Golden Age Manor

especially when personal or financial value after talking to family.

Surveyor asked NHA A if NHA A

may not know how to formally file a grievance and then facility will look into missing items.

On 4/9/25 at 2:55 PM, Surveyor was at nursing station in 100 wing when resident approached desk.

R44 was attempting to communicate a need but was unable to verbalize. R44 was motioning to his clothing and attempting to verbalize needing something. RN I asked if R44 was referring to pads and R44 responded, Yes! Pants! On 4/9/25 at 3:05 PM, Surveyor observed R44 attempting to go through the locked doors that go to basement.

Surveyor observed a staff member ask R44 what R44 needed. R44 indicated needed downstairs while R44 was pulling at R44's pants.

Staff member indicated to R44 that staff member would let activities department know to search down in laundry room for R44's pants.

On 4/10/25 at 12:00 PM, Surveyor interviewed Director of Nursing (DON) B and asked DON B what the process is for resolving grievances related to missing laundry. DON B indicated that DON B recognizes the potential for lost/missing items due to the incorrect labeling process for residents' clothing. DON B acknowledged that this concern of missing laundry items has not been resolved by the facility.

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dementia, constipation, hypertension, neuralgia, osteoarthritis of knee, muscle weakness, spinal

R3's Minimum Data Set (MDS), dated [DATE], documented R3's Brief Interview for Mental Status (BIMS) score as having severely impaired cognition. R3 is dependent on staff for all activities of daily living (ADL) and receives hospice services.

R3's care plans did not have a hospice or end of life plan of care developed.

On 04/08/25 at 3:30 PM, Surveyor asked Nursing Home Administrator (NHA) A if a hospice care plan was developed for R3. NHA A indicated there is no hospice care plan.

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documentation of R55's interventions and R55's care plan should have been updated to indicate

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Review of restorative nursing logs documenting the number of minutes PROM was completed.

The logs started documentation on 03/25/25 with no previous data available.

Staff provided PROM on 03/25/25 and 03/26/25 for 6 minutes, 03/27/25 and 03/28/25 for 12 minutes, 03/29/25 PROM was not completed, 03/30/25 for 10 minutes, 03/31/25 PROM not completed, 04/01/25 for 10 minutes during the AM shift and 5 minutes during the PM shift, 04/02/25 for 6 minutes, 04/03/25, 04/04/25, 04/05/25 and 04/06/25 PROM was not completed, 04/07/25 for 10 minutes, and 04/08/25 PROM was not completed.

On 04/07/25 at 11:39 AM, Surveyor interviewed R9 asking if ROM is completed as ordered. R9 stated having contractures to her legs and the exercises are listed on the bulletin board. R9 likes to have ROM completed at bedtime and R9 needs to ask staff to complete ROM otherwise it does not get done.

On 04/09/25 at 2:31 PM, Surveyor interviewed Registered Nurse (RN) C about ROM program assessments and monitoring. RN C indicated there is no review of the program and therapy would be consulted to evaluate if a decline was noted.

Staff should be documenting when the resident refuses.

Surveyor reviewed R3's number of minutes to complete PROM and R9's logs not being completed. RN C stated R9's ROM tracking was entered incorrectly prior and was not tracked.

Surveyor asked if assessments of the program were completed would this issue have been identified. RN C indicated if the assessments of the program were completed it would have been caught.

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Golden Age Manor 220 Scholl CT Amery, WI 54001

with other behavioral disturbances.

R35's MDS assessment, dated 1/7/25, indicates that R35 has moderate cognitive impairment, and is rated to be dependent to needing substantial assistance for personal cares and activities of daily living. R35 is dependent for mobility, staff use a mechanical lift to transfer from bed to chair and to shower/bathe chair. R35 has no impairment to the upper body but impairment to the lower body.

R35's care plan, dated 1/13/25, does not include pain management.

Surveyor found no pain management care plan or approaches for pain management embedded in other care planned areas either, including the general section titled health maintenance.

R35 has an order in the eMAR for OPIOID MONITORING: The following side effects will be monitored for while resident is on an opioid: -tolerance (more medication may be needed to achieve the same level of pain relief). -Medication is stopped, or a dose is held or missed. -Increased sensitivity to pain. -Constipation. -Nausea, vomiting, and dry mouth. -Sleepiness, dizziness, and/or confusion. -Depression. -Itching and sweating. -Respiratory depression.

Report to provider any noted side effects. 12/31/2024 - Open Ended On 4/8/25 at 8:09 AM, Surveyor interviewed R35 while sitting alone in dining room. R35 denied pain currently. R35 stated that movement hurts the most. R35 stated as long as R35 gets medication on time, R35 usually does not have a lot of pain. R35 stated R35 has other medications they can give R35 when that happens.

On 4/8[TRUNCATED]

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services of a licensed pharmacist.

observations, interviews and record reviews, the facility failed to provide pharmaceutical services

This is evidenced by: Facility policy titled, Administering Medications, with a revised date of 04/2019, states in part: .22.

As required or indicated for a medication, the individual administering the medication records in the resident's medical record: c. the route of administration; d. the injection site (if applicable) R19 was admitted to the facility on [DATE] with a pertinent diagnosis of allergic rhinitis.

R19's orders noted calcitonin spr 200/act instill one spray into 1 nostril once daily - alt nostril daily.

On 04/09/25 at 7:24 AM, Surveyor observed medication administration performed by Licensed Practical Nurse (LPN) H.

Surveyor observed LPN H administer the nasal spray into R19's right nostril.

Surveyor observed LPN H document medication as administered. No documentation of which nostril was noted.

On 04/09/25 at 7:38 AM, Surveyor interviewed LPN H regarding documentation of medication. LPN H stated that staff used to document which nostril the spray was administered, but it went it away a while ago. LPN H stated that she works everyday with R19 and knows which nostril to administer the medication.

On 04/10/25 at 10:24 AM, Surveyor interviewed Director of Nursing (DON) B regarding observation.

DON B stated that nursing staff are expected to document the location a medication is administered to ensure accurate medication adminnistration and was unaware this was not being completed.

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Review of physician order documented, 02/10/25 melatonin tablet; 5 mg; amt: 5 mg; oral Special Instructions: PRN between 0000-0300 for insomnia Once A Day - PRN R9 does not have a sleep care plan developed with non-pharmacological interventions to promote sleep.

R9's medical record did not have sleep assessments and tracking of sleep to determine sleep patterns and effectiveness of the medication.

On 04/09/25 at 1:58 PM, Surveyor interviewed Director of Nursing (DON) B about sleep behavior monitoring and physician rationale for continued medication use. DON B indicated sleep assessments are completed quarterly and the person completing the assessment would interview staff and ask what the resident's normal sleep pattern is.

Surveyor asked if the staff interviewed are the same staff on day and night shift to identify the sleep patterns.

Surveyor asked how are you accurately collecting data to support the need for the sleep medication.

Surveyor asked if all staff are reporting and documenting when all residents are asleep or awake. DON B stated she understands the need to collect data to support the medication use.

Surveyor asked if there was a sleep care plan with non-pharmacological intervention to promote sleep. DON B indicated there was not a complete assessment and there is not a care plan.

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and physician rationale for continued medication use. DON B stated sleep assessments are completed

understands the need to collect data to support the medication use. DON B stated Nurse Practitioner

recommendations and the NP did not address and provide the rationale of why a GDR would be a detriment or negative effect to the resident.

Surveyor asked if there was a sleep care plan with non-pharmacological intervention to promote sleep. DON B indicated there was not an assessment or care plan.

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the food and nutrition service, including a qualified dietician.

of food and nutrition services who had completed the minimum qualification requirements for the

This is evidenced by: On 4/7/25 at 9:10 AM, Surveyor conducted initial tour of the kitchen with Dietary Manager (DM) D.

Surveyor interviewed DM D and requested verification of DM D's qualifications. DM D directed Surveyor to the two certifications on her office wall.

On 4/8/25, Surveyor was provided copies of the certifications. In review of the DM certification, Surveyor noted it is for a Food Protection Manager which is accredited by the American National Standards Institute (ANSI)-Conference for Food Protection (CFP).

Completed 2023-8-10 and valid through 2028-8-10 from the Always Food Safe Company.

On 4/9/2025 at 8:50 AM, Surveyor interviewed Nursing Home Administrator (NHA) A, as DM D was unavailable.

Surveyor asked if the facility has a full-time dietician in house. NHA A indicated they do not.

The dietician is fully remote.

Surveyor asked for any evidence the dietician was monitoring compliance in the kitchen. NHA A did not provide any information. NHA A reported the facility's understanding was the DM certification fell under the state qualifications listed in the SOM F-F801 483.60 (a) (2) (i) .(C) Has similar national certification for food service management and safety from a national certifying body.

Surveyor investigated the certification further and informed NHA A the certificate provided does not meet requirements for Certified Dietary Manager.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

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During this initial tour, Surveyor interviewed DM D, who reported the expectation would be that opened and/or prepared foods would be dated with an opened or prepared on date or a use by date.

DM D did remove potentially hazardous foods and dispose of them.

On 4/08/25 at 11:17 AM, Surveyor observed Head [NAME] G take temperature of foods to be served.

During checking temperature of the foods, Head [NAME] G would stick probe into isopropyl alcohol probe wipe packet, rub probe end and immediately stick in next food item without waiting to let air dry as directed.

This was done with 5 of the 9 foods that were checked during observation.

On 4/08/25 at 11:44 AM, Surveyor interviewed Head [NAME] G, who reported she was trained on checking temperatures of foods a long time ago.

Head [NAME] G reported she was unsure of when that would have been.

Head [NAME] G reported she was not aware of the amount of time to allow cleaner to dry or that probe needs to dry and acknowledged she does not allow probe cleaning wipe to dry before checking temperature between foods.

On 4/09/25, Surveyor informed Nursing Home Administrator A of the deficiencies in food preparation and storage that were observed.

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other precaution sign was noted. R1 was observed sitting in wheelchair in room. R1 had a urinary

exiting the bottom of R1's right pant leg with clear yellow urine.

On 04/08/25 at 12:04 PM, Surveyor asked Registered Nurse (RN) I what the contact precaution sign outside of R1's room was for. RN I stated that it was for R1's roommate.

On 04/10/25 at 10:24 AM, Surveyor interviewed Nursing Home Administrator (NHA) A regarding observation. NHA A stated that R1 should have had EBP order initiated when the urinary catheter was placed. NHA A stated recognition that this had the potential to spread infection and put R1 and other residents at risk.

Example 5 On 4/07/25 at 10:46 AM, Surveyor observed CNA F use sit to stand to transfer R33 from a wheelchair to the toilet. R33 remained on the toilet.

On 4/07/25 at 10:56 AM, CNA F put on gloves and provided incontinence care for R33. CNA F wiped liquid stool from resident buttocks and perineal area.

After getting bowel movement (BM) on gloves, CNA F used a disposable wipe to clean off her gloves. CNA F continued to provide incontinence cares for R33 without changing her gloves.

After cleaning the BM, CNA F removed the gloves, did not practice any form of hand hygiene, and without donning new gloves put R33's clean incontinence pad on and pulled up her pants. CNA F then moved sit to stand lift, transferred R33 into her wheelchair, and removed R33's transfer belt for stand lift. CNA F continued without gloves to push R33 in the wheelchair to door before CNA F stopped and used hand sanitizer.

On 4/07/25 at 11:01 AM, Surveyor interviewed CNA F who reported she had hand hygiene training last month.

When Surveyor asked CNA F what should be done when there are visibly soiled gloves, CNA F reported she was not aware the gloves should be changed and not wiped cleaned. CNA F reported she is aware that she should use hand hygiene when leaving room.

Surveyor pointed out that hand hygiene was not practiced immediately after removing soiled gloves.

On 4/08/25 at 8:29 AM, Surveyor interviewed Licensed Practical Nurse (LPN) E who reported her expectations would be that if gloves are visibly soiled they be removed, and that hand hygiene should be performed immediately when gloves are removed.

On 4/10/25 at 8:45 AM, Surveyor interviewed RN C, who reported the expectation would be soiled gloves be removed, not wiped clean, and hand hygiene be performed immediately after removing gloves, and after resident incontinence cares. RN C acknowledged further infection control/hand hygiene education is required and will be provided.

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Stewardship Program that includes antibiotic use protocols and a system to monitor antibiotic use.

The facility did not ensure a standard of practice for antibiotic use or surveillance was being utilized in the facility's antibiotic stewardship program.

This is evidenced by: The Facility policy titled Antibiotic Stewardship Program, dated 10/23, states in part: The Infection Preventionist is responsible for monitoring; investigating and setting forth a control plan to prevent unnecessary infections.

The IP is responsible for monitoring and trending the facility infection incidence rates and this information is reviewed quarterly assurance committee with the interdisciplinary team and medical director each at least quarterly .

Surveyor reviewed infection surveillance logs dated from February 2024-March 2025.

Surveyor found missing documentation on all line lists for infection surveillance to include complete: -Symptoms onset date. -Culture/test type and result. -Treatment parameters.

Such as Antibiotics of choice and when started and stopped. -Resolution date and times for infections.

On 04/10/25 at 11:12 AM, Surveyor interviewed Infection Preventionist, Registered Nurse (RN) C, about antibiotic tracking and surveillance. RN C indicated that RN C receives a printout from Health Direct on who was on antibiotics for the month.

Surveyor asked RN C when RN C receives this report.

RN C indicated the report is sent roughly two weeks after residents are started on antibiotics for that month and that is when RN C is reviewing antibiotic use.

Surveyor asked RN C how RN C is tracking infections, what kind of antibiotics residents are put on, and how RN C knows when residents are started on antibiotics and is it the correct antibiotic. RN C asked what Surveyor meant. RN C indicated that RN C leaves that up to the doctor to decide on antibiotic use. RN C stated, I am not a doctor. I don't know.

Surveyor asked RN C what criteria is used to determine if an antibiotic is needed or that residents are on the correct antibiotic for their infections. RN C indicated to Surveyor that RN C is unsure what Surveyor is talking about. RN C indicated she does not have a process in place for monitoring correct antibiotic use for residents.

Surveyor asked RN C what criteria RN C utilizes such as the McGeer's or Loeb's criteria. RN C indicated RN C was not using either the McGeer's or Loeb's criteria at all.

Surveyor referred RN C to the CDC guidelines for monitoring antibiotic use and utilizing McGeer's or Loeb's. RN C indicated that she would start utilizing the McGeer's or Loeb's criteria.

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and staff after education, and properly document each resident and staff member's vaccination

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on

ensure offering of current Coronavirus 19 (COVID) vaccination for 1 of 5 residents (R) reviewed. (R1) This is evidenced by: The facility policy titled Influenza and Pneumococcal Vaccinations, dated March 2022, does not refer to COVID vaccinations.

This was the only policy provided when requested.

Two requests for a related policy were made.

The CDC COVID 19 Staying Up to Date with Covid 19 Vaccines states in part: Everyone ages 6 months and older should get a 2024-2025 COVID 19 vaccine. It is especially important to get your 2024-2025 COVID 19 vaccine if you are ages 65 and older, are at high risk for severe Covid-19, or have never received a COVID 19 vaccine.

R1 was admitted to the facility on [DATE] and was admitted with the diagnoses that include: Alzheimer's disease, edema, urinary tract infection, polyneuropathy, chronic kidney disease stage 3b, dementia, depression, anxiety disorder, tremor, bipolar disorder, and insomnia.

Surveyor reviewed R1's electronic medical record and noted it did not contain documentation of R1 being screened and offered COVID 19 Immunization for 2024-2025 vaccination year.

Surveyor requested documentation of immunization documentation in print. No documentation was available.

On 04/10/2025 at 8:05 AM, Surveyor interviewed Infection Preventionist (IP) C regarding immunizations. IP C stated that staff and residents are offered immunizations every year. If there is a Power of Attorney (POA) for the resident, then IP C sends them a letter with the education and consent form and follows up with the POA for questions and consent. IP C stated if the resident is their own person, then IP C educates and gets the consent from them. IP C will get Surveyor copies of all Influenza, Pneumonia, and COVID consents and declinations for 2024/2025 vaccinations and the policy.

On 4/10/2025 at 8:56 AM, IP C provided Surveyor with written copies of consent and declination forms. IP C stated this is what IP C could find.

There was no COVID consent or declination form for R1.

Surveyor asked IP C about COVID paperwork. IP C stated IP C did not think R1 needed to be approached again because she had declined in 2023.

On 4/10/2025 at 11:46 AM, IP C stated to Surveyor that she checked with pharmacy for consents and declinations and that was all we have.

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During the entrance conference, it was noted the facility has a room with less than the required square footage and is occupied by R58. room [ROOM NUMBER] measures 96 1/2 square feet.

On 04/08/25 at 2:34 PM, Surveyor interviewed Nursing Home Administrator (NHA) A regarding the size of room [ROOM NUMBER]. NHA A stated it's less than 100 square feet. NHA A stated we have not made any changes or done any remodeling. It is really only 4 sq. feet too small and not cost effective to remodel the room to expand. We have limited private rooms.

NHA A stated administration reviews the decision to continue to use the room annually. NHA A reported the patients that have been placed in that room like the room. NHA A stated that we explain to the residents and Power of Attorney (POA) the room size difference and they agree to the room before being placed in that room. NHA A stated we always put a smaller ambulatory person in the room.

They have their own bathroom and privacy.

On 04/08/25 at 2:52 PM, Surveyor called R58's POA and left a message on the phone to return the call to Surveyor. A return call was not received.

On 04/09/25, at 07:06 AM, Surveyor interviewed R58. R58 was up in her room watching TV. R58 can't remember how long she has been in this room.

Surveyor noted that she was admitted on [DATE]. R58 likes her small room, stating it is comfy. R58 stated the size fits me well. My friends help me set it up. R58 likes the big window with a ledge to put her things on and stated she can see the sun.

During this initial tour, Surveyor interviewed DM D, who reported the expectation would be that opened and/or prepared foods would be dated with an opened or prepared on date or a use by date. DM D did remove potentially hazardous foods and dispose of them.

On 4/08/25 at 11:17 AM, Surveyor observed Head [NAME] G take temperature of foods to be served.

During checking temperature of the foods, Head [NAME] G would stick probe into isopropyl alcohol probe wipe packet, rub probe end and immediately stick in next food item without waiting to let air dry as directed.

This was done with 5 of the 9 foods that were checked during observation.

On 4/08/25 at 11:44 AM, Surveyor interviewed Head [NAME] G, who reported she was trained on checking temperatures of foods a long time ago.

Head [NAME] G reported she was unsure of when that would have been.

Head [NAME] G reported she was not aware of the amount of time to allow cleaner to dry or that probe needs to dry and acknowledged she does not allow probe cleaning wipe to dry before checking temperature between foods.

On 4/09/25, Surveyor informed Nursing Home Administrator A of the deficiencies in food preparation and storage that were observed.

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Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 525507 B.

Wing 04/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Golden Age Manor 220 Scholl CT Amery, WI 54001