Aria of Waukesha

Inspectors wroteBased on record review, observation and interview, the facility did not ensure a resident with a pressure injury was comprehensively assessed. This was observed with 1(R47) of 4 residents reviewed with pressure injury. * R47 was re-admitted into the facility from the hospital on 1/5/26. The medical record documents a stage 2 wound on the coccyx, with only a measurement, on 1/5/26. On 1/8/26, the wound consult assessment assesses stage 3 pressure injury with treatment. The medical record does not have documentation of treatment implementation until 1/8/26, along with a revised plan of care not initiated until 1/29/26. This resulted in actual harm to R47.

Inspectors wroteBased in interview and record review the facility did not ensure it completed accurate mandatory submission of staffing information based on payroll data in a uniform electronic format to the Centers of Medicare and Medicaid Services (CMS). Staffing information for Fiscal Year Quarter 4 2025 (July 1st, 2025 - September 30th, 2025) of the Payroll Based Journal (PBJ) was not accurately submitted to CMS.This deficient practice has the potential to affect all 56 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility did not have documentation that it implemented an effective water management plan. This deficient practice had the ability to affect all 56 of 56 residents residing at the facility at the time of this recertification survey. [...]

Inspectors wroteBased Observation and interview, the facility did not ensure that 1 (R6) of 16 residents reviewed had clean, comfortable and a homelike environment. *R6 was observed to have mold on the ceiling in R6's room.

Inspectors wroteBased on interview and record review, the facility did not ensure that discharge planning included documented coordination of services, resident participation, and verification of a safe and appropriate transition for 1 (R32) of 2 residents reviewed.* R32's medical record did not contain documentation of a completed discharge summary, documented care conference discharge meeting and confirmation that the post-discharge needs and services for R32 were fully addressed prior to discharge.

Inspectors wroteBased on observation, interviews and record review the facility did not ensure that a resident who is unable to carry out activities of daily living (ADLs) receives the necessary services to maintain good grooming and personal hygiene for 1 of 16 (R23) residents reviewed for ADLs. R23 did not receive showers as requested.

Inspectors wroteBased on record review and interview, the facility did not ensure that based on the comprehensive assessment of a resident, 1 (R4) of 5 residents reviewed, received treatment and care in accordance with professional standards of practice.*R4 has diabetes mellitus and receives scheduled insulin. R4's blood glucose was being obtained 3 times a day without any parameters and without order for treatment for variances in R4's blood glucose.

Inspectors wroteBased on interview and record review, the facility did not ensure the accurate and safe administration of medication for 1 Resident (R5) of 16 reviewed. R5 returned from the hospital with an order for an antibiotic on 12/16/25 and it was not available until 12/18/25, three doses were not provided.

Inspectors wroteBased on record review and interviews, the facility did not ensure pharmacy irregularity reports were maintained in the medical record, and acted upon promptly, by the primary care provider. This was observed with 2 (R10 and R42) of 5 resident pharmacy record reviews. * R10 and R42, had a Medication Regimen Review (MMR) completed by the pharmacist and a separate recommendation report was written for R10 and R42. The recommendation reports were not discovered in the medical record, nor acted upon promptly by the primary care provider.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles and included the expiration date when applicable for 1 of 2 medication carts reviewed. Insulin pens and vials were not dated when opened.

Inspectors wroteBased on observation and interview, the facility did not ensure it was adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside for 1 of 16 (R23) rooms observed. R23 needed to be changed for incontinence and her bedside call light was not functioning.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure each resident receives adequate supervision to prevent accidents for 1 of 3 residents (R1) reviewed for accidents/supervision. The facility did not correctly assess R1's risk for elopement and, thus, did not implement interventions to monitor and supervise R1 to prevent R1 from eloping from the facility. The facility had gaps in the monitoring of the main entrance of the building once the alarm system was turned off and before the area was staffed for the day, allowing R1 to leave the facility unnoticed by staff. R1 was returned to the facility 8 hours later when his family found him 20 miles away from the facility. The facility's failure to provide adequate supervision allowed for R1 to elope from the facility, which created a finding of immediate jeopardy that began on 8/25/25. [...]

Inspectors wroteBased on interview, record review, and facility document review, the facility failed to employ a qualified Dietary Manager (DM) or clinically qualified nutritional professional on a full-time basis to carry out the functions of overseeing the menus. 4 (R25, R9, R11 and R49) of 4 residents interviewed regarding menus and food selection expressed concerns regarding kitchen management.

Inspectors wroteBased on interview, observation, record review, policy review, and review of the United States Department of Agriculture (USDA) website, the facility failed to store food and snacks in a sanitary manner in one of two resident refrigerators (East unit refrigerator). The facility did not ensure items stored in the East unit refrigerator were labeled, dated, and removed, when necessary. This had the potential to cause food-borne illness for residents who utilized the East unit refrigerator.

Inspectors wroteBased on observation, record review, interview, and review of facility policy, the facility failed to ensure staff donned the appropriate personal protective equipment (PPE) when providing direct care to one of 13 residents (Resident (R) 313) on Enhanced Barrier Precautions (EBP) out of a total sample of 25. This failure could promote the spread of multi-drug-resistant organisms throughout the facility.

Inspectors wroteBased on staff interview and record review, the facility did not implement their written policies and procedures to prohibit and prevent abuse for 2 of 8 staff reviewed for caregiver background checks. The facility did not ensure thorough and timely caregiver background checks were completed for Laundry Aide (LA)-C and Certified Nursing Assistant (CNA)-D.

Inspectors wroteBased on record review and interview, the facility failed to have an effective system to ensure each resident received adequate supervision and monitoring to prevent elopement for one of three sampled residents (Resident (R) 1). The facility assessed R1 as an elopement risk and placed a wanderguard device on the resident; however, on 10/01/23 the resident exited the backdoor of the facility and the facility's wanderguard system failed to alarm.

Inspectors wroteBased on interview, and record review the facility did not ensure residents received treatment and care in accordance with professional standards of practice related to completing a thorough assessment of a resident after a fall for 2 (R3 & R2) of 2 Residents reviewed for falls. *R3 sustained unwitnessed falls on 09/13/23 and 09/14/23 and did not have neurological checks completed. *R2 sustained falls two times on 7/27/23, 7/29/23, 9/8/23, 9/14/23, 9/20/23, 9/26/23, and 9/27/23 and neurological checks were not completed.

Inspectors wroteBased on interview and record review the Facility did not ensure 1 (R1) of 1 Resident with an ileostomy/colostomy receive care consistent with professional standards of practice, the comprehensive person centered care plan and resident's goals & preferences.

Inspectors wroteBased on observation, interview, and record review, the facility did not store or prepare food in accordance with professional standards for food safety. This deficient practice had the potential to effect 52 or 53 Residents who receive food from the facility kitchen. * The kitchen and food storage areas were unclean. * Opened canned fruit in the prep cooler was not discarded on or before the expiration date. * Unit refrigerator was unclean. * Multiple food items in unit refrigerator were not labeled with resident name and had no date opened. * Recipe for texture and modified consistency diet for a puree was not followed.

Inspectors wroteBased on observation and interview the facility did not ensure residents the right to a safe, clean, comfortable and homelike environment. This deficient practice has the potential to affect 4 of 12 sampled residents (R's 31, R303, R1, R12) and those residents who utilize common areas such as the hallway between the east and west unit, the outside courtyard, residents who utilize the west unit shower room, residents who utilize the Broda chair, and the 11-15 residents observed eating in the main dining room on 8/15/23 and on 8/16/23. * The facility had an odor of urine. Resident common areas, equipment, and shower room were not clean and were visibly dirty for 2 of 2 units in the facility. In addition, the courtyard used by residents and visitors had multiple cigarette butts on the ground in the seating area. [...]

Inspectors wroteBased on record review and interviews, that facility did not always ensure they obtained accurate weights to be able to comprehensively assess 4 out of 4 (R11, R41, R104 , R28) residents who were at nutritional risk for weight loss. R11, R41, R104 and R28 all had individual plans of care that identified each resident to have an alteration in nutritional status due to diagnosis, alteration in meal consistencies and prior history of weight loss. The facility did not obtain the weights in a consistent manor or provide accurate weights so that a comprehensive nutritional assessment could be completed and individual interventions put into place. This is evidenced by: Policy Review: Weight Management, dated 3/1/2021. Policy statement: The facility's policy is to provide care and services to weight management by State and Federal regulations. Procedure: [...]

Inspectors wroteBased on observation, interview and record review the facility did not ensure residents who are unable to carry out activities of daily living received the necessary services to maintain good grooming and personal and oral hygiene for 2 of 3 (R28 and R44) residents reviewed for activities of daily living. * R28's call light was not answered for a period of 55 minutes while waiting for incontinence care. * R44's pants were visibly wet for at least 2 hours 45 minutes without being toileted or changed. 2 separate subsequent observations revealed times of at least 3 hours without R44 having been toileted, checked for incontinence or changed.

Inspectors wroteBased on record review and interview, the facility did not ensure residents receiving psychotropic medications were comprehensively assessed, along with indications for use. This was observed with 2 (R31 and R44) of 5 residents reviewed for appropriate medications. - R31 did not have an appropriate diagnosis for the use of an anti-psychotic and no assessment, with a end date, for a anti-anxiety as needed. -R44 did not have an appropriate diagnosis for the use of an anti-psychotic.

Inspectors wroteBased on observations and interview, the facility did not ensure garbage and refuse were properly disposed in the outside garbage storage receptacles. This deficient practice had the potential to affect all 53 Residents residing at the facility during the onsite visit. * Excessive litter was observed in the area surrounding three dumpsters which included, paper, wrappers, ketchup packets, mustard packets, plastic cups, cardboard and disposable gloves and spoons.