Amethyst Health of Brown Deer

Inspectors wroteBased on interview and record review, the facility did not ensure 4 (R9, R90, R81, and R28) out of 9 sampled residents were provided and administered medications based upon physician orders and standards of practice for ensuring accurate administration of ordered medications. *R9 did not receive Olanzapine 2.5 mg (milligrams) and Atorvastatin Calcium 40 mg at bedtime and Memantine 5 mg at 2000 (10:00 PM) on 4/7/26 and 4/28/26. R9's medication administration record (MAR) did not accurately detail why R9's medications were not administered on 4/5-4/6/26 when R9 was hospitalized . *R90 had multiple administrations of medications not documented as given during March and May of 2026. *R81 had multiple administrations of medications not documented as given during April and May of 2026. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure a medication was administered with adequate monitoring for 1 (R91) of 1 sampled residents with parameters to hold medication based upon assessed blood pressures at time of medication administration.* The facility did not assure R91's blood pressures were assessed and documented prior to administering Midodrine HCL to R91 as ordered by the physician.

Inspectors wroteBased on interview and record review, the facility did not ensure 3 (R81,R90, and R73) of 3 sampled residents were free from significant medication errors. * R81 had a missing dose of Apixaban (Eliquis) 5 mg on 5/7/26 at 8:00 PM. * R90 had 2 missing doses of Apixaban (Eliquis) 5 mg on 5/7/26 at 8:00 PM and on 3/9/26 at 8:00 AM. *R73 admitted to the facility on [DATE] with an order for Truvada Oral Tablet 200-300mg. Give 1 tablet via G-Tube one time a day . Multiple doses were marked as not administered between 2/25/26 and 3/9/2026 due to waiting for pharmacy. Findings Include: The facility's policy titled Administering Oral Medications dated 8/1/2025 and last revised on 3/1/2026 documented: . Verify that there is a physician's medication order for this procedure. Review the resident's care plan to assess for any special needs of the resident. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not implement effective infection prevention measures to provide a safe, sanitary and comfortable environment and to prevent the development and transmission of communicable diseases and infections for 1 (R53) of 2 residents observed. *Certified Nursing Assistant (CNA)-F did not wear proper personal protective equipment (PPE) while performing peri care on R53 who was in Enhance Barrier Precautions (EBP). The facility's policy and procedure titled, Enhanced Barrier Precautions, implemented 3/25/2024, documents in part: Policy:It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms.3. Implementation of Enhanced Barrier Precautions.b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities.4. [...]

Inspectors wroteUncorrected on revisit Based on observation, record review and staff interviews, the facility did not ensure they provided necessary treatment and services in accordance with standards of practice to 3 out of 4 ( R73, R85, R6) sampled residents reviewed for pressure injuries. * R73 was assessed to be at high risk for developing a pressure injury. A weekly skin check was not completed on 3/21/26. On 3/26/26 it was determined R73 developed a facility acquired stage 2 pressure injury to the back of the left thigh. Although the facility obtained a treatment order for the wound, there was no evidence that the treatment was performed daily, per order, from 3/26/26- 3/30/26. When the facility re-assessed R73's pressure injury to the back of the left thigh on 3/30/26, the wound was now unstageable and noted to have 100% necrotic tissue. [...]

Inspectors wroteUncorrected on revisitBased on interview and record review, the facility did not ensure 1 (R88) of 9 sampled residents received treatment and care in accordance with physician/nurse practitioner orders.*R88's NP requested R88 have daily weight monitoring beginning 3/24/26, and the facility did not implement daily weight monitoring until 4/3/26.

Inspectors wroteUncorrected on revisitBased on interview and record review, the facility did not ensure 1 (R10) of 2 sampled residents with orders to reweigh related to fluxuations in weights.*R10's nurse practitioner (NP) requested R10 be reweighed on 4/9/26, and the facility did not follow up on this request.

Inspectors wroteBased on interview and record review, the facility did not ensure residents requiring respiratory care was provided with oxygen for 1 (R85) of 4 residents reviewed on oxygen. R85 had orders on admission for oxygen therapy 2 liters/minute at night. This order was not transcribed. R85 received oxygen without an active order for oxygen. The oxygen order that was obtained three days after admission did not specify the amount of oxygen to administer and R85 was not being monitored on an ongoing basis to determine the needs of oxygen.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that residents at risk for pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 1 of 2 residents (R3) reviewed for pressure injuries. R3 is at risk for developing pressure injuries. On 1/17/26, facility staff found a left breast abscess that was not comprehensively assessed when identified. On 1/22/26, facility staff documented a new skin issue on R3's upper right gluteus. A treatment order was not placed for this new skin issue until 2/25/26. On 2/2/26, Wound MD-Q assessed R3's wounds for the first time. In an interview, Wound MD-Q stated that after this initial assessment, R3's left breast wound etiology was changed from abscess to pressure. [...]

Inspectors wroteBased on observation and interviews, the facility did not ensure the garbage and refuse were properly disposed in the outside garbage storage receptacles. This deficient practice has the potential to affect all 63 residing at the facility.

Inspectors wroteBased on record review and staff interview, the facility's Quality Assessment and Assurance Committee did not meet at least quarterly to identify and evaluate quality issues through assessment and assurance activities. The deficient practice had the potential to affect all 63 residents in the facility. The Quality Assessment and Assurance (QAA) Committee did not meet on a quarterly basis to determine quality deficiencies within the facility and develop and implement plans of action to correct any deficiencies. The QAA Committee meeting was held on 9/30/25 and 2/13/26 and did not meet for Quarter 4 of 2025.

Inspectors wroteBased on observation, interview and record review, the facility did not establish and maintain an infection prevention and control program based upon current standards of practice, designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections. This deficient practice has the potential to affect all 63 residents. * Staff were observed not wearing appropriate personal protective equipment (PPE) while providing gastrostomy tube (g-tube) cares for R25 and R26. Staff were also observed not performing appropriate hand hygiene during medication pass with R25 and R26. * The facility's Water Management Plan (WMP) was not based on current standards of practice and did not: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure a designated Infection Preventionist works at least part time at the facility for the responsibility of the facility's Infection Prevention Control Program. Director of Nursing (DON)-B was designated as the facility's Infection Preventionist (IP) in addition to performing DON responsibilities and working on the Ventilator Unit as a floor nurse, which resulted in the inability to implement an effective Infection Prevention Control Program.

Inspectors wroteBased on interview and record review, the facility did not ensure that 7 (R6, R3, R55, R7, R36, R8, and R78) of 7 residents reviewed for transfers or discharges received the proper written notice of transfer, written bed hold policy with reserve bed payment identified and that proper notification was sent to the State Long-Term Care Ombudsman. *R6 was transferred to the hospital 10/25/25, 11/9/25, and 1/5/26. The facility was unable to locate a written notice of transfer or bed hold notice from 10/25/25 or 11/9/25 transfers to the hospital. The bed hold notice dated 1/5/26 did not list the bed payment rate. The facility did not notify the State Ombudsman of R6's hospitalizations. *R3 was transferred to the hospital on [DATE]. The bed hold notice dated 12/16/25 did not list the bed hold payment rate. The facility did not notify the State Ombudsman of R3's hospitalization. [...]

Inspectors wroteBased on record review and interview, the facility did not complete and transmit entry tracking, Medicare 5 day, quarterly, or discharge assessments as required for 6 (R25, R28, R40, R44, R64, and R73) of 8 residents reviewed for Minimum Data Set (MDS) assessments and transmission.1.). R25's entry MDS dated [DATE] and quarterly MDS dated [DATE] were not transmitted.2.). R28's quarterly MDS dated [DATE] was not transmitted timely.3.). R40's quarterly MDS dated [DATE] was not transmitted timely. 4.). R44's modification to quarterly MDS dated [DATE] was not transmitted. 5.). R64's entry MDS dated [DATE] was not transmitted timely. 6.). R73's discharge MDS dated [DATE] was not transmitted timely.

Inspectors wroteBased in observation, interview, and record review, the facility did not ensure each resident received adequate supervision and assistance to prevent accidents for 3 (R56 R36, and R73) of 5 residents reviewed for falls and 1 (R39) of 1 resident reviewed for smoking. *R56 was observed walking without a 2 wheeled walker in the hallway. R56's care plan was not revised to indicate accurate transfer status for R56. *R36 had falls on 12/4/2025 and 1/27/2026 that were not thoroughly investigated. *R39 did not have a quarterly smoking assessments completed and R39's smoking care plan was not revised to indicate if R39 was to be supervised or unsupervised when smoking or if R39 was safe to hold onto own smoking materials. *R73 had a fall out of bed on 2/15/2026 that was not thoroughly investigated.

Inspectors wroteBased on observation and interview, the facility did not ensure the storage of drugs and biologicals were stored in locked compartments and permit only authorized personnel to have access to the keys. 1 of 5 medication carts were observed to be unlocked and unattended in access to a public area of the facility. The deficient practice had the potential to affect 10 (vent unit) residents whose medications are stored in the medication cart.

Inspectors wroteBased on observation and interview, the facility did not ensure that food was stored, prepared and served under sanitary conditions in 3 of 3 unit refrigerators. On 2/24/26, at 12:35 PM, a refrigerator was observed to have multiple food and drink items opened and not dated. This deficient practice has the potential to affect 10 residents on the Vent Unit of the facility. On 2/26/26, at 8:39 AM, a refrigerator was observed to have multiple food and drink items opened and not dated. This deficient practice has the potential to affect 14 residents on the Rehabilitation (Rehab) Unit of the facility. The Rehab Unit refrigerator temperature log was noted to have the following missing dates 2/16/26, 2/18/26, 2/21/26, and 2/24/26. On 2/25/26, at 8:44 AM, a refrigerator was observed to have multiple food and drink items opened and not dated. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure 1 (R6) of 1 resident was assessed to self-administer medications. On 2/24/26, Surveyor observed Licensed Practical Nurse (LPN)-R set R6's medications down on R6's bedside table and exit the room. R6 did not have a self-administration assessment completed to identify if R6 was able to safely self-administer medications.

Inspectors wroteBased on interview and record review, the Facility did not ensure the medical record reflected the resident's accurate advanced directive wishes for 1 (R55) of 16 residents reviewed.*R55's Do Not Resuscitate form was signed on [DATE] and scanned into R55's medical record. On [DATE], at the start of Survey, R55's active MD order and Electronic Medical Record (EMR) dashboard documented R55 to have elected a full code status.

Inspectors wroteBased on interview and record review, the facility did not ensure residents whose Medicare part A benefits ended, was provided with written beneficiary protection notifications for 1 (R83) of 3 residents sampled for beneficiary notifications. The facility did not provide R83 with a written Advanced Beneficiary Notice (ABN), which includes financial liability information and appeal rights, at the time Medicare Part A coverage ended.

Inspectors wroteBased on interview and record review, the facility did not ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record and residents who use psychotropic drugs receive behavioral interventions in an effort to discontinue these drugs for 1 of 1 (R9) residents reviewed for psychotropic medications. R9 was hospitalized and re-admitted to the facility with an order for Zyprexa. The facility did not follow up as to why the medication was prescribed and there were no indications for use. R9 admitted to the facility on [DATE] and has diagnoses that include unspecified dementia, unspecified severity with psychotic disturbance, and depression. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure all alleged violations were reported immediately to the State Agency, but not later than 2 hours after the allegation is made if the events that caused the allegation involved abuse, for 1 of 2 Facility Reported Incidents (FRI) reviewed involving R6. On 2/9/26 at 11:00 PM, the Nursing Home Administrator (NHA)-A was made aware of an alleged instance of physical abuse involving R6 and Certified Nursing Assistant (CNA)-BB. NHA-A did not report the alleged incident to the State Agency until 2/10/26 at 6:16 AM.

Inspectors wroteBased on interview and record review, the facility did not ensure an alleged violation of abuse was thoroughly investigated for 1 of 2 Facility Reported Incidents (FRI) reviewed involving R6. On 2/9/26 at 11:00 PM, the Nursing Home Administrator (NHA)-A was made aware of an alleged instance of physical abuse involving R6 and CNA-BB. The investigation of the allegation of abuse did not include interviews with witnesses and staff the allegations were originally reported to.

Inspectors wroteBased on interview and record review, the facility did not ensure Minimum Data Set (MDS) assessments were coded correctly for 2 (R3 and R5) of 16 residents reviewed for MDS accuracy. *R3's MDS for December 2025 was not coded accurately for receiving dialysis. *R5's quarterly MDS for December 2025 was not coded accurately for receiving an antiplatelet medication.

Inspectors wroteBased on interview and record review the facility did not provide the necessary Activities of Daily Living (ADL) services for 1 (R55) of 16 residents who were dependent on staff to provide ADL care. R55 is dependent on staff for bathing and toileting. R55 did not receive showers as care planned. R55 was not checked and changed every 2 hours as care planned.

Inspectors wroteBased on observation, record review and interview, the facility did not ensure that 1 of 17 residents (R3) reviewed received treatment and care in accordance with professional standards of practice.*On 1/17/26, facility staff found a right buttock abrasion that was not comprehensively assessed when found. On 1/22/26, facility staff documented a new skin issue on R3's upper right gluteus. A treatment order was not placed for this new skin issue until 2/25/26. On 2/2/26, Wound MD-Q assessed R3's wounds for the first time. Wound MD-Q could not assess R3's wounds weekly because R3 is out at an off-site dialysis center when wound rounds take place. Facility staff did not complete comprehensive weekly assessments when wound appointments were missed.

Inspectors wroteBased on record review and staff interview, the facility did not ensure that 1 (R7) of 2 residents reviewed for bladder incontinence received the appropriate care and services to help restore continence, prevent urinary tract infections, and receives appropriate treatment and services to restore continence to the extent possible. R7's urinary incontinence was not assessed and care plan interventions for care and treatment of R7's incontinence needs were not accurately documented. This is evidenced by:The facility's catheter care, urinary policy and procedure with a review date of 11/2025 documents:Catheter Evaluation1. Review and document the clinical indications for catheter use prior to inserting. 2. Nursing and the interdisciplinary team should assess and document the ongoing need for a catheter that is in place. [...]

Inspectors wroteNumber of residents sampled: 2Number of residents cited: 2Kristine Based on Concerns with weight loss and no interventions, inconsistent weightsBased on observation, interview, and record review the Facility did not ensure 2 (R33 and R9) of 2 residents received the necessary services for weight loss and acceptable nutrition. * R33 had a 5.14% weight loss in one month that was not desired. A comprehensive assessment was not completed regarding the weight loss. The physician and dietitian were not notified regarding R33's weight loss. R33's care plan was not updated, and interventions were not implemented. * R9's weights were inconsistent with documented weights indicating significant weight loss and/or gain. There is no evidence that the facility or Dietitian questioned the accuracy of the weights entered. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 2 (R5 and R6) of 2 residents reviewed for post-traumatic stress disorder (PTSD) received trauma informed care in accordance with professional stands of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization. R5 and R6 were admitted to the facility with a diagnosis of PTSD. The facility did not complete a trauma assessment or develop a person-centered care plan identifying triggers, interventions, or monitoring for PTSD for R5 or R6.

Inspectors wroteBased on interview and record review, the facility did not ensure the facility implemented monitoring or support of 1 (R6) of 2 sampled residents psychosocial well-being and ongoing safety after an allegation of abuse violation of abuse was made. On 2/24/26 R6 alleged Certified Nursing Assistant (CNA) BB was abusive to R6 during cares. R6 alleged the abuse was physical and verbal in its nature. R6 has a history of post traumatic stress disorder.

Inspectors wroteBased on interview and record review, the facility did not ensure the physician acted upon recommendations by the pharmacist for 1 (R33) of 5 residents reviewed with pharmacy recommendations. R33 had no documented physician response to pharmacist recommendations after medication regimen review on 1/26/26.

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R72 and R57) of 5 residents were offered/administered the influenza vaccine. R72 was admitted to the facility on [DATE]. There is no documentation indicating R72 was offered or administered the influenza vaccine.

Inspectors wroteBased on observation and interview, the facility did not provide a working call light system for 1(R3) of 16 sampled residents.*R3 informed Surveyor that R3's call light above R3's room door does not light up when R3 pushes the call light for help. R3 stated that the light has been like this since last week.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that residents with pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 1 of 2 residents (R3) reviewed for pressure injuries. R3 was high risk for pressure injuries. R3 developed an unstageable sacral pressure injury (PI) which deteriorated to a stage 4 PI with eventual visible bone. The facility failed to correctly implement and/or enter treatment orders from the hospital and the wound MD and could not provide evidence an ordered CT scan was scheduled or completed. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 1 of 1 resident (R3) received the necessary comprehensive assessment or care and treatment for indwelling catheter use. R3 was admitted to the facility on [DATE] with urinary incontinence and at some point, after the admission, the facility was unable to determine when, R3 received an indwelling catheter. There was no physician order for the indwelling catheter, no comprehensive assessment of the catheter and no comprehensive care plan directing the care and treatment of the catheter. On 5/31/25, R3 was discharged to the hospital for a change in condition and was diagnosed with septic shock secondary to UTI (urinary tract infection). The facility's failures contributed to R3 developing septic shock secondary to UTI due to an indwelling catheter. This created a finding of immediate jeopardy that began on 5/31/25. [...]

Inspectors wroteBased on interviews and record review, the Facility did not have a full-time DON (Director of Nursing) from 7/22/25 to 10/19/25 and 11/25/25 to date. The facility failed to meet staffing requirements, resulting in the DON having to work as the Clinical Manager/Floor Nurse filling regularly scheduled shifts. This deficient practice had the potential to affect all 65 residents in the facility.

Inspectors wroteBased on interview and record review, the facility did not develop and implement a comprehensive person-centered care plan for 9 (R1, R3, R5, R6, R7, R8, R9, R11, R12) of 13 residents reviewed to meet a resident's medical, nursing and psychosocial needs that are identified in the comprehensive assessment. *R1 has Atrial Fibrillation (A-Fib) and receives anticoagulant therapy. R1 has history of Intracranial Hemorrhage and hypertension and receives Amlodipine, Carvedilol, Lisinopril, and Hydrochlorothiazide for hypertension. R1 does not have a comprehensive care plan that addresses anticoagulant or blood pressure management. R1's goals for altered neurological status and impaired physical mobility do not reflect appropriate goals. *R3 was assessed to be at risk for pressure injury. [...]

Inspectors wroteBased on observation and interview, the facility did not ensure sufficient nursing staff to meet resident care needs for residents residing in the ventilator unit. This has the potential to affect 11 ventilator residents and 2 residents with tracheostomies. On 2/5/26 the facility's ventilator unit was staffed with Respiratory therapist (RT)-DD, Licensed Practical Nurse (LPN)-BB and Certified Nursing Assistant (CNA)-J. Facility staff assigned to the vent unit work 12-hour shifts. Times of the shifts are 6:00 a.m. to 6:00 p.m. and 6:00 p.m. to 6:00 a.m. On 2/5/26 Surveyor conducted continuous observations on the ventilator unit starting at 8:36 a.m. and until 1:40 p.m. During this observation Surveyor did not observe R5 being provided with incontinence cares & repositioning until 12:31 p.m. at which time R5 incontinence product was saturated with urine and R5 had a bowel movement. [...]

Inspectors wroteBased on interview and record review the facility did not ensure nursing staff working on the ventilator unit had the competency and skill set necessary to care for 13 (R3, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, & R16) of 13 residents who utilize ventilators and/or tracheostomies.

Inspectors wroteBased on observation, interview, and record review the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection for 7 (R13, R10, R3, R6, R5, R12, & R7) of 7 residents.* Staff did not wear appropriate PPE (personal protective equipment) when administering R13's medication via the feeding tube and providing personal cares on 2/5/26. R13 is on EBP (enhanced barrier precautions).*Staff did not wear appropriate PPE when suctioning R10 and during therapy on 2/5/26. R10 is on EBP.*Staff did not wear appropriate PPE when repositioning R3 on 2/5/26. R3 is on EBP and contact isolation.*There is no EBP sign posted outside R6's room and staff did not wear appropriate PPE when transferring R6 from the Broda chair into bed on 2/5/26. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure a baseline care plan was developed and implemented within 48 hours of a resident's admission for 1 (R1) of 1 resident. R1's baseline Activities of Daily Living (ADL) care plan was not completed within the required 48 hours timeframe. The facility did not provide evidence that the baseline care plan was reviewed with R1.

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R2) of 1 received the necessary care and treatment for a venous wound. On 1/10/25, the nurses note document R2 developed a wound to the left heel. There is no comprehensive assessment or treatment order for the left heel wound until 1/12/26. There was no baseline care plan related to skin integrity until 1/12/26.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure 1 (R5) of 3 residents who are fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding. During personal care observations on 2/5/25 R5's head of the bed was lowered flat while the tube feeding continued to be running.

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R1) of 2 residents reviewed for medications were provided pharmaceutical services to meet the needs of the resident. R1 was admitted to the facility on [DATE] and did not receive multiple scheduled medications in January 2026 and February 2026, did not receive as needed (PRN) Hydralazine as ordered for elevated blood pressure (BP), and did not receive multiple scheduled BP checks in January 2026 and February 2026.

Inspectors wroteBased on interview and record review, the facility did not ensure therapy services were provided in a timely manner for 2 (R1 and R2) of 2 residents reviewed for therapy services. *R1 was admitted to the facility on [DATE] for rehabilitation after hospitalization for intracranial hemorrhage requiring Physical Therapy (PT). R1 did not start PT until 1/12/26. *R2 was admitted on [DATE] for rehabilitation. R2 did not receive physical therapy services until 1/8/26. R2 was discharged to the hospital on 1/12/26 and received only 2 physical therapy sessions.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure the Staffing Data Daily postings were displayed or were accurate to the actual staffing of the facility. This has the potential to affect all 65 of 65 residents currently residing in the facility.*The Facility did not have the Staffing Data Daily posting on 2/4/26 and it was not posted prior to 8:44 AM on 2/9/26.* The Facility does not display the Staffing Data Daily postings on weekends.*The Facility does not maintain copies of the Staffing Data Daily postings.*The Facility does not have the required information documented on the Staffing Data Daily postings.

Inspectors wroteBased on observation, interview and record review the facility did not ensure residents with non-pressure wounds received treatment and care in accordance with professional standards of practice for 1 (R6) of 1 residents with a non-pressure wound; and based on interview and record review the facility did not thoroughly complete neurological checks in accordance with professional standards of practice for 1 (R4) of 2 residents reviewed for unwitnessed falls.*R6 has a diagnosis of diabetes and a care plan intervention to inspect feet daily for open areas, sores, pressure areas, blisters, edema or redness. Facility did not provide documentation that daily foot checks were being completed. R6 developed a right heel diabetic wound on 9/22/25. R6's wound MD ordered a treatment that was not put in place by facility staff. [...]

Inspectors wroteBased on interview and record review, the Facility did not ensure the necessary care and services to provide respiratory care for 1 (R6) of 2 Residents receiving oxygen care. *R6's tracheotomy tube was removed on 2/12/25. After removal, R6 was placed on oxygen (O2) via nasal cannula. R6 did not have a physician order for oxygen. R6's care plan was not updated to document the specifics related to R6 receiving O2 via nasal cannula.

Inspectors wroteBased on interview and record review, the facility failed to assess resident's hydration status and supply sufficient fluid intake to maintain proper hydration and health for 1 (R1) of 3 residents reviewed. The facility's repeated and systemic failure to assess and address R1's hydration status and implement pertinent interventions based on such an assessment resulted in R1 being admitted to the Intensive Care Unit (ICU) for Hypernatremia, Acute Kidney Injury, and a Urinary Tract Infection. This created a finding of immediate jeopardy that began on 2/7/2025. Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B were notified of the immediate jeopardy on 3/05/25 at 10:14 AM. The immediate jeopardy was removed on 3/5/25. This deficient practice continues at a scope and severity of a D (potential for harm/isolated).

Inspectors wroteBased on interview and record review, the facility did not develop, implement, and maintain an effective training program for all facility and contracted staff consistent with their expected roles and based on the facility assessment for 8 of 8 facility staff. * Dietary Aide (DA)-J, Housekeeper (HK)-K, Registered Nurse (RN)-I, Registered Dietitian (RD)-L and Certified Nursing Assistants (CNA) CNA-M, CNA-N, CNA-O, CNA-P and CNA-Q did not have documentation that they completed the required training. This practice had the potential to affect all 59 Residents in the facility.

Inspectors wroteBased on interview and record review, the facility did not ensure 6 of 6 direct staff chosen at random received effective communication training. * Registered Nurse (RN)-I, Registered Dietitian (RD)-L, and Certified Nursing Assistants (CNA) CNA-M, CNA-N, CNA-O, CNA-P and CNA-Q did not receive effective communication training. This practice had the potential to affect all 59 Residents in the facility. Findings Include: The facility's In-Service Training, All Staff revised August 2022 documents: Policy Statement All staff must participate in initial orientation and annual in-service training. Policy Interpretation and Implementation .1. All staff are required to participate in regular in-service education. 2. For the purposes of this policy, staff means all new and existing personnel, individuals providing services under contractual agreement, and volunteers. 3. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 8 of 8 facility staff chosen at random received either abuse prevention, activities that constitute abuse, procedures for reporting abuse and/or dementia management training. * Dietary Aide (DA)-J, Housekeeper (HK)-K, Registered Nurse (RN)-I, and Certified Nursing Assistants (CNA) CNA-M, CNA-N, CNA-O, CNA-P and CNA-Q did not receive behavioral health training. In addition, contracted employee, Registered Dietitian (RD)-L did not receive abuse prevention, activities that constitute abuse, procedures for reporting abuse and dementia management training. *DA-J has no documentation that DA-J received abuse prevention, activities that constitute abuse, procedures for reporting abuse and dementia management training. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 8 of 8 facility staff chosen at random received QAPI training. Dietary Aide (DA)-J, Housekeeper (HK)-K, Registered Nurse (RN)-I, and Certified Nursing Assistants (CNA) CNA-M, CNA-N, CNA-O, CNA-P and CNA-Q did not receive QAPI training. In addition, contracted employee, Registered Dietitian (RD)-L did not receive QAPI training. This practice had the potential to affect all 59 Residents in the facility. The facility did not provide staff with the required annual QAPI training which included the elements and goals of QAPI for 5 CNAs, CNA-M, CNA-N, CNA-O, CNA-P, CNA-Q, DA-J, HK-K, RN-I, and RD-L. Findings Include: The facility's In-Service Training, All Staff revised August 2022 documents: Policy Statement .All staff must participate in initial orientation and annual in-service training. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 8 of 8 facility staff chosen at random received infection control training. Dietary Aide (DA)-J, Housekeeper (HK)-K, Registered Nurse (RN)-I, and Certified Nursing Assistants (CNA) CNA-M, CNA-N, CNA-O, CNA-P and CNA-Q did not receive infection control training. In addition, contracted employee, Registered Dietitian (RD)-L did not receive infection control training. The facility did not provide staff with the required annual infection control training which included standards, policies, and procedures of the facility's infection control program for 5 CNAs, CNA-M, CNA-N, CNA-O, CNA-P, CNA-Q, DA-J, HK-K, RN-I, and RD-L. This practice had the potential to affect all 59 residents in the facility. Findings Include: The facility's In-Service Training, All Staff revised August 2022 documents: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 8 of 8 facility staff chosen at random received compliance and ethics training. Dietary Aide (DA)-J, Housekeeper (HK)-K, Registered Nurse (RN)-I, and Certified Nursing Assistants (CNA) CNA-M, CNA-N, CNA-O, CNA-P and CNA-Q did not receive compliance and ethics training. In addition, contracted employee, Registered Dietitian (RD)-L did not receive compliance and ethics training. The facility did not provide staff with the required compliance and ethics training which included standards, policies, and procedures of the facility's compliance and ethics for 5 CNAs, CNA-M, CNA-N, CNA-O, CNA-P, CNA-Q, DA-J, HK-K, RN-I, and RD-L. This practice had the potential to affect all 59 residents in the facility. Findings Include: The facility's In-Service Training, All Staff revised August 2022 documents: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that 5 of 5 CNAs (Certified Nursing Assistants)(CNA) reviewed completed the required annual 12 hours of educational training hours. CNA-M, CNA-N, CNA-O, CNA-P and CNA-Q did not receive annual 12 hours of educational training. This had the potential to affect all 59 residents who reside in the facility.

Inspectors wroteBased on interview and record review, the facility did not ensure 8 of 8 facility staff chosen at random received behavioral health training. Dietary Aide (DA)-J, Housekeeper (HK)-K, Registered Nurse (RN)-I, and Certified Nursing Assistants (CNA) CNA-M, CNA-N, CNA-O, CNA-P and CNA-Q did not receive behavioral health training. In addition, contracted employee, Registered Dietitian (RD)-L did not receive behavioral health training. The facility did not provide staff with the required behavioral health training for 5 CNAs, CNA-M, CNA-N, CNA-O, CNA-P, CNA-Q, DA-J, HK-K, RN-I, and RD-L This practice had the potential to affect all residents with a psychiatric diagnosis and/or that have the potential to experience behavioral health issues in the facility. Findings Include: The facility's In-Service Training, All Staff revised August 2022 documents: [...]

Inspectors wroteBased on observation, record review and interview, the facility did not ensure that 1 (R4) of 4 residents reviewed at risk for the development of pressure injuries receives care, consistent with professional standards of practice, to prevent pressure ulcers. * R4 was observed to have heels resting directly on the mattress and not wearing heel boots to offload pressure per R4's plan of care.

Inspectors wroteBased on observation, record review and interview, the facility did not ensure that 1(R4) of 1 residents with with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable. * R4 was observed not to have on splints on either hand to prevent further contractures and maintain mobility.

Inspectors wroteBased on observation, record review and interview, the facility did not ensure that 1(R4) of 1 residents reviewed received adequate supervision and assistance devices to prevent accidents. * R4's call light was not observed not to be in reach and R4's room door was observed closed despite R4's plan of care documenting that R4's room door had to remain open to ensure R4's safety and supervision.

Inspectors wroteBased on observation, record review and interview, the facility did not ensure that 1 (R4) of 1 residents reviewed that are fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. * R4 was observed to recieve enteral feeding with the head of the bed at less than 30 degrees.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure 2 (R11 and R34) of 3 residents reviewed for accidents received adequate supervision and assistance devices to prevent residents from sustaining continued falls. * On 8/23/24, R11 slipped out of his wheelchair while emptying his urinal and sustained a left hip fracture. R11 had falls on 6/30/24, 7/6/24, 7/16/24, 7/27/24, 8/13/24, 8/23/24, and 9/12/24. The facility did not complete a comprehensive assessment to determine a root cause for each fall, did not reassess interventions to determine if fall interventions were effective, did not complete accurate fall assessments after each fall. R11 experienced falls potentially related to episodes of orthostatic hypertension. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not implement an effective infection control program. This was observed in the facility laundry and preventative outbreak measures. This had the potential to effect the 61 residents currently in the facility. * The facility's soiled laundry area did not have handwashing/hand hygiene accessibility for staff after handling soiled linens. * The facility did not have a process to track staffs' N95 mask fit testing. There was not a system to identify what staff were fit tested to work with residents requiring staff to wear N95 mask PPE (Personal Protective Equipment).

Inspectors wrote2.) R38 was admitted to the facility on [DATE] with diagnosis that include Schizoaffective Disorder, Bipolar Disorder, Dependence on Respirator [Ventilator], Status. R38's Quarterly MDS (minimum data set) assessment dated [DATE] documents: Functional Limitation in Range of Motion: Impairment of both sides of the upper and lower extremity; contractures of the bilateral hands; uses a wheelchair with total assistance from staff for mobility; requires total assist with all cares from staff; Requires 2 assist and mechanical lift for transfers; hearing is adequate. R38 is unable to perform a BIMS (Brief interview for Mental Status) and has been documented by the facility as rarely understood and rarely understands. On 10/29/24, at 10:20 AM, Surveyor completed a record review and noted R38 was being followed by psychiatric services related to the use of Zyprexa. [...]

Inspectors wroteBased on interview and record review, the facility did not accurately complete the PASARR (Preadmission Screening and Resident Review) Level I for residents with a possible serious mental disorder on admission to the referring agency to complete the PASARR Level II for 1 (R27) of 5 residents reviewed for PASARR completion. *R27 had a PASARR Level I completed on admission that did not indicate the use of an antipsychotic medication. A PASARR Level II was not triggered or completed.

Inspectors wroteBased on interview and record review, the facility did not develop and implement a comprehensive person-centered care plan for each resident for 1 (R46) of 17 sampled residents. *R46 did not have a Care Plan for the use of quetiapine, an antipsychotic medication, when it was initiated.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure 1 (R 14) of 2 Residents reviewed for pain management, received pain management consistent with professional standards of practice. *R14 had multiple observations of expressive pain with no effective pain relief, PRN medications available for 4 days until brought forward by Surveyor.

Inspectors wroteBased on record review and interview, the facility did not act upon the pharmacy medication regimen review reports when received. This was observed with 1 (R34) of 5 resident medication reviews. * R34's monthly pharmacy reviews noted an irregularity reported on 6/19/24, 7/29/24 and 10/29/24 (same concerns from previous month's readmission review 9/23/24). There was not documentation the identified irregularities were acted upon by the attending physician.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents who receive psychotropic medications received behavioral interventions and medication side effect monitoring for 2 (R46 and R27) of 5 residents reviewed for unnecessary medications. *R46 did not have documentation of monitoring for side effects of the antidepressant, antianxiety, and antipsychotic medications. R46 did not have a diagnosis for the use of quetiapine on the medication consent form, and an Abnormal Involuntary Movement Scale (AIMS) test was not completed every six months. Behavior monitoring was not documented with individualized behaviors R46 exhibits. *R27 did not have monitoring of side effects for the use of antidepressant and antipsychotic medications.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure the medication error rate was not 5 percent or greater. 2 (R14 and R31) of 4 residents observed during medication pass were affected. The medication error rate was 5.26 percent, 2 errors out of 38 opportunities.

Inspectors wroteBased on observation, interview and record review the facility did not maintain accurate nurse data information. This has the potential to affect all 61 residents currently residing in the facility. * The facility Nurse Staff Posting form does not document actual staff hours, and updates with each shift, and maintained for 18 months.

Inspectors wroteBased upon interview and record review, the facility's governing body failed to fulfill the responsibilities of the governing body to include establishing an implementing policies and procedures regarding the operations of the facility. This has the potential to affect all 56 residents present in the facility at the time of the survey. The facility's governing body did not ensure contracted vendors were reimbursed and paid in accordance with established contracts or billed amounts causing the facility's fiscal accounts to be in arrears. This has created the likelihood where good and services necessary to maintain operations of the facility along with care and treatment of the residents may be impacted by the failures of the governing body.

Inspectors wroteBased on observation, interview and record review the facility did not provide quality of care according to professional standards of practice for 2 (R27 and R19) of 12 residents reviewed for quality of care. *The facility did not implement interventions for R19's toe wounds. R19 did not have a care plan addressing the wounds, nor was the care plan revised when the wounds worsened. The wound to R19's third toe became infected and would not heal. R19 ultimately required an above the knee amputation related to the unhealing wound to the third toe. *R27 was receiving hospice care and did not have a hospice care plan nor a physician's order for hospice.

Inspectors wroteBased on interview and record review the facility did not maintain an infection prevention and control program according to professional standards of practice having the potential to affect all 37 residents residing in the facility at the time of the survey. *The facility did not have a comprehensive water management program including text and/or diagram detailing the facility's water system. The water management plan did not identify control measures the facility would take related to areas that could potentially house Legionella or other waterborne bacteria.

Inspectors wroteBased on record review and interview the Facility did not ensure 1 (R7) of 12 Resident's physician was consulted with regarding medication parameters for a resident. R7 receives Humalog on a sliding scale three times a day with instructions if R7's blood sugar is above 450 to receive 12 units of Humalog and call MD (medical doctor). On 9/2/23 R7's blood sugar was 455. R7 received Humalog 12 units but there is no evidence R7's physician was consulted with.

Inspectors wroteBased on interview and record review the Facility did not ensure 1 (R241) of 1 Residents discharged to the community received a completed discharge summary. R241 was discharged on 8/8/23. The discharge summary information which includes a recapitulation of R241's stay documents the summary is in progress and has not been completed.

Inspectors wroteBased on observation, interview, and record review the Facility did not ensure 1 (R17) of 12 Residents reviewed received required assistance with their ADL's (activities daily living). R17 did not receive incontinence cares according to his plan of care and was observed with two incontinence briefs on.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that the residents received care consistent with professional standards of practice to prevent pressure injuries and residents did not receive necessary treatment and services, consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 2 (R26 and R26) of 4 residents reviewed for pressure injuries. * R26 did not have a comprehensive assessment and measurements of wounds upon readmission from the hospital. *R27 was observed with heels not being offloaded and offloading heels intervention was not included in R27's care plan.

Inspectors wroteBased on observation, interview and record review the facility did not ensure that residents received proper foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s) and assisting the resident in making necessary appointments with qualified healthcare providers such as podiatrists for 1 of 1 (R12) residents reviewed for foot care.

Inspectors wroteBased on observation, interview, and record review the Facility did not provide 2 (R17, R12) of 5 Residents reviewed for falls and 1 (R17) of 2 Residents reviewed with thickened liquids the supervision and assistance to prevent accidents. * R17's falls on 3/15/23, 4/13/23, & 6/4/23 were not thoroughly investigated to help prevent further falls. On 9/11/23 R17 received nectar thick juice. R17's physician orders document honey thick consistency. * R12's fall was not thoroughly investigated and the root cause was not determined to help prevent further falls.

Inspectors wroteBased on observations, interview and record review the facility did not ensure 2 of 2 residents (R244 and R7) reviewed for Dialysis received Dialysis care in accordance with professional standards of practice. *R244 did not have physician's orders for dialysis and the staff were not assessing R244's fistula site on a regular basis. *R7 did not have a physician's order for dialysis and the staff were not assessing R7's dialysis access site on a regular basis.

Inspectors wroteBased on interview and record review, the Facility did not ensure each Resident's drug regimen was free from unnecessary drugs for 1 (R7) of 5 Residents reviewed. * R7's Midodrine HCl 10 mg three times a day was not consistently held for systolic blood pressure above 110.

Inspectors wroteBased on observation, interview, and record review the Facility did not ensure there was a medication error rate below 5 percent. There were 5 medication errors in 34 opportunities which resulted in a medication error rate of 14.71%. Medication errors were identified for R6, R8 & R12. * R6's Mucinex Allergy Tablet was not available to be administered & Artificial Tears Lubricant was not dated when opened. * R8's Colace 100 mg and Cyancobalamin (Vitamin B12) not available. * R12 was administered Guaifenesin liquid versus Guaifenesin oral tablet 100 mg as ordered.

Inspectors wroteBased on observation and interview the Facility did not ensure medications were disposed of when expired and dated when opened in 2 of 2 medication carts and 1 of 1 medication rooms affecting R37 & R21. * R37's Semglee insulin vial was not dated when opened & used. * R21's Lantus pen was not dated when open & used and a dose of Hydralazine HCI 25 mg was expired on [DATE]. * Stock Bisacodyl 5 mg was expired 7/23 in the [NAME] medication cart. * Two white pills were not in a container and were laying in a drawer to the left of the white refrigerator in the north/west medication room.

Inspectors wroteBased on interview, and record review the Facility did not promptly refer a Resident to a oral surgeon for 1 (R7) of 1 Residents reviewed for dental services. The [Name of Dental Company] dentist, who examines Residents in the Facility, on 6/9/23 documents Facility staff needs to set up oral surgery appointment. This appointment was not set up until 9/11/23.