Based on observation, staff and resident interview, and record, review, the facility did not maintain dignity for 3 residents (R) (R20, R11, and R6) of 23 sampled residents. R20 required feeding assistance. On 4/22/25, R20 watched other residents eat in the dining room and waited 16 minutes for assistance. In addition, staff in the dining room did not address or speak to R20. R11 and R6 required feeding assistance. On 4/22/25, staff in the dining room did not speak to R11 and R6 while feeding them. Findings include: The facility's Meal, Preparing Resident for policy, dated 5/2024, indicates: It is the policy of this facility that the primary purpose of preparing the resident for a meal is to serve the meal in a pleasant environment and to make the mealtime a pleasant event. Encourage residents to eat in the dining area. This provides each resident with an opportunity to socialize and make new friends . The facility's Dietary Support Personnel, Sufficient policy, dated 1/2022, indicates: .Sufficient support personnel means having enough dietary and food nutrition staff to safely carry out all the functions of the food and nutrition services. This does not include staff, such as licensed nurses, nurse aides, or paid feeding assistants involved in assisting residents with eating . 1. On 4/22/25 at 11:30 AM, Surveyor observed the noon meal in the dining room and noted 23 residents were in the dining room during the meal. At 11:39 AM, Surveyor observed Lead [NAME] (LC)-H begin to serve residents. At 11:48 AM, Surveyor noted all residents had been served except R20. On 4/22/25 at 11:45 AM, Surveyor observed Certified Nursing Assistant (CNA)-I assist R11 and CNA-F assist R6. Surveyor noted neither CNA-I or CNA-F addressed or talked to R11 or R6 while assisting them with eating. At 11:57 AM, Surveyor observed CNA-I begin to talk and interact with R11. CNA-I continued to converse with R11 and offer choices throughout the end of the meal. CNA-F still had not spoken to R6. On 4/22/25 at 11:53 AM, Surveyor noted R20 was watching residents eat in the dining room. Staff had not yet provided R20 with a meal or drink. Surveyor also noted none of the staff in the dining room (CNA-I, CNA-F, and LC-H) had addressed R20. On 4/22/25 at 11:53 AM, Surveyor interviewed LC-H who indicated R20 requires feeding assistance and it is common for R20 to wait to eat. LC-H indicated there are three residents who require feeding assistance and usually two staff to assist with feeding. LC-H indicated one resident has to wait until the other residents eat before that resident receives assistance. On 4/22/25 at 11:55 AM, Surveyor observed CNA-F stand up and walk away from R6 who had finished eating. CNA-F did not say anything to R6 before leaving the table. Surveyor observed CNA-F walk to R20's table and sit down to assist R20. LC-H brought a plate of food to R20 and R20 was provided with a drink. CNA-F began to feed R20 but did not speak to or address R20. CNA-F did not introduce CNA-F's self to R20, did not describe the food on R20's plate, did not apologize for R20 having to wait 16 minutes to eat, and did not engage in any small talk or conversation. On 4/22/25 at 11:58 AM, Surveyor observed CNA-F stand up from feeding R20 and assist another resident who was exiting the dining room. CNA-F did not say anything to R20 and left the dining area. R20 was left sitting at the table with R20's food and drink. On 4/22/25 at 12:03 PM, Surveyor observed CNA-F walk into the dining room, turn around, and walk back out. R20 was still sitting at the table watching other residents finish their meals. R20's food and drink was still in front of R20. On 4/22/25 at 12:05 PM, Surveyor observed CNA-F walk into the dining room and sit by R20. CNA-F sat down and resumed feeding R20 but did not speak to R20. CNA-F did not ask if R20's food was cold, apologize for leaving R20 in the middle of the meal, or explain where CNA-F had gone for 7 minutes and why R20 had to wait. Surveyor observed CNA-F laugh and talk with staff in the dining room while feeding R20. On 4/22/25 at 12:08 PM, Surveyor observed CNA-I wheel R11 out of the dining room. CNA-I did not speak to R11 while CNA-I wheeled R11 out of the room. On 4/22/25 at 12:33 PM, Surveyor observed CNA-F stand up and use R20's clothing protector to wipe R20's face. CNA-F then pushed R20's wheelchair out of the dining room. CNA-F did not speak to R20 during meal service or when exiting the dining room. On 4/22/25 at 12:34 PM, Surveyor interviewed LC-H who indicated some CNAs talk to residents and some do not. LC-H indicated sometimes staff do not talk to R20 because R20 can not always respond. On 4/22/25 at 1:04 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated staff who assist a resident with eating should talk and interact with the resident, even if the resident is nonverbal or unable to understand what is said to them. DON-B indicated staff should offer bites of food and ensure the resident is satisfied with their food and its temperature. DON-B indicated staff should engage in small talk and ongoing communication with residents as appropriate. DON-B indicated there should be enough staff to feed residents who need assistance with eating. DON-B indicated it is not acceptable for a resident to watch other residents eat for 16 minutes before they receive food and assistance. DON-B indicated staff should not leave a resident for 7 minutes in the middle of feeding them. DON-B indicated it is not acceptable for staff to ignore residents and not speak to them while feeding them. On 4/22/25 at 1:24 PM, Surveyor interviewed CNA-F who verified CNA-F did not talk to R20 or R6 when CNA-F fed R20 and R6 lunch. CNA-F indicated CNA-F was not taught that during CNA training. CNA-F indicated it is typical for R20 or another resident to wait 20 to 30 minutes to be fed while the rest of the residents are eating or being assisted. CNA-F indicated CNA-F left the dining room while feeding R20 to assist another resident out of the dining room. After CNA-F assisted the resident to their room, CNA-F toileted the resident and helped another staff transfer a resident before CNA-F returned to the dining room to resume assisting R20. When asked if it is typical to leave the room while feeding a resident, CNA-F indicated it happens sometimes and depends on the day. When asked why CNA-F did not talk to R20 or R6 while assisting them, CNA-F indicated CNA-F does not have much to say to them. On 4/23/25 at 2:44 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated staff should communicate and interact with residents in the dining room while assisting them. NHA-A indicated it is not acceptable for a resident to wait up to 16 minutes to eat while other residents are being fed. NHA-A indicated it is not acceptable for a CNA to leave a resident while feeding them to provide care for another resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure court-ordered protective placement was obtained for 1 resident (R) (R9) of 2 sampled residents. R9 was under Guardianship. The facility did not ensure court-ordered protective placement in the least restrictive environment was obtained after R9's nursing home stay exceeded 60 days. Findings include: From 4/21/25 to 4/23/25, Surveyor reviewed R9's medical record. R9 was admitted to the facility on [DATE] and had diagnoses including schizophrenia, epilepsy, and major depressive disorder. R9's Minimum Data Set (MDS) assessment, dated 1/15/25, had a Brief Interview for Mental Status (BIMS) score of 00 out of 15 which indicated R9 was unable to complete the interview. R9 had a Guardianship that was activated on 9/29/21. R9's medical record contained a petition for protective placement that was dated 8/22/24. On 4/23/25 at 9:12 AM, Surveyor reviewed R9's medical record with Social Worker (SW)-P who confirmed the petition for protective placement was not the final order. SW-P indicated SW-P would look for the final order. On 4/23/25 at 2:10 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated NHA-A was not aware of protective placement for R9 and would inform SW-P. On 4/23/25 at 3:00 PM, Surveyor interviewed SW-P who indicated the facility usually received protective placement paperwork from the Guardian and the court usually sent paperwork to the facility upon a resident's admission. SW-P indicated the facility should have obtained protective placement for R9 in September or October of 2024 after the final protective placement hearing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not make a prompt effort to investigate and resolve a grievance for 1 resident (R) (R5) of 1 sampled resident. R5 voiced a concern to staff and the Grievance Official that another resident repeatedly woke R5 up in the early morning hours. R5's grievance was not documented, thoroughly investigated, or resolved. Findings include: The facility's Resident and Family Grievances Policy, revised 12/2024, indicates: It is the policy of this facility to support each resident's .right to voice grievances without discrimination or fear of reprisal .Prompt efforts to resolve include facility acknowledgment of a complaint/grievance and actively working toward resolution of the complaint/grievance .1. The Social Worker has been designated as the Grievance Official. 2. The Grievance Official is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusion, leading any necessary investigations by the facility, maintaining the confidentiality of all information associated with grievances, issuing written grievance decisions to the resident, and coordinating with state and federal agencies as necessary in light of specific allegations .4. A resident may voice grievances with respect to .the behavior of staff and other residents, and other concerns regarding their long term care stay .8. Grievances may be voiced in the following forums: a. Verbal complaint to a staff member or the Grievance Official .10. Procedure: .b. The staff member receiving the grievance will record the nature and specifics of the grievances on the designated grievance form or assist the resident .to complete the form .12. The facility will make prompt efforts to resolve grievances. From 4/21/25 to 4/23/25, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had diagnoses including multiple sclerosis and anxiety disorder. R5's Minimum Data Set (MDS) assessment, dated 1/15/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R5 was not cognitively impaired. R5 was responsible for R5's healthcare decisions. On 4/21/25 at 10:24 AM, Surveyor interviewed R5 who indicated R5 is woken up at 5:30 AM due to another resident yelling and screaming down the hall. R5 indicated R5 has informed management, however, R5 does not think they can do anything. On 4/22/25 at 3:58 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-K and asked if CNA-K received any complaints from R5. CNA-K indicated R5 complained about another resident who wakes R5 up with noises in the early morning hours. CNA-K indicated CNA-K has not informed anyone or filed a grievance. CNA-K indicated CNA-K does not work a lot and thought other staff were aware of R5's complaint. On 4/23/25 at 9:10 AM, Surveyor interviewed Social Worker (SW)-P who confirmed SW-P is the facility's Grievance Official. SW-P indicated R5 voiced the same complaint to SW-P. R5 was offered a room change but declined. SW-P indicated SW-P's conversation with R5 and the room change offer were not documented. When Surveyor asked if a grievance should have been filed on R5's behalf, SW-P indicated it was a toss-up if a grievance should have been filed. SW-P indicated since R5 appeared to be upset and brought the issue to Surveyor's attention, SW-P should have filed a grievance. On 4/23/25 at 11:45 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated filing a grievance depended on how upset R5 still was. NHA-A indicated the facility offered R5 options which R5 declined. NHA-A indicated if a resident has a concern, they can start a grievance form. NHA-A indicated NHA-A and SW-P can start a grievance form also. NHA-A indicated the process involves talking with the person who voiced the grievance to see if they want to file a formal grievance. NHA-A does not know if R5 was offered the chance to file a formal grievance and indicated NHA-A did not recently talk to R5 regarding the issue. When Surveyor asked if NHA-A would consider R5 to be still upset if R5 brought the issue to Surveyor's attention, NHA-A indicated it is different for R5 and stated the facility can not do much because they cannot send the other resident away.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure an injury of unknown origin was reported to the State Agency (SA) for 1 resident (R) (R32) of 4 sampled residents. On 4/2/25, staff discovered a hematoma on R32's left forearm. Facility staff and Hospice staff were unsure how the injury occurred. The facility did not report the injury of unknown origin to the SA. Findings include: The facility's Abuse Prevention policy and procedure, updated 7/2024, indicates: Identification of abuse - Identify events, such as but not limited to suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse; and to determine the direction of the investigation. All alleged violations will be reported via phone or in writing within 2 hours to the State Licensing Agency. The facility shall follow up with the State Licensing Agency in writing the findings and results of the completion of the investigation within 5 days . From 4/21/25 to 4/23/25, Surveyor reviewed R32's medical record. R32 was admitted to the facility on [DATE] and had diagnoses including dementia, adult failure to thrive, and palliative care. R32's admission Minimum Data Set (MDS) assessment, dated 2/5/25, had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated R32 had severely impaired cognition. R32 had an activated Power of Attorney for Healthcare (POAHC). A progress note, dated 4/2/25 at 3:14 PM, indicated the writer was informed by staff that R32 had discoloration on the bilateral wrists. Upon assessment, the writer noted R32's wrists contained purplish, red/brown discoloration. R32 denied pain to the areas. The writer was informed by a Hospice Certified Nursing Assistant (CNA) that the discoloration had come and gone over the past few weeks and the Hospice nurse was aware. The Hospice nurse also verified the discoloration had come and gone over the past few weeks and and indicated the discoloration was senile purpura. R32 was interviewed and stated R32 felt safe. The note indicated staff would continue to monitor R32's arms due to R32 having increased negative behavior toward staff with cares. A progress note, dated 4/3/25 at 2:30 PM, indicated Hospice staff were in R32's room doing AM cares when the writer was called into the room and shown R32's left arm that had previous bruising. A raised hematoma that measured 9 centimeters (cm) x 10 cm was noted on the left side of R32's outer forearm. R32 had no complaints of pain or discomfort. R32 refused ice and was combative with staff. The Director of Nursing (DON) was notified. The note indicated staff would notify R32's POAHC and physician. On 4/21/25, Surveyor reviewed a facility investigation for R32's injury of unknown origin. The facility contacted R32's Power POAHC who indicated R32 was combative during a visit on 4/2/25 and hit R32's arms on the bed. The investigation determined the injury occurred when R32 hit R32's arms on the bed during the visit. The injury of unknown origin was not reported to the SA. On 4/21/25 at 2:25 PM, Surveyor interviewed DON-B who indicated the facility completed an investigation for R32's injury of unknown origin. DON-B verified the facility did not report the injury of unknown origin to the SA.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure an injury of unknown origin was thoroughly investigated for 1 resident (R) (R32) of 4 sampled residents. R32 had an injury of unknown origin that was discovered on 4/2/25. The facility did not interview other residents to rule out abuse during the investigation. Findings include: The facility's Abuse Prevention policy and procedure, updated 7/2024, indicates: Identification of abuse - Identify events, such as but not limited to suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse; and to determine the direction of the investigation. The investigation shall consist of: .6. Interviews with other residents to whom the accused employee provides care or services. From 4/21/25 to 4/23/25, Surveyor reviewed R32's medical record. R32 was admitted to the facility on [DATE] and had diagnoses including dementia, adult failure to thrive, and palliative care. R32's admission Minimum Data Set (MDS) assessment, dated 2/5/25, had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated R32 had severely impaired cognition. R32 had an activated Power of Attorney for Healthcare (POAHC). A progress note, dated 4/2/25 at 3:14 PM, indicated the writer was informed by staff that R32 had discoloration on the bilateral wrists. Upon assessment, the writer noted R32's wrists contained purplish, red/brown discoloration. R32 denied pain to the areas. The writer was informed by a Hospice Certified Nursing Assistant (CNA) that the discoloration had come and gone over the past few weeks and the Hospice nurse was aware. The Hospice nurse also verified the discoloration had come and gone over the past few weeks and indicated the discoloration was senile purpura. R32 was interviewed and stated R32 felt safe. The note indicated staff would continue to monitor R32's arms due to R32 having increased negative behavior toward staff with cares. A progress note, dated 4/3/25 at 2:30 PM, indicated Hospice staff were in R32's room doing AM cares when the writer was called into the room and shown R32's left arm which had previous bruising. A raised hematoma that measured 9 centimeters (cm) x 10 cm was noted on the left side of R32's outer forearm. R32 had no complaints of pain or discomfort. R32 refused ice and was combative with staff. The Director of Nursing (DON) was notified. On 4/3/25, the facility began an investigation for R32's injury of unknown origin. The facility interviewed R32 and all staff who worked with R32 on 4/2/25 and 4/3/25. The facility also contacted R32's POAHC who indicated R32 was combative during a visit on 4/2/25 and hit R32's arms on the bed. The facility contacted Hospice and discontinued R32's anticoagulant therapy (which can increase bruising). In addition, R32 was wearing geri-sleeves on each arm to protect R32's arms/skin. The investigation did not include interviews with other residents to rule out abuse. On 4/21/25 at 2:25 PM, Surveyor interviewed DON-B who indicated the facility completed an internal investigation for R32's injury of unknown origin. DON-B verified the facility did not interview other residents to rule out abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not revise a care plans in accordance with current care needs for 1 resident (R) (R32) of 15 sampled residents. R32's care plan was not updated to include calling R32 by R32's preferred names. R32's care plan was also not updated when R32 incurred an injury of unknown origin and geri-sleeves were implemented to protect R32's skin. Findings include: From 4/21/25 to 4/23/25, Surveyor reviewed R32's medical record. R32 was admitted to the facility on [DATE] and had diagnoses including dementia, adult failure to thrive, and palliative care. R32's admission Minimum Data Set (MDS) assessment, dated 2/5/25, had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated R32 had severely impaired cognition. R32 had an activated Power of Attorney for Healthcare (POAHC). On 4/21/25 at 1:15 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-C who indicated when R32 was first admitted , staff called R32 by a shortened version of R32's name. CNA-C indicated R32 also told staff to call R32 grandma which staff sometimes did. CNA-C indicated R32 could be behavioral during cares and sometimes calling R32 grandma helped calm R32. CNA-C indicated one of R32's family members heard CNA-C call R32 grandma when they visited. CNA-C indicated R32's family member stated staff should not call R32 grandma because R32 was not their grandma and R32 did not like that. CNA-C told Assistant Director of Nursing (ADON)-D and the Social Worker (SW) who were going to talk to R32's POAHC. CNA-C was not sure of the outcome of the conversation and indicated CNA-C no longer calls R32 grandma. On 4/21/25 at 2:23 PM, Surveyor interviewed ADON-D who indicated ADON-D was working on the evening that CNA-C called R32 grandma and R32's family member got upset. ADON-D indicated the facility contacted R32's POAHC to explain what happened and that it sometimes helps if staff call R32 grandma when R32 is having difficulty with cares. R32's POAHC gave approval for staff to call R32 grandma if it helped. R32's medial record indicated R32 had an injury of unknown origin that was discovered on 4/3/25. The facility completed an investigation for R32's injury. R32 was known to be combative at times. The investigation indicated R32 was combative, swung R32's arms, and hit R32's arms on the bed during a visit with R32's POAHC. The facility, in conjunction with Hospice staff, initiated geri-sleeves (sleeves worn to protect skin) to protect and prevent injury to R32's skin. On 4/21/25, Surveyor reviewed R32's plan of care and noted there were no care plan updates related to the preferred names staff should call R32 or that R32 should wear geri-sleeves on the bilateral upper extremities. On 4/21/25 at 2:23 PM, ADON-D indicated the facility had not yet care planned the information. On 4/21/25 at 2:25 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed R32's care plan was not updated to include the preferred names staff should call R32 or that R32 should wear geri-sleeves on both arms to protect R32's skin. DON-B confirmed R32's care plan should have been updated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility did not ensure 3 residents (R) (R7, R12, and R186) of 17 sampled residents received assistance as needed to complete activities of daily living (ADLs). R7 did not receive assistance with positioning, toileting, and breakfast. R12 did not receive weekly showers. In addition, the facility did not address R12's request for more showers. R186 did not receive a shower while at the facility. Findings include: The facility's Activities of Daily Living (ADLs) policy, dated 12/2024, indicates: Care and services will be provided for the following ADLs: 1. Bathing, dressing, grooming, and oral care; 2. Transfer and ambulation; 3. Toileting; 4. Eating to include meals and snacks .3. A resident who is unable to carry out ADLs will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene .5. The facility will maintain individual objectives of the care plan. The facility's Resident Showers policy, dated 12/2024, indicates: It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation, and help prevent skin issues as per current standards of practice .1. Residents will be provided showers per request or the facility's schedule protocol and based upon resident safety . 1. From 4/21/25 to 4/23/25, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, dementia, diabetes, moderate protein calorie malnutrition, and dysphagia. R7 received Hospice services. R7's Minimum Data Set (MDS) assessment, dated 3/5/25, indicated R7 required staff assistance with eating set up, substantial/maximal assistance with rolling left and right, and substantial/maximal assistance with toileting. The MDS assessment also indicated R7 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated R7 had severe cognitive impairment. R7 had a Guardian for healthcare decisions. A care plan (initiated 5/5/22) indicated R7 had an ADL self care performance deficit related to immobility, overall decline, and decreased motivation. The care plan contained the following interventions: Bed mobility: Requires substantial/maximal assistance with lying to sitting on end of bed, sitting to lying, and rolling left and right; Eating: May have meals/snacks/drinks independently in room with frequent visual checks at mealtime to ensure safety; and Toilet use: Requires two-person assistance .and is dependent for toileting hygiene. A care plan (initiated 8/9/24) indicated R7 had the potential for pressure ulcer development related to incontinence and spending a lot of time in bed. The care plan contained an intervention for R7 to be repositioned every two hours while in bed as tolerated. A care plan (initiated 5/5/22) indicated R7 was at high nutritional risk secondary to protein calorie malnutrition, Hospice care, Alzheimer's disease, kidney disease, and diabetes. The care plan contained an intervention to monitor/document/report to MD as needed for signs and symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, and if appears concerned during meals. On 4/21/25 at 10:27 AM, Surveyor observed R7 in bed. Surveyor noted R7 was leaning to the right side and had slid to the bottom of the bed. R7 indicated R7 was not comfortable. On 4/23/25 at 8:30 AM, Surveyor observed R7 in bed with the head of the bed elevated 45 degrees. R7 was leaning to the right side. Surveyor noted R7's breakfast tray was not set up and was in front of R7 untouched. The tray contained a plate of food that was uncovered, however, R7's milk, orange juice, and cereal were still covered. On 4/23/25 at 9:31 AM, Surveyor observed R7 in bed with the head of the bed elevated 45 degrees. R7 was leaning to the right side with R7's head touching the right bed rail. R7's breakfast tray was still untouched and not set up for breakfast. On 4/23/25 at 9:36 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-C who stated breakfast trays are usually delivered around 8:00 AM. CNA-C indicated dietary staff were supposed to bring in the tray and remove covers from the plate, liquids, and cereal. CNA-C indicated R7 liked to sleep in and usually did not touch R7's breakfast tray until between 9:30 and 10:00 AM. CNA-C also indicated R7 was repositioned every two hours by CNAs or Hospice staff. CNA-C was assigned to R7 that shift and indicated the AM shift started at 6:00 AM. CNA-C stated CNA-C had not yet turned, repositioned, or checked and changed R7 or checked to see if R7 was eating. On 4/23/25 at 9:43 AM, Surveyor interviewed Assistant Director of Nursing (ADON)-D who indicated ADON-D observed dietary staff pass by with trays approximately 30 minutes ago. ADON-D indicated dietary staff typically set up R7's tray. ADON-D indicated R7 had a history of non-compliance with eating in an upright position and a history of aspiration and recent pneumonia. ADON-D indicated R7 should be repositioned by facility CNAs or the Hospice aide. ADON-D had not observed Hospice with R7 yet that day. ADON-D reviewed orders (dated 9/26/24) that indicated R7 could eat meals and snacks in R7's room unsupervised (discussed with Guardian) and staff should frequently check on R7 during meals and snacks. ADON-D stated CNAs should have offered and/or done repositioning by that time. On 4/23/25 at 10:15 AM, Surveyor interviewed CNA-C who stated R7 was just repositioned and changed for the first time that shift. CNA-C indicated R7 was having difficult eating cereal so another staff was assisting R7 with eating. On 4/23/25 at 3:14 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated staff should check, change, and reposition R7 every 2-3 hours. DON-B indicated most residents are checked, changed, and repositioned before and after meals and before shift change on the AM and PM shifts unless care planned for every 2 hours like R7. DON-B verified the AM shift starts at 6:00 AM and confirmed staff should have checked, changed, and repositioned R7 before 9:36 AM and set up R7's tray before 10:15 AM. DON-B indicated meal set up includes removing covers. On 4/23/25 at 3:24 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-E who indicated LPN-E heard R7 call out at approximately 9:36 AM and checked on R7. With the assistance of Clinical Market Leader (CML)-G, LPN-E checked, changed, and repositioned R7 who was incontinent of a medium amount of urine and a smear of stool. LPN-E indicated R7's condom catheter was not in place. LPN-E reheated R7's plate of food and removed covers from R7's oatmeal and liquids. CML-G assisted R7 with eating oatmeal. LPN-E indicated R7 required assistance with eating at times due to confusion and a history of swallowing issues. R7's Guardian had signed a diet non-compliance form to liberalize R7's diet for comfort when R7 started Hospice services. LPN-E agreed with DON-B that R7 should have been checked, changed, repositioned, and set up, assisted, or frequently checked on during eating. 2. From 4/21/25 to 4/23/25, Surveyor reviewed R12's medical record. R12 was readmitted to the facility on [DATE] and readmitted again on 4/2/25 after a three-day discharge. R12 had diagnoses including traumatic brain injury, urinary incontinence, urinary catheter, morbid obesity with alveolar hypoventilation, and urinary tract infection (UTI). R12's MDS assessment, dated 4/4/25, had a BIMS score of 15 out of 15 which indicated R12 was not cognitively impaired. The MDS assessment also indicated R12 required substantial/maximal assistance with showering/bathing, upper and lower body dressing, and putting on/taking off footwear. On 4/21/25 at 12:15 PM, Surveyor interviewed R12 who indicated R12 did not receive weekly showers and R12's scalp and hair were greasy. R12 indicated R12 would like to shower more than once weekly. R12 indicated R12 told staff that R12 needed to shower more than once per week but still did not receive regular showers. R12 indicated R12 was told staff have a lot of other residents to shower and were not able to give R12 a shower. On 4/22/25, Surveyor observed a grievance from R12, dated 1/6/25. The grievance indicated R12 wanted to shower two times per week. The grievance also indicated R12 wanted staff to wake R12 up and get R12 ready for breakfast daily. The action taken was listed as discussed with resident and staff. The summary of pertinent findings stated resident would like to be up for breakfast daily. The summary of the grievance did not mention R12's shower request. The corrective action taken was listed as Care plan and Kardex (an abbreviated care plan used by nursing staff) updated. Staff aware/updated. R12's plan of care (initiated 10/31/22) indicated R12 had an ADL self care performance deficit related to muscle weakness and fracture to right distal femur that was surgically repaired. The goal indicated R12 will maintain current level of function or improve in: bed mobility, transfers, eating, dressing, grooming, toilet use, and personal hygiene. The plan of care contained the following intervention: Bathing: R12 requires substantial/maximal assistance with shower transfer and requires substantial/maximal assistance with showering and bathing (initiated 1/10/23). Surveyor noted there was not an update to R12's care plan following the grievance request to shower twice per week. R12's Kardex also did not indicate R12 would like to shower twice weekly. On 4/23/25, Surveyor reviewed the facility's shower schedule which indicated R12 was scheduled for a shower on the Monday AM shift. The shower schedule was not updated for twice weekly showers. On 4/23/25 at 10:17 AM, Surveyor interviewed LPN-J who indicated LPN-J fills out a shower sheet for every resident shower. LPN-J indicated shower sheets need to be completed even if the resident refuses the shower and a nurse must still complete a skin check for the resident (which is documented on the shower sheet). LPN-J indicated shower sheets are given to DON-B. On 4/23/25 at 11:15 AM, Surveyor reviewed R12's shower sheets for 1/1/25 through 4/23/25. Surveyor noted 6 shower sheets dated 1/6/25, 1/13/25, 1/20/25, 3/10/25, 4/7/25, and 4/21/25. On 4/23/25 at 11:15 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who confirmed the 6 shower sheets received for R12 were the only shower sheets the facility had for R12 in 2025. On 4/23/25 at 1:14 PM, Surveyor interviewed DON-B who indicated residents should be offered showers at least once weekly. DON-B indicated staff need to fill out a shower sheet or a refusal sheet and a nurse needs to complete a skin check even if the resident did not receive a shower. DON-B indicated if a resident files a grievance indicating they would like two showers per week, the resident should be offered two showers per week. DON-B also indicated the shower schedule, care plan, and Kardex should be updated with the twice weekly schedule. Surveyor and DON-B discussed R12's shower request, grievance, and the 6 shower sheets for R12. When asked why there were only 6 showers for R12 and why R12's care plan and Kardex and shower schedule were not updated after R12 filed a grievance, DON-B indicated there was a break in the system. On 4/23/25 at 2:44 PM, Surveyor interviewed NHA-A who indicated residents should be offered weekly showers. NHA-A indicated R12's shower grievance should have been completed and R12 should have been offered twice weekly showers. NHA-A indicated R12's care plan, Kardex, and shower schedule should have been updated to twice weekly showers. NHA-A also indicated there should have been audits to ensure the grievance was addressed and R12's expectations were met. 3. From 4/21/25 to 4/23/25, Surveyor reviewed R186's medical record. R186 was readmitted to the facility on [DATE] and had diagnoses including methicillin-resistant Staphylococcus aureus (MRSA) infection, epilepsy, morbid obesity, above knee right leg amputation, urinary retention, and urinary tract infection. R186's MDS assessment, dated 4/10/25, indicated R186 required substantial/maximal assistance with showering/bathing, upper and lower body dressing, and putting on/taking off footwear. The MDS assessment had a BIMS score of 10 out of 15 which indicated R186 had moderately impaired cognition. On 4/21/25 at 12:53 PM, Surveyor interviewed R186 who indicated R186 would like a shower. R186 indicated R186 had not been offered a shower since R186 was admitted to the facility two weeks prior. R186's plan of care indicated R186 had an ADL self care performance deficit related to weakness, physical deconditioning, pain, and right above the knee amputation (initiated 4/8/25). The plan of care contained a goal that R186 will safely perform ADLs through the review date. The plan of care contained the following intervention: Bathing (Shower/Bath Self): The resident ranges from being independent to requiring partial/moderate assistance with personal hygiene (initiated 4/8/25). Surveyor noted R186's MDS assessment and plan of care contained conflicting information on the level of assistance R186 needed for showers/bathing. On 4/23/25, Surveyor reviewed the facility's shower schedule which indicated R186 was scheduled for a shower on the Monday PM shift. On 4/23/25 at 10:17 AM, Surveyor interviewed LPN-J who indicated LPN-J fills out a shower sheet for every resident shower. LPN-J indicated shower sheets need to be completed even if the resident refuses the shower and a nurse must still complete a skin check for the resident (which is documented on the shower sheet). LPN-J indicated shower sheets are given to DON-B. On 4/23/25, Surveyor requested shower sheets for R186 since R186's admission on [DATE]. On 4/23/25 at 11:15 AM, NHA-A indicated there were no shower sheets, refusals, or skin check sheets for R186. On 4/23/25 at 1:14 PM, Surveyor interviewed DON-B who indicated residents should be offered showers at least once weekly. DON-B indicated staff need to fill out a shower sheet or a refusal sheet and a nurse needs to complete a skin check even if the resident did not receive a shower. DON-B indicated a resident should be assigned a shower day upon admission. DON-B reviewed R186's medical record and confirmed there were no skin checks completed. DON-B indicated it was not acceptable that R186 had not received a shower since admission. On 4/23/25 at 2:44 PM, Surveyor interviewed NHA-A who indicated residents should be offered weekly showers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility did not provide pharmaceutical services to ensure the accurate administration of medication for 2 residents (R) (R23 and R189) of 3 sampled residents. On 4/22/25, staff administered R23's AM and noon medications more than an hour after the scheduled times. On 4/22/25, staff left R189's medications at the bedside for R189 to self-administer. R189 did not have a physician order to self-administer medication or a self-administration of medication assessment that indicated R189 could safely and accurately self-administer medication. Findings include: The facility's undated Medication Administration-General Guidelines policy indicates: Medications are administered as prescribed in accordance with good nursing principles and practices .Administration: .k. Medications are administered in accordance with written orders of the attending physician .o. Medications are only administered after the 5 rights have been reviewed .4) right time; .r. Medications are administered within 60 minutes of scheduled time .Residents are allowed to self-administer medication when specifically authorized by the attending physician and in accordance with procedures for self-administration of medication . The facility's Self-Administration of Medication policy, dated 4/2025, indicates: Purpose: To determine the ability of alert residents to participate in self-administration of medication. To maintain the safety and accuracy of medication administration .2. If a resident desires to participate in self-administration, the interdisciplinary team will assess and periodically re-evaluate the resident based on changes in the resident's status .4. If the resident is a candidate for self-administration of medication, this will be indicated in the medical record .9. Resident's care plan will be updated to reflect self-administration when applicable. 1. On 4/22/25, Surveyor reviewed R23's medical record. R23 was admitted to the facility on [DATE] and had diagnoses including quadriplegia, major depressive disorder, and history of urinary tract infections (UTIs). R23's Minimum Data Set (MDS) assessment, dated 3/21/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R23 was not cognitively impaired. R23 had a Guardian. On 4/22/25 at 2:01 PM, Surveyor observed Assisted Director of Nursing (ADON)-D prepare R23's noon medications. Per ADON-D, R23's noon medications should be administered during lunch time which was 11:00 AM to 1:00 PM. ADON-D verified R23's noon medications were late. ADON-D indicated R23's AM medications were administered at 10:30 AM and 11:00 AM which is why R23's noon medications were being administered at that time. R23's noon medications were administered at 2:14 PM. R23's Medication Administration Record (MAR) contained the following orders: ~ Buspirone 10 milligram (mg) tablet Give 10 mg three times daily at AM 06 (6:00 AM), Lunch, PM 15 (3:00 PM) ~ Baclofen 20 mg tablet Give 20 mg three times daily at AM 06 (6:00 AM), Lunch, PM 15 (3:00 PM) On 4/22/25 at 2:15 PM, Surveyor interviewed Director of Nursing (DON)-B who verified medication times are an hour before to an hour after the medication is scheduled. DON-B indicated a resident's MAR turns red if the resident's medications are more than an hour past the scheduled time. Surveyor informed DON-B of what Surveyor observed for R23. DON-B verified R23's medications were considered late. 2. On 4/22/25, Surveyor reviewed R189's medical record. R189 was admitted to the facility on [DATE] and had diagnoses including peripheral vascular disease (PVD) and cellulitis. R189's MDS assessment, dated 4/4/25, had a BIMS score of 15 out of 15 which indicated R189 was not cognitively impaired. R189 made R189's own medical decisions. On 4/22/25 at 7:34 AM, Surveyor observed ADON-D prepare R189's AM medication. R189's MAR contained the following orders: ~ Acetaminophen 500 mg Give 1000 mg three times daily ~ Acyclovir 400 mg tab Give 1 tablet twice daily ~ Multivitamin 1 tab Give 1 tablet once daily ~ Vitamin C 1000 mg Give 1000 mg by mouth once daily ~ Vitamin D 1000 international units (IU) Give 1000 units by mouth once daily ~ Prednisolone AC 1%, 1 drop to left eye once daily every other day On 4/22/25 at 7:40 AM, Surveyor observed ADON-D leave a cup with R189's AM medication on R189's bedside table. ADON-D then left R189's room, shut the door, and retrieved Arginaid (wound healing medication) from the medication storage room. R189's medical record did not contain a physician order to self-administer medication or a self-administration of medication assessment that indicated R189 could self-administer medication. On 4/22/25 at 7:47 AM and 8:15 AM, Surveyor interviewed ADON-D who verified ADON-D left R189's AM medication on the bedside table. ADON-D verified R189 did not have a physician order to self-administer medication. ADON-D indicated R189 was going to wait to take the medication. ADON-D indicated ADON-D usually stored prepared medication in a locked medication cart and usually did not leave medication with residents to self-administer without supervision.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not monitor for adverse reactions of a high-risk medication for 1 resident (R) (R86) of 5 sampled residents. R86 was prescribed gabapentin (an anticonvulsant medication). The facility did not monitor for adverse reactions or side effects of the high-risk medication. Findings include: Per medlineplus.gov, potential side effects of gabapentin include: Loss of balance or coordination, double vision, blurred vision, uncontrollable movements of the eyes, difficulty thinking or concentrating, difficulty speaking, headache, drowsiness, dizziness, diarrhea, constipation, loss of appetite, weight loss, nausea, vomiting, and uncontrollable shaking of a part of the body. Some side effects can be serious such as swelling of the face, throat, tongue, lips, and eyes, difficulty swallowing or breathing, hoarseness and seizures . On 4/21/25, Surveyor reviewed R86's medical record. R86 was admitted to the facility on [DATE] and had diagnoses including hemiplegia and hemiparesis following cerebral infarction (stroke) affecting the right dominant side and long-term use of anticoagulants (blood thinning medication). R86's Minimum Data Set (MDS) assessment, dated 4/4/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R86 was not cognitively impaired. R86's medical record contained the following order: ~ Gabapentin capsule 400 milligrams (mg). Give 1 capsule by mouth once daily for neuropathic pain. Give 1 capsule by mouth in the afternoon for neuropathic pain. Give 1 capsule by mouth at bedtime for restless leg syndrome. R86's medical record did not indicate R86 was monitored for adverse reactions/side effects of gabapentin. On 4/23/25 at 3:05 PM, Surveyor interviewed Director of Nursing (DON)-B who reviewed R86's medical record and confirmed R86's medical record did not contain monitoring interventions for adverse reactions/side effects of gabapentin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure 1 resident (R) (R187) of 5 sampled residents was monitored for adverse reactions to psychotropic medication. R187 had an order for paliperidone (an antipsychotic medication). R187's medical record did not contain an Abnormal Involuntary Movement Scale (AIMS) assessment (a rating scale designed to measure involuntary movements known as tardive dyskinesia which is a disorder that can develop as a side-effect of long-term treatment with antipsychotic medication) for the use of paliperidone. Findings include: The facility's Use of Psychotropic Medication(s) policy, dated 12/2024, indicates: .1. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include, but are not limited to the following categories: antipsychotics, antidepressants, antianxiety, and hypnotics .13. Residents who receive an antipsychotic medication will have an Abnormal Involuntary Movement Scale (AIMS) test performed on admission, quarterly, with a significant change in condition, change in antipsychotic medication, as needed (PRN), or per facility policy . On 4/23/25, Surveyor reviewed R187s medical record. R187 was admitted to the facility on [DATE] and had diagnoses including vascular dementia, paranoid schizophrenia, portal vein thrombosis, and atrial fibrillation. R187's Minimum Data Set (MDS) assessment, dated 4/4/25, had a Brief Interview for Mental Status (BIMS) score of 15 of 15 which indicated R187 was not cognitively impaired. R187 had an order for paliperidone (an antipsychotic medication used to treat mental disorders including schizophrenia). R187's medical record did not contain an AIMS assessment. On 4/23/25, Surveyor asked to review R187's AIMS assessment. On 4/23/25 at 3:15 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated that facility did not have an AIMS assessment for R187. On 4/23/25 at 4:07 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-D who indicated an initial AIMS assessment should have been completed on the day of admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection. This practice had the potential to affect more than 4 of the 39 residents residing in the facility. Enhanced Barrier precautions (EBP) were not implemented for R187 who had an indwelling urinary catheter. Staff did not complete appropriate hand hygiene after providing care for R6. Residents were not offered hand hygiene prior to the lunch meal on 4/22/25. Finding includes: The facility's ICPC Standard and Transmission-Based Precautions (TBP) policy, dated 2/2025, indicates: .Enhanced Barrier Precautions (EBP): Expand the use of personal protective equipment (PPE) and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of multidrug-resistant organisms (MDROs) to staffs' hands and clothing then indirectly transferred to residents or from resident to resident (e.g., residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs.) A. The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with: i. Wounds and/or indwelling medical devices regardless of MDRO colonization; ii. MDRO infection or colonization .C. Examples of high-contact resident care activities requiring gown and glove use for enhanced barrier precautions include: i. dressing; ii. bathing/showering; iii. transferring; iv. providing hygiene; v. changing linens; vi. changing briefs or assisting with toileting; vii. device care or use: central vascular line (including hemodialysis catheters) indwelling urinary catheter, feeding tube, tracheostomy/ventilator .vii. wound care: any skin opening requiring a dressing . The facility's Infection Control Policy/Procedure for Laundry Services, dated 3/2025, indicates: It is the policy of this facility to ensure a clean supply of linens and to protect employees who handle and process the laundry. 1. Routine handling of soiled linens: A. Soiled linen should be handled as little as possible and with a minimum of agitation to prevent gross microbial contamination of the air and of persons handling the linen. B. All soiled linen should be bagged or put into carts at the location where used . The facility's Hand Washing policy, dated 3/2025, indicates: It is the policy of this facility to cleanse hands and prevent transmission of possible infectious material and provide a clean, healthy environment for residents and staff .For specific hand washing and waterless hand hygiene procedures, the facility refers to the Centers for Disease Control and Prevention (CDC) and the World Health Organization current guidelines. The Centers for Disease Control and Prevention (CDC) About Handwashing information from CDC.gov, dated 2/16/24, indicates: Many diseases and conditions are spread by not washing hands with soap and clean, running water. Hand washing with soap is one of the best ways to stay healthy. If soap and water are not readily available, use a hand sanitizer with at least 60% alcohol to clean your hands. Washing hands can keep you healthy and prevent the spread of respiratory and diarrheal infections. Germs can spread from person to person or from surface to person when you: Touch your eyes, nose, and mouth with unwashed hands; Prepare or eat food and drinks with unwashed hands; Touch surfaces or objects that have germs on them; Blow your nose, cough, or sneeze into your hands and then touch other peoples' hands or common objects. You can keep yourself and your loved ones healthy by washing your hands often, especially during key times when you are likely to get and spread germs: Before, during, after preparing food; Before and after eating food . The facility's Meal, Preparing Resident for policy, dated 5/2024, indicates: .9. Encourage and assist residents to wash his/her hands and face before receiving the meal or to use wipes available in the dining areas . 1. From 4/21/25 to 4/23/25, Surveyor reviewed R187's medical record. R187 was admitted to the facility on [DATE] and had diagnoses including cerebral infarction, vascular dementia, urinary retention, and urinary device. R187 had an indwelling urinary catheter. R187's Minimum Data Set (MDS) assessment, dated 4/4/25, had a Brief Interview for Mental Status (BIMS) score of 15 of 15 which indicated R187 was not cognitively impaired. On 4/21/25 at 1:01 PM, Surveyor interviewed R187 and noted there was not an EBP sign or a PPE cart near the entrance to R187's room. R187 indicated staff complete catheter care for R187 approximately 4 to 5 times per day. Surveyor also noted there was not a PPE cart inside the room. On 4/23/25 at 10:08 AM, Surveyor interviewed R187 and observed an EBP sign on the wall near the entrance to R187's room and a PPE cart near the foot of R187's bed. R187 was unsure why the cart was place there and indicated staff recently put it there. When asked if staff wear gowns and gloves during catheter care, R187 stated staff wear gloves but do not wear gowns. R187's medical record contained a physician order, dated 3/27/25, for a 16 French Foley catheter and Foley catheter care per facility policy. R187's plan of care contained an intervention for catheter care beginning 4/2/25. R187's plan of care also indicated R187 should be on EBP (initiated 4/2/25). On 4/23/25 at 10:52 AM, Surveyor interviewed Director of Nursing (DON)-B who was also the facility's Infection Preventionist (IP). DON-B indicated DON-B put an EBP sign near R187's door on the evening of 4/21/25. DON-B verified R187 should have been on EBP prior to 4/21/25 since R187 returned from the hospital with a catheter. When asked why R187 was not on EBP from 3/27/25 to 4/21/25, DON-B indicated it was missed. 2. On 4/21/25 at 12:20 PM, Surveyor observed Certified Nursing Assistant (CNA)-F exit R6's room with a clear plastic bag of unknown items in one hand and a Hoyer sling in the other hand. Surveyor noted CNA-F was not wearing gloves. CNA-F walked down the hall to two covered receptacles. CNA-F unsnapped the lid of one receptacle, placed the plastic bag inside, and snapped the lid in place. CNA-F then unsnapped the lid of the second receptacle, put the Hoyer sling and another item in the receptacle, and snapped the lid in place. Without completing hand hygiene, CNA-F then walked down the hall and into the dining room to assist residents. On 4/21/25 at 12:22 PM, Surveyor attempted to interview CNA-F who indicated CNA-F was in the middle of getting residents out of the dining room and did not have time to talk to Surveyor. On 4/21/25 at 1:25 PM, Surveyor interviewed CNA-F who became agitated when Surveyor asked what was in the clear plastic bag that Surveyor observed CNA-F carrying at 12:20 PM. CNA-F indicated the bag contained a poopy diaper. CNA-F indicated CNA-F also carried a soiled Hoyer sling and a resident's pants and put them in the laundry receptacle. CNA-F verified CNA-F should have completed hand hygiene after placing the items in the receptacles but indicated CNA-F only lifted the garbage lids and did not put CNA-F's whole hand inside. CNA-F then unsnapped the lid of a nearby garbage receptacle with bare hands, lifted the lid, waved a hand over the garbage, and snapped the lid back in place. CNA-F did not complete hand hygiene after touching the garbage can lid. Surveyor then observed CNA-F use a touch screen on the wall with a bare hand directly after opening the garbage can. When Surveyor asked if CNA-F should have completed hand hygiene after touching the garbage can, CNA-F forcefully put CNA-F's hand under a hand sanitizer dispenser causing hand sanitizer to get on the touch screen and Surveyor. CNA-F completed hand hygiene and yelled, There are you happy now? CNA-F then left the area. On 4/23/25 at 1:14 PM, Surveyor interviewed DON-B who indicated the proper procedure to remove soiled linens and clothing from a resident's room is to bag the items for transport and complete hand hygiene immediately after placing the items in the soiled linen receptacle. DON-B indicated staff should complete hand hygiene after depositing garbage in the garbage receptacle before doing anything else. 3. On 4/22/25 at 11:30 AM, Surveyor observed the noon meal and noted there were 20 residents in the dining room. Surveyor noted there were no sanitizing hand wipes on the tables. At 11:39 AM, the lunch meal was served to the residents. At 11:45 AM, Surveyor observed R5 arrive in the dining room. R5 was served drinks and a meal but was not offered hand hygiene prior to eating. At 12:04 PM, R26 entered the dining room. At 12:06 PM, R26 was served drinks and a meal but was not offered hand hygiene prior to eating. On 4/22/25 at 11:59 AM, Surveyor interviewed R188 who indicated R188 was not offered hand hygiene prior to the meal. On 4/22/25 at 12:28 PM, Surveyor interviewed R26 who indicated R26 was not offered hand hygiene before the meal and was not usually offered hand hygiene before meals. On 4/22/25 at 12:34 PM, Surveyor interviewed Lead [NAME] (LC)-H who indicated CNAs should offer residents hand hygiene before meals. LC-H indicated there are hand wipes available for residents and showed Surveyor the hand wipes in the dining room. LC-H indicated the CNAs in the dining room for lunch were CNA-F and CNA-I. On 4/22/25 at 1:04 PM, Surveyor interviewed DON-B who indicated residents should be offered hand hygiene prior to meals. DON-B indicated residents should be offered hand sanitizing wipes or a pump of hand sanitizer gel to sanitize hands before eating. On 4/22/25 at 1:24 PM, Surveyor interviewed CNA-F who indicated CNA-F did not offer residents hand hygiene during the lunch meal. When Surveyor asked why hand hygiene was not offered, CNA-F replied, I don't know. I couldn't tell you. On 4/23/25 at 2:44 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated staff have been trained and should follow the facility's infection control and hand hygiene policies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure an allegation of neglect was reported to the State Agency (SA) for 1 resident (R) (R1) of 3 sampled residents. On 7/18/24, R1 had a fall with major injury. R1's care plan contained an intervention for a sensor alarm on R1's bed. The facility's fall investigation indicated a sensor alarm was not on R1's bed at the time of the fall. The facility did not report the potential neglect to the SA. Findings include: The facility's Abuse Prevention policy, with a revision date of July 2024, indicates: It is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation .Identification of Abuse - Identify events, such as but not limited to, suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse; and to determine the direction of the investigation. 1. Bruises, skin tears and injuries of unknown source will be investigated to rule out abuse .Investigation - All identified events are reported to the Administrator/Designee immediately and will be thoroughly investigated .The investigation shall consist of: .5. An interview with staff members (on all shifts) having contact with the resident(s) during the period of the alleged incident; .Reporting/Response - All alleged violations will be reported via phone or in writing within 2 hours to the State Licensing Agency. The facility shall follow-up to the State Licensing Agency in writing the findings and results of the completion of the investigation within 5 days .Definitions - Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . On 9/11/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including dementia, left humerus fracture, and hypertension. R1's Minimum Data Set (MDS) assessment, dated 6/14/24, stated R1's Brief Interview for Mental Status (BIMS) score was 2 out of 15 which indicated R1 had severe cognitive impairment. R1's medical record indicated R1 had an activated Power of Attorney for Healthcare (POAHC). A fall investigation indicated R1 had an unwitnessed fall in R1's room on 7/18/24 at approximately 3:45 AM. R1 was found on R1's back on the floor. R1's bed was in the lowest position and a floor mat was in place. When asked what happened, R1 stated, I was trying to walk. An assessment indicated R1's vital signs, neurological checks, and range of motion to left upper and lower extremities were at baseline. R1 complained of right upper extremity and right hip/lower extremity pain with movement. A Hoyer lift was used to assist R1 into bed. A Hospice nurse arrived to assess R1 and discussed R1's condition with R1's POAHC. The Hospice nurse and R1's POAHC decided to have staff monitor R1 throughout the day to determine if further measures should be taken. Pain medication was administered to ensure comfort for any complaints or signs of pain. Due to R1 guarding R1's right hip and upper right thigh, an order was received at approximately 3:00 PM to obtain an X-ray of R1's right hip. An X-ray was obtained at the facility on 7/18/24 at approximately 5:20 PM. Per the guidance of the Hospice nurse and R1's POAHC, the facility continued previously ordered Hospice comfort medication and repositioning to ensure comfort. The X-ray report, dated 7/19/24, indicated R1 had an acute basil cervical right femoral neck fracture. Following Hospice, Medical Doctor (MD), and POAHC notification, a decision was made to keep R1 comfortable with appropriate pain management in the facility. On 7/19/24 at 10:10 AM, R1 passed away. The fall investigation indicated 20 staff were interviewed regarding the use of a sensor alarm on R1's bed. Approximately half of the staff remembered a bed alarm in use for R1 and the other half did not remember ever seeing a bed alarm in use for R1. On 9/11/24 at 12:30 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-D via telephone. CNA-D indicated CNA-D observed R1 lying sideways on the floor following R1's fall on 7/18/24. R1's bed was in a low position and a fall mat was on the floor. CNA-D indicated there was not a sensor alarm on R1's bed. On 9/11/24 at 2:30 PM, Surveyor interviewed Regional Administrator (RA)-C who indicated the facility initiated an investigation on 7/19/24 and did not have a clear picture of the circumstances surrounding the fall at that time. RA-C indicated the facility identified on 7/22/24 that staffs' use of R1's bed alarm was inconsistent with R1's care plan. RA-C verified R1's fall with injury was not reported to the SA. RA-C indicated the facility didn't think the fall would be considered or classified as neglect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure the provision of an assistive device to prevent accidents for 1 resident (R) (R1) of 3 sampled residents. R1's plan of care contained an intervention for a sensor alarm on R1's bed. On 7/18/24 at 3:45 AM, R1 sustained a fall with injury. The sensor alarm was not in place at the time of the fall. Findings include: The facility's Falls Program policy, revised 9/2024, indicates: It is the policy of this facility to reduce the number and severity of falls and to identify high risk residents and take precautionary measures .Falls Interdisciplinary Team (IDT): .2. When a fall occurs, the Falls IDT will meet the next business day to discuss the fall, interventions, and review risk management. A Fall IDT note will be made regarding the fall. Risk Management will be left open for 7 days with the IDT to re-evaluate effectiveness of interventions. A closing Fall IDT note will be completed after 7 days. The Director of Nursing (DON) and the Nursing Home Administrator (NHA) will sign a Risk Management and Lock Assessment. The facility's Fall Program policy also indicates: It is the policy of this facility to develop an acute care plan post-fall. Purpose: To implement interventions that assure maximum resident safety . On 9/11/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including dementia, left humerus fracture, and hypertension. R1's Minimum Data Set (MDS) assessment, dated 6/14/24, stated R1's Brief Interview for Mental Status (BIMS) score was 2 out of 15 which indicated R1 had severe cognitive impairment. R1's medical record indicated R1 had an activated Power of Attorney for Healthcare (POAHC). R1's care plan, dated 8/5/21, indicated R1 was at risk for falls related to a history of falls. The care plan contained a goal that R1 would not sustain serious injury through the review date. The care plan contained the following interventions: ~ Bed in the lowest position (initiated 6/7/24) ~ Sensor alarm on bed (initiated 5/7/24) ~ Floor mats at bedside when sleeping (initiated 4/22/24) A nursing progress note, dated 5/10/24 at 3:56 PM, indicated R1 fell on 5/7/24 and obtained a skin tear. An alarm was placed as an immediate intervention due to R1's continued attempts to self-transfer. R1's POAHC and the IDT were in agreement with the intervention. Surveyor reviewed R1's fall history. R1 had numerous falls within the past year, including 3 falls in July of 2024 (76/24, 7/14/24, and 7/18/24). On 7/18/24 at 3:45 AM, R1 had an unwitnessed fall in R1's room. At the time of the incident on 7/18/24, R1 was found on the floor with R1's bed in the lowest position and a floor mat in place; however, there was no sensor alarm on R1's bed. On 9/11/24 at 12:30 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-D via telephone. CNA-D indicated during rounds on 7/18/24, CNA-D heard R1 call for help and yell louder as CNA-D approached R1's room. CNA-D indicated R1 was lying sideways behind R1's wheelchair. R1's bed was in a low position and a fall mat was on the floor. CNA-D indicated there was not a sensor alarm on R1's bed and R1 usually didn't have a bed alarm. CNA-D notified the nurse and an assessment was completed. Surveyor reviewed a fall investigation for R1's fall on 7/18/24. The investigation indicated 20 staff were interviewed regarding the use of a sensor alarm on R1's bed. Approximately half of the staff remembered a bed alarm and the other half did not remember ever seeing a bed alarm in use for R1. On 9/11/24 at 2:33 PM, Surveyor interviewed Regional Administrator (RA)-C who verified a sensor alarm was not in place at the time of R1's fall on 7/18/24. RA-C verified R1's care plan included an intervention for a sensor alarm on R1's bed and indicated the sensor alarm should have been in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure monitoring of high-risk medications for 1 Resident (R) (R140) of 5 sampled residents. The facility did not monitor R140 for adverse effects of anticoagulant, antidepressant, and diuretic medication. Findings include: MEDSCAPE (a web based medical resource [DATE]) identifies warfarin as an anticoagulant medication that reduces the formation of blood clots in veins or arteries, which can reduce the risk of stroke, heart attack or other serious conditions. Adverse reactions/side effects include: hemorrhage (bleeding), intraocular hemorrhage, abdominal pain, flatulence, alopecia (hair loss), rash, pruritus (itching), taste disturbance, tissue necrosis, headache, lethargy, dizziness, anemia, hepatitis, respiratory tract bleeding, hypersensitivity reaction, blood dyscrasias (disease or disorders of blood), fever, purple toe syndrome, and increased fracture risk with long-term usage. MEDSCAPE identifies sertraline as an antidepressant medication that includes the following common side effects: dry mouth, drowsiness, dizziness, insomnia, fatigue, hyperhidrosis (excessive sweating), tremor, anorexia, weight loss, headache, nausea, flatulence, diarrhea, acute abdominal pain, dyspepsia, and agitation. MEDSCAPE identifies furosemide as a diuretic medication that helps the body get rid of extra water and includes the following common side effects: orthostatic hypotension (low blood pressure caused by change in position from sitting or lying to standing ), blurred vision, anorexia, headache, diarrhea, abdominal pain with cramps, drowsiness, dizziness, muscle spasm, weakness, confusion, fainting, nausea/vomiting, unusual dry mouth/thirst, and fast/irregular heartbeat. On 2/21/24, Surveyor reviewed R140's medical record. R140 was admitted to the facility on [DATE] and had diagnoses including atrial fibrillation, hypertension, lymphedema (swelling), diabetes mellitus type 2, and major depressive disorder. R140's Baseline Care Plan (CP) was completed on 2/19/24. R140's Comprehensive CP was initiated on 2/18/24 and had a due date for completion of 3/8/24. R140 had a physician order, dated 2/21/24, for warfarin sodium oral tablet give 2 mg (milligrams) by mouth one time a day every Monday Tuesday, Thursday, Friday, and Sunday until 3/19/24 and give 3 mg by mouth one time a day every Wedneday and Saturday until 3/19/24. Surveyor noted R140 did not have a care plan that addressed anticoagulant use and monitoring interventions for adverse reactions of warfarin. R140 had a physician order, dated 2/17/24, for sertraline HCl oral tablet give 25 mg by mouth one time a day for major depressive disorder. Surveyor noted R140 did not have a care plan that addressed antidepressant use and monitoring interventions for adverse reactions of sertraline. R140 had a physician order, dated 2/17/24, for furosemide oral tablet give 40 mg by mouth one time a day for fluid retention in legs. Surveyor noted R140's medical record did not include monitoring for adverse reactions of furosemide and R140 did not have a care plan that addressed diuretic use and monitoring interventions for adverse reactions of furosemide. On 2/21/24 at 9:24 AM, Surveyor interviewed Director of Nursing (DON)-B who verified residents prescribed high-risk medications, such as warfarin, sertraline, and furosemide, should have monitoring interventions for side effects and adverse reactions in their plan of care. DON-B confirmed R140 was prescribed warfarin, sertraline, and furosemide upon admission on [DATE]. DON-B also verified R140's Baseline CP and current Comprehensive CP did not contain adverse reactions or side effect monitoring for the high risk medications.

Based on observation, record review and staff interview, the facility did not ensure privacy was maintained for 3 Residents (R) (R16, R28 and R29) of 4 residents reviewed for privacy. R16's room contained a monitor with video and audio capabilities brought in by R16's roommate's (R28) health care decision maker. The monitor was installed in the shared room without R16's knowledge or consent. R28's room contained a monitor with video and audio capabilities. R28's medical record did not contain a signed consent for the monitor to be placed in R28's room. R29's room contained a monitor with video and audio capabilities brought in by R29's roommate's (R8) Power of Attorney (POA). The monitor was installed in the shared room without R29's knowledge or consent. Findings include: The facility's Use of Electronic Monitoring Equipment in Resident Rooms document dated 7/10/2019, contained the following information: The facility is committed to the promotion of the safety of residents and to the maintenance of an environment conductive to the delivery of quality healthcare while preserving the privacy rights of all residents. Accordingly, the facility has restrictions in the use of video devices to record the activities of residents during the course of their admission .The purpose of this policy is to establish guidelines relative to the act of electronically monitoring the activities of individual residents at the request and with the consent of the resident or his/her responsible party, and simultaneously preserving the safety and privacy of all residents and employees. Terms: 1. The resident or the resident's responsible party must consent, in writing (and supply monitoring device), to the placement of the video device in the residents room .3. The video device cannot have audio capabilities, nor shall audio be obtained via use of a camera or recording device, due to privacy concerns of other residents and staff . 1. On 2/15/23, Surveyor reviewed R16's medical record. R16 was admitted to the facility with diagnoses to include displaced intertrochanteric fracture of right femur (fractures of the proximal thigh bone), Alzheimer's disease, dementia, major depressive disorder and anxiety disorder. R16's Minimum Data Set (MDS) assessment, dated 12/20/22, contained a Brief Interview for Mental Status (BIMS) score of 6 which indicated R16 had severely impaired cognition. R16 also required extensive assistance with activities of daily living (ADLs) and had an activated health care decision maker. R16's medical record did not contain documentation or consent that an audio/video monitor was placed in R16's shared bedroom. 2. On 2/15/23, Surveyor reviewed R28's medical record. R28 was admitted to the facility with diagnoses to include nutritional problem related to congestive heart failure, chronic kidney disease stage 3, diabetes and morbid obesity. R28's MDS assessment, dated 12/13/22, contained a BIMS score of 3 which indicated R28 had severe cognitive impairment. R28 also required moderate to extensive assistance for ADLs and had an activated health care decision maker. R28's care plan dated, 1/12/23, stated R28 was At risk for falls related to weakness, history of falls. The care plan contained the following intervention: Video/audio monitor placed in room, to be kept at nursing station. Resident aware of monitor. Monitor placed per family request. On 2/15/23 at 1:50 PM, Surveyor observed the shared room of R16 and R28 and noted a video camera, with what appeared to be a speaker on the bottom, located on a dresser positioned toward the right side of the shared bedroom. Surveyor noted the camera was pointed away from both beds and was positioned backwards. On 2/15/23 at 1:55 PM, Surveyor observed a monitor with a speaker and video screen located at the nurses' station. Surveyor interviewed Licensed Practical Nurse (LPN)-E who stated the camera was turned around and positioned toward R28's bed when R28 was in bed. LPN-E confirmed audio was available on the unit and stated facility staff keep the volume low during the day because R28 and R16 had family visits which were R28 and R16's private time. LPN-E verified the monitor picked up audio of R16 during the day and night. On 2/15/23 at 2:06 PM, Surveyor interviewed Nursing Home Administrator Consultant (NHAC)-C. NHAC-C was not aware R16 and R28 had a video/audio monitor in their room with a corresponding monitor at the nurses' station. NHAC-C stated NHAC-C was aware another resident had a monitor and stated the resident's health care decision maker was responsible for purchasing the equipment and consent was obtained to place the monitor in the resident's room. Surveyor requested the facility's policy regarding the use of electronic monitoring equipment as well as consents for the monitor in R16 and R28's shared room. On 2/15/23 at 2:10 PM, Surveyor interviewed LPN-F. Surveyor observed LPN-F turn up the volume of R16 and R28's monitor at the nurses' station while another Surveyor went to R16 and R28's room to conduct an audio test of the monitor. Surveyor at the nursing station heard Surveyor in R16 and R28's room clearly state test, test which confirmed the audio on the monitor was enabled and available. Surveyor in R16 and R28's room verified Surveyor stood in the middle of the room to conduct the audio test. On 2/15/23 at 3:03 PM, Surveyor interviewed R16. R16 indicated no knowledge of what the video/audio monitor was when questioned by Surveyor. R16 further stated R16 was not aware conversations between R16 and anyone who visited R16's room were able to be heard via the corresponding monitor in the nurses' station. R16 verified R16 did not consent to having a video/audio monitor in R16's shared bedroom. 3. On 12/15/23, Surveyor reviewed R29's medical record. R29 was admitted to the facility with diagnoses to include diabetes, arthritis and Parkinson's disease. R29's MDS assessment, dated 12/13/22, contained a BIMS score of 10 which indicated R29 had moderately impaired cognition. On 2/15/23 at 1:55 PM, Surveyor observed a video monitoring device at the East wing nurses' station. Surveyor interviewed LPN-E regarding the video monitoring device. LPN-E stated the monitoring device was brought in by Power of Attorney (POA)-M to monitor R8 and was at the nurses' station for at least five years. LPN-E also confirmed the monitoring device had audio capability and R8's roommate (R29) could be heard on the monitor. On 2/15/23 at 2:04 PM, Surveyor entered R29's room and noted the video/audio monitor was placed on a radio on top of a three-drawer cabinet between the television and the bathroom door. Surveyor interviewed R29 regarding the monitor. R29 stated R29 was not aware of the monitor and did not give consent for the monitor to be installed in the shared room. R29 stated, It's no big deal, but I would like to know about it. On 2/15/23 at 2:06 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and NHAC-C regarding the video/audio monitors. Both NHA-A and NHAC-C stated they were unsure if consents were signed by R16, R28 and R29. NHA-A and NHAC-C also stated R16 and R29 were probably not aware of the monitors. On 2/15/23 at 2:08 PM, Surveyor entered R29's room to test audio on the video/audio monitor while another Surveyor was at the nurses' station. Surveyor stood in front of the monitor in the middle of R29's shared room and stated test, test. Surveyor at the nurses' station confirmed test, test verbalized by the Surveyor in R29's room was heard via the monitor at the nurses' station. The facility was unable to provide Surveyor consents for placement of the video/audio monitors in the shared bedrooms of R16, R28 and R29.

Based on record review and staff interview, the facility did not implement its written policies and procedures to ensure 1 (Licensed Practical Nurse (LPN)-L) of 8 staff had a thorough background check completed every four years. LPN-L was hired on 6/1/14. The facility was not able to provide proof LPN-L had Department of Justice (DOJ) or Integrated Background Information System (IBIS) letters completed within the past four years as required. Findings include: The Wisconsin Caregiver Program Manual for Entities Regulated by the Division of Quality Assurance (P-00038 updated 2/2016) states, After the initial background check at the time of employment or contracting, entities must conduct new caregiver background checks at least every four years or at any time within that period that an entity has reason to believe new checks should be obtained. Surveyor reviewed facility's Abuse: Prevention and Prohibition Against policy contained the following information: Screening: 2. The Facility will not hire or retain any person, directly or indirectly who: ~Has been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; ~Has had a finding entered into the State nurse aide registry or Office of Inspector General database concerning abuse, neglect, mistreatment of residents and of misappropriation of their property; or ~Has disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. On 2/13/23, Surveyor selected a sample of employees to review for background check compliance, including LPN-L. On 2/14/23, the facility provided Surveyor with the requested background check documents. Surveyor reviewed the provided caregiver background check records which included DOJ and IBIS letters, dated 10/17/17, for LPN-L. On 2/14/23 at 1:45 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated that was the most recent background information the facility had for LPN-L. On 2/14/23 at 1:49 PM, Surveyor interviewed Nursing Home Administrator Consultant (NHAC)-C who confirmed NHAC-C expected employee background checks were conducted every four years.

Based on record review and resident, family and staff interview, the facility did not ensure 1 Resident (R) (R13) of 2 residents reviewed received assistance with arrangements for an audiology (ear doctor) appointment to obtain hearing aids. The facility did not assist R13 with scheduling an audiology appointment in order to obtain hearing aids. Findings include: From 2/13/23 through 2/15/23, Surveyor reviewed R13's medical record. R13 was responsible for R13's own decision making. R13's Minimum Data Set (MDS) assessment, dated 11/22/22, contained a Brief Interview for Mental Status (BIMS) score of 15 which indicated R13 had intact cognition. R13's medical record indicated R13's last audiology appointment was on 8/12/21. On 2/13/23 at 1:19 PM, Surveyor interviewed R13. R13 stated R13 did not have hearing aids and wanted hearing aids. Surveyor noted R13 was unable to hear adequately and repeatedly asked Surveyor to repeat questions. R13 was only able to hear adequately when Surveyor was close to R13 and increased the volume of Surveyor's voice. On 2/14/23 at 1:16 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-K who verified R13 did not have hearing aids. On 2/14/23 at 2:20 PM, Surveyor interviewed R13's spouse who indicated R13 requested hearing aids during a care conference on 1/4/23. The facility stated R13 needed a hearing test first; however, R13 has not heard anything from the facility. R13's spouse stated they informed the facility they wanted R13 to have hearing aids in order to converse and hear visitors adequately without repeatedly asking, What did you say? On 2/14/23 at 1:21 PM, Surveyor interviewed Social Worker (SW)-J who confirmed hearing aids were discussed at R13's care conference on 1/4/23. On 2/15/23 at 9:38 AM, Surveyor interviewed R13 regarding the care conference. R13 stated R13 informed staff R13 wanted hearing aids and R13's spouse agreed. R13 stated staff informed R13 hearing aids might fall out in bed; however, R13 still wanted hearing aids. During the interview, Surveyor repeated questions several times in order for R13 to adequately hear. R13 confirmed the facility has not followed up on R13's request for hearing aids. On 2/15/23 at 10:18 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Nursing Home Administrator Consultant (NHAC)-C who confirmed the facility should have followed up on R13's request for hearing accommodation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview and record review, the facility did not ensure food accommodations were made for 2 Residents (R) (R190 and R14) of 2 residents with food allergies or intolerances. R190's medical record documented R190 was allergic to egg whites. R190's meal ticket did not contain the allergy and R190 was served eggs on multiple occasions. R14's medical record documented R14 was allergic to pineapple. R14's meal ticket did not contain the allergy. Findings include: Wisconsin Food code 2022 documents at section 3-101.11 Safe, Unadulterated, and Honestly Presented. food shall be safe, unadulterated, and, as specified under § 3-601.12, honestly presented. Note: The following common ingredients may cause allergic reactions: eggs (albumen, whites, meringue); Milk and Milk Products (Whey, Nonfat Dry Milk, Casein, Sodium Caseinate etc.); Peanuts (peanut butter, unrefined peanut oil, and flour); Wheat & Wheat Proteins (malt, caramel color, flour); Tree Nuts (almonds, walnuts, pecans, etc.; each is a separate allergen, or the unrefined oils of these products); Soybeans and Soy Products (hydrogenated soy protein, tofu, and unrefined soybean oil); fish; Shellfish; and Crustaceans. Note: The following common ingredients may cause adverse reactions: Monosodium Glutamate, Strawberries, Chocolate, Sulfites, and food colors. The facility's food allergies policy contained the following information: Residents with food allergies and/or intolerances will be identified upon admission and steps will be taken to prevent resident exposure to allergen(s). 1. From 2/13/23 to 2/15/23, Surveyor reviewed R190's medical record. R190 was admitted to the facility with diagnoses to include congestive heart failure, chronic kidney disease, major depression, anxiety and hypokalemia (low potassium). R190's Minimum Data Set (MDS) assessment, dated on 2/13/23, contained a Brief Interview for Mental Status (BIMS) score of 15 which indicated R190 had intact cognition. R190's medical record also documented R190 had allergies to include egg whites with hives as the reaction. The allergy was added to R190's medical record on 5/27/22 from R190's admission. On 2/14/23 at 8:33 AM, Surveyor observed R190's breakfast meal and noted the following items on R190's plate: toast, scrambled eggs, banana, oatmeal and coffee. R190 stated if R190 consumed eggs, hives would develop all over R190's body. R190 stated R190 did not inform dietary staff who delivered the breakfast tray because R190 told staff too many times already. R190 stated R190 would eat the other foods, but not the eggs. Surveyor reviewed R190's meal ticket which read on one side: Breakfast Menu: hot or cold cereal, scrambled eggs, toast, banana. The other side of R190's meal card contained R190's name, diet and beverage textures and R190's dining location. Surveyor noted the following date and time in the bottom left hand corner: 2/9/2023 7:13 AM. Surveyor did not observe any allergies noted on R190's meal ticket. On 2/13/23 at 9:38 AM, Surveyor interviewed R190 who stated R190 continued to receive eggs for breakfast, although R190 was allergic to egg whites and has informed dietary aides multiple times when R190's breakfast trays was delivered. On 2/14/23 at 1:55 PM, Surveyor reviewed R190's lunch meal ticket. Surveyor noted the ticked contained a date of 2/14/23, but did not note any allergies or dislikes. On 2/14/23 at 1:01 PM, Surveyor interviewed R190 and R190's spouse who both indicated R190 informed the facility of R190's raisin dislike and allergic reaction to egg whites. On 2/15/23 at 9:33 AM, Surveyor again interviewed R190 who stated dietary aides were informed multiple times of R190's egg allergy; however, no substitutes were offered. On 2/15/23 at 10:05 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A regarding food allergies. NHA-A stated NHA-A expected the admission nurse to obtain allergies from a resident's hospital discharge/admission paperwork. NHA-A stated the admission nurse was expected to enter the allergies in the resident's medical record and on a communication form to be sent to the dietary department. On 2/15/23 at 10:43 AM, Surveyor interviewed Director of Nursing (DON)-B who stated DON-B expected the admitting nurse to be thorough and ensure food allergies were documented on the Dietary Communication form. On 2/14/23 at 2:42 PM, Surveyor interviewed Dietary Aide (DA)-G who stated dietary information entered into the menu matrix and printed on meal tickets depended on what the admission nurse filled out on the Dietary Communication form because dietary staff did not utilize medical records. On 2/14/23 at 2:56 PM, Surveyor and DA-G both reviewed R190's Dietary Communication form, dated 2/7/23. DA-G verified there were no food allergies documented. On 2/14/23 at 11:31 AM, Surveyor reviewed R190's Nutrition admission Evaluation, dated 6/1/22, and noted the following information: Dislikes: eggs allergic, raisins. On 2/15/23 at 8:57 AM, Surveyor reviewed R190's Initial admission Record, dated 2/7/23, and noted an egg white allergy was documented in addition to other allergies. On 2/15/23 at 9:04 AM, Surveyor reviewed R190's Nutrition/Hydration Risk Evaluation, dated on 2/10/23 and noted under section VIII: Food Preferences: Food-Related Allergy/Intolerance was not checked to include egg whites. On 2/15/13 at 10:29 AM, Surveyor reviewed R190's hospital Discharge summary, dated [DATE], and noted egg white was documented as an allergy along with other allergies. 2. On 2/14/23, Surveyor reviewed R14's medical record. R14 was admitted to the facility on [DATE] with diagnoses to include diabetes with diabetic chronic kidney disease (uncontrolled diabetes causing kidney disease by damaging blood vessels and tiny filters called nephrons in the kidneys), morbid obesity and depression. R14's MDS, dated [DATE], contained a BIMS score of 15 which indicated R14 had intact cognition and required moderate to extensive assistance with activities of daily living (ADLs). On 2/14/23 at 11:28 AM, Surveyor interviewed DA-G regarding the process for identifying food allergies. DA-G stated food allergies were communicated to dietary staff at admission as nursing staff completed the resident's Diet Communication form and provided the form to kitchen staff. DA-G verified Diet Communication forms were obtained at admission for all residents and food allergies were added to the resident's meal ticket which was used for every meal service. DA-G stated the process was done in order to ensure food allergens were not served to residents with food allergies. On 2/14/23 at 12:39 PM, Surveyor interviewed R14. R14 stated R14 had an allergy to fresh pineapple. R14 provided Surveyor with lunch meal ticket, dated 2/14/23. Surveyor noted the lunch meal ticket did not contain any allergies for R14. On 2/15/23 at 9:30 AM, DA-G provided Surveyor with R14's Diet Communication form, dated 10/31/22. Surveyor noted the form documented R14 had an allergy to pineapple.

Based on observation, staff interview and record review, the facility did not ensure food was handled, stored and prepared in a sanitary manner. The practice had the potential to affect 39 of 39 residents. The facility did not monitor and document food holding and food cooling temperatures. The facility did not ensure food was stored in a clean, dry location not exposed to splash, dust or contamination. The facility did not have a working handwashing sink separate from sinks used for food prep, warewashing and eye washing. Dietary staff did not wait two minutes to take microwave reheated food temperatures to ensure food was heated evenly. Findings include: During an initial tour of the kitchen on 2/13/23 at 9:00 AM, Dietary Director (DD)-D was unsure what food code the facility used as a standard of practice. On 2/13/23 at 11:15 AM, Surveyor interviewed Dietary Aide (DA)-G who was also unsure what food code the facility used as a standard of practice. On 2/15/23 at 9:37 AM, Surveyor interviewed Nursing Home Administrator Consultant (NHAC)-C who stated the facility did not have kitchen policies and procedures, but followed the Wisconsin Food Code as their standard of practice. 1. Food Holding Temperatures The Wisconsin Food Code 2022 documents at 3-501.16: Time/Temperature Control for Safety Food, Hot and Cold Holding .Time/Temperature Control for Safety Food shall be maintained: (1) At 57°C (135°F) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11 (B) or reheated as specified in 3-403.11 (E) may be held at a temperature of 54°C (130°F) or above; P or (2) At 5°C (41°F) or less. In a January 2001 report, the National Advisory Committee on Microbiological Criteria for Foods (NACMCF) recommended that the minimum hot holding temperature specified in the Food Code: ~Be greater than the upper limit of the range of temperatures at which Clostridium perfringens and Bacillus cereus may grow; and ~Provide a margin of safety that accounts for variations in food matrices, variations in temperature throughout a food product, and the capability of hot holding equipment to consistently maintain product at a desired target temperature. Clostridium perfringens has been reported to grow at temperatures up to 52°C (126°F). Growth at this upper limit requires anaerobic conditions and follows a lag phase of at least several hours. The literature shows that lag phase duration and generation times are shorter at incubation temperatures below 49°C (120°F) than at 52°C (125°F). Studies also suggest that temperatures that preclude the growth of Clostridium perfringens also preclude the growth of Bacillus cereus. The Centers for Disease Control (CDC) estimates that approximately 250,000 foodborne illness cases can be attributed to Clostridium perfringens and Bacillus cereus each year in the United States. These spore-forming pathogens have been implicated in foodborne illness outbreaks associated with foods held at improper temperatures. This suggests that preventing the growth of these organisms in food by maintaining adequate hot holding temperatures is an important public health intervention. Taking into consideration the recommendations of NACMCF and the 2002 Conference for Food Protection meeting, the Food and Drug Administration (FDA) believes that maintaining food at a temperature of 57°C (135°F) or greater during hot holding is sufficient to prevent the growth of pathogens and is therefore an effective measure in the prevention of foodborne illness. During an initial tour of the kitchen with DD-D on 2/13/23 at 9:00 AM, Surveyor observed the oven set to 275°F. Surveyor observed DD-D open the oven which contained a steam table container covered in aluminum foil. DD-D confirmed the food in the container was the entree for lunch which was put in the oven at approximately 7:30 AM to be held for lunch service. Surveyor noted the facility's Food Temperature Record for the 2/13/23 lunch meal had an undocumented entree cooking temperature. DD-D stated cooking temperatures were taken prior to when meal items were delivered to the upper-level dining room; however, food temperatures were not taken in the dining room prior to service. DD-D stated lunch service began at 11:30 AM and the possibility of a temperature log being placed in the upper-level dining room to obtain food temperatures could occur. On 2/13/23 at 11:25 AM, Surveyor observed Dietary Aide (DA)-G remove pork chops, au gratin potatoes and California blend vegetables from the oven. DA-G stated staff documented cooking temperatures on a Food Temperature Record. Surveyor observed DA-G take and record the following temperatures: Mechanical soft California blend vegetables - 186°F Mechanical soft pork chops - 206°F General diet pork chops - 210°F General diet California blend vegetables - 191°F General diet au gratin potatoes - 208°F Surveyor noted pureed meal temperatures were not taken prior to the items being delivered to the dining room. Surveyor observed DA-G place lunch menu items on a rolling cart, remove pre-pureed food for two residents from the walk in cooler and place the food on a rolling cart. The rolling carts were loaded onto a dumbwaiter to be delivered to the upper-level dining room. DA-G stated pre-pureed foods were pureed when cooked and reheated in a microwave in the dining room. On 2/13/23 at 11:28 AM, Surveyor observed DA-G load the steam table with lunch items for hot holding prior to meal service. Surveyor noted holding temperatures were obtained prior to meal service. At 12:00 PM, Surveyor noted all resident meals were served in the dining room and all room trays were plated and being distributed. Surveyor noted holding temperatures were not obtained throughout the meal service. DA-G stated leftovers were not kept and, therefore, holding temperatures were not taken. Surveyor noted a Food Temperature Record was not available in the dining room. On 2/14/23 at 11:20 AM, Surveyor observed DA-H load the steam table with lunch items. Surveyor noted DA-H did not take holding temperatures before meal service began at 11:30 AM. Surveyor requested DA-H obtain holding temperatures prior to beginning food service. Surveyor observed DA-H obtain the following food temperatures: Baked chicken - 197°F, Mashed potatoes - 178°F Stewed tomatoes - 173°F Immediately after taking food temperatures, Surveyor observed DA-H plate the lunch items for residents. Surveyor noted DA-H did not document food holding temperatures and there was not a Food Temperature Record in the dining room. Surveyor noted lunch service ended at 12:30 PM and holding temperatures were not obtained throughout the meal service. On 2/15/23 at 9:45 AM, Surveyor interviewed DA-G regarding the facility's process for cooking foods and obtaining cooking and holding temperatures. DA-G indicated meat for lunch is put in the convection oven after breakfast is cooked at 7:30 AM. DA-G stated the meat is removed from the oven and a cooking temperature is obtained; however, the temperature is not recorded at the time the meat is cooked. DA-G stated the meat is then put in gravy and placed in the oven for holding until it is taken out of the oven to be temped. The cooking temperature is documented on the Food Temperature Record and the meat is loaded onto a food cart and taken to the dining room. DA-G stated the only time staff deviate from that routine is if the entree is meatloaf which is slow cooked beginning at 7:30 AM. DA-G stated meatloaf is removed from the oven prior to meal service and the temperature is obtained and documented on the Food Temperature Record prior to staff delivering the lunch meal to the dining room. DA-G stated most starches and vegetables are cooked right before service at approximately 11:00 AM and placed in the oven at a low temperature for holding. Food temperatures are obtained when the items are removed from the kitchen oven at approximately 11:25 AM and prior to when the food is transported via dumbwaiter to the dining room. DA-G confirmed the temperatures documented on the Food Temperature Record are the cooking temperatures. DA-G stated holding temperatures are not obtained because food temperatures are obtained prior to the items being transported to the dining room. DA-G stated all food temperatures are taken in the kitchen and there is not a Food Temperature Record located in the dining room where the items are placed in the steam table and held for service. 2. Cooling Temperatures The Wisconsin Food Code 2022 documents at section 3-501.14: Cooling. (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 57°Celsius (C) (135°Fahrenheit) (F) to 21°C (70°F); and (2) Within a total of 6 hours from 57°C (135°F) to 5°C (41°F) or less. (B) time/temperature control for safety food shall be cooled within 4 hours to 5°C (41°F) or less. The Wisconsin Food Code 2022 section 3-501.15 documents: Cooling Methods. (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under § 3-501.14 by using one or more of the following methods based on the type of food being cooled: (1) Placing the food in shallow pans; (2) Separating the food into smaller or thinner portions; (3) Using rapid cooling equipment; (4) Stirring the food in a container placed in an ice water bath; (5) Using containers that facilitate heat transfer; (6) Adding ice as an ingredient; or (7) Other effective methods. During an initial tour of the kitchen on 2/13/23 at 9:00 AM, Surveyor observed an unlabeled and undated aluminum foil-sealed steam table container on the food prep counter. DD-D verified the container contained ground beef with peas for the lunch meal. DD-D stated the ground beef and peas were probably made this morning at 7:30 AM; however, DD-D was unsure how long the ground beef and peas were on the food prep counter. Surveyor observed DD-D obtain the temperature of the ground beef with peas at 90.6°F. DD-D recovered the container, marked the container with the date and contents and placed the container in the walk-in cooler. Surveyor noted the food temperature was not documented on a cooling log. Surveyor interviewed DD-D regarding cooling. DD-D stated the facility did not have food cooling logs because the facility did not keep leftovers. On 2/14/23 at 9:27 AM, Surveyor observed one undated covered bowl labeled chicken and one undated covered bowl labeled cake on the food prep counter. DA-G verified the bowl labeled chicken was pureed chicken in gravy for lunch service. DA-G stated the chicken was cooked, pureed, and placed in the bowl prior to DA-G's arrival at 7:00 AM. DA-G stated the usual process was to puree food and put the pureed items immediately in the refrigerator. DA-G stated DA-H must have gotten busy since the items were not placed in the walk-in cooler. Surveyor observed DA-G place both undated bowls in the walk in cooler. Surveyor noted food temperatures were not obtained on either bowl. Surveyor interviewed DA-G regarding food cooling logs. DA-G stated the facility did not keep leftovers and did not have cooling logs. 3. Food Storage The Wisconsin Food Code documents at section 3-305.11: Food Storage. (A) Except as specified in (B) and (C) of this section, food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. During an initial tour of the kitchen on 2/13/23 at 9:00 AM, Surveyor and DD-D observed a dry, brownish-red stain on the floor of the walk-in cooler. DD-D stated the stain was blood from thawing beef. DD-D pointed to a five-pound roll of ground beef inside a clear plastic container on the bottom shelf. The container was located several inches to the right of the stain. Surveyor and DD-D also observed onion peels/skins and a potato on the floor of the cooler. During an initial tour of the kitchen on 2/13/23 at 9:00 AM, Surveyor and DD-D observed the walk-in freezer. Surveyor and DD-D noted an empty Folgers coffee box, several plastic food container wrappers used in the packing and wrapping of freezer items and several pieces of packing tape on the floor under shelves that contained food. On 2/14/23 at 10:25 AM, Surveyor and DA-G observed a brownish-red stain on the floor of the walk-in cooler. DA-G stated staff were expected to clean spills and removed food items from cooler and freezer floors immediately. DA-G stated DA-G did not notice the stain prior to Surveyor's initial kitchen tour on 2/13/23. DA-G stated DA-G was notified of the stain on 2/13/23 and planned to clean the walk-in cooler on 2/14/23. Surveyor interviewed DA-G regarding the kitchen cleaning schedule. DA-G stated the kitchen had a routine cleaning procedure and cleaning log. DA-G provided Surveyor with a Cook's Cleaning List for January 2023 and February 2023. Surveyor reviewed the lists and noted the January 2023 cleaning item Freezer and Cooler (Swept, mopped and dates have been checked on all food items) was completed on 1/30/23. Surveyor noted the Cook's Cleaning List for February 2023 did not have a documented date for Freezer and Cooler (Swept, mopped and dates have been checked on all food items). On 2/15/23 at 9:32, Surveyor and Registered Dietician (RD)-I observed an empty Folgers coffee box, several plastic food container wrappers used in the packing and wrapping of freezer items, several pieces of packing tape and four pieces of orange colored food debris on the floor under shelves that contained food. RD-I stated the food debris appeared to be possibly sweet potatoes. RD-I stated the unclean condition of the freezer was uncommon for the facility and RD-I did not previously observe the walk-in freezer in that condition. 4. Handwashing Sink The Wisconsin Food Code 2022 documents at 2-301.15: Where to Wash. (A) Food employees shall clean their hands in a handwashing sink or approved automatic handwashing facility and may not clean their hands in a sink used for food preparation or warewashing, or in a service sink or a curbed cleaning facility used for the disposal of mop water and similar liquid waste. The Wisconsin Food Code 2022 documents at 4-501.16: Warewashing Sinks, Use Limitation. (A) A warewashing sink may not be used for handwashing as specified in § 2-301.15. During an initial tour of the kitchen on 2/13/23 at 9:00 AM, Surveyor observed a three basin sink in the warewashing room, a single basin sink with a paper towel dispenser, a garbage receptacle and a sink labeled eye wash station. Surveyor attempted to wash hands in the single basin sink. The sink sensor did not recognize Surveyor's hands and did not turn on. Surveyor interviewed DD-D regarding which sink staff used for handwashing. DD-D stated the single basin sink was the handwashing sink. Surveyor again attempted to wash hands in the single basin sink; however, no water came out of the faucet. DD-D stated the sink was working this morning and stated the other two sinks could be used for handwashing. Surveyor used the sink labeled eye wash station to wash hands. Surveyor observed food particles in the bottom of the sink. Surveyor also noted the garbage receptacle next to the sink did not have a self-opening lid. On 2/13/23 at 11:15 AM, Surveyor observed DA-G wash hands prior to meal service in the sink labeled eye wash station. Surveyor interviewed DA-G regarding which sink was the handwashing sink. DA-G stated the handwashing sink was the single basin sink to the left of the sink labeled eye wash station. DA-G confirmed the eye wash station sink was used for handwashing because the sensor on the handwashing sink did not work for a while and DA-G kept forgetting to tell maintenance about it. Surveyor interviewed DA-G regarding use of the three basin sink in the warewashing room. DA-G stated the sink was used for cleaning, pre-rinsing, and presoaking dishes. On 2/14/23 at 9:15 AM, Surveyor entered the kitchen and attempted to wash hands in the handwashing sink; however, the handwashing sink was not in operation and Surveyor used the eye wash station sink to wash hands. At 9:30 AM, Surveyor observed DA-G and DA-H wash hands in the eye wash station sink prior to warewashing. On 2/14/23 at 11:15 AM, Surveyor entered the kitchen and attempted to use wash hands in the handwashing sink; however, the handwashing sink was not in operation and Surveyor used the eye wash station sink to wash hands. At 11:20 AM, Surveyor observed DA-G and DA-H wash hands prior to meal prep in the eye wash station sink. On 2/15/23 at 9:12 AM, Surveyor entered the kitchen and attempted to wash hands in the handwashing sink; however, the handwashing sink was still not operational. Surveyor washed hands in the eye wash station sink and noted food particles in the sink. On 2/15/23 at 9:35 AM, Surveyor interviewed RD-I who stated RD-I was not aware the handwashing sink was still not in working order and would speak with maintenance about fixing the sink. 5. Reheating Food for Hot Holding The Wisconsin Food Code 2022 documents at section 3-403.11: Reheating for Hot Holding. (A) Except as specified under (B), (C), and (E) of this section, Time/Temperature control for food 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. (B) Except as specified under (C) of this section, Time/Temperature control for food 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 2/13/23 at 11:20 AM, Surveyor observed DA-G puree au gratin potatoes and California mixed vegetables for two meals. DA-G then placed the items in bowls on the service cart to bring to the dining room. At 11:38 AM, Surveyor observed DA-G cover and microwave one meal at a time for 2 ½ minutes, remove the meal and immediately obtain food temperatures. Surveyor noted the following food temperatures: Pureed pork chop - 180°F Pureed au gratin potatoes - 184°F Pureed California mixed vegetables - 182°F. Surveyor noted the microwave reheated food was not stirred prior to obtaining temperatures nor was the food covered and allowed to sit for two minutes prior to obtaining temperatures. Surveyor observed DA-G immediately serve the meals to the residents. Surveyor interviewed DA-G regarding the process of microwaving pureed meals and documenting temperatures. DA-G stated there was not a food temperature log for microwave reheating. DA-G verified the microwave reheated meal temperatures were obtained immediately after microwaving and the meals were then served. On 2/14/23 at 11:29 AM, Surveyor observed DA-H cover and microwave a pureed meal for 2 ½ minutes, remove the meal and immediately obtain food temperatures Surveyor noted the following food temperatures: Pureed chicken - 189°F Stewed tomatoes -177°F Surveyor noted the microwave reheated meal was immediately served to the resident. Surveyor also noted the food temperatures were not documented.