**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 2 R13 was admitted to the facility on [DATE]. Diagnoses included mild protein-calorie malnutrition. R13's Minimum Data Set (MDS) assessment, completed on 12/17/24, confirmed R13 scored 12/15 during Brief Interview for Mental Status (BIMS), indicating mild cognitive impairment. R13 eats independently after set-up. R13's care plan included areas of concern related to nutrition and dehydration due to potential for weight loss. On 03/03/25 at 11:23 AM, Surveyor interviewed R13. R13 resides on the third floor of the facility. R13 stated the facility's meals are 'lousy.' Surveyor asked R13 to describe the lousy food, and R13 responded, It's just lousy, that's all I can say about it. Example 3 R29 was admitted to the facility on [DATE]. Diagnoses included heart failure, atrial fibrillation, and history of chronic non-pressure ulcer of lower leg. R29's MDS assessment, completed on 12/04/24, confirmed R29 scored 13/15 during BIMS, indicating intact cognition. R29 eats independently after set-up. R29's nutritional assessment indicated her body mass index is slightly below healthful range for geriatric population. R29's goal for weight stabilization is gradual weight gain within a healthful range. On 03/03/25 at 10:59 AM, Surveyor interviewed R29. R29 resides on the third floor of the facility. R29 stated she eats meals in her room. R29 reported the facility's meals are not 'that good,' and often meals are cold or lukewarm. R29 stated food is covered, but the plates are cold, so all hot food items are cooled when placed on a cold plate. On 03/03/25 at 11:38 AM, Surveyor observed dietary staff prepare food carts to be served on the second and third floors. Surveyor noted the facility's kitchen is located on the first floor. Surveyor observed the second-floor food cart was a covered and insulated cart. Surveyor observed the third-floor food cart was uncovered and not insulated. On 03/03/25 at 11:55 AM, Surveyor observed staff passing meal trays to residents residing on the third floor, including R13 and R29. On 03/03/25 at 12:06 PM, Surveyor received last tray on the third-floor meal cart. Meal served was fried chicken with gravy, mashed potatoes, sliced carrots, and a dinner roll. Surveyor taste tested all food items and noted each item to be lukewarm. Based on observation and interview, the facility did not always serve food to 4 out of 13 residents (R11, R13, R23, and R29) that was palatable and served at the proper temperature. R11, R13, R23, and R29 all had food complaints that food was not palatable. This is evidenced by: Example 1 Federal regulation §483.60(d)(2) states, each resident receives and the facility provides food and drink that is palatable, attractive, and at a safe and appetizing temperature. On 03/03/25 at 11:10 AM, Surveyor observed lunch food arrived in steam table containers that were transported from a sister facility. Surveyor requested a test tray to be sent on the last cart to be delivered to the wing. Surveyor observed Dietary Staff (DS) C place food on steam table. Ground chicken and chopped carrots did not fit and were placed against the wall on the outer edge of the steam table. Food temperatures were checked and revealed the following: Chicken 166 degrees. Mashed potatoes 142 degrees. Carrots 182 degrees. Gravy 177 degrees. Minced and moist carrots 126 degrees. DS C microwaved the carrots and rechecked the temperature which then read 170 degrees. Ground chicken that did not fit on steam table was 167 degrees. Chopped carrots that did not fit on steam table were 166 degrees. At 11:24 AM, DS C started dishing food onto plates. At 11:42 AM, Surveyor observed DS C retrieve a plastic divider plate with a sealed lid. Surveyor asked DS C who receives it and why. DS C stated, [R23] requests it to keep the food warmer. Surveyor followed the last meal cart with the test tray on it. At 12:01 PM, Surveyor tested the food immediately after all trays were passed. Test tray temperatures were as follows: Milk 55 degrees. Mashed potatoes 113. Chicken 118. Carrots 104. Surveyor sampled the food and found it to be lukewarm and milk was warmer than desired. On 03/04/25 at 8:36 AM, Surveyor interviewed Nursing Home Administrator (NHA) A who was informed that multiple residents complained about receiving cold food and that a test tray confirmed it. NHA A stated they were not aware, it is not acceptable and will look into it. Example 4 R23 was admitted to the facility on [DATE]. Diagnoses include type 2 insulin dependent diabetes mellitus. R23's Minimum Data Assessment (MDS), dated [DATE], stated R23's Brief Interview for Mental Status (BIMS) score was 13 out of 15, indicating intact cognition. On 3/03/25 at 10:28 AM, Surveyor interviewed R23. R23 complained the food is terrible and not nutritious. R23 reported the food is not good. R23 provided Surveyor with several notes taken on the daily menus. Surveyor reviewed her notes and noted several of complaints of food dislikes, cold food that should have been served warm, and meats that were dry and hard to chew. On 3/3/25 at 11:55 AM, Surveyor observed lunch trays being served to residents on third floor in their rooms due to COVID outbreak. R23 reported the food was not very warm and the meat was dry. Example 5 R11 was admitted to the facility on [DATE]. Diagnoses include morbid (severe) obesity, weakness, and vitamin D deficiency. Minimum Data Set (MDS) assessment, dated 1/14/25, states R23's Brief Interview for Mental Status (BIMS) score is 15 out 15, indicating intact cognition. On 3/03/25 at 10:06 AM, Surveyor interviewed R11. R11 reported the facility food is their weak point. R11 stated the food is not always hot or very good. R11 reported the food comes from the other place so by the time it gets here, it is cold.

Based on observation, interview and record review, the facility did not ensure proper sanitization and food handling practices to prevent the outbreak of foodborne illness for all 29 residents. -Chemical dishwasher temperature did not reach the required 120 degrees. -Perishable item was only good for 24 hours after thawing. Item was not labeled to ensure it was discarded timely to prevent foodborne illnesses to the residents. Evidenced by: Example 1 According to federal regulation §483.60(i)(1)-(2), Low Temperature Dishwasher (chemical sanitization): Wash - 120 degrees F; and Final Rinse - 50 ppm (parts per million) hypochlorite (chlorine) on dish surface in final rinse. On 03/03/25 at 8:50 AM, Surveyor observed Dietary Staff (DS) C wash dishes in the dishwasher. DS C stated that it is a chemical sanitizing dishwasher. Surveyor asked where the thermometer is that they record the dishwasher temperatures. DS C showed Surveyor the thermometer on the lower unit of the dishwasher and began a washing cycle. Surveyor observed and confirmed with DS C that the temperatures reached a high of only 106 degrees. DS C ran the dishwasher a second time and it read 104 degrees. DS C reached out to Nursing Home Administrator (NHA) A who contacted Maintenance Director (MD) D. At 9:49 AM, MD D stated he adjusted the mixing valve and to try it again. At that time the temperature read 110 degrees. DS C then ran the dishwasher and took the temperature in the standing water immediately after a cycle and it read 104 degrees. DS C was asked if this was concerning, and DS C stated it was and it needs to be fixed. On 03/03/25 at 10:26 AM, Surveyor requested dishwasher manufacturer instructions. Instructions state: Operator Procedures .5. Fill machine with water using Fill Switch. If water temperature gauge has not reached 120 degrees F (49 degrees C) when the water level is just below the overflow, drain water from the machine and continue to fill until proper temperatures is attained. Dishwasher water did not reach the required temperatures to ensure dishes are properly sanitized. Example 2 According to federal regulation §483.60(i)(2), facilities must store, prepare, distribute and serve food in accordance with professional standards for food service safety. 2017 Recommendations of the United States Food and Drug Administration Food Code states. Food Receiving and Storage - When food, food products or beverages are delivered to the nursing home, facility staff must inspect these items for safe transport and quality upon receipt and ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all PHF/TCS foods stored in the refrigerator or freezer as indicated. On 03/03/25 at 9:43 AM, Surveyor was inspecting the resident refrigerator in the dry storage room located next to the kitchen. Surveyor discovered an open bag that had printing on it that read, Mini cream puffs, good for 24 hours after thawing. There was no open or discard dates on the item. Surveyor brought DS C to the storage room refrigerator to look at the concern. Surveyor asked DS C what was in the bag. DS C replied, Cream puffs, with no dates on them. The activity staff probably forgot to date them. DS C then discarded the cream puffs. NHA A was made aware and asked Surveyor which refrigerator the item was found in. Surveyor informed NHA A it was in the resident refrigerator in the dry storage area by the kitchen.

Based on record review and interview, the facility did not ensure that 1 of 5 staff reviewed for verification of a current Nurse Aide Registry were on the Wisconsin registry before starting work in the facility. This has the potential to affect all 31 residents. Certified Nursing Assistant (CNA) C was not on the Wisconsin Nurse Aide Registry and was working in the facility at the time of the discovery. Findings include: On 1/31/24, Surveyor reviewed CNA certifications for a sample of 5 CNAs. CNA C was hired on 6/19/23. Nursing Home Administrator (NHA) A provided a state of Michigan CNA registry for CNA C. No Wisconsin CNA registry information was provided. On 1/31/24 at 12:22 PM, Surveyor interviewed NHA A about the missing Wisconsin CNA Registry for CNA C. NHA A stated CNA C had lost her social security card and had been unable to obtain CNA registry in Wisconsin. NHA A stated that they have been working on this for a while now. On 1/31/24 at 1:57 PM, NHA A provided Surveyor with a Wisconsin CNA registration for CNA C with a valid date of 1/31/24. This was completed today after Surveyor asked for the registry. Surveyor asked NHA A for a policy regarding employment requirements for a position requiring licensure or certification. NHA A provided Surveyor with the new employee checklist. NHA A stated this was all they had. According to the Wisconsin Nurse Aide Training and Registry team, nurse aides must be listed on the Wisconsin Nurse Aide Registry in order to be employed in any federally eligible health care setting in Wisconsin. Surveyor reviewed the staffing schedule and identified CNA C was scheduled and worked since hire date 6/19/23, prior to obtaining Wisconsin CNA registry, and NHA A confirmed this.

Based on interviews and record review, the facility failed to submit Centers for Medicare and Medicaid Services (CMS) mandatory Payroll Based Journal (PBJ) data for the third quarter of 2023 (April 1-June 30). This has the potential to affect all 31 residents. This is evidenced by: Surveyor noted the facility failed to submit PBJ data for Fiscal Year Quarter 3. On 1/31/24 at 2:41 PM, Surveyor completed an interview with Nursing Home Administrator (NHA) A and Payroll Specialist (PS) D about the PBJ submissions. PS D stated the facility attempted to submit PBJ on the deadline date but was unable to do so. PS D stated that PS D was unaware that this needed to be submitted prior to the deadline date. PS D stated that he made sure Quarter 4 was submitted on-time and stated the next quarter submission, due 2/14/24, would also be submitted on time. Surveyor then reviewed the staff schedules for that time period (April 1 -June 30, 2023) and compared the data with time punches. There were no concerns uncovered related to licensed staff coverage or Certified Nursing Assistant coverage. The facility had failed to submit PBJ data for third quarter. Surveyor reviewed the PBJ submission for Fiscal Year 2023 Quarter 4 (July 1 - September 30). The facility was noted to have submitted the 4th quarter's data on 11/8/23, accurately. The facility is in compliance as of 09/30/23. This was cited past noncompliance.

Based on observation, interview and record review, the facility did not provide the services needed to maintain mobility for 1 of 3 residents reviewed (R20). R20's plan of care includes an ambulation program twice daily. The program was not implemented as directed in the care plan. This is evidenced by: Surveyor reviewed the facility policy titled Restorative Nursing Services dated as revised on July 2017. The policy in part states: ~Residents will receive restorative nursing care as needed to help promote optimal safety and Independence. ~Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitation services. ~Residents may be started on restorative nursing upon admission, during course of stay or when discharged from rehabilitative care. ~Restorative goals and objectives are individualized and resident-centered, and are outlined in the residents plan of care . On 01/24/23 at 12:38 PM, Surveyor spoke with R20 in his room. Surveyor observed R20 in a wheelchair. R20 informed the Surveyor he had a stroke which affected his ability to walk. He has a restorative walking program in place. R20 further expressed the program is supposed to occur daily but it occurs 1 to 3 times a week, depending on the restorative aide's schedule. R20 expressed he is scheduled for re-evaluation from therapies at the sister facility some time this month, which has not yet occurred. Resident stated he would like to improve his ambulation to be able to discharge home. Surveyor reviewed R20's record and noted R20's diagnosis includes: Hemiparesis and hemiplegia affecting his left non-dominant side following cerebral infarction (stroke), difficulty walking and weakness. R20's Minimum Data Set (MDS) most recently completed on 12/20/22 (Annual) notes R20 understands, is understood and is cognitively intact. He walks in room and corridor with extensive assistance of 1 staff. He has a range of motion impairment affecting one side, upper and lower. Previous comprehensive MDS (admission) completed 12/27/21 notes R20 walks in room and corridor with extensive assistance of 1 staff and has range of motion impairment on one side upper and lower. R20's care plan notes: Problem start date: 12/21/2021 Walking: health maintenance related to restorative/maintenance program: walking Goal target date: 3/05/2023: In next 3 months will ambulate 100 feet twice per day or as tolerated with walker and assist of one staff with w/c (wheel chair) follow. Approach: start date: 12/21/2021: walks with assist of one, gait belt, wheeled walker and wheel chair following behind two times a day with a goal of 125 feet. On 01/24/23 at 1:37 PM, Surveyor observed Restorative Aide (RA) C place a gait belt on R20's waist. RA C assisted R20 to stand. Using a 2 wheeled walker RA C assisted R20 to ambulate up hallway holding gait belt and pulling his wheelchair behind. RA C and R20 walked to end of hall and back to his room. Surveyor reviewed Restorative Nursing Data from 11/01/23 to 1/24/23. The data shows R20's walking program occurred as follows: November 2022: One time a day: 4 occasions Unanswered: 15 occasions Not performed: (refusal, unavailable): 11 occasions There is not a second opportunity noted any of the 30 days. December 2022: Twice a day as outlined in R20's care plan: 3 occasions One time a day: 7 occasions Unanswered: 13 occasions Not performed: 15 occasions There is not a second opportunity noted on 4 days. January 2023: 1/01/23-01/25/23: Twice a day as outlined in R20's care plan: 3 occasions One time a day: 7 occasions Unanswered: 17 occasions Not performed: 20 occasions On 1/25/22 at 1:40 PM, Surveyor spoke with Director of Nursing (DON) B about R20's restorative walking program. DON B indicated the goal of R20's program is to maintain his mobility walking status to walk twice a day with staff assistance of 1 for up to 125 feet. DON B explained the facility noted a few months ago certified nursing assistants (CNAs) were having problems completing the restorative programs. The facility designated one of their CNAs to conduct restorative programs initially one day a week and as of January 9th, 3 days a week. The expectation is for CNAs to conduct the programs the days the restorative aide is not scheduled. On 1/26/23 at 9:00 AM, Surveyor spoke with RA C about R20's walking program. RA C expressed she has worked at the facility several years and is familiar with R20. RA C expressed she works at the facility full time, part time as a restorative aide and part time as a certified nursing assistant. RA C explained she started the restorative aide position one day a week 3 weeks ago and went to 2-3 days a week 2 weeks ago. RA C expressed the days she is designated to restorative R20 ambulates with her down the hall as observed by the surveyor. The days she works as a Certified Nursing Assistant she does not have time to do R20's walking program or other residents' restorative programs. RA C further explained the data collection does not have an option to note not offered so she will not answer the question, thus the system reads unanswered or not performed. On 1/26/23 at 9:10 AM, Surveyor spoke with CNA D about R20's walking program. CNA D indicated she has worked at the facility many years and is familiar with R20. CNA D indicated there are times R20 does not want to walk at the time the CNAs are available to walk him so she will chart refused or unavailable. CNA C further expressed sometimes the CNAs do not have enough time in a day to offer R20 his walking program thus they will not answer the question for walking program and it shows as unanswered. The facility has added a restorative aide to help with resident programs but the restorative aide only works 1-3 days a week. Certified Nursing Assistants are supposed to do the programs when the restorative aide is not scheduled but they do not have the time to do them.