Every finding on record at Shorehaven HLTH & Rehab CTR

Based on interview and record review, the facility did not ensure that 2 (R1 and R3) of 2 residents with allegations of abuse were reported to the State Agency and one or more law enforcement entities. *On 2/9/26, R3 alleged Certified Nursing Assistant (CNA)-D pushed R3 against the wall and slapped R3 on the face with a wet rag. The facility did not report the allegation of abuse within 2 hours to the State Agency as required and the facility did not report the allegation of abuse to law enforcement as required. *On 1/25/26, R1 and R2 were involved in a resident-to-resident altercation. R1's allegation of abuse was not submitted to the State Agency timely and law enforcement was not notified. Findings include: The facility's policy titled F600 Freedom from Abuse, Neglect, Exploitation and Misappropriation dated 8/30/1999, last revised 11/2024, documents the following: Reporting and reasonable suspicion of a crime in a long-term care facility: If anyone is observed or suspected to be attempting to hurt or threaten a resident, intervention will be done to stop him or her. Make sure the resident is safe. Immediately report this in a nursing supervisor. The supervisor will report to the Director of Nursing (DON) and the Nursing Home Administrator (NHA) immediately. If neither is available, the Assistant Director of Nursing (ADON) or house charge Registered Nurse (RN) will be contacted. Supervisors should interview staff person(s), family member(s), or visitor(s) as to what they had witnessed. This information will be shared with the NHA and DON. The accused person will be asked to leave the property until an investigation is concluded. If it is a staff member, he/she will be suspended until an investigation is concluded. Social Services should be involved with the family and resident. Recording of abuse will also be done to State licensing and credentialing department when alleged suspect is in position licensed by the State. Investigation of known incidents when abuse, neglect, exploitation or misappropriation is known, steps may consist of: After the resident is deemed safe and the accused individual is removed from the room/household a supervisor or team leader will notify the NHA and DON. Interview all the accused individual(s) allegedly responsible for act, resident, witness, family members and other residents as deemed necessary. May need to involve other regulatory authorities i.e. Reporting to the office of caregiver quality, law enforcement and adult protective services. The NHA to report to state within the allowed time frame and complete the appropriate paperwork depending on the situation. Protecting residents during investigation: When a staff member in a suspected, the staff member will be sent home and not be able to return to work unless the investigation demonstrates the employee is not guilty of abuse or misappropriation. 1.) R3 is a [AGE] year-old resident who was admitted to the facility on [DATE]. R3's diagnoses include Vascular Dementia (decline in mental function caused by reduced blood flow to the brain), generalized anxiety disorder, weakness, and legal blindness. R3's Quarterly Minimum Data Set (MDS) completed on 12/23/25, documents that R3 experiences delusions and has verbal behaviors towards others that occur 1-3 days of the week. R3 was assessed as having a Brief Interview for Mental Status (BIMS) score of 9 indicating that R3 has moderate cognitive impairment. R3's care plan documents: Impaired thought process: (R3) gets mixed up at times and forgets where (R3) is or what is going on. (R3) has a diagnosis of vascular dementia and is forgetful, due to this (R3's) daughter in law, is my activated power of attorney and helps me make decisions (start date 10/1/25, last reviewed 2/10/26). Interventions include: Support and reassure (R3) when in new situations (start date 2/10/26). Encourage (R3) to verbalize feelings, concerns and fears. Help (R3) clarify misbeliefs and provide support (start dated 2/10/26). Respect (R3's) right to make decisions (start dated 2/10/26). Give (R3) options to make decisions regarding daily tasks that need to be completed (start date 2/10/26). Activities of Daily Living (ADL)s Functional Status/Rehabilitation Potential Restorative Nursing Programs: (R3) is in need of skill training and practice in transfers, walking and dressing/grooming. Interventions include: Transfers: Staff will assist (R3) with transfers in and out of bed, in and out of chair and onto and off the toilet using a [NAME] Steady by providing verbal cues for proper hand and foot placement as well as encouragement to stand tall at least three times daily (start date 9/15/25). Bed mobility: staff will assist (R3) with repositioning and sitting at edge of bed as needed (start date 9/15/25). On 3/5/26, Surveyor reviewed the facility self-report which documents the following: *On 2/9/26, at approximately 12:30 AM, CNA-D performed cares for R3. R3 alleged CNA-D pushed R3 against the wall and bar of the Sara Steady. R3 alleged CNA-D also hit R3 with a wet rag 6 times across R3's face. *Statement from the Director of Social Services (DOSS)-F documenting DOSS-F met with R3 on 2/9/26. R3 notified DOSS-F of an allegation of abuse from a staff member last night. DOSS-F notified the Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the allegation. *Statement from DOSS-F documenting R3's Power of Attorney (POA) was notified of the allegation. *Statement from DON-B documenting DON-B contacted Registered Nurse (RN)-E by phone to discuss RN-E's progress note dated 2/9/26. RN-E documented R3 alleged abuse during cares with CNA-D. RN-E stated CNA-D was assisting R3 with cares when R3 alleged CNA-D pushed and slapped R3. RN-E assessed R3 who reported pain. RN-E documented no signs of swelling, redness or bruising during R3's assessment. *Statement from DON-B documenting DON-B contacted CNA-D by phone who stated R3 alleged CNA-D was performing cares on R3 when R3 alleged CNA-D hit R3. CNA-D stated she attempted to get the nurse after R3's abuse allegations and CNA-D could not leave R3 due to R3 attempting to self-transfer. CNA-D assisted R3 back to bed and reported the abuse allegation to the RN-E. *Resident interviews were performed with 6 residents on the unit R3 resides on. No concerns of abuse or safety were documented during resident interviews. *Summary of investigation by NHA-A which documents CNA-D was providing cares to R3 on 2/9/26, at approximately 12:30 AM when R3 alleged CNA-D hit and grabbed R3. CNA-D notified RN-E who assessed R3. RN-E stated R3 alleged CNA-D pushed R3 against a wall and the bar of the Sara Steady and CNA-D slapped R3 6 times in the face with a wet rag. Resident interviews were performed with no concerns identified. DOSS-F notified R3's POA of abuse allegations. R3's care plan was reviewed and updated. Surveyor notes, RN-E did not report allegations of abuse to NHA-A or DON-B. Surveyor notes CNA-D continued to work and completed her shift after allegation of abuse with R3. Surveyor notes the facility did not contact law enforcement with allegations of abuse with R3. On 3/5/26, at 11:07 AM, Surveyor interviewed DOSS-F who stated she talked with R3 at breakfast time on 2/9/26 and R3 expressed allegations of abuse from the prior night. R3 alleged a staff member hit R3 with a rag. DOSS-F stated she immediately reported the allegation to NHA-A and DON-B. On 3/5/26, at 11:40 AM. Surveyor interviewed CNA-D who stated R3 alleged CNA-D hit R3. CNA-D stated she attempted to walk out of R3's room after R3 alleged abuse but could not leave the room due to R3 attempting to self-transfer and CNA-D did not feel it was safe for CNA-D to leave R3 to self-transfer. CNA-D stated she notified RN-E of the abuse allegations. CNA-D stated she continued to work her shift but had no further interactions with R3 and that RN-E cared for R3 the rest of the shift. On 3/5/26, at 12:15 PM, Surveyor interviewed RN-E who stated CNA-D notified her that R3 alleged abuse with CNA-D. RN-E stated she continued cares for R3 for the remainder of the shift and CNA-D no longer cared for R3. RN-E stated she reported the incident to the day shift nurse during rounds (change of shift). RN-E stated she also reported it to the night shift supervisor but was not clear with the night shift supervisor that it was an allegation of abuse. RN-E stated she took it as R3 being confused rather than looking at it from and abuse allegation. RN-E then stated she should have removed CNA-D and report the allegation to administration right away. On 3/5/26, at 12:47 PM, Surveyor interviewed DON-B who stated DOSS-F found out about the allegation of abuse with R3 while doing her morning rounds on 2/9/26. DON-B stated an investigation was immediately started. DON-B stated police were not notified due to R3 not having any injuries. Surveyor notified DON-B of concerns with RN-E not notifying administration of allegation of abuse and the facility not reporting R3's abuse allegation to law enforcement. DON-B acknowledged these concerns. 2.) R1 is a [AGE] year-old resident who was admitted to the facility on [DATE]. R1's quarterly Minimum Data Set (MDS) completed on 12/6/25, documents R1 as having a Brief Interview for Mental Status (BIMS) score of 14, indicating that R1 is cognitively intact. R2 is a [AGE] year-old resident who was admitted to the facility on [DATE]. R2's diagnoses include Alzheimers disease with late onset, and dementia with psychotic disturbance. R2's annual Minimum Data Set (MDS) completed on 12/15/25, documents R2 as having a Brief Interview for Mental Status (BIMS) score of 4, indicating that R2 is severely impaired. On 3/5/26, Surveyor reviewed the Facility self-report which documents the following: On 1/25/26 at dinner, R2 was seated at a table across from R1 in a common area. R2 moved to the opposite side of the table, pulled R1's hair, and shook R1's wheelchair. R1 called out, and staff who were present in the room immediately intervened and separated the residents. RN assessed R1 and found no injuries. One on one support was provided. R2 returned to R2's baseline behavior. R2 has a diagnosis of dementia with psychotic disturbance and a known history of grabbing and striking out at staff, which is typically managed with redirection, one on one support, calming touch, and environmental changes. R1 stated R1 feels safe and did not express ongoing concerns. R2 was placed on frequent checks following the incident. Police were not contacted as no injury occurred and both residents were successfully redirected. Care plans have been updated. R2 was placed on frequent checks for 3 days and will continue to be monitored closely for any behavioral incidents; no further incidents have occurred to date. R1's statement was obtained. Staff statements were obtained. R2's care plan was updated on 1/26/26 addressing behavior problems and interventions. R1 and R2's Power of Attorney's notified. Director of Nursing and physicians notified. Surveyor notes the Facility did not contact law enforcement. On 3/5/26, Surveyor reviewed the Alleged Nursing Home Resident Mistreatment, Neglect and Abuse Report, Misconduct Incident Report. This report was submitted on 1/26/26 at 9:10 AM. The incident occurred 1/25/26 at 12:00 PM. Allegations of abuse must be reported within 2 of the suspected abuse to DQA (Department of Quality Assurance). The Facility submission was 19 hours and 10 minutes late. On 3/5/26, Surveyor reviewed the Misconduct Incident Report. This report was submitted on 1/28/26, meeting the timeline of report completion within 5 days. Report indicates the police were not contacted. On 3/5/26 at 10:44 AM, Surveyor interviewed R1 and R1's [daughter] who was visiting R1 at the time. R1 stated R1 recalls the incident and R1 is just fine. R1 stated R2 had never shown any signs of aggression before the incident and R2 has never shown any signs of aggression following the incident. Surveyor asked R1 if the staff provided care and monitoring following the incident and R1 stated, Oh yes, they looked me over and took care of me. Surveyor asked R1 if R1 was injured during this incident and R1 stated, no but R1 did not expect it. R1 stated staff continued to follow up with R1 many times to see how R1 was doing. R1 stated R1 is very comfortable at the Facility and R1 feels safe and secure. R1's [daughter] stated the Facility immediately contacted the family and stated this Facility is the very best place for R1. [Daughter] has no concerns and stated the incident was handled appropriately. On 3/5/26, at 12:51 PM Surveyor met with Director of Nursing (DON)-B. Surveyor asked DON-B if Facility contacted the police regarding the resident to resident altercation between R1 and R2 that occurred on 1/26/26 and DON-B replied, No. Surveyor notified DON-B of concerns with the late reporting of the initial Alleged Nursing Home Resident Mistreatment, Neglect and Abuse Report, Misconduct Incident Report and not calling the police with abuse allegation. No additional information was provided at this time.

Based on interview and record review, the facility did not ensure 1 (R3) of 3 residents reviewed for allegation of abuse were provided a thorough investigation after the alleged violation. The facility's self-report dated 2/9/26 indicated Certified Nursing Assistant (CNA)-D pushed R3 against the wall and slapped R3 on the face with a wet rag. CNA-D continued to work with other residents after abuse allegations on 2/9/26. Findings include: The facility's policy titled F600 Freedom from Abuse, Neglect, Exploitation and Misappropriation dated 8/30/1999, last revised 11/2024, documents the following:Reporting and reasonable suspicion of a crime in a long-term care facility:If anyone is observed or suspected to be attempting to hurt or threaten a resident, intervention will be done to stop him or her.Make sure the resident is safe.Immediately report this in a nursing supervisor.The supervisor will report to the Director of Nursing (DON) and the Nursing Home Administrator (NHA) immediately. If neither is available, the Assistant Director of Nursing (ADON) or house charge Registered Nurse (RN) will be contacted. Supervisors should interview staff person(s), family member(s), or visitor(s) as to what they had witnessed. This information will be shared with the NHA and DON. The accused person will be asked to leave the property until an investigation is concluded. If it is a staff member, he/she will be suspended until an investigation is concluded. Social Services should be involved with the family and resident.Recording of abuse will also be done to State licensing and credentialing department when alleged suspect is in position licensed by the State.Investigation of known incidents when abuse, neglect, exploitation or misappropriation is known, steps may consist of:After the resident is deemed safe and the accused individual is removed from the room/household a supervisor or team leader will notify the NHA and DON.Interview all the accused individual(s) allegedly responsible for act, resident, witness, family members and other residents as deemed necessary.May need to involve other regulatory authorities i.e. Reporting to the Office of Caregiver Quality, law enforcement and adult protective services.The NHA to report to state within the allowed time frame and complete the appropriate paperwork depending on the situation.Protecting residents during investigation:When a staff member in a suspected, the staff member will be sent home and not be able to return to work unless the investigation demonstrates the employee is not guilty of abuse or misappropriation. R3 is a [AGE] year-old resident who was admitted to the facility on [DATE]. R3's diagnoses include Vascular Dementia (decline in mental function caused by reduced blood flow to the brain), generalized anxiety disorder, weakness, and legal blindness. R3's Quarterly Minimum Data Set (MDS) completed on 12/23/25, documents that R3 experiences delusions and has verbal behaviors towards others that occur 1-3 days of the week. R3 requires partial/moderate assistance with rolling left to right and going from sitting to standing. R3 requires substantial/maximal assistance when going from sitting to lying position. R3 is dependent on staff for toileting hygiene and transfers. R3 is frequently incontinent of urine and always incontinent of bowels. R3 was documented as having a Brief Interview for Mental Status (BIMS) score of 9 indicating that R3 has moderate cognitive impairment. On 3/5/26, Surveyor reviewed the facility self-report which documents the following:*On 2/9/26, at approximately 12:30 AM, CNA-D performed cares for R3. R3 alleged CNA-D pushed R3 against the wall and bar of the Sara Steady. R3 alleged CNA-D also hit R3 with a wet rag 6 times across R3's face.*Statement from the Director of Social Services (DOSS)-F documenting DOSS-F met with R3 on 2/9/26. R3 notified DOSS-F of an allegation of abuse from a staff member last night. DOSS-F notified the Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the allegation.*Statement from DOSS-F documenting R3's Power of Attorney (POA) was notified of the allegation.*Statement from DON-B documenting DON-B contacted Registered Nurse (RN)-E by phone to discuss RN-E's progress note dated 2/9/26. RN-E documented R3 alleged abuse during cares with CNA-D. RN-E stated CNA-D was assisting R3 with cares when R3 alleged CNA-D pushed and slapped R3. RN-E assessed R3 who reported pain. RN-E documented no signs of swelling, redness or bruising during R3's assessment.*Statement from DON-B documenting DON-B contacted CNA-D by phone who stated R3 alleged CNA-D was performing cares on R3 when R3 alleged CNA-D hit R3. CNA-D stated she attempted to get the nurse after R3's abuse allegations and CNA-D could not leave R3 due to R3 attempting to self-transfer. CNA-D assisted R3 back to bed and reported the abuse allegation to the RN-E.*Resident interviews were performed with 6 residents on the unit R3 resides on. No concerns of abuse or safety were documented during resident interviews.*Summary of investigation by NHA-A which documents CNA-D was providing cares to R3 on 2/9/26, at approximately 12:30 AM when R3 alleged CNA-D hit and grabbed R3. CNA-D notified RN-E who assessed R3. RN-E stated R3 alleged CNA-D pushed R3 against a wall and the bar of the Sara Steady and CNA-D slapped R3 6 times in the face with a wet rag. Resident interviews were performed with no concerns identified. DOSS-F notified R3's POA of abuse allegations. R3's care plan was reviewed and updated.Surveyor notes, CNA-D continued to work with other residents after abuse allegations on 2/9/26. On 3/5/26, at 11:07 AM, Surveyor interviewed DOSS-F who stated she talked with R3 at breakfast time on 2/9/26 and R3 expressed allegations of abuse from the prior night. R3 alleged a staff member hit R3 with a rag. DOSS-F stated she immediately reported the allegation to NHA-A and DON-B. On 3/5/26, at 11:40 AM. Surveyor interviewed CNA-D who stated R3 alleged CNA-D hit R3. CNA-D stated she attempted to walk out of R3's room after R3 alleged abuse but could not leave the room due to R3 attempting to self-transfer and CNA-D did not feel it was safe for CNA-D to leave R3 to self-transfer. CNA-D stated she continued to work her shift but had no further interactions with R3 and that RN-E cared for R3 the rest of the shift. On 3/5/26, at 12:15 PM, Surveyor interviewed RN-E who stated CNA-D notified her that R3 alleged abuse with CNA-D. RN-E stated she continued cares for R3 for the remainder of the shift and CNA-D no longer cared for R3. RN-E stated she reported the incident to the day shift nurse during rounds (change of shift). RN-E stated she also reported it to the night shift supervisor but was not clear with the night shift supervisor that it was an allegation of abuse. RN-E stated she took it as R3 being confused rather than looking at it from and abuse allegation. RN-E then stated she should have removed CNA-D and report the allegation to administration right away. On 3/5/26, at 12:47 PM, Surveyor interviewed DON-B who stated DOSS-F found out about the allegation of abuse with R3 while doing her morning rounds on 2/9/26. DON-B stated an investigation was immediately started. Surveyor notified DON-B of concerns with CNA-D continued to work her shift after R3 alleged abuse with CNA-D. DON-B acknowledged these concerns.

Dishwasher Temperatures: The 2022 Wisconsin Food Code documents at 4-501.110 .Mechanical Warewashing Equipment, Wash Solution Temperature: (A) The temperature of the wash solution in spray type warewashers that use hot water to sanitize may not be less than: (1) For a stationary rack, single temperature machine, 74° C (165° F); (2) For a stationary rack, dual temperature machine, 66° C (150° F); (3) For a single tank, conveyor, dual temperature machine, 71° C (160°F); or (4) For a multitank, conveyor, multitemperature machine, 66° C (150° F). The facility's Maintenance, Sanitation and Safety policy, revised 1/2018, indicates: .Sanitation: The Food Service Manager, with the help of the Dietitian, is responsible for the supervision and training of employees in proper sanitation within the food service department .The Food Service Manager is responsible for maintaining report files for dish machine service and taking corrective action if necessary .All resident dishes (china, cups, silverware) are washed by staff on each unit after each meal in the dishwasher. The dishwashers are checked daily to ensure they are maintaining temperatures .A warewashing procedure is developed and followed .The Food Service Manager and Dietitian are responsible for maintaining safety standards. The Director of Food Service is responsible for developing safety rules and reviewing them with all employees . On 6/10/25 at 8:22 AM, Surveyor toured the Turnberry unit kitchen and reviewed the June 2025 Household Dishwasher Record. The form indicated the wash cycle should be 150 degrees or higher and the final rinse cycle should be 180 degrees or higher. The form contained one slot labeled AM Shift and one slot labeled PM Shift for each date in June. The June log contained one entry for a dishwasher temperature on 6/10/25. Surveyor noted all other dates did not have documentation to indicate the dishwasher temperatures were monitored. On 6/10/25 at 8:42 AM, Surveyor toured the [NAME] unit kitchen and reviewed the June 2025 Household Dishwasher Record. The form indicated the wash cycle should be 150 degrees or higher and the final rinse cycle should be 180 degrees or higher. The form contained one slot labeled AM Shift and one slot labeled PM Shift for each date in June. The log had missing dishwasher temperatures on 6/1/25, 6/5/25, 6/6/25, and 6/9/25 and only contained documentation for either the AM or PM shift from 6/2/25 through 6/4/25 and 6/7/25 through 6/8/25. During the unit kitchen tour, Surveyor interviewed HM-J who worked in the [NAME] and Turnberry units on the AM shift. HM-J confirmed the logs only had slots for the AM and PM shifts. HM-J indicated the dishwasher is continuously run because breakfast is cooked on the unit and dishes for all meals are washed in the unit dishwashers. HM-J indicated the logs should be filled out and previous logs are kept in the kitchen with DD-E. On 6/10/25 at 11:13 AM, Surveyor interviewed DD-E who indicated unit dishwashers are used to wash cooking dishes, utensils, plates, cups, and anything that is used for food service on the unit. DD-E indicated Homemakers and CNAs are responsible for documenting dishwasher temperatures in the AM and PM on each unit. Surveyor noted the Turnberry unit did not have a June 2025 Household Dishwasher Record. Surveyor requested copies of the [NAME] and Turnberry dishwasher logs for May and June 2025. On 6/11/25, Surveyor received and reviewed copies of the dishwasher logs for the [NAME] and Turnberry units. The May 2025 dishwasher log for the [NAME] unit did not contain temperature documentation for 5/8/25, 5/16/25, and 5/21/25. All other days contained either an AM or PM temperature only. The May 2025 dishwasher log for the Turnberry unit did not contain temperature documentation for 5/1/25, 5/4/25 through 5/5/25, 5/7/25 through 5/11/25, 5/15/25 through 5/17/25, 5/19/25, 5/24/25 through 5/25/25, and 5/28/25 through 5/31/25. All other days contained either an AM or PM temperature only. The June 2025 Turnberry unit dishwasher log did not contain temperature documentation for 6/2/25 through 6/8/25 and for 6/11/25 and contained either an AM or PM temperature only for 6/1/25, 6/9/25, and 6/10/25. Cooked Food Temperatures and Hot/Cold Holding Temperatures: The 2022 Wisconsin Food Code documents at 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. The 2022 Wisconsin Food Code documents at 3-401.11 Raw Animal Foods: .(A) Except as specified under (B), (C), and (D) of this section, raw animal foods such as eggs, fish, meat, poultry, and foods 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: (1) 63° C (145° F) or above for 15 seconds for: P (a) Raw shell eggs that are broken and prepared in response to a consumer's order and for immediate service . The 2022 Wisconsin Food Code documents at 3-501.19 Time as a Public Health Control: (A) Except as specified under (E) of this section, if time without temperature control is used as the public health control for a working supply of time/temperature control for safety food before cooking, or for ready to eat time/temperature control for safety food that is displayed or held for sale or service .(1) The food shall have an initial temperature of 5 degrees C (41 degrees F) or less when removed from cold holding temperature control, or 57 degrees C (135 degrees F) or greater when removed from hot holding temperature control . On 6/10/25 at 8:42 AM, Surveyor toured the [NAME] unit kitchen and reviewed Meal Service Temperature Logs. Surveyor noted there were not Meal Service Temperature Logs for 6/8/25 to 6/14/25. At that time, Surveyor interviewed HM-J who worked on the [NAME] and Turnberry units during the AM shift. HM-J indicated breakfast is cooked in each unit kitchen. HM-J indicated lunch and dinner are cooked in the main kitchen, brought to the units, and served from the [NAME] unit steam table. HM-J confirmed meal temperatures should be documented on Meal Service Temperature Logs. On 6/10/25, Surveyor requested May and June 2025 Meal Service Temperature Logs from DD-E. On 6/11/25, Surveyor received and reviewed Meal Service Temperature Logs provided by DD-E and noted the following: ~ From 5/425 through 5/10/25: Breakfast on 5/4/25, 5/6/25, and 5/9/25 indicated Made to Order and did not contain temperatures. Lunch on 5/4/25, 5/9/25, and 5/10/25 did not contain documentation of food held for service temperatures. Supper on 5/7/25 and 5/8/25 did not contain documentation of food held for service temperatures. ~ From 5/11/25 through 5/17/25: Breakfast on 5/11/25, 5/12/25, 5/13/25, 5/15/25, and 5/17/25 did not contain documentation of cooked food or cold food temperatures. Lunch on 5/12/25, 5/15/25, and 5/17/25 did not contain documentation of hot/cold holding temperatures. Supper on 5/16/25 did not contain documentation of hot/cold holding temperatures. ~ From 5/18/25 through 5/24/25: Breakfast on 5/18/25, 5/21/25, and 5/23/25 did not contain cooked food or cold food temperatures; 5/20/25 and 5/21/25 indicated Made to Order for cooked food temperatures. Lunch on 5/18/25, 5/19/25, and 5/23/25 did not contain documentation of hot/cold food holding temperatures. Supper on 5/21/25 did not contain documentation of hot/cold food holding temperatures. ~ From 5/25/25 through 5/31/25: Breakfast on 5/26/25 and 5/30/25 did not contain documentation of cooked food or cold food temperatures; 5/5/27 indicated Made to Order for cooked food temperatures. ~ From 6/1/25 through 6/7/25: Breakfast on 6/1/25 ,6/2/25, 6/3/25, 6/5/25, and 6/7/25 did not contain documentation of cooked food or cold food temperatures. A Meal Service Temperature Log for the week of 6/8/25 through 6/14/25 was not provided. On 6/11/25 at 9:34 AM, Surveyor interviewed DD-E who indicated there was no log for 6/8/25 through 6/14/25 and confirmed cooked food and hot/cold holding temperatures were not consistently documented. DD-E confirmed staff on the units who work in the kitchen are trained to take cooked food and hot/cold holding temperatures for every meal. Refrigerator and Freezer Temperatures: The 2022 Wisconsin Food Code documents at 3-202.11 Temperature: .Perishable food items must be stored at appropriate temperatures to prevent spoilage and reduce the risk of foodborne illnesses. Refrigerators should be set below 41° F (5° C) and freezers at or below 0° F (-18° C). During a tour on 6/10/25 at 8:22 AM, Surveyor noted the Turnberry unit did not have a refrigerator or freezer temperature log. Surveyor also noted the [NAME] unit June 2025 refrigerator and freezer temperature log did not contain temperatures for 6/6/25 or 6/9/25. At that time, Surveyor interviewed HM-J who indicated temperatures for the [NAME] and Turnberry unit refrigerators and freezers are documented on a log located on the refrigerator/freezer. HM-J indicated the previous months are given to DD-E for filing. On 6/11/25 at 9:34 AM, Surveyor interviewed DD-E who indicated refrigerator and freezer temperatures should be monitored and documented daily. Surveyor requested copies of the [NAME] and Turnberry unit refrigerator and freezer temperature logs for May and June of 2025. On 6/11/25, Surveyor received and reviewed the May 2025 [NAME] unit refrigerator/freezer temperature log and noted there were no refrigerator/freezer temperatures documented for 5/725, 5/8/25, 5/16/25, and 5/21/25. Surveyor also received and reviewed the May 2025 Turnberry unit refrigerator/freezer temperature log and noted the log only contained temperature documentation for 5/3/25. A June 2025 log for the Turnberry unit was not provided to Surveyor. On 6/11/25 at 11:05 AM, DD-E approached Surveyor and confirmed the facility did not have a June 2025 record of refrigerator and freezer temperatures for the Turnberry unit. On 6/11/25 at 9:34 AM, Surveyor interviewed DD-E who indicated staff should follow the Wisconsin Food Code for policies and procedures regarding food storage, dating, hot/cold food cooked and holding temperatures, and daily refrigerator and freezer temperatures as well as dishwashing sanitization procedures. DD-E indicated staff were probably not aware of the Wisconsin Food Code and indicated DD-E would share the information with staff. Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect all 78 residents residing in the facility. Staff did not ensure time/temperature control foods were labeled with open and use-by dates and/or discarded when they expired. Staff did not wear hair restraints consistently in the kitchen. Staff did not follow safe food cooling protocol. Staff were unaware of temperature requirements when testing parts per million (PPM) of the sanitizing solution. Unit kitchen dishwashers were not consistently monitored for appropriate temperatures. Holding and cooking temperature logs for food served to residents were incomplete. Findings include: Open/Unlabeled/Undated/Expired Food: The 2020 Wisconsin Food Code documents at 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking: (A) Except when packaging food using a reduced oxygen packaging method as specified under § 3-502.12 and except as specified in (E), (F), and (H) of this section, refrigerated, ready to eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature and time combination of 5 degrees Celsius (C) (41 degrees Fahrenheit (F)) or less for a maximum of 7 days. The day of preparation shall be counted as day 1 .(2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety .(D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: .(3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section .Disposition: (A) A food specified under 3-501.17 (A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17 (A) Except time that the product is frozen; (2) Is in a container or package that does not bear a date or day. The facility's Safe Food Storage policy, revised 9/2017, indicates: .Food brought into the facility will be properly labeled and dated the day the item is brought into the facility. Routine inspections will be made to unit refrigerators. All efforts of staff are to ensure safe food storage of any food items stored on units and/or in resident rooms .The following procedure will be applied to all unit refrigerators: Inspected daily by household personnel .Items used or opened will be kept a maximum of three days .Beverages and food items provided by food service may be stored in the refrigerator for use by household staff. When cans and bottles are opened, they must be dated with the date the product was opened and covered properly with covers provided . On 6/9/25 at 9:35 AM, Surveyor began an initial kitchen tour with Director of Dining (DD)-E who indicated the facility follows the Wisconsin Food Code. During the tour, Surveyor and DD-E observed the following: Dry Storage: ~ One container of yellow cake mix dated 4/16 with no use-by date ~ One container of Krusteaz pancake mix dated 11/11 (open date per DD-E) with no use-by date ~ One container of vanilla pudding dated 6/3 (open date per DD-E) with no use-by date ~ One container of cocoa powder dated 3/16 with no use-by date ~ Two containers of almonds (one dated 12/19 and the other dated 6/27) with no use-by dates ~ One container of chocolate chips dated 4/12/25 with no use-by date ~ One container of powdered sugar dated 6/7 with no use-by date ~ One gallon of liquid smoke dated 11/8 with no use-by date ~ One undated container of potatoes ~ One container of angel food mix dated 2/26 with no use-by date ~ One container of split peas dated 5/19 with no use-by date ~ One container of spaghetti noodles dated 5/19 with no use-by date ~ One container of barley dated 3/12 with no use-by date ~ One container of stuffing mix dated 6/2 with no use-by date ~ One container of potato pancake mix dated 6/3 with no use-by date ~ One container of potato pearls dated 6/4 with no use-by date ~ One container of spaghetti noodles dated 5/19 with no use-by date ~ One package each of beef gravy, pork gravy, chicken gravy, and turkey gravy with various open dates and no use-by dates Main/Walk-In Cooler: ~ Three packages of shredded cheese (two dated 6/5 and one dated 6/8) with no use-by dates ~ Eight packages of wrapped cheese slices dated 6/3 with no use-by dates ~ One container of pears dated 6/9 with no use-by date ~ A tub with several raw racks of ribs in a plastic bag that was open to air dated as pulled from the freezer on 6/6 with no use-by date ~ Two packages of raw brats with a pulled date of 6/8 and no use-by date ~ Five packages of precooked chicken with pulled dates of 6/8 and no use-by dates ~ One container with 34 servings of cooked BBQ pork dated 2/4 and pulled 6/8 with no use-by date ~ One package of liquid eggs dated 6/4 with no use-by date ~ One package of cooked turkey cooked 5/11 and pulled 6/9 with no use-by date Reach-In Cooler: ~ One container of pureed bread dated 6/7 with no use by date ~ One container of egg salad dated 6/8 with no use-by date ~ One container of pureed tomato dated 6/8 with no use-by date Freezer: ~ Four tubs with numerous packages of cooked and wrapped roast beef dated between January and June with no use-by dates ~ One tub with packages of cooked and wrapped turkey with various dates and no use-by dates ~ Numerous packages of cooked ground hamburger with various dates and no use-by dates ~ Two containers of cooked Swedish meatballs (dated 4/27 and 5/14) with no use-by dates ~ Three containers of cooked spaghetti meat sauce (dated 3/22, 3/27, and 6/3) with no use-by dates ~ Four containers of cooked diced ham (one dated 4/25/25, one dated 5/30, and two dated 5/6) with no use-by dates ~ One container of cooked ground pork dated 6/8 with no use-by date ~ Two containers of beef stock dated 6/4 with no use-by dates ~ One container of 20 servings of cooked Sloppy Joes dated 2/2/25 with no use-by date ~ One container of ham stock dated 6/3 with no use-by date ~ One container of poppy seed butter blend dated 6/10/25 with no use-by date ~ Three large loaves of raw meatloaf dated 3/27 with no use-by dates During the initial tour on 6/9/25 at 9:35 AM, Surveyor interviewed DD-E who did not know the dating policy or use-by dates for dry good items. DD-E indicated DD-E had started the process of completing Certified Dietary Manager training. When Surveyor asked how staff know the use-by dates for open and/or made items, DD-E indicated staff would not know the use-by dates and the facility needed to establish a new process. DD-E indicated use-by dates in the cooler are three days but also indicated DD-E was not sure of the use-by dates for some of the items. DD-E indicated DD-E was not sure of the use-by dates for items in the freezer but thought six months for the roast beef. DD-E could not locate the facility's dating policy and indicated DD-E would keep looking. On 6/10/25 at 11:08 AM, DD-E provided Surveyor with a Food Storage Chart printed from FoodSafety.gov and stated the facility uses the chart but follows the Wisconsin Food Code as their policy. Unit Kitchens: On 6/9/25 at 10:06 AM, Surveyor toured the [NAME] unit kitchen and observed the following items in the refrigerator: ~ One open container of Grove brand apple juice dated 4/5/25 ~ One open and undated container of [NAME] brand sliced strawberry topping ~ Three unopened and undated containers of [NAME] brand sliced strawberry topping ~ One open and undated container of Half and Half Surveyor observed the following items in the freezer: ~ One undated bag of English muffins ~ Three undated bags of waffles ~ One open and undated jar of Smucker's brand strawberry jam ~ One undated bag of sausage patties Surveyor also observed several prepackaged and vacuum-sealed bags with the following pureed items: ~ One package of pears (date packaged 10/7/24), one package of pears (dated packaged 12/2/24) and four packages of pears (dated packaged 10/25/24) ~ One package of berries (dated 1/20/25) and five packages of berries (dated packaged 12/31/24) ~ Eight packages of bacon (labeled packaged 1/20/25) ~ Nine packages of [NAME] (labeled packaged 2/12/25) ~ Three packages of [NAME] (labeled packaged 2/6/25) Surveyor noted each prepackaged pureed item did not contain a use-by date. On 6/9/25 at 11:44 AM, Surveyor toured the Turnberry unit kitchen and observed the following items in the refrigerator: ~ One open and undated bottle of pear juice ~ One open and undated bottle of orange juice ~ One open and undated jar of concord grape jelly ~ One open and undated bottle of cranberry juice ~ Two undated cartons of strawberries ~ One open and undated raspberry Danish ~ One open and undated bottle of white grape juice ~ One open and undated jar of mayonnaise ~ One open and undated jar of Smucker's brand strawberry jam ~ One open and undated bottle of BBQ sauce ~ One open and undated bottle of Caesar salad dressing ~ One unopened bag of prepackaged hard-boiled eggs with a use-by date of 5/31/25 ~ Four bags of grapes with no received, open, or use-by dates Surveyor observed the following items in the freezer: ~ One undated raspberry Danish ~ Three undated bags of waffles ~ Multiple hashbrown patties in an undated one-gallon plastic bag ~ Three undated gallon-size plastic bags of egg patties ~ Three undated gallon-size plastic bags of sausage patties Following the observations, Surveyor interviewed Certified Nursing Assistant (CNA)-I who indicated kitchen staff bring the items to the units. CNA-I indicated the items should be dated when they arrive. CNA-I indicated Homemakers or CNAs who work in the kitchen are responsible for labeling items when they are opened and should indicate when the items should be used by. During a tour of the Turnberry kitchen on 6/10/24 at 8:22 AM, Surveyor observed undated raspberry Danish served to residents during breakfast. During a tour of the [NAME] unit kitchen on 6/10/25 at 8:42 AM, Surveyor noted the following items were added to the refrigerator from the previous observation on 6/9/25: ~ Five coffee creamers (one was open and all were undated) On 6/10/25 at 11:13 AM, Surveyor interviewed DD- E who indicated the prepackaged pureed items came from the vendor. DD-E indicated Homemakers and CNAs are responsible for labeling items when opened. DD-E indicated the facility follows their policy and the foodsafety.gov Cold Food Storage chart for cold storage use-by dates. Surveyor noted fully cooked, vacuum-sealed at plant unopened food contained a use-by date of 1-2 months for the freezer. DD-E indicated the prepackaged pureed foods should be discarded. On 6/10/25 at 12:13 PM, Surveyor observed the following items in the [NAME]/Sunny Creek second floor kitchenette with Homemaker (HM)-C: Cooler: ~ One container of egg salad dated 6/8 with no use-by date ~ One package of pickles dated 6/4 with no use-by date ~ One container of egg custard dated 6/9 with no use-by date ~ One container of sour cream dated 5/30 with no use-by date ~ One unlabeled container of a pasta salad (per HM-C) dated 6/9 with no use-by date ~ One unlabeled package of cut tomatoes (per HM-C) dated 6/2 with no use-by dates ~ One unlabeled package of lettuce (per HM-C) dated 6/7 with no use-by date ~ One unlabeled package of pork cutlets (per HM-C) dated 6/4 with no use-by dates ~ One unlabeled package of two browning heads of lettuce (per HM-C) dated 5/20 with no use-by date ~ One unlabeled package with two heads of lettuce (per HM-C) dated 6/3 with no use-by date ~ One package of carrots dated 6/2 with no use-by date ~ Two packages of shredded cheese dated 5/26 with no use-by dates ~ One package of cooked bacon dated 6/10 with no use-by date ~ One package of hashbrowns dated 6/10 with no use-by date ~ One unlabeled and uncovered pan of cherry dessert (per HM-C) dated 6/3 with no use-by date ~ One unlabeled pan of white cake (per HM-C) dated 6/9 with no use-by date ~ One unlabeled pan of banana cream dessert (per HM-C) covered with ripped aluminum foil and with a knife in the dessert dated 6/8 with no use-by date ~ One unlabeled pan of orange Jell-O (per HM-C) dated 6/8 with no use-by date Freezer: ~ Four packages of egg patties (dated 5/1, 5/1, 5/17, and 6/1) with no use-by dates ~ One package of hot dogs dated 6/9 with no use-by date ~ Three packages of sausage patties (one dated 5/8 and two dated 5/26) with no use-by dates ~ One unlabeled and undated package of hashbrown patties (per HM-C) ~ One open, unsealed, unlabeled, and undated package of uncooked bacon (per HM-C) ~ Two packages of ham (dated 11/24 and 1/21) with no use-by dates On 6/10/25 at 12:31 PM, Surveyor interviewed HM-C who indicated food in the unit refrigerators and freezers should be labeled and dated and fully covered. As Surveyor and HM-C pulled out the lettuce, tomatoes, and desserts, HM-C indicated the items were expired and should have been discarded after three days. HM-C indicated HM-C was embarrassed by the unlabeled, undated, and expired food in the refrigerator and was not aware of the use-by dates. HM-C also indicated it was not acceptable for staff to leave a knife in the dessert. On 6/11/25 at 9:34 AM, Surveyor interviewed DD-E who indicated DD-E will work on sharing the Wisconsin Food Code with staff. DD-E indicated staff should follow the Wisconsin Food Code for use-by dates and dating food items. Hair Restraints: The 2022 Wisconsin Food Code documents at Hair Restraints 2-402.11 Effectiveness:.(B) .Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, and linens, and unwrapped single-service and single-use articles. The facility's Food Service Personnel Management policy, revised 2/2025, indicates: To achieve standards set by federal, state and local agencies .3. Personal Hygiene: .b. A hair net must be worn at all times when handling or preparing food to prevent hair from contaminating food or surfaces. If staff are working on the households on a side where food is not out, hairnets do not need to be worn (example: doing dishes or getting a resident water) .f. Long hair must be pulled back securely - no scarves or flowers . During the initial kitchen tour on 6/9/25 at 9:35 AM, Surveyor noted DD-E's bangs covered DD-E's forehead and were not restrained while DD-E prepared food. Surveyor also noted approximately 3 to 4 inches of the sides of DD-E's hair were pulled out of the hair restraint near DD-E's ears. On 6/9/25 at 11:58 AM, Surveyor observed CNA-F walk behind the [NAME]/Sunny Creek kitchen area without a hair restraint when HM-C was serving food. There was dessert on the counters on both sides of the kitchen when CNA-F walked by. On 6/10/25 at 8:52 AM, Surveyor observed HM-C serve food in the [NAME]/Sunny Creek kitchen with HM-C's bangs exposed in the front, sides, and back of HM-C's hair restraint. On 6/10/25 at 11:38 AM, Surveyor observed CNA-D walk behind the [NAME]/Sunny Creek kitchen area without a hair restraint when staff were preparing food. CNA-D retrieved drinks for residents. At 11:40 AM, CNA-D asked HM-C for a hair restraint. HM-C showed CNA-D where the hair restraints were kept. CNA-D applied a hair restraint and kept working in the kitchenette. On 6/10/25 at 11:41 AM, Surveyor interviewed CNA-D who indicated CNA-D had not worn a hair restraint before 6/10/25. When asked why CNA-D put on a hair restraint that day, CNA-D indicated CNA-D was told by management that CNA-D needs to start wearing a hair restraint in the kitchenette. On 6/10/25 at 11:52 AM, Surveyor observed CNA-F enter the [NAME]/Sunny Creek kitchenette while food was being served. CNA-F wore a hair restraint, however, 3 to 4 inches of CNA-F's hair was not restrained on the right side. On 6/11/25 at 9:34 AM, Surveyor interviewed DD-E who indicated DD-E will work on sharing the Wisconsin Food Code with staff. DD-E indicated staff need to wear hair restraints in the kitchen and kitchenettes when they prepare, serve, and are around food. Safe Cooling: The 2022 Wisconsin Food Code documents at section 3-501.14 Cooling: (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 57° Celsius (C) (135° Fahrenheit (F)) to 21° C (70° F); and (2) Within a total of 6 hours from 57° C (135° F) to 5° C (41° F) or less. (B) Time/temperature control for safety food shall be cooled within 4 hours to 5° C (41° F) or less. The 2022 Wisconsin Food Code documents at section 3-501.15 Cooling Methods: (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under § 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 Post Cooking Cooling policy, dated 2/16/22, indicates: To prevent bacterial growth and ensure resident safety, all potentially hazardous foods that require cooling must be cooled rapidly and monitored to meet time/temperature standards. 1. Temperature check after cooking. Immediately after cooking is completed, staff must: measure the internal temperature of the food using a calibrated, sanitized food thermometer. Record the time, temperature, food item, and staff initials on the Cooks Temp Log. 2. Initiate cooling. Begin cooling immediately using one of the following approved methods: Refrigerator Cooling, .Freezer Quick Cool, .3. Storage after cooling. Once the food has reached 41° F or below: Cover, label with product name, cooling completion date, and use-by date. Store according to FIFO (first in, first out) procedures. During the initial kitchen tour on 6/9/25 at 9:35 AM, Surveyor and DD-E observed the following cooked and cooled foods in the walk-in freezer and walk-in cooler: Freezer: ~ Four tubs with numerous packages (30+) of cooked and wrapped roast beef dated between January and June ~ One tub with packages of cooked and wrapped turkey with various dates ~ Numerous packages of cooked ground hamburger with various dates ~ Two containers of cooked Swedish meatballs (dated 4/27 and 5/14) ~ Three containers of cooked spaghetti meat sauce (dated 3/22, 3/27, and 6/3) ~ Four containers of cooked diced ham (one dated 4/25/25, one dated 5/30, and two dated 5/6) ~ One container of cooked ground pork dated 6/8 ~ One container of 20 servings of cooked Sloppy Joes dated 2/2/25 Cooler: ~ One container of pasta salad dated 6/9 ~ One package of cooked pork cutlets dated 6/4 ~ One package of cooked turkey dated 5/11 ~ One container of 34 servings of cooked BBQ pork dated 2/4 During the initial kitchen tour on 6/9/25 at 9:35 AM, Surveyor interviewed DD-E who indicated the facility does not use food cooling logs. When asked how staff track cooked food cooling, DD-E indicated staff do not measure or track food cooling. On 6/11/25 at 9:34 AM, Surveyor interviewed DD-E who indicated DD-E was not aware of the cooked food cooling requirements in the Wisconsin Food Code. Sanitizing Solution: The 2022 Wisconsin Food Code documents at section 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 Maintenance, Sanitization and Safety policy, dated 1/2018, indicates: Maintenance, sanitization, and safety according to federal, state, and local agencies .B. Sanitization. 1. The Food Service Manager, with the help of the Registered Dietitian, is responsible for the supervision and training of employees in proper sanitization within the Food Service Department. During the initial kitchen tour on 6/9/25 at 9:35 AM, Surveyor reviewed the Dish Machine Temperature Log which contained a column for sanitizer testing. Surveyor noted every entry in the sanitizer testing column for May and June 2025 read 200. The log did not contain

Based on staff interview and record review, the facility did not ensure 1 resident (R) (R9) of 2 sampled residents received written information on the duration of the bed hold policy, the reserve bed payment policy, and the right to return to the facility. Neither R9 or R9's representative were provided with a written bed hold notice that included the duration of the bed hold policy, the reserve bed payment policy, and the right to return to the facility when R9 was transferred to the hospital on 6/6/25. Findings include: The facility's Bed Hold policy, dated 11/2016, indicates: .Before any hospital transfer or therapeutic leave, the facility will provide written information specifying: i. Duration of state bed-hold policy; ii. Reserve bed payment policy (if applicable); iii. Facility's bed-hold periods and return policies; iv. Any cost associated with bed hold beyond state limits; v. Resident's rights to appeal discharge decisions . From 6/9/25 to 6/11/25, Surveyor reviewed R9's medical record. R9 was admitted to the facility on [DATE] and had a diagnosis of dementia. R9's Minimum Data Set (MDS) assessment, dated 3/19/25, indicated R9 had moderate cognitive impairment. R9 had an activated Power of Attorney for Healthcare (POAHC). R9's medical record indicated R9 was sent to the hospital for evaluation on 6/6/25. Surveyor requested a copy of the bed hold notice for R9's hospital transfer. On 6/11/25, Surveyor reviewed a Financial Consent to Bed Hold document that was signed on 3/10/22. On 6/10/25 at 2:54 PM, Surveyor interviewed Director of Nursing (DON)-B and reviewed the facility's bed hold procedure. DON-B indicated the facility reviews the bed hold policy with residents as part of the admission packet. DON-B indicated residents sign a Financial Consent to Bed Hold form upon admission. DON-B indicated when a resident is transferred to the hospital, a bed hold letter is included in the paperwork that is sent with the resident. If a resident spends the night in the hospital, a staff member calls the resident or their representative to confirm their bed hold preference and documents the conversation in a progress note. On 6/10/25, Surveyor reviewed the bed hold letter and noted it did not include the daily rate for the bed reserve payment. The bed hold letter also did not contain a signature line for the resident to acknowledge receipt of the bed hold policy. On 6/11/25 at 8:38 AM, Surveyor interviewed Social Worker (SW)-L who indicated when a resident is transferred to the hospital, a bed hold notice is sent with the resident in a packet of paperwork. SW-L indicated a bed hold notice is not discussed with the resident if the resident returns from the hospital the same day. If the resident is admitted to the hospital overnight, the facility asks hospital staff to provide the bed hold notice to the resident. SW-L indicated when a resident is admitted overnight, SW-L calls the resident or their representative the following day to discuss the bed hold policy. SW-L indicated SW-L does not discuss the daily rate or appeal rights with the resident or their representative. On 6/11/25 at 10:12 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A about the bed hold procedure. NHA-A confirmed a bed hold form is signed upon admission to the facility. NHA-A indicated the bed hold letter is provided to a resident before transfer and a phone call is made the next day to discuss the bed hold with the resident or their representative. NHA-A indicated the reserve bed payment rate is discussed during the follow-up phone call. On 6/11/25 at 10:45 AM, Surveyor interviewed Registered Nurse (RN)-M who indicated RN-M informs residents that bed hold information is available in the hospital paperwork packet. RN-M indicated the bed hold letter is not given directly to the resident or their representative.

Based on observation, staff interview, and record review, the facility did not provide the necessary respiratory care and services for 1 resident (R) (R1) of 2 sampled residents. The facility did not ensure R1's oxygen orders were consistently followed. Findings Include: The facility's Oxygen Administration Concentrators policy, revised 4/19/25, indicates: .Procedure: .C. Press power switch on position and adjust oxygen flow .D. Read the center of the ball with the meter at eye level. If unable to obtain the proper flow rate, check for kinks in the tubing or loose connections. From 6/9/25 to 6/11/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including hemiplegia and hemiparesis following unspecified cerebrovascular disease, spinal stenosis, lumbar, major depressive disorder, and unspecified thoracic, thoracolumbar and lumbosacral intervertebral disc disorder. R1's Minimum Data Set (MDS) assessment, dated 12/17/24, had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R1 had moderately impaired cognition. R1's most recent MDS assessment, dated 3/19/25, did not contain a BIMS score. A care plan, dated 1/17/23 and last revised 3/26/25, indicated R1 had low oxygen readings when asleep due to sleep apnea related to a stroke and used a BiPAP machine. The care plan contained indicated R1 needed help putting on the BiPAP nasal mask with 4 liters of oxygen at bedtime. The care plan indicated R1 wore the mask throughout the night and during the day when R1 napped in bed. R1's Treatment Administration Record (TAR) contained the following orders: ~ Oxygen at 4 liters at bed time (HS) for continuous positive airway pressure (CPAP), dated 2/1/21 to 6/10/25. ~ Oxygen at 4 liters when using BiPAP every shift, dated 6/10/25. On 6/9/25 at 1:58 PM, Surveyor observed R1 asleep in bed. R1 used a bilevel positive airway pressure (BiPAP) machine and had an oxygen concentrator that was set at 1 liter of oxygen. On 6/10/25 at 9:40 AM, Surveyor observed R1 asleep in bed with the BiPAP machine on, however, the oxygen concentrator was not on. On 6/10/25 at 9:43 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-G about R1's oxygen. LPN-G entered R1's room and turned the oxygen concentrator on. Surveyor noted the oxygen level was set at 1.5 liters which LPN-G confirmed. On 6/10/25 at 12:02 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed R1's oxygen concentrator should be set at the level ordered by the physician.

Based on interview, record review, facility document review, and facility policy review, the facility failed to ensure staff applied a foot pedal to a wheelchair during transport of the resident to prevent an accident for 1 of 3 sampled residents (R1) reviewed for accidents. Findings included: R1 was admitted to the facility on [DATE]. The Resident Face Sheet revealed the resident had a medical history that included diagnoses of hemiplegia and hemiparesis following a cerebral infarction affecting the right side, vascular dementia, pain, and weakness. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/20/24, revealed R1 had a Staff Assessment for Mental Status (SAMS), which revealed the resident had moderately impaired cognitive skills for daily decision making. The MDS indicated the resident used a wheelchair for mobility and was dependent on staff for activities of daily living. R1's Care Plan, with a problem start date of 10/11/22 and revised on 05/14/24, documented the resident used a wheelchair to get around. The facility's undated investigation report revealed on 05/02/24 at 9:30 AM, staff noted R1 had increased pain on their right side, mostly in their leg. Per the report, later in the day on 05/02/24, it was witnessed that CNA C (Certified Nursing Assistant) wheeled R1 out of their room to the dining room without a foot pedal on the right side of the wheelchair. R1 put their right foot down while the wheelchair was in motion, and R1's foot went backwards. The report revealed during a routine visit by the Nurse Practitioner, on 05/07/24, the resident grimaced when their ankle was assessed and an x-ray was ordered. The x-ray report revealed R1 had moderate malleolar soft tissue swelling, acute distal fibular shaft fracture (the most common type of ankle fracture, usually the result of inversion), and an acute medial malleolus (lowest part of the long bone of the leg) fracture. According to the report, the facility was unable to determine how the fracture occurred because R1's pain began prior to the staff not utilizing the foot pedal. The investigation report revealed R1's care plan was updated to ensure staff knew they needed to place the right foot pedal on the resident's wheelchair. During an interview on 06/24/2024 at 3:42 PM, CNA C stated she propelled R1 from their room to the dining room without the wheelchair pedal under R1's right foot. CNA C stated she noticed R1's right foot was under the wheelchair, when the resident cried out. CNA C stated she rolled the wheelchair backwards and got R1's foot out from under the wheelchair. CNA C stated LPN D (Licensed Practical Nurse) and RN E (Registered Nurse) came over, and LPN D went to R1's room to get the foot pedal. CNA C stated LPN D witnessed R1's foot under the wheelchair. During an interview on 06/25/24 at 10:35 AM, R1's Responsible Party (RP) stated when they pushed R1 in their wheelchair, the right wheelchair foot pedal was always in place. The RP stated R1 could propel themselves in the wheelchair with their left foot. The RP stated R1's right side was affected by a stroke. During an interview on 06/25/24 at 1:16 PM, RN E stated she heard R1 cry out, and went to ask R1 what was wrong. RN E stated the resident had a habit of crying out and was difficult to understand. RN E stated she did not witness R1's foot under the wheelchair, but did see that R1 did not have the right foot pedal on their wheelchair. RN E stated R1 did not seem to be in pain, after the incident, and went to the common area and played cards. During an interview on 06/25/24 at 2:00 PM, DON B (Director of Nursing) stated the resident had increased pain prior to the incident and she would not have expected an x-ray right away if the resident did not complain of pain. During an interview on 06/25/24 at 2:06 PM, NHA A (Nursing Home Administrator) stated accidents would happen and she expected staff to learn from the accident through education so that it would not happen again. During a return telephone call on 06/26/24 at 7:03 PM, LPN D stated she was in the dining room with her supervisor, RN E, when she heard R1 cry out. LPN B stated she turned around and saw R1's foot under the wheelchair and CNA C pulled the wheelchair back. LPN D stated she went to R1's room to get the right foot pedal for the resident's wheelchair. LPN D stated she did not assess R1's leg because the resident always had right leg pain and swelling, so it would be hard to determine if symptoms were the result of the incident. LPN D stated she had the Advanced Practice Nurse Practitioner look at R1's ankle, and an x-ray was ordered.

Based on observation, record review, and interview, the facility did not ensure food was prepared safely and temperatures taken in 5 of 5 household kitchens. This deficient practice has the potential to affect 80 of the 82 residents currently residing in the facility who receive their meals from the household kitchens. * End of service temperature checks were not being completed 4 times a month on AM and PM shift. * Temperatures were not being taken for breakfast food cooked in the individual household kitchens. Findings: The facility policy, entitled Food Preparation, revised 2/2009, states, D. A thermometer is used during food preparation to insure proper cooking temperatures for all food items. H. The Food Service cook record the temperature of the food at each meal to determine if the food is cooked and maintained at correct temperature. The facility policy, entitled Steam Table, Use of, revised 3/2017, states H. Complete end of service temperature check sheet, this is done once a week on AM and PM shift. On 02/21/24 at 07:41 AM, Surveyor spoke to Dietary Manager (DM)-C regarding observing temperature of food at the holding site. DM-C informed Surveyor that temperatures are taken at the end of service of the last plate served and that this end temperature is taken 4 times a month on both AM (lunch) and PM (Dinner) service. On 02/21/24 at 07:55 AM, Surveyor interviewed Homemaker-D on Woodland/Sunnyfield Unit who was serving breakfast that consisted of French toast bake and bacon. Surveyor asked where the French toast bake and bacon were cooked. Homemaker-D confirmed that both items were cooked in the unit's kitchen. Surveyor asked if a temperature was taken of cooked food items prior to service and Homemaker-D stated they were not as temperatures are taken at the end of service once a week. Homemaker-D pointed out an End of Service Temperature Check Sheet located on the refrigerator. Surveyor notes an end of service temperature taken on 2/10/24 AM shift and 2/19/24 on AM shift. Surveyor asked Homemaker-D when eggs are made to order are the eggs tempt prior to service? Homemaker-D stated no. Homemaker-D stated that they use a binder which has all the recipes and bake times. They follow these instructions to prepare the food and then serve it. There is no documentation of any PM shift end of service temperature checks completed. On 02/21/24, at 08:20 AM, Surveyor requested the food temperature policy from the Nursing Home Administrator (NHA)-A. On 02/21/24 at 01:39 PM, Surveyor spoke with Homemaker-E on TurnBerry unit. Surveyor asked Homemaker-E where the French toast back and bacon were cooked for the mornings breakfast. Homemaker-E stated that most breakfast items are cooked right in the kitchen on the units. She stated that temperatures are not taken after making the food since they are following the recipe and cook time is in the binder provided. Homemaker-E showed the binder to Surveyor which gave instructions for how to prepare and cook food items and it does reference the internal cooking temperature of the food item. Surveyor asked how do they know the food items has reached the appropriate internal temperature if they are not taking a temperature at the end of cooking? Homemaker-E stated that they follow the cooking time and that it's assumed the item is cooked thoroughly. Surveyor reviewed the End of Service temperature Check Sheet located on the refrigerator and noted documentation of an end of service temperature taken on 2/3/24 on AM shift, 2/8/24 on AM shift and 2/17/24 on AM shift. There is no documentation of a PM shift end of service temperature taken on PM shift for those days. On 02/21/24, at 01:45 PM, Surveyor interviewed DM-C regarding breakfast food prepared and make on the unit kitchens. DM-C stated that staff should be taking temperatures of breakfast food after they are done cooking it. Surveyor informed DM-C of the concern that there does not appear to be a temperature log for breakfast food. The only temperature logs in the unit kitchens are the End of Service Temperature Check Sheet and those do not document breakfast items. DM-C stated she would look for logs. On 02/22/24, at 08:34 AM, Surveyor spoke with NHA-A regarding the concern that there is no evidence that food cooked in the unit kitchens are having their temperature taken prior to service to ensure that food has been cooked to the proper internal temperature. Surveyor also explained that it does not appear that staff are following policy to complete the End of Service Temperature Check Sheet per policy as temperature checks are not being completed 4 times per month on both AM and PM shift. NHA-A states she would look into this. On 02/22/24, at 08:56 AM, NHA-A provided Surveyor with copies of the End of Service Temperature Check Sheets from each of the unit kitchens. NHA-A stated that there is a lot of missing temperatures and staff were not following the instructions therefore they will need to do re-education. On 02/22/24, at 10:02 AM, DM-C confirmed that there is not temperature log for breakfast food cooked on the units. No additional information was provided.

Based on interview and record review, the facility did not ensure that Residents without a Pressure Injury (PI) do not develop pressure injuries, and receive appropriate care, treatment, & preventative measures to promote healing for 1 (R9) of 3 Residents reviewed for pressure injuries. * R9 was admitted to the facility on [DATE] with diagnoses which included a right hip fracture. The admission body check documents a 3.0 x 1.8 cm (centimeter) purple area that is not open potentially indicating the presence of a DTI (deep tissue injury). The wound assessment 8/9/22 documents a Stage 2 PI with 90% slough & 10% epithelial tissue. R9's pressure injury was not staged correctly as a Stage 2 pressure injury does not include slough. The 8/17/22 wound assessment continues to stage R9's pressure injury as a Stage 2 with 100% granulation tissue. R9's pressure injury was staged incorrectly as a Stage 2 doesn't contain granulation tissue. On 8/18/22 R9's skin integrity care plan was revised. The wound assessment dated [DATE] staged the PI as Unstageable with the wound bed being 100% slough. There were no revisions to R9's care plan after 8/18/22. On 8/25/22 the nurses note documents NP (Nurse Practitioner) updated per facility policy for an order for a wound culture. The wound specimen from coccyx collected on 8/25/22 and verified on 8/30/22 documents pseudomonas aeruginosa & mixed aerobic flora. On 8/30/22 during treatment change, the dressing was completely saturated with a foul odor. An order was received on 8/30/22 for Cipro 500 mg twice daily for 7 days. The wound assessment dated [DATE] documents Stage 4 with 50% granulation, 50% slough, and exposed bone. There was no revision to R9's care plan. On 10/27/22, R9's pressure injury had an increase in drainage with the drainage being described as cloudy tan serosanguineous and a slight odor. A wound culture and sensitivity were ordered. On 10/30/22, lab results revealed MRSA (Methicillin-resistant Staphylococcus aureus) in R9's pressure injury and an antibiotic was again ordered. On 10/31/22, a second antibiotic was ordered. R9's wheelchair & recliner cushion and mattress as observed by Surveyor are not appropriate for a Stage 4 pressure injury. The Facility's failure to assess and stage R9's pressure injury correctly, failure to revise R9's skin integrity care plan when R9's coccyx pressure injury declined on 8/25/22 to Unstageable, and when the pressure injury became infected on 8/30/22 & R9 was prescribed an antibiotic, and the failure to revise the care plan on 9/1/22 when R9 was identified with a Stage 4 PI with bone exposed, created a finding of Immediate Jeopardy (IJ) which began on 8/30/22. Surveyor notified NHA (Nursing Home Administrator) A, DON (Director of Nursing) B, CEO (Chief Executive Officer) M, & COO (Chief Operating Officer) N of the immediate jeopardy on 11/2/22 at 3:41 p.m. The immediate jeopardy was removed on 11/3/22. The deficient practice continues at a scope and severity of an E (potential for harm/pattern) as the facility continues to implement its action plan. Findings include: The facility policy and procedure last revised on 8/19 titled: Prevention and Care of Pressure Injuries indicates under policy: All residents that are at risk for developing a pressure injury will have preventative measure implemented to prevent and or aid in the healing of pressure injuries. Under Pressure Injury Grading System for Stage II (2) documents Partial thickness loss of dermis presenting as a shallow open ulcer with red of sic (or) pink wound bed, without slough. May also present as an intact or open/ruptured blister. This stage should not be used to describe perineal dermatitis, maceration, or excoriation. Under recommendations for treatment and care for Stage III (3) and Stage IV (4) documents Desired outcome: Promote healing and reduce bacterial growth, evaluate, and monitor. All recommendations per MD (medical doctor) order. 1. Keep wound clean by using Wound Cleanser or normal saline. 2. Reduce bacterial growth: Local Infection - (edema, pus, erythema, exudates, etc.) Topical anti-microbial therapy if applicable. Systemic infection - (chills, fever, elevated WBC (white blood count)) obtain order for culture and/or antibiotic therapy, if applicable. 3. Adequate nutritional intake, ongoing consultation with Dietician. 4. Assure a low-pressure environment - pressure reducing mattress, R9 was admitted to the facility on [DATE] with diagnoses including right hip fracture, HTN (hypertension), and chronic congestive heart failure. The hospital discharge summary dated 8/9/22 includes documentation for skin indicating: no evidence of rash or excoriations. Review of the undated and unsigned admission body check includes a circle at the coccyx area on the diagram with documentation of 3.0 cm (centimeter) x 1.8 cm purple without open area. The description on this admission body check would indicate R9 has a potential DTI (deep tissue injury). The nurses note dated 8/9/22 documents Patient is A&O x4 (alert and orientated times four) with periods of forgetfulness. Is able to make her needs known. Is very HOH (hard of hearing). Wears Bil (bilateral) hearing aids which does not seem to help. Transfers with 1A (one assist) [NAME] steady. Denies pain upon this assessment. VSS (vital signs stable), HRR (heart rate regular), no abnormal sounds noted. No cough or SOB (shortness of breath) noted. LSCTA (lung sounds clear to auscultation). Abd (abdomen) soft n/t (non-tender) with BS (bowel sounds) x4. Scattered bruising to BUE (bilateral upper extremities). Abrasion to her R (right) elbow and coccyx with treatment done. Protective cream applied to coccyx. Continent of B&B (bowel and bladder) with clear yellow urine noted. NP (non pitting) edema noted to BLE (bilateral lower extremities). Is on a general NAS (no added salt) diet. Surgical dressing to R (right) hip with small amount of drainage noted. Area outlined to monitor. Call light and pendent within reach. The wound assessment dated [DATE] documents Stage II (2), location not identified. Measurements are 4 cm x 2.3 cm, exudate is light serosanguineous and wound bed is 90% slough & 10% epithelial tissue. For wound edges/margins the assessment documents Edge attached to base; Irregular wound edges; Macerated soft. Under comments documents, Area was cleansed with wound cleanser, hydrogel applied to wound bed, skin prep to peri wound and covered with an Optifoam dressing. Minimal amount of drainage noted. Surveyor noted R9's pressure injury was incorrectly staged, as a Stage 2 pressure injury does not have slough and PI should have been staged as Unstageable. Surveyor also noted the documentation on what R9's skin conditions were upon admission has conflicting information on what R9's coccyx condition was on admission. The APNP (Advance Practice Nurse Prescriber) rehab admission note dated 8/11/22 does not include documentation of R9's pressure injury. On 8/11/22, the coccyx treatment for hydrogel, skin prep, and Optifoam was discontinued, and a new treatment was ordered to cleanse the wound with wound cleanser or soap & water, pat dry, and apply Chymosin barrier cream twice a day & prn (as needed). The Alteration in skin integrity care plan with a start date of 8/11/22 & last reviewed/revised on 10/27/22 documents the following approaches: * Equagel cushion to be in place where I am sitting in recliner or wheelchair. Start date of 8/11/22. * SKIN: Help turn/reposition every 2 hours. Side to side when in bed with pillow support. Start date of 8/11/22. * Follow Standard of Care Protocol for Skin Care. Start date of 8/11/22 & discontinued on 10/13/22. The Standard of care protocol for skin has approaches of: Complete a body check on all admissions, readmissions, and before and after ER (emergency room ) visits/hospitalization s. Complete a Braden Scale upon admission/readmission and every week for three weeks thereafter, quarterly, and change of condition. Thorough skin inspection to be done weekly during bath by the nurse who should fill out a skin audit observation after the bath. A standard pressure relief cushion should be in the chair and a standard pressure relief mattress on the bed. Should keep skin clean and dry. Should apply moisture barrier cream after resident has an incontinent episode. Apply sunscreen, sunglasses, and hat with a brim, if it's anticipated that there could be prolonged exposure to the sun. Follow basic good skin care which includes washing, rinsing, and dry thoroughly should be provided to residents requiring assistance with personal hygiene. Be aware of any allergies or sensitive skin when ordering lubricants or creams. Reposition residents with pillows behind the back and between the legs. Avoid positioning directly on the hip bone. Off load resident's heels in bed. If braces, casts, or splints are used, daily skin checks should be done to monitor for s/s (signs/symptoms) skin breakdown. Weekly measurements of all wounds (surgical wounds, pressure ulcers, skin tears, venous stasis ulcers, abrasions, lacerations, etc.) should be done until healed. The measurements and progress should be documented. The Dietitian and WCC/RN (Wound Care Certified/Registered Nurse) should be updated if a resident has a Stage 1 or greater ulcer for dietary interventions and wound treatment. The resident's physician and family or POA-HC (power of attorney health care) should be updated on skin integrity. Treatments should be according to the physician's order. A referral to the Wound Clinic for consult as needed. * SKIN: Please move the Equagel cushion to the recliner or wheelchair. Start date of 8/18/22. Surveyor noted there are no revisions to R9's skin integrity care plan after 8/18/22. The wound assessment dated [DATE] documents Stage II (2). Measurements are 3.2 cm x 1.5 cm x 0.1 cm, exudate is light serous and wound bed is 100% epithelial tissue. For wound edges/margins the assessment documents Edge attached to base; Irregular wound edges. The nurses note dated 8/11/22 documents Right elbow skin tear almost healed, no longer needs a dressing. Tx (treatment) changed to apply skin prep to right elbow BID (twice a day), to leave steri-strip in place. Stage II coccyx wound treatment changed from hydrogel with Optifoam dressing to applying Chamosyn (sic) barrier cream BID and PRN (as needed). NP (Nurse Practitioner) updated per facility policy to wound care dressing treatment changes. To off-load pressure to buttock with repositioning Q2 (every two) hours and turning side to side with pillow support Q2 hours while in bed, Equagel cushion to be in place in recliner or wheelchair when pt (patient) sitting in it. Educations provided to pt about importance off off-loading pressure to buttock area, pt verbalized understanding. The physician order dated 8/11/22 documents 1 packet Juven BID (twice a day) ok to mix with juice or water and 1 oz (ounce) liquid protein (active) supplement BID ok to mix with Juven. On 8/15/22 the order was changed from BID to QD (every day). R9's admission MDS (minimum data set) with assessment reference date of 8/16/22 documents a BIMS (brief interview mental status) score of 13 which indicates cognitively intact. R9 is coded as not having any behaviors including refusal of cares. R9 requires limited assistance with one-person physical assist for bed mobility & ambulation, extensive assistance with one-person physical assist for transfer & toilet use, and is independent with set up for eating. R9 is at risk for pressure injuries and is coded as having one Stage 2 pressure injury, present upon admission. The pressure injury CAA (care area assessment) dated 8/18/22 under analysis of findings documents R9 was admitted with a stage II pressure injury to her coccyx. She also has a skin tear to her right elbow. Treatments are done as ordered. Interventions in place to reduce pressure. According to the hospital discharge summary dated 08/09/22, R9 underwent an ORIF (open reduction and internal fixation) of her right hip fracture which was sustained from a fall. Her incision has no s/s (signs/symptoms) of infection. During the seven-day look back period, she was continent of bowel per vitals and occasionally incontinent of bladder per POC (plan of care). Staff assist with incontinence care. Her Braden score was 18. She needs limited assist with bed mobility per POC. A pressure reduction cushion is in the chair, and a standard pressure relief mattress is on the bed. Skin is inspected with cares, and a skin audit is done weekly. The dietician has met with her and completed the nutritional assessments. PT, OT, and ST (physical therapy, occupational therapy, and speech therapy) have done their evaluations (see PT/OT/ST assessments). She is participating in therapies as ordered to regain her strength and endurance and to improve her mobility so she can be more independent with bed mobility, transfers, and ambulation. The wound assessment dated [DATE] documents Stage II (2). Measurements are 4 cm x 1.5 cm, tissue type is granulation. Surveyor noted R9's pressure injury is incorrectly staged, as a Stage 2 does not have granulation tissue. The pressure injury should have been staged as a Stage 3. The initial physician visit dated 8/17/22 under review of systems includes documentation of Reports: buttocks pain does have history of previous right superior and inferior pubic rami fractures. Under objective for musculoskeletal documents: Dressing over right lateral hip with just small soiling no tenderness over dressing. There is no documentation or reference regarding R9's coccyx pressure injury. The wound assessment dated [DATE] documents Stage II (2). Measurements are 4.5 cm x 2 cm, exudate is light serosanguineous and wound bed is 100% epithelial tissue. For wound edges/margins the assessment documents Edge attached to base; Macerated/soft; Well defined wound edges. Under comments it is documented Stage 2 to coccyx is stable. Minimal amount of serosanguineous drainage noted. Treatment order changed to cleanse area with wound cleanser, apply hydrogel to wound bed, cover with Optifoam dressing. QOD (every other day) and PRN (as needed). Writer encouraged patient to utilize wheelchair cushion while sitting in recliner. R9's skin integrity care plan was revised on 8/18/22 with addition to Please move the Equagel cushion to the recliner or wheelchair. There were no further revisions to R9's skin integrity care plan. On 8/23/22, the treatment was changed to cleanse wound, apply hydrogel, cover with Optifoam every other day. On 8/26/22 this treatment was changed from every other day to twice daily. The wound assessment dated [DATE] documents stage as Unstageable Slough and/or Eschar, measurements are 6.5 cm x 6 cm x 0.2 cm, exudate is moderate seropurulent, wound bed is 100% slough, and wound healing status is documented as declining. Surveyor noted there are no revisions to R9's skin integrity care plan. The nurses note dated 8/25/22 documents Coccyx wound is larger, wound bed covered in slough tissue and is now an Unstageable pressure injury. Drainage is moderate sero-purulent drainage, no odor noted, peri-wound is red, but does blanch. To continue with current dressing change tx and off-loading interventions. NP updated per facility policy for an order for a wound culture. The wound assessment dated [DATE] documents stage as Unstageable Slough and/or Eschar, measurements are 7.7 cm x 4.4 cm x 2.8 cm, exudate is moderate serous, wound odor is pungent odor, wound bed is 100% slough, wound edges/margins are well defined wound edges, and wound healing status is stable. Under comments documents Slough area detached from R side of wound on R gluteal, exposed 2.8 cm tunneling noted. Treatment order changed per wound nurse recommendations. On 8/29/22 it is documented in R9's medical record the treatment was changed and indicates it was changed to the Stage 2 coccyx: Cleanse area with wound cleanser, pack tunneled area with Maxorb AG (silver), apply hydrogel slough areas, cover with sacral Optifoam dressing twice a day. The nurses note dated 8/30/22 documents Patient is A&O x 4 with occasional forgetfulness and confusion. No complaints of pain at time of assessment. Transfers and ambulates with 1A (one assist) using WW (wheeled walker). Heart rate and rhythm regular with murmur. +2 pitting edema to RLE (right lower extremity) and +1 pitting edema to LLE (left lower extremity). Tubigrips applied and BUE elevated when able. Strength is strong and equal with hand grasp and foot press. Unstageable pressure injury to coccyx area which has declined, slough present and tunneling. Treatment done this morning; previous dressing was completely saturated, foul odor present. Call light within reach, safety maintained. The wound specimen from coccyx collected on 8/25/22 and verified on 8/30/22 documents pseudomonas aeruginosa & mixed aerobic flora. The nurses note dated 8/30/22 documents NOR (new order received) from APNP for Lasix 20mg (one time), Cipro 500mg BID (twice a day) x7 days, Florastor 250mg BID x10 days, and check BMP (basic metabolic panel) in the morning. The wound assessment dated [DATE] documents stage as Stage IV (4), measurements are 7.5 cm x 3 cm x 2. cm, exudate is heavy seropurulent, there is no wound odor, wound bed is 50% granulation & 50% slough, wound edges/margins on assessment indicate edge is not attached to base and wound healing status is declining. Under comments documents Undermining 2.0 cm from 2 o'clock-9 o'clock. Slough tissue is lifting. Base of wound granulation tissue with exposed bone. The nurses note dated 9/1/22 documents Coccyx wound assessed. Wound continues to decline quickly. There is exposed bone at wound base. Wound does appear as a Kennedy ulcer. To continue with current dressing change orders and off-loading interventions. If family agrees to hospice care, goal to be geared towards comfort over wound healing. Surveyor noted there was no documentation that the physician or nurse practitioner were consulted with or notified of this at this time. The nurses note dated 9/2/22 documents: Patient is A&O x3 (alert and orientated times three) with times of forgetfulness but is able to make her needs known appropriately. VSS (vital signs stable). denies pain unless its during coccyx dressing change. Hand and foot grasps strong and equal. Transfers using 1A (one assist) WW (wheeled walker) and GB (gait belt) and tolerates well. Walks to and from the bathroom and to and from meals. Needs extensive assist with lower ADLs (activities daily living) and dressing. Once set up for grooming she can do that independently. HRR (heart rate regular). Has +1 pitting edema to BLE (bilateral lower extremities), tubi grips are on. Coccyx wound dressing changed this morning and the previous dressing was about half saturated with foul smelling tan colored drainage, the area was cleansed and packed per order. Call light within reach and safety maintained. On 9/2/22 the treatment remained the same except for instead of covering the pressure injury with a sacral Optifoam dressing, the covering was changed to an Optilock dressing and secure with paper tape. The frequency remained the same at twice a day. The nurses note dated 9/6/22 documents, Large section of slough/dead tissue has fallen off of wound. Area cleansed and dressing changed. The social service note dated 9/8/22 documents: Care conference held today, in attendance was resident's daughter (name), son (name), writer, and nursing. Lengthy discussion regarding hospice services and education on their services. Family in agreement with hospice services after discussion with resident and other family members. Resident and family choice for hospice agency is (name.) All questions answered, no concerns at this time. The nurses note dated 9/8/22 documents: Coccyx wound assessed, measured and dressing change provided. The coccyx wound is stable, wound bed does appear clean, mild odor noted before cleansing, drainage to old dressing seropurulent. Pt (patient) assisted to left side in bed with staff assistance and tolerated dressing change well. To continue with current dressing change tx (treatment) and off-loading interventions. The wound assessment dated [DATE] documents stage as Stage IV (4), measurements are 6 cm x 6 cm x 2. cm, exudate is moderate purulent, wound odor is mild, wound bed is 80% granulation & 20% slough, wound edges/margins on assessment indicate edge not attached to base and wound healing status is stable. Under comments documents Tunnel at 12 o'clock 4.0 cm, and 1 o'clock 4.5 cm with undermining 2 o'clock-4 o'clock 3.0 cm and 9 o'clock-11 o'clock 1.0 cm. The note dated 9/12/22 documents, Writer notified by (hospice company) hospice nurse that resident, with her family present, signed onto hospice services this morning. No concerns at this time. The nurses note dated 9/15/22 documents: Coccyx wound assessed, measured and dressing changed. Wound appears clean with 90% granulation tissue and 10% slough tissue. No odor noted and drainage is moderate serous. Pt tolerated dressing change well. To continue with current dressing change orders and off-loading. The wound assessment dated [DATE] documents stage as Stage IV (4), measurements are 7.0 cm x 3 cm x 2.5 cm, exudate is moderate serous, there is no wound odor, wound bed is 90% granulation & 10% slough, wound edges/margins indicate edge not attached to base and wound healing status is stable. Under comments documents, Tunnel at 11 o'clock 4.0 cm, and 12 o'clock 3.0 cm with undermining 9 o'clock-10 o'clock 2.0 cm and 1-3 o'clock 2.0 cm. The significant change MDS with an assessment reference date of 9/21/22 documents a BIMS of 12 which indicates moderately impaired. R9 requires extensive assistance with one-person physical assist for bed mobility, transfer, & toilet use, and requires supervision with set up for eating. R9 is at risk for pressure injuries and is coded as having one Stage 2 pressure injury. Surveyor noted the pressure injury should have been coded as a Stage 4. Surveyor also noted the decline in R9's assessed need for assistance since the admission MDS dated [DATE]. Surveyor noted this decline is not addressed in R9's plan of care. The Pressure injury CAA dated 9/29/22 under analysis of findings documents R9 was admitted with a stage II pressure injury to her coccyx. Treatments are done as ordered. Interventions in place to reduce pressure. During the seven-day look back period, she was continent of bowel per vitals and frequently incontinent of bladder per POC. Staff provide incontinence care. Her Braden score was 17. A pressure reduction cushion is in the chair, and a standard pressure relief mattress is on the bed. Skin is inspected with cares, and a skin audit is done weekly. The dietician has met with her and completed the nutritional assessments. She is at risk for malnutrition. She has started hospice services due to declining self-care abilities and mobility. Surveyor noted the change in R9's assessed needs for assistance are not reflected in R9's care plan. The wound assessment dated [DATE] documents stage as Stage IV (4), measurements are 6 cm x 3 cm. There is no depth documented. Exudate is moderate serous, there is no wound odor, wound bed is 90% granulation & 10% slough, wound edges/margins are well defined wound edges and wound healing status is stable. Under comments documents 2.5 cm tunnel from 11 o'clock-1 o'clock, 1.5 cm undermining from 2-4 o'clock and 1.5 cm from 9-10 o'clock. On 9/22/22 the treatment to the wound bed stayed the same with the covering being changed to a bordered foam sacral dressing or Optilock dressing secured with paper tape. The frequency remained the same at twice a day. The APNP note dated 9/26/22 under history, present illness includes documentation of: Due to condition with large sacral wound, pt stopped therapy. Discussion with family led to hospice eval with desire for comfort and wound healing Coccyx DTI (deep tissue injury) Open to bone with tunneling. Treated with Cipro x 10 days 8/30/22 due to infection with pseudomonas. It has improved but is still open. Per wound care RN on 9/22 wound is 90% granulation 10% slough without odor and moderate serous drng (drainage). The wound assessment dated [DATE] documents stage as Stage IV (4), measurements are 6 cm x 3 cm x 0.5 cm. Exudate is moderate serous, there is no wound odor, wound bed is 100% granulation, wound edges/margins are rolled under/thickened and wound healing status is stable. Under comments documents, No discomfort during dressing change. This was completed by a registered nurse. The wound assessment dated [DATE] documents stage as Stage IV (4), measurements are 5.5 cm x 2.5 cm x 1 cm. Exudate is moderate serous, there is no wound odor, wound bed is 100% granulation, wound edges/margins are well defined wound edges and wound healing status is stable. Under comments documents 4.0 cm tunnel from 11 o'clock, 12 o'clock 2.5 cm tunnel. undermining from 1-4 o'clock and 9-10 o'clock 1.5. This assessment was completed by the facility wound nurse. The nurses note dated 9/29/22 documents, Coccyx wound assessed, measured and dressing changed. Wound appears clean with 100% granulation tissue. No odor noted and drainage is moderate serous. Pt (patient) tolerated dressing change well. To continue with current dressing change orders and off-loading. Hospice updated to needed wound supplies per facility policy. On 9/29/22 the treatment for the wound bed and for the dressing covering the coccyx remained the same except the order included: if Maxorb Ag was not available Aquacel rope may be used. The wound assessment dated [DATE] documents stage as Stage IV (4), measurements are 5.5 cm x 2.5 cm x 1.2 cm. Exudate is moderate serous, there is no wound odor, wound bed is 100% granulation, wound edges/margins are well defined wound edges and wound healing status is stable. Under comments documents 4.0 cm tunnel from 11 o'clock, 3.0 cm at 12 o'clock. Undermining 2.0 cm from 1-3 o'clock and 9-10 o'clock. The wound assessment dated [DATE] documents stage as Stage IV (4), measurements are 5 cm x 2.5 cm x 1.2 cm. Exudate is moderate serous, there is no wound odor, wound bed is 100% granulation, wound edges/margins are well defined wound edges and wound healing status is improving. Under comments documents 4.0 cm tunnel from 11 o'clock, 2.5 cm at 12 o'clock, 3.0 cm at 9 o'clock. Undermining 1.5 cm from 1-2 o'clock and 10 o'clock. The physician progress note dated 10/19/22 under HPI (history present illness) documents, Reviewed care with RN Care Coordinator (name.) This is my second visit with her. I had seen her 2 months ago on rehab. She had the right femur fracture. She says it is not really pain but discomfort. She has a (sic) ulcer on her coccyx that (RN Care Coordinator name) says measures 5 x 2.5 x 1.2 in depth she says it is stage IV (4). The wound assessment dated [DATE] documents stage as Stage IV (4), measurements are 5 cm x 2.5 cm x 1.2 cm. Exudate is moderate serosanguineous, there is no wound odor, wound bed is 100% granulation, wound edges/margins are well defined wound edges and wound healing status is stable. Under comments documents 4.0 cm tunnel at 11 o'clock, 2.0 cm at 12 o'clock, 2.0 cm at 9 o'clock. Undermining 1.5 cm from 1-2 o'clock and 10 o'clock. The nurses note dated 10/20/22 documents Wound to coccyx area assessed and measured. Wound continues to be stable with no s/sx of infection. Wound is not draining as heavily, tx (treatment) changed from BID to daily. To continue with offloading interventions. On 10/20/22 the coccyx pressure injury treatment was changed to cleanse area with wound cleanser, gently pack tunneled area with Maxorb AG (may use plain Maxorb or Aquacel/Aquacel ag rope if Maxorb ag supply is not available) apply hydrogel to wound and cover with bordered foam sacral dressing daily and prn (as needed). The nurses note dated 10/23/22 documents Coccyx wound draining into incontinence pad and somewhat odorous. Contact isolation implemented. Surveyor noted there was no physician notification. Surveyor noted there were no details of a consultation despite indicating the wound was somewhat odorous. The wound assessment dated [DATE] documents stage as Stage IV (4), measurements are 5 cm x 2.5 cm. There is no depth documented. Exudate is moderate seropurulent, there is no wound odor, wound bed is 100% epithelial tissue, wound edges/margins are Edge attached to base and wound healing status is stable. Surveyor noted this assessment was completed by a Licensed Practical Nurse and there is no indication the physician or nurse practitioner were consulted with. The wound assessment dated [DATE] documents stage as Stage IV (4), measurements are 5.5 cm x 2 cm x 0.5 cm. Exudate is heavy seropurulent, there is a slight foul odor, wound bed is 100% granulation tissue, wound edges/margins are well defined wound edges and wound healing status is declining. Under comments documents, There is a 1.5 cm x 1.0 cm eschar area to left side of coccyx wound that is communicated with undermining of wound. The nurses note dated 10/27/22 documents Coccyx wound has increased drainage and has a cloudy tan serosanguineous drainage with increased erythema to peri-wound, slight odor noted. Dressing tx (treatment) changed from daily to BID (twice daily). NP (Nurse Practitioner) updated per facility policy to frequency to dressing changes and of wound observations. Wound culture and sensitivity requested and obtained. On 10/27/22 the coccyx pressure injury treatment was changed to Cleanse area with wound cleanser, gently pack tunneled area with Maxorb AG (may use plain Maxorb or Aquacel/Aquacel ag rope if Maxorb ag supply is not available) apply hydrogel to wound and cover with bordered foam sacral dressing BID & PRN. The physician orders dated 10/27/22 documents coccyx wound culture and sensitivity. The nurses note dated 10/30/22 documents Updated (name,) APNP, on culture with sensitivity. Received order for Doxycycline for 10 days and Florastor for 14 days. POA (power of attorney) for HC (healthcare), here to visit and updated on new orders. The lab report dated 10/30/22 documents Staphylococcus aureus, methicillin resistant. The nurses note dated 10/31/22 documents, Resident remains on report to monitor r/t (related to) NOR (new order received) for ABT (antibiotic)/Doxycycline for MRSA (methicillin-resistant staphylococcus aureus) of coccyx wound. No adverse effects noted from ABT use. Skin is warm, dry and color is WNL (within normal limits)/pink. Resident denies pain/discomfort to coccyx area, dressing remains C/D/I. (clean/dry/intact) Temp (temperature) is 97.6 The physician order dated 10/31/22 documents: Add Amoxicillin 500 mg BID x 7 days dx (diagnosis) infection to coccyx wound. On 10/31/22 at 9:15 a.m., Surveyor observed R9 sitting in a wheelchair with a cushion in her wheelchair and being wheeled by activities staff to a Halloween activity. On 10/31/22 at 10:35 a.m., Surveyor asked R9 if she has any open areas. R9 replied, yes on my butt but they take care of it. Surveyor asked R9 how she received this area. R9 replied I don't know. On 10/31/22 at 2:24 p.m., Surveyor observed R9 sitting in a wheelchair in her room with a male visitor sitting next to her. On 11/1/22 at 7:07 a.m., Surveyor observed R9 sitting in a wheelchair at a dining room table. R9 has a cushion in her chair. R9 was inquiring why she was up so early and indicated she wanted to go back to bed. After observing R9, Surveyor went to R9's room to see if there was a cushion in R9's personal type recliner. Surveyor observed a cushion in the personal type recliner with the cover indicating Invacare floair, and noted there is not a specialized mattress on R9's bed. On 11/1/22 at 8:31 a.m., Surveyor spo

Based on interview and record review, the facility did not refer 1 (R62) of 1 residents reviewed for a Level II PASARR (Preadmission Screen and Resident Review) whom was found to have a newly diagnosed mental illness and prescribed psychotropic medication used to treat the symptoms of the mental illness. On 4/13/2022 R62 was diagnosed with Generalized Anxiety Disorder and started to receive Depakote and the Zoloft. On 5/11/2022 R62 was diagnosed with Psychotic disorder with delusions due to known physiological condition. On 5/11/2022 R62 began receiving Abilify to treat symptoms. On 7/7/2022 R62 was diagnosed with Alzheimer's disease with late onset and on 10/19/2022 R62 was diagnosed with Dementia in other diseases classified elsewhere, unspecified severity with other behavioral disturbances. The facility had not completed a new level 1 or 2 PASARR screen for R62 until Surveyor inquired about the screen. Findings include: The facility policy, entitled Preadmission Screening and Resident Review (PASRR) (sic), dated 7/17/2017, states: I. Purpose: To identify individuals with mental illness and/or intellectual developmental disability to ensure appropriate placement. D. If the resident has a change in condition, which affects BIMS (exception: a physical change such as a stroke will not warrant a PASRR) or changes in psychotropic medication, a new PASRR will be completed. R62 was admitted to the facility on [DATE], and had diagnoses that include displaced fracture of medial condyle of left tibia, subsequent encounter for closed fracture with routine healing, unspecified fracture of lower end of left femur, subsequent encounter for closed fracture with routine healing and chronic kidney disease stage 3 unspecified. R62's Admission MDS (Minimum Data Set) dated, 2/22/2022, indicated that R62's BIMS (Brief Interview of Mental Status) was scored at a 4 indicating severe cognitive impairment. Section I, Active Diagnoses, does not have any check marks for anxiety, psychotic disorder, or Alzheimer's. No check marks under Psychiatric/Mood Disorders or Neurological sections. Section N, Medications, documents no antidepressants or antianxiety medication given over the past 7 days. R62's Quarterly MDS (Minimum Data Set) dated, 8/25/2022, documents a BIMS score of 3, indicating R62 is severely cognitively impaired. Section I, Active Diagnoses documents Psychotic disorder with delusions due to known physiological condition and anxiety. Section N, Medications, documents antidepressants were given in the past 7 days. On 10/31/2022, Surveyor review R62's current medications on the Medication Administration Record (MAR). The MAR documents that R62 is currently receiving Depakote 125mg BID (two times per day), Depakote 250mg HS (at bedtime), and Zoloft 100mg HS (at bedtime). Review of R62's medical record documents an initial PASARR Level I screen dated 2/14/2022. This document that R62 is not suspected of having a serious mental illness or developmental disability. It also documents that R62 has not received psychotropic medications to treat symptoms or behaviors of a major mental disorder in the past six months. Surveyor could not locate any additional PASARR Level I or Level II screens in R62's chart. Surveyor notes that a new PASARR Level I screen should have been completed when R62 received a diagnosis of Generalized Anxiety Disorder on 4/13/2022 and started to receive Depakote and the Zoloft. Additionally, on 5/11/2022 R62 was diagnosed with Psychotic disorder with delusions due to known physiological condition and began receiving Abilify to treat symptoms. On 7/7/2022 R62 was diagnosed with Alzheimer's disease with late onset and on 10/19/2022 R62 was diagnosed with Dementia in other diseases classified elsewhere, unspecified severity with other behavioral disturbances. On 11/01/2022, at 9:45 AM, Surveyor requested copies of R62's PASARRS from DON-B. On 11/01/2022, at 2:24 PM, facility provided a copy of the admission PASARR Level I screen dated 2/14/2022. The DON-B then provided another PASARR Level I screen dated 11/1/2022 and stated that the SW-E (Social Worker) submitted another PASARR Level I today. On 11/02/2022, at 9:48 AM, Surveyor interviewed SW-E and asked who is responsible to complete PASARR screens. SW-E informed the Surveyor that upon admission typically the director of Social Services completes the admission PASARR and then the unit SW would be responsible to complete any future PASARR screens should a resident need one. Surveyor asked SW-E what would happen if after admission a resident presented with a mental illness and/or stated receiving psychotic medication for behavior or symptoms of a mental illness. SW-E informed Surveyor that a new Level I screen would be completed. Surveyor informed SW-E that a PASARR Level I screen could not be located in R62's chart after receiving new psychotic/mood disorder diagnoses and psychotropic medication which started back in April 2022. SW-E was not sure why one was not completed for R62. SW-E stated, for sure she should have had a new Level I completed when the psychotropic medication was started. SW-E then stated that she did complete a new PASARR Level I screen earlier today. On 11/2/2022, DON-B, was notified on the concern regarding R62 and missing PASARR screens. No further information was provided as to why the facility did not refer R62 for a Level II PASARR Screen prior to 11/1/2022.

Based on record review and interview, the Facility did not ensure that 1 (R29) out of 5 residents reviewed for unnecessary medication received behavior monitoring based on their targeted behaviors. R29 was administered Lexapro 10 mg (milligrams) without behavior monitoring completed for the continued use of this medication. Findings include: R29's diagnoses includes late onset Alzheimer's disease and depressive disorder. The quarterly MDS (minimum data set) with an assessment reference date of 9/20/22 documents R29's short & long term memory is ok and is severely impaired for cognitive skills for daily decision making. R29 has a total mood score of 9 which indicates mild depression. R29 is coded as having received an antidepressant in the last 7 days. The physician order dated 8/10/22 documents Lexapro (escitalopram oxalate) tablet 10 mg (milligrams); amt (amount): 10 mg: oral once a day PM (evening). The psych consult dated 8/10/22 documents occasionally mildly teary if she remembers husband's death. Recommendations were to add Lexapro. The psych consult dated 9/14/22 documents no change in treatment. During R29's record review Surveyor was unable to locate behavior monitoring for R29's Lexapro. On 11/1/22 at 10:40 a.m. Surveyor informed RN/CC (Registered Nurse/Care Coordinator)-C Surveyor noted R29 is receiving Lexapro 10 mg once daily. Surveyor informed RN/CC-C Surveyor was unable to locate behavior monitoring for use of this medication. RN/CC-C informed Surveyor behavior monitoring is not in the electronic record and is on paper. RN/CC-C informed Surveyor they do not monitor behavior at this time but would look to see if there is any behavior monitoring. On 11/2/22 at 8:17 a.m. RN/CC-C informed Surveyor R29 was initially started on Lexapro 10 mg on 12/8/21 and in January 2022 Lexapro was increased to 20 mg as R29 stated she had feelings of depression. RN/CC-C explained R29 has had a long slow gradual decline and started hospice on June 8th. RN/CC-C informed Surveyor in March most of R29's oral medications including Lexapro were discontinued as she would close her mouth and turn her head. RN/CC-C informed Surveyor Lexapro 10 mg was started on 8/10/22 as she was crying out in bed and had more anxiety in relation to pain. Surveyor asked RN/CC-C if there is any behavior monitoring for R29. RN/CC-C replied no. Surveyor asked whether there should be behavior monitoring for R29. RN/CC-C replied that's debatable. RN/CC-C informed Surveyor when [name of] psych NP (nurse practitioner) comes in she will speak with her and the staff. RN/CC-C informed Surveyor the CNA's (Certified Nursing Assistants) on days are regular staff. Surveyor informed RN/CC-C R29's behavior for being placed on Lexapro should be monitored to help determine if the medication should continue, be decreased or discontinued. RN/CC-C informed Surveyor she can get a behavior monitoring sheet going. On 11/2/22 at approximately 3:50 p.m. Administrator-A and DON (Director of Nursing)-B were informed of the above.

Based on observation, record review and interview, the facility did not ensure 1 (R79) of 7 Residents reviewed with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. *R79's care plan documented R79 was to receive passive range of motion (PROM) 2-3x per week and R79 did not receive PROM services 2-3x per week. Findings Include: Surveyor reviewed the Restorative Nursing Program policy and procedure revised 3/21 and noted the following: Policy: To supplement nursing service in delivering restorative nursing practices through ambulation, range of motion, bed mobility, dressing, grooming, transfers, eating and or swallowing, communication, splint and or brace device. Procedure: 1. All restorative nursing staff will respect the same policies and procedures of this facility. d. Will consist of Restorative Assistants and Restorative Nurse 2. Referral will come because of an individual need--so noted by the attending physician, care coordinator, household coordinator, and/or therapy department. 1. Resident will be added to the Rehabilitative Nursing schedule as appropriate. 2. The Restorative Nursing Assistant and Household Certified Nursing Assistants(CNAs) will do active assistive and passive forms of range of motion, according to specific needs. 3. Residents being seen for ambulation may range from walking with weight bearing to increasing their distance and/or motivation with ambulation. 4. Restorative Nurse will consult with Care Coordinators and Physical Therapist as needed, concerning specific Resident problems. 4. Documentation of services a. On a daily record--set up for each Resident in the program. b. Approximately every month an evaluation will be done by the Nurse for all maintenance restorative programs. c. Approximately once a week an evaluation will be done by the nurse for all restorative/rehab programs. R79 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R79 has an activated Health Care Power of Attorney(HCPOA). R79's Annual Minimum Data Set (MDS) dated [DATE] documents R79 has both short and long term memory impairments and demonstrates severely impaired skills for daily decision making. R79 also has signs of [CONDITION(S)], specifically inattention and disorganized thinking. R79's MDS also documents R79 requires extensive assistance with bed mobility, transfers, dressing, toileting, and eating. The MDS documents R79 has a swallowing disorder-holding food in mouth/choking or residual food in mouth after meals and is on a mechanically altered diet. Surveyor reviewed R79's care card provided during the survey process and noted that as of 6/17/20, R79 would like PROM to left arm 2-3x a week with skilled restorative aid (Rehab Asst.-E). Surveyor reviewed R79's comprehensive care plan and noted the following applicable: Activities of Daily Living (ADL) Functional/Rehabilitation Potential. Restorative Nursing Programs: I would like to get range of motion using my right arm and right leg propelling myself in my wheelchair. I would also like to continue to receive passive range of motion exercises to my left arm. Start: 4/28/20 Edited: 8/9/21 Goal: I would like to be able to propel myself in my wheelchair using my right hand and foot. I would like to do my soup can exercises using my right arm 3x a week. I would like to avoid contractures to my left arm doing PROM exercises. Approaches Start: 6/17/20 Edited: 8/6/20 Brace to left shoulder Start: 6/17/20 Edited: 1/6/21 I would like to have PROM to my left shoulder 2-3x per week with the skilled restorative aid(Rehab Asst.-E). Surveyor reviewed R79's Occupational Therapy(OT) discharge summary dated 6/16/20 and noted the following was documented: Nursing staff and restorative nursing staff has been educated in proper home exercise program(HEP)/PROM and upper extremity(UE) ADL carryover with R79. Restorative nursing has been educated in need for gentle left UE PROM as R79 with severe subluxation issues. Surveyor requested documentation of R79's PROM being performed by Rehab Asst.-E from June 1, 2021-August 18, 2021. Surveyor noted the following for R79's PROM: 6/10/21 for 6 minutes 6/24/21 for 15 minutes 7/14/21 for 10 minutes 7/30/21 for 10 minutes Surveyor noted that R79 only received PROM services 2x in the month of June and 2x in the month of July. Per documentation, R79 did not receive any PROM in the month of August. R79 was to receive PROM 2-3x per week as per care plan with a start date of 6/17/20. During the survey process, Surveyor did observe R79 with a left shoulder sling (brace) on as per care plan with a start date of 6/17/20. On 8/18/21 at 10:44 AM, Surveyor interviewed Rehab Asst. E who was to be performing PROM on R79. Rehab Asst-E stated that R79 has not been receiving PROM 2-3x per week because Rehab Asst.-E has been very busy with other things. Rehab Asst.-E stated the most R79 has received PROM is 1-2x per week. Rehab Asst.-E stated last week Rehab Asst.-E was on vacation so no PROM services got done with R79. Rehab Asst.-E stated, I'm not going to lie and document something that I didn't do. On 8/18/21 at 11:10 AM Director of Nursing (DON-B) confirmed that R79 has not been receiving R79's PROM as documented on R79's care plan. Surveyor shared the concern with DON-B that R79 did not receive PROM 2-3x per week and DON-B is aware that it is a problem. No further information was provided by DON-B at this time. On 8/18/21 at 11:20 AM, Surveyor interviewed Certified Nursing Assistant (CNA-D) in regards to R79. CNA-D stated that sometimes CNA-D performs PROM by moving R79's arm in and out. Surveyor asked what arm does CNA-D perform PROM on, and CNA-D answered with right arm. CNA-D confirmed that CNA-D has not been trained as a restorative aid but does range of motion with ADLs.

Based on observations, record review and interview, the facility did not ensure that 1 (R56) of 1 residents reviewed for nutrition addressed R56's change in nutritional status. *R56 sustained a weight loss of 6 % body weight from 7/21/21 to 7/28/21. The facility did not update R56's physician or responsible party to address R56's weight loss. The facility did not initiate new interventions or update R56's plan of care to address R56's weight loss. Findings include: R56 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R56's Minimum Data Set with an Assessment Reference Date of 7/15/21 reflects a BIMS (brief interview for mental status) score of 7, indicating severe cognitive impairment. R56 is not able to participate in daily decision making and has an activated health care power of attorney. On 8/17/21 at 8:25 AM, Surveyor reviewed R56's weight record. Per R56's Physician orders, R56 is to be weighed weekly on their shower day (Wednesday). Surveyor reviewed weights for July 2021. On 7/21/21, a weight of 101.8 pounds was recorded in R56's medical record. On 7/28/21, a weight of 95.0 pounds was recorded in R56's medical record. Surveyor calculated a weight loss of 6.8 pounds (6%) from 7/21/21 to 7/28/21. On 8/17/21 at 11:20 AM, Surveyor reviewed R56's Nutrition Care plan dated 6/12/21 with a Revision date of 7/19/2021. Surveyor did not identify any new interventions related to R56's 6% weight loss that occurred on 7/28/21. On 08/17/21 at 2:56 PM, Surveyor conducted an interview with Dietician-F. Surveyor asked Dietician-F if R56 should be weighed on a weekly basis. Dietician responded that R56 is to be weighed weekly on their shower days. Surveyor asked Dietician-F if there had been any weekly weights recorded for R56 for August 2021. Surveyor asked if Dietician-F was aware of R56's weight loss of 6.8 pounds (6%) from 7/21/21 to 7/28/21. Dietician-F responded that they would need to look into R56's medical record as they had not seen R56 since 7/12/21. On 8/17/21 at 3:09 PM, Dietician-F confirmed that they could not locate documentation for R56's weekly weights for August 2021. On 8/28/21 at 1:45 PM, Surveyor interviewed DON-B. Surveyor asked if a resident had a significant weight loss, should the resident's physician and resident representative be made aware of the weight loss. DON-B confirmed that this would be correct. Surveyor shared with DON-B that R56 had experienced a 6.8 pound (6%) weight loss from 7/21/21 to 7/28/21 without notification to R56's physician, resident representative and dietician. Surveyor shared additional concerns that the facility did not have documented weekly weights for August 2021 and that there were no updates to R56's nutritional care plan related to the 6.8 pound (6%) weight loss. No additional information was provided at this time.

Based on observation, interview, and record review, the facility did not ensure a paid feeding assistant provided dining assistance for residents with no complicated feeding problems; and did not ensure annual education and an evaluation was provided to paid feeding assistant, (Social Worker/SW -C) who was observed providing assisting to 2 (R17&R79) of 2 residents who were observed receiving assistance. *On [DATE], R17 has an altered diet with swallowing guidelines and was being assisted with a meal by a Paid Feeding Assistant who had not been provided with in-service/education related to feeding Residents since [DATE]. *On [DATE], R79 has an altered diet with swallowing guidelines and was being assisted with a meal by a Paid Feeding Assistant who had not been provided with in-service/education related to feeding Residents since [DATE]. Findings Include: Surveyor reviewed the facility's Swallow Guidelines policy and procedure revised ,d+[DATE] and noted the following: Purpose: To aid in identifying Residents that have swallow guidelines during activities/special events/meals. To alert staff, volunteers, and family members of restrictions and swallow guidelines for Residents. Surveyor also reviewed the facility's Dining Assistance policy and procedure revised ,d+[DATE] and noted the following: Policy: Only Certified Nursing Assistants(CNAs), Licensed Health Care staff and staff that have successfully completed a State certified Feeding Assistant program, may assist a Resident with meals. Procedure: Any Resident that has dysphagia, frequent coughing episodes during meals, or has swallowing guidelines should only be fed by a Certified Nursing Assistant (CNA), Nurse, or Speech Therapy(ST). A paid feeding assistant is not able to assist these Residents. 1) R17 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Vascular Parkinsonism, Dysphagia, [CONDITION(S)], and Dementia. R17 has an activated Health Care Power of Attorney (HCPOA). R17's Quarterly Minimum Data Set (MDS) dated [DATE] documents R17 has both short and long term memory impairments and demonstrates severely impaired skills for daily decision making. R17 also has signs of [CONDITION(S)], specifically inattention and altered level of consciousness. R17's MDS also documents R17 requires extensive assistance with bed mobility, dressing, and eating. R17 is total dependence for transfers and toileting. The MDS documents R17 has a mechanically altered diet. Surveyor reviewed the Care Area Assessment (CAA) dated [DATE] which documents that R17 is on a therapeutic/mechanically altered mechanical soft/no added salt diet for diagnosis of dysphagia. Surveyor noted R17's Nutritional assessment dated [DATE] documents that R17 is unable to eat without assistance. Surveyor noted on R17's discharge summary from ST on [DATE], it is documented to facilitate safety and efficiency, it is recommended R17 use the following strategies and/or maneuvers during oral intake; general swallow techniques/precautions, rate modification and bolus size modifications upright posture for 30 minutes after meals. R17's care card provided to Surveyor during the survey process documents that as of [DATE], R17 requires constant supervision and R17 must be helped with meal by nurse or CNA. Surveyor reviewed R17's comprehensive care plan and notes the following problem applicable: Impaired swallowing: R17 has had more trouble chewing meat Start: [DATE] Edited: [DATE] Goal: R17 will use compensatory swallowing strategies during intake of food/liquids Edited: [DATE] Approaches: Positioning: Upright at 75 to 90 degree. Position head and trunk in midline. Remain upright for at least ,d+[DATE] minutes following a meal. Feed slowly. Bite size at ,d+[DATE] teaspoon presentation. Liquids via straw Start: [DATE] Supervision: Constant supervision. Must help R17 with meal by nurse or CNA. Start: [DATE] Edited: [DATE] On [DATE] at 12:30 PM, Surveyor observed Social Worker(SW-C) sitting on a 4 wheeled walker feeding R17 soup that contained noodles and small pieces of meat. SW-C also served R17 soda out of a plastic cup with a straw. Surveyor observed R17 to be sitting upright in a broda chair and R17 is sleeping intermittently. 2) R79 was admitted to the facility on [DATE] with diagnoses of [CONDITION(S)] and [CONDITION(S)] following Cerebral Infarction affecting left non-dominant side, Dysphagia, Type 2 Diabetes Mellitus, Major Depressive Disorder, and Delusional Disorders. R79 has an activated Health Care Power of Attorney(HCPOA). R79's Annual Minimum Data Set (MDS) dated [DATE] documents R79 has both short and long term memory impairments and demonstrates severely impaired skills for daily decision making. R79 also has signs of [CONDITION(S)], specifically inattention and disorganized thinking. R79's MDS also documents R79 requires extensive assistance with bed mobility, transfers, dressing, toileting, and eating. The MDS documents R79 has a swallowing disorder-holding food in mouth/choking or residual food in mouth after meals and is on a mechanically altered diet. Surveyor noted on R79's discharge summary from ST dated [DATE], staff and R79 educated on swallow safety protocol and safest diet. Per current physician orders, R79 has been on a mechanical soft diet as of [DATE]. R79's care card provided to Surveyor during the survey process documents that as of [DATE], R79 needs staff to help with meals. R79's comprehensive care plan has the following problem: Alteration in Nutrition: R79 requires an altered texture diet. Start: [DATE] Edited: [DATE] Goal: R79 will not have significant weight loss while at Shorehaven Edited: [DATE] Approaches: Follow swallow guidelines as established by ST Start: [DATE] R79 will accept 1:1 assistance with all meals Start: [DATE] On [DATE] at 12:41 PM, Surveyor observed SW-C feeding R79 lunch which consisted of grilled pork chop, sour cream mashed potatoes, peas and carrots, and chocolate eclair torte. Surveyor was provided a list of staff who have completed the paid feeding assistant class. SW-C completed the course in 2008. Surveyor was provided a list of Residents who require swallowing guidelines and both R17 and R79 are on the list due to a diagnosis of dysphagia. On [DATE] at 8:09 AM, Director of Nursing (DON-B) informed Surveyor that the facility does not have a paid feeding program but there are staff who have had the certification for years and then they receive annual training . The non CNAs who have the certification can feed any Resident that does not have swallowing guidelines. On [DATE] at 11:42 AM , Surveyor interviewed SW-C in regards to both R17 and R79. SW-C stated SW-C normally does not assist R17 with eating. SW-C stated SW-C fed R17 because there were no CNAs in the dining room. SW-C normally does not assist R79 with eating but R79's son was visiting and due to COVID, R79 could not eat lunch in the room with R79's son. SW-C asked R79 if R79 wanted assistance so R79 could get to visit and R79 said yes. Swallowing guidelines are just swallowing guidelines R17 is on mechanical soft with thin liquids . Surveyor asked SW-C what swallowing guidelines need to be followed for both R17 and R79. SW-C replied, Swallowing guidelines are 'just swallowing guidelines. SW-C could not clarify that statement for Surveyor. SW-C stated both R17 and R79 are on a mechanical soft diet with thin liquids. On [DATE] at 11:50 AM, DON-B confirmed Residents who having swallowing guidelines should not be fed by a feeding assistant that is not a CNA. DON-B confirmed that also includes Residents with a diagnosis of dysphagia. DON-B stated that SW-C knows better to not feed R17 and R79. DON-B stated SW-C normally does not feed Residents. Surveyor shared the concern with DON-B that SW-C was feeding R17 and R79 who have a diagnosis of dysphagia and have swallowing guidelines. On [DATE] at 12:12 PM, DON-B, stated that yearly inservicing was being done for the paid feeding assistants prior to COVID but when COVID started, the training stopped. SW-C last received the inservicing on [DATE] which covered a choking check off and a feeding assistant competency evaluation skills examination for feeding Residents and handwashing. Surveyor also notes SW-C's Cardiopulmonary Resuscitation (CPR) expired on [DATE]. DON-B stated that during COVID, the facility limited the amount of staff to renew their CPR certification and SW-C was not on the list. DON-B is aware that per facility policy, SW-C should not have been feeding R17 and R79. No further information was provided at this time.

Based on observation, interview, and record review, the facility did not ensure hazards were identified while smoking for 1 (R16) of 1 residents reviewed for smoking safety. R16 was not assessed for smoking safety. Findings: R16 had uncontrolled diabetes due to non-compliance with medications and a history of being a heavy smoker. R16 was admitted to the facility 2/26/2019 from the community to stabilize medically in order to return to the community. R16 also has [DIAGNOSES REDACTED]. R16's fall risk assessment dated [DATE] had a score of 5 indicating a moderate risk for falls. R16's admission Minimum Data Set (MDS) assessment dated [DATE] coded R16 as needing stand-by assistance for transfers and ambulation out of the room. R16's Brief Interview for Mental Status (BI[CONDITION]) score was 12 indicating moderate cognitive impairment. R16 was coded as being a smoker. The Cognitive Care Area Assessment (CAA) stated R16 is alert and oriented but some memory loss is evident. Family confirms that they were observing some increased forgetfulness in (R16's) home as evidenced by noncompliance with medications. The Fall CAA stated R16 had not had any falls in the past six months, but the fall assessment showed a moderate risk for falls and R16 has memory issues and poor safety awareness. From 2/26/19 to 3/12/2019, R16 attended Speech Therapy, Occupational Therapy, and Physical Therapy to regain optimal functional abilities with a goal of moving to an assisted living facility. Therapies ended when R16's abilities plateaued. The facility policy and procedure entitled Resident Smoking dated 3/2017 states: On October 1, 2004 (the facility) adopted a No Smoking Policy for the entire campus. II. PROCEDURE: 1. During the preadmission residents/responsible parties will be questioned about smoking habits. 2. (The facility's) smoking policy (which prohibits smoking on the entire campus) will be clearly explained. 3. The staff will answer any questions the resident/responsible party may have about the resident smoking policy. 4. The potential resident will then be able to make an informed choice by knowing that they will not be allowed to smoke on this campus. For potential residents, if they chose to continue to smoke, it would be in their best interest to seek another health care facility that could accommodate their needs related to smoking. 5. If after clearly understanding that (the facility) is a smoke free campus, the potential resident still requests admission to (the facility), the following will be shared: 1. Since (the facility) is a smoke free campus, residents will be shown the boundaries of the campus and where safe smoking would be allowed. Independent residents without cognitive or physical disabilities would be able to transport themselves to any area off (the facility) campus to smoke as they wish. Residents must inform staff that they are leaving the facility. 2. If a resident has cognitive and/or physical disabilities, and would need assistance, the facility would request family assistance to transport resident to assure safety. Family should inform staff that they are taking the resident off campus. 3. If family assistance is not available, in weather above 32 degrees, staff will transport the resident one time per 24-hour shift during the hours of 8:00 am and 8:00 pm to a safe smoking area off campus. The staff member will only transport resident and observe the resident from a distance. They will not assist to light the smoking material, nor will they hold the smoking material for the resident. This is done to protect staff against secondhand smoke. On 3/5/2019, Physical Therapy revised R16's Activities of Daily Living care plan: R16 can walk independently with 4 wheeled walker. On 3/16/2019 at 11:47 AM in the progress notes, nursing charted R16 removed the [MED] and smoked three cigarettes per family member when out on pass. On 3/20/2019 at 3:58 PM in the progress notes, nursing charted R16's family member discussed possible activation of R16's Health Care Power of Attorney (HCPOA). R16's primary physician was contacted and the physician didn't feel R16 met the statutory definition of incapacity. On 4/10/2019 at 3:07 PM in the progress notes, staff charted R16 was observed smoking on the facility property. R16 was approached by the social worker and the Registered Nurse Care Coordinator (RNCC) to relinquish the cigarettes and lighter. R16 refused. The non-smoking policy was explained to R16. On 4/12/2019 at 3:12 PM in the progress notes, Social Services charted a discussion was held with RNCC, R16, and R16's family member. R16 could smoke with family off campus. R16 stated understanding of not being able to smoke on facility property. Staff offered to lock up smoking materials and would supply them when requested. R16 denied having any smoking materials. On 4/12/2019, smoking was added to R16's psychosocial care plan. The intervention states: Explain non smoking policy on (facility's) property. (R16) and family told the (R16) can smoke with her family off of (facility's) property. On 5/15/2019 at 10:27 AM in the progress notes, staff charted a first signature for incapacitation was received and a second opinion would be obtained. On 6/2/2019, R16's fall risk assessment had a score of 1 indicating a low risk for falls. R16's quarterly MDS assessment dated [DATE] has a BI[CONDITION] score of 13 indicating little to no cognitive impairment. On 6/4/2019 at 1:16 PM in the progress notes, nursing charted R16 took a walk before lunch and on return, R16's breath smelled like cigarette smoke. On 6/5/2019 at 11:37 AM in the progress notes, Social Services charted a second physician evaluated R16 for activation of HCPOA. A discussion with the physicians and social worker determined R16's HCPOA would not be activated at that time. On 6/24/2019 at 7:30 PM in the progress notes, nursing charted the smell of cigarette smoke was coming from R16's room. R16 had been smoking in the bathroom. R16 stated she couldn't go outside to smoke because it was raining. At 9:06 PM, nursing charted R16 smoked another cigarette in the bathroom after being confronted for smoking the first cigarette. On 6/26/2019 at 3:46 PM in the progress notes, Social Services charted a meeting was held with R16, R16's family member, and facility staff. The No Smoking Policy was reviewed and R16 acknowledged signing the agreement upon admission. The rules were explained: R16 may smoke independently on public grounds or when on pass with family. Due to the violation of R16 smoking in the room, the cigarettes and lighter were locked up and may be requested when wanted except if the weather is deemed to be unsafe for R16 to go out in. Staff explained if there was another violation of the policy, R16 would be given a 30-day notice of involuntary discharge. The offer to locate a facility that allows smoking was also offered. On 6/27/2019, R16's psychosocial care plan was revised with the following intervention: SAFETY-SMOKING: If I want to have a cigarette, please have me see the nurse. On 8/22/2019 in the progress notes, nursing charted R16 tripped and fell on the sidewalk while going out to smoke. R16 was transported to the emergency room and was returned to the facility with bruising to left shoulder and hip. On 9/2/2019, R16's fall risk assessment had a score of 1 indicating a low risk for falls. On 9/3/2019, R16 was evaluated by Physical Therapist (PT)-H. The clinical impression states: Patient is independent and safe with transfers and ambulation and can walk 100 feet without any LOB (loss of balance) including out to where she smokes her cigarettes. PT-H was interviewed 9/10/2019 at 9:10 AM by Surveyor. PT-H stated R16 was completely independent and didn't need therapy. On 9/10/2019 at 8:37 AM, Surveyor interviewed Social Worker (SW)-F regarding R16's smoking. SW-F stated R16 was originally only allowed to smoke when with family. The facility has not had any smokers in the past and the facility is a non-smoking facility so there was no pattern to follow with R16. R16 was considered safe with ambulation by Physical Therapy evaluation. With the weather changing, it will be more difficult to have R16 go outside to smoke. When R16 was first admitted , R16's mentation wasn't very good, but with the stabilization of blood sugars, R16's mentation has improved. When talk of other facilities had been brought up, R16 didn't want to leave. SW-F had noticed R16 has decreased the amount of smoking since the fall on 8/22/2019 and R16 is concerned about winter coming. On 9/10/2019 at 8:45 AM, Surveyor interviewed RNCC-G regarding a smoking assessment for R16. RNCC-G stated the facility does not have a smoking assessment. When asked how it was determined R16 was safe to smoke independently, RNCC-G stated R16 was independent with a walker. Surveyor brought up concerns that R16 wasn't evaluated for safety while smoking, such as capability to light a cigarette or put the cigarette out once finished smoking. RNCC-G agreed there was no evaluation of those aspects of smoking. On 9/10/2019 at 1:06 PM, Surveyor interviewed RN-I regarding R16's smoking. RN-I stated R16 initially had poor recall. Now R16 only needs medication management for [MED]. R16's cigarettes and lighter are locked up in the medication room and R16 asks for them when R16 wants them to go outside or when R16 goes out with family members. The administration had a meeting with R16 to lay down the law (6/24/2019) and right after they left the room, R16 had another cigarette. R16 has the right to smoke and they accommodate R16. R16 is forgetful about stuff, but doesn't forget to go off campus to smoke. R16 had a [MED] initially, but has been weaned off of that per choice. When asked if any smoking assessment was done, RN-I didn't know. On 9/10/2019 at 1:19 PM, Surveyor interviewed R16 and R16's family member. When asked about the facility smoking policy, R16 stated the nurses hold onto the cigarettes and lighter. When R16 asks, staff give R16 two cigarettes at a time and goes out by the tree on the sidewalk to smoke. Family member stated since R16 fell (8/22/2019) R16 has smoked less. R16 and R16's family member stated concern about winter weather and agreed that might be a good time to stop smoking altogether. On 9/10/2019 at 1:28 PM, Surveyor met with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B to discuss concerns with a lack of smoking assessment for R16. R16 had mild cognitive impairment on admission. Discussion was had regarding activating R16's HCPOA due to questionable mentation. Therapy evaluated R16 and determined R16 could be independent with ambulation, but no assessment was done specifically to determine the safety of R16's ability to light a cigarette, remain safe while smoking, or extinguish the cigarette when done smoking. NHA-A and DON-B agreed the facility did not have an assessment that encompassed those aspects of smoking safety. No other information was provided at that time.

Based on observation, interview, and record review the facility did not implement an ongoing infection prevention and control program to help control the spread of infection to the extent possible for 1 (R11)of 2 sampled residents reviewed for infection control practices. -Staff was observed using up and down motions during pericare, placing contaminated linens on the chair and nightstand in the resident's room, and touching multiple items with gloved hands used to provide pericare during an observation of R11 receiving incontinence care. Findings include: The facility's PERINEAL CARE FOR THE FEMALE RESIDENT AND INCONT (incontinence) CARE policy and procedure, revised 7/19, states E. Wash entire perineal area with soap and water, moving from front to back (not back and forth), while using a clean area of the washcloth for each stroke or clean washcloth for each stroke. F. Rinse entire perineal area, moving from front to back while using a clean area of the washcloth or clean washcloth for each stroke. Wash also any area that had contact with urine/stool. For example: thigh areas. G. Dry entire perineal area moving from back to back, using a blotting motion with a towel. H. Turn resident onto side if doing pericare in bed. I. Wash, rinse, and dry buttocks and perianal area without contaminating perineal area. J. Remove went incontinence pad or protective linen after drying buttocks .O. Wash your hands. On 09/04/19 at 02:40 PM the surveyor observed CNA (certified nursing assistant)-D in the room with R11. At 02:43 PM the surveyor observed CNA-E enter the room with a lift. The surveyors observed CNA-D and CNA-E transfer R11 from a broda chair into her bed. The surveyors observed CNA-D and CNA-E remove R11's pants, socks and [MEDICATION NAME]. The surveyor observed CNA-D remove her gloves and apply new gloves. The surveyor observed CNA-D wet a washcloth and apply a cleanser to the washcloth, and provide peri care to R11. The surveyor observed CNA-D cleanse R11's peri area with an up and down motion (not a front to back motion). The surveyor observed R11 be postioned on her side and her backside area cleansed. The surveyor observed CNA-D touch R11's left leg with the same gloved hand worn when providing peri care. The surveyor observed CNA-D place the washcloth used to provide peri care on the nightstand table, and the towel used to dry R11's peri area and other linens on a chair in the room. The surveyor observed CNA-D move R11's broda chair with the same gloved hands used to provide peri care. The surveyor observed CNA-D touch a pillow, sheets, and the lowering control of the bed with the same gloved hands worn while providing peri care. The surveyor observed CNA-D remove her gloves and place R11's call light within reach. CNA-D did not wash her hands after removing her gloves. At 02:54 PM the surveyor observed CNA-D wash her hands with soap and water and observed the linens placed in a bag. On 09/10/19 at 11:41 AM The surveyor interviewed ICP (infection control preventionist)-C. The surveyor asked what is the expectation for staff to do with linens after providing incontinence care. ICP-C stated linens are to be bagged and taken to the shoot. The surveyor asked if used washcloths should be placed on the bedside table. ICP-C stated no. The surveyor asked if staff should wash their hands after providing incontinence care. ICP-C stated yes, definitely. The surveyor informed ICP-C of the above observation.

Based on record review and staff interview, the facility did not ensure residents received antibiotic medication only with an active infection. This was observed with 3 (Resident #16, #15 and #9) of 18 resident medication reviews. Resident #16, #15 and #9 received antibiotic medication without meeting the criteria for a infection. Findings include: On 10/22/14 at 8:15 a.m. the Director of Nurses provided the facility's definition of infections. The facility uses McGeers definitions of infections. The criteria for a symptomatic UTI is as follows: 2 of the following signs or symptoms: costovertebral angle pain or tenderness, new or marked increase in suprapubic tenderness, gross hematuria, new or marked increase in incontinence, new or marked increase in urgency, new or marked increase in frequency; AND at least 1 of the following: a voided urine culture with greater or equal to 10, 000,00 CFU/ml of no more than 2 species of organism, a positive culture with greater or equal to 10,000,00 CFU/ml of any microorganisms from straight in/out catheter specimen. 1.) Resident #16 medical record was reviewed by Surveyor # . Resident #16 physician ordered a urinalysis upon admission into the facility. Resident #16 was not symptomatic for a UTI (urinary tract infection). Resident #16 physician wanted to treat for a UTI anyway, and prescribed [MEDICATION NAME] 500 milligrams three times a day for 7 days. This did not meet the criteria for prescribing an antibiotic for a UTI. On 9/5/14 a follow-up urinalysis was ordered by the physician. Resident #16 was not showing any infection symptoms for a UTI. The physician was made aware of this and wanted to treat anyway. Resident #16 physician ordered [MEDICATION NAME] 100 milligram twice a day for 7 days for a UTI. This UTI did not meet the criteria for an UTI. On 10/9/14 Resident #16 physician ordered another follow-up urinalysis. Resident #16 was not showing any active symptoms of a UTI. Resident #16 physician wanted to treat for a UTI anyway. Residents #16 physician [MEDICATION NAME] milligrams twice a day for 7 days. Resident #16 did not meet the criteria for a UTI. On 10/21/14 at 2:20 p.m. Surveyor # spoke with DON-B (Director of Nurses). DON-B indicated that Resident #16 physician was explained the criteria the facility used to treat infections. The facility uses McGeers criteria for treating infections. DON-B was aware that Resident #16 did not meet this criteria; however the physician still wanted to prescribe antibiotics. The facility's Medical Director is aware and no plan has been developed to address antibiotic use without active infections. On 10/22/14 at 8:00 a.m. the DON-B provided the Infection detail report from the facility's infection surveillance monitoring. Resident #16 did not meet the definition of infection for receiving the antibiotics [MEDICATION NAME] and Cipro. These antibiotics were administered to Resident #16 without signs or symptoms of an active infection. 2.) Resident #15 medical record was reviewed by Surveyor # . Resident #15 physician ordered a urine culture and then to [MEDICATION NAME] milligrams twice a day for 7 days. Resident #15 [MEDICATION NAME] milligrams twice a day on 10/16/14, 10/17/14/ 10/18/14 and 10/19/14 in the morning. Resident #15 final culture of the urine was completed on 10/18/14. This urine culture showed the microorganism was resistant to [MEDICATION NAME]. Resident #15 received an antibiotic that was not effective against the microorganism that was discovered. Resident #15 physician then discontinued [MEDICATION NAME] ordered the antibiotic Bactrim twice a day for 10 days. Resident #15 received the [MEDICATION NAME] indications for use. On 10/21/14 at 2:20 p.m. Surveyor # spoke with DON-B (Director of Nurses). DON-B indicated that the facility uses McGee criteria for treating infections. DON-B was aware that Resident #15 did not meet this criteria; however the physician still wanted to prescribe antibiotics. The facility's Medical Director is aware and no plan has been developed to address antibiotic use without active infections. On 10/22/14 at 8:00 a.m. the DON-B provided the Infection detail report from the facility's infection surveillance monitoring. Resident #15 did not meet the definition of infection for receiving the antibiotic Cipro. This antibiotic was administered to Resident #15 without signs or symptoms of an active infection with the urine culture results. 3.) On 10/20/14 surveyor # began record review for Resident #9. According to the facility progress note dated 10/7/14 Resident #9 had a catheter removed and began voiding frequently with complaints of "a little burning" during urination but stated this was "nothing unusual, and a hormonal thing ". On 10/8/14 the facility obtained a urine culture and started Resident #9 on 250mg [MEDICATION NAME], BID for 7 days. The record indicates that the urine dip was positive for [MEDICATION NAME], leukocytes, and blood. The progress note also indicates that an order was received by the Advance Practice Nurse Practitioner directing the facility to obtain a urine culture and start [MEDICATION NAME] specimen is obtained. Surveyor # reviewed the results from the culture taken 10/8/14 and it indicated that the resident had several organisms present in the urine which increases the possibility of contamination. There was no urinalysis present in the record at this time that would confirm a positive result related to a urinary tract infection. The progress note dated 10/9/14 indicates that the resident continues to report a burning sensation with urination. The progress note dated 10/11/14 indicates that the resident stated that she still has some burning with urination, but not always. This was reported on the 4th day that the resident had been receiving a 7 day course of antibiotic therapy for the treatment of [REDACTED]. Progress note dated 10/15/14 states that "the resident has [MEDICATION NAME] am shift" but "still having some slight burning at times" . Surveyor # spoke with Care Coordinator-C who indicated that the resident was started on the antibiotics due to reporting symptoms consistent with a UTI. She also confirmed that the facility did not obtain a urine sample to confirm a positive result. On 10/21/14 Surveyor # spoke with Director of Nursing-B who stated the facility only uses the " dip method " when testing for urinary tract infection because "this is what the hospitals do". She also stated that whenever the Ecoli organisms in the culture are over 100,000 the doctor automatically prescribes an antibiotic. Surveyor # was also provided with the facility infection control tracking sheet for Resident #9 that indicates that she presented various symptoms of a urinary tract infection. The facility reported that they follow the McGeers criteria when treating infections. The McGeers Criteria policy states that the resident must be experiencing symptoms of a UTI, in addition to having at least 105 cfu/ml of no more than 2 species of microorganisms in voided urine. According to the result of the urine culture for Resident #9 there were at least 4 microorganisms present which is over the required amount. The facility was informed of these findings during the daily exit on 10/21/14.

Based on observation, interview and record review, facility staff left medications with a resident who had not been assessed as safe to self-administer drugs. A LPN (Licensed Practical Nurse) prepared MicroK (potassium) and [MEDICATION NAME] for Resident #11 and set them on the dining room table where Resident #11 was sitting. The LPN left the table before Resident #11 consumed the medications. While Resident #11 did eventually consume almost all of the MicroK, the LPN did not come back to see if Resident #11 took the medications, and Resident #11 only consumed less than 50% of the [MEDICATION NAME]. Again, the LPN did not see how much Resident #11 took of the [MEDICATION NAME], and initialed the medications as given. No assessment for self-administration of medications had been conducted with Resident #11. DON (Director of Nurses)-B stated Resident #11 was not appropriate to be self-administering medications. Findings include: On 8/14/12 at 12:18 p.m., Surveyor # observed LPN-C prepare MicroK 20 meq. (milliequivalents) with water and one packet of sugar as Resident #11 prefers, and LPN-C poured 17 grams of [MEDICATION NAME] into Resident #11's coffee and stirred it. LPN-C administered one tablet of [MEDICATION NAME] S.R. (sustained release) 15 mg. (milligrams) whole in applesauce to Resident #11 while she was sitting at a dining room table. LPN-C then handed Resident #11 the glass of MicroK, which Resident #11 immediately started drinking. LPN-C stated to Resident #11 "you don't have to drink it all right now" and Resident #11 set the glass on the table. LPN-C left the table and returned to the medication stand computer and initialed the medications as given. LPN-C then continued to prepare and administer medications to other residents, but did not watch Resident #11 consume either the MicroK or the [MEDICATION NAME], nor did she come back to Resident #11's table to assess the progress Resident #11 was making in consuming the medications. LPN-C left the dining room at 12:27 p.m. and was in the hall near the dining room until 12:46 p.m. when she left to go to another household. LPN-C could not see Resident #11 during this time. LPN-C did not check to see what if any of the MicroK or [MEDICATION NAME] Resident #11 consumed before leaving the household. Surveyor # observed staff assist Resident #11 to a recliner near the television, and the glasses of MicroK and [MEDICATION NAME] remained on the table. The MicroK was almost all gone (approximately one swallow left), and the coffee with the [MEDICATION NAME] was still half-full. At 12:53 p.m., Housekeeper-D removed Resident #11's dirty dishes from the table and put them on a cart with other dirty dishes and took them to the kitchen area for washing. Surveyor # reviewed Resident #11's medical record and did not observe any assessment for her to self-administer medications. On 8/15/12 at the daily exit meeting, Surveyor # shared the above observations with facility staff. At the daily exit meeting on 8/16/12, Surveyor # asked if there was any additional information regarding LPN-C leaving the medications with Resident #11, and not observing to see if Resident #11 actually consumed the medications. Director of Nursing (DON)-B stated a self-administration of medication assessment was not conducted because Resident #11 was not appropriate to self-administer her medications. DON-B further stated LPN-C was a new nurse and she would speak to her regarding this matter. No further information was provided.

Based on observation and interview the Facility did not ensure food was serviced under sanitary conditions. During food temperature checks Cook E utilized the same probe wipe cloth in between testing the temperature of various food items. Cook E did not properly sanitize the thermometer used to take the food temperatures. This deficient practice has the potential to affect all 110 Residents residing at the Facility. Findings include: 1. On 6/23/10 from 11:16 a.m. to 11:23 a.m., Surveyor # observed Cook-E take food temperatures without gloves on. Cook-E obtained a probe wipe cloth from the dispenser and held the cloth in her left hand. With her right hand Cook-E took the temperature of pureed lasagna, spaghetti sauce, pureed green beans, roast beef, beef gravy, and mashed potatoes. In between each food item, Cook-E used the same probe wipe cloth to wipe the thermometer. Cook-E did not fold the probe wipe cloth or use a different area on the probe wipe cloth to ensure the thermometer was sanitized. After taking the temperature of the mashed potatoes and wiping the thermometer, Cook-E placed the probe wipe cloth on the counter and took out a pan of green beans. Cook-E picked up the same probe wipe cloth, placed the cloth in her left hand and took the temperature of mixed vegetables, corn, asparagus and two pans of green beans. In between each food item, Cook-E used the same place on the probe wipe cloth to wipe the thermometer. After taking the temperature of the green beans and wiping the thermometer, Cook-E placed the probe wipe cloth on the counter. Cook-E placed the mixed vegetables, corn, and asparagus into the holder. Cook-E then picked up the probe wipe cloth off the counter and took the temperature of pureed soup, pork roast, pureed roast beef, and ground beef. In between each food item, Cook-E used the same place on the probe wipe cloth to wipe the thermometer. Cook-E placed the probe wipe cloth on the counter and informed Surveyor # that she was waiting for the french fries to be done. Cook-E then obtained a new probe wipe cloth from the dispenser and took the temperature of the lasagna. On 6/23/10 at 11:25 a.m., Surveyor # noted on the back of the probe wipe dispenser #2 documents, "Disinfect probe or utensil then dispose of wipe properly. Keep lid closed when not in use." On 6/23/10 at 11:28 a.m., Surveyor # interviewed FSD (Food Service Director)-G regarding the use of the probe wipe cloth. FSD-G informed Surveyor # that staff can continue to use the cloth until there was visible food on the cloth. Surveyor # shared the observations of Cook-E using the same area on the probe wipe cloth to wipe the thermometer and not using a new section of the cloth. On 6/23/10 during the daily exit conference the Administrator and Director of Nursing were informed of the above.

Based on record review and staff interview, the facility did not ensure injuries of unknown origin are thoroughly investigated. This was observed with 2 of 5 injuries of unknown origin investigations reviewed. * On 2/16/10, Resident #11 developed 3 bruises on the inner thigh and the facility did not have evidence of a thorough investigation. * On 1/18/10, Resident #11 had a bruise on the buttock that the facility self-reported to the state agency. This report did not contain evidence of a thorough investigation. According to the "The Wisconsin Caregiver Program Manual" for entities regulated by the Division of Quality Assurance, State of Wisconsin, (Rev.04/09) regarding "Misconduct Reporting and Investigations" states, "Caregiver misconduct means: Abuse of a client, or neglect of a client, or Misappropriation of a clients property." Under "Misconduct Reporting and Investigations," the "Wisconsin Caregiver Program Manual" defines abuse, neglect, misappropriation of clients property, as well as injuries of unknown source. The "Wisconsin Caregiver Program Manual" defines an injury of unknown source is as "the source of the injury was not observed by any person or the source of the injury could not be explained by the resident and the injury is suspicious because of the extent of the injury or the location of the injury or the number of injuries observed at one particular point in time or the incidence of injuries over time." The "Wisconsin Caregiver Program Manual" defines an entities internal investigation responsibilities which states: All entities regulated by DQA (Division of Quality Assurance) must conduct a thorough internal investigation and document the findings for all allegations or incidents at the entity. A thorough internal investigation may include: * Collecting and preserving any physical and documentary evidence; * Interviewing alleged victims and witnesses; * Collecting other corroborating/disproving evidence; * Involving other regulatory authorities who can assist (e.g., local law enforcement, elder abuse agency, Adult Protective Service agency, DQA, Board on Aging Ombudsman, Client Right's Specialist, et.) and * Documenting each step taken during the internal investigation. These steps should be taken as part of the entity's initial attempt to determine what, if anything, happened and to determine the complete factual circumstances surrounding the alleged incident. The facility did not complete thorough investigations involving the bruises on Resident #11 by interviewing additional staff to identify any witnesses who may be able to identify the cause of the bruises, to corroborate/disprove any evidence and documenting each step taken during the internal investigation. Findings include: 1. Resident #11's medical record was reviewed by Surveyor # . Resident #11 has Dementia. The nurses notes, dated 2/16/10, indicate Resident #11 has 3 bruises on the inner right thigh near the groin. The physician and family member were notified. The entry does not state the origin of the bruises. On 6/22/10 at 10:45 a.m., Surveyor # requested additional information pertaining to Resident #11's bruises on the right inner thigh from DON-B (Director of Nurses). On 6/22/10 at 3:00 p.m., DON-B indicated that a message was left with LPN-C (Licensed Practical Nurse) who documented on 2/16/10 in Resident #11's nurses notes about the 3 bruises on the right inner thigh. LPN-C is currently on leave. DON-B was not able to locate an investigation pertaining to Resident #11's 3 bruises. On 6/23/10 at 7:45 a.m. DON-B spoke with Surveyor # . DON-B was unable to locate a investigation into Resident #11's 3 right inner thigh bruises. The facility was not able to provide a thorough investigation to determine the origin of Resident #11's 3 inner right thigh bruises. 2. The facility self-reported to the state agency a bruise of unknown origin on Resident #11's buttocks. This bruise measured 10 cm (centimeters) by 4.5 cm. This facility self-report was reviewed by Surveyor # on 6/21/10. The bruise was discovered on 1/18/10 at 4:00 p.m. by staff that were transferring Resident #11 on to the toilet. The completed facility investigation contained 1 interview from a direct care staff that worked the day shift on 1/18/10; 1 interview from the direct care staff that reported the bruise on the evening shift; and the night nurse from the evening before. The origin of the bruising could not be determined per the investigation summary by DON-B (Director of Nurses). The investigation statements indicate that Resident #11 requires 2 staff to assist with transfers and can be combative. On 6/21/10 at 3:05 p.m., Surveyor # requested to review any additional information pertaining to Resident #11's bruise investigation from DON-B. On 6/22/10 at 9:20 a.m., DON-B spoke with Surveyor # regarding Resident #11's bruise investigation. DON-B did not have any additional information and does not recall the details of the investigation. Surveyor # requested the nurse staff in schedules from 1/17/10 - 1/19/10 from DON-B at this time. On 6/22/10 at 10:53 a.m., the nurse staff schedules were received by DON-B. The schedules reveal that there were 4 other staff members working on Resident #11's household/unit on 1/18/10 on the morning shift that were not interviewed. There were 3 other staff members working on Resident #11's household/unit on 1/18/10 when the bruise was discovered. There were other staff members on the household of Resident #11 that could have had information about Resident #11 bruise. The facility did not have evidence that these staff members were interviewed during Resident #11 bruise investigation. On 6/22/10 at 3:45 p.m., Surveyor # spoke to RN-D (Registered Nurse) who was the nurse on 1/18/10 when Resident #11's bruise was reported to him/her, due to being the nurse on Resident #11 household/unit. RN-D could not recall anything about the investigation.

Based on record review and staff interview, the facility staff did not follow the facility's policy and procedure in regards to conducting a thorough investigation for 2 of 5 injuries of unknown origin reviewed. * On 2/16/10, Resident #11 developed 3 bruises on the inner thigh and the facility did not have evidence of a thorough investigation. * On 1/18/10, Resident #11 had a bruise on the buttock that the facility self-reported to the state agency. This report did not contain evidence of a thorough investigation. The facility's policy and procedure titled, "Prevention and reporting of resident abuse, misappropriation and injuries of unknown origin" dated as revised 5/10, indicates that all injuries of unknown origin will be thoroughly investigated, which includes interviewing all staff that work on the household/unit. Findings include: 1. Resident #11's medical record was reviewed by Surveyor # . Resident #11 has Dementia. The nurses notes dated 2/16/10, indicate Resident #11 has 3 bruises on the inner right thigh near the groin. The physician and family member were notified. The entry does not state the origin of the bruises. On 6/22/10 at 10:45 a.m., Surveyor # requested additional information pertaining to Resident #11 bruises on the right inner thigh from DON-B (Director of Nurses). On 6/22/10 at 3:00 p.m., DON-B indicated that a message was left with LPN-C (Licensed Practical Nurse) who documented on 2/16/10 in Resident #11 nurses notes about the 3 bruises on the right inner thigh. LPN-C is currently on leave. DON-B was not able to locate an investigation pertaining to Resident #11's 3 bruises. On 6/23/10 at 7:45 a.m., DON-B spoke with Surveyor # . DON-B was unable to locate an investigation into Resident #11's 3 right inner thigh bruises. The facility was not able to provide a thorough investigation to determine the origin of Resident #11's 3 inner right thigh bruises. On 6/23/10 at 1:05 p.m., Surveyor # reviewed the facility's policy and procedures on injuries of unknown origin investigations with Administrator-A. The policy and procedures for prevention and reporting of injuries of unknown origin were revised on 5/10. Administrator-A indicated that all staff on the household will be interviewed as part of the investigation. 2. The facility self-reported to the state agency a bruise of unknown origin on Resident #11's buttocks. This bruise measured 10 cm (centimeters) by 4.5 cm. This facility self-report was reviewed by Surveyor # on 6/21/10. The bruise was discovered on 1/18/10 at 4:00 p.m. by staff that were transferring Resident #11 on to the toilet. The completed facility investigation contained 1 interview from a direct care staff that worked the day shift on 1/18/10; 1 interview from the direct care staff that reported the bruise on the evening shift; and the night nurse from the evening before. The origin of the bruising could not be determined per the investigation summary by DON-B (Director of Nurses). The investigation statements indicate that Resident #11 requires 2 staff to assist with transfers and can be combative. On 6/21/10 at 3:05 p.m., Surveyor # requested to review any additional information pertaining to Resident #11's bruise investigation from DON-B. On 6/22/10 at 9:20 a.m., DON-B spoke with Surveyor # regarding Resident #11 bruise investigation. DON-B did not have any additional information and does not recall the details of the investigation. Surveyor # requested the nurse staff in schedules from 1/17/10 - 1/19/10 from DON-B at this time. On 6/22/10 at 10:53 a.m., the nurse staff schedules were received by DON-B. The schedules reveal that there were 4 other staff members working on Resident #11 household/unit on 1/18/10 on the morning shift that were not interviewed. There were 3 other staff members working on Resident #11's household/unit on 1/18/10 when the bruise was discovered. There were other staff members on the household of Resident #11 that could have had information about Resident #11 bruise. The facility did not have evidence that these staff members were interviewed during Resident #11 bruise investigation. On 6/22/10 at 3:45 p.m., Surveyor # spoke to RN-D (Registered Nurse) who was the nurse on 1/18/10 when Resident #11's bruise was reported to him/her, due to being the nurse on Resident #11 household/unit. RN-D could not recall anything about the investigation. On 6/23/10 at 1:05 p.m., Surveyor # reviewed the facility's policy and procedures on injuries of unknown origin investigations with Administrator-A. The policy and procedures for prevention and reporting of injuries of unknown origin were revised on 5/10. Administrator-A indicated that all staff on the household will be interviewed as part of the investigation.