Every finding on record at Villa Marina Health and Rehabilitation Center

Based on record review and interview, the facility did not ensure to accurately code the Minimum Data Set (MDS) assessments for 1 of 5 sampled residents (R) reviewed. (R54) The facility did not complete a discharge MDS when R54 was discharged from the facility on 04/03/26. This is evidenced by:The facility policy titled MDS Completion and Submission Timeframes with the revised date of September 2010 documented The Assessment Coordinator or Designee shall be responsible for entering that resident assessments are submitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current federal and state guideline.Discharge Assessment - return not anticipated: the facility has the discharge date plus 14 calendar days to complete the assessment and then an additional 14 calendars to send the transmission to CMS.R54 was admitted to the facility on [DATE] and discharged on 04/03/26.R54's medical record documented MDS was completed on 02/24/26 an entry assessment and on 03/02/26 a scheduled 5-day assessment. The computer system documented Discharge Assessment Late OBRA ARD DUE DATE: 04/03/2026 Completion Due Date: 04/17/2026. On 04/03/2026 at 12:41 PM, R54's nursing progress notes documented discharge: [R54] is discharged home today via his sister and brother-in-law. All belongings packed up and left with resident. On 07/07/26 at 7:41 AM, Surveyor interviewed Registered Nurse (RN) G, the MDS coordinator asking if R54 should have a discharge MDS completed when discharged on 4/3/26. RN G stated when R54 was discharged RN G was off and should have been caught when they returned to work. RN G checked the computer system and verified the discharge MDS was not completed. RN G checked their record keeping of planned discharges and R54 was not on the list of planned discharges. RN G stated that when the computer system discharges a resident the MDS report the computer system generates would not have discharges to be scheduled and only goes back 31 days. RN G stated they missed doing R54's discharge MDS. On 07/07/26 at 9:12 AM, Surveyor interviewed Nursing Home Administrator (NHA) A about their discharge MDS process. NHA A indicated a discharge MDS should be completed when the discharge occurred. Surveyor reviewed with NHA A of R54's missed discharge MDS. NHA A stated there should be a process to ensure they are not missed.

Based on observation, interview and record review, the facility did not ensure that an allegation of misappropriation of money was thoroughly investigated for 1 of 2 residents (R) reviewed (R63) out of 5 sampled residents.On 05/15/26, the facility was made aware of R63's allegation of missing money. The facility did not complete interviews with all staff and residents to ensure a thorough investigation into the allegation. This is evidenced by:Facility's policy titled Resident Abuse- Prevention/Investigation with the revised date of February 2026, documented 1. The Administrator, Director of Nursing/Charge Nurse and/or the Social Worker will conduct an in-depth investigation, when the initial investigation determined that misconduct did occur or is still suspected.Interviewing other residents to determine if they have been abused or mistreated. Interviewing staff who worked the same shift as the accused to determine if they ever witnessed any mistreatment by the accused. Interviewing staff who worked previous shifts to determine if they were aware of an injury or incident.R63 was admitted to the facility on [DATE]. R63's current diagnoses of cerebral infarction and quadriplegia C5-C7. On 04/23/26, the Minimum data Set (MDS) assessment documented a Brief Interview of Mental Status (BIMS) score of 13/15, meaning cognitively intact.Review of facility's reported incident documented on Friday 05/15/26, R63 notified staff they realized between 05/02/26 and 5/15/26, they were missing cash from their envelope that they keep in their bedside drawer. On 5/18/26, Social Services Director (SSD) C was notified that the laundry staff found $60 in the dryer after washing some of R63's clothing. R63's room search was completed, staff interviewed, and police notified. SSD C spoke to R63, offering $60 as well as checking pockets of R63's clothing to ensure rest of the cash wasn't in R63's pockets. R63 declined all offered as they told SSD C that money is not his and he would have never put cash in their pockets, therefore no need to check clothing. R63 also declined another search of room. Surveyor noted the facility's investigation did not complete interviews with laundry staff and other facility staff. The investigation did not include interviews with residents to identify additional resident concerns about missing money. On 07/06/26 at 11:45 AM, Surveyor interviewed R63 about missing money. R63 stated they have no issues with money missing. Money went missing and facility reimbursed them and gave them a lock box so that they could take the key when they left the room. R63 had no idea who took the money. R63 stated it's been taken care of and has no further concerns. Never happened before or after. On 07/06/2026 1:56 PM, Surveyor interviewed SSD C about R63's report of missing money. SSD C stated they got a mix of interviews with staff and would leave the questionnaire out for staff to answer and give to SSD C. Laundry found $60.00 in the dryer with his clothes. Went to give the money to R63 and R63 stated the $60.00 was not theirs and would never put their money in pockets. R63 would not let SSD C check their room again. Didn't suspect foul play and not sure if money was left in pockets or given to family. R63 refused SSD C to contact family about the missing money. Surveyor asked SSD C if they had talked with other resident to see if they were missing money. SSD C can't recall off the top of their head if talked to other residents. SSD C talked with laundry/housekeeping supervisor about the missing money, and they were going to talk with their staff. SSD C stated would have talked to other residents but there were no other reports or grievances of missing money. R63 was reimbursed. SSD C stated Nursing Home Administrator (NHA) A talked with police when this first occurred. On 07/06/26 at 2:15 PM, Surveyor interviewed NHA A asking if the facility's investigation of missing money should have included interviews of residents to identify additional concerns. NHA A stated other residents should be interviewed. Policy and grievance reporting requires staff and residents to be interviewed. Surveyor asked if for this incident other resident interviews should be expected. NHA A stated it is expected other residents to be interviewed. On 07/06/26 at 2:53 PM, Surveyor interviewed NHA A asking if interviews with residents if they were missing money when the $60.00 was found. NHA A stated they did ask residents and staff, and no one claimed to be missing money. NHA did not write those interviews down of which residents that were asked. On 07/07/2026 at 7:25 AM, Surveyor interviewed Certified Nursing Assistant (CNA) D about facility staff asking residents if they are missing money. CNA D stated they don't know of any other residents missing money. On 07/07/2026 at 7:30 AM, Surveyor interviewed Licensed Practical Nurse (LPN) F about residents being asked about missing money. LPN F stated staff were being asked if they knew of anyone missing $60.00. They never heard of missing money being an issue and if we know a resident has money, they are encouraged to put the money in the facility account. On 07/07/26 at 8:45 AM, Surveyor interviewed SSD C about investigation of the found $60.00. SSD C stated it was assumed that it was R63's money and no other residents were asked. On 07/07/26 at 9:03 AM, Surveyor interviewed Dietary/Laundry Manager (DM) H about R63 missing money and staff being interviewed. DM H stated staff are given a form from SSD C to fill out about missing items. Staff did find money in the dryer. The dryer had R63's laundry and residents from the same wing. DM H stated can't say if all staff had filled out the forms this would be kept track by SSD C. There has been a change in staff since May, and they get trained in abuse, neglect and misappropriation of property. Not aware of residents stating to staff of missing money. On 07/07/26 at 9:37 AM, Surveyor interviewed CNA E about facility staff asking residents about missing money. CNA E stated we never had a problem of missing money. Don't think the facility asked other residents if they were missing money. There was a form for staff to fill out by SSD C about missing money.On 07/07/26 at 11:06 AM, Surveyor interviewed Director of Nursing (DON) B asking when R63 reported missing money if staff and resident interviews were completed. DON B stated staff interview sheets were started and talked with R63. SSD C keeps track of all interviews. On 07/07/26 at 11:39 AM, Surveyor interviewed NHA A about the investigation with R63's missing money and the investigation was not complete when all staff and residents were not interviewed. NHA A stated they have identified there are missing interviews and are currently working with SSD C to ensure a thorough investigation is completed.

Based on record review and interview, the facility did not conduct a Preadmission Screening and Resident Review (PASRR) Level II screen for R9, who has a serious mental disorder and is taking psychotropic medication to treat symptoms of major mental disorder to ensure they receive care and services in the most integrated setting appropriate to their needs. The facility practice affected 1 of 1 resident reviewed (R9) out of 5 sampled residents.Findings include: Surveyor reviewed the facility policy titled, PASSRR-Pre-admission Screening and Resident Review, read in part, If the potential admission has a MI (mental illness) or ID (intellectual disability) diagnosis and are coming for more than 30 days, Level I and other pertinent information will be sent to [Behavioral Consulting Services] prior to admission to conduct a Level II screen and approve admit. R9 was admitted [DATE], with diagnoses including post traumatic stress disorder (PTSD). Surveyor reviewed R9's record and noted their physician orders included Seroquel for treatment of PTSD, since their admission. Surveyor reviewed R9's record and located a Level I PASARR screening dated 05/20/26, noting R9 has a major mental disorder and has taken psychotropic medications to treat symptoms or behaviors of a major mental disorder.Surveyor reviewed R9's record and could not locate a Level II PASRR screening.On 07/06/26 at approximately 12:30 PM, Surveyor interviewed R9. R9 did not know about PASSRRs related to their admission. R9 did not report any negative outcome. On 07/06/26 at 1:50 PM, Surveyor interviewed Social Services Director (SSD) C, who is responsible in part for the facility's PASRR screening process. SSD C stated a positive PASSRR I would indicate a level II to be completed and referred to the appropriate behavioral health consulting agency. SSD C stated PTSD would be a diagnosis which would trigger a PASSRR II. Surveyor and SSD C reviewed R9's PASSRR I and SSD C stated a PASSRR II should have been completed, but she was not sure why. SSD C stated she would check R9's record and provide an update. SSD C updated Surveyor and stated R9's PASSRR II was missed and not completed, and she would correct this. On 07/07/26 at 11:30 AM, Surveyor updated Nursing Home Administrator (NHA) A of the deficient practice. NHA A agreed this was a deficient practice and did not have additional questions.

Based on interview and record review, the facility did not complete a thorough investigation of the alleged violation, maintain documentation that an alleged violation was thoroughly investigated, and prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation of an alleged violation is in progress for 1 of 3 residents (R) reviewed. (R2)The facility did not update R2's physician regarding the allegation of sexual misconduct by staff.The facility did not suspend accused staff of making inappropriate sexual statements while the investigation was being conducted.The facility did not re-educate staff regarding abuse/misconduct policies and procedures following the incidents for R2.The facility policy dated 10/15/17, titled, Resident Abuse-Prevention/Investigation, indicates: .2. The Director of Nursing (or designated representative such as the charge nurse on duty) will contact the Resident's physician.7. If a staff member is accused or suspected of abuse, mistreatment, neglect, exploitation or misappropriation of resident property, the facility will immediately remove that staff member from the facility and the schedule pending the outcome of the investigation.Villa [NAME] Health and Rehabilitation Center will provide ongoing staff training on the subject of Abuse, Neglect, Exploitation and Misappropriation of property, Injuries of Unknown Source, catastrophic reactions, burnout, and resident against resident aggression, as appropriate.R2 was admitted to the facility on [DATE], with diagnoses that included pneumonia, stroke, Lewy Body Dementia, hallucinations, amnesia, and cognitive communication deficit. R2's Minimum Data Set (MDS), dated [DATE], indicated that R2 scored a 14/15 on the Brief Interview of Mental Status (BIMS) which means R2 is cognitively intact. R2 is independent with eating and bed mobility but requires staff supervision for transfers and toileting.On 02/09/26, Surveyor reviewed the facility grievances and requested the investigation for R2's incident that occurred on 01/05/26. The investigation noted that R2 accused Registered Nurse (RN) C of offering sex to R2. Surveyor attempted to speak with R2; however, R2 declined due to not feeling well. Surveyor reviewed the facility investigation and R2's electronic health record and found no evidence that R2's physician was updated, RN C was not suspended pending the investigation, and ongoing education was not provided to all staff.On 2/9/26 at 2:35 PM, Surveyor interviewed Director of Nursing (DON) B, and asked for proof the physician was updated, proof that RN C was removed from the facility pending the investigation, and proof of ongoing education for all staff regarding abuse. DON B stated the doctor was not updated since their investigation and the police could not substantiate the allegation occurred. Surveyor asked if it was possible the allegation could have been a decline in R2's condition which DON B agreed it could have and agreed the doctor should have been notified. DON B reported RN C was in the office and had no resident contact, and they were able to complete the investigation within 2 hours, therefore they did not feel it was necessary for RN C to be suspended. Surveyor asked DON B how they could prove RN C was in the office and not posing a risk for other residents during the time of the investigation. DON B stated she cannot prove it because RN C was still punched in at the time. DON B voiced understanding of the importance of the accused staff to be out of work status and removed from the building. Surveyor asked why there was not on-going education for all staff regarding abuse following the incident. DON B stated she did not feel it was necessary since the allegation could not be substantiated, however agrees that re-education would be beneficial.

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, are reported immediately to other officials including the State Agency (SA) in accordance with State law through established procedures for 1 of 3 sampled residents (R). (R1)The facility did not report R1's injury of unknown origin within two hours, as the allegation involved potential abuse.The facility did not submit the misconduct incident reportwith investigation findings for R1 within five business days of discovery of the incident. The facility did not report allegation of sexual abuse to R2 within two hours to the SA.The facility did not submit the misconduct incident report with investigation findings for R2 within 5 business days of the allegationThe facility policy titled, Resident Abuse - Prevention/Investigation, dated 10/15/17, states, Villa [NAME] Health and Rehabilitation Center requires all staff to report any suspicion of abuse, neglect, exploitation or misappropriation including suspicious bruising, occurrences, patterns and trends that may constitute abuse immediately to the Administrator or designee to determine the direction of the investigation. In doing so will ensure all alleged violations involving mistreatment, neglect, or abuse or exploitation including injury of unknown source, and misappropriation of resident property are reported.R1 was admitted to the facility on [DATE], with diagnoses that included respiratory failure, heart failure, bone cancer, and pleural effusion (fluid around the lungs). R1's Minimum Data Set (MDS), dated [DATE], included a Brief Interview of Mental Status (BIMS) score of 13/15, which indicates R1 has intact cognition. R1 was dependent on staff for eating, bed mobility, transfers, and toileting and used a wheelchair for mobility and a mechanical lift for transfers. On 02/09/26, Surveyor requested and reviewed the complete self-report. The self-report noted that on 08/30/25 at around 11:00 AM, R1 was found with dark purple bruising (5 inches by 2-3 inches) on left ribs from armpit into ribcage. The final report had a submission date of 11/17/25, which is not within the 5-day reporting requirement.On 02/09/26, Surveyor reviewed facility grievances and discovered that R2 accused Registered Nurse (RN) C of trying to have sex with R2. Surveyor requested the complete investigation and found no evidence that the allegation was reported to the State Agency.R2 was admitted on [DATE] with diagnoses that include pneumonia, stroke, Lewy Body, hallucinations, amnesia, and cognitive communication deficit. R2's MDS, dated [DATE], shows a BIMS score of 14/15 indicating intact cognition, is independent with eating and bed mobility, and requires supervision/touch assistance with transfers and toileting. On 02/09/26 at 2:30 PM, Surveyor interviewed Social Worker (SW) D and asked why R1's injury of unknown origin final report was not submitted within the 5-day requirement. SW D stated that SW D is new to the position (less than 3 months) and the previous Social Worker did not ensure it was completed. Surveyor asked SW D why the sexual misconduct allegation was not reported to the State Agency. SW D stated they felt the entire investigation was completed within the 2-hour timeframe, R1 has a diagnosis of Lewy Body Dementia, and the police did not feel it was substantiated, therefore SW D felt it was not necessary.On 02/09/26 at 3:32 PM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked what the reporting expectation would be for R1's injury of unknown origin and R2's sexual misconduct report. NHA A stated that both should have been reported within 2 hours and the final report submitted within 5 days. When asked for the supporting documentation, NHA A stated R1's report to the State Agency was extremely late and they did not report R2's allegation at all which should have been reported.

Based on observation, interview and record review, the facility did not prepare, distribute and serve food in accordance with professional standards for food service safety for 64 of 64 residents resulting in possible contamination of all residents' food.Facility staff did not wear gloves during preparation and serving of food,Facility staff did not perform hand hygiene and don new gloves after touching contaminated surfaces. This is evidenced by:The facility policy titled, Handling Raw Foods, updated 06/25/2012, states in part, Plastic food service gloves will be worn .when hands will be in direct contact with food and for preparing food to eat .Single use gloves will be used for only one task, used for no other purpose and discarded when damaged, soiled or interruptions occur in operation. Regulations also state in part: Cross-contamination can occur when harmful substances, i.e., chemical or disease-causing microorganisms are transferred to food by hands (including gloved hands), food contact surfaces, sponges, cloth towels, or utensils that are not adequately cleaned .Food preparation or service area problems/risks to avoid include .handling food with bare hands .staff distributing meals without first properly washing their hands.On 09/16/2025 between 7:34 AM and 8:00 AM, Surveyor observed:Dietary [NAME] (DC) H distributed food into dishes wearing a glove on right hand only, while left hand remained gloveless. DC H touched utensils, clean bowls and kitchen counter surfaces with both hands during food distribution. DC H walked around kitchen touching several countertop and equipment surfaces and returned to distributing food into dishes without removing contaminated glove, performing hand hygiene, or donning new gloves. During breaks in serving food, DC H wiped surrounding kitchen surfaces with a dish cloth while wearing same glove on right hand. DC H used both hands while wiping surfaces with dirty dish cloth. DC H did not remove contaminated gloves or perform hand hygiene prior to resuming food distribution into clean dishes. DC H touched clean dishes with both hands. DC H grabbed muffins with ungloved hand and placed on plates. DC H coughed into ungloved hand and then resumed serving food without performing hand hygiene and donning new gloves. DC H walked away from food distribution area, grabbed a pan of potatoes, opened oven door and placed potatoes in oven while wearing same glove on one hand. No hand hygiene was performed prior to returning to food distribution, and DC H was wearing same contaminated glove.During food distribution, DC H moved to stove and cracked eggs into a frying pan while wearing same glove. DC H did not perform hand hygiene before or after food preparation and returned to food distribution. DC H removed glove and left kitchen, walked into dining area to talk to a resident, touched resident on shoulders, then went back into kitchen without performing hand hygiene or donning new gloves to resume food preparation and serving. On 09/17/2025 at 3:25 PM, Surveyor interviewed Dietary Manager (DM) I and asked what dietary staff expectations are during food preparation and serving. DM I stated staff should always perform hand hygiene and wear gloves on both hands when prepping and serving foods. DM I stated gloves should be changed and hand hygiene performed if any surface area other than the food, or dishes food is placed into, is touched.

Based on observation, interview and record review, the facility did not maintain an infection prevention program designed to provide a safe and sanitary environment to prevent the transmission of communicable disease and infection. This had the potential to affect 9 of 64 residents. (R3, R32, R14, R43, R48, R58, R12, R46 and R51) Staff did not perform hand hygiene during water pass and in between residents. This had the potential to affect 7 of 7 residents (R) observed during water pass (R3, R32, R14, R43, R48, R58, R12). Staff did not maintain a clean environment during dressing change. This had the potential to affect 1 out of 2 residents (R) observed for wound care (R46). Observation of medication administration for 1 (R51) of 3 residents found the facility did not implement appropriate infection prevention and control practices during medication administration which could have caused contamination of a medication bottle upon opening. Example 1 Findings include: Facility's policy titled, Handwashing/Hand Hygiene states in part, Indications for Hand Hygiene 1. Hand Hygiene is indicated: .e. after touching the residents' environment. On 9/15/2025 at 2:06 PM, Surveyor observed Certified Nursing Assistant (CNA) G delivering fresh clean water cups and removing used water cups, without performing hand sanitization in between rooms and/or clean to used cups. CNA G passed clean water cups and removed used cups in R3, R32, R14, R43, R48, R58, and R12's rooms before Surveyor stopped her. Surveyor interviewed CNA G, who reported she usually does practice hand hygiene in between residents and forgot. CNA G explained she has worked 5 days in a row. On 9/17/2025 at 9:58 AM, Surveyor interviewed Registered Nurse (RN) C, who stated the expectation would be hand hygiene be performed after touching used (dirty) water cups and before touching/delivering clean water cups and after entering a resident's room before going into the next resident room. Example 2 Facility's procedure document titled, Dressings, Dry/Clean, which states in part, 1.Establish a clean field. 2. Place the clean equipment on the clean field .11. Using clean technique, open other products. R46 was admitted on [DATE] with diagnoses including, in part, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene, unspecified fall, subsequent encounter, muscle weakness (generalized). R46's most recent Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 15/15 indicating R46 is cognitively intact. R46 required substantial assist from staff for some activities of daily living (ADLs). R46's orders include, in part, Wound care to right knee (Wound #1) . Change daily. Wound care to left second Toe (Wound #2) . Change three times weekly. RN C reported R46's wounds to knee and toes are a result of trauma following a fall in her home prior to admission. On 9/16/2025 at 8:34 AM, Surveyor observed wound care performed by Licensed Practical Nurse (LPN) F with RN C present. LPN F removed R46's dressing. Surveyor noted wound bed with red granulation tissue, edges defined, and no signs or symptoms of infection. LPN F cleansed wound. Surveyor observed LPN F apply ointment to the wound bed with a tongue blade, which was not kept in clean environment and not wrapped to keep the applicator in a clean environment. During R46's dressing change, Surveyor observed LPN F set the hand sanitizer bottle and wound cleanser bottle directly on the floor, and after setting bottles in the unclean area, continued to touch the bottles with clean gloves to continue with R46's wound care. On 9/16/2025 at 9:05 AM, Surveyor interviewed LPN F about setting bottles used during wound care directly on floor. LPN F stated she realized there was cross contamination when using her clean gloves to touch the hand sanitizer bottle and then continuing to provide R46's wound care. Surveyor observed tongue blades are kept uncovered and on the outside of the medication cart for that entire wing. LPN F reported she did ask for individually wrapped tongue blades and has not yet received them. LPN F verbalized agreement that there is a potential for contamination to the uncovered tongue blades left out on the medication cart. On 9/16/2025 at 9:14 AM, Surveyor interviewed Infection Preventionist, RN C. RN C stated she did see the sanitizer bottle and wound wash be placed directly on the floor and verbalized this is considered an unclean surface. RN C stated her expectation would be that a clean environment be maintained during wound cares. Surveyor interviewed RN C about the tongue blades that are left uncovered on medication cart and used to apply ointment directly onto R46's wound. RN C verbalized the potential for infection, and shortly after interview, RN C returned with individually wrapped tongue blades and replaced the open ones on the medication cart. Example 3 Facility policy, titled Handwashing/Hand Hygiene under Promoting Healthy Hand Skin and Fingernails, updated 10/2023, states in part, Personnel with direct-care resident responsibilities should maintain short, natural fingernails .fingernails should not extend past the fingertips. Facility policy also indicates all personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. On 09/17/2025 at 7:43 AM, Surveyor observed LPN E administer medications to R51. LPN E performed hand hygiene, then proceeded to prepare R51's medications. LPN E opened and distributed medications from the medication cart for R51. LPN E retrieved R51's Lactulose (a laxative medication given for constipation) from a medication drawer that contained medications in larger bottles. The Lactulose for R51 was in a new, unopened bottle. The opening of the Lactulose bottle contained a foil seal covering, as packaged by the pharmaceutical company for safety. LPN E attempted to remove foil seal by peeling it back with fingers. LPN E was not successful in removing foil seal. Without performing a repeat hand hygiene, LPN E used own thumbnail to puncture foil seal on bottle opening. LPN E's thumbnail was approximately one half inch longer than its nailbed and entered part ways into bottle, touching the remaining foil seal and rim of bottle. Remnants of foil seal remained on Lactulose bottle. LPN E poured Lactulose through foil seal remnants into a medication cup. LPN E administered the Lactulose to R51. On 09/17/2025 at 2:15 PM, Surveyor interviewed Infection Preventionist, RN C, and asked what the facility standard is for opening a new medication bottle containing a foil seal to maintain infection control practice and avoid contamination. RN C stated that if unable to peel back a foil seal with fingers, RN C would suggest using bandage scissors which have been wiped down with an alcohol wipe and allowed to air dry and puncture the foil seal with them. After doing hand hygiene, RN C stated then if needed, remove any remaining foil with fingers while avoiding entering bottle, or touching rim of bottle.

Based on record review and interview, the facility did not provide Notice of Bedhold, Notice of Transfer and/or did not notify the Ombudsman of a resident who was transferred from the facility to a hospital for 3 of 4 residents (R) (R4, R11 and R76). Evidenced by:The facility provided Surveyor with a one-page document titled Notice of Transfer or Discharge, which is a blank document that is provided to the residents/resident representatives upon transfer or discharge that explains the reason for transfer/discharge and an area for resident/representative signature and indicated this was the facility's policy. On 05/15/25, R76 was admitted to the facility and discharged home on [DATE]. R76 received a Notice of Transfer, but the Ombudsman was not notified of the discharge. On 08/04/25, R11 was admitted to the facility and discharged home on [DATE]. R11 received a Notice of Transfer, but the Ombudsman was not notified of the discharge. On 08/20/25, R4 was admitted to the facility and was transferred to the hospital on [DATE] for change in condition. Record review shows that R4 declined a bedhold, but did not receive a Notice of Transfer. On 09/16/2025 at 1:46 PM, Surveyor interviewed Nursing Home Administrator (NHA) A and Social Services Director (SSD) D, regarding supportive documentation of Notice of Transfer and Ombudsman Notification being completed for above residents. NHA A stated she was unable to provide supportive documentation or information requested. NHA A stated transfer/discharge information was being sent to Ombudsman at this time.

Based on interview and record review, the facility did not describe building water systems using a flow diagram where legionella and other opportunistic waterborne pathogens can grow and spread. This has the potential to affect all 70 residents in the facility. This is evidenced by: The facility policy, entitled, Water Management Program to Reduce Legionella Growth & Spread, indicates, in part, Our facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella . 1. Legionella can grow in parts of building water systems that are continually wet ., and certain devices can spread contaminated water droplets via aerosolization. 2. Legionellosis outbreaks are generally linked to locations where water is held or accumulates and pathogens can reproduce . The Center for Disease Control and Prevention (CDC) guidelines, entitled Controlling Legionella in potable water systems, last reviewed March 15, 2024, states in part: Flush low-flow piping runs and dead legs at least weekly and flush infrequently used fixtures (e.g., eye wash stations, emergency showers) regularly as-needed to maintain water quality parameters within control limits. On 07/24/24 at 12:21 PM, Surveyor reviewed the facility's Water Management Plan (WMP) and did not find a record of maintenance, inspections, or flushing of areas of concerns that required flushing. Surveyor did not observe a flow diagram or WMP with locations of hotspots/stagnation areas deemed high risk areas of Legionella growth. On 07/24/24 at 1:04 PM, Surveyor interviewed Maintenance Staff (MS) O who provided flow sheets where water temperatures are checked and explains interventions if temperatures are not met. Surveyor asked MS O for the diagram showing distinct quality control measures where stagnation/hot spots are located throughout the facility and the flow of water. MS O was unable to locate any diagram and reported Maintenance Director was called and said they do not have one. On 07/24/24 at 1:34 PM, Surveyor interviewed Nursing Home Administrator (NHA) A and was informed the facility did not have a diagram to prevent legionella that identifies areas of potential stagnation or hot spots and what control measures are in place. NHA A stated NHA A did not know they needed to do this and acknowledges the facility does not have this in place.

Based on observation and interviews, the facility did not ensure they distributed and served food in accordance with professional standards for food service safety. Facility did not take temperatures of food served to residents from the anytime menu; this had the potential to affect 3 residents (R9, R58, and R65) out of 70. The temperature log was not completely filled out; this has the potential to affect all 70 residents. Temperatures of beverages served were not being done; this has the potential to affect all 70 residents. Findings include: Facility policy titled Food Temperatures reads in part Food temperatures will be taken and recorded when food removed from oven or refrigerator at start of food service at each meal. Temperatures will be recorded on Food Temperature Record at each meal. On 07/23/24 at about 11:17 AM, Surveyor observed [NAME] L taking temperatures of food on the steamtable and documenting the temperatures. Surveyor observed the tray line for lunch. Surveyor observed [NAME] L plate up at separate times 2 hamburgers which were retrieved from the steamer and served without checking the temperature of the hamburger patties. Surveyor observed [NAME] L put prepackaged macaroni and cheese on a plate in the microwave to heat the food. [NAME] L served the macaroni and cheese without taking temperature of the macaroni and cheese. These items were being prepared for R9, R58, and R65. On 07/23/24 at about 12:05 PM, Surveyor interviewed Dietary Manager (DM) K and asked if they take temperatures of the anytime menu items that residents order like hamburgers. DM K indicated generally no, we should be, though everything is pre-cooked. Surveyor asked DM K if the kitchen staff takes temperature of juice. DM K indicated they do not; once it is poured they put it into the cooler and bring it out just before serving. Surveyor reviewed the Food Temperature Record for the month of July 2024. On 07/04/24, there were no temperatures recorded for breakfast meal, lunch or supper. On 07/16/24, there were no food temperatures recorded for breakfast or lunch. On 07/18/24, there were no food temperatures documented for breakfast or lunch. There is a spot for milk temperature, but no documentation on the records and no spot for juice to be documented. On 07/23/24 at about 2:09 PM, Surveyor interviewed Nursing Home Administrator (NHA) A and told NHA A about Surveyor's observations. NHA A indicated all food should have temperatures checked to ensure safety.

Based on observation, interview and record review, the facility did not maintain confidentiality of resident medical record information for 4 of 7 sampled and supplemental residents (R) (R55, R25, R70, and R1) reviewed. This is evidenced by: Surveyor requested and reviewed the facility policy titled Security of Medication Cart dated April 2007. The policy in part reads: ~2. The medication cart should be parked in the doorway of the resident's room during the medication pass. The cart doors and drawers should be facing the resident's room . Surveyor requested and reviewed the facility policy titled Annual HIPAA Privacy and Security Training dated 2014. The training document in part reads: ~indicates that staff should make HIPAA Compliance a daily habit by locking computers when stepping away from staff's desks and turning over sensitive documents when stepping away . On 07/23/24 at 6:33 AM, Surveyor observed medication administration performed by Registered Nurse (RN) C. RN C prepared R55's medications and left the medication cart. Surveyor observed medication cart facing the hallway to the common area and computer open with R55's medical record on the screen. RN C entered R55's room and administered medications to R55. On 07/23/24 at 6:38 AM, RN C exited R55's room and walked to medication cart. RN C proceeded down hallway to the next room for medication administration. On 07/23/24 at 6:40 AM, Surveyor observed medication administration performed by RN C. RN C prepared R25's medications and left the medication cart. Surveyor observed medication cart facing the hallway to the common area and computer open with R25's medical record on the screen. RN C entered R25's room and administered medications to R25. On 07/23/24 at 6:49 AM, RN C exited R25's room and walked to medication cart. RN C proceeded down hallway to the next room for medication administration. On 07/23/24 at 6:51 AM, Surveyor observed medication administration performed by RN C. RN C prepared R70's medications and left the medication cart. Surveyor observed medication cart facing the hallway to the common area, computer open with R70's medical record on the screen. RN C entered R70's room and administered medications to R70. On 07/23/24 at 6:58 AM, RN C exited R70's room and walked to medication cart. Surveyor interviewed RN C and asked what expectation was for keeping residents' medical records confidential. RN C indicated that RN C should have minimized the medical record in between administering medications and that RN C had left the computer screen open and shouldn't have. On 07/24/24 at 7:13 AM through 7:34 AM, Surveyor observed R1's enteral feeding performed by Licensed Practical Nurse (LPN) F, treatment nurse. Surveyor observed LPN F leave computer open with treatment cart facing the hallway for others to visualize the computer screen and entered R1's room. Surveyor observed LPN F leave the treatment cart with R1's medical information open while LPN F was in R1's room completing treatment. On 07/24/24 at 11:37 AM, Surveyor interviewed Director of Nursing (DON) B and asked expectation for keeping resident medical records confidential during medication administration. DON B indicated that expectation is that all staff when leaving the medication cart minimize or exit out of the electronic health record when leaving the medication cart to protect resident's privacy.

Based on observation and interview, the facility did not ensure all drugs and biologicals were stored and labeled in accordance with currently accepted professional principles and did not ensure only authorized personnel had access to medication carts. This occurred for 1 of 2 medication carts observed. Findings include: Surveyor requested and reviewed the facility policy titled Security of Medication Cart dated April 2007. The policy in part reads: -1. The nurse must secure the medication cart during the medication pass to prevent unauthorized entry. -2. The medication cart should be parked in the doorway of the resident's room during the medication pass. The cart doors and drawers should be facing the resident's room. -3. When it is not possible to park the medication cart in the doorway, the cart should be parked in the hallway against the wall with doors and drawers facing the wall. The cart must be locked before the nurse enters the resident's room. -4. Medication carts must be securely locked at all times when out of the nurse's view . On 07/23/24 at 6:51 AM, Surveyor observed medication administration performed by Registered Nurse (RN) C. RN C prepared R70's medications and left the medication cart unlocked. Surveyor observed medication cart facing the hallway to the common area, with medication cart unlocked. RN C entered R70's room and administered medications to R70. Surveyor observed medication cart unattended down the hall. On 07/23/24 at 6:58 AM, RN C exited R70's room and walked to medication cart. Surveyor interviewed RN C and asked what expectation was for making sure medications are locked and secure. RN C indicated that RN C should keep the medication cart always locked when RN C is not right beside the medication cart. On 07/24/24 at 11:37 AM, Surveyor interviewed Director of Nursing (DON) B and asked expectation for locking medication carts. DON B indicated that medication carts should be always locked unless the nurse is beside the medication cart. Surveyor indicated to DON B that RN C was observed leaving medication cart unlocked down the hallway when going into R70's room. Surveyor observed RN C in R70's room for 7 minutes without monitoring of the unlocked medication cart. DON B indicated that RN C should have locked the medication cart if it was out of RN C's sight and down the hall.

Based on observation and interview, the facility did not provide pharmaceutical services, including procedures that assure that accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident, for 1 of 1 medication rooms reviewed. The facility did not accurately label open dates on 2 of 2 resident (R25 and R73) controlled medications observed stored in the refrigerator of the medication room. The facility did not ensure destruction of controlled medication occurred timely after resident (R73) passed away in the facility April 26, 2024. Findings include: Surveyor requested and reviewed the facility policy titled Discarding and Destroying Medications dated November 2022. The policy in part reads: Schedule II, III, and IV controlled substances are disposed of in accordance with state regulations, and federal guidelines regarding disposition of controlled medications . Surveyor requested and reviewed Medication Storage Pharmacy review for the last 6 months. The pharmacy review for month of June dated 06/19/24. The medication storage review in part reads: In the fridge and medication room pharmacy review indicates that there is one undated bottle of Lorazepam concentration not dated when opened . On 07/23/24 at 8:27 AM, Surveyor toured medication room storage area with Director of Nursing (DON) B. Surveyor observed Lorazepam 2mg/ml oral concentration received from pharmacy on 05/31/24, located in the refrigerator on the door labeled with R25's identification on it for R25's use only. Surveyor observed no open date label on the bottle of Lorazepam. Surveyor also observed another bottle of liquid Lorazepam 2mg/ml oral concentration received from pharmacy on 04/17/24, labeled with a R73's information but no open date on the bottle of Lorazepam. On 07/23/24 at 8:35 AM, Surveyor interviewed DON B and asked what the process is for labeling opened bottle of liquid Lorazepam. DON B indicated that all bottles should be labeled with the open date. Surveyor asked how staff would know when the medication is expired if there was no opened label date on the bottle. DON B indicated that DON B would need to reach out to pharmacy but that normally staff would go off the date the medication was received by pharmacy. Surveyor requested policy on handling expired medications. Surveyor asked how the process works for destructing medications then if the Lorazepam was deemed to be expired. DON B indicated that staff destructs controlled medications always with two licensed individuals within 72 hours of the discontinued use. On 07/23/24 at 10:31 AM, Surveyor asked Registered Nurse (RN) E if RN E could let Surveyor into medication room to verify the Lorazepam bottles one more time. Surveyor observed R73's Lorazepam bottle to be missing out of refrigerator in the medication room. Surveyor interviewed RN E and asked what normal process is for destructing medications in a timely fashion. RN E indicated that staff would want to destruct any controlled medications right away if the medication is not being used. Surveyor asked RN E when R73 was discharged from the facility. RN E indicated that on 04/26/24, R73 had passed away and was no longer in the facility. On 07/23/24 at 10:37 AM, Surveyor interviewed DON B and asked where R73's Lorazepam medication out of fridge in medication storage room went. DON B indicated that once DON B and Surveyor found the expired Lorazepam in the refrigerator, DON B and another RN came and destroyed Lorazepam and threw in the hazard sharp container in the storage room. DON B indicated that the Lorazepam should have been destructed and removed within 72 hours after R73 had passed back in April 2024.

Based on observation, interview and record review, the facility did not ensure a resident received treatment based on current standards of practice for Gastrostomy (G) tube for 1 of 2 residents (R) with a G-tube. (R1) Staff did not check for proper placement of R1's G-tube when providing treatment and administering nutrition via G-tube. This is evidenced by: Facility policy entitled Administering medications through Enteral Tube, no revision date known, stated in part, .Verify placement of feeding tube: If suspect improper tube positioning, do not administer feeding or medication, notify the charge nurse or physician . The American Association of Critical Care Nurses, April 2016, Initial and Ongoing Verification of Feeding Tube Placement in Adults advises, .Checking Tube Location at Regular Intervals After Feedings Are Started, Unfortunately, feeding tubes can become dislocated during use. For this reason, it is necessary to monitor tube location at regular intervals while the tube is being used for feedings or medication administration. Observing for change in external tube length .Reviewing routine chest and abdominal radiography reports .Observing for changes in volume of feeding tube aspirates .Testing pH and observing the appearance of feeding tube aspirate if feedings have been off for at least 1 hour . R1 was admitted to the facility on [DATE] with diagnoses that included dysphasia and quadriplegic cerebral palsy. R1's care plan was initiated on 05/10/24, and included the following interventions: PEG TUBE: -Check placement and patency of feeding tube before each feeding or medication administration. On 07/24/24 at 7:13 AM, Surveyor observed R1's enteral feeding performed by Licensed Practical Nurse (LPN) F, treatment nurse. Surveyor observed LPN F announce LPN F's self to R1. Surveyor observed that LPN F did not check placement before flushing G-tube with 50ml of water and then started the enteral feeding of Nepro Carb Steady formula at 60ml per hour. On 07/24/24 at 7:36 AM, Surveyor interviewed LPN F and asked what the expectation is for checking placement of G-tube before starting R1's enteral feeding. LPN F indicated the facility follows physician orders. LPN F indicated there was no physician order for checking placement of the G-tube before starting enteral feeding. LPN F indicated that LPN F is from Minnesota and there are different practices in Wisconsin. LPN F indicated that since there was not a physician order, that checking placement did not need to be completed before flushing the G-tube and starting the enteral feeding. On 07/24/24 at 7:40 AM, Surveyor interviewed Director of Nursing (DON) B and asked what expectations are for checking placement of R1's G-tube before administering medications or starting enteral feeding. DON B indicated that expectation is to always auscultate, push air, and listen. Surveyor asked DON B if it was normal to not check placement due to not having a physician order. DON B indicated that we don't perform Gastric Residual Volume (GRV) by drawing back contents unless we have a physician order, but it is expected the staff always auscultate to check for placement that the G-tube is in place. Surveyor reviewed the State Operations Manual (SOM) which indicates that verifying tube placement before feedings and administering medications through feeding tube is recommended by checking Gastric Residual Volume (GRV). Surveyor observed and reviewed facility policy. Surveyor did not find guidance in the policy that was consistent with current standards of practice to check g-tube placement.

Based on observation, interview and record review, the facility did not ensure activities of daily living (ADL) of grooming, personal hygiene, and oral hygiene were provided for 1 of 3 residents (R425) reviewed. This is evidenced by: The facility policy entitled, Activities of Daily Living (ADL), Supporting, stated in part, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. R425 was admitted to the facility on [DATE] with diagnoses including left femur fracture, diabetes, pressure ulcer left buttock and sacrum, chronic leukemia, and severe kidney disease with ileostomy. R425's care plan was initiated on 07/11/24, and included the following: COGNITION: -Alert and oriented x3 (person, place, time) BATHING and MORNING/BEDTIME CARES: -Substantial max assist RE-POSITIONING: -Use assist of two, substantial max assist to reposition every 2 hours and as needed. -Up in chair no more than 2 hours at a time 3 times a day. ORAL CARE: -Set up/clean up, assist if needed EATING: -Independent with set up. APPROACH: -Provide setup, oversight, encouragement, cueing, physical assistance, full staff performance assistance for mobility, dressing, eating toileting, personl hygiene, oral care, and bathing as needed. TOILET USE: -Has urostomy, empty when 1/3 full. -Not always aware of bowel needs, check and change or offer toileting every 2-3 hours and as needed. -Use 2 assist to check and change due to chronic pain. TRANSFER -Stand aide with 2 assist. -Dependent. On 07/23/24 at 10:51 AM, Surveyor observed Certified Nursing Assistant (CNA) M and CNA N provide morning cares to R425. Both CNAs sanitized hands and donned appropriate personal protective equipment. CNA M applied pants around ankles, threaded catheter bag through pant leg. CNA N removed R425's gown and applied shirt. CNA M retrieved the EZ stand lift. CNA N assisted R425 to sit on the edge of the bed and applied shirt. CNA M and CNA N assisted R425 to transfer from bed to wheelchair via EZ lift. CNA N guided R425, unlocked wheels on lift and pulled R425's pants up. R425 was then lowered into the wheelchair. CNA M unhooked lift sling, moved catheter bag under R425's wheelchair, and removed the lift. CNA N doffed PPE. CNA M applied shoes and combed R425's hair, then left the room. Surveyor noted that R425 did not offer or provide oral care or wash up R425 prior to dressing him. On 07/23/24 at 11:18 AM, Surveyor interviewed R425 and asked if a bed bath was completed at all that morning. R425 stated, No. I was not washed up and cannot remember when my dentures were last brushed, but it was not today. Surveyor observed that R425 had crusty light brown matter in mustache and on chin. R425 also had moderate amount of light beige eye drainage to both eyes. On 07/23/24 at 11:34 AM, Registered Nurse (RN) H assessed R425 and noticed and cleaned R425's eyes and face. On 07/23/24 at 2:00 PM, Surveyor interviewed Director of Nursing (DON) B and asked what the expectation for morning care would be. DON B stated it is expected that the CNA is to provide partial bed baths every day unless they have a shower. Partial bed bath includes face, underarms, hands, peri area, and bottom. They are also expected to provide oral care and shaving. DON B was informed of the observation and stated R425 should not have matter in eyes or on face if recently washed up and will follow up on it.

Based on the interview and record review, the facility did not report 2 of 3 (R49, R33) potential misconduct incidents to the State's Office of Caregiver Quality (OCQ) via the State's Misconduct Incident Reporting (MIR) system immediately upon learning of the incident. Findings include: The facility's policy and procedure for Abuse Prevention, last reviewed 10/15/17, includes, in part: The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. The purpose of the policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. This will be done by: * Following actions will be taken immediately when an alleged incident of a resident has been reported. -No later than 2 hours after allegation if events cause serious bodily injury. -No later than 24 hours if events did not result in serious bodily injury. *A Misconduct Incident Report will be completed within 5 working days of the incident or date the facility became aware of the incident . Example 1 On 07/23/24 at 8:27 AM, Surveyor toured medication room storage area with Director of Nursing (DON) B. Upon touring the medication storage room, DON B divulged to Surveyor that the facility had to change a few of their processes when it came to narcotic count due to a narcotic diversion with a Licensed Practical Nurse (LPN) G back in May 2024. Surveyor asked DON B to explain what had occurred as Surveyor was unaware of the event. DON B indicated that on 05/16/24 a concerned Registered Nurse (RN) D came to DON B to discuss missing Lorazepam tablets observed from R49's medication blister pack. DON B indicated through thorough investigation it was found that LPN G had taken around 26 tablets of Lorazepam from R49's blister pack locked in medication cart. DON B indicated that at the time the facility was not storing Schedule C IV medications in a double locked area. On 07/23/24 at 10:33 AM, Surveyor interviewed DON B and asked for DON B to explain the investigative process for the missing narcotics and why the incident was not reported to Department of Health Services. DON B indicated that during investigation once it was triggered that there were missing narcotics, Nursing Home Administrator (NHA) A and DON B began their investigation and screened all residents that were on Schedule C II-V on 05/16/24. On 05/17/24, law enforcement was notified and the State Board of Nursing. DON B indicated that Department of Health Services was not notified and that DON B and NHA A did not report the narcotic diversion to the regulatory agency because they did not think they had to. NHA A indicated that NHA A followed the state regulations of Wisconsin chapter 961 and NHA A did not report the narcotic diversion to the Department of Health Services as misappropriation. 43352 Example 2 Facility policy titled Resident Abuse - Prevention/Investigation dated 10/15/2017 reads in part In addition, the facility should report any violations as appropriate to: the [NAME] County Sheriff's Department. R9 was admitted to the facility on [DATE] and has diagnoses that include type 2 diabetes, major depressive disorder, hypertension, and edema. R33 was admitted to the facility on [DATE] and has diagnoses that include dementia, deaf and anxiety disorder. On 07/11/2024, R9 reported to DON B that another resident, R33, came up to R9 and gave R9 the middle finger with an angry face and punched R9 on left upper arm. DON B talked with R9 in the evening. R9 was doing okay just confused on why that other resident, R33, hit R9. R9 was comforted to know the facility has a plan in place so it won't happen again. On 07/11/2024 at 3:48 PM, per Registered Nurse (RN) H's nursing note which read in part, Went to circle area on [R9] where [R9] was hit for monitoring [RN H] noted that [R9] had started to develop a bruise that is light purple to the area measuring 3 cm x 3.5 cm, area was slightly raised and firm to the touch, [R9] indicated that area was very tender when touched, [RN H] outlined the bruise. On 07/12/24 at 11:03 AM, RN H wrote, Bruise to L arm about the size of a baseball. Spreading outside of initial circled bruise area. Provided [R9] with emotional support. Informed that measures are being taken to help prevent this happening again. Expressed gratitude. Will continue to monitor and assess per protocol. On 07/13/24 at 2:00 AM, RN I wrote in part, Able to use left arm without difficulty; Left upper arm bruise is now dark and spread well beyond originally marked area; States that it only hurts now occasionally if touched. On 07/23/24 at about 1:50 PM, Surveyor interviewed Social Services Director (SSD) J about the above incident and asked if the police were notified of the incident. SSD J indicated they were not. R9 and family decided together they did not want to report it. On 07/23/24 at approximately 2:09 PM, Surveyor interviewed NHA A and asked when they would call the police. NHA A indicated if something is stolen/misplaced they would call the police. Surveyor asked if the police were called for the resident to resident altercation. NHA A indicated no, they failed to do that step when R9 was injured by R33.

Based on interview and record review, the facility failed to follow procedures that prohibit and prevent abuse, neglect, and exploitation of residents. The facility did not perform a Wisconsin background check for a staff member that has direct contact with residents and works in a Wisconsin facility. This was found for 1 of 8 staff members investigated for background check compliance. Findings include: The facility policy entitled, Resident Abuse - Prevention/Investigations, dated 10/15/17 states: All potential employees will submit to a criminal conviction history check done through the Wisconsin State Police Department, and other sources as applicable, prior to being employed and every 4 years if employed. On 07/23/24 at 3:00 PM, Surveyor performed record review of eight employees' background checks and found that one employee, Certified Nursing Assistant (CNA) N, did not have a Wisconsin Department of Justice (DOJ) or Integrated Background Information System (IBIS) that would indicate if CNA N had a criminal background in the state of Wisconsin. CNA N's only background information was for the state of Minnesota. On 07/24/24 at 1:17 PM, Surveyor interviewed Human Resources Director (HRD) P about the missing background information for Wisconsin. HRD P had not completed a Wisconsin DOJ and IBIS letter request as the staff member commuted from a nearby state and did not reside in Wisconsin. They did some Wisconsin DOJ and IBIS checks for other employees in similar situations, but they were not sure if it was required due to the staff member's home location. They must have just missed this one or were not sure it needed to be done. On 7/24/24 at 1:21 PM, Surveyor interviewed Nursing Home Administrator (NHA) A regarding expectations for background checks. NHA A said they would expect that the proper background checks including Wisconsin DOJ and IBIS letter be completed, to keep residents safe.

Based on observations and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This practice had the potential to affect 16 of 56 residents residing in the facility (R258, R28, R26, R2, R40, R29, R30, R13, R3, R1, R43, R7, R32, R36, R17, R52). Example 1: The facility did not provide hand hygiene to the residents before eating meals. This is evidenced by: DQA (Division of Quality Assurance) memo number 11-025 outlines Resident Hand Hygiene. Included in the memo is the following: Resident handwashing is an integral component of all nurse aide training program curriculum. Nurse aides are trained to offer, encourage and/or assist residents to perform handwashing to include but not limited to; before eating .Nursing home feeding assistants are trained to assist residents to wash their hands before eating. The facility policy, titled, Preparing the Resident for a Meal Dated: September 2010, states: .Steps in the procedure .6. Encourage the resident to wash his or her face and hands. Assist as needed . On 07/10/23 at 11:45 AM, Surveyor observed a food tray being delivered to R258; food was covered when entering the room, and hand hygiene was not offered when food was presented to the resident. On 07/11/23 at 7:49 AM, Surveyor observed breakfast being presented to residents in a smaller dining room near residents' rooms. Food was presented to R28, but no hand hygiene was offered. R28 was grabbing cups and spoons off their plate. R26 was presented with food, food uncovered, and no hand hygiene product was on the table. On 07/12/23 at 7:32 AM, Surveyor observed R2 entering the dining room for breakfast; no hand hygiene was provided to R2 prior to meals being distributed. On 07/12/23 at 8:23 AM, Surveyor spoke with CNA (Certified Nursing Assistant) G and asked what the process was to ensure residents received hand hygiene prior to meals. CNA G stated that it is different for all residents, but we usually say, Hi would you like to wash your hands, to most residents before meals. For some residents, we help clean up after eating too. On 07/12/23 at 9:15 AM, Surveyor interviewed DON (Director of Nursing) B and asked what their expectations would be regarding hand hygiene for residents at mealtimes. DON B stated that the residents have the option to use hand sanitizer at the door or sanitation wipes on the tables. DON B would expect that hand hygiene is encouraged, but some residents refuse due to just washing their hands after using the restroom in their rooms. 47284 Example #2 On 07/10/23 at 11:54 AM, Surveyor observed Certified Nursing Assistant (CNA) C providing food trays to the residents (R) in the rooms located in the 400 hall. The residents receiving the food trays were: R40, R29, R30, R13, R3, R1, R43, R7, R32, R36, and R17. All the residents who received the food trays listed above were not offered hand hygiene before the meal. On 07/10/23 at 12:10 PM, Surveyor interviewed R3 asking if staff offered hand hygiene before meals. R3 said staff do not offer hand hygiene before meals. On 07/10/23 at 12:17 PM, Surveyor interviewed R36 asking if staff offered hand hygiene before meals. R36 said the staff do not offer hand hygiene, but she is independent and washes her hands before she eats. On 07/10/23 at 12:23 PM, Surveyor spoke with R29 and R40 to see if staff offered hand hygiene before meals and they both said no. On 07/11/23 at 8:13 AM, Surveyor observed CNA D and CNA E providing food trays to the residents in the rooms located in the 400 hall. The residents receiving the food trays were: R40, R29, R30, R13, R3, R1, R43, R7, R32, R36, and R17. All the residents who received the food trays listed above were not offered hand hygiene before the meal. 17661 Example 3 R52 was admitted to the facility with medical diagnoses that include, but are not limited to Unspecified Severe Protein-Calorie Malnutrition, Chronic Obstructive Pulmonary Disease, Abnormal Weight Loss, Chronic Respiratory Failure with Hypoxia, Type 2 Diabetes Mellitus without complications, Spinal Stenosis, and Muscle Weakness. The most recent Minimum Data Set Assessment (MDSA) completed for R52 was a quarterly assessment with an Assessment Reference Date of 7/5/23. According to this MDSA, R52 requires staff assistance to meet her most basic daily tasks of bed mobility, transfers, ambulation and personal hygiene. R52 is set up for meals and supervised by staff on her eating abilities. Following set-up of the meal, R52 eats independently. R52 has a Brief Interview of Mental Status (BIMS) score of 13/15 (scores of 13 to 15 suggests the individual is cognitively intact). R52's weaknesses were based on recall of information. On 7/10/23, Surveyor observed R52 receive her meal by CNA F at 11:35 AM in her room. R52 was seated on the side of the bed with oxygen being administered via a nasal cannula. CNA F placed the meal tray on R52's over the bed table, encouraged R52 to eat and then left the room. Although CNA F sanitized her own hands prior to serving R52 and upon leaving the room, she did not offer or encourage to cleanse R52's hands prior to the meal service. Surveyor again observed R52 on 7/11/23 at 7:39 AM for room meal service. R52 was served her morning meal at 7:41 AM by CNA F who assisted R52 to sit up on the side of the bed and encouraged her to eat. CNA F then left the room, stating to R52 that she will leave the tray and return to check on her. Again, while CNA F sanitized her hands before obtaining R52's meal tray, and again upon leaving the room, there was no attempt made to assist R52 with the same. On 7/12/23 at 11:58 AM, Surveyor approached R52, who was again sitting on the side of her bed and eating her noon meal. Surveyor asked R52 if staff offer to wash her hands or use a hand wipe before eating. R52 stated, No, not really. I guess I never really thought about it. I really don't do anything like digging around in dirt, just lay here in bed or go into the bathroom. I guess I really should, but never really considered it.

Based on observation, policy review, and interview, the facility did not operationalize their infection control program to prevent the spread of infection during cares. This occurred for 1 of 17 residents, Resident (R) R15. Facility staff did not perform perineal and catheter cares in a hygienic manner when providing cares or perform hand hygiene when removing gloves while providing care for R15. This is evidenced by: The facility policy entitled Perineal Care, dated 02/18 states, .wash the perineal area starting with the urethra and working outward .continue to wash the penis, scrotum and inner thighs .moving from inside outward . R15's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R15 requires assistance with all Activities of Daily Living (ADLs). On 05/19/21 at 8:44 a.m., Surveyor observed Certified Nursing Assistants (CNA) C and CNA D assist R15 with perineal/catheter care. CNA C was in the room when Surveyor entered. CNA D entered the room with a stand up lift machine. CNA D did not perform hand hygiene upon entering the room. CNA C removed R15's pants, and replaced them with the clean pajama pants. CNA C went to the sink and obtained 4-5 washcloths, adding a no rinse perineal wash. CNA C cleansed R15's bilateral groin area. After cleansing this area and without obtaining one of the clean cloths, CNA C washed R15's meatal opening, using an inner to outer motion, cleansing the catheter tubing in a downward motion. Next, without changing gloves or performing hand hygiene, CNA C used a clean washcloth to cleanse R15's scrotal area. Without changing gloves or washing hands, CNA C applied [MEDICATION(S)] ointment to the meatal area, reaching into the jar twice. After applying the ointment, CNA C changed gloves, but did not wash hands. CNA C and CNA D assisted R15 onto the bathroom commode, using the stand up lift. After R15 was finished on the commode, CNA C applied gloves and used a disposable wipe to cleanse R15's rectal area, using a front to back motion. CNA C then changed gloves without performing hand hygiene. CNA C and CNA D assisted R15 into a standing position in the stand up lift, and adjusted R15's clothing. CNA C removed gloves and performed hand hygiene. CNA D left the room and did not perform hand hygiene before leaving the room. At 10:01 a.m., Surveyor interviewed CNA C. Surveyor asked CNA C to describe the steps of the procedure, beginning with the cleansing of the meatus. CNA C stated that she guessed she should have washed the meatal area first. CNA C stated that she did not know she should have performed hand hygiene and changed gloves before applying the ointment. At 10:35 a.m., Surveyor interviewed Director of Nursing (DON) B and Registered Nurse (RN) E, who functions as the facility's Infection Control Preventionist. Surveyor asked if CNA C had performed the cares correctly. DON B and RN both agreed that facility staff demonstrated cross contamination during the procedure, including when applying the ointment. DON B stated that clean perineal care is reviewed with CNAs throughout the year as part of infection control training. RN E stated the facility would perform more audits to ensure that staff are providing perineal cares competently. RN E stated she would replace the [MEDICATION(S)] that had become contaminated.

Based on interview, policy review, and record review the facility failed to follow COVID 19 testing requirements as outlined in CMS Memo QSO 20-38 (Center for Clinical Standards and Quality/Quality, Safety, & Oversight Group). The facility was currently in outbreak status and located in a county with high positivity rates which required the facility to test staff twice per week. The facility mandated all staff to test every Monday and recommended staff to be tested for the second time every Thursday. All staff were not tested twice per week. These staff were allowed to work with no additional transmission precautions implemented or any change in the work duties This deficiency had the potential to affect 46 of 57 residents who had not already contracted COVID 19. This is evidenced by: According to the QSO 20-38 memo published August 26, 2020, facilities are required to test based on two separate criteria, outbreak and routine. The outbreak testing parameters according to the memo are every 3-7 days all staff and residents should be tested until there are no new cases identified for at least 14 days. The facility was in compliance with this criteria. The second criteria for testing according to QSO 20-38 memo was for routine testing of staff based on the county positivity rates. The facility was located in a county with a high positivity rate. The minimum testing frequency for a nursing home in a red or high positivity rate county is twice weekly. The facility was conducting routine and outbreak testing every Monday in accordance with the standards. On11/19/20 the facility went from a yellow or medium county positivity rate to a red or high county positivity rate. On 11/23/20, the facility implemented twice weekly testing every Monday and Thursday. Surveyor reviewed the facility's schedules for all departments and compared the schedule with testing dates. During the week of 12/02/20, twenty six staff did not get COVID19 tested a second time and worked at least one day until the next scheduled COVID19 testing day. During the week of 12/07/20, twenty three staff did not get COVID19 tested a second time and worked at least one day until the next scheduled COVID19 testing day. During the week of 12/14/20, twenty five staff did not get COVID19 tested a second time and worked at least one day until the next scheduled COVID19 testing day. These staff were allowed to work with no additional transmission precautions implemented or any change in the work duties. On 12/22/20, Surveyor reviewed the facility policy titled Refusal of Testing for COVID-19. The policy was based off of the QSO 20-38 memo. The policy stated residents and staff have the right to refuse testing; however there was no guidance or additional staff instructions if testing was not conducted in accordance with the QSO 20-38 memo. The QSO 20-38 memo does acknowledge staffs' right to refuse testing; however the facility must develop procedures to manage staff refusal. The facility did provide a procedure of what to do when staff refuse during an outbreak, but did not provide any procedures of what to do when staff refuse routine testing. The QSO 20-38 memo provided an example of staff who refuse testing during an outbreak be prohibited from entering the facility or working until the outbreak has resolved. On 12/22/2020 at 9:29 a.m., Surveyor interviewed the DON (Director of Nurses) and the IP (Infection Preventionist) regarding the facility's COVID19 outbreak that started on 11/12/2020. The DON stated the facility was informed of the high (red) county positivity rate on 11/19/20 and was informed of the twice weekly required testing. The DON stated twice weekly testing was started on 11/23/20. The DON stated all staff were mandated to test every Monday and highly recommended to test every Thursday. The DON stated staff are not offered an alternate testing day other than Mondays and Thursdays and are not required or offered an opportunity to test before their shift begins if they did not complete the second testing for the week. The facility was not in compliance with the routine testing criteria once the county positivity rate increased to red or high. The DON stated staff have the right to refuse testing and are allowed to work as long as the staff person has had a negative COVID19 test in the last seven days. The DON stated if staff refuse testing, the staff must sign a declination form indicating reason for refusal. The Surveyor requested evidence of this process and the DON stated staff are no longer signing any declination form. The DON stated staff were not mandated to test twice weekly. The DON stated many staff live a distance away and the twice weekly testing was difficult for those staff. All staff were required to test on Mondays. The Surveyor asked why staff who may have missed the second weekly testing were not tested prior to their next shift and the DON stated staff were not offered that opportunity. The DON stated staff are tested using the PCR (polymerase chain reaction) molecular method. The DON stated the facility also can test staff or residents using the [MEDICATION NAME] POC (point of care) [MEDICATION NAME] rapid test method using either the BD Veriter or the BinaxNOW system. The DON stated testing equipment using the BD Veriter or BinaxNOW systems are in good supply.