Amethyst Health of Wausau

Inspectors wroteBased on record review and interview, the facility did not ensure residents were free of misappropriation and/or exploitation. The facility's failures of not thoroughly investigating and not reporting to the State Agency (SA) or local authorities when suspected misappropriation was first discovered on 10/08/25 left the residents at continued risk of misappropriation, exploitation, and mishandling of resident funds. Five residents (R) R1, R2 R3, R4, and R8 were affected. All residents who made payments at the facility were at risk. R1's funds were misappropriated when a check in the amount of $2,040, which was meant for R1's care/room charges, was deposited into a bank account only Business Office Manager (BOM)-D was aware of and had access to withdraw funds from. R2's family member (FM)-J had contacted the facility about where R2's money was going. [...]

Inspectors wroteBased on record review and interview, the facility did not report suspected misappropriation and/or exploitation of resident funds to the State Agency (SA) or to local authorities immediately upon discovery. The facility's failure to report the allegations affected 5 residents (R) of 8 residents (R1, R2, R3, R4, and R8) reviewed and had the potential to affect other residents who had financial accounts or made payments at the facility. Nursing Home Administrator (NHA)-A identified concerns related to misappropriation and/or exploitation on 10/8/25 after reviewing a bank statement of an account under the facility name that NHA-A was not aware existed. The statement showed a cash withdrawal and a money order. The bank informed NHA-A that Business Office Manager (BOM)-D had a checkbook and debit card for this account. NHA-A believed BOM-D opened this account. [...]

Inspectors wroteBased on record review and interview, the facility did not thoroughly investigate suspected misappropriation and/or exploitation of resident funds. The facility's failure to investigate the alleged misappropriation/exploitation affected 5 residents (R) of 8 residents (R1, R2, R3, R4, and R8) reviewed and had the potential to affect other residents who had financial accounts or made payments at the facility. Nursing Home Administrator (NHA)-A identified concerns related to misappropriation and/or exploitation on 10/8/25 after reviewing a bank statement of an account under the facility name that NHA-A was not aware existed. The statement showed a cash withdrawal and a money order. The bank informed NHA-A that Business Office Manager (BOM)-D had a checkbook and debit card for this account. [...]

Inspectors wroteBased on record review and interviews, the facility administration did not ensure resources or practice to effectively and securely manage resident finances were in place to ensure the integrity of resident accounts and to maintain the highest practicable psychosocial well-being of each resident. This had the potential to affect any resident utilizing the facility's billing office(s) or third-party billing company. Administration did not have an effective tracking system of payments coming into the facility by residents and/or representatives. Administration did not hold the Business Office Manager, (BOM)-D, and/or third-party billing company accountable to safe, secure, and accurate handling of resident finances. Administration did not have practices in place to ensure insurances payments (i.e. [...]

Inspectors wroteBased on record review and interview, the facility did not implement policy and procedures related to screening employees for a prior history of abuse, neglect, exploitation of residents, or misappropriation of resident property for 1 of 13 employees reviewed. The facility did not ensure their abuse policy was implemented when one employee's Background Information Disclosure (BID), Department of Justice Response (DOJ), and Government Findings report was not obtained before employee started working at facility, Registered Nurse (RN) H.This is evidenced by:Facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, with a revised date of 04/2021, states in part: The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 4. [...]

Inspectors wroteBased on interview and record review, the facility did not provide care and treatment consistent with professional standards of practice, for 1 of 3 sampled residents (R2). The facility did not complete comprehensive assessments after R2 was re-admitted to the facility, following a hospitalization, and removal of an indwelling catheter. According to the Wisconsin Nurse Practice Act, N6.03(1), A RN (Registered Nurse) shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness, or care of the ill. The nursing process consists of the steps of assessment, planning, intervention, and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a). Assessment. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure required infection control training was completed for 2 out of 2 staff in Housekeeping (HSK). (HSK E and HSK D). This has the potential to affect all 33 residents. Housekeeping staff HSK E and HSK D were not provided the required infection control training since being hired.

Inspectors wroteBased on interview and record review, the facility did not designate a person to serve as the director of food and nutrition services who had completed the minimum qualification requirements for the position. This practice has potential to affect all 32 residents residing in the facility. Dietary Manager (DM) C has been in the position since February 2025 and has not enrolled in a nationally recognized/state approved course. The facility does not have a full-time Registered Dietician (RD) at the facility and has not applied for or received a waiver. On 09/03/25 at 1:21 PM, Surveyor interviewed Dietary Manager (DM) C who reported becoming Dietary Manager in February 2025. When DM C was asked about qualifications, DM C stated she was not a certified dietary manager, certified food service manager, nor had a related associate degree. [...]

Inspectors wroteBased on observation and interview, the facility did not ensure proper sanitation practices to prevent the outbreak of foodborne illness, which had the potential to affect all 32 residents.-The facility did not label 2 opened cartons of soy milk.-The facility did not ensure thermometer probes remained sanitary prior to inserting into food. The facility policy titled, Food Storage - Refrigeration, dated 04/01/16, reads in part: Foods shall be stored in an organized manner and shall be maintained in their original containers unless they are considered a leftover. All leftovers shall be labelled (sp) and dated with expiration dates. The facility policy titled, Food Preparation and Serviced, dated November 2022, reads in part: [...]

Inspectors wroteBased on observation and interview, the facility did not implement infection prevention and control interventions to provide a safe and sanitary environment to help prevent the development and transmission of infections. This had the potential to affect all 32 residents (R). Staff did not change gloves and wash hands after picking up a soiled item off the floor in the kitchen. Facility staff did not use personal protective equipment (PPE) when administering subcutaneous medication to a resident (R36). Facility staff did not conduct hand hygiene after removal of soiled gloves during cares for R29. Example 1 The facility policy dated 04/01/16, titled, Sanitation - Handwashing, states in part, Employees shall wash their hands: . (5) after handling soiled equipment; (6) as much as possible during food preparation to remove soil and contamination and to prevent cross contamination; [...]

Inspectors wroteBased on record review and interview, the facility did not complete a Significant Change in Status Assessment (SCSA) for 1 resident (R1) of 12 sampled residents reviewed. R1 was admitted to hospice care on 04/10/25. A SCSA was not completed for R1. This is evidenced by: According to the Resident Assessment Instrument (RAI) manual, a significant change in status is required when a resident enrolls in a hospice program. R1 was admitted to the facility on [DATE] and has diagnoses that include Chronic Obstructive Pulmonary Disease (COPD), acute and chronic respiratory failure with hypoxia, quadriplegia, deaf and nonspeaking, unspecified psychosis. R1 has a BIMS score of 13/15, indicating R1 is cognitively intact. R1 is deaf and able to read lips and written communication. R1 verbally expresses self but difficult to understand speech. R1 makes own health care decisions. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure discharge Minimum Data Set (MDS) assessment was transmitted in the timeframe prescribed in the Long-Term Care Facility Resident Assessment instrument (RAI)_3.0 User's Manual for 1 of 12 residents (R) R22, reviewed for late Minimum Data Set (MDS) assessments. This is evidenced by:The Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual dated 10/2024 documents: Transmitting Data: Providers must transmit all sections of the MDS 3.0 required for their State-specific instrument. Assessment Transmission: Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date. All other MDS assessments must be submitted within 14 days of the MDS completion Date. R22 was admitted to the facility on [DATE] and was discharged on 04/25/25. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure resident (R) care conferences were offered or care plans were revised to provide the needed direction to staff in providing individualized care and services for 2 of 12 residents (R) (R33, R34) reviewed for care planning. The facility did not ensure resident (R33), or their representative had the right to participate in the care planning process. R34's care plan for ambulation was not completed or updated to reflect R34's current ambulation status. The facility's Performance Improvement Project, initiated on 7/28/25, states in part:6. Care Conferences will be conducted upon admission, quarterly, and PRN. Resident/Resident Representative and Interdisciplinary Team (IDT) will review, update, and sign the Comprehensive Care Plan. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received care and treatment in accordance with professional standards of practice for 2 of 12 residents (R) reviewed for quality of care (R29, R1). R29 did not receive adequate weekly assessment and monitoring of moisture associated dermatitis wounds. R1 was not repositioned according to R1's care plan and facility policy, which caused R1 pain, the potential for skin shearing, and the potential for shoulder injury by improper repositioning. This is evidenced by: Example 1 R29 was admitted to the facility on [DATE]. R29's current diagnoses include altered mental status, cognitive communication deficit, weakness, reduced mobility, and sepsis due to Escherichia coli. Hospital after visit summary, dated 08/25/25, documented wound care left buttock wounds: Cleanse wound(s) with saline. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents received care and treatment based on professional standards of practice related to assessment and monitoring of pressure injuries for 2 of 5 residents (R), R41 and R21, reviewed for pressure injuries. R41's hospital discharge summary noted a pressure injury to right heel that was being treated at outpatient wound care clinic twice weekly. R41's pressure injury was not comprehensively assessed by the facility until 9/3/25. R41's interventions to offload heels when in bed were not implemented and R41 missed wound care appointment on 9/2/25. R21's care plan show shows no updates on new pressure injury versus abscess on left ischium as noted on wound assessment. No staging of area is documented in R21's medical record. No new interventions are in place in care plan. This is evidenced by: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure residents (R) with indwelling Foley catheters received care and treatment consistent with professional standards of practice to prevent complications or urinary tract infections (UTI) from the catheter for 1 of 3 residents (R) reviewed, R29. R29 did not have physician orders for the Foley catheter and was not provided appropriate catheter care to prevent transmission of infections. This is evidenced by:Facility's policy titled Enhanced Barrier Precautions dated 03/25/24, read in part. Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs tarted gown and gloves use during high contact resident care activities.4. High-Contact resident care activities include:.g. Device care or use: [...]

Inspectors wroteBased on interview and record review, the facility did not follow professional standards of practice of care for a resident who received medication through a peripherally inserted central catheter (PICC) for 1 of 1 resident (R) R29, reviewed. This is evidenced by:Facility's policy titled Central Venous Catheter Care and Dressing Changes, revision date March 2022, read in part. 3. Change the dressing if it becomes damp, loosened or visibly soiled and: a. at least every 7 days for TSM (transparent semi-permeable membrane dressing) dressing.5. Assess central venous access devices with each infusion and at least daily: a. visually inspect the entire infusion system (solution, administration set and dressing).d. Palpate and inspect the skin, dressing and securement device for signs of complications .e. Ask the resident if he or she is experiencing pain, tingling or numbness. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure money in the resident's fund account were returned back to the resident and/or Resident Representative (RP) within 30 days after discharge or resident expiring for three of four Residents (R) reviewed for money due after discharge (R6, R7, R8).

Inspectors wroteBased on observation, interview, and record review the facility failed to assess the need for a Wander Guard alarm, failed to assess if the Wander Guard alarm was a restraint, and failed to obtain a physician's order and written consent prior to the use of a Wander Guard alarm for one of one sampled resident (Resident (R) 4) reviewed for restraints out of a total sample of 10. These failures placed R4 at risk of having a physical restraint without indication for use

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to review and revise the comprehensive person-centered care plan to include refusal of pressure ulcer treatments and management for one of three residents (Resident (R) 1) reviewed for pressure ulcers out of a total sample of 10. This failure had the potential for R1 to experience adverse effects from refusing care.

Inspectors wroteBased on record review, interviews, and document review, the facility failed to administer pain medications per physician orders for one of three residents (Resident (R)1) reviewed for pain medications out of a total sample of 10 residents. This failure had the potential for R1 to have negative outcomes from receiving too much or too little pain medication.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to have physician ordered medication available to be administered to two of three (Resident (R)1 and R2) residents reviewed for medication administration out of a total sample of 10 residents. This failure had the potential for R1 and R2 to experience unmet care needs.

Inspectors wroteBased on interview, observation, record review, and facility policy review, the facility failed to follow infection control practices during a dressing change for one of one resident (Resident (R)2) observed for a dressing change, and failed to follow infection control practices when a suprapubic catheter drainage bag was laying on the floor for one of two residents (Resident (R)3) reviewed for catheters out of a total sample of 10 residents. This failure had the potential for R2 and R3 to be exposed to infections.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure necessary care and services were provided to promote healing and/or prevent pressure injuries (PI) from worsening/developing for 1 of 3 residents (R1) reviewed for pressure injuries. The facility did not complete an admission skin assessment of R1's sacral wound.

Inspectors wroteBased on observation, interview and record review, the facility did not provide the needed supervision to prevent accidents for 1 of 3 residents (R) R5, reviewed for accidents. Facility staff did not provide supervision while R5 was eating breakfast. Speech Therapy instructions and care plan indicated R5 required supervision to eat. This is evidenced by: Example 1 R5's progress notes indicated he had a coughing/choking episode while eating in his room, on 07/03/24. R5's care plan was updated on 07/03/24, to include: Aspiration Precautions: Alternate liquid and solid swallows. Sit upright (90 degrees) when eating and drinking either in bed or wheelchair. Diet: regular, regular consistency with thin liquids, finger foods as able. Adaptive equipment: inner lipped 3 compartment plate, Kennedy cup with lid, standard spoon with foam handle. Eating: Close supervision and assist with food. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not accurately assess pain to ensure pain management for 1 of 1 resident reviewed for pain (R22). R22's pain assessments were not accurate and R22's care plan was not individualized. This is evidenced by: The facility's policy titled, Pain- Clinical Protocol (March 2018) reads in part, The nursing staff will assess each individual for pain upon admission to the facility, at quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. The staff and physician will evaluate how pain is affecting mood, activities of daily living, and the resident's quality of life, as well as how the pain may be contributing to complications such as gait disturbances, social isolation, and falls. [...]

Inspectors wroteBased on observation, record review and interview, the facility did not implement enhanced barrier precautions consistent with current infection control standards of practice for 1 resident (R) reviewed on enhanced barrier precautions (R7). This is evidenced by: Surveyor reviewed the facility policy title, Enhanced Barrier Precautions, dated 03/25/24. The policy in part states: Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of Multidrug-resistant Organisms (MDROs) that employs targeted gown and gloves use during high-contact resident care activities that include: [...]

Inspectors wroteBased on interview, and invoice review, the facility failed to have a governing body, or a designated person function as a governing body to legally establish and implement policies regarding management and operation of the facility; the facility is in financial arrears for services that can directly affect resident care such as pharmaceutical services and the electronic healthcare software. This has the potential to affect all 25 residents residing in the facility. This is evidenced by: Policy Number: CP 1.1.0 A, in part: Governing Body Duties and Responsibilities: A. Policies and Procedures: The Governing Body is legally responsible for establishing and implementing policies regarding the management and operation of the facility. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 1 resident (R) of 3 sampled residents' (R1) comprehensive care plans were reviewed and revised in accordance with the resident's current status. R1's care plan was not updated with current discharge information to return to community, not updated with goals, and not updated regarding intervention for evaluation of resident's motivation and ability to safely return to the community.

Inspectors wroteBased on interview and record review, the facility did not maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized in accordance with accepted professional standards and practices in 2 of 3 total residents (R) reviewed (R1, R2). R1's and R2's medical record contained no documentation related to discharge planning to an assisted living facility. Example 1 On 09/11/23, Surveyor reviewed R1's medical record. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not notify a resident's primary provider when there was a change of condition for 2 of 12 residents (R32 and R137) reviewed for notification of changes. - R32's primary provider was not notified for seven days after new onset edema (swelling caused by excess fluid trapped in the body's tissues). Actual harm occurred when R32 was transferred to the emergency room and diagnosed with a deep vein thrombosis (DVT). R32 was prescribed a medication to treat and prevent blood clots. Note: a DVT is a blood clot in a vein. If the blood clot or part of the blood clot loosens it can travel through the bloodstream and restrict oxygen to the lungs, causing lung damage or death. - The facility did not update the physician as ordered when R137 had greater than a three pound weight increase in a day and when R137 was not weighed daily. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure treatment and care were provided in accordance with professional standards of practice for 2 of 12 sampled residents (R32, R12). - The facility did not thoroughly assess R32's new onset edema (swelling caused by excess fluid trapped in the body's tissues). Actual harm occurred, when after seven days, R32 was sent to the emergency room for medical evaluation that confirmed that R32 was diagnosed with a deep vein thrombosis. Note: a DVT is a blood clot in a vein. If the blood clot or part of the blood clot loosens it can travel through the bloodstream and restrict oxygen to the lungs, causing lung damage or death. - The facility did not ensure R12 received wound treatment on 7 occasions per physician orders. This is evidenced by: [...]

Inspectors wroteBased on observation, staff interview and record review, the facility did not ensure food was stored and served under sanitary conditions. This practice had the potential to affect all 31 residents (R) residing in the facility. Food items in the refrigerator were past used by date: parmesan cheese, bacon, uncovered celery, hard boiled eggs, sour cream, chocolate milk and cottage cheese. Dietary Aide (DA) T touched ready to eat foods with contaminated gloved hands. This is evidenced by: The facility uses the Food and Drug Administration (FDA) Food Code as its standard of practice. Based on the Food and Drug Administration (FDA) Food Code, the day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. [...]

Inspectors wroteBased on observations, interviews and record review, the facility did not ensure the dishwashers were maintained and in safe operating condition. This has the potential to affect all 31 residents residing in the facility. The dishwasher was not operating properly. After the dishwasher's wash cycle, the water would not properly drain causing it to overflow on the floor of the dish room. This has the potential to spread on clean dishes in the dishwashing area.

Inspectors wroteBased on observation and interview, the facility did not ensure each resident is treated with dignity in a manner and in an environment that promotes enhancement of his or her quality of life. This occurred for 3 of 12 sampled residents (R2, R20, R28) and one supplemental resident (R7). - R2 requested staff assistance for over 40 minutes while he sat in urine-soaked pants. - R20 was assisted through the hallway to the shower with hip, thigh and buttock exposure. The indwelling Foley catheter drainage bag was placed on the side of the wheelchair arm rest and urine collecting in the bag was visible to all who looked. - R28 was noted to have the urinary catheter drainage bag with urine exposed to passersby in the hallway. - R7 had a runny nose in which staff used the clothing protector to wipe the dripping and the same clothing protector was used for meal service. This is evidenced by: [...]

Inspectors wroteBased on record review and interview, the facility did not ensure that 5 of 6 residents (R19, R13, R7, R20, and R10) reviewed for accidents, had adequate supervision and interventions in place to prevent accidents. - R19 was identified as a fall risk and sustained four documented falls at facility since 06/06/23. The facility did not identify a root cause for each documented fall, revise the care plan, or implement individualized resident-centered interventions to reduce risk of future falls. - R13 was identified as a fall risk and sustained 8 falls (07/01/23, 07/03/23, 07/08/23, 07/10/23, 07/20/23, 07/31/23, 08/01/23 and0 08/05/23) wherein 5 of the falls dated 07/08/23, 07/10/23, 07/20/23, 07/31/23, and 08/01/23 had no identifying causes of the falls or appropriate interventions taken to prevent another fall from occurring. [...]

Inspectors wroteBased on observation and interview, the facility did not establish and implement an ongoing infection prevention and control program to prevent and control the onset and spread of infection as evidenced by the cumulative failures of the following observations. - The facility did not ensure 11 residents (R) (R5, R7, R10, R11, R13, R15, R19, R20, R2, R3, R29) were given the opportunity to conduct hand hygiene prior to meal services; - Staff did not practice proper hand hygiene with meal service; - Staff held clean linens against their potentially contaminated uniform tops during transport; - Mechanical lifts were not disinfected after each use and prior to use for additional residents; and - Staff did not provide proper hand hygiene during resident cares. This is evidenced by: DQA (Division of Quality Assurance) memo number 11-025 outlines Resident Hand Hygiene. [...]

Inspectors wroteBased on record review and interview, the facility did not implement policy and procedures related to screening employees for a prior history of abuse, neglect, exploitation of residents, or misappropriation of resident property for 2 of 8 staff reviewed. Facility did not complete criminal background checks every four years for 2 of 8 employees reviewed.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure timely assistance for 2 of 8 residents observed for Activities of Daily Living (R2 and R20) who are dependent on staff to receive these cares. - R2 went without assistance with ADLs, specifically toileting/incontinence care. R2 requested staff assistance for over 40 minutes, while he sat in urine-soaked pants. - R20 did not receive oral care. This is evidenced by: R2 was admitted to the facility on [DATE]. R2's diagnoses include Parkinson's disease, history of stroke, above the knee amputation, and seizures. R2's Minimum Data Set (MDS), dated [DATE], confirmed R2 scored 12/15 during Brief Interview for Mental Status (BIMS), indicating moderately impaired cognition. R2 understands and is understood by others, and he is able to make his needs known. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility did not ensure 1 of 6 residents reviewed (R20) for pressure injuries (PI) received necessary treatment and services, consistent with professional standards of practice to prevent new injuries from developing. R20 has an extensive history of stage III pressure injuries on her sacrum and coccyx region with a large area of scar tissue that formed once the injury healed over and remains a very high risk of this area reopening. Two extended observations were conducted of R20 in which repositioning or offloading was not offered or attempted for an extended period of time. This is evidenced by: According to the National Pressure Injury Advisory Panel (NPIAP) 2019, page 115, . Repositioning and mobilizing individuals is an important component in the prevention of pressure injuries. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility did not ensure 3 of 4 residents (R) reviewed (R20, R21 and R31) for restorative programming, received appropriate treatment and services to maintain or prevent further reduction in range of motion (ROM). R20, R21 and R31 had a therapy screen completed with recommendations for staff to follow through with restorative exercises. This is not being completed and was never implemented on the care plans for staff to follow. This is evidenced by: Example 1 R20 has medical diagnoses that include but are not limited to hemiplegia right dominant side, congestive heart failure, adult failure to thrive, obesity, muscle weakness, and right below the knee amputation. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility did not ensure 2 of 4 residents reviewed with catheters (R20 and R25) received appropriate treatment and services to prevent urinary tract infections (UTIs) to the extent possible. R20 and R25 both have indwelling urinary Foley catheters of which observations were made of no catheter care and the tubing and urinary collection bags were frequently above bladder level, posing a risk for urinary backflow into the bladder and a potential UTI. This is evidenced by: According to the Centers for Disease Control and Prevention (CDC), to prevent Catheter Associated Urinary Tract Infections (CAUTI) it is strongly recommended to . 1. maintain unobstructed urine flow; 2. Keep the catheter and collecting tube free from kinking; and 3. Keep the collecting bag below the level of the bladder at all times. [...]

Inspectors wroteBased on record review and interview the facility did not assure the accurate administrating of all drugs to meet the needs of each resident, resulting in 1 of 1 resident (R12) reviewed did not have insulin held per physician orders. The facility staff did not hold administering insulin to R12 as precsribed by the physician. This is evidenced by: The facility policy entitled Medication Holds revised April 2007, states .the nursing staff must document in the resident's medication administration record (MAR) that such medication(s) is being held. R12 was admitted on [DATE] and has an order for insulin Lantus 16 units one time a day for diabetes mellitus and to hold if accucheck is less than 120 or refuses meals. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide occupational therapy services to assess and direct the implementation and use of adaptive equipment at mealtime for 1 of 1 resident (R7), a supplemental sample, reviewed for use of adaptive equipment. R7 was not provided with specialized occupational therapy services to determine the need for and use of adaptive equipment with mealtime. R7 did not receive his adaptive cup for two of three meals observed. R7 received and used adaptive silverware that was not assessed, care planned for or documented within the medical record. This is evidenced by: R7 was admitted to the facility on [DATE], and has diagnoses that include cerebral infarction, dysphasia, aphasia, autistic disorder, and a history of aspiration pneumonia. [...]

Inspectors wroteBased on interview and record review, the facility does not provide a bed hold notice upon transfer to the hospital. This occurred for 2 of 2 sampled residents (R) (R25, R31) who transferred to the hospital. The facility has no system in place to notify residents when a transfer occurs. This has the potential to affect all 31 residents that reside in the facility. R25 transferred to the hospital, and neither R25 nor his decision maker were notified about the facility's bed-hold policy. R31 transferred to the hospital and was not notified about the facility's bed-hold policy. This is evidenced by: 1.) R25 was admitted to the facility on [DATE], and has diagnoses that include metabolic encephalopathy, communication deficit, dementia. R25 has an activated power of attorney (POA) for healthcare, to assist with decision making. [...]