondish colored hair came with the aide and said I needed an enema. (Resident #1) stated that this same lady worked the other day and she is a very nice person but did not listen to (resident #1) today. (Resident #1) told them 'no I do not want an enema' because (resident #1) had a BM the other day. (Resident #1) stated that (resident #1) was in bed and they both grabbed (resident #1) and again (resident #1) stated 'no I do not need one' but she kept jabbing it and trying to fight me. All three of them were rolling around, according to (resident #1), and then (resident #1) felt it go in. (Resident #1) stated it was frightful. (Resident #1) stated, 'I do not know why this would happen to me' when (resident #1) was looking at her face telling her 'no (resident #1) did not want it' and thought it was just terrible. The statement further indicated the resident complained of a sore rectum and was bothered by this incident." SW-G also interviewed resident #1's roommate, resident #2, who indicated the curtain was closed but resident #2 heard everything and it was upsetting. Resident #2 reports that resident #1 was having a hard time telling them something and the two females in the room kept talking. Resident #2 states that resident #2 heard resident #1 say 'no' several times and they continued doing what they were doing. On 6/14/13 at 10:40 a.m., surveyor # interviewed resident #1 regarding the incident. Resident #1 stated, "I'm still bothered by it. It was terrible. One was putting it (the suppository) in and the other was holding me down. I still have after effects of it. I don't know if it bled or not, but I had a feeling for a couple days where I couldn't sit down decent. They did an examination to make sure I wasn't injured. It all went so fast, I'm not sure what happened. It hurt every time I sat down. They said I needed an enema and I didn't need one. I'm sure I hollered enough. I didn't want it. She (LPN-A) didn't say, 'I'm going to give it anyway.' She just said, 'You have to have an enema.' It really hurt me. Whenever I see them, I think of that. One was jabbing me and the other tried to hold me down. Tears come to my eyes thinking about it." CNA-C indicated in a written statement, "I was getting (resident #1) up this morning and she say (sic) that she had to get (resident #1) a suppository. (Resident #1) say (sic) that (resident #1) didn't need one because (resident #1) had a BM (bowel movement) yesterday but the nurse stated that (resident #1) was on he (sic) list for one and gave it to (resident #1) anyway. (Resident #1) was mad at her." On 6/14/13 at 10:05 a.m., surveyor # interviewed CNA-C via the telephone. CNA-C stated "We were getting resident #1 up and LPN-A said, "I have to give you a suppository." LPN-A gave it to him even though he said he had a BM yesterday and didn't want one. LPN-A said "You have to have one anyway." I didn't know the resident could refuse a suppository. Resident #1 wasn't struggling, we had turned him to the side toward me and she was in back of him. Resident #1 said it in a loud voice. Resident #1 was struggling a little bit, probably 3 times at the most. LPN-A wasn't agitated. She's a good nurse. I don't think she was forcing him. They had a list of who they needed to give it to. I felt he had his rights. Resident #1 is in his right mind. LPN-A is hard of hearing in 1 ear. I have to repeat myself. I don't know if she heard him or not. I believe that she didn't hear him. She had to be right up on you to hear." On 6/14/13 at 5:45 p.m., surveyor # interviewed LPN-A via telephone. LPN-A stated, "I heard the resident say he didn't think he needed the suppository because he had a BM the day before after I gave the suppository. I didn't hear resident #1 say no. Resident #1 didn't indicate that through body language either. Resident #1 wasn't struggling. I wouldn't give a resident a med if they refused it. All PRN (as needed) meds should be documented on the MAR (Medication Administration Record) but sometimes I find out things that were given in shift report and it's not necessarily always on the MAR. I don't remember if resident #1 had anything prior to the suppository. I don't remember hearing it or giving anything else. Normally, we try prune juice or MOM first. I know resident #1 refused MOM in the past because of the taste. Resident #1 refused a suppository in the past also. When I asked if resident #1 wanted it and started to give it, resident #1 said he then felt like he had to go so I stopped and we got resident #1 to the bathroom. Resident #1 didn't seem upset to me on the 24th. I know they (the facility) thought maybe I didn't hear resident #1 refuse before I gave the suppository. I suppose it's possible. I just didn't see any signs to indicate that. Resident #1 was on his side with his back to me." On 6/14/13 at 9:07 a.m., surveyor # interviewed DO (Director of Operations)-B who stated, "We felt she (LPN-A) didn't intentionally force resident #1. We thought it was due to hearing. LPN-A has been here a long time..very soft spoken, mellow, wouldn't fit the bill of doing something wrong. She went to Occupational Health and here is the report. She had a hearing aid in when the incident happened. They're working on replacing the hearing aid with a digital one. Meanwhile, while that's being done, we didn't remove her from work completely. No other staff observed her not hearing something or reacting to something. She understands she is to take someone with her if she thinks she can't hear anything. We had her watch a video about resident rights." DO-B also indicated resident #1 was "not real loud, not soft spoken..neutral." DO-B further stated, "She (LPN-A) said resident #1 didn't resist or strike out...resident #1 said, 'I said no' and resident #1 didn't say anything more than that. DO-B further indicated that LPN-A was not defensive during the interview, was very concerned and stated she would not give the suppository if she thought it was refused. DO-B stated, "Resident #1 has confusion at times. Resident #1 is interviewable but will mix things up and get confused. Resident #1 is animated and sensitive. We've known him for years." Regarding CNA-C, DO-B stated, "CNA-C said that she heard resident #1 say 'no' but resident #1 didn't struggle. CNA-C said because it was something resident #1 needed, she didn't think that resident #1 could say no. She was reeducated about residents' rights...can refuse meds, pills, etc. She was told that if anything makes her feel uncomfortable or that something isn't right, report it and let us determine if it's abuse. She was reeducated verbally and (LPN-A)'s was the video. LPN-A watched the video before she came back to work and followed up with Occupational Health." DO-B stated, "Charting for resident #1 showed no BM since 6/20/13 before the suppository was given. Resident #1 had an extra large BM on the 24th. We would start a protocol for BM...least invasive moving up to suppository and enema. If resident #1 kept refusing, we'd call the MD (Medical Doctor). If the nurse can't adequately explain the need, then the DON, SW, etc. would encourage the resident. With some people, we'd get the family involved." On 6/14/13 at 12:45 p.m., surveyor # interviewed SW-G regarding resident #1. SW-G stated, "(Resident #1) was upset...felt (resident #1) made it clear (resident #1) didn't want it. I explained when one hasn't had a BM for 3 days, it's typical to receive a suppository. We try prune juice and MOM first. I don't know the whole protocol." On 6/14/13 at 3:00 p.m., surveyor # interviewed RN-D regarding the facility's bowel protocol. RN-D stated, "Usually, if a resident goes 3 days without (a BM), we'll do MOM or prune juice first. Some will require a second dose of MOM. (Resident #1) had MOM several times...MOM two times, suppository, MOM." Surveyor # requested a copy of resident #1's PRN medication record for the month of April. On 6/14/13 at 3:20 p.m., RN-D approached surveyor # with a copy of resident #1's MAR and stated, "Here is the MAR. It's not according to what I told you. This is totally not according to what we do. It doesn't appear that resident #1 had MOM before unless it was given and not charted." Surveyor # reviewed resident #1's April 2013 MAR and noted 2 entries for April. On 4/5/13 at 5:40 p.m., 30 ml (milliliters) of MOM was given to the resident and on 4/24/13 at 6:00 a.m., a [MEDICATION NAME] suppository was given. It was not indicated or documented that resident #1 received either prune juice, MOM or any other less invasive intervention prior to the suppository being administered. Surveyor # reviewed nurses' notes and noted there was no documentation for resident #1 on 4/19, 4/20, 4/21, 4/22 or 4/23. Surveyor # and the facility were unable to determine that less invasive measures were attempted prior to the administration of the suppository. On 6/14/13 at 3:30 p.m., surveyor # interviewed DON-E regarding the facility's bowel protocol. DON-E stated, "She (LPN-A) should do other measures first...best practice would be to give prune juice and encourage fluids...by day 2, should offer MOM. Those should be tried before the suppository because the suppository is more invasive." On 6/14/13 at 12:30 p.m., surveyor # interviewed DO-B regarding staff reeducation relating to a resident's right to refuse medication and/or treatment following the incident. DO-B stated, "I just reeducated CNA-C and those involved because it was an isolated incident and never came up before. I looked at it like CNA-C was newer and didn't know. I don't believe LPN-A intentionally gave it. I didn't think the nursing staff needed to be educated. It isn't a pattern. Would it be beneficial? No. I interviewed a variety of staff for statements and they knew. Depending on the situation, I feel like if it comes up again, then we have a problem. I don't think it was a problem beyond the players involved." On 6/14/3 at 1:50 p.m., DO-B provided surveyor # with the facility's abuse training materials which included a video and manual. DO-B also provided surveyor # with a copy of a posting created by the facility prior to the incident. The posting stated, "ATTENTION ATTENTION Reminders regarding Abuse, Neglect, Mistreatment, Misappropriation and Injury of Unknown Origin" and had a bullet point that stated: 5.) Forcing someone to take medication could be classified as abuse. DO-B stated, "I believe all other CNA's know this. I believe the staff reads the signs." DO-B verified to surveyor # that she didn't speak with ALL nursing staff regarding a resident's right to refuse medication and, therefore, could not be sure that all staff members were aware of that right. DO-B also stated staff were not asked to sign an inservice that they read the information on the posting, therefore, she could not be sure that all staff had, in fact, read the posting and/or understood the information. DO-B expressed understanding the facility needed to make sure all CNAs were aware of their obligation to inform an RN or LPN if a resident refused medication and the RN or LPN appeared to not have heard the refusal. DO-B also expressed understanding that the facility should have provided reeducation to all staff right away and not waited until another incident occurred and a pattern was established. In addition, nursing staff wasn't reeducated on the bowel protocol as the facility was unaware that LPN-A hadn't attempted less invasive measures prior to administering the suppository.