**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure a Pre-admission Screening and Resident Review (PASRR) Level I Screen was submitted for a Level II Screen when a 30-day hospital exemption expired for 2 residents (R) (R56 and R49) of 18 sampled residents. R56 and R49 were identified on their PASRR Level I Screens as suspected of having a serious mental illness. The facility did not submit for PASRR Level II Screens when R56 and R49's 30-day hospital exemptions expired. Findings include: 1. On [DATE] Surveyor reviewed R56's medical record. R56 had a diagnosis of anxiety disorder and was prescribed Ativan (an anti-anxiety medication). R56's Minimum Data Set (MDS) assessment, dated [DATE], had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R56 was not cognitively impaired. R56's medical record indicated R56 was screened for mental illness, developmental disabilities, and intellectual disabilities on [DATE] and granted a 30-day hospital exemption for a PASRR Level II Screen. R56's medical record did not indicate there was submission for a PASRR Level II Screen after R56's 30-day exemption expired. 2. On [DATE], Surveyor reviewed R49's medical record. R49 had diagnoses of insomnia, depression, and anxiety disorder. R49 was prescribed zolpidem tartrate (a sedative/hypnotic medication), Zoloft (an antidepressant medication) and oxazepam (a sedative medication used to treat anxiety). R49's MDS assessment, dated [DATE], had a BIMS score of 8 out of 15 which indicated R49 had moderate cognitive impairment. R49's medical record indicated R49 was screened for mental illness, developmental disabilities, and intellectual disabilities on [DATE] and granted a 30-day hospital exemption for a PASRR Level II Screen. R49's medical record did not indicate there was submission for a PASRR Level II Screen after R49's 30-day exemption expired. On [DATE] at 3:00 PM, Surveyor requested PASRR Level I and Level II Screens for R56 and R49 from Director of Nursing (DON)-B. On [DATE] at 11:06 AM, Surveyor reviewed R56's updated PASRR Level I Screen which was dated [DATE] and R49's updated PASRR Level I Screen which was dated [DATE]. On [DATE] at 1:02 PM, Surveyor interviewed Admissions Coordinator (AC)-D who confirmed AC-D was responsible for completing PASRRs for residents. AC-D indicated R56's PASRR Level I Screen was completed on [DATE] with a 30-day hospital exemption and should have been submitted for a Level II Screen when the 30-day exemption expired. AC-D verified R49's PASRR Level I Screen was completed on [DATE] with a 30-day hospital exemption and should have been submitted for a Level II Screen when the 30-day exemption expired.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure ongoing communication with the dialysis center or ensure ongoing monitoring of the fistula site for 1 resident (R) (R6) of 1 sampled resident. R6 received dialysis three times weekly. The facility did not ensure ongoing communication with the dialysis center or routinely monitor R6's fistula site. Findings include: The facility's Dialysis policy, revised 7/2018, indicates: There should be a pulse, buzzing, or thrill feeling in the fistula or graft. This is the blood rushing through the area. Check the fistula or graft daily. The facility's Hemodialysis Catheters-Access and Care of policy, revised 2023, indicates: Care of arteriovenous fistulas (AVFs) and arteriovenous grafts (AVGs) .Check patency of the site at regular intervals. Palpate the site to feel the thrill or use a stethoscope to hear the whoosh or bruit of blood flow through the access. From 5/5/25 to 5/7/25, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] and had diagnoses including dementia, anxiety, end stage renal disease, dependence on renal dialysis, and type 2 diabetes mellitus with diabetic neuropathy. R6's Minimum Data Set (MDS) assessment, dated 3/20/25, had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R6 had moderate cognitive impairment. R6's care plan indicated R6 received hemodialysis three times weekly related to end stage renal disease. R6's care plan and Medication Administration Record (MAR) did not indicate the facility monitored R6 for bruit/thrill daily. In addition, R6's medical record contained only eight dialysis communication entries from 6/22/24 through 2/18/25. (The entries were dated: 2/18/25, 1/30/25, 1/21/25, 7/4/24, 6/29/24, 6/27/24, 6/25/24, and 6/22/24.) On 5/6/25 at 1:30 PM, Surveyor interviewed Licensed Practical Nurse (LPN)- E who confirmed monitoring for bruit/thrill was not on R6's MAR or Treatment Administration Record (TAR). LPN-E indicated bruit/thrill should be monitored each shift. On 5/6/25 at 10:26 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated the facility's policy should be followed along with the physician's orders. On 5/6/25 at 2:15 PM, Surveyor requested R6's aftercare visit instructions related to a fistulagram (an X-ray procedure used to evaluate dialysis access). DON-B provided Surveyor with a radiology pre-procedure note, not the aftercare visit instructions for care of the fistula. On 5/7/25 at 11:15 AM, Surveyor interviewed DON-B who indicated bruit/thrill is managed by the dialysis center. Surveyor requested the last visit sheet from dialysis. On 5/7/25 at 11:44 AM, Surveyor interviewed Registered Nurse (RN)-F about communication with the dialysis center. RN-F was not sure what information was sent with R6 but assumed R6's weight and vital signs were sent. RN-F was unsure if the facility received a report from the dialysis center upon R6's return. On 5/7/25 at 12:02 PM, Surveyor interviewed Unit Coordinator (UC)-G who indicated R6 should be sent to each dialysis appointment with an envelope containing a face sheet, appointment sheet, and medication list. UC-G indicated weights and vital signs are not normally sent with residents. UC-G indicated the dialysis center calls or faxes the facility if new orders are given. UC-G indicated appointment sheets are scanned in residents' medical records. On 5/7/25 at 12:20 PM, Surveyor interviewed Dialysis RN (DRN)-H who indicated the facility does not send anything with R6. When Surveyor indicated staff said an envelope with a face sheet, appointment sheet, and medication sheet are sent to each dialysis appointment, DRN-H indicated the dialysis center does not receive that information and they do not have a communication binder for R6. DRN-H indicated if the dialysis center issues new orders, the dialysis center calls or faxes the facility. When Surveyor asked if bruit/thrill should be monitored daily, DRN-H indicated that is the facility's decision, but it should be done daily and especially before and after dialysis.

Based on observation, staff interview, and record review, the facility did not ensure the accurate administration of medication for 1 resident (R) (R13) of 4 residents observed during medication administration During the AM medication pass on 5/5/25, R13 received Senna-Plus instead of Senna. Findings include: The facility's Administrating Medications policy, dated 2001, indicates: .4. Medication are administered in accordance with prescriber orders .10. The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. On 5/5/25 at 9:20 AM, Surveyor observed Registered Nurse (RN)-F administer R13's medication. One of the medications administered was Senna-Plus (which is a mixture of sennosides (a stimulant laxative) and docusate sodium (a stool softener)). On 5/6/25 at 8:00 AM, Surveyor reviewed R13's Medication Administration Record (MAR) which indicated R13 should have received Senna 8.6 milligrams (mg) daily for constipation. Surveyor noted RN-F administered Senna-Plus to R13 instead of Senna. On 5/6/25 at 10:26 AM and 11:17 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated medication should be administered per the order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not implement their antibiotic stewardship program to ensure the accurate use of antibiotics for 3 residents (R) (R19, R122, and R264) of 6 sampled residents. R19 did not meet McGeer's criteria for a urinary tract infection (UTI) but received antibiotic therapy. The physician was not asked if the antibiotic should have been continued when R19 did not meet the criteria for a UTI. R122 did not meet McGeer's criteria for a skin and soft tissue infection (SSTI) but received antibiotic therapy. The physician was not asked if the antibiotic should have been continued when R122 did not meet the criteria for an SSTI. R264 did not meet McGeer's criteria for a respiratory tract infection (RTI) but received antibiotic therapy. The physician was not asked if the antibiotic should have been continued when R264 did not meet the criteria for an RTI. Findings include: The facility's Antibiotic Stewardship policy, revised 12/2016, indicates: .11. When a culture and sensitivity (C&S) is ordered, lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued . The facility's Antibiotic Stewardship-Orders for Antibiotics policy, revised 12/2016, indicates: .3. Appropriate indications for use of antibiotics include: a. criteria met for clinical definition of active infection or suspected sepsis; and b. pathogen susceptibility, based on culture and sensitivity, to antimicrobial (or therapy begun while culture is pending) . 1. From 5/5/25 to 5/7/25, Surveyor reviewed R19's medical record. R19 was admitted to the facility on [DATE] and had diagnoses including abscess of abdominal wall, anemia, malignant neoplasm of endometrium, methicillin- resistant Staphylococcus aureus (MRSA) infection, and fibromyalgia. R19's Minimum Data Set (MDS) assessment, dated 3/10/25, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R19 had intact cognition. R19's medical record included McGeer's criteria for a UTI that indicated the date of infection was 12/10/24. The form indicated R19 met the criteria for a UTI without an indwelling catheter. Upon review of R19's culture, it was noted the culture grew 50,000 organisms per milliliter which did not meet McGeer's criteria of more than 100,000 organisms per milliliter. R19 took nitrofurantoin (an antibiotic medication) for 5 days. The facility did not update the physician that R19 did not meet the criteria for infection and antibiotic use. On 5/7/25 at 2:23 PM, Surveyor interviewed Director of Nursing (DON)-B and Infection Preventionist (IP)-C who did not comment when Surveyor asked if R19 met McGeer's infection criteria and if the physician was notified. 2. From 5/5/25 to 5725, Surveyor reviewed R122's medical record. R122 was admitted to the facility on [DATE] and had diagnoses including malignant neoplasm of duodenum, bacterial infection, and stage 2 pressure ulcer of the sacral region. R122's MDS assessment, dated 4/30/25, had a BIMS score of 14 out of 15 which indicated R122 had intact cognition. R122's medical record included a McGeer's SSTI criteria form that indicated the date of infection was 5/2/25. The form indicated R122 met the criteria for infection, however, only 2 of 4 required new or increasing signs or symptoms were identified which indicated R122 did not meet infection criteria. Surveyor also noted R122 was not on the May 2025 resident infection line list. R122 received cephalexin (an antibiotic medication) twice daily for 10 days from 5/2/25 to 5/11/25. The facility did not update the physician that R122 did not meet the criteria for infection. On 5/6/25 at 12:05 PM, Surveyor interviewed IP-C who indicated R122 must have been forgotten on the resident infection line list. IP-C agreed R122 did not meet the criteria for infection based on the fact that R122 had only 2 of 4 required new or increasing signs or symptoms. On 5/7/25 at 11:30 AM, DON-B indicated resident infection line lists are not filled out until the end of each month when they are brought to Quality Assurance Performance Improvement (QAPI) meetings and are reviewed. On 5/7/25 at 1:39 PM, IP-C provided Surveyor with a revised McGeer SSTI infection criteria form and indicated R122 did meet McGeer's criteria. Surveyor reviewed the updated McGeer SSTI criteria form and noted R122 met 3 of 4 required criteria but still did not meet all criteria for infection. 3. From 5/5/25 to 5/7/25, Surveyor reviewed R264's medical record. R264 was admitted to the facility on [DATE] and had diagnoses including unspecified injury of head, chronic obstructive pulmonary disease, and atherosclerotic heart disease. R264's MDS assessment, dated 2/19/25, had a BIMS score of 13 out of 15 which indicated R264 had intact cognition. R264's medical record included a McGeer's common cold symptoms or pharyngitis criteria under the RTI topic that did not document any signs or symptoms but contained sinus infection handwritten. The form did not indicate if the criteria for infection was met. R264 was prescribed amoxicillin (an antibiotic medication) for 10 days. R264's physician was not notified that R264 did not have any cold symptoms or signs of pharyngitis and did nor meet the criteria for infection. On 5/7/25 at 2:18 PM, Surveyor interviewed DON-B and IP-C who did not comment when Surveyor asked about R264's use of an antibiotic without signs or symptoms of infection or follow-up with the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility did not ensure medications for 8 residents (R) (R13, R30, R26, R46, R14, R263, R20, and R0) in 1 of 2 medication carts were labeled and/or dated appropriately. In addition, the facility did not ensure expired treatment supplies were removed from storage in 1 of 4 medication storage areas and did not ensure medication was stored appropriately. Medication was left unattended on top of the medication cart. A medication storage area contained undated and expired resident and stock medications and medical supplies. A medication cart contained unlabeled, undated, and expired resident and stock medications. Findings include: The facility's Administering Medications policy, dated 2001, indicates: The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. The facility's Medication Labeling and Storage policy, dated 2001, indicates: .3. If the facility has discontinued, outdated, or deteriorated medication or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying the items .4. Compartments (including but not limited to drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. The facility's Ophthalmic Medications policy, dated 6/2021, indicates: If the manufacturer states a specific expiration date upon opening this date should be used to determine when to discard the eye preparation. If a manufacturer is unable to provide an expiration date once the medication is open, current standards of practice generally recommend discarding the eye drop after 28 days because sterility cannot be guaranteed beyond that point. On [DATE] at 8:43 AM, Surveyor observed License Practical Nurse (LPN)-O during medication administration and noted a Med Pass 2.0 supplement on the medication cart did not contain an open date. LPN-O verified the container of Med Pass should have been dated when opened. On [DATE] at 9:01 AM, Surveyor observed medication on top of a medication cart in the hallway. When Registered Nurse (RN)-F returned to the cart, RN-F stated RN-F supposed Surveyor wrote RN-F up for leaving medications on the cart. Surveyor confirmed with RN-F that medication should not be left unattended on the cart when RN-F is in a resident's room. On [DATE] at 9:20 AM, Surveyor noted R13's Arnuity Ellipta inhaler (commonly used to manage asthma) did not contain an open date. A pharmacy label indicated the inhaler expired 42 days after opening. Surveyor also noted R13's Lantus insulin (a long-acting insulin used to manage blood sugar levels) did not contain an open date. On [DATE] at 8:45 AM, Surveyor observed the medication storage room and noted the following: ~ Twenty BD Vacutainer Luer-Lok access devices with expiration dates of [DATE] ~ Sixteen Cardinal Health lubricating jelly 0.11 ounce (oz) packets with expiration dates of [DATE] ~ One purple vial blood tube with an expiration date of [DATE] ~ Two red top tubes with expiration dates of [DATE] ~ Nine light blue top tubes with expiration dates of [DATE] ~ One Sol-Care Luer Lock safety syringe 3 milliliter/without needle with an expiration date of [DATE] ~ One 22 gauge x 1 inch in BD Insyte Autoguard needle with an expiration date of [DATE] ~ One bottle of zinc 50 milligrams (mg) with an expiration of 4/2025 ~ An open and undated package of DuoNeb vials for R30 ~ Five bottles of Air Power guaifenesin expectorant 200 mg for R26 with expiration dates of [DATE], [DATE], [DATE], [DATE], and [DATE] ~ One bottle of Medline Remedy Phytoplex skin repair cream with an expiration date of 3/2023 ~ One 19 oz container of fiber powder with an expiration date of 4/2025 ~ One female urinary specimen kit with an expiration date of [DATE] ~ One Dri-[NAME] hearing aid dehumidifier with an expiration date of [DATE] On [DATE] at 9:41 AM, Surveyor interviewed LPN-O who verified the above items were expired. On [DATE] at 12:18 PM, Surveyor observed a medication cart and noted the following: ~ An open, unlabeled, and undated Symbicort inhaler for R26 ~ Open and undated bottles of fluticasone prop nasal spray for R46, R14, R13, and R263 ~ A bottle of Artificial Tears for R26 with an open date of [DATE] ~ An open and undated bottle of Artificial Tears for R14 ~ A bottle of Artificial Tears for R13 with an open date of [DATE] ~ A bottle of Bausch and Lomb Muro 128 5% eye drops for R26 with an expiration date of [DATE] ~ An open and undated bottle of Rocklatan eye drops for R14 ~ A bottle of Assure Prism control solution with an expiration date of [DATE] ~ An open and undated bottle of ProSource ~ An open and undated bottle of Deep Sea nasal spray for R14 ~ An open and undated albuterol inhaler for R13 ~ An open and undated package of DuoNebs for R20 with one remaining vial ~ An open and undated package of DuoNebs for R0 with six vials in the bottom of the box and four vials in open foil ~ An open and undated bottle of hydrogen peroxide 3% USP 10 volume On [DATE] at 1:04 PM, Surveyor interviewed LPN-E who verified the above items were unlabeled, undated, and/or expired. On [DATE] at 10:26 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated medications such as eye drops, inhalers, and nebulizer packets should be dated when opened. Regarding eye drop and inhaler expiration dates, DON-B provided Surveyor with expiration sheets. DON-B confirmed expired items should be disposed of. DON-B stated the facility does audits and indicated staff should check dates before use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R39's medical record indicated R39 had chronic diabetic wounds. On 5/5/25 at 10:40 AM, Surveyor observed 3 staff (2 therapy staff and one CNA) transfer R39 without wearing PPE. R39's room did not contain a sign on or near the door that indicated R39 was on EBP. On 5/6/25 at 8:15 AM, Surveyor noted an EBP sign was on R39's door. On 5/6/26 at 10:26 AM, Surveyor interviewed DON-B who indicated PPE should be worn during high-contact cares such as hygiene, dressing, linen changes, and cares involving open areas and and body fluids for residents who are on EBP. DON-B indicated residents with wounds should be on EBP and confirmed R39 should be on EBP. On 5/6/25 at 1:07 PM, Surveyor observed CNA-R assist R39 to the restroom without PPE. When Surveyor asked CNA-R if PPE was required, CNA-R indicated no because R39 did not have any open wounds. Surveyor then interviewed CNA-T who indicated PPE should be worn if toileting or transferring a resident on EBP. On 5/6/25 at 2:30 PM, Surveyor observed DON-B and Medical Doctor (MD)-S complete wound care for R39. DON-B and MD-S donned gowns and gloves. During the observation, Surveyor noted DON-B and MD-S kneeled on the floor without a barrier. When wound care was finished, Surveyor interviewed DON-B who confirmed there should have been a barrier on the floor. MD-S and DON-B indicated R39's wounds were present upon admission. DON-B confirmed R39 should have been on EBP since R39 was admitted on [DATE]. 3. On 5/5/25 at 8:43 AM, Surveyor observed RN-F administer medication to R25 who was on EBP. R25 complained of pain in the right fifth toe. RN-F removed R25's sock and assessed R25's right fifth toe without gloves or a gown. When RN-F left R25's room, RN-F confirmed R25 was on EBP for a right ankle infection in the hardware. When Surveyor asked if RN-F should have donned gloves and a gown prior to touching R25's right foot, RN-F indicated PPE was only needed when toileting R25 due to something in R25's urine. 4. On 5/5/25 at 9:01 AM, Surveyor observed RN-F attempt to obtain R4's blood pressure with a vitals machine which was not successful. RN-F then attempted to obtain R4's blood pressure with a wrist cuff from the mediation cart which was also not sucsessful. RN-F then obtained a manual cuff and stethoscope from the medication cart and successfully obtained R4's blood pressure. RN-F then put the wrist and manual cuffs and stethoscope back in the medication cart without sanitizing them and did not sanitize the vitals machine. On 5/5/25 at 9:19 AM, Surveyor interviewed RN-F after RN-F finished administering medication to R4 and had moved on to the next resident. When Surveyor asked if the blood pressure cuffs and stethoscope should have been sanitized, RN-F indicated they should have been but did not sanitize them. Based on observation, staff interview, and record review, the facility did not 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 59 residents residing in the facility. Seven staff who tested positive for COVID-19 and two staff with gastrointestinal (GI) symptoms returned to work earlier than recommended by the Centers for Disease Control and Prevention (CDC) and/or the Wisconsin Department of Health Services (DHS) whose guidelines the facility followed. R39 had chronic diabetic wounds that were present upon admission and was put not on enhanced barrier precautions (EBP) until 5/6/25. Staff did not did not wear the appropriate PPE during cares and knelt on the floor without a barrier during wound care. R25 was on EBP. Staff did not ensure proper personal protective equipment (PPE) was worn when assessing R25's toe. Staff did not ensure a vitals machine, blood pressure equipment, and a stethoscope were sanitized after use for R4 Findings include: The CDC webpage COVID-19, last updated on 3/18/24, contains an article titled Interim Guidance for Managing Healthcare Personnel (HCP) with SARS-CoV-2 Infection or Exposure to SARS-CoV-2 that indicates: The following are criteria to determine when HCP with SARS-CoV-2 infection could return to work .HCP with mild to moderate illness who are not moderately to severely immunocompromised could return to work after the following criteria have been met: ~ At least 7 days have passed since symptoms first appear if a negative viral test is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7), and ~ At least 24 hours have passed since the last fever without the use of fever-reducing medications and symptoms (e.g., cough, shortness of breath) have improved. Either NAAT (molecular) or antigen testing may be used. If using an antigen test, HCP should have a negative test obtained on day 5 and again 48 hours later Per the Wisconsin DHS website, last updated 3/18/25, webpage titled Preventing and Controlling Respiratory Illness Outbreaks in Long-Term Care Facilities and Other Health Care Settings .Long Term Care Facilities are strongly encouraged to maintain and update a line list during an acute respiratory illness (ARI) outbreak to organize case information .DHS recommends facilities continue to share them with public health as part of shared outbreak response . The Wisconsin DHS online booklet Prevention and Control of Acute Gastroenteritis Outbreaks in Wisconsin Long-Term Care Facilities, dated 12/2017, indicates: .A staff illness policy should be developed and implemented, and all employees should be educated about the policy. The policy should clearly outline staff responsibilities for when and how to inform management of illness .and should outline the policy for returning to work (48 hours after signs and symptoms subside) .Staff should exclude themselves from resident care and food service duties at the onset of symptoms, including nausea, vomiting, abdominal pain, and/or diarrhea. Such exclusions shall remain in effect until the employee is asymptomatic and free of diarrhea and vomiting for 48 hours . The facility's Enhanced Barrier Precautions Policy, dated 1/2025, indicates: The purpose of this policy is to reduce the transmission of multidrug-resistant organisms (MDROs) and other infectious agents within the facility by implementing enhanced barrier precautions (EBPs) for residents at increased risk for infection or colonization .Infection control practices requiring the use of persona protective equipment (PPE) during certain high-contact resident care activities, even when standard isolation precautions are not indicated. High-Contact Resident Care Activities: activities involving potential exposure to infectious agents, including dressing, bathing/showering, transferring, providing hygiene (toileting), changing lines, device care or use, and wound care .EBP must be implemented for residents known or suspected to be colonized or infected with MDROs or those at risk for such colonization (e.g., residents with indwelling devices, open wounds, or recent hospitalizations). 2 .Healthcare personnel (HCP) must wear gloves and gowns during high-contact care activities .5 .Place signage outside residents' rooms to indicate the implementation of EBPs and the required PPE for care .7 .High-touch surfaces and equipment in residents' care areas should be cleaned . 1. On 5/6/25 at approximately 9:45 AM, Surveyor reviewed staff infection line lists from December 2024 through May 2025. The line list header titles included: staff name, illness type, illness start date, positive test date, symptoms, unit last worked, COVID retest date (48 hours prior to return), and return to work date. Surveyor noted staff with COVID-19 completed 1 retest prior to returning to work. The December 2025 staff infection line list indicated 7 staff tested positive for COVID-19 and 6 staff returned to work prior to the CDC recommendations: ~ Certified Nursing Assistant (CNA)-I had COVID-19 with a first symptom date of 12/22/24. CNA-I was retested on [DATE] and returned to work on 12/30/24. ~ Registered Nurse (RN)-J had COVID-19 with a first symptom date of 12/20/24. RN-J was retested on [DATE] and returned to work on 12/27/24. ~ CNA-K had COVID-19 with a first symptom date of 12/22/24. CNA-K was retested on [DATE] and returned to work on 12/29/24. ~ CNA-L had COVID-19 with a first symptom date of 12/21/24. CNA-L was retested on [DATE] and returned to work on 12/31/24. ~ CNA-M had COVID-19 with a first symptom date of 12/30/24. CNA-M was retested on [DATE] and returned to work on 1/7/25. ~ CNA-N had COVID-19 with a first symptom date of 12/30/24. CNA-N was retested on [DATE] and returned to work on 1/9/25. The January 2025 staff infection line list indicated 1 staff had GI symptoms of nausea, vomiting, and diarrhea and returned to work prior to DHS recommendations of 48 hours from the last GI symptom: ~ RN-P had GI illness with a first symptom date of 1/15/25 and returned to work on 1/17/25. (The line list did not indicate the date of RN-P's last symptom.) The March 2025 staff infection line list indicated 1 staff tested positive for COVID-19 and returned to work prior to the CDC recommendations: ~ Hospitality Aide (HA)-Q had COVID-19 with a first symptom date of 3/8/25. HA-Q was retested on [DATE] and returned to work on 3/14/25. The April 2025 staff infection line list indicated 1 staff had GI symptoms of vomiting and returned to work prior to DHS recommendations of 48 hours from the last GI symptom: ~ CNA-R had GI illness with a first symptom date of 4/13/25 and returned to work on 4/16/25. (The line list did not indicated the date of CNA-R's last symptom.) On 5/7/25 at 12:03 PM, Surveyor interviewed Infection Preventionist (IP)-C, Director of Nursing (DON)-B, and Nursing Home Administrator (NHA)-A and reviewed the staff line list concerns. DON-B stated the staff infection line list return-to-work dates were not correct as listed. NHA-A stated the facility's previous IP was still learning the role and left unexpectedly; therefore, the previous IP's documentation was incorrect. DON-B indicated DON-B would provide time clock punches for staff with COVID-19 to verify if the previous IP's documentation was correct for return-to-work dates. When Surveyor asked about the facility's return-to-work policy for staff with GI illness, IP-C indicated staff with GI illness can return to work 48 hours after the last GI symptom. DON-B indicated the facility does not have a GI policy that includes criteria for return to work and stated the facility follows the CDC and WI DHS guidelines. When Surveyor asked where the facility documents staffs' last GI symptom in order to determine when staff should return to work, no response was provided. DON-B indicated DON-B would also provide time clock punches for staff with GI symptoms to determine when they returned since the line list might be incorrect. On 5/7/25 at approximately 2:00 PM, DON-B provided staff time punches and new staff infection line lists for December 2024 through May 2025. The new line lists correlated with the time punches; however, they did not provide the dates of last symptoms. On 5/7/25 at 2:52 PM, Surveyor interviewed DON-B who verified staff with COVID-19 completed one COVID-19 antigen test 48 hours prior to returning to work. The CDC COVID HCP return-to-work guidelines indicated 2 antigen tests should be completed prior to returning to work, if both antigen tests are negative staff can return after day 7 since the start of symptoms but if 1 of the 2 tests is positive, staff cannot return until after day 10. Since the facility did not follow the guidelines for the completion of 2 tests prior to returning to work, staff were not able to return until after day 10.

Based on staff interview and record review, the facility did not ensure the Infection Preventionist (IP) completed specialized training in infection prevention and control. This had the potential to affect all 59 residents residing in the facility. IP-C and Director of Nursing (DON)-B shared infection prevention duties for the facility since of March 2025. IP-C did not complete specialized training and DON-B had not begun specialized training. Nursing Home Administrator (NHA)-A indicated a permanent IP was hired and had started infection prevention and control training on 5/5/25. Findings include: Centers for Medicare & Medicaid Services (CMS) Memo QSO-22-19-NH, revised 6/29/22, indicates: In 2016, CMS overhauled the Requirements for Participation for Long-Term Care (LTC) facilities which was implemented in three phases: .Phase 3 (11/28/19) .regulations which require nursing homes to have an Infection Preventionist who has specialized training onsite at least part-time to effectively oversee the facility's infection prevention and control program. The facility did not have an infection prevention and control policy that outlined the facility's infection prevention and control program, provided a description of the Infection Preventionist's training requirements, or identified the number of hours or time needed for infection prevention and control in the facility. On 5/6/25 at 9:32 AM, Surveyor interviewed NHA-A, DON-B, and IP-C who all indicated the previous IP left the facility unexpectedly in March of 2025. A new IP was hired but was on leave until 5/5/25 when the new IP started training. NHA-A indicated the new IP was completing the Centers for Disease Control and Prevention (CDC) IP training this week and wound care training next week. NHA-A indicated IP-C was asked to fill the IP role and complete wound nurse rounds until the new IP completed training. NHA-A indicated IP-C started duties in March of 2025 and worked 1-2 days per week and DON-B assisted with IP duties. IP-C indicated IP-C started the CDC IP training modules but had not completed them. DON-B did not have IP training and was not currently completing IP training. Surveyor was provided with IP-C's progress in the CDC training program which included 24 modules of training. Surveyor noted IP-C completed 10 modules with the last module completed on 3/26/25. On 5/6/25 at approximately 9:45 AM, Surveyor reviewed staff infection line lists from December 2024 through May 2025. Surveyor identified 8 instances where staff returned to work prior to the CDC recommendations for staff with COVID-19 illness. Surveyor identified 2 instances where staff returned to work early after gastrointestinal (GI) illness symptoms of nausea, vomiting and/or diarrhea. (See F880 for further information.) On 5/7/25 at 11:30 AM, Surveyor interviewed NHA-A, DON-B, and IP-C regarding antibiotic therapy concerns for 3 residents. (See F881 for further information.) DON-B indicated the facility does not currently have a trained IP that can train the new IP so there are gaps in the process. On 5/8/25 at approximately 1:30 PM, Surveyor reviewed the Facility Assessment which did not specify the number of hours or time needed for the IP position.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 1/9/25, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and had diagnoses including hemiplegia (weakness on one side of the body) and hemiparesis (paralysis on one side of the body) following nontraumatic intracranial hemorrhage affecting the left non-dominant side, weakness, type 2 diabetes, acquired absence of right leg above knee, and need for assistance with personal care. R3's MDS assessment, dated 12/26/24, had a BIMS score of 15 out of 15 which indicated R3 was not cognitively impaired. R3 had a care plan for potential impairment to skin integrity related to immobility with left sided weakness, recent intracranial hemorrhage, and occasional bowel and bladder incontinence. The care plan contained an intervention to leave the lift sling underneath R3. R3's medical record indicated R3 did not have any pressure injuries. On 1/9/25 at 11:17 AM, Surveyor observed staff transfer R3 from bed to recliner via Hoyer lift. When staff completed the transfer, staff left the sling underneath R3. On 1/9/25 at 11:53 AM, Surveyor interviewed R3 who confirmed staff leave the Hoyer sling underneath R3 which was fine with R3. R3 indicated R3 slept in a recliner at night and the sling remained under R3 while R3 slept. R3 stated R3 asked staff to place a blanket between R3 and the sling at night because sleeping on the sling was uncomfortable. [NAME] 1/9/25 Based on observation, staff interview, and record review, the facility did not ensure care plans were reviewed and revised for 3 residents (R) (R11, R5, and R3) of 13 sampled residents. R11, R5, and R3's care plans were not updated with interventions related to leaving Hoyer slings underneath R11, R5, and R3. Findings include: The facility's Lifting Machine, Using a Mechanical Policy, dated July 2017, indicates: The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device .Steps in procedure: .20. Carefully remove the sling from under the resident. Be mindful of the resident's position and balance, and skin . 1. On 1/9/25, Surveyor reviewed R11's medical record. R11 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, history of left above the knee surgical amputation, osteomyelitis of left foot, and diabetes. R11's Minimum Data Set (MDS) assessment, dated 11/21/24, had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated R11 had moderate cognitive impairment. R11 had an activated Power of Attorney for Healthcare (POAHC). R11 had a care plan for actual impairment to skin integrity related to fragile skin on bilateral buttock and hips. A Braden Scale assessment, dated 11/20/24, contained a score of 12 out of 23 which indicated R11 was at high risk for skin breakdown On 1/9/25 at 11:30 AM, Surveyor observed R11 in a Geri chair with a Hoyer lift sling underneath R11. R11 had a specialty mattress on R11's bed and cushion in R11's Geri chair. On 1/9/25 at 11:30 AM, Surveyor interviewed R11 who indicated the Hoyer sling was left under R11 in the Geri chair and removed when R11 was in bed. R11 denied any discomfort from the sling. On 1/9/25 at 1:46 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-G who verified a Hoyer sling was left underneath R11 in the Geri chair. CNA-G indicated staffs' usual practice was to leave Hoyer slings underneath residents in Geri chairs and wheelchairs and remove the slings when residents transfer into bed. On 1/9/25 at 1:59 PM, Surveyor interviewed CNA-H who indicated Hoyer slings remain underneath residents while they are in Geri chairs and wheelchairs and are removed when residents are transferred into bed. 2. On 1/9/25, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE]. R5 received Hospice services and had diagnoses including history of fracture of left femur. R5's MDS assessment, dated 12/16/24, had a BIMS score of 0 out of 15 which indicated R5 had severe cognitive impairment. R5 had an activated POAHC. R5 had a care plan for potential impairment to skin integrity related to immobility and was at risk for moisture-associated skin damage (MASD) due to frequent bladder incontinence. A Braden Scale assessment, dated 12/31/24, contained a score of 18 out of 23 which indicated R5 was at moderate risk for skin breakdown. On 1/9/25 at 2:05 PM, Surveyor observed R5 in a recliner with a Hoyer sling underneath R5. R5 had a pressure reduction mattress on R5's bed and a cushion in R5's wheelchair. On 1/9/25 at 2:05 PM, Surveyor interviewed R5 who indicated the Hoyer sling was left underneath R5 in the recliner and wheelchair. R5 indicated the sling did not cause irritation or discomfort. On 1/9/25 at 1:46 PM, Surveyor interviewed CNA-G who verified a Hoyer sling was left underneath R5. CNA-G indicated staffs' usual practice was to leave Hoyer slings underneath residents in Geri chairs and wheelchairs and remove the slings when residents transfer into bed. On 1/9/25 at 1:59 PM, Surveyor interviewed CNA-H who indicated Hoyer slings remain underneath residents in Geri chairs and wheelchairs and are removed when residents are transferred into bed. On 1/9/25 at 2:45 PM, Surveyor interviewed Director of Nursing (DON)-B and Nursing Home Administrator (NHA)-A. DON-B indicated Hoyer slings are left underneath residents in Geri chairs and wheelchairs if the residents don't mind. DON-B verified the facility's policy states slings should be removed. NHA-A indicated a company representative provided an inservice to staff last week and instructed staff that leaving Hoyer slings underneath residents in Geri chairs and wheelchairs is an acceptable practice. NHA-A did not have the literature or documentation from the representative or manufacturer to support the practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure the adequate use of assistive devices to prevent injury for 1 resident (R) (R3) of 2 sampled residents. R3 indicated the lift battery often died while R3 was mid-transfer and R3 was left hanging in the lift while staff replaced the battery. Findings include: On [DATE], Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and had diagnoses including hemiplegia (weakness on one side of the body) and hemiparesis (paralysis on one side of the body) following nontraumatic intracranial hemorrhage affecting the left non-dominant side, weakness, type 2 diabetes, acquired absence of right leg above the knee, and need for assistance with personal care. R3's Minimum Data Set (MDS) assessment, dated [DATE], had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R3 was not cognitively impaired. R3's care plan indicated R3 was a 2 person Hoyer lift transfer when R3's left leg prosthesis was off. If R3's left leg prosthesis was on, R3 was a pivot disk transfer. On [DATE] at 11:53 AM, Surveyor interviewed R3 who indicated the lift battery often died while R3 was in the air mid-lift. R3 stated staff needed to leave the room to get a new battery. R3 stated staff recently left R3 hanging in the lift to get another battery. R3 indicated R3 talked to maintenance staff because R3 knew of a place that rebuilt batteries. R3 indicated the facility stated they had ordered new batteries. On [DATE] at 4:11 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-L who usually worked the night (NOC) shift. CNA-L confirmed lift batteries died mid-transfer. When Surveyor asked if a lift battery had ever died during a transfer with R3, CNA-L indicated the lift battery died that morning while R3 was mid-transfer. CNA-L indicated one of the staff left the room to get another battery because there was another lift outside the door. CNA-L indicated CNA-L had recently received lift training and it was a split second decision not to use the manual while the battery was changed because there was a lift outside R3's room. On [DATE] at 2:15 PM, Surveyor interviewed CNA-N who indicated the lift indicates how much battery is left, however, CNA-N did not check the battery life. CNA-N indicated batteries are changed when they are low and not on a scheduled basis. On [DATE] at 1:42 PM, Surveyor interviewed Maintenance Director (MD)-M and Nursing Home Administrator (NHA)-A who indicated MD-M had just ordered two batteries which should arrive on [DATE]. MD-M indicated if staff have problems with a battery, MD-M tests the battery to see if it holds a charge. MD-M indicated batteries last approximately 6 months. MD-M indicated there were two chargers on each unit that held at least 2 extra batteries and at least 4 Hoyer lifts and 4 EZ stand lifts. Surveyor, MD-M, and NHA-A observed the batteries and chargers on one of the wings. Surveyor noted there was one battery in the charger. MD-M indicated the facility was waiting for the new batteries. NHA-A indicated when a lift is turned on, the lift shows the remaining battery power. NHA-A indicated the lift company recently completed training with staff. NHA-A indicated there is a manual release that staff should use if a battery dies mid-transfer. NHA-A indicated staff should lower the resident with the manual release, changed the battery, and complete the transfer. NHA-A confirmed residents should not be left hanging in the lift if a battery dies during a transfer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility did not provide appropriate care and services for 2 residents (R) (R10 and R12) of 6 sampled residents with an indwelling catheter. On 1/9/25, R10 and R12's catheter drainage bags were observed in contact with the floor. Findings include: The facility's Catheter, Urinary Policy, dated August 2022, indicates: The purpose of this procedure is to prevent urinary-associated complications, including urinary tract infections .Infection Control: .2. Be sure the catheter tubing and drainage bag are kept off the floor . 1. On 1/9/25, Surveyor reviewed R10's medical record. R10 was admitted to the facility on [DATE] and had diagnoses including history of supracondylar fracture of the left femur, right tibial fracture, and hypertension. R10's Minimum Data Set (MDS) assessment, dated 12/23/24, had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R10 had moderate cognitive impairment. R10's medical record indicated R10 was responsible for R10's healthcare decisions. On 1/9/25 at 11:20 AM, Surveyor observed R10 and noted R10's catheter bag was covered by a dignity shield and attached to the side of R10's bed which was in the lowest position. R10's dignity shield and catheter bag were laying on the floor. On 1/9/25 at 11:25 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-E who verified R10's catheter bag was on the floor. CNA-E indicated when CNA-E put R10's bed in the lowest position, CNA-E did not notice that R10's catheter bag was in contact with the floor. CNA-E verified catheter bags should not touch the floor. 2. On 1/9/25, Surveyor reviewed R12's medical record. R12 was admitted to the facility on [DATE] and had diagnoses including history of hemiplegia (weakness on one side of the body) and hemiparesis (paralysis on one side of the body), anemia, and gross hematuria. R12's MDS assessment, dated 11/21/24, had a BIMS score of 5 out of 15 which indicated R12 had severely impaired cognition. R12 had an activated Power of Attorney for Healthcare (POAHC). On 1/9/25 at 11:40 AM, Surveyor observed R12. Surveyor noted R12's dignity covered catheter bag was attached to R12's wheelchair frame below the seat. R12's catheter bag and dignity shield were dragging on the floor. On 1/9/25 at 11:50 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-F who verified R12's catheter bag was in contact with the floor. LPN-F raised R12's catheter bag and verified catheter bags should not touch the floor. On 1/9/25 at 12:02 PM, Surveyor interviewed Director of Nursing (DON)-B who verified catheter bags should not touch the floor. DON-B indicated DON-B expects staff to adjust catheter bags so they do not touch the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility did not ensure a prescribed diet was followed for 1 resident (R) (R3) of 3 sampled residents. R3 was prescribed a consistent carbohydrate hydro-oligomeric diet (CCHO) (a diet designed to manage blood sugar levels in individuals with diabetes or prediabetes). R3's diet order was not consistently followed. Findings include: The facility did not have a policy regarding following diets. On 1/9/25, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and had diagnoses including type 2 diabetes. R3's Minimum Data Set (MDS) assessment, dated 12/26/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R3 was not cognitively impaired. R3's medical record indicated R3 was prescribed a CCHO diet. During in interview with R3 on 1/9/25 at 12:06 PM, staff delivered R3's meal tray. R3 took the dessert but declined the rest of the tray because R3 had ordered out for lunch. Surveyor reviewed R3's meal ticket and tray. R3's meal ticket stated R3 was on a CCHO diet and indicated R3 should have received a half piece of cake. Surveyor noted R3 had received a full piece of cake which R3 accepted. When Surveyor stated R3's meal ticket indicated R3 should have received a half piece of cake, R3 indicated R3 was okay with a larger piece of cake that day. On 1/9/25 at 12:32 PM, Surveyor interviewed [NAME] (CK)-I and Dietary Aid (DA)-J who were serving lunch in the dining room. Surveyor observed 2 trays of desserts on a cart. The top tray had a mix of cake sizes and the bottom tray had one smaller piece of dessert. When asked the reason for the different cake sizes, CK-I indicated there wasn't a reason. CK-I indicated some pieces of cake were too big and CK-I cut them so they were not so big. CK-I and DA-J indicated some residents asked for smaller pieces so there were a few smaller pieces in case someone asked. Surveyor showed R3's meal ticket to CK-I and DA-J who indicated R3 may have requested a full piece of cake since a couple days prior to the meal staff asked residents what they would like. When Surveyor indicated R3's meal ticket said a half piece of cake, CK-I and DA-J indicated they give residents what they want. On 1/9/25 at 2:11 PM, Surveyor interviewed Dietary Manager (DM)-K who confirmed R3 should have received a half piece of cake due to R3's CCHO diet. DM-K indicated the facility did not have a policy regarding following appropriate diets, however, staff were expected to follow residents' diet cards.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 1 resident (R) (R13) of 13 residents observed during the provision of cares. R13 was on enhanced barrier precautions (EBP) which required staff to wear personal protective equipment (PPE) during high-contact cares. On 1/9/25, staff transferred and provided wound care for R13 without wearing PPE. In addition, Surveyor observed staff exit R13's room with a vital signs machine. Staff did not appropriately disinfect the machine after use. Findings include: The facility's Enhanced Barrier Precautions (EBP) policy, dated 5/1/24, indicates: .EBP: Infection control practices requiring the use of personal protective equipment (PPE) for certain high-contact resident care activities, even in the absence of standard indications for isolation. 2. High-Contact Resident Care Activities: Activities that involve potential exposure to infectious agents such as: dressing .transferring .wound care . The facility's Cleaning and Disinfection of Resident-Care Items and Equipment policy, revised October 2018, indicates: .Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). On 1/9/25, Surveyor reviewed R13's medical record. R13 was admitted to the facility on [DATE] and had diagnoses including severe sepsis with septic shock, lymphoma, candidiasis (yeast infection), open wound right ankle, open wound left ankle, open wound of the left buttock, stem cell transplant, bone marrow transplant, and need for assistance with personal care. R13's medical record contained an order, dated 1/8/25, for EBP: wounds every shift infection control. R13 also had an order, dated 1/7/24, for EBP: open wound left flank and left gluteal . On 1/9/25 at 12:05 PM, Surveyor observed R13's room and noted an EBP sign on the door. Licensed Practical Nurse (LPN)-C was in the room. When LPN-C opened the privacy curtain, Surveyor noted LPN-C was not wearing PPE. Surveyor interviewed LPN-C who stated LPN-C completed wound care for R13 prior to exiting the room. LPN-C confirmed LPN-C did not wear PPE during wound care. When Surveyor asked if LPN-C should have worn PPE, LPN-C indicated PPE was not needed. When Surveyor asked about the EBP sign on R13's door, LPN-C indicated the sign meant LPN-C needed to wash hands before and after leaving the room. On 1/9/25 at 12:08 PM, Surveyor knocked and entered R13's room. CNA-D was in the room and had just assisted LPN-C with wound care. CNA-D was also not wearing PPE. Surveyor then observed CNA-D transfer R13. CNA-D assisted R13 to stand with a gait belt and walker, pulled up R13's pants, and walked across the room to R13's recliner. CNA-D made R13's bed and adjusted a pillow behind R13's back. CNA-D performed hand hygiene prior to exiting the room with a vital signs machine. On 1/9/25 at 12:15 PM, Surveyor observed CNA-D put the vital signs machine in the hallway and walk away. Surveyor stopped CNA-D and asked if the machine needed to be sanitized. CNA-D indicated the machine would need to be sanitized depending on which resident used it last. CNA-D confirmed CNA-D obtained R13's vital signs. When Surveyor asked CNA-D if R13 was on EBP, CNA-D indicated R13 was on EBP but CNA-D was not sure why. When Surveyor asked if PPE should be worn when assisting with wound care and transfers, CNA-D indicated PPE only needed to be worn during cares like showering and washing a resident. On 1/9/25 at 1:33 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B who confirmed staff should wear PPE during high-contact cares. DON-B also confirmed durable medical equipment should be sanitized between each resident use.

**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 abuse was thoroughly investigated for 2 residents (R) (R5 and R6) of 13 sampled residents. The facility did not report a resident-to-resident altercation between R5 and R6 to the State Agency (SA) in a timely manner because staff did not report the incident timely to administration. The facility could not provide proof of education for the staff who were working when the resident-to-resident altercation occurred. Findings include: The facility's Patient Protection Program Freedom from Abuse, Neglect, and Exploitation policy, dated 3/2025, indicates: The facility must take the following actions in response to an alleged violation of abuse, neglect, exploitation, and mistreatment: Take appropriate corrective action, because of investigation findings .Internal Reporting. A. Employees must always report any abuse or suspicion of abuse immediately to the Administrator or Abuse Coordinator Designee. External Reporting: Initial reporting of allegations: If an incident or allegation is considered reportable, the Administrator or designee will make an initial (immediate or within 24 hours) report to the State Agency. On 10/7/24, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] with diagnoses including degeneration of nervous system due to alcohol, weakness, and cognitive communication deficit. R5's Minimum Data Set (MDS) assessment, dated 9/9/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R5 had intact cognition. R5 was R5's own decision maker. On 10/7/24, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] with diagnoses including dementia with other behavioral disturbance. R6's MDS assessment, dated 7/5/24, indicated R6 was severely cognitively impaired. R6 had an activated decision maker. On 10/7/24, Surveyor reviewed a facility-reported incident (FRI) that indicated on the 7/19/24 PM shift, R5's roommate called staff into R5's room and said there was an incident between R5 and R6. R5 reported to staff that R6 yelled and rammed R6's wheelchair into R5 while R5 was in the activity room watching TV. R5 also reported that staff removed R6 from the activity room. R5 could not recall the name of the staff or the time of the incident. Staff immediately reported R5's allegation to a nurse; however, the nurse did not notify administration of the incident. The nurse filled out a grievance form and left a message for the Social Worker regarding the incident. Surveyor reviewed the facility's investigation which indicated staff were aware of the incident on the 7/19/24 (Friday) PM shift; however, administration did not become aware of the incident until 7/22/24 (Monday). An investigation was initiated and the incident was reported to the SA on 7/22/24 which was beyond the 24 hour reporting requirement. The investigation indicated the facility was not able to determine which staff intervened to remove R6 from the activity room during the incident. Surveyor reviewed education, dated 7/23/24 to 7/25/24, related to reporting incidents to administration in a timely manner. Surveyor reviewed the education sign-in sheets and compared the sign-in sheets to the PM shift schedule on 7/19/24. Surveyor noted Certified Nursing Assistant (CNA-D), CNA-E, and Hospitality Aid (HA-F) were not on the sign in-sheets but had worked on 7/19/24. The facility indicated additional abuse training, including reporting requirements, was completed on 8/26/24 and 8/27/24; however, Surveyor could not locate CNA-D, CNA-E, or HA-F's names. On 10/7/24 at 2:17 PM, Surveyor interviewed Nursing Home Administrator (NHA)-C who could not provide proof that education was completed for CNA-D, CNA-E, and HA-F. NHA-C confirmed education should have been completed since CNA-D, CNA-E, and HA-F were working when the incident occurred.

Based on staff interview and record review, the facility did not ensure their abuse policy was implemented for 1 of 8 employees reviewed for background checks. Certified Nursing Assistant (CNA)-J's background check information did not contain an out-of-state criminal or caregiver background check. Findings include: The facility's Patient Protection Program: Freedom from Abuse, Neglect, and Exploitation document indicates: Screening components: .It is the policy of this facility to screen employees and volunteers prior to working with residents. Screening components include verification of references, certification and verification of license and criminal background check .Employee screening and training: Before new employees are permitted to work with residents, references provided by the prospective employee will be verified as well as appropriate board registrations and certifications regarding the prospective employee's background. The facility will not employ or otherwise engage individuals who have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law .A criminal background check will be conducted on all prospective employees as provided by the facility's policy on criminal background checks. A significant finding on the background check will result in denied employment consistent with the criminal background check policy in accordance with state and federal regulation On 3/10/24, Surveyor requested a staff list from Nursing Home Administrator (NHA)-A. On 3/11/24, Surveyor reviewed the staff list and requested background check information for eight staff, including CNA-J's background check and CNA registry information from Assistant Nursing Home Administrator (ANHA)-C. On 3/12/24, Surveyor reviewed CNA-J's background check information and noted CNA-J was hired by the facility on 11/7/23 and had a caregiver background check completed on 10/27/23. Surveyor noted CNA-J's caregiver background check indicated CNA-J lived outside the state of Wisconsin within the last 3 years. Surveyor reviewed the background check information provided by the ANHA-C and noted out-of-state criminal and caregiver background checks were not included. On 3/12/24 at 10:17 AM, Surveyor requested an out-of-state criminal and caregiver background check for CNA-J from NHA-A. On 3/12/24 at 2:56 PM, NHA-A indicated to Surveyor that the facility did not complete out-of-state criminal or caregiver background checks for CNA-J and did not have information to provide to Surveyor.

Based on staff interview and record review, the facility did not ensure an allegation of neglect was thoroughly investigated for 1 Resident (R) (R204) of 1 sampled resident. The facility did not thoroughly investigate R204's allegation of neglect. Findings include: The facility's Patient Protection Program, Freedom from Abuse, Neglect and Exploitation policy indicates: It is the policy of the facility to maintain an environment where residents are free from abuse, neglect, exploitation and misappropriation of resident property and all resident, staff, families, visitors, volunteers and resident representatives are encouraged and supported in reporting any suspected acts of abuse, neglect, misappropriation of resident property or exploitation .The resident has the right to bee free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart .This regulation was written to provide protections for the health, welfare and rights of each resident residing in the facility. To provide these protections, the facility must develop written policies and procedures to prohibit and prevent abuse, neglect, exploitation of residents and misappropriation of resident property. These written policies must include, but are not limited to, the following components: Screening, Training, Prevention, Identification, Investigation, Protection and Reporting/Response .Abuse Policy Requirements: .It is the policy of this facility to train employees, throughout orientation and ongoing sessions on issues related to abuse and prohibition practices .Staff and volunteers will receive education about resident mistreatment, neglect and abuse, including injuries of unknown source, exploitation and misappropriation of property upon first employment and annually after that incorporating the following elements .orientation and ongoing programs .communication of reports of resident mistreatment, neglect, and/or abuse, including injuries of unknown source, and misappropriation of property .Review of facility abuse policies and procedures: .E. Investigation .It is the policy of this facility that reports of abuse are promptly and thoroughly investigated .The facility will take all necessary actions as a result of the investigation, including .training of staff about changes made as a result of the investigation and reporting . On 3/10/24, Surveyor reviewed a facility-reported incident (FRI), dated 2/23/24, that indicated R204 reported to nursing staff that Certified Nursing Assistant (CNA)-W told R204 to eat dinner in R204's room and stay in R204's wheelchair from 3:00 PM-10:00 PM because CNA-W was too busy to use the Hoyer lift to transfer R204 into bed as requested. Surveyor reviewed the facility's investigation which indicated the police were notified, R204 was interviewed and monitored for psychosocial harm, and other residents and staff were interviewed. Surveyor noted abuse/neglect education was not provided to staff following the incident. On 3/10/24, Surveyor reviewed R204's medical record. R204 had diagnoses including infection and inflammatory reaction due to internal right knee prosthesis, cellulitis of the right lower limb, type 2 diabetes, end stage renal disease, and unspecified open wound on buttock. R204's Minimum Data Set (MDS) assessment, dated 2/28/24, contained a Brief Interview for Mental Status (BIMS) score of 15 out 15 which indicated R204 had intact cognition. The MDS also indicated R204 required full assistance with activities of daily living (ADLs). On 3/10/24 at 10:53 AM, Surveyor interviewed R204 who did not have concerns with staffing or R204's current care and treatment. R204 indicated the facility was a good place to live and any concerns R204 had with care were addressed and have not reoccurred. On 3/11/24 at 10:06 AM, Surveyor interviewed Assistant Nursing Home Administrator (ANHA)-C and Nursing Home Administrator (NHA)-A regarding the neglect investigation involving R204. ANHA-C indicated CNA-W was an agency employee whose contract was not renewed and CNA-W did not return to the facility. ANHA-C stated CNA-J was on duty during the allegation of neglect and received verbal education which was not documented. ANHA-C confirmed education was not provided to other staff following the allegation. ANHA-C verified staff education should have been completed and stated it was an oversight on ANHA-C's part.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure 3 Residents (R) (R204, R36, and R19) of 4 residents reviewed for hospitalizations received a written notice of transfer, including the reason for the transfer, location of the transfer, appeal rights, and contact information for the State Long-Term Care Ombudsman. In addition, the facility did not notify the Ombudsman of the transfers. R204 was transferred to the hospital on 2/27/24. R204 was not provided a written transfer notice and the Ombudsmen was not notified of the transfer. R36 was transferred to the hospital on [DATE] and 11/27/23. R36 was not provided written transfer notices and the Ombudsmen was not notified of the transfers. R19 was transferred to the hospital on [DATE] and 2/27/24. R19 was not provided written transfer notices and the Ombudsmen was not notified of the transfers. Findings include: The facility's Transfer or Discharge Documentation document, revised 12/2016 indicates: When a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider .When a resident is transferred or discharged from the facility, the following information will be documented in the medical record: a. The basis for the transfer and discharge. b. That an appropriate notice was provided to the resident and/or legal representative .i. Other as appropriate and necessary . 1. On 3/11/24, Surveyor reviewed R204's medical record. R204 was transferred to the hospital on 2/27/24 due to a low blood sugar level. R204's medical record did not indicate R204 received a written transfer notice or that the Ombudsman was notified. R204 did not have an activated power of attorney for healthcare (POAHC). On 3/11/24 at 4:00 PM, Surveyor requested a copy of the written transfer notice provided to R204 and a copy of the Ombudsman notification. On 3/12/24 at 9:20 AM, Assistant Nursing Home Administrator (ANHA)-C confirmed a written transfer notice was not provided to R204. Surveyor reviewed the facility's February 2024 Ombudsman transfer notification and noted the Ombudman was not notified of R204's transfer on 2/27/24. 3. On 3/11/24, Surveyor reviewed R19's medical record. R19 was transferred to the hospital on [DATE] due to right sided weakness and on 2/27/24 due to a fall with a head injury. Surveyor noted R19's medical record did not indicate R19 (who did not have an activated POAHC) was provided written transfer notices or that the Ombudsman was notified of the transfers. On 3/12/24 at 11:21 AM, Surveyor requested a copy of the written transfer notices provided to R19 and notification to the Ombudsman of R19's transfers. On 3/12/24 at 12:29 PM, ANHA-C confirmed written transfer notices were not provided to R19. On 3/11/24 at 12:41 PM, Surveyor interviewed NHA-A who indicated NHA-A expects nurses to use the facility's transfer form when a resident is transferred to the hospital. On 3/11/24 at 1:03 PM, Surveyor reviewed the facility's Ombudsman transfer notifications for December 2023 and February 2024 and noted the Ombudsman was not notified of R19's transfers on 12/12/23 and 2/27/24. 2. On 3/11/24, Surveyor reviewed R36's medical record. R36 was transferred to the hospital on [DATE] due to acute kidney injury and on 11/27/23 due to low blood pressure, headache and dizziness. Surveyor noted R36's medical record did not indicate R36 was provided a written transfer notice for either transfer or that the Ombudsman was notified of the transfers. On 3/12/24 at 11:21 AM, Surveyor requested a copy of the written transfer notices provided to R36 and notification to the Ombudsman of R36's transfers. On 3/12/24 at 12:29 PM, ANHA-C confirmed written transfer notices were not provided to R36. On 3/11/24 at 12:41 PM Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated NHA-A expects nurses to use the facility's transfer form when a resident is transferred to the hospital. On 3/11/24 Surveyor reviewed the facility's Ombudsman transfer notifications for November 2023 and noted the Ombudsman was not notified of R36's transfers on 11/21/23 and 11/27/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure 3 Residents (R) (R204, R36 and R19) of 4 residents reviewed for hospitalizations received written information of the duration of the facility's bed hold policy, the reserve bed payment policy, and the right to return to the facility. R204 was transferred to the hospital on 2/27/24 and was not provided a copy of the facility's bed hold policy. R36 was transferred to the hospital on [DATE] and 11/27/23 and was not provided copies of the facility's bed hold policy. R19 was transferred to the hospital on [DATE] and 2/27/23 and was not provided copies of the facility's bed hold policy. Findings include: The facility's Bed-Holds and Returns policy, revised 3/2022, indicates: Resident and/or representative are informed (in writing) of the facility and state (if applicable) bed hold policies .1. All residents/representatives are provided written information regarding the facility bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalizations or therapeutic leave). Residents are provided written information about these policies at least twice: well in advance of any transfer (e.g., in the admission packet) and at the time of transfer (or, if the transfer was an emergency, within 24 hours). The facility's Bed Hold Notification document indicates: Bed hold occurs when an individual is transferred to the hospital for medical care or when an individual is on therapeutic leave .Medical Assistance will pay for a resident's bed to be held for up to 15 days when they are admitted to the hospital. After the 15th day, the resident or family will be asked if they wish to continue to hold the bed using private funds .The resident or family has the option to hold the bed indefinitely. The bed will be held at the bedhold rate .Surveyor noted the Bed Hold Notification form listed the 2022 rate for semi-private, private, and enhanced private rooms. Surveyor also noted an area on the form that indicated if the resident wanted to hold the bed or decline a bed hold contained a signature line and date for the resident or resident's representative to sign. 1. On 3/11/24, Surveyor reviewed R204's medical record. R204 was transferred to the hospital on 2/27/24 due to a low blood glucose reading. R204's medical record did not indicate a copy of the bed hold policy was provided to R204 (who did not have an activated power of attorney for healthcare (POAHC)). On 3/12/24 at 9:20 AM, Assistant Nursing Home Administrator (ANHA)-C confirmed R204 was not provided with the facility's bed hold policy when R204 was transferred to the hospital. 4. On 3/11/24, Surveyor reviewed R19's medical record. R19 was transferred to the hospital on [DATE] due to right sided weakness and on 2/27/24 due to a fall with a head injury. Surveyor noted R19's medical record did not indicate a copy of the bed hold policy was provided to R19 (who did not have an activated POAHC). On 3/12/24 at 11:21 AM, Surveyor requested a copy of the bed hold policy that was provided to R19 for the transfers on 12/12/23 and 2/27/24. On 3/12/24 at 12:29 PM, ANHA-C confirmed the bed hold policy was not provided to R19 for either transfer. On 3/11/24 at 12:41 PM, Surveyor interviewed NHA-A who indicated NHA-A expects nurses to provide a copy of the facility's bed hold policy and transfer form when a resident is transferred to the hospital. 2. On 3/11/24, Surveyor reviewed R36's medical record. R36 was transferred to the hospital on [DATE] due to acute kidney injury and on 11/27/23 due to low blood pressure, headache and dizziness. Surveyor noted R36's medical record did not indicate a copy of the bed hold policy was provided to R36. On 3/12/24, Surveyor requested a copy of the facility's bed hold policy that was provided to R36 for the transfers on 11/21/23 and 11/27/23. On 3/12/24 at 12:29 PM, ANHA-C confirmed the bed hold policy was not provided to R36 for either transfer. ANHA-C indicted that a nursing note was completed, but not a written bed hold. On 3/11/24 at 12:41 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated NHA-A expects nurses to provide a copy of the facility's bed hold policy when a resident is transferred to the hospital

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility's Falls and Fall Risk Managing policy, revised 12/2007, indicates: Based on previous evaluations and current data, staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling .Prioritizing Approaches: 1. The staff with the input of the Attending Physician will identify appropriate interventions to reduce the risk of falls. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions .4. If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant .6. In conjunction with the Attending Physician, staff will identify and implement relevant interventions to try to minimize serious consequences of falling. The facility's Assessing Falls and Their Causes policy, revised 10/2010, indicates: The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall .1) After a fall: a. If a resident has just fallen or is found on the floor without a witness to the event, nursing staff will record vital signs and evaluate for possible injuries .f. Documentation will include any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility; and any changes in level of responsiveness/consciousness and overall function. It will note the presence or absence of significant findings. g. An incident report must be completed for resident falls. The incident report form should be completed by the nursing supervisor on duty at the time and submitted to the Director of Nursing no later than 24 hours after the fall occurs .Documentation: When a resident falls, the following information should be recorded in the resident's medical record .2. Assessment data. 3. Interventions, first aid, or treatment administered .5. Completion of a falls risk assessment. 6. Appropriate interventions taken to prevent future falls .Reporting: .2. Report other information in accordance with the facility policy and professional standards of practice. The facility's Neurological Assessment, revised 10/2010, indicates: The purpose of this procedure is to provide guidelines for a neurological assessment .2) when following an unwitnessed fall; 3) subsequent to a fall with a suspected head injury; or 4) when indicated by resident condition. General Guidelines: 1. Neurological assessments are indicated: .b. following an unwitnessed fall; c. following a fall or other accident/injury involving head trauma; 2. When assessing neurological status, always include frequent vital signs .Steps in the Procedure: .3. Perform neurological checks with the frequency as ordered or per falls protocol. 4. Determine resident's orientation to time, place and person. 5. Take temperature, pulse, respirations, blood pressure .7. Check pupil reaction .8. Determine motor ability: a. Have resident move all extremities; b. Ask resident to squeeze your fingers. Note strength bilaterally, c. Have resident plantar and dorsiflex. Note strength bilaterally. Ask resident if he/she has any numbness or tingling in legs/feet/toes and document accordingly. 9. Determine sensation in extremities .Documentation: The following information should be recorded in the resident's medical record: 1) The date and time the procedure was performed. 2. The name and title of the individual who performed the procedure. 3. All assessment data obtained during the procedure. 4. How the resident tolerated the procedure. 5. If the resident refused the procedure, the reason why and the intervention taken. 6. The signature and title of the person recording the data . From 3/10/24 to 3/12/24, Surveyor reviewed R19's medical record. R19 was admitted to the facility on [DATE] with diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebrovascular accident (stroke) affecting the right dominant side, repeated falls, and difficulty in walking. R19's Minimum Data Set (MDS) assessment, dated 2/23/24, contained a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R19 had moderately impaired cognition. R19 had a fall with head injury during the night shift on 2/26/24 when R19 reached for a remote control and fell out of bed. R19 was sent to the Emergency Department (ED) and returned to the facility several hours later on 2/27/24. A progress note, dated 2/27/24 at 1:32 AM, indicated a raised edge mattress and low bed position would be implemented following R19's fall. On 3/11/24 at 10:48 AM, Surveyor interviewed CNA-M who indicated a new fall intervention for R19 was to check on R19 more often. The intervention was not included in R19's plan of care. On 3/11/24 at 1:35 PM, Surveyor noted R19's bed did not have a raised edge. Surveyor interviewed R19 who confirmed R19's bed did not have a raised edge and stated staff only check on R19 when R19 activates R19's call light. On 3/11/24 at 1:51 PM, Surveyor reviewed the Interdisciplinary Team's (IDT) review of R19's fall on 2/26/24 and noted the IDT still agreed with the current intervention (continue to monitor). On 3/11/24 at 2:33 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-K who indicated R19's fall interventions included a mat by the bed and a noodle on one side of the bed. Surveyor noted neither of the interventions were included in R19's plan of care. On 3/11/24 at 2:42 PM, Surveyor interviewed LPN-K regarding R19's new interventions post fall. LPN-K indicated R19's new fall interventions included Velcro on R19's remote control; however, LPN-K was unsure if the intervention was in R19's care plan. When Surveyor asked LPN-K if R19's care plan was revised, LPN-K reviewed R19's care plan and confirmed R19's care plan was not revised or updated and did not contain R19's new fall interventions. On 3/11/24 at 2:47 PM, Surveyor interviewed LPN-L regarding fall interventions implemented after R19's fall on 2/26/24. LPN-L stated there were no new interventions after R19's fall. LPN-L indicated neurochecks should have been completed every 15 minutes x 4, every 30 minutes x 4, every hour x 4 and every shift x 72 hours. At 2:53 PM, LPN-L confirmed R19's bed did not have a raised edge. On 3/11/24 at 3:03 PM, Surveyor interviewed Director of Nursing (DON)-B regarding the interventions implemented after R19's fall on 2/26/24. DON-B indicated Velcro was put under R19's television remote to prevent the remote from falling which was the root cause of R19's fall. DON-B indicated Velcro, a reacher and clip (call light) interventions were on the Point Click Care (PCC) (computerized medical record) dashboard. Per DON-B, the dashboard could only be accessed by administration and nurses. DON-B confirmed the interventions were not contained in area that CNAs could access. DON-B agreed CNAs should be able to access new fall interventions and verified R19's care plan should have been updated with the new interventions. DON-B verified neurochecks were not completed under R19's PCC assessment tab, but stated R19's progress notes indicated neurochecks were completed and within normal limits. On 3/12/24 at 10:57 AM, Surveyor interviewed DON-B who reviewed R19's neurochecks for the 2/26/24 fall and verified the neurochecks were not completed. DON-B indicated although nursing notes indicated neurochecks were completed, DON-B expects staff to complete neurochecks using the neurocheck form under the assessment tab in PCC. DON-B agreed neurochecks should be completed every 15 minutes x 4, every 30 minutes x 4, every hour x 4 and every shift x 72 hours. Based on observation, resident and staff interview, and record review, the facility did not ensure each resident received adequate supervision and assistive devices, did not ensure fall assessments were completed, and did not ensure interventions to prevent falls were implemented for 2 Residents (R) (R12 and R19) of 18 sampled residents. On 3/11/24, staff used a lift with defective brakes and a defective sling to transfer R12. Staff did not appropriately assess R19 following a fall with head injury on 2/26/24. In addition, the facility did not update R19's care plan with interventions to prevent future falls. Findings include: The facility's Safety and Supervision of Residents policy, dated 12/2007, indicates: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Resident Risks and Environmental hazards: Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include: b. Safe lifting and movement of residents. c. Falls . The EZ Way Smart Stand Operator's Instructions indicate: The only time you should lock the wheels of the EZ Way Smart Stand when in use is when you are raising or lowering the patient during ambulation. To operate the EZ Way Smart Stand follow the steps .Pre Operation check: Before operating the unit, complete a maintenance safety check for loose nuts and bolts and damaged parts. Also ensure the harness is not ripped, frayed, or showing signs of wear. 1. On 3/10/24 at 10:15 AM, Surveyor was approached by Certified Nursing Assistant (CNA)-G who showed Surveyor an EZ stand sling with a broken clip on a shelf near the C wing nurses' station. Surveyor noted the black plastic clip that went into the receiving end had one intact prong and one broken prong. CNA-G indicated CNA-G only worked occasionally at the facility but believed other staff used the sling to transfer R17 that morning. CNA-G stated CNA-G previously told staff 5 times that the sling was broken and should be removed from the unit. When Surveyor asked if CNA-G informed Nursing Home Administrator (NHA)-A or Director of Nursing (DON)-B, CNA-G indicated CNA-G told a few full time staff and a nurse. CNA-G indicated CNA-G pulled the sling from the unit and handed it to a full time staff, but the sling came back. CNA-G also indicated CNA-G wrote a note on the sling that indicated the sling was broken; however, staff continued to use the sling. On 3/11/24 at 1:42 PM, Surveyor observed CNA-H transfer R12 via EZ stand lift. CNA-H opened the lift's legs and put the lift under R12. CNA-H indicated CNA-H would usually engage the brakes, but the brakes on the lift didn't work. CNA-H then lifted R12 from the wheelchair and transferred R12 to R12's recliner. When Surveyor asked CNA-H if the other EZ stand lift had working brakes, CNA-H indicated the brakes on the other lift worked, but the lift was in use so CNA-H had to use the lift with the broken brakes. CNA-H indicated the facility only had 2 EZ stand lifts. When Surveyor asked CNA-H if management was aware that the lift's brakes didn't work, CNA-H indicated CNA-H was not sure. Surveyor also noted the sling CNA-H used to transfer R12 contained a broken prong on the waist strap. On 3/12/24 at 11:23 AM, Surveyor interviewed NHA-A who verified the sling and EZ stand lift were used to transfer residents on the C Wing. NHA-A verified staff should not have used the lift and stated the sling should have been removed from the unit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interview, and record review, the facility did not ensure 1 Resident (R) (R34) of 1 resident received the necessary care and services for respiratory therapy. The facility provided R34 with respiratory therapy via CPAP (continuous positive airway pressure) without a physician's order. In addition, R34's need for and use of CPAP therapy was not care planned for assessment, evaluation, or monitoring. Findings include: The facility's CPAP Therapy policy, revised 10/2010, indicates: Purpose: 1) To provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen. 2) To improve arterial oxygenation in residents with respiratory insufficiency, obstructive sleep apnea (OSA), or restrictive/obstructive lung disease .apnea .Preparation: .3) Review the physician's orders .Document the following in the resident's medical record: 1) General assessment prior to procedure; 2) Time CPAP was started and duration of the therapy; 3) Mode and settings for the CPAP; .5) How the resident tolerated the procedure; and 6) Oxygen saturation during therapy . The facility's Respiratory Therapy-Prevention of Infection policy, revised 4/2012, indicates: The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment .Preparation: 1) Review the resident's care plan to assess for any special circumstances or precautions related to the resident .General Guideline: 1) Distilled water used in respiratory therapy must be dated and initiated when opened and discarded after 24 hours; 2) Condensate in the breathing circuits must be drained back into waste bottles, which must be marked with resident's name, and emptied into the toilet or hopper at the end of every shift. Condensate should be considered infectious. Condensate should never be drained back into the breathing circuit or cascade .Steps in the Procedure: .4) Check water levels of refillable humidifier units daily .If the water level falls below the fill line .e) Change the reservoir every 48 hours . From the website: https://www.sleepfoundation.org/cpap/how-to-clean-a-cpap-machine: Continuous positive airway pressure (CPAP) machines are a standard treatment for sleep apnea, a serious breathing disorder. While they are an effective way to treat sleep apnea, CPAP machines do require frequent care and cleaning. Given that the mask, tubing, and other components are breathed into and deliver air throughout the night, their cleanliness can be a serious health concern. Daily cleaning removes dangerous microbes, mold, dust, and debris to ensure your CPAP treatment makes you feel better and not worse. While daily cleaning may seem overwhelming, it is a relatively quick process that is easy to integrate into your daily schedule. Manufacturers and experts tend to recommend daily cleaning of your CPAP machine's components, and users should commit to weekly cleaning at a minimum. On 3/10/24, Surveyor reviewed R34's medical record. R34 was admitted to the facility on [DATE] with diagnoses including obstructive sleep apnea (OSA), dementia, weakness, and anxiety. R34's Minimum Data Set (MDS) assessment, dated 12/20/23, contained a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated R34 had moderate cognitive impairment. R34's medical record indicated R34 had an activated Power of Attorney (POA). During multiple observations from 3/10/24 through 3/12/24, Surveyor observed a CPAP machine on R34's bedside table. The machine's tubing was not labeled with a date to indicate when it was last changed. On 3/10/24 at 12:52 PM, Surveyor interviewed R34 who indicated R34 did not always use the CPAP machine because not all staff were educated on the CPAP mask/machine. Surveyor reviewed R34's physician orders and noted R34 did not have an order for CPAP therapy. On 3/11/24 at 3:36 PM, Surveyor reviewed R34's plan of care which did not mention R34's need for CPAP therapy and did not contain a cleaning schedule. On 3/12/24 at 11:03 AM, Surveyor interviewed Director of Nursing (DON)-B who verified R34 received CPAP therapy. DON-B verified R34 did not have a physician's order for CPAP therapy or a care plan that addressed the use of CPAP therapy and how and when the equipment should be cleaned. DON-B verified R1's care plan should contain reference to R34's need for CPAP therapy. DON-B also indicated R34's CPAP tubing should be labeled with a date/time to indicate when the tubing was last changed to help aid with infection prevention.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure monitoring of a high risk medication was provided for 1 Resident (R250) of 5 residents reviewed for unnecessary medication. R250 had physician orders for short-acting and long-acting insulin (used to treat high blood sugar). R250's plan of care did not contain interventions to monitor R250 for signs and symptoms of hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar). Findings include: On 3/12/24, Surveyor reviewed R250's medical record. R250 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (a disease in which blood sugar levels are too high). R250's medical record contained the following physician orders: ~ Humalog Injection Solution 100 unit/ml (units per milliliter) (Insulin Lispro) (short-acting insulin) Inject as per sliding scale: if 120-149 = 2 units; 150-199 = 4 units; 200-249 = 6 units; 250-299 = 8 units; 300-349 = 10 units 350 or more *12 units & call MD (Medical Doctor), subcutaneously (under the skin) one time a day for diabetes .Prime 2 units before each dose. Glucose <70 hypoglycemia treatment, 70-119 *No corrective insulin. ~ Lantus Subcutaneous Solution 100 unit/ml (Insulin Glargine) (long-acting insulin) Inject 25 unit subcutaneously at bedtime for diabetes ~ Lantus Subcutaneous Solution 100 unit/ml (Insulin Glargine) Inject 30 unit subcutaneously one time a day for diabetes R250's plan of care did not contain interventions that alerted staff to monitor R250 for signs and symptoms of hypoglycemia or hyperglycemia. On 3/12/24 at 1:20 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated R250's comprehensive care plan was not yet completed and staff were working off of R250's baseline care plan. DON-B verified the need to monitor for signs and symptoms of hypoglycemia and hyperglycemia was not addressed on R250's baseline care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interview, and record review, the facility did not promote and facilitate resident self-determination for 6 Residents (R) (R1, R4, R10, R25, R27, and R39) of 6 residents. Staff did not allow R1, R4, R10, R25, R27 and R39 to make choices regarding their meals. Finding include: 1. R1 was admitted to the facility on [DATE] with diagnosis including dementia, anxiety, and malignant neoplasm of transverse colon. R1's Minimum Data Set (MDS) assessment, dated 1/24/24, contained a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated R1 had moderate cognitive impairment. R1 had an activated power of attorney for healthcare (POAHC). R1's plan of care indicated R1 had a 2 gm (gram) (2000 mg (milligrams)) NA (sodium), CCHO (carbohydrate-controlled), mechanical soft diet with regular/thin liquids. R1's plan of care indicated R1 should consume adequate caloric intake and the nutrients should meet R1's metabolic needs. According to the lunch menu on 3/11/24, residents on a CCHO diet should receive 1 chicken breast, 4 ounces (oz) of broccoli, a 1/2 cup of buttered noodles, and a 1/2 square of devil's food pudding cake. A meal ticket on R1's tray indicated R1's diet was 2 gram sodium-mechanical soft and contained the following instructions: *Double Protein and Vegetable Portions; and *No beets or tacos or chicken. Per R1's meal ticket, R1's main meal was listed as: ground chicken breast, broccoli, garlic bread, devil's food pudding cake, buttered noodles, and low sodium soup with ground meat. On 3/11/24 at 12:43 PM, [NAME] (CK)-P and Regional Manager (RM)-N discussed R1's meal in front of Surveyor. Initially, CK-P stated R1 could have pasta and sauce without meat. RM-N stated R1 needed double protein. CK-P and RM-N then determined R1 should receive 2 grilled cheese sandwiches to replace the chicken from R1's meal. RM-N stated R1 needed 2 grilled cheese sandwiches instead of 1 because R1's diet order included double protein. For lunch on 3/11/24, R1 received 2 grilled cheese sandwiches, 4 oz. of broccoli, and 1 piece of devil's food pudding cake. R1 did not receive a double portion of vegetables, buttered noodles, soup, or garlic bread which were listed on R1's meal ticket. R1 was not asked what R1 wanted in place of the protein (chicken) on the menu and was not provided an adequate protein equivalent. On 3/11/24 at 12:46 PM, Surveyor interviewed CK-P and indicated R1's meal ticket didn't include a grilled cheese sandwich. When asked how CK-P knew what R1 wanted, CK-P stated R1 didn't like chicken, tacos, or beef. CK-P indicated R1's meal ticket indicated R1 doesn't like beets, but should say beef. On 3/12/24 at 8:32 AM, Surveyor interviewed R1 who said staff don't ask R1 what R1 wants to eat. 2. R4 was admitted to the facility on [DATE] with diagnosis including stroke with right side paralysis, epilepsy, and dementia. R4's MDS assessment, dated 1/17/24, indicated R4 was rarely or never understood. R4 had an activated POAHC. R4's plan of care indicated R4 had a regular, pureed texture diet with regular/thin liquids. R4's plan of care indicated R4 should be offered double entrees at meals and indicated to give R4 as many choices as possible about care and activities. According to the lunch menu on 3/11/24, residents on pureed diets should receive a serving (#6 scoop) of pureed chicken pasta alfredo, a serving (#12 scoop) of pureed broccoli, a serving (# 20 scoop) of pureed garlic bread, and a serving (#12 scoop) of pureed devil's food pudding cake. Per R4' plan of care, R4 should have been offered a double portion of chicken alfredo. R4's meal ticket contained an instruction for double portions. Per R4's meal ticket, R4's main meal was listed as: pureed chicken pasta alfredo, pureed broccoli, pureed garlic bread, and pureed devil's food pudding cake. On 3/11/24 at 12:35 PM, Surveyor noted R4 received 1 scoop of pureed chicken, 1 scoop of mashed potatoes, 1 scoop of alfredo sauce, 1 scoop of pureed broccoli, and a container of pureed chocolate cake for lunch. R4 was not provided pureed pasta, pureed garlic bread, or double portions. Mashed potatoes were not on the menu or R1's meal ticket. On 3/11/24 at 12:35 PM, Surveyor interviewed CK-P who stated residents on pureed diets don't usually receive pasta. On 3/11/24 at 2:03 PM, Surveyor interviewed Registered Dietitian (RD)-V, RM-N, and Dietary Manager (DM)-O. DM-O stated the 4 residents on pureed diets do not fill out meal ticket slips indicating what they prefer for meals. DM-O stated R4 and another resident are nonverbal. When asked if nonverbal residents can read, DM-O stated, I don't know. DM-O verified R4 wasn't asked what R4 wanted and indicated R4 was delusional and would eat butterscotch pudding and oatmeal for every meal. DM-O stated R4's daughter wanted staff to give R4 mashed potatoes. When asked if R4's daughter was able to make choices on behalf of R4, DM-O was unsure. 3. R10 was admitted to the facility on [DATE] with diagnosis including Alzheimer's disease, stage two chronic kidney disease, and failure to thrive. R10's MDS assessment, dated 1/22/24, indicated R10 was rarely or never understood. R10 had an activated POAHC. R10's plan of care indicated R10 had a regular, pureed texture diet with regular/thin liquids. R10's plan of care indicated R10 should be offered double entrees at meals, should consume adequate caloric intake, and the intake of nutrients should meet R10's metabolic needs. According to the lunch menu on 3/11/24, residents on pureed diets should receive a serving of pureed chicken pasta alfredo, a serving of pureed broccoli, a serving of pureed garlic bread, and a serving of pureed devil's food pudding cake. Per R10's plan of care, R10 should have been offered a double portion of chicken alfredo. R10's meal ticket contained an instruction for double entrees. Per R10's meal ticket, R10's main meal was listed as: pureed chicken pasta alfredo, pureed broccoli, pureed garlic bread, and pureed devil's food pudding cake. On 3/11/24 at 12:35 PM, Surveyor noted R10 received 1 scoop of pureed chicken, 1 scoop of mashed potatoes, 1 scoop of alfredo sauce, 1 scoop of pureed broccoli, and a container of pureed chocolate cake for lunch. R10 did not receive pureed pasta, pureed garlic bread, or a double entree. Mashed potatoes were not on the menu or on R10's meal ticket. On 3/11/24 at 12:35 PM, Surveyor interviewed CK-P who stated residents on pureed diets don't usually receive noodles. On 3/11/24 at 2:03 PM, Surveyor interviewed RD-V, RM-N, and DM-O. DM-O stated residents who receive pureed diets do not fill out meal ticket slips indicating what they prefer. When asked how staff know what the residents want, DM-O stated R10 loves oatmeal and sweets. 4. R25 was admitted to the facility on [DATE] with diagnosis including psychotic disorder with delusions, Parkinson's disease, and heart failure. R25's MDS assessment, dated 1/19/24, contained a BIMS score of 14 out of 15 which indicated R25 did not have impaired cognition. R25 had an activated POAHC. R25's plan of care indicated R25 had a regular, pureed texture diet with regular/thin liquids. R25's plan of care indicated R25 should consume adequate caloric intake and the intake of nutrients should meet R25's metabolic needs. R25 had a previous significant weight loss of 8% in three months on 10/23/23. According to the lunch menu on 3/11/24, residents on pureed diets should receive a serving of pureed chicken pasta alfredo, a serving of pureed broccoli, a serving of pureed garlic bread, and a serving of pureed devil's food pudding cake. Per R25's meal ticket, R25's main meal was listed as: pureed chicken pasta alfredo, pureed broccoli, pureed garlic bread, and pureed devil's food pudding cake. On 3/11/24 at 12:35 PM, Surveyor noted R25 received 1 scoop of pureed chicken, 1 scoop of mashed potatoes, 1 scoop of alfredo sauce, 1 scoop of pureed broccoli, and a container of pureed chocolate cake for lunch. R25 did not receive pureed pasta or pureed garlic bread. Mashed potatoes were not on the menu or on R25's meal ticket. On 3/11/24 at 12:35 PM, Surveyor interviewed CK-P who stated residents on pureed diets don't usually receive noodles. On 3/11/24 at 2:03 PM, Surveyor interviewed RD-V, RM-N, and DM-O. DM-O stated R25's meals depend on R25's moods and indicated R25 had Parkinson's disease with delusions. 5. R27 was admitted to the facility on [DATE] with diagnosis including Alzheimer's disease, stage 3 chronic kidney disease, and anemia. R27's MDS assessment, dated 1/3/24, indicated R27 was rarely or never understood. R27 had an activated POAHC. R27's plan of care indicated R27 had a regular, pureed texture diet with regular/thin liquids. R27's plan of care indicated R27 should consume adequate caloric intake and the intake of nutrients should meet R27's metabolic needs. According to the lunch menu on 3/11/24, residents on pureed diets should receive a serving of pureed chicken pasta alfredo, a serving of pureed broccoli, a serving of pureed garlic bread, and a serving of pureed devil's food pudding cake. Per R27's meal ticket, R27's main meal was listed as: pureed chicken pasta alfredo, pureed broccoli, pureed garlic bread, pureed devil's food pudding cake. On 3/11/24 at 12:35 PM, Surveyor noted R27 received 1 scoop of pureed chicken, 1 scoop of mashed potatoes, 1 scoop of alfredo sauce, 1 scoop of pureed broccoli, and a container of pureed chocolate cake for lunch. R27 did not receive pureed pasta or pureed garlic bread. Mashed potatoes were not on the menu or on R27's meal ticket. On 3/11/24 at 2:03 PM, Surveyor interviewed RD-V, RM-N, and DM-O. DM-O indicated R27 was non-verbal and stated R27 eats everything. 6. R39 was admitted to the facility on [DATE] with diagnoses including transient cerebral ischemic attack, bipolar disorder, and epilepsy. R39's MDS assessment, dated 12/29/23, contained a BIMS score of 12 out of 15 which indicated R39 had moderately impaired cognition. R39 did not have an activated POAHC. R39 had an order for a regular diet with chopped meats and regular/thin liquids. R39's plan of care indicated R39 should consume adequate caloric intake and the intake of nutrients should meet R39's metabolic needs. R39's plan of care also indicated staff should offer substitutions if R39 was eating less than 50% of meals. According to the lunch menu on 3/11/24, residents on a regular diet should receive 6 oz. of chicken pasta alfredo, 4 oz. of broccoli, 1 piece of garlic bread, and 1 square of devil's food pudding cake. R39's meal ticket contained the following instructions: Grilled Cheese Sandwich; *No brats/peas/beets; and Extra fruit-No watermelon. Per R39's meal ticket, R39's main meal was listed as: chopped chicken pasta alfredo, broccoli, garlic bread, and devil's food pudding cake. Items listed under Always Available were: hamburger on bun, grilled cheese sandwich, chopped deli sandwich, macaroni and cheese, homemade soup, shredded garden salad, yogurt, cottage cheese, and fruit. Grilled cheese sandwich, cottage cheese, and fruit were highlighted in pink. Surveyor noted R39 received noodles and alfredo sauce for lunch. R39 did not receive chicken, garlic bread, and broccoli. R39 also did not receive a grilled cheese sandwich, cottage cheese, or fruit as highlighted on the meal ticket. On 3/11/24 at 12:44 PM, CK-P and RM-N discussed R39's meal in front of Surveyor. CK-P told RM-N that R39 doesn't eat broccoli or chicken. On 3/11/24 at 12:46 PM, Surveyor interviewed CK-P. When CK-P indicated CK-P decided to leave the chicken and broccoli off R39's tray, RM-N interjected and stated, You can't do that. When Surveyor asked if R39 filled out the highlighted meal ticket, CK-P stated CK-P filled out the slip and made the choices for R39. When Surveyor asked how CK-P knew what R39 wanted/liked, CK-P stated, Because that's what (R39) gets every day. On 3/11/24 at 2:03 PM, Surveyor interviewed RD-V, RM-N, and DM-O. When asked how staff know what residents want to eat if residents don't fill out a slip and staff don't ask them, DM-O stated, I don't know. I never thought of asking (them). When Surveyor asked if staff should decide what residents receive for meals if residents don't fill out a slip and staff don't ask them, RM-N stated residents should receive the full menu if they haven't chosen anything and their preferences don't indicate otherwise. RM-N stated the facility has plans to put a new system in place with the goal to ask residents each day what they want for the next day. When Surveyor asked RD-V, RM-N and DM-O if they felt residents' choices were being honored, RM-N stated, Nope.

Based on staff and resident interview and record review, the facility did not make a prompt effort to resolve grievances for 5 Residents (R) (R210, R211, R28, R209 and R13) of 7 sampled residents. R210 reported to staff that R210 was missing numerous articles of clothing. The facility did not resolve the grievance in a timely manner. R211 reported to staff that R211 was missing a nightgown. The facility did not resolve the grievance in a timely manner. R209 reported to staff that R209 was missing numerous articles of clothing. The facility did not resolve the grievance in a timely manner. R28 reported to staff that R28 was missing bed linens. The facility did not resolve the grievance in a timely manner. R13 reported to staff that R13 was missing numerous articles of clothing. The facility did not resolve the grievance in a timely manner. The facility's grievance log contained missing clothing items or laundry concerns for 1 resident in September 2023, 1 resident in November 2023, and 2 residents in December 2023. The facility was unable to provide Surveyor with grievance investigation forms. Findings include: The facility's Grievance Policy and Procedure, reviewed 1/8/20, indicates: It is the intent of this policy to support each resident's right to voice grievances and concerns and to assure that after receiving a grievance, the facility actively seeks a resolution and keeps the resident and/or family member appropriately apprised of its progress toward a resolution .Procedure .6. The Grievance Officer needs to investigate the concern further to determine if it can be resolved and will complete the review within 2 business days of the grievance. If it involves another department, the department head should also be notified and work as a team to investigate and find a resolution to the problem. The Grievance Officer will ensure that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, steps taken to investigate, a summary of pertinent findings or conclusions regarding resident concerns, a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issues .10. A copy of all investigation will be kept in a file in the Social Service Office. Odd Fellow Home will maintain evidence demonstrating the resolution of complaints and grievances for the past three years . On 3/11/24 Surveyor reviewed the facility's grievance log and requested grievance investigation forms for missing laundry items on the log. Surveyor noted the grievance log contained missing clothing items or laundry concerns for 1 resident in September 2023, 1 resident in November 2023, and 2 residents in December of 2023, as well as 3 grievances in January of 2024 and 2 grievances in February of 2024. On 3/11/24 Surveyor received the following grievance investigation forms and noted the following: 1. R210 filed a grievance on 1/31/24 that indicated R210 was missing pants, underwear, a t-shirt and a night shirt. The investigation section of the form was blank and the findings section indicated staff could not find the items. The action taken section indicated staff will mark clothing before sending clothing to laundry. The grievance follow-up section contained the findings and indicated the person who voiced the concerns was satisfied. The form contained the name of the person who completed the form, but the completed date was blank. The notes section of form indicated the clothing was not found and a message was left on 2/5/24. The grievance form was signed by Social Worker (SW)-D on 2/5/24 and Assistant Nursing Home Administrator (ANHA)-C on 2/13/24. R210 was no longer a resident of the facility. 2. R211 filed grievance on 1/31/24 that indicated R211 was missing a night gown. The investigation section of the form was blank and the findings section indicated staff did not find the night gown after looking for weeks. The action taken section, the person completing form, and the completed date were blank. The grievance follow-up section contained the findings and indicated the person who voiced the concerns was satisfied with the findings. The notes section of form indicated the clothing was not found and there was an update on 2/2/24. The form was signed by SW-D on 2/2/24 and ANHA-C on 2/13/24. R211 was no longer a resident of the facility. 3. R28 filed a grievance (on a missing items form found in the facility's grievance file) on 2/27/24 that indicated R28 was missing a bottom sheet, a top sheet, and a pillowcase. The form indicated the items were last seen on 2/7/24 in R28's bedroom. R28's room was searched. Housekeeping staff and R28's family/Power of Attorney (POA) were notified. The resolution section indicated the items were not in laundry and the facility would reach out to a friend who did R28's laundry. The signatures lines for the Social Services Director and Administrator were blank. On 3/12/24 at 8:15 AM, Surveyor interviewed R28 who stated the missing items were not found or replaced and R28 was not satisfied with the resolution. 4. R209 filed a grievance on 1/31/24 that indicated R209 was missing a nightgown, a couple pair of pants, and a couple shirts. The investigation information was blank and the findings section indicated staff could not find the items. The action taken section indicated staff will be mark clothing before sending clothing to laundry. The findings were reported to R209 on 2/5/24 and the form indicated R209 was both satisfied and unsatisfied with the findings. The notes section indicated the items were still not found. The form was signed by SW-D on 2/6/24 and ANHA-C on 2/13/24. R209 was no longer a resident of the facility. 5. R13 filed a grievance on 2/27/24 that indicated R13 was missing a nightgown, a blouse, 2 winter caps, and a leather coin purse that did not contain money. The investigation information was blank and the findings section indicated the items were not found. The action taken section indicated staff would continue to look. The findings were reported to R13 on 3/1/24. The form indicated R13 was both satisfied and unsatisfied with the results. The notes section indicated R13 wanted the items back and staff continued to look for them. On 3/11/24, Regional Consultant (RC)-E indicated on the form that a black dress and floral gown were located in lost and found and were washed and returned to R13. The form was signed by SW-D on 3/6/24. The Administrator's signature line was blank. On 3/12/24 at 8:30 AM, Surveyor interviewed R13 who indicated there was no resolution for R13's missing items. R13 indicated some of the items were found yesterday (3/11/24). R13 indicated R13 would like all the missing items returned or would like reimbursement. On 3/11/24 at 8:41 AM, Surveyor interviewed Supervisor (SP)-F who indicated the laundry department has had lost resident items and stated in January of 2024, a process was implemented to have nursing staff put a newly admitted resident's name on a bag prior to the resident's clothing being sent to laundry to be washed so that laundry staff could label the clothing. SP-F stated laundry staff took lost and found items to residents recently to locate residents who were missing items. SP-F stated when residents inform staff of missing items, laundry staff begin looking for the items, and let staff know if the items are found in laundry. On 3/11/24 at 2:45 PM, Surveyor interviewed RC-E who indicated when residents submit grievances regarding laundry, laundry staff are notified. When Surveyor interviewed RC-E about recent grievances regarding laundry, RC-E stated since November 2023, the facility's laundry process was revamped and there were no complaints since December 2023. When Surveyor provided RC-E with grievance forms from January 2024 and February 2024, RC-E indicated RC-E was not aware of the grievances. On 3/11/24 at 2:55 PM, Surveyor interviewed SW-D who indicated the process for grievances regarding laundry is to alert laundry staff right away, check the resident's room, and if not found, follow-up with the resident. SW-D indicated the resident can be reimbursed while the facility continues to look for the items. Surveyor interviewed SW-D regarding the grievances filed by R210, R211, R28, R209 and R13. SW-D indicated the items were not found, reimbursement did not occur, and the facility is still looking for the items. SW-D indicated the facility looks for items for 5-7 days and indicated the grievance should be resolved at that time. On 3/11/24 at 3:45 PM, ANHA-C indicated to Surveyor that ANHA-C was looking for the grievance forms requested from Surveyor for grievances filed in September, October, November, and December 2023. On 3/12/24 at 9:30 AM, Surveyor interviewed ANHA-C who indicated the facility was continuing to look for R28's items, as well as the other residents' missing items. In regard to the facility's grievance policy that indicates grievances should be resolved within two days, ANHA-C indicated the time frame wasn't long enough for the facility to find the items and resolve the grievance. ANHA-C also indicated the facility could offer reimbursement. ANHA-C provided a document from SP-F that was titled Steps Taken to Locate Items and listed the following: Check label, look in to be labeled bin, check in resident room, check soiled linens and clean linen closet, 2/5/24 followed up with Certified Nursing staff, reminder to have personal clothing sent down to laundry to be labeled. When Surveyor indicated the process prior to 2/5/24 (on the 1/31/24 grievances) indicated nursing staff will mark clothing before sending clothing to laundry, ANHA-C indicated laundry staff just completed a lost and found look through to find lost clothing for residents. ANHA-C indicated laundry staff looked through all unclaimed laundry and indicated missing clothing or lost items continue to occur. ANHA-C also confirmed the facility did not have grievance forms for the requested grievances in September, October, November, and December 2023. ANHA-C stated ANHA-C thought the previous administrator threw away the grievance forms after a complaint survey was conducted in September 2023 and confirmed the facility did not maintain a copy of the grievances and resolutions per the facility's policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure 1 of 5 Certified Nursing Assistants (CNAs) was eligible to work in a federally certified facility. This practice had the ability to affect multiple residents in the facility. CNA-I was employed by the facility. CNA-I was not currently eligible to work in federally certified nursing homes because CNA-I's certification had lapsed. Findings include: The facility's Patient Protection Program: Freedom from Abuse, Neglect, and Exploitation document indicates: Screening components: Abuse Policy Components: It is the policy of this facility to screen employees and volunteers prior to working with residents. Screening components include verification of references, certification and verification of license and criminal background check. Procedure .employee screening and training: before new employees are permitted to work with residents, references provided by the prospective employee will be verified as well as appropriate board registrations and certifications regarding the prospective employee's background. The facility will not employ or otherwise engage individuals who have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. On [DATE], Surveyor requested the facility's staff list from Nursing Home Administrator (NHA)-A. On [DATE], Surveyor reviewed the staff list and requested CNA-I's background check and CNA registry information from Assistant Nursing Home Administrator (ANHA)-C. On [DATE], Surveyor reviewed CNA-I's background check information and noted CNA-I was hired by the facility on [DATE] as a CNA/Med Tech. CNA-I's registry information indicated CNA-I's employment eligibility to work in federally certified nursing homes had lapsed. Surveyor noted CNA-I's certification was issued on [DATE] and expired on [DATE]. CNA-I's CNA registry information did not indicate CNA-I completed the Medication Technician training to be certified to administer medication in federally certified nursing homes. On [DATE] at 10:17 AM, Surveyor interviewed NHA-A who indicated NHA-A was unaware that CNA-I was not on the Nurse Aide Registry until Surveyor requested CNA-I's registry information. NHA-A indicated CNA-I has been working as a CNA, but should not have been. NHA-A stated NHA-A called and informed CNA-I that until CNA-I completes the nurse aide competency testing, CNA-I cannot be employed by the facility as a CNA. NHA-A indicated CNA-I was immediately removed from the schedule. At that time, ANHA-C confirmed CNA-I had not worked as a Med Tech at the facility. Surveyor requested CNA-I's time cards for hours worked as a CNA. On [DATE], Surveyor reviewed CNA-I's time card documentation that indicated CNA-I worked the following shifts as a CNA: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE].

Based on observation, staff interview, and record review, the facility did not follow menu serving sizes, individualized diets, and food preparation recipes to ensure nutritional needs were met for multiple residents residing in the facility. During the 3/10/24 lunch meal, staff did not follow menu serving sizes for residents who received chicken drumstricks as their main entree. During the 3/11/24 lunch meal, staff did not follow R1, R4, and R10's individualized diets. During the 3/11/24 lunch meal, staff did not follow a recipe when making mashed potatoes for 4 residents who received pureed diets. Findings include: The facility's contracted company's Standardized Recipes policy, dated 2/19/24, indicates: Standardized recipes will be used when preparing the menu items .3. Cooks/chefs are expected to use and follow the recipes provided. The facility's extended menu contained the lunch meal serving sizes for regular portions and mechanically altered food. Per the 3/10/24 lunch menu, the serving size for baked chicken drumsticks was 2 baked chicken drumsticks for residents on a regular diet and 1 #8 scoop (4 ounce (oz)) of pureed chicken drumstick for residents on a pureed diet. During the lunch meal on 3/10/24, Surveyor noted staff served smaller serving sizes than the menu indicated for baked chicken drumsticks. On 3/10/24 at 2:07 PM, Surveyor interviewed Dietary Aide (DA)-T who indicated residents' meal tickets did not describe what the serving size was supposed to be. DA-T also stated DA-T had to ask about serving sizes because there wasn't enough chicken for lunch. DA-T stated [NAME] (CK)-P made the drumsticks, but there was only 1 case of drumsticks available. On 3/11/24 at 10:54 AM, Surveyor interviewed CK-P who confirmed CK-P prepared the chicken drumsticks for lunch on 3/10/24. CK-P stated residents were supposed to receive 2 drumsticks each, but only received 1 because there weren't enough drumsticks ordered. CK-P stated CK-P would have served chicken breasts also, but then there would not have been enough chicken for the chicken alfredo on the 3/11/24 lunch menu. CK-P indicated CK-P told Dietary Manager (DM)-O there were not enough drumsticks to serve for lunch, but was unsure if anything was done. On 3/11/24 at 11:09 AM, Surveyor interviewed Regional Manager (RM)-N who stated RM-N expected staff to follow the menu and follow the recipes listed on the menu. On 3/11/24 at 11:39 AM, Surveyor interviewed DM-O who verified residents should have received 2 drumsticks for lunch on 3/10/24, but only received 1 drumstick. DM-O stated 1 box of chicken drumsticks wasn't received with the facility's order. Surveyor and DM-O reviewed the order and delivery sheet and noted only 1 box of chicken drumsticks was ordered. Per the vendor's nutritional facts sheet for the chicken drumsticks, one serving contains 22 grams of protein. Surveyor noted residents who received 1 drumstick (1/2 serving) received 11 grams of protein and residents with double protein diets received 1/4 of their ordered protein for lunch on 3/10/24. 2. The facility's contracted company's Diet Policies and Description of Diets policy, revised 11/7/21, indicates: .9. The facility will utilize the tray identification system to ensure diet accuracy in the service of meals. 10.When diet orders are changed, the tray card and care plan will be changed to reflect the change in order. The lunch menu on 3/11/24 contained 6 oz. chicken alfredo pasta, 4 oz. broccoli, 1 slice garlic bread, and 1 square devil's food pudding cake. A meal ticket (that kitchen staff use while serving the meal) on R1's tray contained the following special instructions: *Double protein and vegetable portions; and *No beets or tacos or chicken. The meal ticket indicated the following under main meal: ground chicken breast, broccoli, garlic bread, devil's food pudding cake, buttered noodles, and low sodium soup with ground meat. R1's diet was listed as 2 grams NA (sodium)-mechanical soft. On 3/11/24 at 12:43 PM, CK-P and RM-N discussed R1's meal in front of Surveyor and determined R1 should receive 2 grilled cheese sandwiches to replace the chicken. RM-N stated R1 needed 2 grilled cheese sandwiches instead of 1 because R1 had an order for double protein. R1 was served 2 grilled cheese sandwiches, 4 oz. of broccoli, and 1 square of devil's food pudding cake. R1 did not receive a double portion of vegetables and did not receive buttered noodles or garlic bread. In addition, a grilled cheese sandwich was not on R1's meal ticket. On 3/11/24 at 3:54 PM, Surveyor interviewed CK-U who verified CK-U made 2 grilled cheese sandwiches for R1 at lunch. CK-U stated CK-U put 2 slices of American cheese on each of the grilled cheese sandwiches. Per the vendor's nutritional facts sheet for chicken breasts, a serving of chicken is 4 oz. with 25 grams of protein. Per R1's diet order, R1 should have received double protein (50 grams of protein) during the 3/11/24 lunch meal. Per the vendor's nutritional label for the American Pasteurized Processed cheese slices used for the grilled cheese sandwiches, 1 serving of cheese is 2 slices. Each serving of cheese has 5 grams of protein. Surveyor noted R1 received 10 grams of protein for 2 grilled cheese sandwiches instead of 50 grams of protein for the double chicken alfredo portion indicated on the menu and R1's meal ticket. On 3/11/24, a meal ticket on R4's tray contained the following special instructions: *Dislikes Tuna; and *Double Portions. The meal ticket also indicated the following under main meal: pureed chicken pasta alfredo, pureed broccoli, pureed garlic bread, and pureed devil's food pudding cake. R4's diet was listed as regular-pureed. For lunch on 3/11/24, R4 received 4 oz. of pureed chicken, 4 oz. of mashed potatoes, 2 oz. of alfredo sauce, 4 oz. of pureed broccoli, and a container of pureed chocolate cake. R4 did not receive pureed pasta, pureed garlic, or double portions. In addition, mashed potatoes were not on the lunch menu or on R4's meal ticket. On 3/11/24, R10's lunch meal ticket contained the following special instructions: *Ice Cream Cup; and *Double Entrees. The meal ticket also indicated the following under main meal: pureed chicken pasta alfredo, pureed broccoli, pureed garlic bread, and pureed devil's food pudding cake. R10's diet was listed as regular-pureed. For lunch on 3/11/24, R10 received 4 oz. of pureed chicken, 4 oz. of mashed potatoes, 2 oz. of alfredo sauce, 4 oz. of pureed broccoli, and a container of pureed chocolate cake. R10 did not receive pureed pasta, pureed garlic bread, or a double entree portion. In addition, mashed potatoes were not on the menu or on R10's meal ticket. 3. On 3/11/24 at 11:47 AM, Surveyor observed CK-P prepare instant mashed potatoes. CK-P used a previously opened bag of Idahoan Creamy Classic Instant Potatoes and free poured the remainder of the bag into a pot of hot water. CK-P then took a new bag of Idahoan Creamy Classic Instant Potatoes and free poured more instant potatoes into the pot. CK-P did not follow a recipe to ensure nutritional needs were met or consistency expectations were followed. On 3/11/24 at 11:49 AM, Surveyor interviewed CK-P who stated CK-P does not follow a recipe and just eyeballs it when making mashed potatoes. Surveyor noted the mashed potatoes were served for lunch for 4 of 4 residents who received pureed diets. On 3/11/24 at 11:09 AM, Surveyor interviewed RM-N who stated RM-N expects staff to follow the menu when cooking. RM-N also stated RM-N expects staff follow recipes for the food listed on the menu.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 50 residents residing in the facility. Staff did not ensure time/temperature control foods were labeled with open or use-by dates. Staff did not wear hair restraints consistently throughout the kitchen. Kitchen equipment and food services areas were not in a clean and sanitary condition. Staff did not properly heat food in the microwave that was served to residents. Staff did not follow safe food cooling protocols. Staff were unaware of temperature requirements when testing parts per million (PPM) of the sanitizing solution. Staff did not perform appropriate hand hygiene and safe food handling practices while cooking and serving food Findings include: On 3/10/24 at 9:25 AM, Dietary Manager (DM)-O indicated the facility follows the Wisconsin Food Code as their standard of practice. 1. Open/Unlabeled/Undated/Expired Food: The Wisconsin Food Code 2020 documents at 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when packaging food using a reduced oxygen packaging method as specified under § 3-502.12, and except as specified in (E), (F), and (H) of this section, refrigerated, ready to eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature and time combination of 5 degrees C (Celsius) (41 degrees F (Fahrenheit)) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1 .(2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety .(D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: .(3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section .Disposition. (A) A food specified under 3-501.17 (A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17 (A) Except time that the product is frozen; (2) Is in a container or package that does not bear a date or day. The facility's undated Date Food and Nutrition Services Dating and Policy and Procedure indicates: 1. Staff will immediately check for dating on arrival of new product to the facility. If there is no identifying date, one must be written on in permanent marker. 2. When opening a food item, each item must contain the use by dating and/or date open .A. Date product with current date opened. B. When using the UBD (use-by dating) use the current (contractor) maintenance dating chart and/or Foodkeeper App. During an initial tour of the kitchen with DM-O on 3/10/24 at 9:25 AM, Surveyor observed the following: Dry Storage -An unlabeled, undated half full 8 quart covered container of taco seasoning (per DM-O). -An 18 quart container of milk powder (10 quarts full) with an open date of 8/12/22 and no use-by date. -A container of breadcrumbs with no use-by date. -An unlabeled, undated 1/3 full 22 quart container of dry peas (per DM-O). -An unlabeled, undated 22 quart container Panko breadcrumbs (per DM-O). -An unlabeled, undated 1/4 full 32 ounce (oz.) package of powdered sugar. -An undated 1/4 full 24 oz. Cherry Jello. -An undated 1/4 full 24 oz. lemon pie filling. -An undated 1/8 full cheese cake mix. -A half full 5 pound package of spaghetti noodles with no use-by date. -A 12 oz. package of gluten free elbow noodles with no use-by date. -An open, undated container of liquid lemon extract with no use-by date. -An open, undated container of liquid vanilla with no use-by date. -A bulk container of oats that was labeled and dated inaccurately (per DM-O). -A bulk container of flour with an inaccurate label and no use-by date (per DM-O). Walk-In Cooler -An open package of 6 hard-boiled eggs with no use-by date. -An open package of Heath candy crumbles with no use-by date. -An unlabeled, undated 4 oz. container of rotten salad (per DM-O). -An open 2 pound package of Hillshire Farms sliced ham with no use-by date. -An open 2 pound package of Hillshire Farms sliced turkey with no use-by date. Reach-In Cooler -Approximately 3 inches of cheese slices with no use-by date. -An open 5 pound package of shredded cheese with no use-by date. -A 4 quart container of chicken chili with no use-by date. -Three pans of unlabeled, undated 2 oz. disposable containers of sour cream and tartar sauce (per DM-O). -An open and undated container of cottage cheese. -An open gallon of mayonnaise with no use-by date. -An open (dated 6/6/23), 1/8 full gallon container of thousand island dressing with no use-by date. -A container of cooked pasta (made 3/5/24) with no use-by date. Freezer -An open, unsealed, undated half-full 3 pound bag of spaetzle dumplings. -An open, unlabeled, undated package of fish fillets (per DM-O). [NAME] Kitchenette Refrigerator/Freezer -An open, unlabeled, undated packaged of waffles. -An unlabeled, undated package of buns. -3 unlabeled, undated fruit cups. Main Kitchenette Refrigerator/Freezer -An open, unlabeled, undated package of waffles. -3 unlabeled, undated containers of what appeared to be salads. -1 unlabeled, undated container of what appeared to be macaroni and cheese. -7 unlabeled, undated containers of what appeared to be cottage cheese. During an initial kitchen tour on 3/10/24, Surveyor interviewed DM-O who verified the facility uses a FIFO or first in/first out food storage process. DM-O indicated staff are supposed to date items with an open or made date as well as a use-by date. DM-O stated DM-O would dispose of many of the unlabeled, undated items. Surveyor observed DM-O dispose of several items during the tour. During a subsequent kitchen visit on 3/11/24 at 10:41 AM with Regional Manager (RM) N, Surveyor noted the dried peas, taco seasoning, 2 pastas and Panko breadcrumbs listed above were still in the dry storage area without labels or dates. RM-N indicated the items should have dates. 2. Hair Net Use: The Wisconsin Food Code, Hair Restraints documents at 2-402.11 Effectiveness.(B) .Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. On 3/10/24 at 8:14 AM, Surveyor observed [NAME] (CK)-P in the dish area. CK-P wore a hairnet over a headband. Surveyor noted the back of the headband was halfway up the back of CK-P's head which left the lower half of CK-P's hair exposed. On 3/10/24 at 9:03 AM, Surveyor observed Dietary Aide (DA)-S serve food and operate equipment in the kitchenette of the main dining room. Surveyor noted DA-S was not wearing a hairnet or a beard guard. On 3/11/24 at 10:59 AM, Surveyor observed DA-S walk into the main kitchen without a hairnet or beard guard. Regional Manager (RM)-N told DA-S to put a hairnet on. On 3/11/24 at 11:20 AM, Surveyor observed DA-S prepare silverware in the kitchen with a hairnet, but no beard guard. On 3/11/24 at 12:06 PM, Surveyor observed CK-U in the main kitchen by the hand washing station. CK-U was not wearing a hairnet or a beard guard. RM-N asked CK-U to put on a hairnet and beard guard on. On 3/11/24 at 12:40 PM, Surveyor observed CK-P serve food in the main dining room kitchenette. CK-P wore a hairnet over a headband. Surveyor noted the back of the headband was halfway up the back of CK-P's head which left the lower half of CK-P's hair exposed. When asked, CK-P pulled the hairnet down. On 3/11/24 at 1:15 PM, Surveyor observed CK-U in the main kitchen by the prep table. CK-U was wearing a beard guard that was below CK-U's mouth and did not cover CK-U's facial hair. On 3/11/24 at 3:54 PM, Surveyor observed CK-U cook food in the main kitchen by the grill. CK-U was wearing a beard guard that hung down around the back of CK-U's neck and did not cover CK-U's facial hair. On 3/11/24 at 11:28 AM, Surveyor interviewed DA-S who indicated DA-S did not know there were beard guards. On 3/11/24 at 1:11 PM, Surveyor interviewed CK-P who stated CK-P was having CK-P's hair shaved that night and pulled the hairnet down over CK-P's hair. CK-P stated CK-P knew CK-P needed to wear a hairnet that covered CK-P's hair and stated CK-P had so much hair CK-P didn't know what to do with it. On 3/11/24 at 1:15 PM, Surveyor interviewed CK-U who stated CK-U worked in the facility for a couple of months and never wore a beard guard before 3/11/24. CK-U stated CK-U's facial hair was not a violation and CK-U did not feel CK-U needed to wear a beard guard. 3. Cleanliness: The Wisconsin Food Code documents at 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils: (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. The Wisconsin Food Code documents at 4-602.12 Cooking and Baking Equipment. (B) The cavities and door seals of microwave ovens shall be cleaned at least every 24 hours by using the manufacturer's recommended cleaning procedure. The Wisconsin Food Code documents at 4-903.11 Equipment, Utensils, Linens, and Single Service and Single Use Articles. (B) Clean equipment and utensils shall be stored .(2) Covered or inverted. During the initial kitchen tour on 3/10/24, Surveyor observed the following: Main kitchen - -The inside of the microwave contained food debris on the walls and ceiling. -The front of the grill contained food debris. -The large mixer was not covered -The shelves below the prep area contained food debris and were not clean On 3/11/24 at 10:32 AM, Surveyor observed the same cleanliness issues in the main kitchen. On 3/12/24 at 8:36 AM, Surveyor observed the following: Kitchenette, Main Dining Room- -The inside of the microwave contained food debris on the walls and ceiling. -The refrigerator contained food debris and spills. On 3/10/24 at approximately 10:00 AM, Surveyor interviewed DM-O who confirmed the microwave was not clean. DM-O lifted the pans that covered the grill and confirmed the grill was not clean. DM-O stated DM-O expected staff to clean the grill after use. DM-O stated the grill was not used often and thought the grill had not been used in months. DM-O stated the shelves were cleaned weekly on Sundays and confirmed the shelves would be cleaned that day. On 3/11/24 at 10:32 AM, Surveyor interviewed RM-N who confirmed the microwave was still not clean. On 3/11/24 at 10:34 AM, Surveyor interviewed DM-O who confirmed the grill was still not clean. DM-O stated the grill was not cleaned on 3/10/24 because staff had too many things on their to do list. On 3/11/24, Surveyor reviewed the daily cleaning check list and noted the cleaning check list for March was not filled out and contained multiple empty spots. 4. Microwave Protocol: 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 3/10/24 at 9:03 AM, Surveyor observed DA-S prepare and serve food in the main dining room kitchenette. Surveyor observed DA-S cook a pastry in the microwave. DA-S then removed the pastry from the microwave and delivered the pastry to a resident. DA-S did not obtain the temperature of the pastry when removed from the microwave and did not wait two minutes to obtain the reheated food temperature to ensure the food was heated evenly. On 3/10/24 at 9:09 AM, Surveyor observed DA-S cook a second pastry in the microwave. DA-S then removed the pastry from the microwave and delivered the pastry to a resident. DA-S did not obtain the temperature of the pastry when removed from the microwave and did not wait two minutes to obtain the reheated food temperature to ensure food was heated evenly. Surveyor noted a policy on the front door of the microwave in the main dining room kitchenette that stated: Microwaving food: All food needs to be in a microwave safe bowl and must be covered. After reheating food, it must sit for two minutes so the heat can disperse . 5. Safe Cooling: 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 documents at section 3-501.15 Cooling Methods. (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under § 3-501.14 by using one or more of the following methods based on the type of food being cooled: (1) Placing the food in shallow pans; (2) Separating the food into smaller or thinner portions; (3) Using rapid cooling equipment; (4) Stirring the food in a container placed in an ice water bath; (5) Using containers that facilitate heat transfer; (6) Adding ice as an ingredient; or (7) Other effective methods. On 3/10/24, Surveyor reviewed the facility's Cooling Down Foods-Tracking Chart. The policy for cooling was listed at the top of the chart. The policy indicated staff are supposed to chart food cooled including initial temperature and hourly temperatures while cooling and then verify with a manager. The chart for March was blank. On 3/11/24 at 10:43 AM, Surveyor reviewed the facility's cooling log. DM-O stated the cooling log was empty for March because the fall and winter menu doesn't have pasta or potato salad or things that need to be cooled. On 3/11/24 at 10:44 AM, Surveyor interviewed RM-N regarding the cooling log. When Surveyor asked about food items in the reach-in cooler, including the white chicken chili and pasta made on 3/5/24, RM-N confirmed the items should have been cooled within 6 hours and tracked on the cooling log. On 3/11/24 at approximately 10:48 AM, Surveyor interviewed DM-O regarding the cooling log. DM-O stated DM-O doesn't cool much. When asked about the white chicken chili and pasta from the reach-in cooler, DM-O stated, I guess that should have been cooled. I guess they all would. RM-N then interjected and stated, Anything cooked needs to be cooled and be on the log. 6. Sanitizing Solution Log: The Wisconsin Food Code 2022 documents at section 4-501.116 Warewashing Equipment, Determining Chemical Sanitizer Concentration. Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device. The facility's Sanitizer Test Strip Log states employees will record the reading before using the sanitizer bucket and record any corrective action if taken. According to the manufacturer, the sanitizing bucket needs to be redone with every meal service or if the appropriate concentration is not reached. The facility used Quat sanitizer. The manufacturer directions indicated the PPM for appropriate sanitization was 200-400 PPM for the sanitization buckets and for cookware, dishes, and utensils for manual dishwashing. The test strip package insert for test strips used to test the PPM of sanitizing solution in sanitizing buckets and sinks indicated the water temperature should be between 65-75-degrees F for testing. On 3/12/24 at 8:25 AM, Surveyor observed a green sanitizer bucket in the [NAME] kitchenette. On 3/12/24 at 8:36 AM, Surveyor observed a green and a red sanitizer bucket in the main dining kitchenette. On 3/12/24 at 8:40 AM, Surveyor observed two sanitizer buckets in the main kitchen and asked to review the sanitizer testing log which was provided by CK-R. Surveyor noted the log was filled out for 8 of 12 days in March and was not filled out on 3/4/23. 3/9/24, 3/10/24, and 3/12/24. CK-R then ran a test strip under the sanitizer dispenser, briefly flashed the test strip at Surveyor, said the sanitization level was good, and tossed the the strip in the garbage. Surveyor noted there were sanitizer buckets in the kitchen being used by staff that were not tested. On 3/12/24 at 8:42 AM, Surveyor interviewed CK-R and asked how the sanitizer was tested. When Surveyor asked if the temperature of the water was taken or if the PPM were recorded, CK-R indicated CK-R was not aware that either needed to be completed. Surveyor noted CK-R recorded all of the entries on the current sanitizer test strip log. On 3/12/24, Surveyor reviewed the sanitizer test strip log and noted staff should mark ok if the strip reveals the appropriate concentration. The log contained 3 times slots for each day, however, only 1 time slot was filled out for the 9 days that were addressed. There were no staff initials. Surveyor also noted there were no spots to record the PPM concentration or the water temperature which were both imperative to determine if the sanitizer was at an appropriate concentration for use. 7. Hand Hygiene: The Wisconsin Food Code Chapter 2 Personal Cleanliness at 2-301.14 titled When to Wash indicates: Food employees shall clean their hands and exposed portions of their arms as specified under 2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; (B) After using the toilet room; (C) After caring for or handling service animals or aquatic animals as specified in 2-403.11 (B); (D) Except as specified in 2-401.11 (B) After coughing, sneezing, using a handkerchief or disposable tissue, using tobacco, eating, or drinking; (E) After handling soiled equipment or utensils; (F) During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (G) When switching between working with raw food and working with ready-to-eat food; (H) Before putting on gloves to initiate a task that involves working with food; and (I) After engaging in other activities that contaminate the hands. The facility's contracted company's Maintenance Handwashing policy indicates: Hands and exposed portions of arms (or surrogate prosthetic devices) should be washed immediately before engaging in food preparation. 1. When to wash hands: A. When entering the kitchen at the start of the shift. B. After touching bare human body parts other than clean hands and wrists. C. After using the restroom. D. After caring for or handling sercie animals or aquatic animals. E. After coughing, sneezing, using a tissue, using tobacco, eating or drinking. F. After handling soiled equipment or utensils. G. During food preparation as often as necessary to remove soil or contamination and prevent cross contamination when changing tasks. H. When switching between working with raw food and working with ready to eat food. I. Before donning disposable gloves for working with food and after gloves are removed. J. After engaging in other activities that contaminate the hands . The facility's Handwashing/Hand Hygiene policy, dated 8/2019, indicates: .2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .6. Wash hands with soap and water for the following situations: a. When hands are visibly soiled; b. After contact with a resident with infection .7. Use alcohol based hand rub containing at least 62% alcohol or, alternatively, soap and water for the following situations: a. Before and after coming on duty; b. Before and after direct contact with residents; .f. Before and after donning sterile gloves; .m. After removing gloves; .o. Before and after eating or handling food; p. Before and after assisting a resident with meals . On 3/10/24 at 9:03 AM, Surveyor observed DA-S prepare food in the main dining room and kitchenette with gloved hands. DA-S then delivered food to residents in the dining room. DA-S touched DA-S' pants while delivering food and continued to serve and deliver food with the same gloved hands. Surveyor did not observed DA-S change gloves or perform hand hygiene between tasks or residents. On 3/11/24 at 11:23 AM, Surveyor observed DA-Q scoop mandarin oranges from a can into cups with gloved hands. DA-Q put the scoop down, reached into the can of oranges, grabbed an orange with a gloved hand, and put the orange in DA-Q's mouth. DA-Q then left the room and came back with one gloved hand. DA-Q poured the rest of the can of oranges into a container, covered and labeled the contained, and placed the container in the refrigerator. DA-Q then removed DA-Q's glove and moved to another task without performing hand hygiene. On 3/11/24 at 12:02 PM, Surveyor observed CK-P cook food in the main kitchen. CK-P then walked into the dish area and changed gloves, but did not perform hand hygiene. On 3/11/24 at 12:12 PM Surveyor observed CK-P temp food in the main kitchenette. CK-P removed gloves, picked up plate covers, and brought them to the sink. CK-P then changed gloves and began to serve food. CK-P did not perform hand hygiene between tasks or glove changes. On 3/11/24 from 12:24 to 12:59 PM, Surveyor observed DM-O who was watching CK-P temp and serve food. DM-O was on the opposite side of the serving area. DM-O touched DM-O's hair (with a hairnet on), and touched DM-O's face and lips multiple times DM-O's bare left hand. At 12:36 PM, DM-O touched DM-O's nose with a bare hand. At 12:58 PM, Surveyor observed DM-O help residents remove plastic wrap from their cake with bare hands. DM-O did not perform hand hygiene after touching DM-O's self and changing tasks. On 3/11/24 at 12:26 PM, Surveyor observed CK-P serve food in the kitchenette. CK-P removed one pair of gloves and put on a new pair of gloves. CK-P did not do perform hand hygiene between glove changes. On 3/10/24, Surveyor observed 17 residents in the main dining room during the breakfast meal (from entrance, to meal service, to exit) and noted none of the residents were offered hand hygiene. On 3/11/24, Surveyor observed 22 residents in the main dining room during the lunch meal (from entrance, to meal service, to exit) and noted none of the residents were offered hand hygiene. On 3/11/24 at 11:30 AM, Surveyor interviewed RM-N who stated staff eating food out of a container while prepping food was unacceptable. On 3/11/24 at 1:26 PM, Surveyor interviewed DA-Q who verified DA-Q picked an orange out of the can with DA-Q's gloved hand and ate it because it was just so little and cute. DA-Q apologized when asked about food contamination. When asked why DA-Q did not complete hand hygiene, DA-Q said, I forgot. I'm sorry darling. On 3/11/24 at 2:03 PM, Surveyor interviewed RD-V, RM-N, and DM-O. When Surveyor asked what the expectation is for staff who touch their face, lips, hair, and nose with bare hands, DM-O stated staff should wash their hands and rewash them every time they touch themselves. DM-O stated if staff are wearing gloves, staff should wash their hands after removing gloves and should change gloves between tasks.

Based on observation and staff interview, the facility did not ensure garbage and refuse were properly disposed of in outside garbage receptacles. This practice had the potential to affect all 50 residents residing in the facility. On 3/10/24, the lids on 3 outside refuse dumpsters were open and there was garbage on the ground. Findings include: During an initial kitchen tour on 3/10/24 at 10:13 AM, Surveyor and Dietary Manager (DM)-O observed 3 outside refuse dumpsters with open lids. Surveyor and DM-O observed a bag of garbage on the ground behind the middle dumpster and scattered pieces of paper on the ground around the 3 dumpsters. On 3/10/24 at 10:14 AM, Surveyor interviewed DM-O who indicated the lids were most likely open for ease of use, but should be shut to keep rodents out. DM-O went between the dumpsters and looked at the bag of garbage on the ground. DM-O stated the garbage was CNA (Certified Nursing Staff) stuff and left the bag of garbage on the ground behind the dumpster.

Based on staff interview and record review, the facility did not ensure it completed mandatory submission of staffing information based on payroll data in a uniformed format to the Centers for Medicare & Medicaid Services (CMS). This practice had to the potential to affect all 50 residents residing in the facility. Staffing information for Quarter 1 (October 1-December 31), Quarter 2 (January 1-March 31), Quarter 3 (April 1-June 30), and Quarter 4 (July 1-September 30) of the Payroll Based Journal (PBJ) was not submitted to CMS. Findings include: The Centers for Medicare & Medicaid Services (CMS) Electronic Staffing Data Submission Payroll-Based Journal, Long-term Care Facility Policy Manual, dated June 2022, indicates: Chapter 1: Overview, 1.1 introduction .(U) mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS .1.2 Submission Timelines and Accuracy. Direct care staffing and census data will be collected quarterly and is required to be timely and accurate .Report Quarter: staffing and census data will be collected for each fiscal quarter. Staffing data includes the number of hours paid to work by each staff member each day within a quarter. Census data includes the facility's census on the last day of each of the three months in a quarter. The fiscal quarters are as follows: Fiscal Quarter, Date range: Quarter 1 (October 1-December 31), Quarter 2 (January 1-March 31), Quarter 3 (April 1-June 30), Quarter 4 (July 1-September 30) . On 3/10/24, Surveyor reviewed the PBJ Staffing Data Report, CASPER Report 1705D for Fiscal year 2023 run on 3/5/24 which indicated: Quarter 1, Quarter 2, Quarter 3, and Quarter 4 triggered failed to submit data for the quarter which automatically triggered all metrics: one star rating, excessively low weekend staffing, no Registered Nurse (RN) hours, and failed to have licensed nursing coverage 24 hours/day. On 3/10/24 at 9:09 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated NHA-A was responsible for submitting PBJ data to CMS. NHA-A stated prior to February 2024, another employee who was no longer employed by the facility was responsible for submitting the data. NHA-A indicated the previous employee was the only employee at the time who had access to submit PBJ data to CMS. On 3/12/24 at 10:17 AM, Surveyor reviewed the PBJ data with NHA-A for Quarters 1, 2, 3, and 4. Surveyor interviewed NHA-A regarding the metric failed to submit data for quarter which was indicated for all four quarters. Surveyor reviewed with NHA-A that all metrics, including one star rating, excessively low weekend staffing, no RN hours, and failed to have licensed nursing coverage 24 hours/day were triggered for all four quarters. NHA-A indicated the previous employee who was responsible for PBJ reporting was employed from 3/28/23 through 2/9/24. NHA-A stated NHA-A was not aware payroll data was not submitted and indicated NHA-A was aware the facility had a one-star rating but did not know why. Surveyor reviewed staff schedules and punch cards during the time frame specified in the triggered quarters as well as during the annual recertification survey. Surveyor noted the staffing level documentation provided was appropriate and verified the triggered metrics were due to failure to submit the data.

Based on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program based on current standards of practice, designed to provide a safe environment and to help prevent the development and transmission of communicable disease and infection. This practice had the potential to affect all 50 residents residing in the facility. The facility did not have a system for preventing the growth and spread of Legionella in the facility's water system. The facility's Water Management Plan (WMP) was not based on current standards of practice and did not: Describe the building's water system using text and an accurate flow diagram of the system; Include an assessment of the facility's water system to identify all locations where Legionella could grow and spread; Maintain acceptable ranges of control limits (temperature ranges) and corrective actions when control limits are not met; Include a process to confirm the WMP is being implemented and is effective. Findings include: The 7/6/18 revised Centers for Medicaid & Medicare Services (CMS) Quality, Safety and Oversight Letter 17-30 titled Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease (LD) contains the following information: Facilities must have water management plans and documentation that, at a minimum, ensure each facility: -Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g., Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility's water system. -Develops and implements a water management program that considers the ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) industry standard and the CDC (Centers for Disease Control and Prevention) toolkit. -Specifies testing protocols and acceptable ranges for control measures and documents the results of testing and corrective actions taken when control limits are not maintained. The 6/24/21 CDC Toolkit titled Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings identifies the key elements of a water management program for healthcare facilities that include: 1. Establish a water management program team. 2. Describe the building water system using text and flow diagrams. 3. Identify areas where Legionella could grow and spread. 4. Describe where control measures should be applied and how to monitor them. 5. Establish ways to intervene when control limits are not met. 6. Make sure the program is running as designed and is effective. 7. Document and communicate all the activities. The CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings located at https://www.cdc.gov/infectioncontrol/guidelines/core-practices/index.html#anchor_72633 contains the following information: This document concisely describes a core set of infection prevention and control practices that are required in all healthcare settings, regardless of the type of healthcare provided. The practices were selected from among existing CDC recommendations and are the subset that represent fundamental standards of care that are not expected to change based on emerging evidence or to be regularly altered by changes in technology or practices and are applicable across the continuum of healthcare settings . Core Practice Category 4. Performance Monitoring and Feedback notes: 1. Identify and monitor adherence to infection prevention practices and infection control requirements. 2. Provide prompt, regular feedback on adherence and related outcomes to healthcare personnel and facility leadership. 3. Train performance monitoring personnel and use standardized tools and definitions. 4. Monitor the incidence of infections that may be related to care provided at the facility and act on the data and use information collected through surveillance to detect transmission of infectious agents in the facility. The facility's undated Water Management Program to Reduce Legionella Growth and Spread indicates: Purpose: To monitor and manage the water system at Odd Fellow Home to reduce the risk of the growth and spread of Legionella. On 3/12/24 at 1:02 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated the Maintenance Director was responsible for the WMP. NHA-A indicated the information given to Surveyor was the only information available for the WMP. NHA-A verified the facility did not have a Facility Assessment to identify sources for the growth of Legionella. NHA-A also verified the facility did not have a process or flow diagram to identify Legionella in the facility.

Based on staff interview and record review, the facility did not implement written policies and procedures to prohibit mistreatment, neglect and abuse of residents for 3 staff (Certified Nursing Assistant (CNA)-C, CNA-D and Registered Nurse (RN)-E) of 8 staff reviewed during the caregiver program compliance check. CNA-C was hired on 8/14/15. The facility did not have a current completed Background Information Disclosure (BID) form for CNA-C. CNA-D was hired on 2/28/19. The facility did not have a current completed BID form for CNA-D. RN-E was hired on 3/4/16. The facility did not have a current completed BID form for RN-E. Findings include: The facility's undated Abuse Prohibition Policies and Procedures states the facility will encourage and support all residents, staff, families, visitors, volunteers and resident representatives in reporting any suspected acts of abuse, neglect, exploitation, involuntary seclusion or misappropriation of resident property. One of the components of the policy includes screening of potential employees. Upon a decision to hire an employee, all employees are required by State Law to accurately complete a Wisconsin BID form. The Human Resources Director makes routine reviews of the Caregiver Misconduct Registry and licensure of nurses. 1. On 9/11/23, Surveyor reviewed background check information for CNA-C. The facility did not have a current BID form for CNA-C. The BID form provided to Surveyor from the facility was dated 8/25/18. 2. On 9/11/23, Surveyor reviewed background check information for CNA-D. The facility did not have a current BID form for CNA-D. The BID form provided to Surveyor from the facility was dated 2/22/19. 3. On 9/11/23, Surveyor reviewed background check information for RN-E. The facility did not have a current BID form for RN-E. The BID form provided to Surveyor from the facility was dated 9/5/18. On 9/11/23 at 3:50 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A regarding BID forms for CNA-C, CNA-D and RN-E. NHA-A verified CNA-C, CNA-D and RN-E did not have current BID forms on file and stated the facility was advised at the annual survey and completed audits, but did not follow through as CNA-C, CNA-D and RN-E did not have current completed BID forms.

Based on staff interview and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 1 Resident (R) (R2) of 9 residents. The facility did not conduct a thorough investigation of an allegation of abuse involving R2 when the facility did not prevent further potential abuse of R2 and other residents while the investigation was in progress. Certified Nursing Assistant (CNA)-F was not removed from resident care while the potential allegation of abuse was investigated. In addition, R2's plan of care was not changed as indicated by the facility. Findings include: The facility's undated abuse policy and procedure indicates all residents will be treated with courtesy and respect in full recognition of their dignity and individuality by all they encounter, including, but not limited to employees. Once an allegation of abuse is reported to a staff supervisor or nurse on duty, the supervisor/nurse begins the investigation after assuring safety of resident. The alleged staff member or other person may have no further contact with residents, and may be suspended, if necessary, until the investigation is complete. 1. On 9/11/23, Surveyor reviewed R2's medical record. R2 was admitted to the facility with diagnoses to include encephalopathy, bipolar disorder and dementia. R2's Quarterly Minimum Data Set (MDS) assessment, dated 8/18/23, documented R2's cognition was 12 out of 15 (the higher the score, the more cognizant). On 9/11/23, Surveyor reviewed a facility-reported incident (FRI) regarding R2. The FRI indicated the incident occurred on 6/28/23 at 7:45 AM. R2 indicated R2's wrist had gotten stuck the wrong way while getting up this morning. R2 stated CNA-F helped R2 get out of bed, grabbed R2 by one wrist instead of two wrists to help R2 sit up, and caused R2's wrist to hurt. R2's right wrist was wrapped with an ace wrap and iced. An X-ray was completed on 6/29/23 that showed no acute fracture or dislocation. R2's care plan was updated to include the preference of using two hands to assist to sit up. On 9/11/23 at 1:30 PM, Surveyor interviewed CNA-F regarding the potential allegation of abuse. CNA-F verified when CNA-F assisted R2 to sit up, CNA-F used one of R2's hands and was not aware of R2's preference of using two hands. CNA-F stated CNA-F continued working with R2 and other residents all of CNA-F's shift. CNA-F was called and interviewed regarding the potential allegation of abuse approximately two hours after CNA-F's shift ended. On 9/11/23 at 2:17 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who verified CNA-F was allowed to work with R2 and other residents the entire shift. NHA-A then stated staff should have completed interviews first and had CNA-F sit in the office until the potential allegation was unsubstantiated. On 9/11/23 at 2:29 PM, Surveyor interviewed CNA-H and CNA-I regarding R2's care plan. CNA-H and CNA-I verified using two hands to assist R2 when sitting up was not on R2's care plan or the CNA care plan. CNA-H and CNA-I stated since they regularly work on R2's unit, they are aware R2 prefers to use both hands because using one hand hurts R2. On 9/11/23 at 2:49 PM, Surveyor interviewed Social Worker (SW)-G regarding the potential allegation of abuse. SW-G verified CNA-F should have been removed from resident care until the potential allegation of abuse was unsubstantiated.

Based on staff interview, and record review, the facility did not provide pharmaceutical services to assure the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals when 1 licensed nurse (Registered Nurse (RN)-E) of approximately 22 licensed nurses reportedly destroyed narcotic medication without a witness present. Staff reported RN-E destroyed narcotic medication alone which was not in accordance with the facility's policy and was in direct violation of the restrictions imposed on RN-E's license. The allegation was not investigated by the facility to determine if the allegation occurred, if narcotic medication was missing and if misappropriation occurred. Findings include: The facility's Controlled Substances policy, dated April 2019, contained the following information: The facility complies with all laws, regulations and other requirements related to handling, storage, disposal and documentation of controlled medications. 11. Upon Disposition: b. Medications that are opened and subsequently not given (refused or only partially administered) are destroyed. Waste and/or disposal of controlled medications are done in the presence of the nurse and a witness who also signs the disposition sheet. On 6/28/23, Surveyor investigated a concern that RN-E destroyed narcotic medication alone without a witness present. On 6/28/23 at 2:36 PM, Surveyor interviewed Medication Technician (MT)-C who worked with RN-E on the 3/28/23 PM shift. MT-C stated MT-C entered the medication room and observed what appeared to be a Vicodin (a controlled substance/narcotic medication used to treat moderate to severe pain) pill on the floor. MT-C picked up the pill and noted the markings. When MT-C asked RN-E about the pill, RN-E stated the pill must have fallen on the floor when RN-E destroyed medication earlier. MT-C stated RN-E indicated RN-E destroyed medication alone. MT-C stated MT-C felt it was wrong and texted Director of Nursing (DON)-B about the incident a few days later. MT-C asked DON-B if MT-C needed to fill out any paperwork. MT-C stated DON-B said MT-C did not need to fill out paperwork and DON-B would take care of the concern. MT-C stated MT-C did not hear anything further. On 6/28/23 at 2:54 PM, Surveyor interviewed RN-E who stated RN-E did not destroy any narcotic medication at the facility. On 6/28/23 at 2:57 PM, Surveyor interviewed DON-B who stated DON-B was not aware RN-E destroyed narcotic medication alone and no one reported that RN-E destroyed narcotic medication alone. DON-B stated DON-B did not investigate any allegations that narcotic medication was destroyed without the presence of two staff. On 6/29/23 at 10:14 AM, Surveyor interviewed MT-C again via phone. MT-C verified MT-C worked with RN-E on 3/28/23 and found a Vicodin pill on the med room floor when RN-E was present. MT-C stated MT-C knew the pill was Vicodin, because MT-C double checked the numbers on the pill. MT-C again indicated RN-E stated the pill was on the floor from when RN-E destroyed medication earlier. MT-C stated RN-E then panicked and took the pill from MT-C. MT-C stated MT-C reported the incident to DON-B via text on 4/1/23. MT-C provided Surveyor a copy of the text which was sent at 10:09 PM on 4/1/23 and contained the following information: MT-C (a portion of the text reads): .Tuesday when I worked with (RN-E) I found a Vicodin on the floor in the nurses station and I wasn't missing any so I asked (RN-E) and (RN-E) said (RN-E) was destroying them (earlier) and must have dropped it. (I don't know) (RN-E) could have done it with day shift earlier but just in case I wanted to tell you (I don't know) if I was supposed to fill something out or what. DON-B's response: Hmm I'll check it out thanks for the info. On 6/28/23, Surveyor reviewed the facility's drug destruction record. On 3/20/23 at 3:00 PM, Surveyor noted 9 oxycodone 5 mg (milligram) tablets were destroyed and initialed by two staff members. On 4/13/23 at 3:00 PM, 29 hydrocodone tablets were destroyed and initialed by two staff members. The drug destruction record did not indicate Vicodin was destroyed on 3/28/23. On 6/28/23, Surveyor reviewed RN-E's nursing license and noted RN-E was reprimanded by the Wisconsin Board of Nursing on 7/17/17 and required to successfully complete medication administration and documentation education related to improper administration, wasting, and documentation of administration of narcotic medication. On 9/30/21, a nursing home that employed RN-E submitted a Misconduct Incident Report to the Wisconsin Department of Health Services that alleged RN-E took narcotics from residents. RN-E was fired from the facility in November of 2021 after refusing a urine drug screen. On 3/17/22, RN-E was placed on administrative leave from employment at a hospital pending discrepancies found in RN-E's medication administration between 1/26/22 and 3/13/22. RN-E's license was suspended by the Board of Nursing on 4/13/23 and contained multiple restrictions, including the following: 1. RN-E could not work as a nurse, or other health care provider, in a setting in which RN-E had access to controlled substances; 2. RN-E could not work as a nurse in the following settings: home health care, hospice, pool nursing, assisted living, agency, skilled nursing facilities, or in a correctional setting. On 6/2/23, the Wisconsin Board of Nursing issued a stay of suspension continuous, contingent upon RN-E's compliance with the terms and conditions of the Order issued on 4/13/23. On 6/28/23, Surveyor interviewed Nursing Home Administrator (NHA)-A who verified NHA-A did not check the restrictions on RN-E's license when RN-E indicated via email on 6/2/23 that RN-E's license was active, but limited and RN-E could provide resident care. NHA-A was notified by Department of Safety and Professional Services (DSPS) Regulatory Specialist (RS)-H on 6/12/23 that RN-E could work at the facility under the direct supervision of DON-B and Assistant Director of Nursing (ADON)-G, but could not provide resident care, administer medication or be near the medication cart.

Based on staff interview and record review, the facility did not ensure 1 licensed nurse (Registered Nurse (RN)-E) of 22 licensed nurses had an active license that allowed RN-E to provide resident care and administer medication. This had the potential to affect 40 residents who resided in the facility and received care or medication from RN-E. RN-E provided care and administered medication on multiple occasions in June of 2023 which was in direct violation of the restrictions imposed on RN-E's nursing license. Findings include: The facility's Credentialing of Nursing Service Personnel policy, dated May 2019, contained the following information: Policy interpretation and implementation: 1. Nursing personnel who require a license or certification to perform resident care or treatment without supervision or direction within the scope of the individual's license or certification must present verification of such license or certification prior to or upon employment. 2. Nursing personnel requiring a license/certification are not permitted to perform direct resident care services until all licensing/background checks have been completed. 3. Upon obtaining the applicant's informed consent to conduct a license/certification background investigation, the director of nursing services, or designee, will: a. contact the appropriate state licensing board to obtain a letter of verification/computer printout of such license/certification. On 3/14/23, RN-E was hired as the facility's infection preventionist and wound care nurse. Documents indicated RN-E's nursing license was valid at the time of hire. On 4/14/23, Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B became aware that RN-E's nursing license was suspended. RN-E was sent home pending communication from Department of Safety and Professional Services (DSPS). On 4/25/23, the Board of Nursing liaison gave approval via email for RN-E to work as the facility's infection preventionist under the direct supervision of DON-B. Surveyor reviewed the 4/13/23 document, State of Wisconsin Before the Board of Nursing in the Matter of Disciplinary Proceeding Against (RN-E) which indicated the Wisconsin Board of Nursing issued a Final Decision and Order and suspended RN-E's registered nurse license for an indefinite period. The document contained the following information: On 7/13/17, the Board issued a Final Decision and Order which reprimanded and required RN-E to successfully complete medication administration and documentation education related to RN-E's improper administration, wasting and documentation of administration of narcotic medication. On 10/4/17, RN-E's license was reinstated to full, unencumbered status after RN-E successfully competed the required education. On approximately 1/22/22, RN-E completed an online renewal application for RN-E's registered nurse license. RN-E failed to disclose retail theft and disorderly conduct convictions from 10/10/19. On 9/30/21, a nursing home that employed RN-E submitted a Misconduct Incident Report to the Wisconsin Department of Health Services that alleged RN-E took narcotics from residents. RN-E was fired from the facility in November of 2021 after refusing a urine drug screen. On 3/17/22, RN-E was placed on administrative leave from employment at a hospital pending discrepancies found in RN-E's medication administration between 1/26/22 and 3/13/22. RN-E tested positive for methamphetamines without a valid prescription. The Final Decision and Order, dated 4/13/23, contained multiple conditions, including the following: 1. RN-E could not work as a nurse, or other health care provider, in a setting in which RN-E had access to controlled substances; 2. RN-E could practice only under the direct supervision of a licensed nurse or other licensed health care professional, approved by the Board or its designee, who received a copy of the Order;. 2. RN-E could practice only in a work setting and work position pre-approved by the Board or its designee. Requests for pre-approval must be accompanied by a current job description, name and contact information of the direct supervisor, and written acknowledgment from the employer that a copy of the Order and any subsequent orders modifying the original Order were received and that the restrictions would be accommodated; 3. RN-E could not work as a nurse in the following settings: home health care, hospice, pool nursing, assisted living, agency, skilled nursing facilities, or in a correctional setting. On 6/2/23, RN-E was granted a stay of suspension continuous, contingent upon RN-E's compliance with the terms and conditions of the Order. On 6/2/23, RN-E sent an email to DON-B that indicated RN-E's license was changed to active, but limited and RN-E could provide resident care. The facility allowed RN-E to provide resident care and administer medication on 6/7/23, 6/10/23, 6/11/23, and 6/12/23. Per an interview with DON-B, RN-E administered oxycodone to 7 different residents and administered medication to a total of 40 residents during that time. On 6/12/23, NHA-A received an email from DSPS Regulatory Specialist (RS)-H that indicated RN-E could not provide resident care or have access to the medication cart or residents. RN-E was sent home pending clarification and approval from DSPS for Assistant Director of Nursing (ADON)-G and DON-B to be RN-E's direct supervisors. On 6/13/23, RS-H gave approval for DON-B and ADON-G to supervise RN-E. RS-H also indicated RN-E was only allowed to work from RN-E's office as the infection preventionist and could not interact with residents. On 6/28/23, Surveyor interviewed NHA-A who verified the NHA-A did not verify the restrictions on RN-E's license when RN-E indicated via email on 6/2/23 that RN-E's license was active, but limited and RN-E could provide resident care. Per DSPS and RS-H, NHA-A stated RN-E was currently approved to work at the facility under the direct supervision of DON-B and ADON-G, but could not provide resident care, administer medication or be near the medication cart. On 7/11/23, NHA-A verified to Surveyor via email that NHA-A did not report to DSPS or RS-H that RN-E violated the terms and conditions imposed on RN-E's license on 6/7/23, 6/10/23, 6/11/23, and 6/12/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure allegations of abuse were reported to the State Agency (SA) for 2 Residents (R) (R8 and R1) of 8 sampled residents. R8 alleged physical abuse on 4/18/23. The facility did not report the allegation of abuse to the SA. The facility investigated an allegation of abuse involving R1. The facility did not timely submit the required 5-day report to the SA. Findings include: The facility's undated Patient Protection Program policy contained the following information: Any nursing home employee or volunteer who becomes aware of abuse, mistreatment, neglect, exploitation or misappropriation shall immediately report to the Nursing Home Administrator. The Nursing Home Administrator or designee will report abuse to the State Agency per State and Federal requirements .The follow-up investigative notes will be submitted via the WI DHS (Wisconsin Department of Health Services) Misconduct Incident Reporting System (MIR) within five working days of the initial report. On 4/25/23, Surveyor reviewed R8's medical record. R8 was admitted to the facility on [DATE] with diagnoses to include cognitive communication deficit and anxiety disorder. R8's Minimum Data Set (MDS) assessment, dated 3/8/23, contained a Brief Interview for Mental Status (BIMS) score of 00 out of 15 which indicated R8 had severe cognitive impairment. R8's Power of Attorney for Healthcare (POAHC) document, dated 3/20/07 and activated on 5/6/21, and indicated R8's POAHC agent was responsible for R8's healthcare decisions. On 4/25/23, Surveyor reviewed a Resident Grievance/Complaint Investigation Report, initiated by R8's POAHC agent and dated 4/18/23, that stated, I was in by (R8) and (R8) got tense and stated that's the witch when CNA (Certified Nursing Assistant) came in - I asked what (R8) meant and stated to me, '(CNA's) mean to me, feels like I'm beaten up, don't know why I am here.' Happened around late morning/lunch time in room . On 4/25/223, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses to include Alzheimer's disease. R1's MDS assessment, dated 1/23/23, contained a BIMS score of 5 out of 15 which indicated R1 had severe cognitive impairment. R1's POAHC document, dated 1/11/01 and activated on 12/7/14, indicated R1's POAHC agent was responsible for R1's healthcare decisions. On 4/25/23, Surveyor reviewed facility-reported incident (FRI) investigative documents which included the Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report, dated 3/31/23, for an allegation which allegedly occurred on 3/21/23 and was discovered on 3/30/23. In addition, included was the Misconduct Incident Report (required five-day report), dated 4/17/23. Included in the investigative documents was abuse investigation education, dated 4/13/23 and signed by Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, the facility's Social Worker and a Registered Nurse. The education stated, When completing an investigation of an allegation of abuse, there needs to be 100% completion of education to all staff, prior to the submission of the final report .Self-report initial reports must be submitted within 2 hours of notification or up to 24 hours if the report is not abuse related. Self-report 5 Day/Final reports must be submitted by the end of the 5th day of the investigation . On 4/25/23 at 1:46 PM, Surveyor interviewed NHA-A who verified R1's five-day report should have been submitted on or before 4/7/23. NHA-A indicated NHA-A did not have the investigative documents completed by other management staff to submit on 4/7/23 and stated, That's what prompted the education on (4/13/23). I knew we were going to be late because I was waiting for documentation. NHA-A stated NHA-A submitted the report on 4/17/23 when NHA-A received all the required documentation. NHA-A stated the investigation related to R1's situation was complete on 4/13/23, but management staff had not provided NHA-A the documents to submit. NHA-A verified other management staff have MIR access and stated, But they have never done the actual submission as they were never expected to in the past. When questioned about the Resident Grievance/Complaint Investigation Report initiated by R8's POAHC agent, NHA-A reviewed the documents and stated, I was not aware of this. NHA-A verified what was documented was an allegation of abuse and should have been reported 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 allegation of abuse was thoroughly investigated for 1 Resident (R) (R8) of 8 sampled residents. R8 alleged physical abuse on 4/18/23. The facility did not thoroughly investigate the allegation of abuse. Findings include: The facility's undated Patient Protection Program policy contained the following information: It is the policy of this facility that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated. On 4/25/23, Surveyor reviewed R8's medical record. R8 was admitted to the facility on [DATE] with diagnoses to include cognitive communication deficit and anxiety disorder. R8's Minimum Data Set (MDS) assessment, dated 3/8/23, contained a Brief Interview for Mental Status (BIMS) score of 00 out of 15 which indicated R8 had severe cognitive impairment. R8's Power of Attorney for Healthcare (POAHC) document, dated 3/20/07 and activated on 5/6/21, indicated R8's POAHC agent was responsible for R8's healthcare decisions. On 4/25/23, Surveyor reviewed a Resident Grievance/Complaint Investigation Report, initiated by R8's POAHC agent and dated 4/18/23, that stated, I was in by (R8) and (R8) got tense and stated that's the witch when CNA (Certified Nursing Assistant) came in - I asked what (R8) meant and stated to me, '(CNA's) mean to me, feels like I'm beaten up, don't know why I am here.' Happened around late morning/lunch time in room . The documents included a handwritten note from a CNA, which only included the CNA's first name, dated 4/18/23; a handwritten note from a Licensed Practical Nurse (LPN), which only included the LPN's first name, dated 4/18/23; and a handwritten, unsigned brief interview with R8, dated 4/18/23. The documents did not include interviews with other residents or staff and did not indicate how the facility would protect R8 and other residents. On 4/25/23 at 1:46 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who, when questioned about the Resident Grievance/Complaint Investigation Report initiated by R8's POAHC agent, reviewed the documents and stated, I was not aware of this. NHA-A verified what was documented was an allegation of abuse which should have been reported to the SA and thoroughly investigated.

Based on observation, staff interview, and record review, the facility did not ensure the resident environment remained free of accident hazards for 1 Resident (R) (R26) of 13 sampled residents reviewed for safety. R26 did not have access to a call light when R26's door was closed and R26 was calling out for help. Findings include: R26 was admitted with diagnoses to include Alzheimer's disease with late onset, asthma, dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance, major depressive disorder recurrent, anxiety disorder, overactive bladder, and weakness. On 3/7/23 at 8:53 AM, Surveyor walked past R26's room and noted the door was closed all the way. Surveyor continuously observed R26's door from across the hall beginning on 3/7/23 at 8:53 AM. R26's call light was not activated. Staff were observed in the hall, but none at the same time as R26 was yelling. Surveyor noted staff did not check on R26 until 9:59 AM. Surveyor noted the following: On 3/7/23 at 8:56 AM, R26 yelled, Can somebody open the door please! On 3/7/23 at 8:57 AM, R26 yelled, Can somebody open the door! I need ! On 3/7/23 at 8:57 AM, R26 yelled, Can somebody open the door! I need ! On 3/7/23 at 9:04 AM, Surveyor heard inaudible yelling from R26's room. On 3/7/23 at 9:05 AM, R26 yelled, Can somebody open the door! On 3/7/23 at 9:07 AM, R26 yelled, Can somebody open this front door! On 3/7/23 at 9:11 AM, R26 yelled, Somebody open the door! On 3/7/23 at 9:32 AM, R26 yelled, Someone open the door now! On 3/7/23 at 9:33 AM, Surveyor heard inaudible yelling from R26's room and noted R26's voice became softer. On 3/7/23 at 9:59 AM, Surveyor observed Certified Nursing Assistant (CNA)-H enter R26's room. Surveyor observed CNA-H set up R26 for a virtual visit. Surveyor and CNA-H verified R26's call light was placed on the bed above R26's right shoulder. Surveyor asked if R26 knew where the call light was. R26 stated no and reached with R26's left hand to try to find the call light. R26 was able to reach a stuffed animal next to R26's right upper arm. Surveyor pointed out where the call light was and asked if R26 could reach it. R26 tried and stated no. On 3/7/23 at 10:19 AM, Surveyor interviewed CNA-H who verified R26 would not have been able to reach the call light in the position the call light was in. CNA-H stated the call light was usually on R26's stomach. CNA-H stated R26 asks staff to close R26's door at times. R26 stated R26 was yelling because R26 had to use the bathroom. Surveyor and CNA-H then exited R26's room and left the door open. Prior to exiting the room, Surveyor noted CNA-H did not move the call light within R26's reach. On 3/7/23 at 10:24 AM, Surveyor interviewed CNA-I who worked on R26's unit since 6:00 AM. CNA-I stated CNA-I gave R26 breakfast in bed. CNA-I stated the last time CNA-I saw R26, R26's door was open. CNA-I stated R26 typically had a round, easy to activate soft-touch call light on the bedside table or the bed railing next to R26. CNA-I stated R26 occasionally used the call-light, but mostly kind of yells. CNA-I stated some days R26 wanted the door open and some days R26 wanted the door closed. On 3/7/23 at 10:30 AM, Surveyor interviewed Medication Technician (MT)-J who worked on R26's unit since 6:00 AM. MT-J stated MT-J had not been in R26's room yet. MT-J stated R26 yells and doesn't use a call light so staff keep R26's door partially open. On 3/7/23 at 10:33 AM, Surveyor interviewed CNA-K who stated CNA-K did not close R26's door. CNA-K stated CNA-K had not entered R26's room yet that shift. On 3/7/23 at 10:47 AM, Surveyor interviewed Director of Nursing (DON)-B stated DON-B expected R26's call light to be in reach since R26 was capable of using the call light. DON-B stated R26 cannot make major position changes, but can move R26's arms and legs a little. On 3/7/23 at 1:00 PM, Surveyor reviewed R26's medical record which included a care plan intervention, implemented on 9/3/22, that stated: Keep call-light, personal items and frequently used items within reach .(R26) has potential for confusion, disorientation, forgetfulness due to unspecified dementia . (R26) has alteration in behavior related to dementia, depression, and anxiety.

Based on interview and record review, the facility did not ensure a resident or resident's representative was provided education regarding the risks versus benefits of COVID-19 immunization and did not obtain consent or refusal for COVID-19 immunization for 1 Resident (R) (R29) of 5 residents reviewed for immunizations. R29's medical record did not contain documentation to indicate R29 or R29's representative was provided education by the facility regarding COVID-19 immunization and offered the opportunity to receive or decline COVID-19 immunization. Findings include:: The Centers for Medicare and Medicaid Services (CMS) Quality, Safety & Oversight Group (QSO) Memo (Ref: QSO-21-19-NH) released on May 11, 2021, addresses the Interim Final Rule related to COVID-19 Vaccine Immunization Requirements for Residents and Staff, which includes requirements for educating residents or resident representatives and staff regarding the benefits and potential side effects associated with the COVID-19 vaccine, and offering the vaccine. Additionally, the facility must maintain appropriate documentation to reflect that the facility provided the required COVID-19 vaccine education, and whether the resident and staff member received the vaccine. The Centers for Disease Control and Prevention (CDC) document titled COVID-19 Risks and Information for Older Adults CDC-COVID-19 Risks and Information for Older Adults last reviewed on 2/22/23 contains the following information: Older adults (especially those aged 50 years and older) are more likely than younger people to get very sick from COVID-19. The risk increases with age. This means they are more likely to need hospitalization, intensive care, or a ventilator to help them breathe, or they could die. Most COVID-19 deaths occur in people older than 65. Other factors can also make you more likely to get very sick from COVID-19. These include not getting vaccinated, or having underlying medical conditions-like chronic lung disease, heart disease, or a weakened immune system. Often, the more health conditions you have, the higher your risk of becoming very sick if you get COVID-19. On 3/7/23, Surveyor reviewed R29's medical record. R29 was admitted to the facility with diagnoses to include: anemia (low iron levels in the blood), dementia and endometrial cancer. R29 had an Activated Power of Attorney (POA) who was responsible for R29's health-care decisions. R29's Minimum Data Set (MDS) assessment, dated 11/22/22, indicated R29 required extensive assistance with activities of daily living (ADLs), was incontinent of bowel and bladder and required set up and assistance of one staff for eating. A progress note, dated 1/16/23, indicated R29 tested positive for COVID-19. R29's oxygen level was 88% on room air and supplemental oxygen was applied at 2 liters per nasal cannula. No other respiratory distress or shortness of breath was noted. A progress note, dated 1/17/23, contained the following information: R29 stated this morning R29 did not feel well, but stated R29 felt better this afternoon. R29 is on 2 liters of oxygen. Lung sounds are diminished with no signs or symptoms of respiratory distress. R29 denied pain, a sore throat, a headache, and nausea. R29 is tired and listless and needs encouragement and cues to eat and drink, otherwise R29 falls asleep and does not eat. R29 did take fluids well with staff cueing and encouragement. A progress note, dated 1/18/23, contained the following information: R29 was lethargic this morning and had a difficult time staying awake. A Certified Nursing Assistant (CNA) reported R29 was weak and did not feel putting R29 in a wheelchair would be safe. R29 required total assistance with eating and drinking at breakfast. R29 was hallucinating and seeing things on the wall. Advanced Practice Nurse Prescriber (APNP) was updated on R29's change of condition. APNP assessed R29 and ordered R29 be sent to the emergency room (ER) for evaluation. A progress note, dated 1/18/23, indicated R29 was admitted to the hospital. Hospital discharge paperwork, dated 1/21/23, contained the following information: R29 had hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions) and hypercapnia (a breathing problem making it difficult to take in oxygen and breathe out carbon dioxide) upon admission. R29's discharge diagnoses included acute hypoxemic respiratory failure due to COVID-19 (severely decreased oxygen levels that occur over a relatively short period of time) and community-acquired pneumonia. R29 was treated for breathing difficulties due to COVID-19 with a BiPAP (a ventilator device that helps with breathing) and supplemental oxygen. R29 was prescribed Decadron (used to treat breathing problems) for symptomatic COVID-19 infection and discharged back to the facility on 1/21/23. On 3/7/23 at 10:47 AM, Surveyor interviewed Director of Nursing (DON)-B who verified R29 and R29's POA were not offered COVID-19 immunization by the facility. DON-B confirmed the only documentation COVID-19 immunization was offered, accepted, or declined was in a progress note in R29's medical record that indicated a message was left for R29's POA on 10/14/22 to contact the facility regarding consent to accept or decline COVID-19 immunization for R29. DON-B verified the facility did not follow through on obtaining consent to accept or decline and R29 remained unvaccinated for COVID-19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not establish and maintain an infection control program designed to help prevent the development and transmission of disease and infection. This practice had the potential to affect all 52 residents residing in the facility. The facility did not conduct continuous infection surveillance including tracking and trending of illnesses, potential infectious agents, and monitoring of resident signs and symptoms of infection or potential infection. In addition, the facility did not maintain surveillance logs to help the facility recognize and track trends or patterns of infections and help prevent the spread of communicable diseases within the facility. Findings include: The facility's Surveillance for Infections policy, dated September 2017, contained the following information: The Infection Preventionist will conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions. Policy Interpretation and Implementation: 1. The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and HAIs to guide appropriate interventions, and to prevent future infections .5. Nursing Staff will monitor residents for signs and symptoms that may suggest infection, according to current criteria and definitions of infections, and will document and report suspected infections to the Charge Nurse as soon as possible .9. If transmission-based precautions or other preventative measures are implemented to slow or stop the spread of infection, the Infection Preventionist will collect data to help determine the effectiveness of such measures .Data Collection and Recording .4. For targeted surveillance using facility-created tools, follow these guidelines: a. Daily (as indicated): Record detailed information about the resident and infection on an individual inspection report for (e.g., Infection Treatment/Tracking Report, Infection Report Form, or similar form). b. Monthly: Collect information from individual resident infection reports and enter line listing of infections by resident for the entire month (e.g., Line Listing of Infections by Resident, or similar form). c. Monthly: Summarize monthly data for each nursing unit by site and by pathogen (e.g., Facility-wide Monthly Infection Report by Site, Facility-Wide Monthly Infection Report by Pathogen, or similar form.) d. Monthly/Quarterly: Identify predominant pathogens or sites of infection among residents in the facility or in particular units by recording them month to month and observing trends .e. Monthly/Quarterly: Compare incidence of current infections to previous data to identify trends and patterns. Use an average infection rate over a previous time period (for example, over the past 12 months) as a baseline. Compare subsequent rates to the average rate to identify possible increases in infection rates . 1. On 3/7/23, Surveyor reviewed the facility's infection control documentation which contained the following information: The facility's antibiotic line list documented on 11/28/22, R39 was prescribed an antibiotic for a urinary tract infection (UTI). Surveyor did not observe documentation of lab monitoring, cultures, McGeer's criteria, signs or symptoms, or effectiveness of the antibiotic. Surveyor requested the information; however, the information was not provided. Review of staff COVID-19 antigen test results for December 2022 indicated Certified Nursing Assistant (CNA)-L tested positive for COVID-19 on 12/28/22. Surveyor noted the Staff Acute Respiratory Illness (ARI) Outbreak line list for December 2022 did not include CNA-L's well date, symptom monitoring, or return to work date. Surveyor requested the information; however, the information was not provided. Review of resident COVID-19 antigen test results for January 2023 indicated R32 tested positive for COVID-19 on 1/5/23. Surveyor noted R32 was not listed on the facility's Resident ARI Outbreak line list and the facility did not begin surveillance for an outbreak at that time. Review of staff COVID-19 antigen test results for January 2023 indicated Medication Technician (MT)-J tested positive for COVID-19 on 1/4/23. Surveyor noted MT-J was not listed on the Staff ARI Outbreak line list and the facility did not begin surveillance for an outbreak at that time. The Resident ARI Outbreak line list beginning on 1/11/23 and ending on 2/11/23 contained the following information: Outbreak documentation for January 2023 began with R26's onset date of 1/11/23. R26's comments section listed antigen positive. For 17 of 17 residents who were identified as having signs and symptoms of ARI, the outbreak line list did not contain documentation of COVID-19 lab results, influenza lab results, or well dates. Surveyor requested documentation; however, the documentation was not provided. Review of the Staff ARI Outbreak line list beginning on 1/11/23 and ending on 2/23/23 noted outbreak documentation beginning with CNA-M's onset date of 1/10/23 and indicated CNA-M was COVID-19 positive. For 14 out of 16 staff who were identified as having signs and symptoms of ARI, the outbreak line list documented COVID-19 lab results as positive. The outbreak line list did not contain documentation of influenza lab results or well dates. Surveyor requested documentation; however, the documentation was not provided. The facility's ARI Outbreak line list beginning on 2/13/23 and ending on 3/1/23 contained the following information: R31 presented with respiratory symptoms on 3/1/23; however, the facility did not initiate transmission-based precautions (TBP) until 3/6/23 which was six days after the onset of symptoms. On 3/7/23 at 3:48 PM, Surveyor interviewed Director of Nursing (DON)-B and Nursing Home Administrator (NHA)-A regarding the facility's infection control surveillance, policies, and procedures. NHA-A verified Infection Preventionist (IP)-C began employment with the facility in October of 2022 and left employment on 2/27/23. NHA-A verified NHA-A and DON-B along with Minimum Data Set Coordinator (MDS)-D were responsible for the facility's infection control program since IP-C left. NHA-A stated the facility's clinical dashboard was an internal dashboard the facility used to track investigations, falls, precautions, skin, or anything nursing staff and administration determined needed to be followed up on. NHA-A verified R32 was exposed to influenza A by a visitor and tested positive for COVID-19 on 1/4/23. R32's COVID-19 antigen test was discussed on the clinical dashboard; however, an outbreak line list and surveillance of signs/symptoms of illness for residents and staff was not begun at that time. NHA-A stated IP-C sent a facility-wide email precaution lists that contained the infection type, start date, and end date of infections as well as what type of personal protective equipment (PPE) staff should wear. NHA-A and DON-B verified the information was not tracked on a line list, signs/symptoms list, or any infection control document on a consistent basis and was sent via email every couple of days. DON-B confirmed there was no infection control documentation other than the resident and staff ARI Outbreak line lists from January 11, 2023 through March 1, 2023. DON-B verified the facility did not track UTIs or gastrointestinal (GI) illnesses. On 3/8/23 at 11:01 AM, Surveyor interviewed DON-B who indicated the facility hired a Registered Nurse (RN) Consultant to work with the facility on a systems plan. The systems plan included working with IP-C and developing policies, procedures and an overall to-do list for the infection control program. DON-B stated the RN Consultant started on 1/13/23 and worked for three weeks. The Consultant developed a to do list for IP-C including: IP-C to set up surveillance procedures and surveillance forms were in place. Line lists for staff symptoms were initiated. Line lists for resident symptoms were initiated. Residents requiring enhanced barrier precautions were placed on precautions. IP-C to educate staff on when precautions are required. DON-B confirmed the policies and procedures for infection control were not in place prior to the Consultant working with IP-C in January of 2023. DON-B also stated the Consultant was hired to assist with the infection control program as the facility was not doing what we needed to do, just some of what we needed to do in regard to the overall infection prevention program. DON-B stated as of 2/7/23, each unit had a binder with logs for real-time symptom monitoring. DON-B verified symptom monitoring was not being performed on a consistent basis or appropriately documented as monitored previously. DON-B stated information was used by the Infection Preventionist to collect data, put residents on precautions if required, and track and prevent outbreaks. DON-B confirmed all nursing staff can place a resident on precautions. DON-B stated the charge nurse adds the precautions to the resident's medical record and continues communication with the Infection Preventionist. DON-B confirmed CNA-L and MT-J tested positive for COVID-19 prior to the development of the facility's ARI Outbreak line list and were not contained on the list, therefore, infection surveillance was not performed and DON-B was unsure why. On 3/8/23 at 11:36 AM, Surveyor interviewed DON-B regarding antibiotic stewardship. DON-B stated the facility did not have an antibiotic stewardship program and only monitored antibiotic use during morning meetings. The monitoring consisted of when the antibiotic was prescribed, and for what infection; however, no other data was collected or analyzed. DON-B stated the facility had a binder for antibiotic stewardship that was started in January of 2023. DON-B confirmed the binder contained the McGeer's criteria, but did not contain any other information. DON-B stated when the binder was initiated, IP-C was supposed to train nursing staff on how to use the McGeer's criteria. DON-B verified the facility did not have a staff training list, a sign-in sheet, or verification that staff received the training as indicated. DON-B stated the Infection Preventionist that was in place prior to IP-C had a system for tracking and documenting the entire infection prevention program; however, since July 2021 when that IP left, the program was not consistently monitored and data was not consistently collected to prevent and identify infections. DON-B verified the facility did not have UTI surveillance other than monthly Quality Assurance program tracking of some data, but it was not analyzed. DON-B stated farming out the pieces of the infection prevention program was not helpful or effective. 3. R31 was admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (COPD,) hypertension, cardiomegaly (an enlarged heart,) and a new diagnosis of pneumonia on 3/5/23. R31's Brief Interview for Mental Status (BIMS) score on 1/2/23 was 15 out of 15 which indicated R31 had intact cognition. On 3/6/23 at 12:31 PM, Surveyor interviewed R31 who stated R31 was on an antibiotic, Z-Pack. R31 expressed concerns of feeling tired, but stated the medication was helping. Surveyor observed R31 cough and asked R31 what the Z-Pack was for, however, R31 was not sure. From 3/6/23 through 3/8/23, Surveyor reviewed R31's medical record which included notes of respiratory symptoms that began on 2/28/23 when R31 complained of a runny nose. On 3/1/23, R31's symptoms progressed to a moderate productive cough with yellow sputum and nebulizer treatments were started. On 3/2/23, R31's symptoms continued and laboratory monitoring and a chest X-ray were obtained. On 3/5/23, R31 was diagnosed with pneumonia following the chest X-ray. R31 was started on the antibiotic azithromycin (Z-Pack.) On 3/6/23 at 1:00 PM, Surveyor observed staff place an isolation cart and a contact and droplet precaution sign on on R31's door. Surveyor interviewed Unit Coordinator (UC)-F regarding R31's precautions. UC-F stated R31 had pneumonia. Surveyor reviewed the facility's line list which included R31's date of onset (3/1/23) and negative COVID-19 test; however, R31 was not placed on TBP until 3/6/23. On 3/8/23 at 9:21 AM, Surveyor interviewed RN-G who stated at the first sign of respiratory symptoms, residents should be placed on TBP. RN-G stated RN-G was not sure why TBP were not initiated for R31 until 3/6/23. On 3/8/23 at 9:48 AM, Surveyor interviewed DON-B who stated the facility's IP would follow residents with new onset of symptoms and initiate the proper precautions; however, the facility's IP quit on 2/27/23. DON-B stated nursing staff have access to the items to initiate TBP and should have done so in the absence of the IP. 2. Testing of Staff and Residents During an Outbreak Investigation: An outbreak investigation is initiated when a single new case of COVID-19 occurs among residents or staff to determine if others have been exposed. An outbreak investigation would not be triggered when a resident with known COVID-19 is admitted directly onto TBP (transmission-based precautions), or when a resident known to have close contact with someone with COVID-19 is admitted directly onto TBP and develops COVID-19 before TBP are discontinued. In an outbreak investigation, rapid identification and isolation of new cases is critical in stopping further viral transmission. On 3/7/23, Surveyor reviewed R32's medical record which indicated R32 tested positive for COVID-19 on 1/4/23. The facility performed a rapid COVID-19 test on 1/3/23 which was negative. The facility tested R32 because R32 was identified as a close contact for influenza A exposure during visitation. The facility also performed a respiratory panel on R32. According to R32's medical record, R32 was placed on TBP; however, a specific date was not identified and R32 was not on the facility's COVID-19 Outbreak line list. The first documented resident on the line list was R26 on 1/11/23. The first staff member identified on the COVID-19 line list was CNA-M on 1/10/23. On 3/7/23 at 3:47 PM, Surveyor interviewed NHA-A and DON-B regarding the facility's infection control program. NHA-A stated the Public Health (PH) Department was notified on 1/12/23 regarding the facility's COVID-19 outbreak. NHA-A also stated the facility hired a Consultant to assist with the facility's Infection Control program. The Consultant revised the facility's COVID-19 testing and infection control program policies on 1/18/23. NHA-A stated the previous Infection Preventionist updated the team on 1/18/23 of the current COVID-19 line list which listed the first case on 1/10/23. NHA-A stated CNA-M was the first staff diagnosed with COVID-19 (1/10/23) and R26 (1/11/23) was the first resident diagnosed with COVID-19. NHA-A stated the facility tested all residents and staff upon identification of the COVID-19 cases on 1/11/23. The facility did not conduct contact tracing or staff and resident testing prior to 1/11/23. NHA-A stated the communication from the previous Infection Preventionist was via emails which contained precaution lists, but not true line lists. NHA-A stated the facility also monitored infections on the clinical dashboard which was reviewed Monday through Friday. On 3/8/23 at 11:01 AM, Surveyor interviewed DON-B who stated the facility was aware they were only doing some of what they were supposed to do for infection control, which is why they hired the Consultant. DON-B also stated staffing circumstances contributed to the lack of infection control surveillance. DON-B stated the facility implemented a binder for each unit to log real time symptom monitoring and staff audit logs. DON-B stated the Infection Preventionist looked at the logs, however, as of 3/8/23, the facility did not have an Infection Preventionist so DON-B monitored the logs. DON-B verified there were no additional testing documents or line lists for December 2022 through January 10, 2023. DON-B also verified additional staff tested positive for COVID-19 and were not on the current COVID-19 line list. DON-B stated CNA-L tested positive on 12/28/22 and MT-J tested positive on 1/4/23.

Based on staff interview and record review, the facility did not maintain an infection prevention and control program (IPCP) that included a functional antibiotic stewardship program. This had the potential to affect all 52 residents residing in the facility. Findings include: The facility's Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcomes document contained the following information: Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship. Policy Interpretation and Implementation: 1. As part of the facility's Antibiotic Stewardship Program, all clinical infections treated with antibiotics will undergo review by the Infection Preventionist, or designee. 2. The IP, or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics . 3. At the conclusion of the review, the provider will be notified of the review findings. 4. All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. The information gathered will include: a. Resident name and medical record number; b. Unit and room number; c. Date symptoms appeared; d. Name of antibiotic (see approved surveillance list); e. Start date of antibiotic; f. Pathogen identified (see approved surveillance list); g. Site of infection; h. Date of culture; i. Stop date; j. Total days of therapy; k. Outcome; and l. Adverse events. On 3/8/23 at 11:36 AM, Surveyor interviewed Director of Nursing (DON)-B who stated the facility was not currently implementing their antibiotic stewardship program. DON-B did not have documentation to support the implementation of the antibiotic stewardship program for an undetermined amount of time due to recent changes in staffing and did not have a named staff in charge of implementing the antibiotic stewardship program. DON-B stated there was a binder started that included utilizing McGeer's Criteria and education was put out to staff; however, DON-B did not have staff signatures or proof to ensure the education was completed. DON-B stated during morning meeting on Monday through Friday, the daily clinical dashboard (part of residents' electronic medical records) was reviewed by staff which included discussing antibiotic usage; however, DON-B confirmed when an antibiotic is ordered, there is no system in place to ensure the correct usage of that antibiotic. On 3/8/23 at 12:18 PM, DON-B stated DON-B found monthly antibiotic monitoring forms on the shared drive for November 2022, December 2022, January 2023, and February 2023 that the facility's former Infection Preventionist filled out; however, the documents did not include required documentation for appropriate monitoring of antibiotic use or the use of McGeer's criteria.

Based on staff interview and record review, the facility did not ensure the facility's Infection Preventionist (IP) completed specialized training in infection prevention and control. This had the potential to affect all 52 residents residing in the facility. IP-C started as the facility's designated IP on 8/22/22; however, IP-C did not complete specialized training for infection prevention and control until 2/20/23 and IP-C's employment at the facility ended on 2/27/23. Director of Nursing (DON)-B, Nursing Home Administrator (NHA)-A and Minimum Data Set Coordinator (MDS)-D became the facility's designated full-time IPs on 2/27/23; however, DON-B, NHA-A and MDS-D did not complete specialized training for infection prevention and control. Findings include: CMS (Centers for Medicare and Medicaid Services) Ref: QSO-22-19-NH last revised date: June 29, 2022 contains the following information: In 2016, CMS overhauled the Requirements for Participation for Long-Term Care (LTC) facilities (i.e., nursing homes), which was implemented in three phases: Phase 3 - November 28, 2019 .Phase 3 .regulations which require nursing homes to have an Infection Preventionist (IP) who has specialized training onsite at least part-time to effectively oversee the facility's infection prevention and control program (IPCP). On 3/7/23, Surveyor reviewed the facility's Infection Preventionist training. A training certification for former IP-C, dated 2/20/23, was the only IP training certificate located in the facility's IP training file. On 3/7/23 at 3:48 PM, Surveyor interviewed DON-B and NHA-A as part of the infection control task. DON-B and NHA-A verified they were designated as the facility's full-time IP along with MDS-D. Surveyor asked DON-B and NHA-A if either completed infection control courses as required by CMS. DON-B and NHA-A verified they did not complete IP training, but would begin the Centers for Disease Control and Prevention (CDC) infection prevention training soon. DON-B and NHA-A confirmed IP-C was hired as the designated IP on 8/22/22; however, IP-C did not have previous CMS required IP training. DON-B and NHA-A verified IP-C did not complete the CMS required IP training until right before IP-C ended employment with the facility on 2/27/23. DON-B and NHA-A stated when IP-C's employment ended, DON-B, NHA-A and MDS-D became the facility's designated IPs. On 3/8/23 at 11:37 AM, Surveyor interviewed DON-B who indicated the facility had several changes in the IP position. DON-B stated the facility had a previous IP who completed CMS required training, but ended employment with the facility on 7/21/22. DON-B verified after 7/21/22, the IP position was designated to several employees including Registered Nurse Insurance Coordinator (RNIC)-E, DON-B and NHA-A. DON-B verified RNIC-E did not complete CMS required IP training, but performed portions of the IP position in addition to DON-B and NHA-A. DON-B stated the IP roles and responsibilities were shared amongst DON-B, RNIC-E and NHA-A until IP-C was hired on 8/22/22. DON-B confirmed since IP-C left employment on 2/27/23, the IP roles and responsibilities have been shared between DON-B, NHA-A and MDS-D despite the fact none of them completed specialized training required by CMS to perform the IP role.

Based on staff interview and record review, the facility did not conduct testing of residents and staff consistent with current standards of practice for COVID-19 testing. This had the potential to affect all 52 residents residing in the facility. The facility did not initiate an outbreak investigation, conduct COVID-19 testing or complete contract tracing when a new case of COVID-19 was identified among residents or staff. Findings include: CMS (Centers for Medicare and Medicaid Services) Memo QSO-20-38-NH, dated 8/26/2020 and revised 9/23/22, provides guidance for COVID-19 testing of nursing home staff and residents and contains the following information: To enhance efforts to keep COVID-19 from entering and spreading through nursing homes, facilities are required to test residents and staff based on parameters and a frequency set forth by the HHS (Health and Human Services) Secretary .2. An outbreak investigation is initiated when a single new case of COVID-19 occurs among residents or staff to determine if others have been exposed .In an outbreak investigation, rapid identification and isolation of new cases is critical in stopping further viral transmission. Upon identification of a single new case of COVID-19 infection in any staff or resident, testing should begin immediately (but not earlier than 24 hours after the exposure, if known). Facilities have the option to perform outbreak testing through two approaches, contact tracing or broad-based (e.g. facility-wide) testing. If the facility has the ability to identify close contacts of the individual with COVID-19, they could choose to conduct focused testing based on known close contacts .Close contact refers to someone who has been within 6 feet of a COVID-19 positive person for a cumulative total of 15 minutes or more over a 24-hour period. On 3/7/23, Surveyor reviewed the facility's COVID-19 antigen test documentation. Surveyor noted on 1/4/23, R32 tested positive for COVID-19. Documentation indicated a COVID-19 test was performed on 1/3/23 with a negative result. The facility also conducted a respiratory panel for R32 on 1/4/23 because R32 was identified as a close contact for influenza A during visitation. Test results indicated R32 was positive for COVID-19. According to R32's medical record, R32 was placed on transmission-based precautions (TBP) with no specific date the precautions started or ended. Surveyor also noted R32 was not on the facility's COVID-19 outbreak line list. Contact tracing and resident and staff testing for COVID-19 was not documented. The first documented resident on the line list was R26 on 1/11/23. The first staff member identified on the COVID-19 line list was Certified Nursing Assistant (CNA)-M on 1/10/23. On 3/7/23 at 2:25 PM, Surveyor interviewed CNA-M who stated CNA-M came to work feeling cruddy, with the start of a cold on 1/9/23. CNA-M verified CNA-M did not report the illness and worked the entire shift. CNA-M stated on 1/10/23, CNA-M still did not feel well and had a runny nose and cough. CNA-M reported the illness and tested positive for COVID-19 on 1/10/23. CNA-M reported CNA-M did not feel well on 1/10/23 because a resident (R32) CNA-M worked with was just taken off of COVID precautions which made CNA-M think reporting the illness was important since CNA-M didn't feel well on 1/9/23 and felt more ill the following day. On 3/7/23 at 3:47 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B regarding COVID-19 testing. NHA-A stated Public Health (PH) was notified on 1/12/23 regarding the facility's COVID-19 outbreak. NHA-A stated the previous Infection Preventionist (IP) (IP-C) updated the current COVID-19 line list for staff on 1/18/23 and documented the first staff COVID-19 case on 1/10/23. IP-C documented the first resident COVID-19 case on 1/11/23. NHA-A confirmed the facility tested all residents and staff upon identifying the COVID-19 cases on 1/11/23. NHA-A and DON-B verified the facility did not conduct staff and resident testing after identifying R32 tested positive for COVID-19 on 1/4/23. NHA-A stated the COVID-19 line list, beginning 1/10/23 for staff and 1/11/23 for residents, did not contain well dates. DON-B verified additional staff tested positive for COVID-19, but were not on the current COVID-19 line list nor was any testing, contact tracing or surveillance conducted when Certified Nursing Assistant (CNA)-L tested positive for COVID-19 on 12/28/22 and Medication Technician (MT)-J tested positive for COVID-19 on 1/4/23. NHA-A also verified an outbreak investigation did not begin following those COVID-19 positive tests. NHA-A further stated COVID-19 infection prevention was provided by monitoring signs and symptoms of infection. NHA-A stated when a resident or staff tested positive for COVID-19, an outbreak investigation began. NHA-A confirmed R32 had a respiratory panel conducted as well as a COVID-19 test due to being in close contact with influenza A from a visitor. NHA-A confirmed R32 tested positive for COVID-19 on 1/4/23. DON-B indicated, and NHA-A confirmed, DON-B and IP-C sent an email to NHA-A on 1/5/23 and asked if close contacts of R32 should be tested for COVID-19, specifically those that sat with R32 at lunch in the dining room. NHA-A verified NHA-A responded yes to the email and instructed DON-B and IP-C to perform COVID-19 tests on residents who sat with R32 in the dining room. DON-B stated information would be gathered on when close contacts of R32, CNA-L and MT-J were tested and the results would be provided to Surveyor. On 3/8/23 at 11:38 AM, DON-B requested to speak with Surveyor regarding close contact testing and documentation for R32, CNA-L and MT-J. DON-B confirmed there was no documentation regarding COVID-19 tests performed on close contacts of R32, CNA-L and MT-J. DON-B stated close contact was when an individual was within six feet for greater than 15 minutes at one time within the last 48 hours of an individual with COVID-19.