Every finding on record at St Marys Home for the Aged

Based on staff interview and record review, the facility did not ensure reconciliation of discharge medications for 1 resident (R) (R51) of 2 sampled residents. R51 was private pay status and discharged to an Assisted Living (AL) facility on 8/25/25. Medications were not sent with R51 at the time of discharge. The pharmacy was not able to fill all of R51's medications because some were filled by the nursing facility less than 30 days prior. The facility delivered some medications to R51's AL facility on 8/26/25 but did not have a record of which medications were delivered. R51 missed three doses of a Parkinson's medication.Findings include:The facility's Discharge Planning policy, revised 3/31/17, indicates: .5. Implement Discharge Plan: .f. Communicate discharge plan to appropriate members of the care team.From 12/1/25 to 12/3/25, Surveyor reviewed R51's medical record. R51 was admitted to the facility on [DATE] following a hospital stay from 7/20/25 to 8/5/25 due to respiratory failure secondary to pericardial effusion and possible pneumonia. R51 was intubated during the hospital stay and had a pacemaker installed. R51 had diagnoses including Alzheimer's/dementia, Parkinson's disease, anxiety, depression, congestive heart failure, and pulmonary hypertension. R51 had an activated Power of Attorney for Healthcare ((POAHC)-K). R51 discharged from the facility to an AL facility on 8/25/25.On 12/2/25 at 2:41 PM and 12/4/25 at 9:41 AM, Surveyor interviewed Assisted Living Director (ALD)-M via phone who indicated ALD-M spoke with nursing facility Social Worker (SW)-L via phone and in person when ALD-M dropped off admission paperwork at the nursing facility on Friday (8/21/25) and again via phone on Monday (8/25/25). ALD-M stated ALD-M told SW-L that the AL facility didn't take admissions on Fridays or unless they could get residents' medications. ALD-M indicated POAHC-K wanted to admit R51 as soon as possible, however, ALD-M indicated R51 would be admitted on [DATE]. ALD-M indicated on Friday (8/21/25), ALD-M received a signed medication list from the facility and contacted the pharmacy. The pharmacy indicated they could have R51's medications at the AL facility on Sunday (8/24/25). When ALD-M arrived at work on 8/25/25, there were no medications for R51. ALD-M contacted the pharmacy who indicated R51's nursing facility had already filled the medications and the pharmacy could not re-fill them. ALD-M contacted the nursing facility on 8/25/25 and told SW-L the admission was on hold unless the nursing facility sent medications with R51 because the AL facility could not fill the medications. ALD-M indicated SW-L stated the facility could send the medications; however, R51 did not have the medications when R51 arrived at the AL facility. ALD-M indicated when R51 arrived without medications on the evening of 8/25/25, ALD-M contacted the facility and spoke with someone who stated to call back in the morning because everyone was gone. ALD-M stated a family member went to R51's home that evening and retrieved some of R51's medications. ALD-M notified SW-L on Tuesday (8/26/26) morning that R51's medications weren't sent. ALD-M indicated SW-L stated R51 was in private pay status for a day or two prior to discharge due to an appeal. ALD-M stated the nursing facility eventually found some R51's medications and SW-L drove them to the AL facility after lunch on 8/26/25. ALD-M did not have documentation of which medications were delivered. ALD-M checked R51's Medication Administration Record (MAR) and noted R51 had missed 3 doses of carbidopa levodopa (1 dose on the evening of 8/25/25 and 2 doses on 8/26/26) (used to treat symptoms of Parkinson's disease such as stiffness, tremors, and slowness of movement.) R51 had also missed the PM dose of amantadine on 8/25/25 (used to treat movements related to Parkinson's disease). On 12/2/25 at 1:46 PM, Surveyor interviewed SW-L who did not recall a conversation with the AL facility about medications prior to R51's discharge. After SW-L was notified by ALD-M on 8/26/25 that the AL facility did not have medications to give R51, SW-L delivered prescription cards to ALD-M. SW-L verified R51 was in private pay status on the weekend prior to discharge and indicated prescriptions are sent to the pharmacy and it's between the receiving facility and the family to have them filled.On 12/2/25 at 3:05 PM, Surveyor interviewed Nurse Manager (NM)-I who did not recall any conversations or issues with R51's medications. NM-I indicated the nursing facility does not send medications with residents upon discharge. NM-I indicated orders are sent to the receiving pharmacy and medications that are left at the facility are sent back to the pharmacy to be charged back.On 12/3/25, Surveyor requested a list of medications that were delivered by the nursing facility to the AL facility. Neither facility was unable to provide the information. On 12/3/25 at 9:46 AM, Surveyor interviewed Director of Nursing (DON)-B and NM-I who indicated a Nurse Practitioner e-scribed the medications to the receiving pharmacy. NM-I thought SW-L took pain medications to the AL facility on 8/26/25. DON-B called SW-L who indicated SW-L delivered more than just pain medications; however, SW-L couldn't recall what SW-L delivered. NM-I confirmed there were no progress notes or documentation regarding which medications were delivered. On 12/3/25 at 11:50 AM, Surveyor interviewed [NAME] Specialist (BS)-N from the nursing facility's pharmacy. The facility provided a bill with a statement date of 8/31/25 that was sent to POAHC-K regarding medication costs owed from the pharmacy. The bill contained the following medications dated 8/22/25 - quetiapine, amantadine, and carbidopa levodopa; and the following medications dated 8/25/25 - quetiapine, melatonin, coenzyme Q, amantadine, calcium citrate with vitamin D, and carbidopa levodopa. Surveyor reviewed another bill with a statement date of 9/30/25 that reflected a charge back for the calcium citrate with vitamin D dated 8/25/25. No other medications were charged back. BS-N indicated the medications dated 8/25/25 were R51's private pay medications and the nursing facility received them on 8/22/25. BS-N indicated the medications could have been sent with R51 to the AL facility upon discharge. BS-N stated because they were filled by the facility, the other pharmacy could not fill them.On 12/3/25 at 12:36 pm, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated the facility offered reimbursement for the medications and provided the AL facility with a form to bill the nursing facility for any associated costs. NHA-A indicated the issue was on the AL facility side and it was on the AL facility to ensure they had the medications. NHA-A was not aware that R51 had missed several doses of medication. NHA-A indicated the facility discharged R51 with orders and gave the AL facility an opportunity for reimbursement if charges were incurred. On 12/4/25 at 10:10 AM, Surveyor requested via voicemail documentation from NHA-A regarding who NHA-A provided the reimbursement form to and when. NHA-A left a return voicemail for Surveyor on 12/8/25 at 12:43 PM that indicated NHA-A did not have documentation on who received the form or when the form was sent.On 12/4/25 at 11:30 AM, Surveyor interviewed ALD-M via phone who indicated ALD-M did not speak with NHA-A, did not receive a reimbursement form, and did not recall any reimbursement discussions with the nursing facility. ALD-M indicated ALD-M spoke with SW-L a couple of times during the admission process and with a nurse on 8/21/25 when ALD-M was at the nursing facility to assess R51 for admission.

Based on staff and resident representative interview and record review, the facility did not ensure a new diagnosis of schizophrenia met clinical criteria for 1 resident (R) (R1) of 1 sampled resident.R1 was admitted to the facility on [DATE]. On 6/6/25, R1 received a new diagnosis of schizophrenia. The facility did not have evidence that R1's diagnosis met the diagnostic criteria in The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Findings includeAccording to The American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) (a resource used by mental health professionals to diagnose mental disorders), to meet the criteria for a diagnosis of schizophrenia, the patient must have experienced two (or more) of the following, each present for a significant portion of time during a 1 month period (or less if successfully treated). At least one of these must be delusions, hallucinations, or disorganized speech: delusions; hallucinations; disorganized speech (e.g., frequent derailment or incoherence); grossly disorganized or catatonic behavior; negative symptoms (i.e., diminished emotional expression or avolition) .Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet the above criteria (i.e., active phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested only by negative symptoms or by two or more symptoms listed above present in an attenuated form For a significant portion of time since the onset of the disturbance, level of functioning in one or more major areas, such as work, interpersonal relations, or selfcare is markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, there is a failure to achieve expected level of interpersonal, academic, or occupational functioning) .Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition .If there is a history of autism spectrum disorder or a communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are also present for at least 1 month (or less if successfully treated).On 12/1/25, Surveyor reviewed R1's medical record. R1 had diagnoses including dementia, generalized anxiety disorder, major depressive disorder, and insomnia due to other mental disorder. On 6/6/25, a diagnosis of schizophrenia was added to R1's diagnoses list. R1's Minimum Data Set (MDS) assessment, dated 9/4/25, had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated R1 had severe cognitive impairment. R1 had a court-ordered Guardian for decision making.A care plan, dated 6/20/25, indicated R1 required antidepressant medication due to depression, had occasional issues with mood and behavior due to dementia, anxiety, and restlessness, and required the use of psychotropic medication due to a diagnosis of schizophrenia. R1's physician orders included the following:~ Trazadone 50 milligrams (mg) for anxiety/insomnia~ Abilify 2 mg for depression~ Sertraline 50 mg for generalized anxiety disorder~ Donepezil HCL 10 mg for dementiaDespite the indication in R1's care plan, Surveyor noted R1 did not have any medication orders for a diagnosis of schizophrenia.Psychiatric provider notes during R1's stay at the facility included diagnoses of generalized anxiety disorder, major depressive disorder, and insomnia due to other mental disorder. The notes did not include a diagnosis of schizophrenia or indicate R1 had delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, or diminished emotional expressions that were continuous signs of the disturbance for at least 6 months. All psychotropic medications were prescribed and monitored by R1's psychiatric provider.On 12/2/25, Surveyor reviewed R1's behavioral charting from 12/1/24 through 12/2/25. Surveyor noted no documentation of behaviors to support a diagnosis of schizophrenia.On 12/2/25 at 9:32 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated the facility's MDS nurse who worked remotely found the schizophrenia diagnosis in documentation for R1. The diagnosis was then added to R1's MDS assessment and a new Preadmission Screening and Resident Review (PASSR) was completed. DON-B indicated DON-B would provide the medical documentation regarding the schizophrenia diagnosis.On 12/2/25 at 1:35 PM, Surveyor interviewed DON-B who contacted the MDS nurse for the documentation that prompted the MDS nurse to update R1's MDS assessment on 6/6/25 with a diagnosis of schizophrenia. On 12/3/25 at 11:09 AM, DON-B provided Surveyor with a physician note with a schizophrenia diagnosis. The Skilled Nursing Home Physician Visit note, dated 6/6/25, was signed by a primary care physician (PCP). DON-B was not aware of the PCP and thought the visit occurred in a physician's office. The note indicated the visit was conducted at the facility and was a required skilled nursing facility visit for Medicare compliance. DON-B indicated DON-B would provide additional information prior to the 6/6/25 visit that supported the diagnosis of schizophrenia.On 12/3/25 at 11:15 AM, DON-B approached Surveyor and stated DON-B spoke with R1's Guardian ((GD)-F) who indicated R1 had a history of mental illness and an inpatient mental health stay years ago. DON-B indicated DON-B would check the facility's health care system for more information prior to R1's admission. On 12/3/25 at 12:12 PM, Surveyor interviewed GD-F who indicated R1 never had a diagnosis of schizophrenia. GD-F was not aware that a schizophrenia diagnosis was added to R1's diagnoses list. GD-F confirmed R1 had an inpatient mental health stay in 2018 that included paranoia which was attributed to multiple medication changes. GD-F indicated the only other diagnosis that was proposed was bipolar disorder which was never diagnosed. GD-F verified R1 was followed by psychiatry for several years. GD-F indicated R1 had had no ill effects on R1's mental health since the 2018 inpatient stay when R1 was detoxed off all medications and then restarted on medications that are still prescribed. GD-F indicated the medications have successfully managed R1's mental health and R1 has been happy and doing well at the facility. GD-F expressed concern about the physician note that mentioned a schizophrenia diagnosis and indicated R1's psychiatric provider handles all mental health treatment for R1. GD-F was concerned that a new diagnosis was given without GD-F's knowledge or consultation. GD-F did not want medication changes for R1 based on the diagnosis. On 12/3/25, DON-B provided Surveyor with documentation from R1's psychiatric provider for 9/21/21 through R1's admission to the facility. The documentation included diagnoses of generalized anxiety disorder, major depressive disorder, and insomnia due to other mental disorder. DON-B was not aware of any supporting documentation for the schizophrenia diagnosis.

Based on observation, staff interview, and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for 2 residents (R) (R23 and R12) of 3 sampled residents.R23 had a history of falls. R23's care plan contained an intervention for a call light within reach with prompt response to requests. During multiple observations, R23 did not have a call light within reach.R12 had a history of falls. R12's care plan contained an intervention to have a walker in front of R12 when in bed and in R12's recliner. During multiple observations, R12 did not have a walker in front of R12 when in bed or the recliner.Findings include: The facility's Fall Prevention Program policy, revised 1/8/19, indicates: .1. Ensure the environment is free from accident hazards over which we have control and that we provide supervision and assistive devices to each resident to prevent avoidable accidents in accordance with state and federal regulations. 1. On 12/1/25, Surveyor reviewed R23's medical record. R23 had diagnoses including dementia, muscle weakness, abnormalities of gait and mobility, age-related physical debility, history of falling, difficulty in walking, and cognitive communication deficit. R23's Minimum Data Set (MDS) assessment, dated 11/13/25, had a Brief Interview for Mental Status (BIMS) score of 0 out of 15 which indicated R23 had severe cognitive impairment. R23 had an activated decision maker for healthcare decisions. A care plan, dated 11/30/25, indicated R23 had falls related to anxiety and dementia and needed extensive assistance of one staff and a Medstand for transfers. The care plan contained the following interventions: white socks during weekdays (otherwise attempts to self-transfer to change), assist of one for all activities of daily living (ADLs), call light within reach with prompt response to all requests (dated 3/1/24) and 30-minute safety checks (dated 11/30/25). R23's medical record indicated R23 fell on 1/15/25, 7/13/25, and 11/20/25. A fall investigation, dated 1/15/25, indicated R23 did not have access to the call light, reached to pick up a blanket, fell face forward out of the wheelchair, and obtained a bruise and abrasion on the forehead. On 12/1/25 at 8:08 AM, Surveyor observed R23 in a recliner without a call light within reach. Surveyor observed an easy button call light on the nightstand in front of R23's bed which was not within reach. A call light attached to the wall was tucked behind the bed and not within reach. On 12/1/25 at 1:35 PM, Surveyor observed R23 asleep in a recliner without a call light within reach. Surveyor observed an easy button call light on the nightstand in front of R23's bed which was not within reach. A call light attached to the wall was tucked behind the bed and not within reach. On 12/2/25 at 7:43 AM, Surveyor observed R23 in the middle of R23's room in a wheelchair without a call light within reach. Surveyor observed an easy button call light on the nightstand in front of R23's bed which was not within reach. A call light attached to the wall was tucked behind the bed and not within reach. On 12/2/25 at 11:07 AM, Surveyor observed R23 in a recliner without a call light within reach. Surveyor observed an easy button call light on the nightstand in front of R23's bed which was not within reach. A call light attached to the wall was tucked behind the bed and not within reach. Surveyor interviewed Certified Nursing Assistant (CNA)-D who transferred R23 into the recliner. CNA-D indicated CNA-D forgot to give R23 the call light and confirmed R23 did not have access to a call light. On 12/3/25 at 9:25 AM and 10:02 AM, Surveyor observed R23 in a recliner without a call light within reach. Surveyor observed an easy button call light hooked to R23's bed and a push button call light behind the bed. On 12/3/25 at 1:07 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed staff are trained on the facility's policy that indicates all residents should have access to a call light. DON-B indicated staff should ensure residents are provided with a call light in order to receive prompt assistance. 2. From 12/1/25 to 12/3/25, Surveyor reviewed R12's medical record. R12 was admitted to the facility on [DATE] and had a diagnosis of hemiplegia. A care plan, with an initiation date of 5/3/23, indicated R12 had falls related to cognitive decline and lack of safety awareness and required moderate assistance with ambulation. The care plan contained an intervention, dated 1/28/24, for a walker within reach at all times - at the bedside or in front of the recliner when sitting. R12's CNA care plan (an abbreviated care plan used by nursing staff) indicated the walker should be at the bedside when R12 is in bed and in front of the recliner when R12 is sitting in the room. On 12/1/25 at 9:54 AM and 12/2/25 at 10:01 AM, Surveyor observed R12 in bed with the bed in the lowest position. R12's walker was not in front of the bed. Surveyor noted the walker was on the opposite side of the room. On 12/2/25 at 1:43 PM, Surveyor observed R12 in a recliner. R12's walker was not in front of R12. Surveyor interviewed CNA-D who indicated CNA-D did not work on R12's unit often and the CNA who was working was new. When Surveyor indicated R12's care plan (posted in the room) indicated R12 should have a walker in front of the bed and/or recliner, CNA-D put the walker in front of R12. CNA-D indicated care plans should be followed. On 12/2/25 at 3:13 PM, Surveyor interviewed DON-B who confirmed care plans should be followed and R12 should have a walker next to R12 when in bed and the recliner.

Based on observation, staff and resident interview, and record review, the facility did not provide necessary respiratory care and services for 2 residents (R) (R1 and R5) of 2 sampled residents.R1 had diagnoses of obstructive sleep apnea (OSA) and chronic obstructive pulmonary disease (COPD). R1 had an order for a bilevel positive airway pressure (BiPAP) machine with oxygen provided by a concentrator and connected to the machine via tubing. Staff did not clean R1's BiPAP machine per manufacturer's instructions. In addition, two open one-gallon jugs of distilled water for use with R1's BiPAP machine were expired. R5 had a diagnosis of OSA and an order for a continuous positive airway pressure (CPAP) machine. Staff did not clean R5's CPAP machine per manufacturer's instructions.Findings include:The facility's Using a CPAP machine policy, dated [DATE], indicates: CPAP is used to treat patients with obstructive sleep apnea or to help decrease a patient's work of breathing while increasing oxygen saturation in the blood. Equipment: nasal mask or full face mask; soft cap; whisper swivel, tubing; CPAP (BiPAP if applicable) in-line pressure adapters (if supplemental oxygen is prescribed); .Since there are various models of CPAP units, it is not practical to include every manual within this policy and procedure. A copy of the manual should accompany the specific unit being used for a resident. If the manual is not present, call (the respiratory care provider) and an additional one will be provided to you .Precautions: Wash soft cap or headgear in mild soap, rinse and lay flat, or hang to dry as needed .The [NAME] Dream Station manufacturer's manual indicates: .Cleaning the Tubing .Hand wash the tubing and the mask and adaptor (if included) before first use and daily. For daily cleaning, disconnect the tubing from the device and the mask, and, if included, disconnect the mask adaptor from the tubing. For the flexible tubing, gently wash the tubing and mask and adaptor in a solution of warm water and liquid dish soap. Rinse thoroughly. Air dry. Inspect the tubing and mask adaptor for damage or wear. Discard and replace if necessary .Using expired distilled water in a [NAME] CPAP machine is not recommended due to the potential risks associated with using contaminated water. The water may contain bacteria or other contaminants that could be harmful if inhaled. It is crucial to use fresh, filtered water to ensure safe and effective treatment. If you have an expired distilled water bottle, it is best to discard it and replace it with fresh distilled water to maintain the health and functionality of your CPAP machine.The Air Fit ResMed Mask user guide indicates: Cleaning Your Mask: Mask and headgear should only be handwashed by gently rubbing in warm (approximately 86 Fahrenheit (F)/30 Celsius (C)) water using mild soap. All components should be rinsed well with drinking quality water and allowed to air dry out of direct sunlight .Daily/After Each Use: Disassemble the mask components according to the disassembly instructions. Handwash the separated mask components (excluding headgear and soft sleeves). To optimize the mask seal, facial oils should be removed from the cushion after use. Use a soft bristle brush to clean the vent. Inspect each component and, if required, repeat washing until visually clean. Rinse all components well with drinking quality water and allow to air dry out of direct sunlight. When all components are dry, reassemble according to the reassembly instructions. Disposable filter to be replaced monthly.Harvard Health Publishing of Harvard Medical school, dated [DATE], indicates:.A CPAP machine is one of the best treatments for people with obstructive sleep apnea, a condition that causes you to stop breathing periodically during sleep. The pauses in sleep occur when muscles in the throat relax so much that they block the airway. CPAP keeps your airway open. The CPAP system consists of a small bedside pump that pushes a forceful stream of air through a tube and into a mask you wear while you sleep. Bacteria and mold can accumulate in different parts of the device .The mask sits on the face, in contact with organisms on the skin. Over time, bacteria and oils on a dirty mask may give you a rash or infection on the skin .Given that the mask, tubing, and other components are breathed into and deliver air throughout the night, their cleanliness can be a serious health concern. Daily cleaning removes dangerous microbes, mold, dust, and debris .CPAP machines are humid and often warm, making them the perfect home for mold, bacteria, viruses, and other harmful microbes. Cleaning your CPAP components regularly washes these microbes away and prevents them from reaching dangerous levels, but neglecting your CPAP machine's hygiene can lead to both acute and chronic respiratory conditions.1.On [DATE], Surveyor reviewed R1's medical record. R1 had diagnoses including dementia, acute and chronic respiratory failure, COPD, hypertensive heart and chronic kidney disease with diabetes type 2, chronic kidney disease stage 3, and pneumonia (on [DATE]) treated with antibiotics until [DATE]. R1's Minimum Data Set (MDS) assessment, dated [DATE], had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated R1 had severe cognitive impairment. R1 had a court-ordered Guardian for decision making. On [DATE] at 10:15 AM, Surveyor interviewed R1 and observed a BiPAP machine with supplemental oxygen attached in the room. R1 was using supplemental oxygen from an oxygen concentrator. Surveyor noted R1's BiPAP mask appeared dirty/greasy and contained white matter around the inside and outside. R1 was not sure who cleaned the BiPAP machine and supplies. Surveyor also observed two open and partially used one gallon jugs of distilled water next to the nightstand. One jug contained a use-by date of [DATE] and the other jug contained a use-by date of [DATE]. On [DATE] at 1:45 PM, Surveyor noted R1's BiPAP mask appeared dirty/greasy and contained white matter around the inside and outside similar to Surveyor's earlier observation. On [DATE] at 12:57 PM, Surveyor noted R1's BiPAP mask appeared dirty/greasy and contained white matter around the inside and outside as well as hair and what appeared to be dried skin particles. Surveyor interviewed R1 who was unsure if staff cleaned the mask. R1's medical record contained the following physician orders:~ BiPAP with oxygen at night and during naps (fill with water). ~ Humidified oxygen at 2 liters with rest and 3 liters with activity at all times. Surveyor noted R1's care plan and Treatment Administration Record (TAR) did not contain any other orders or instructions for care of the BiPAP machine or supplies.On [DATE] at 9:19 AM, Surveyor again interviewed R1 who was not sure who cleaned the BiPAP machine or supplies and hadn't seen anyone do so. R1 could not recall the last time the mask was cleaned and stated the mask was really dirty. Surveyor noted the mask was in the same unclean condition as previous observations. R1 indicated nursing staff fill the machine with water. 2. On [DATE], Surveyor reviewed R5's medical record. R5 had a diagnosis of OSA. R5's MDS assessment, dated [DATE], had a BIMS score of 15 out of 15 which indicated R5 had intact cognition. R5 was R5's own decision maker. On 12/125 at 9:11 AM, Surveyor interviewed R5 who indicated staff do not clean R5's CPAP machine and R5 could not complete the task independently. Surveyor noted R5 had a CPAP machine with nasal mask. The mask appeared greasy and contained what appeared to be white, flaky, skin particles. The CPAP filter was black and contained dust-like particles on the filter and inside the filter cabinet. On [DATE] at 11:00 AM, Surveyor interviewed R5 who indicated R5 rinsed the tubing and mask at home but did not think nursing staff had done so since R5 was admitted . Surveyor noted the mask and filter were in the same condition as previously observed on [DATE].Surveyor noted R5's medical record did not contain orders for cleaning the CPAP machine, mask, tubing, or filter. On [DATE] at 9:27 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-C who indicated nurses are required to clean CPAP machines. CNA-C indicated CNAs are not responsible for cleaning or maintaining CPAP or BiPAP machines. On [DATE] at 9:33 AM, Surveyor interviewed Director of Nursing (DON)-B who confirmed Licensed Practical Nurses (LPNs) and Registered Nurses (RNs) are required to clean all CPAP and BiPAP machine filters, tubes, and masks for residents. DON-B indicated residents who have CPAP or BiPAP machines have cleaning orders on their TAR. DON-B was not aware that R1 and R5's TARs did not include instructions for care and wasn't aware the machines/parts were not cleaned per manufacturer's recommendations and the facility's policy. On [DATE] at 12:35 PM, DON-B approached Surveyor and confirmed R1 and R5's masks were not cleaned and their TARs did not contain instructions or orders to clean the machines, masks, tubing, or filters.

Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 3 residents (R) (R42, R11, and R1) of 16 sampled residents. R42 was on droplet precautions. Staff provided care for R42 without wearing personal protective equipment (PPE).R11 was on contact precautions. Staff provided care for R11 without wearing PPE. R1 had a diagnosis of pneumonia. R1 was not listed on the facility's infection control resident line list for surveillance. Findings include:The facility's Infection Prevention and Control Program policy, revised 1/1/25, indicates: .4. The Infection Prevention Committee (ICP) will make recommendations about how to best maintain a safe, sanitary, and comfortable environment for residents and staff and how to prevent the development and transmission of disease and infection .11. All residents on transmission precautions (contact, droplet, airborne) will be clinically reviewed by the Registered Nurse (RN) Manager or Director of Nursing (DON)/Infection Preventionist (IP). The appropriate care plan will be developed and communicated to all other department with a need to know .The facility's Infection Control Surveillance, Documentation, Monitoring, and Data Analysis policy, revised 1/1/25, indicates: .c. This process consists of collecting/documenting on individual cases and comparing the collected data to standard written definitions of infections as outlined in McGeer's Definition of Infection .d. The licensed staff evaluates the appropriate use of antibiotics in addition to evaluating prudent use of antibiotics .4. Data Analysis: a. Data analysis includes the following elements on each infection to detect clusters and trends: type of infection; date of onset; location in facility; and appropriate lab information .1. On 12/1/25, Surveyor reviewed R42's medical record. R42 was admitted to the facility on [DATE] and had diagnoses including quadriplegia C1-C4, spondylosis, and anxiety. R42's Minimum Data Set (MDS) assessment, dated 10/10/25, had a Brief Interview for Mental Status (BIMS) score of 5 out of 15 which indicated R42 had severe cognitive impairment. R42 had an activated Power of Attorney for Healthcare (POAHC). R42's medical record indicated R42 was diagnosed with pneumonia on 10/18/25. Surveyor observed a droplet precautions sign posted outside R42's room and a PPE cart near the door.On 12/1/25 at 9:53 AM, Surveyor observed Certified Nursing Assistant (CNA)-E enter R42's room without wearing PPE. CNA-E spoke with R42, removed food items from the bedside table, retrieved items for R42, and walked out of the room with a breakfast tray. On 12/1/25 at 9:58 AM, Surveyor interviewed CNA-E who indicated R42 was no longer on droplet precautions and PPE was not necessary. On 12/2/25 at 11:40 AM, Surveyor observed CNA-G in R42's room without PPE. CNA-G adjusted R42's pillow cases, linens, and items on R42's bedside table. CNA-G sanitized hands prior to leaving the room. On 12/2/25 at 11:45 AM, Surveyor interviewed CNA-G who indicated staff only have to wear PPE when emptying R42's Foley catheter and can't apply PPE every time they enter the room. 2. On 12/1/25, Surveyor reviewed R11's medical record. R11 was admitted to the facility on [DATE] and had diagnoses including Parkinson's disease, epilepsy, falls, and urinary tract infection (UTI). R11's MDS assessment, dated 10/26/25, had a BIMS score of 9 out of 15 which indicated R11 had moderate cognitive impairment. R11 had an activated POAHC. R11's medical record indicated R11 was diagnosed with a UTI on 10/15/25. Surveyor observed a contact precautions sign posted outside R11's room and a PPE cart near the door.On 12/1/25 at 10:09 AM, Surveyor observed CNA-E enter R11's without donning PPE to adjust the call light. On 12/1/25 at 10:12 AM, Surveyor interviewed CNA-E who indicated staff do not have to don a gown and gloves unless they provide direct care to R11. On 12/1/25 at 10:30 AM, Surveyor observed Housekeeper (HK)-H clean R11's room without wearing PPE. On 12/1/25 at 10:32 AM, Surveyor interviewed HK-H who indicated PPE use is based on the type of precautions. HK-H indicated HK-H only wears gloves when vacuuming and had worn a gown and gloves while cleaning the toilet but took them off. On 12/2/25 at 1:15 PM, Surveyor interviewed Director of Nursing (DON)-B and Nurse Manager (NM)-I. NM-I indicated staff should wear PPE for all resident cares for those on contact precautions and staff should apply PPE for all situations when entering the room of a resident on droplet precautions. NM-I indicated staff are expected to follow precautions signs posted outside resident rooms. On 12/2/25 at 2:34 PM, Surveyor again interviewed NM-I who indicated R11 was currently on a supplement for preventative UTI management. NM-I indicated R11 had two UTIs in September and one on 10/15/25 which is why R11 was on contact precautions. 3. On 12/1/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including dementia, acute and chronic respiratory failure, and chronic obstructive pulmonary disease (COPD). R1's MDS assessment, dated 9/4/25, had a BIMS score of 6 out of 15 which indicated R1 had severe cognitive impairment. R1 had a Guardian for healthcare decisions. On 12/2/25, Surveyor reviewed the facility's infection prevention surveillance resident line lists. R1 was not on the line list for surveillance despite a pneumonia diagnosis on 8/27/25 for which R1 was treated with antibiotics.On 12/3/25 at 1:59 PM, Surveyor interviewed DON-B who indicated a pneumonia diagnosis should be documented on the facility's surveillance line list. DON-B verified staff did not add R1 to line list for a pneumonia diagnosis on 8/27/25.

Based on staff and resident representative interview and record review, the facility did not provide restorative therapy to increase and/or prevent decrease in range of motion (ROM) or activities of daily living (ADLs) for 1 resident (R) (R51) of 1 sampled resident.Power of Attorney for Healthcare (POAHC)-K received notice on 8/19/25 that R51's Medicare benefits were ending. Therapy was not provided while POAHC-K pursued an appeal.Findings include:The Notice of Medicare Non-Coverage (NOMNC) form indicates: .You have the right to appeal this decision to end Medicare coverage for your services. This means you'll get an independent medical review right away. Your services will continue during the appeal. From 12/1/25 to 12/3/25, Surveyor reviewed R51's medical record. R51 was admitted to the facility on [DATE] following a hospital stay from 7/20/25 to 8/5/25 where R51 had respiratory failure thought to be secondary to pericardial effusion and possible pneumonia. R51 was intubated and received a pacemaker during the hospital stay. R51 had diagnoses including Alzheimer's disease/dementia, Parkinson's disease, anxiety, depression, congestive heart failure, and pulmonary hypertension. R51 had an activated POAHC (POAHC-K).Therapy records indicated R51 received occupational, physical, and speech therapy during R51's rehabilitation stay at the facility from 8/6/25 through 8/21/25. R51 was on a Medicare Advantage Plan while at the facility.POAHC-K was notified via phone on 8/19/25 of R51's NOMNC form (a form that lets residents/decision makers know that Medicare coverage will be ending and will no longer be a payor source). The NOMNC form gives residents/families a chance to appeal the decision. POAHC-K appealed the decision on 8/19/25. The facility was notified that R51 lost the first level appeal on 8/21/25.On 12/3/25 at 10:10 AM, Surveyor interviewed Therapy Director (TD)-J who indicated R51's last day of therapy was 8/21/25. TD-J indicated if a resident/family chooses to appeal the ending of therapy, therapy's process is to continue to see the resident until the results of the appeal are received. TD-J was not aware there was a second level appeal for R51 and indicated Social Worker (SW)-L or the marketing department usually lets TD-J know if there is a further appeal. TD-J indicated if TD-J had known that a second level appeal was being pursued, R51's therapy would have continued. On 12/3/25 at 1:24 PM, Surveyor interviewed SW-L who was notified on 8/21/25 that R51 lost the first appeal. SW-L indicated the appeal company informed the facility about the level 2 appeal. After SW-L received the information, SW-L and Nurse Manager (NM)-I notified POAHC-K via phone that a second level appeal can take up to 2 weeks and if the appeal is lost, R51 would be liable for any charges starting on 8/22/25. After the conversation, SW-L was under the impression that POAHC-K was going to pursue discharge to an Assisted Living (AL) facility and save R51's money to pay for the AL facility. SW-L thought POAHC-K was going to cancel the level 2 appeal that was in progress and stated AL staff were at the nursing facility on 8/21/25 to assess R51. The facility thought R51 was discharging on 8/21/25; however, R51 did not discharge until 8/25/25. SW-L indicated SW-L usually informs therapy of a level 2 appeal so they knew to continue therapy. Based on the phone conversation with POAHC-K and the information that R51 was discharging to an AL facility, SW-L did not pass the information on. The facility received paperwork on 8/26/25 that indicated R51's level 2 appeal was denied. SW-L indicated if POAHC-K wanted to continue with the level 2 appeal, therapy should have continued. SW-L stated therapy does not usually occur on the day of discharge. SW-L would have encouraged R51 not to discharge because if R51 won the appeal, therapy could not resume if R51 was no longer at the facility. SW-L stated the facility received notice on 10/8/25 that POAHC-K was pursuing a third level of appeal. SW-L did not have documentation of the conversations with POAHC-K.On 12/4/25 at 8:13 AM, Surveyor interviewed POAHC-K via phone who recalled a phone conversation with SW-L about the level 2 appeal. POAHC-K indicated POAHC-K had no intention of stopping the second level appeal and chose to continue the discharge R51 had to leave or pay privately. POAHC-K indicated therapy should have continued until R51 discharged .

Based on staff interview and record review, the facility did not ensure a Significant Change in Status (SCIS) Minimum Data Set (MDS) assessment was completed timely for 1 resident (R) (R1) of 3 sampled residents. R1 met the criteria for a Significant Change in Status MDS assessment on 3/15/25. A SCIS assessment was not completed. Findings include: The Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) manual 3.0 states a Significant Change in Status MDS must be completed when the Interdisciplinary Team determines a resident meets the significant change guidelines for either a major decline or a major improvement. A significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions; the decline is not considered self-limiting; 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan. The facility's Significant Change of Resident's Condition or Status policy, revised 2/21/19, indicates: .2. Significant change of condition related to MDS criteria. a. A significant change (based on MDS guidelines) of condition is a decline or improvement in the resident's status that: .ii. Impacts more than one area of the resident's health status; .7. Significant change assessments: a. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by current Omnibus Budget Reconciliation Act (OBRA) regulations governing resident assessments and as outlined in the MDS RAI instruction manual. On 4/30/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including traumatic subdural hemorrhage, flaccid hemiplegia affecting right dominant side, left subdural hematoma, and history of falls. R1's MDS assessment, dated 2/17/25, had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 which indicated R1 had moderate cognitive impairment. R1 had an activated Power of Attorney for Healthcare ((POAHC)-E). R1's MDS assessment, dated 2/17/25, indicated the following: ~ No impairment in extremities ~ Eating assist - set up ~ Brushing teeth - no assistance ~ Mobility - partial/moderate assist, helper does half the effort ~ Chair to bed transfer - partial/moderate assist, helper does half the effort ~ Walking - walk 10 feet with supervision and touching assistance; walk 50 feet with supervision, touching assistance, and verbal cues ~ Wheelchair - wheel 50 feet with 2 turns - requires verbal cues or touching/steadying assistance ~ Swallowing - no loss of liquids, coughing, or chewing difficulties On 4/30/25, Surveyor reviewed a Certified Nursing Assistant (CNA) care plan, dated 4/9/25, that was posted on the wall in R1's room. The care plan indicated R1 required a medical stand with the assistance of 2 staff for all transfers. The care plan also indicated R1 needed assistance with activities of daily living (ADLs), including eating and thorough hygiene, due to right-sided weakness. R1 had an order for an easy chew diet with soft, bite-sized meat (pureed soup) and mildly thick liquids. On 4/30/25 at 12:37 PM, Surveyor interviewed Registered Nurse (RN)-F who indicated the last MDS assessment RN-F completed was dated 2/17/25. RN-F indicated R1 was discharged from Hospice services in early February. RN-F did not complete a SCIS MDS assessment because RN-F was not sure if R1 met the requirements of a significant change in status. On 4/30/25 at 1:15 PM, Surveyor interviewed Director of Rehab (DOR)-C who reviewed R1's therapy notes and indicated R1 required a sit-to-stand lift with the assistance of 2 staff for transfers. DOR-C indicated R1 was unable to stand at a walker with moderate assistance of 2 staff. DOR-C stated R1 had decreased range of motion (ROM)and strength in the right extremities and indicated R1 required the assistance of 1 staff for eating due to decreased strength and ROM in the right arm. DOR-C indicated R1 coughed with liquids and was changed to mildly thick liquids. R1 was prescribed an easy chew, soft, bite-sized diet. DOR-C indicated R1 had a significant decline in ADL function since 3/15/25. On 4/30/25 at 3:29 PM, Surveyor interviewed CNA-D who indicated R1 required a sit-to-stand lift with the assistance of 2 staff for transfers and was unable to stand at a walker with assistance. CNA-D stated R1 was able to self-propel a wheelchair a few feet, however, staff pushed R1 in wheelchair because propelling a wheelchair was difficult for R1. CNA-D indicated R1 required the assistance of 1 staff for dressing and brushing R1's teeth. CNA-D verified R1 required assistance with eating and was on thickened liquids. On 4/30/25 at 2:26 PM, Surveyor interviewed POAHC-E via telephone who stated R1 had a SCIS on 3/15/25. POAHC -E indicated R1's ADL functional abilities had declined since 3/15/25. On 4/30/25 at 3:14 PM, Surveyor interviewed NHA (Nursing Home Administrator)-A who indicated the facility was aware of R1's change in condition and verified a SCIS MDS assessment was not completed.

Based on staff interview and record review, the facility did not ensure vaccinations were reviewed, offered, or administered for 1 Resident (R) (R13) of 5 sampled residents. The facility did not offer R13 the PCV20(R) vaccine. Findings include: Abbreviations (www.cdc.gov): PCV13: 13-valent pneumococcal conjugate vaccine (Prevnar13(R)) PCV15: 15-valent pneumococcal conjugate vaccine (Vaxneuvance(R)) PCV20: 20-valent pneumococcal conjugate vaccine (Prevnar 20(R)) PPSV23: 23-valent pneumococcal polysaccharide vaccine (Pneumovax23(R)) The most recent Centers for Disease Control and Prevention (CDC) recommendations for pneumococcal vaccinations indicate: For adults [AGE] years or older who have only received PPSV23, the CDC recommends: Give 1 dose of PCV15 or PCV20. The PCV15 or PCV20 dose should be administered at least 1 year after the most recent PPSV23 vaccination. Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. For those who have received PCV13 and 1 dose of PPSV23, the CDC recommends you give 1 dose of PCV20 at least 5 years after the last pneumococcal vaccine. For adults [AGE] years or older who have received PCV13, give 1 dose of PCV20 or PPSV23 at least 1 year after PCV13. Regardless of vaccine used, their vaccines are then complete. The facility's undated Infection Prevention and Control Manual Pneumococcal Vaccine Program indicates: It is the policy of this facility that residents will be offered immunization(s) against pneumococcal disease in accordance with Advisory Committee on Immunization Practices (ACIP) recommendations .Refer to https://www.cdc.gov/vaccines/vpd/pneumo/hcp/recommendations.html for more details. On 8/14/24, Surveyor reviewed R13's medical record. R13 was admitted to the facility on [DATE] and had diagnoses including moderate dementia and chronic obstructive pulmonary disease (COPD). R13 had an activated Power of Attorney (POA) for medical decisions. R13's medical record indicated R13 received a PCV13 vaccine on 11/6/15 and a Pneumococcal vaccine on 6/9/17. R13 was due to receive the PCV20 vaccine as of 6/9/22 (five years after the last vaccine). R13's medical record did not indicate R13 was offered or administered the PCV20 vaccine. On 8/14/24 at 1:49 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated any needed vaccinations should be offered to residents within two weeks of admission to the facility. On 8/14/24 at 2:11 PM, Surveyor again interviewed DON-B who confirmed R13 had not been offered the PCV20 vaccine since R13 was admitted to the facility.

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 30 residents residing in the facility. Cold food items were served outside the temperature safe zone and dessert was not covered appropriately during meal service. Hand hygiene was not completed appropriately during lunch service on 6/20/22. Findings include: On 6/21/23 at 1:20 PM, Certified Dietary Manager (CDM)-E stated the facility follows the Wisconsin Food Code. 1. Cold Temperature Foods/Uncovered Items The Wisconsin Food Code at 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding states: .Time/Temperature control for safety food shall be maintained: .(2) At 5 degrees Celsius (41 degrees Fahrenheit) or less. The Wisconsin Food Code also states at 3-307.11 Miscellaneous Sources of Contamination: Food shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 and 3-306. The facility's Food Temperature Verification Recording policy, revised 8/22/19, contained the following information: 3.1 Culinary Services Aid will properly take food temperatures of hot and cold foods following the Taking Proper Food Temperature Work Instruction. 3.2 The temperature will be documented in the Food Temperature log and the Culinary Aide will initial that the log has been accurately filled out. 3.4 If cold food is not at the correct temperature, a supervisor will need to verify if the food item is safe to serve based on the allotted two hour timeframe. On 6/20/23 beginning at 11:15 AM, Surveyor observed lunch service in the side 1 dining room. The facility used a main kitchen in the lower level to prepare food which was sent in bulk to the kitchens on the units for meal service. Surveyor observed Dietary Staff (DS)-D place food items in the steam table. Surveyor also observed a banana cream pie on the counter with 5 slices of pie on individual plates. The pie slices were uncovered for the duration of the meal service (until 12:08 PM). Surveyor also noted the regular pie and the pureed pie were not chilled during the meal service. On 6/20/23 at 11:15 AM, Surveyor observed DS-F in the side 2 dining room and noted slices of pie were plated and uncovered on the counter. Surveyor did not observe staff temp the pie for the duration of the meal service. On 6/20/23 at 11:26 AM, Surveyor observed DS-D obtain temperatures of hot food items in the steam table prior to meal service. DS-D documented the temperatures on a Food Temperatures for Hot and Cold Food form. On 6/20/23 at 11:34 AM, Surveyor interviewed DS-D regarding obtaining cold food temperatures prior to meal service. DS-D stated staff who trained DS-D told DS-D not to take temperatures of cold food items. DS-D stated 3 different staff trained DS-D on different days and they all did different things. DS-D stated DS-D obtained hot food temperatures at the start and end of meal service. Surveyor noted the log sheet DS-D filled out had space to record cold food item temperatures. On 6/20/23 at 12:08 PM, Surveyor observed DS-D serve the last piece of pie with the last resident meal. Surveyor asked DS-D to temp the remaining pie on the counter, including the pureed pie. The remaining banana cream pie in the original container was 66 degrees. The pureed banana cream pie located in the last steam well (which was not turned on) was 60 degrees. On 6/21/23, the facility provided meal service temperature logs for breakfast and lunch on 6/20/23 and 6/21/23. The logs did not contain chilled beverage or chilled dessert temperatures; however, hot food temperatures were documented. Surveyor noted there was space designated on the logs for Breakfast: Frozen Items, Cold Beverage, and Hot Beverage; and for Lunch/Dinner: Chilled Dessert, Cold Entree, Frozen Items, and Cold Beverage. On 6/21/23 at 1:20 PM, Surveyor interviewed CDM-E who stated CDM-E did not expect staff to take cold food/drink temperatures prior to meal service. CDM-E also stated the pie should remain at 40 degrees or below. 2. Hand Hygiene The Wisconsin Food Code at 3-304.15 Gloves, Use Limitation indicates: If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. The Wisconsin Food Code at Chapter 2 Personal Cleanliness at 2-301.14 titled When to Wash states: Food employees shall clean their hands and exposed portions of their arms as specified under 2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; .(E) After handling soiled equipment or utensils; (F) During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (G) When switching between working with raw food and working with ready-to-eat food; (H) Before putting on gloves to initiate a task that involves working with food; and (I) After engaging in other activities that contaminate the hands. The facility's Glove Usage in Culinary Services policy, revised 6/19/19, contained the following information: 3.2 If used, single-use gloves shall be used to do only one task such as working with ready-to-eat food or with raw animal food. They should be used for no other purpose, discarded when damaged or soiled or when interruptions occur in the operation, and after four hours if working on the same task. 3.4 Hands must be washed before putting on gloves and after removing gloves. On 6/20/23 at 11:37 AM, Surveyor observed DS-D remove gloves and don clean gloves without cleansing hands. DS-D then touched a resident's meal card and picked up a plate. With the same gloved hands, DS-D opened a bag of buns, removed a bun, and removed the cover from a container of Italian sausage. DS-D picked up a sausage with a gloved hand and placed the sausage in the bun. On 6/20/23 at 11:41 AM, Surveyor observed DS-D remove gloves, wash hands, and don clean gloves. Surveyor observed DS-D touch DS-D's glasses and face. With the same gloved hands, DS-D picked up a board with a lunch menu and carried the board to a resident. The resident told DS-D what the resident wanted for lunch which included chicken and banana cream pie. DS-D then removed gloves and, without cleansing hands, donned clean gloves. DS-D carried a plate to a resident, removed gloves, and without cleansing hands, donned clean gloves. DS-D then picked up a bun with a gloved hand and opened the bun. On 6/20/23 at 12:01 PM, Surveyor observed DS-D don gloves without cleansing hands. DS-D touched the refrigerator door handle with the right gloved hand, removed an item and closed the door. With the same gloved hands, DS-D removed 2 slices of bread from a bag, used a knife to spread an item on the bread, picked up lunch meat and placed the meat on the bread. With the same gloved hands, DS-D opened the refrigerator door and returned items to the refrigerator. DS-D then returned to the food prep area, picked up the sandwich and put the sandwich on a plate. On 6/21/23 at 1:20 PM, CDM-E stated the expectation for hand hygiene is to touch ready-to-eat food with gloved hands only. When Surveyor informed CDM-E of Surveyor's observations during meal service, CDM-E verified DS-D should not have touched other items with a gloved hand before touching ready-to-eat food. CDM-E also verified hand washing should be completed between glove changes.

Based on staff interview and record review, the facility did not ensure monitoring of a high-risk medication for 1 Resident (R) (R15) of 5 residents reviewed. R15's medical record did not contain monitoring for the side effects of Lasix (a diuretic medication). Findings include: According to the Davis's Drug Guide for Nurses 18th edition copyright 2023 adverse reactions/side effects of diuretic medication include thirst, dry mouth, lethargy, weakness, hypotension, and oliguria (abnormally small amouts of urine) .Monitor daily weight, intake and output ratios, amount and location of edema, lung sounds, skin turgor, and mucous membranes .Monitor blood pressure and pulse before and during administration. On 6/22/23, Surveyor reviewed R15's medical record and noted R15 had a physician's order for Lasix 20 mg (milligrams) (a loop diuretic (water pill) that prevents the body from absorbing too much salt) daily for a diagnosis of congenital heart failure. Surveyor noted R15's medical record did not include monitoring for side effects or adverse reactions to Lasix. On 6/22/23 at 9:16 AM, Surveyor interviewed Director of Nursing (DON)-B who stated residents prescribed high-risk medications, such as Lasix, should have medication monitoring for side effects and adverse reactions in their plan of care. DON-B confirmed R15 was administered Lasix daily and verified R15's medical record did not contain monitoring for side effects or adverse reactions to Lasix. On 6/22/23 at 9:24 AM, Surveyor interviewed Nurse Manager (NM)-C who stated the plan of care for residents prescribed high-risk medications, such as Lasix, should contain medication monitoring. NM-C verified R15's plan of care did not contain monitoring for side effects or adverse reactions to Lasix.

Based on staff and resident interview, and record review, the facility did not ensure the accurate administration of medication for 1 Resident (R) (R4) of 13 sampled residents. R4 did not receive scheduled pain medication timely when the facility ran out of the medication and did not have a current prescription. Findings include: R4 was admitted to the facility on [DATE] with diagnoses that included osteoarthritis, presence of cardiac pacemaker, generalized anxiety disorder, radiculopathy lumbar region (inflammation of a nerve root in the lower back which causes symptoms of pain or irritation in the back and down the legs .commonly referred to as sciatica). R4's most recent Minimum Data Set (MDS), dated [DATE], contained a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R4 was not cognitively impaired. R4 had a care plan related to pain. On [DATE] at 9:55 AM, Surveyor interviewed R4 who stated R4 did not get R4's scheduled hydrocodone (a narcotic medication used to treat moderate to severe pain) earlier that morning. R4 stated hydrocodone was scheduled 3 times per day (7:00 AM, 3:00 PM, and 11:00 PM) and R4 liked to take the 11:00 PM dose prior to going to bed so staff did not have to wake R4 to take the medication. R4 wondered why staff did not notice R4's hydrocodone was going to run out. R4 stated R4 was stressed and had a pain level of 5 or 6 out of 10. R4 stated R4 had Tylenol available, but did not feel Tylenol touched the pain. R4 stated R4 took hydrocodone due to a severe case of sciatica and the last dose R4 received was at 9:00 PM on [DATE]. R4 stated R4 knew staff were working on getting a new prescription; however, R4 was upset R4's prescription ran out. R4 also stated R4 had therapy shortly. On [DATE], Surveyor reviewed R4's medical record and noted R4 had an order for hydrocodone bitartrate-acetaminophen (325 mg (milligrams)-7.5 mg tablet) three times daily at 8:00 AM, 3:00 PM and 11:00 PM related to pain. Surveyor reviewed R4's Medication Administration Record (MAR) and noted the following: ~On [DATE], hydrocodone was administered at 7:01 AM, 3:55 PM, and 10:17 PM. ~On [DATE] at 11:13 AM, Registered Nurse (RN)-G documented hydrocodone was held-awaiting script. ~On [DATE] at 3:41 PM, documentation indicated hydrocodone was not available ~On [DATE] at 8:26 PM, the MAR indicated hydrocodone was administered and R4's pain level prior to administration was moderate-quality of pain/ache throb. On [DATE] at 9:29 AM, Surveyor interviewed R4 who stated R4 received hydrocodone that morning and at approximately 9:00 PM the previous night. When asked if R4 missed 2 doses of hydrocodone, R4 stated R4's spouse came to the facility and brought R4's medication from home (which was the same prescription), so R4 only missed one dose and took hydrocodone sometime mid-morning. R4 stated R4 was informed when the prescription arrived, but told staff R4 wanted to wait to take the next dose so R4 could get back on schedule and ensure there were 8 hours between doses. On [DATE], Surveyor reviewed R4's medical record and recalled Surveyor interviewed R4 on [DATE] at 9:55 AM. Surveyor noted R4's current hydrocodone prescription was received via fax at 11:09 AM. Surveyor concluded R4 took R4's medication from home sometime between 9:55 AM and the time the fax was received for the new medication. On [DATE] at 12:25 PM, Surveyor interviewed RN-G who worked the AM shift on [DATE] and verified R4 did not receive the 7:00 AM dose of hydrocodone. RN-G stated R4's prescription ran out and because hydrocodone was a narcotic, a new prescription was needed. RN-G stated the previous shift attempted to contact the physician on the evening of [DATE] to obtain a renewal of R4's prescription, but did not receive a response. RN-G stated RN-G notified an Advanced Practice Nurse Prescriber (APNP) and called the APNP's office to request a renewal of the prescription. RN-G stated RN-G refaxed the request and APNP sent the request through. RN-G stated the facility had the prescription available in contingency; however, because R4's prescription expired and the medication was a narcotic, there was no way to access the medication without a new prescription and number. RN-G thought the new prescription came through sometime around noon. RN-G said the situation was not ideal and R4 was upset and highly anxious about it. RN-G was not aware R4 took medication brought from home. On [DATE] at 12:44 PM, Surveyor interviewed Director of Nursing (DON)-B and Nurse Manager (NM)-C who were both unaware R4's hydrocodone ran out and R4 took medication form home. NM-C stated prescriptions should be looked at ahead of time, but R4's must have been missed. NM-C stated a medication error sheet should have been filled out and NM-C would look into the claim R4's spouse brought medication from home. In a follow up interview at 2:00 PM, NM-C stated the facility's Ordering Schedule II Controlled Medications policy indicated: Federal law requires that a pharmacy has a written prescription signed by a licensed prescriber before it may fill a schedule II controlled substance prescription for a resident in a long-term care facility. The policy also stated: When a continuance prescription is about to be exhausted, the pharmacy will send by facsimile or mail, a new prescription request to the physician's office for signature. NM-C stated NM-C would contact the pharmacy because, per policy, the pharmacy should keep track of schedule II medications as well.

Based on staff interview and record review, the facility did not ensure comprehensive care plans were developed for 3 Residents (R) (R6, R12, and R22) of 13 sampled residents. The facility did not develop a hospice care plans for R6 and R12 when R6 and R12 started hospice services. The facility did not develop a care plan which included the intervention of a splint to R22's left arm. Findings include: 1. R6 was admitted to the facility on [DATE] and had diagnoses that included encounter for palliative care, Alzheimer's disease with late onset, adult failure to thrive, and vascular dementia. Between 6/20/23 and 6/22/23, Surveyor reviewed R6's medical record and noted R6 started hospice services on 2/27/23. R6's medical record did not contain a plan of care for hospice services. On 6/22/23 at 9:38 AM, Nurse Manager (NM)-C confirmed R6 did not have a care plan related to hospice services and stated one was just added. Surveyor again reviewed R6's medical record and noted a hospice care plan was added on 6/22/23. 2. R12 was admitted to the facility on [DATE] and had diagnoses that included encounter for palliative care, hemiplegia (paralysis on one side of the body) and hemiparesis (muscle weakness or paralysis on one side of the body) following cerebral infarction (stroke), and vascular dementia. Between 6/20/23 and 6/22/23, Surveyor reviewed R12's medical record and noted R12 started hospice services on 4/28/23. R12's medical record did not contain a plan of care related to hospice services. On 6/22/23 at 9:26 AM, NM-C stated the facility used paper care plans for Certified Nursing Assistants (CNAs) that are posted in residents' rooms and updated by hand. NM-C stated care plans were also contained in residents' medical records. NM-C stated it was a team effort to ensure care plans were updated. NM-C confirmed R12 did not have a hospice care plan in place and stated the facility was lacking in care plan updates because staff had to prioritize resident care. NM-C stated a hospice care plan was added to R12's record that morning after Surveyor brought the issue to the facility's attention. 45943 3. On 6/21/23, Surveyor reviewed R22's medical record. R22 had diagnoses that included Parkinson's disease and chronic lymphedema left arm following left mastectomy. Documentation of Therapy Recommendations/Occupational Therapy (OT) on 3/2/23 indicated: 1. (Resident) to wear splint throughout daytime and bedtime (through night) take off for meals. After meals, perform washing of hands for food residue and dry when completed. 2. Check for skin integrity. If redness or irritation noted, let therapy department know and take splint off immediately. A physician note, dated 4/27/23, indicated OT provided splinting and compression. R22's medical record did not contain a care plan intervention for a splint to the left arm related to lymphedema. On 6/22/23 at 9:30 AM, Surveyor interviewed DON-B who verified the intervention of splint to the left arm was not included in R22's primary care plan or the CNA care plan (prior to 6/21/23). DON-B verified the following was added to the CNA care plan on 6/21/23: 3. (Left) lymphedema: Monitor skin for redness: Splint to be worn throughout the day and at night: OFF for meal-time, wash hands after meals-when fully dry, reapply. Monitor skin integrity. DON-B also verified the following was added to R22's primary care plan on 6/21/23: Problems/Strengths: Has edema secondary to history of breast cancer and breast removal-lymphedema. Interventions included: monitor feet and hands for edema, warmth and color and monitor for shortness of breath .Monitor skin for redness. OT for lymphedema treatment. Splint to be worn throughout the day and at night: Off for meal time-wash hands after meals-when fully dry reapply. Monitor skin integrity.

Based on observations, interviews, and record review, the facility did not maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent or contain the transmission of communicable diseases and infections such as COVID-19. This had the potential to affect all 28 resident residing in the facility. Furthermore, based on record review, observations and interviews, the facility did not ensure staff performed proper hand hygiene for 1 Resident (R) (R9) of 3 residents observed during provision of cares. The facility did not require staff to wear N95 respirator into a resident's room who is in quarantine related to COVID-19 precautions. The facility did not require staff to wear eye protection while in a resident care area unless staff go into a resident's room who is in quarantine or isolation related to COVID-19 precautions. Certified Nursing Assistant (CNA)-C did not perform appropriate hand hygiene during R9's provision of perineal care on 7/12/22. Additionally, CNA-D did not perform appropriate hand hygiene during R9's provision of perineal care on 7/12/22. Findings include: 1. According to the facility policy titled Preparedness for COVID-19 Policy with revision date of 6/24/20 stated: .3.5 .This information complements, but does not replace, the general infection prevention and control recommendations for COVID-19 . (Infection Control: Severe acute respiratory syndrome coronavirus 2 ([CONDITION(S)]-CoV-2) | CDC.) According to The Centers for Disease Control and Prevention (CDC) document titled Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes | CDC last updated on 2/2/22 stated: .Manage Residents who had Close Contact with Someone with [CONDITION(S)]-CoV-2 Infection Residents who are not up to date with all recommended COVID-19 vaccine doses and who have had close contact with someone with [CONDITION(S)]-CoV-2 infection should be placed in quarantine after their exposure, even if [CONDITION(S)] testing is negative. HCP (healthcare provider) caring for them should use full PPE (gowns, gloves, eye protection, and N95 or higher-level respirator) . According to https://covid.cdc.gov/covid-data-tracker, 7/11/22 through 7/13/22, Manitowoc County's COVID-19 community transmission level was high. According to Centers for Medicare and Medicaid Services (CDC), the National Healthcare Safety Network (NHSN) Data Week Ending 6/19/22 for the facility indicated: Recent Percentage of Residents who completed Primary Vaccination: 87.1 Recent Percentage of Staff with Completed Primary Vaccination: 91.0 On 7/12/22 at 9:05 AM, Surveyor observed an isolation cart outside of R77's door. There were no signs indicating what type of personal protective equipment staff must wear to enter R77's room. In the isolation cart were gowns, surgical masks, gloves, and eye protection. There were no other type of facial coverings or N95 respirators available in the cart. On 7/12/22 at 9:14 AM, Surveyor interviewed NI-E who stated NI-E and staff need to use a surgical mask while in the R77's room and that R77 was on quarantine. NI-E stated NI-E will take off surgical mask that NI-E wears in R77's room and places the mask in a paper bag for the duration of the shift. NI-E stated the surgical mask in the paper bag is re-used by NI-E when NI-E needs to re-enter R77's room. NI-E stated the facility does not require staff to wear N95s in a resident's room who is on quarantine. On 7/12/22 at 1:12 PM, Surveyor interviewed DON-B who stated staff need to wear full PPE of surgical mask, eye protection, gown, and gloves. when entering a resident's room on quarantine. DON-B stated the facility does have N95s and employees have been fit tested . On 7/13/22 at 10:29 AM, Surveyor interviewed DON-B who stated staff need to wear a face covering into a newly admitted , asymptomatic, fully vaccinated resident's room DON-B stated if a resident was COVID-19 positive and symptomatic, the facility would require the staff to wear an N95 into that resident's room. 2. According to the facility policy titled Preparedness for COVID-19 Policy with revision date of 6/24/20 stated: .3.5 .This information complements, but does not replace, the general infection prevention and control recommendations for COVID-19 . (hyperlink within document to Infection Control: Severe acute respiratory syndrome coronavirus 2 ([CONDITION(S)]-CoV-2) | CDC) .Implement Universal Use of Personal Protective Equipment for HCP: Additionally, HCP working in facilities located in counties with substantial or high transmission should also use PPE as described below: .Eye protection (i.e., goggles or a face shield that covers the front and sides of the face) should be worn during all patient care encounters . On 7/12/22 at 9:02 AM, Surveyor observed multiple staff in the resident dining area not wearing eye protection. Residents were observed in the space. During observations on 7/11/22, 7/12/22, and morning of 7/13/22, Surveyor did not observe staff wearing eye protection, unless staff were in R77's room. On 7/12/22 at 9:14 AM, Surveyor interviewed NI-E who stated staff only need to wear eye protection when staff enter a resident's room who is on transmission based precautions for COVID-19 and not while around residents not on transmission based precautions. NI-E stated staff disinfect eye protection after exiting a resident's room who is on quarantine. Used a bleach wipe to disinfect eye protection. On 7/13/22 at 1:21 PM, Surveyor interviewed DON-B who stated the facility does not require staff to wear eye protection unless staff are entering the room of a resident on quarantine or isolation for COVID-19. 3. Facility provided policy titled Handwashing with revision date of 6/22/20 stated, . Hand hygiene will be performed at a minimum: after removal of gloves, before and after resident care . To prevent and control healthcare acquired infections . On 7/11/22, Surveyor reviewed R9's medical record. R9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's medical record indicated R9 had just completed antibiotic treatment on 7/10/22 for Urinary Tract Infection and that R9 had a chronic history of [CONDITION(S)] (a highly contagious bacteria that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon). On 7/12/22 at 9:59 AM, Surveyor observed CNA-C assist R9 to the toilet and provide perineal care. During the provision of care, Surveyor observed CNA-C transfer R9 to toilet from wheelchair using a mechanical sit-to-stand lift. Surveyor observed CNA-C pull R9's pants down and remove R9's incontinence product. Surveyor observed CNA-C, without performing hand hygiene, put on gloves and continue with the provision of care. Surveyor observed CNA-C provide perineal care using disposable wipes and, without changing gloves and performing hand hygiene, put new incontinence product on R9 and pull R9's pants up. Surveyor observed CNA-C remove CNA-C's gloves then, without performing hand hygiene, maneuver sit-to-stand lift to transfer R9 back to wheelchair, position R9 comfortably in wheelchair, open R9's room door, place sit-to-stand lift in hallway, apply R9's foot pedals to wheelchair, leave R9's room then state, I forgot the garbage. Surveyor observed CNA-C re-enter R9's room, remove filled garbage bag from can in R9's bathroom and place new garbage bag in can. CNA-C then was observed to wash CNA-C's hands. On 7/12/22 at 10:12 AM, Surveyor interviewed CNA-C who verified CNA-C should have performed hand hygiene before and after glove use. On 7/12/22 at 4:12 PM, Surveyor observed CNA-D assist R9 to toilet and provide perineal care. During the provision of care, Surveyor observed CNA-D transfer R9 to toilet from recliner using a mechanical sit-to-stand lift. Surveyor observed CNA-D put on gloves, pull R9's pants down and remove R9's incontinence product which was soiled with urine and stool. Surveyor observed CNA-D, with same gloved hands, open closet door, obtain new incontinence product and wash linen, wet one washcloth and wash R9's face, place new incontinence product around R9's legs, touch lift controller to raise R9 to standing position, and provide perineal care with disposable cloths. Surveyor observed CNA-D remove gloves, perform hand hygiene and put on new gloves. Surveyor observed CNA-D provide perineal care with new disposable cloths then, without changing gloves or performing hand hygiene, provide additional perineal care by washing, rinsing and drying R9's perineal area with wash linen. Surveyor observed CNA-D, with same gloved hands, open drawers looking for barrier cream, pull up and fasten R9's incontinence product and pull up R9's pants. Surveyor observed CNA-D removed CNA-D's gloves and, without performing hand hygiene, use mechanical sit-to-stand lift to transfer R9 to wheelchair, position R9 for comfort, apply foot pedals to wheelchair, place call light within R9's reach, remove filled garbage bag, remove soiled linen bag, place clean bag in garbage can and then wash CNA-D's hand followed by hand hygiene with alcohol based hand rub. On 7/12/22 at 4:31 PM, Surveyor interviewed CNA-D who indicated staff are supposed to wash hands numerous times during perineal care. CNA-D verified CNA-D should have performed hand hygiene before and after glove use and whenever moving from dirty to clean task. CNA-D stated, I didn't do those things. On 7/12/22 at 4:38 PM, Surveyor interviewed Director of Nursing (DON)-B. Following discussion of the above two situations, DON-B indicated facility expectation was that staff were to wash hands before and after glove use, change gloves with hand hygiene between and always hand hygiene when moving from dirty to clean tasks.

Based on interview and record review, the facility did not provide adequate monitoring for the medication regimen of 2 Residents (R) (R24 and R13) of 5 sampled residents reviewed for unnecessary medications. R24 was receiving [CONDITION(S)] medications and the facility did not ensure R24 received a gradual dose reduction, unless clinically contraindicated, in an effort to discontinue these medications. R13 had a physician's order for PRN (as needed) [MEDICATION(S)] (a [CONDITION(S)] medication used to treat anxiety and restlessness) beyond the 14 day required limit. The facility did not ensure R13's physician reviewed for extension of order as required. 1. R24 was admitted to the facility on [DATE] with diagnosis to include but not limited to: Dementia, Major Depressive disorder, Anxiety, [CONDITION(S)], [CONDITION(S)] and was admitted to hospice services on [DATE]. R24's Minimum Data Set (MDS) assessment dated [DATE] stated R24's Brief Interview for Mental Status (BIMS) score was ,d+[DATE] which showed no cognitive impairment. On [DATE], the Surveyor reviewed R24's physician orders which included: [MEDICATION(S)] 10 milligrams (MG) tablet oral daily 8:00 AM for Anxiety and depression. [MEDICATION(S)] 25 MG tablet 12.5 MG oral daily 8:00 AM for depression. [MEDICATION(S)] 50 MG tablet 50 MG oral every bedtime 8:00 PM for depression. The medication listed are categorized as [CONDITION(S)] medications, which under federal regulation require attempts to gradually reduce the dose unless clinically contraindicated. The Surveyor reviewed the Consultant Pharmacist's Medication Regimen Review dated [DATE]. Recommendation was sent to the physician to attempt a gradual dose reduction (GDR) on R24's [MEDICATION(S)] 12.5 MG, [MEDICATION(S)] 50 MG and [MEDICATION(S)] 10 MG. On [DATE] hospice reviewed R24's mood, behaviors and other documentation which would indicate any clinical contraindication and documented support of GDR recommendation. On [DATE] the physician signed the Note to Attending Physician/Prescriber that listed recommendation by the pharmacist and hospice for the GDR. No orders were obtained by the facility nor was the GDR started for R24. On [DATE] at 2:00 PM, the Surveyor interviewed the Director of Nursing (DON)-B who explained a call was placed to the physician to obtain order to begin the GDR for R24. 2. On [DATE], Surveyor reviewed R13's medical record. R13 was admitted to the facility on [DATE] with diagnoses to include [CONDITION(S)] Disorder (a serious mental illness characterized by extreme mood swings) and Unspecified Dementia (a group of symptoms associated with a decline in memory severe enough to reduce a person's ability to perform everyday activities) with Behavioral Disturbance. R13's medical record contained the following physician's order which started [DATE]: ~ [MEDICATION(S)] 2mg/1ml (milligrams per milliliter) solution give 0.25ml = 0.5mg po (orally) every hour as needed restlessness, anxiety R13's medical record did not contain documentation to indicate required 14 day stop date for the above PRN order. R13's medical record did not contain documentation of physician review to indicate need to extend order beyond required 14 day limit. On [DATE] at 1:01 PM, Surveyor interviewed Director of Nursing (DON)-B when DON-B provided Surveyor with the following documents: ~ Prescription dated [DATE] which included, .[MEDICATION(S)] (brand name for [MEDICATION(S)]) 2mg/1ml: Give 0.25ml po/sl (orally or sublingually (under the tongue)) Q (every) 1 HR (hour) for restlessness/PRN anxiety dispense #60, fill 30 ml per fill . ~ Physician Orders for Hospice Patient dated [DATE] which indicated name of nurse receiving verbal order, was unsigned by physician, contained a fax stamp in upper left corner of JUL-,d+[DATE] ([DATE]) 10:58 (10:58 AM) From: [named Hospice company] and stated, [MEDICATION(S)] Instructions: 2mg/ml liquid solution. Give 0.25 ml Q 1 hour PRN for anxiety restlessness for duration of life. DON-B verified above Physician Orders for Hospice Patient was not on R13's medical record until faxed to facility on [DATE]. DON-B verified facility did not alert R13's physician of 14 day required limit for PRN [CONDITION(S)] medications in [DATE] when order was received or when 14 day limit would have expired.

Based on observation and staff interview, the facility did not ensure hand hygiene was offered to Residents (R) before meal service for 5 (R14, R33, R34, R35, and R36) of 37 residents at the facility. R14, R33, R34, R35, and R36 were not offered hand hygiene before lunch meal service on 6/7/2021. Findings include: On 6/7/21 beginning at 11:29 AM, Surveyor observed Certified Nursing Assistant (CNA)-G transporting residents to unit dining room. Surveyor observed a container of hand sanitizing wipes on counter of kitchenette but no staff picked up container to offer hand hygiene to residents prior to meal delivery to tables. Surveyor observed R14, R33, R34, and R36 were transported and not offered hand hygiene. R36 was provided full eating assistance by staff. R33 ate barbeque chicken and corn on the cob with R33's hands. On 6/7/21 at 11:46 AM, Surveyor followed CNA-G to R35's room for meal tray delivery. CNA-G did not offer hand hygiene to R35 at the time of meal delivery. At 12:03 PM, Surveyor interviewed CNA-G who confirmed hand hygiene was supposed to be offered to residents before meals but was not on 6/7/21. CNA-G verified the facility had hand sanitizing wipes in the kitchenette/dining area for residents who ate in the dining room. CNA-G was uncertain what type of hand hygiene should be offered to residents who ate in rooms and commented that perhaps a washcloth could be utilized.

Based on staff interview and record review, the facility did not ensure background checks were completed every four years for 1 employee (Certified Nursing Assistant (CNA)-I) of 8 employees reviewed for background checks. The facility did not completed a background check for CNA-I since 2016. Findings include: On 6/8/21, Surveyor reviewed a sample of employee background checks. CNA-I's most recent Background Information Disclosure (BID) was dated 3/29/2016. CNA-I's Department of Justice (DOJ) and Integrated Background Information System (IBIS) checks were dated 4/8/2016. On 6/8/21 at 2:23 PM, Surveyor interviewed Human Resources (HR)-C about background checks. HR-C verified background checks must be completed at least every four years for employees and explained the facility began running background checks every other year to help ensure all employee's checks are completed timely. HR-C was not able to explain why CNA-I's background check was more than four years old and confirmed CNA-I's background check should have been done more recently than 2016.

Based on record review and staff interview, the facility did not ensure each resident's attending physician documented in their medical record that an irregularity had been identified in the resident's medication regimen and what actions were taken to address the irregularity for 1 Resident (R) (R4) of 5 sampled residents. The facility failed to update R4's physician with the consulting pharmacist's recommendations. Findings include: On 6/9/2021, the Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] with diagnoses to include [CONDITION(S)], dementia, coronary artery disease and [CONDITION(S)] (stroke-like attack). R4's most recent MDS (Minimum Data Set) dated 3/2/2021 documented R4 had a BIMS (Brief Interview for Mental Status) score of 12/15 indicating moderately impaired cognition. R4's medical record contained the following physician's orders: [MEDICATION(S)] (an antidepressant) 50 milligrams (mg) daily [MEDICATION(S)] XL (an antidepressant) 150 mg twice daily The Surveyor noted a Pharmacy Consultation Report dated 03/04/2021 that stated, (R4) receives [MEDICATION(S)] and [MEDICATION(S)] The Pharmacy Consultation Report further documented that R4 was receiving multiple antidepressants for depression concomitantly (at the same time) without documentation in the medical record of an inadequate response to monotherapy (use of a single drug to treat a disease or condition) recommending R4's physician consider a dose reduction in either of the antidepressants and a) if this therapy is to continue, it is recommended that the prescriber document an assessment of the risk versus benefit, indicating that it continues to be a valid therapeutic intervention for this individual; and b) the facility interdisciplinary team ensure ongoing monitoring for effectiveness and potential adverse consequences such as changes in appetite and falls. Rationale for recommendation includes: Evidence for the effectiveness and safety of combined antidepressant medications is limited and should only be used in certain situations. The form did not contain MD (Medical Doctor)-H's signature nor did the form contain instructions to indicate whether or not MD-H wished to change R4's medication regimen or contain rationale for not changing the regimen. On 06/09/2021 at 2:03 PM, the Surveyor interviewed Nursing Home Administrator (NHA)-A regarding the Consultation Report. NHA-A verified the Consultation Report was not signed by R4's physician. NHA-A further indicated the Consultation Report had not been forwarded to R4's physician at the time it was received by the facility and that the facility would forward the report to R4's physician at this time.

Based on observation, staff interviews and record review, the facility did not ensure a Resident (R) with a Deep Tissue Injury (DTI) received care and services to treat the pressure injury for 1 (R24) of 3 sampled residents reviewed for pressure injuries. The facility did not ensure R24's heels were not in shoes and free floated or in a heel protector when R24 was resting in a recliner. Findings include: Certified Nursing Assistant (CNA) communication sheet, dated 6/9/21, documented R24 had a suspected DTI to bottom of right heel. Care instructions included: no shoes at any time; grippy socks only; float heels. R24's in room care plan documented R24 was to have a heel protector to right heel. Surveyor noted in room care plan did not address shoe use. On 6/7/21 at 10:40 AM, Surveyor observed hospice Registered Nurse (RN)-J provide [MEDICATION(S)] treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . R24 was seated in recliner at the time of observation with heels free floating. On 6/9/21 at 9:52 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-E regarding R24's DTI. LPN-E explained that R24's DTI was first discovered by a night nurse and the area almost looked like a bruise. The facility stopped using shoes for R24 except for during mechanical lift assisted transfers. R24 wore grippy socks all the time so R24's feet wouldn't get cold. On 6/9/21 at 10:42 AM, Surveyor observed R24 seated in recliner in R24's room. R24 was wearing shoes with feet on the ground. R24's upper body was leaning to the right and R24's was sleeping. At 10:45 AM, Surveyor located and interviewed CNA- F. CNA-F verified being the staff person who assisted R24 to R24's recliner. CNA-F indicated being aware of R24's DTI on right heel but not aware of care plan not to wear shoes. CNA-F showed Surveyor R24's care plan, which was posted in R24's room behind the entry door. CNA-F reviewed R24's care plan with Surveyor. R24's care plan did not document shoes should be off unless transferring but did document a heel protector was to used for right heel. CNA-F used walkie-talkie to communicate with LPN-E. At 10:52 AM, LPN-E arrived at R24's room and verified R24's shoes should be off and heels should be free floated when in recliner. LPN-E explained to CNA-F that R24's shoes should only be in use during transfers. While CNA-F removed shoes and searched for heel protector without success. CNA-F proceeded to free floated R24's. LPN-E directed CNA-F how to obtain a heel protector for R24. LPN-E then explained to Surveyor that LPN-E discussed shoe use with hospice RN-J on 6/7/21 and both were in agreement that R24 should not wear shoes unless transferring.

Based on staff interview and record review, the facility did not ensure the facility assessment was reviewed and updated at least annually. This had the potential to effect all 37 residents. The facility did not review and update the facility assessment since 12/12/2019. Findings include: On 6/9/21 at 3:55 PM, Nursing Home Administrator (NHA)-A provided Surveyor with most recent facility assessment review dated 12/12/2019. Surveyor noted the average daily census at the time of most recent assessment was 65 to 80 residents. Census at the time of investigation was 37 residents. NHA-A explained the facility thought Centers for Medicare & Medicaid Services (CMS) had waived annual review and updates for facility assessment requirements in light of the federal health emergency (COVID-19 pandemic) and required review every two years during that time.

Based on observation, staff interview, and record review, the facility did not ensure food was held and reheated to safe temperatures. These practices had the potential to affect 25 or more residents of 64 total residents in the facility. Unit C and D kitchenette mashed potatoes were 132 degrees Fahrenheit (F) when placed in the steam table for hot holding. No corrective action was taken to reheat to a safe temperature prior to hot holding. 25 residents resided on units C and D. Units A, B, C, and D kitchenettes puree foods were microwave reheated to 140 degrees in one unit and no temperature was taken after microwave reheating on another unit. Neither unit covered the product and waited 2 minutes for the temperature to equalize prior to taking temperatures. 49 total residents resided on units A, B, C, and D. Findings include: On 7/22/19 at 9:13 AM, Dietary Manager (DM)-B indicated to Surveyor that the facility kitchen utilized the Wisconsin (WI) Food Code as its standard of practice. WI Food Code (YEAR) documents: 3-403.11 Reheating for Hot Holding. (A) Except as specified under ¶¶ (B), (C), and (E) of this section, POTENTIALLY HAZARDOUS FOOD (TIME/TEMPERATURE CONTROL FOR SAFETY FOOD) that is cooked, cooled, and reheated for hot holding shall be reheated so that all parts of the FOOD reach a temperature of at least 74°C (165°F) for 15 seconds. P (B) Except as specified under ¶ (C) of this section, POTENTIALLY HAZARDOUS FOOD (TIME/TEMPERATURE CONTROL FOR SAFETY FOOD) reheated in a microwave oven for hot holding shall be reheated so that all parts of the FOOD reach a temperature of at least 74°C (165°F) and the FOOD is rotated or stirred, covered, and allowed to stand covered for 2 minutes after reheating On 7/22/19 at 11:41 AM, Surveyor observed DC-C taking hot holding temperatures of lunch meal foods on kitchenette for units C an D and noted the Food Temperatures for Hot and Cold Foods log documented a safe hot holding temperature of over 140 degrees F. The mashed potatoes were 132 degrees F. At that time, Surveyor interviewed DC-C about holding temperatures. DC-C indicated a goal of 140 degrees for hot holding. No action was taken at this time to reheat foods to a safe temperature. At 12:02 PM, DC-C indicated the pureed foods (no temperatures taken earlier of these) were below temperature and DC-C microwave reheated pureed pork steak and pureed green beans. When the microwave process was complete, DC-C removed the pureed food from the microwave and without covering or waiting two minutes, took the temperature which was 140 degrees F. DC-C indicated 140 degrees was the goal temperature and sent the food out for service. On 7/22/19 at 12:15 PM, Surveyor observed DC-D in kitchenette serving units A and B. DC-D was microwaving pureed corn which DC-D removed from the microwave and immediately trayed for service. Surveyor intervened and requested a temperature. DC-D indicated to Surveyor the pureed corn was cool to the touch prior to microwaving which is why DC-D microwaved the food. DC-D did not cover or wait 2 minutes for the temperature to equalize before taking the puree corn temperature. DC-D said, The temperature's jumping around. while attempting to take the temperature. DC-D explained microwaving was not a usual practice during lunch meal service but the container was cool to the touch so DC-D knew it wasn't the right temperature which is why the microwave was used. On 7/24/19, the facility provided the Food Temperatures for Hot and Cold Foods log from the kitchenette for units C and D. Surveyor noted mashed potatoes and pureed foods were not logged.