Autumn Lake Healthcare at Greenfield

Inspectors wroteBased on observation, interview and record review, the facility failed to 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 7 (R66, R109, R34, R10, R33, R5 and R8) of 13 residents reviewed for pressure injuries from a sample of 19. *R66 has a history of a healed stage 4 pressure injury to the sacrum and is at high risk for pressure injuries. R66's sacral pressure injury reopened on 1/17/25 and again on 6/10/25. On 11/21/25, R66's sacral pressure injury showed signs of infection and a wound culture was ordered. Results on 11/24/25 documented a staph infection. Wound Nurse Practitioner (NP)-F ordered an MRI to the sacrum to rule out osteomyelitis. The MRI was not completed until 2/25/26. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure 4 (R21, R66, R109, and R7) of 19 sampled residents received treatment and care based upon a comprehensive assessment and a comprehensive person centered plan of care and in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act.) *R21 returned from an appointment outside of the facility on 10/27/25 with a large hematoma on the front of R21's left shin. R21's leg wound opened and needed to be debrided on 11/19/25. On 11/26/25, R21's left leg wound became infected. Facility staff did not follow Wound Nurse Practitioner (NP)-F's treatment orders. R21's wound required placement of a midline IV (intravenous) and 2 different IV antibiotics to treat the infection. *R66 experienced a respiratory change of condition in the early morning of 2/15/26. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure each resident received adequate supervision and assistance devices to prevent accidents for 4 (R11, R33, R7 and R108) of 7 sampled residents reviewed for accidents. *On 3/27/26, at 6:15 AM, R11 sustained an unwitnessed fall that resulted in a right hip fracture requiring surgery. R11 was found lying on their fall mat next to their bed by facility staff. R11 was assessed as having difficulty with performing Range of Motion (ROM) with their right leg and increased pain. Facility staff used a mechanical lift to get R11 back into bed even though R11 had changes with their right leg ROM and increased pain. The facility did not complete a thorough fall investigations. *On 4/4/25, at 10:45 AM, R33 sustained a fall during cares. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure sufficient nursing staff was provided to all residents to maintain or attain their highest practicable physical, mental, and psychosocial well-being. Surveyor conducted a record review of the facility's nursing staff schedule and verified the facility is not providing staffing levels that meet the facility's identified staffing needs documented in the facility assessment for the night shift. The facility did not consistently designate a licensed nurse to serve as a charge nurse on each tour of duty. This deficient practice has the potential to affect all 83 residents residing at the facility.

Inspectors wroteBased on interview and record review, the Facility did not ensure 4 (R2, R91, R4, & R5 ) of 5 sampled residents reviewed for unnecessary medications received psychotropic medications that were ordered properly, had appropriate indications for use, were monitored and care planned. * R2's as needed lorazepam medication used for anxiety did not have an end date. * R91 did not have an up to date Abnormal Involuntary Movement Scale (AIMS) assessment completed while receiving a psychotropic medication and as needed lorazepam medication did not have an end date. * R4 was receiving a psychotropic medication without an indication for use and no monitoring of behaviors. * R5 started a hypnotic medication for insomnia. The facility did not complete a sleep assessment. R5 did not have a care plan related to their insomnia.

Inspectors wroteBased on interview and record review, the facility did not ensure upon transfer or discharge of 6 (R105, R103, R13, R8, R14 and R66) of 7 sampled residents the resident was provided proper notices related to transfer and bed hold, and a process was established to ensure the Ombudsman was notified of the resident transfers and discharges in the facility. * R105 was discharged home 1/30/26. The facility did not notify the Ombudsman of this discharge. * R103 was discharged home 3/6/26. The facility did not notify the Ombudsman of this discharge. * R13 was transferred to the hospital on 5/31/26 and has not yet returned to the facility. The facility did not have documentation of providing bed-hold information, a transfer notice and notification to the Ombudsman regarding the transfer. [...]

Inspectors wroteBased on interview and record review the facility did not ensure that 4 out of 5 Certified Nursing Assistants (CNAs) completed required dementia training annually. This has the potential to affect a pattern of the 83 residents residing in the facility who receive care from the 4 staff members.*CNA-Q, CNA-R, CNA-S, and CNA-V did not have documentation they had completed required dementia training.

Inspectors wroteBased on interviews and record review, the facility did not resolve a grievance as outlined in the facility policy for 1 (R105) of 2 residents reviewed for grievances. On 1/27/26 R105's family member sent an email correspondence to the Nursing Home Administrator (NHA)-A requesting that the content of the email regarding concerns with R105's discharge planning and a pressure injury be processed as a formal complaint. The facility did not have any evidence of R105's complaint being submitted as a grievance nor any resolution to the complaint.

Inspectors wroteBased on record review and staff interview, the facility did not ensure allegations of neglect, misappropriation of property, and injuries of unknown origin, were thoroughly investigated. This was observed with 3 (R106, R32 and R21) of 3 sampled residents. * R106 nurses notes included documentation on, 3/21/26 and 3/31/26, on care concerns provided by the facility. There is no further documentation of these concerns being investigated. * On 1/12/26 R32 reported his wallet containing $1000.00 was missing. The facility did not conduct a thorough investigation as the facility did not interview any ancillary staff such as housekeeping & activities who worked the floor from the time R32 went to the bank until R32's money was discovered missing. [...]

Inspectors wroteBased on 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/hygiene for 1 (R31) of 19 sampled residents reviewed for bathing.*R31 did not consistently receive showers or bed baths.

Inspectors wroteBased on interview and record review, the facility did not ensure 3 (R108, R4, and R31) out of 19 sampled residents were provided and administered medications based upon physician orders and standards of practice for ensuring accurate administration of ordered medications. * R108 had multiple medications that were not administered from September to November of 2025 with notations that indicated the medications were not available to administer as ordered. * R4 had tooth pain and facial swelling. Chlorhexidine Gluconate solution was not administered as ordered by the physician. * R31 had multiple medications and treatments that were not documented as being administered or completed as ordered. Findings Include: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure nurse staff posting information was accurate. Review of nursing schedules and the nurse staff posting from 5/3/26 through 6/6/26 revealed 17 of 35 days had discrepancies between the documents. This resulted in inaccuracies with the total number and actual hours worked for Certified Nursing Assistant (CNA) directly responsible for resident care each shift. This has the potential to affect 83 of 83 residents residing at the facility.

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to ensure residents were free from sexual abuse for 1 resident (R) of 3 residents reviewed for abuse (R2), R1 had a previous documented incident of trying to kiss another resident and there was a reported incident of R1 attempting to fondle the breasts of R2, a cognitively impaired resident. The facility failed to implement effective preventive measures after these incidents. R1 was later found by staff with his hand down R2's pants. Following this incident, not all caregivers were aware of the need to monitor the whereabouts of R1 or to keep R1 and R2 separated. The facility's failure to keep R2 free from sexual abuse created a finding of immediate jeopardy that began on 11/20/25. [...]

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to report allegations of abuse to the state agency for two of four residents (Resident (R) 1 and R2) reviewed for allegations of abuse out of 17 sampled residents. As a result of this deficient practice, the facility failed to investigate these incidents and implement interventions to prevent further occurrence, and R1 continued to touch R2 inappropriately. Cross Reference: F600 Freedom from Abuse.

Inspectors wroteBased on observations, record review, interviews, and policy review, the facility failed to maintain the cleanliness of a nebulizer mask for one of one resident (Resident (R) 7) reviewed for nebulizer use out of 17 sampled residents. This deficient practice increased the risk of infection for residents requiring nebulizer therapy.

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to provide a fish-free meal to one resident (Resident (R) 13) with a documented fish allergy out of three residents reviewed for food allergies from a sample of 17 residents. This failure had the potential for R13 to experience a severe anaphylactic reaction.

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to maintain a complete and accurate medical record for one of 17 sampled residents (Resident (R) 5). This failure resulted in the medical record not accurately showing whether R5's medication was administered.

Inspectors wroteBased on interviews and record review, the facility did not resolve a grievance as outlined in the facility's grievance policy for 1 (R1) of 3 residents reviewed for grievances. R1's [family member] filed a grievance on 2/22/25 with concerns related to oxygen levels too high, staff not re-approaching R1 when R1 refuses to take medication or personal cares, R1 not getting out of bed due to refusals, broken laundry basket and two missing night gowns. The facility did not resolve R1's grievance related to the broken laundry basket or the two missing night gowns.

Inspectors wroteBased on interview and record review the facility did not report 1(R2) of 2, reportable incidents reviewed, to the State survey agency and/or Law Enforcement within the required timeframe. *On 02/24/2025, The facility was made aware of R2's missing money. The facility did not notify the local Law Enforcement within the required timeframe.

Inspectors wroteBased on interview and record review the facility did not ensure that 1 (R2) of 1 allegations of mistreatment involving residents were thoroughly investigated. * R2 reported allegations of retaliation from a staff member and the allegations were not reported to the Nursing Home Administrator (NHA)-A in a timely manner. Certified Nursing Assistant (CNA)-O continued to work in resident care the rest of the shift.

Inspectors wroteBased on observation, interview, and record review, the facility did not implement a comprehensive person-centered care plan to meet a resident's mental and psychosocial needs that are identified in the comprehensive assessment for 1 (R2) of 6 residents reviewed. * R2 had interventions documented in the focus area of R2's care plan which documented, Attempt to limit the assignment of new staff to the resident or have established staff members slowly introduce new staff to her, when possible, to help set positive tone. The care plan was not observed to be in place during survey or as being utilized in the resident's cares. The focused intervention was not on the resident's care card for Certified Nursing Assistant (CNA) staff to be aware of the intervention.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that residents with a pressure injury or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 1 (R1) of 2 residents reviewed for pressure injuries. R1 was admitted to the facility on [DATE] with a Stage 3 sacrum pressure injury. There was not a comprehensive assignment until 2/11/25 and a wound treatment was not started until 2/11/25. R1 was transferred to the hospital on 2/26/25 & returned to the facility on 3/5/25. R1's weekly pressure injury assessment dated [DATE] incorrectly stages R1's right & left buttocks pressure injuries. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not ensure each resident received adequate supervision and assistive devices to prevent accidents for 2 (R3 & R1) of 2 residents reviewed. * R3 fell on 3/3/23. The facility did not thoroughly investigate the fall including whether prior fall interventions to prevent falls were in place. R3 was observed to be transferred without a gait belt by Certified Nursing Assistant (CNA)-F whom unaware R3 required the use of a gait belt during transfers. * R1's fall on 12/23/24 was not thoroughly investigated.

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R4) of 2 residents reviewed for nutritional concerns maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance. R4 was admitted to the facility on [DATE] and discharged to the hospital due to a change in condition on 2/15/25. While R4 was at the facility, the facility did not have any evidence how much R4 was eating at every meal, despite R4 being a diabetic and requiring a food for insulin administration.

Inspectors wroteBased on interview and record review, the facility did not ensure 1 (R4) of 1 resident prescribed insulin received the insulin as ordered. R4 was admitted to the facility on [DATE] at 12:00 p.m. with orders for sliding scale insulin at all meals and at bedtime. The MAR(medication administration record) reveals a blood glucose level was not checked at supper and the sliding scale insulin was not given to R4. The MAR reveals the bedtime blood glucose level was checked and it was 288. R4 received lantus 30 units at bedtime but did not receive the bedtime sliding scale insulin that was ordered.

Inspectors wroteBased on interview and record review, the facility did not ensure 1(R5) of 3 residents reviewed for lab results had obtain it in a timely manner. The facility obtained an order on 12/19/24 for a UA (urinalysis) and C&S (culture and sensitivity) for R5. The facility collected the urine, but the lab facility did not receive it and the facility had to obtain another sample on 12/21/24. The laboratory facility did not receive the lab specimen until 12/22/24. On 12/25/24 the lab results revealed a UTI (urinary tract infection) and R5 received an order for antibiotics.

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 1 (R1) of 2 Residents. * Appropriate hand hygiene was not observed during incontinence cares for R1. Facility staff were not wearing gowns during R1's care & treatment observations while R1 is on EBP (enhanced barrier precautions). There was not a sign posted for enhanced barrier precautions on R1's door nor was there a PPE (personal protective equipment) cart outside the room on 3/24/25 & early morning of 3/25/25.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure nurse staffing data to include the date, resident census, and the total actual hours worked by Registered Nurses, Licensed Practical Nurses, and Certified Nurse Aides, was posted on a daily basis. * The Facility did not update Nurse Staff Posting a document that was displayed in a visible location in the Facility. During weekend, there are no staff members responsible for changing out the nurse staffing posting until Monday morning when the facility receptionist returns to work. Nurse Staff Postings were not being displayed daily or maintained for the 3 months reviewed. This deficient practice has the potential to affect all 82 residents currently residing in the Facility.

Inspectors wroteBased on observations and interview, the facility did not store food in accordance with professional standards for food service safety. This deficient practice had the potential to affect 80 of 80 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility did not ensure their abuse policy and procedure was implemented for 3 of 8 employees reviewed for 4-year background checks. Certified Nursing Assistant (CNA)-U, Medication Technician (MT)-V, and Cook-W did not have up to date background checks completed within the four year time frame. CNA-U and MT-V worked on specific units of the facility while Cook-W did not have direct contact with residents. This deficient practice has the potential to affect 1 unit of residents where CNA-U and MT-V could potentially be providing care.

Inspectors wroteBased on interview and record review, the Facility did not ensure the medical record reflected the advanced directive wishes for 1 (R47) of 18 residents reviewed. R47's Cardiopulmonary Resuscitation (CPR) Preference form indicated that R47 did not want CPR attempts, however R47's electronic medical record (EMR) indicated R47 was to have CPR performed.

Inspectors wroteBased on interview and record review, the facility did not complete a Quarterly Minimum Data Set (MDS) assessment timely for 2 (R71 and R45) of 2 residents reviewed for timely assessments. *R71 had a Quarterly MDS assessment dated [DATE] with sections signed as completed on 11/20/2024, 11/21/2024, and 11/24/2024. The assessment was signed in Section Z: Assessment Administration as being completed on 11/12/2024. *R45 had a Quarterly MDS assessment dated [DATE] with sections signed as completed on 12/2/2024, and 12/3/2024. The assessment was signed in Section Z: Assessment Administration as being completed on 11/13/2024.

Inspectors wroteBased on interview and record review, the facility did not transmit a Quarterly Minimum Data Set (MDS) assessment within 7 days after the assessments was completed for 2 (R71 and R45) of 2 residents reviewed for timely assessments. *R71 had a Quarterly MDS assessment dated [DATE]. The assessment was signed in Section Z: Assessment Administration as being completed on 11/12/2024. The assessment was not submitted to the Centers for Medicare and Medicaid Services (CMS) until 12/10/2024. *R45 had a Quarterly MDS assessment dated [DATE]. The assessment was signed in Section Z: Assessment Administration as being completed on 11/13/2024. The assessment was not submitted to CMS until 12/10/2024.

Inspectors wroteBased on record review and interview, the facility did not accurately screen residents for a mental disorder for 1 (R8) of 1 residents reviewed for PASSAR (Preadmission Screen and Resident Review) Level I and requiring a Level II screening. R8 was admitted to the facility with diagnoses of mental disorders and was not evaluated on the PASSAR Level I screen as having any mental disorders. The Level 2 PASSAR screen was never completed due to the inaccurate PASSAR Level I screen.

Inspectors wroteBased on interview and record review, the facility did not develop and implement a comprehensive person-centered care plan for 2 (R8 and R36) of 18 residents reviewed to meet a resident's medical, nursing and psychosocial needs that are identified in the comprehensive assessment. * R8 has Chronic Obstructive Pulmonary Disorder (COPD) and receives oxygen therapy. R8 receives Torsemide for diuresis. R8 does not have a comprehensive care plan that addresses oxygen or diuretic therapy. * R36 did not have a catheter care plan implemented when returning from the hospital with a foley catheter in place.

Inspectors wroteBased on interview, record review and observation, the facility did not ensure 1(R27) of 1 resident reviewed with limited range of motion, received appropriate treatment to prevent further contractures and decreased range of motion in R27's upper and lower extremities. * The facility failed to implement R27's range of motion restorative program ordered and initiated on 9/30/24 by the physical therapy department.

Inspectors wroteBased on interview and record review, the facility did not ensure that 1 (R335) of 3 residents reviewed for falls had adequate supervision and assistance devices to prevent accidents. R335 did not have a care plan for falls, even after a post fall on 9/28/2024, developed that contained interventions in place to prevent falls and accidents.

Inspectors wroteBased on the comprehensive assessment of a resident, the facility did not ensure that residents received the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices, related to pain management for 1 of 4 (R38) residents reviewed for pain. R38 is a hospice patient and was not administered his scheduled pain medication as ordered.

Inspectors wroteBased on interview and record review, the facility did not ensure the accurate and safe administration of medication for 1 (R47) of 5 residents reviewed. R47 had a Consultant Pharmacist Recommendation to Physician form that was signed by the Nurse Practitioner ordering a medication change be initiated that was not acted upon by the facility.

Inspectors wroteBased on interview and record review, the facility did not ensure 1 (R37) of 5 residents that are on antipsychotic medications received a gradual dose reduction. R37 has a diagnosis of dementia with psychotic disturbance and major depressive disorder. R37 receives olanzapine 2.5 mg (milligram) daily, an antipsychotic medication. R37 receives olanzapine for sundowning with dementia. The 10/16/24 pharmacy recommendation documents that there should be a gradual dose reduction (GDR) attempt for R37 olanzapine. The NP (nurse practitioner) (unknown) noted a GDR was not needed due to psychiatric disorder. There is no evidence R37 has a psychiatric diagnosis and a GDR was not attempted.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents with pressure injuries received care consistent with professional standards of practice to promote healing for 2 (R14 and R13) of 3 residents reviewed with pressure injuries. *R14 was admitted to the facility on [DATE] with a Stage 3 pressure injury to the right buttock. The pressure injury was comprehensively assessed and documented on 9/24/2024 when R14 was seen by Wound Physician-I, four days after admission. *R13 was observed sitting in a Broda chair without heel boots on and the feet pressed up against the footboard of the Broda chair. R13 was to have bilateral heel boots on per the Skin Integrity Care Plan.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents received adequate assistance devices to prevent accidents for 1 (R13) of 3 residents reviewed for accidents. *R13's At Risk for Falls Care Plan had the intervention of bilateral fall mats on the floor. Observations were made of R13 having one fall mat on the floor and not two fall mats.

Inspectors wroteBased on record review and interviews, the facility did not ensure 1 (R10) of 1 residents reviewed for catheters received appropriate care and treatment of the catheter. R10 did not have physician orders for the care and treatment of their Foley catheter.

Inspectors wroteBased on observation, interview and record review, the Facility did not ensure that Residents with a pressure injury or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 1 (R10) of 3 Residents reviewed for pressure injuries. R10 had a history of pressure injuries. R10 was admitted with a Stage 3 pressure injury on the right & left buttocks, an unstageable pressure injury on the right heel and a stage 3 pressure injury on the left heel. R10's right buttocks was identified as being healed on 5/28/24, the left buttocks pressure injury was healed on 6/11/24, the right heel was healed on 7/30/24, & the left heel was healed on 8/6/24. On 7/15/24, R10 developed three Stage 3 pressure injuries on the coccyx, left & right buttock. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not ensure each resident receives adequate supervision or assistance devices to prevent accidents for 1 (R8) of 3 residents reviewed for accidents. *R8 was re-admitted to the facility on [DATE] and had a significant change in R8's cognition and activities of daily living (ADL's) performance and enrolled onto Hospice services. R8 care plan and certified nursing (CNA) care [NAME] was not revised to indicate R8's decline. R8 had a fall on 5/18/2024 that resulted in a dislocated finger with avulsion and 3 sutures for a laceration.

Inspectors wroteBased on interview and record, the facility did not ensure 1 (R5) of 1 residents was assessed by the interdisciplinary team to determine it was clinically appropriate to self administer medication. R5 was applying medihoney on her left posterior wound without being assessed for her ability to self administer treatments.

Inspectors wroteBased on interview and record review, the facility did not ensure 2 (R1 and R3) of 4 Residents reviewed received a prompt resolution to grievances filed, including steps taken to investigate the grievance, a summary of pertinent findings, conclusion, statements as to whether the grievance was confirmed or not confirmed, corrective actions taken by the facility, and the date the written decision was issued. *R1's representative filed a grievance with the facility and there is no evidence if the grievance was confirmed or not or if R1's representative was informed of the corrective actions taken by the facility and resolution. The facility did not have any documentation this grievance was investigated promptly and resolved. [...]

Inspectors wroteBased on record review and staff interview, the facility did not ensure all allegations involving potential abuse were thoroughly investigated and residents were protected from further abuse while alleged abuse investigations were conducted for 2 of 2 self report reviewed. * A Facility Misconduct Incident self-report submitted to the State Agency on 4/2/24 documents R7 and R6 had a resident to resident altercation where R7 had approached R6 and pulled their hair and possibly slapped R6 in the head. The facility did not conduct a thorough investigation into this allegation of abuse when the facility's investigation did not include documented interviews from other Residents in order to determine a possible pattern of abuse. [...]

Inspectors wrote2.) The facility's Elopements and Wandering Residents policy and procedure implemented 5/10/24 documents: . Policy: This facility ensures that Residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person centered plan of care. Policy Explanation and Compliance Guidelines: . 2. The facility shall establish and utilize a systematic approach to monitoring and managing Residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. 3. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering b. [...]

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R7) of 1 residents reviewed was receiving psychoactive medications with proper indications. *R7 is receiving Donepezil and Olanzapine for Dementia behaviors without any documented behavior monitoring.

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 1 (R10) of 1 Residents. * Appropriate hand hygiene was not observed during incontinence cares for R10 and staff were not wearing gowns during this care observation for R10 who is on EBP (enhanced barrier precautions). There was not a sign posted for enhanced barrier precautions on R10's door nor was there a PPE (personal protective equipment) cart outside the room.

Inspectors wroteBased on observation, interview, medication audit review, and facility policy review, the facility failed to ensure medication administration was timely resulting in an error rate of 74.07% with 20 errors for 4 residents (R16, R17, R18, and R2) out of a possible 27 opportunities. Licensed Practical Nurses (LPN C and LPN D) and Certified Medication Technician (CMT) E failed to provide medication within the specified/allowed administration time limit.

Inspectors wroteBased on personnel record review, interview, and facility policy review, the facility failed to provide training to staff regarding abuse, neglect, exploitation, and dementia management for 4 of 4 agency staff (Licensed Practical Nurse (LPN) D, Certified Nursing Assistant (CNA) F, CNA8, and CNA9) personnel records reviewed. This training oversight could negatively impact the care provided to all 85 residents residing at the facility.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to ensure one (Resident (R)1) of one reviewed was free from abuse from another resident (R2) out of a sample of 18 residents.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure conditions in the kitchen were sanitary in accordance with professional standards for food safety. This deficient practice had the potential to effect 73 out of 75 Residents who receive food from the facility kitchen. *The grease trap below the food serving table was covered with food particles. *The kitchen staff were not verifying the internal temperature of the dishwashing machine at the utensil rack to ensure the machine was operating properly.

Inspectors wroteBased on observation, interview and record review the facility did not ensure medications were stored at the proper temperature. This had the potential to affect 29 of 29 residents residing on the 1st floor. *The medication room refrigerator had a temperature log that was not filled out. The last date on the log was from 08/26/23. The September temperature log had not been started. This refrigerator contained seven residents individually labeled medications, a container with stock insulins, two boxes of Bisacodyl Suppositories to be used as needed for any resident on the 1st floor.

Inspectors wroteBased on observation, interview, and record review the Facility did not ensure quality of care was provided for 2 (R175 & R4) of 18 Residents. * On 6/27/23 Advanced Practical Nurse Practitioner (APNP)-D's note documents to hold R175's Metoprolol succinate ER (extended release) 25 mg (milligrams) for 48 hours. The medication was administered. Metoprolol succinate ER 25 mg does not include parameters of when to hold this medication. * R4 was prescribed medication for edema. The edema was not assessed by the facility and a care plan not developed for management of edema. On 9/7/23 R4 had a 17.3 pound weight gain in one week that was not reported to her physician and assessed until 9/11/23.

Inspectors wroteBased on observation, interview and record review, the facility did not provide proper interventions to prevent pressure injuries for 2 (R41, R43) of 8 Residents reviewed for pressure injuries. *R41 was admitted to the facility with an unstageable pressure injury. Surveyor made observations of R41's air mattress operating at an improper setting. *R43 is at risk for pressure injuries. Surveyor made observations of R43's air mattress operating at an improper setting.

Inspectors wroteBased on observation, interview and record review the facility did not ensure 1 (R4) of 3 residents reviewed for weight received the necessary services to assist with nutritional maintenance. * R4 had a significant weight loss that was not comprehensively assessed, R4's physician was not updated and a comprehensive assessment was not completed.

Inspectors wroteBased on interview and record review the Facility did not ensure the physician acted upon recommendations by the pharmacist for 2 (R2, R52) of 5 Residents reviewed for unnecessary medications. *On 6/17/23, pharmacy recommendations were given for R2 and not followed up upon in a timely fashion. The facility could not provide documentation of Monthly Pharmacy Review for March 2023, April 2023, May 2023 and July 2023 for R2. * The facility could not provide documentation of Monthly Pharmacy Review for March 2023, April 2023, May 2023 and July 2023 for R52.

Inspectors wroteBased on observation, interview, and record review the Facility did not ensure there was a medication error rate below 5 percent. There were 3 medication errors in 35 opportunities which resulted in a medication error rate of 8.57%. Medication errors were identified for R10 and R69. *R69 had a physician's order for 1000 mg (Milligrams) of Metformin. R10 was given 500 mg of Metformin. *R10 had a physician's order for Tamsulosin 0.4 mg, give 2 tablets daily. R10 only received 1 tablet of Tamsulosin 0.4 mg. *R10 had a physician's order for Oxybutin ER (extended release) 10 mg tablet. R10 did not receive this medication and there was a lack of follow up by the Medication Technician (MT), MT-G.

Inspectors wroteBased on observations, record review, and interview, the facility did not ensure 2 of 6 Residents (R) reviewed for quality of care received treatment and care in accordance with standards of practice (R80 and R81.) The facility did not provide for the care and treatment of a non-pressure wound for 1 of 1 (R80) sampled residents with non-pressure wounds and did not conduct adequate neurological checks for 1 of 3 (R81) residents reviewed for falls. * R80 was admitted to the facility on [DATE]. On 5/17/22 R80's Braden Scale documented R80 was high risk for developing wounds. On 5/23/22, the wound care doctor documented an open area to the left buttock and requested a dermatology consult to rule out eczema versus psoriasis. The dermatology consult was not followed up on by the facility. [...]

Inspectors wroteBased on observation, staff interviews and record review the facility did not ensure that they provided the necessary care and treatment to 2 of 2 (R10 and R47) residents reviewed with pressure ulcers to promote the healing and prevent new ulcers from developing. R10 was noted to have an open blister to the right heel that went without a comprehensive assessment until the area became worse. R10 was also observed to have an area to the left heel that went without an assessment and was observed to have a treatment in place without a physician order. R47 developed an intact blood filled blister to the right heel. The facility did not comprehensively assess the area to ensure that the proper treatment and interventions were in place to assist in healing the area. This is evidenced by: [...]

Inspectors wrote3. R88's Quarterly Minimum Data Set with an Annual Reference Date of 1/3/22 documents: Bed mobility - how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture, as Extensive 2 person assist. R88's Care Plan (CP) Focus area initiated 1/2/20 documents: (R88) is at risk for falls r/t (related to) Fall history, impaired balance, psychotropic medication use, behaviors, cognitive loss, fall risk tool score. Interventions include: (R88) needs a safe environment with: Adequate glare-free light; a working and reachable call light, handrails on walls in hallways and bathrooms, personal items within reach - Date Initiated: 1/2/20. Bed in lowest position - Date Initiated: 1/2/20 Anticipate and meet (R88)'s needs - Date Initiated: 1/2/20. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 1 (R70) residents reviewed. The facility was not monitoring NP-C's notes requesting lab orders starting on 1/13/22. Lab collections were not obtained timely with no follow through on results. The results of labs were not available in R70 medical record so that NP-C could monitor the results. NP-C ordered the labs because R70 was more confused, falling and declining. On 3/6/22, R70 was documented as having a fall. On 3/14/22, R70 had another fall, hitting her head and was sent to the emergency and hospitalized for an altered mental status and severe sepsis. This is evidenced by: The facility Policy titled: Lab (Laboratory) and Diagnostic Test Results - Clinical Protocol, revised October 2010 documents (in part) . 1. [...]

Inspectors wroteBased on observation and interview the facility did not maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections. The facility did not ensure proper cleaning and disinfecting of shared glucometers. This deficient practice had the potential to affect 4 residents (R13, R53, F56 and R73) residing on the same unit who utilized the shared glucometer. The facility did not clean and disinfect the glucometer, which is shared between residents, after use.

Inspectors wroteBased on record reviews and interviews, the facility did not develop a comprehensive person-centered care plan for 1 (R4) of 3 residents reviewed for Nutrition. * The Facility did not develop a comprehensive, person-centered care plan to acknowledge R4's Nutritional needs and address R4's severe weight loss.

Inspectors wroteBased on record review and interview, the facility did not ensure 1 (R246) of 1 residents reviewed for bathing assistance did not receive appropriate services to maintain or improve his/ her ability to carry out her bathing activities of daily living. This is evidenced by: R246 was admitted to the facility on [DATE] for short-term rehabilitation and discharged on 2/14/22. R246 had diagnosis that include Alzheimer's Disease. The admission Minimum Data Set (MDS), dated [DATE] states the following: Section F04000- Interview for daily preferences: C. How important is it to you to choose between a tub bath, shower, bed bath or sponge bath? 2- somewhat important. Section: G0110 Activities of Daily Living Assistance J. Personal hygiene- Supervision, Set-up only. Section G0120 Bathing- Self-performance- Supervision, 1-person physical assist. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that 2 (R346, R247) of 2 Residents reviewed who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good hygiene. * R346 did not receive assistance from staff with personal hygiene, including toileting in accordance with their plan of care * R247 did not receive assistance from staff with bathing in accordance with their plan of care.

Inspectors wroteBased on observation, record review and interview, the facility did not ensure 2 (R12 & R52) of 5 residents reviewed with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. * R12 was observed not wearing a palm guard to prevent a decrease in range of motion per R12's plan of care. * R52 was observed not wearing prevalon boots and a knee brace to prevent a decrease in range of motion per R52's plan of care.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that 1 (R6) of 4 residents reviewed received appropriate treatment and services to prevent urinary tract infections. * R6 was observed to her catheter drainage tubing on the floor.

Inspectors wroteBased on record reviews and interviews, the facility did not adequately address Nutrition needs for 2 (R4, R52) of 3 residents reviewed for Nutrition. * The Facility did not monitor R4's weight per Physician's orders and sustained a severe weight loss of 76.8 pounds or 31% weight loss in 6 months. * The Facility did not monitor R52's weight per Physician's orders and sustained a severe weight loss 23.2 pounds or 13.2% weight loss in 6 months.

Inspectors wroteBased on interview and record review this facility did not act timely or did not act on recommendations based on a pharmacist medication regimen review report for 3 (R90, R53, and R77) of 5 residents reviewed. *R90 had pharmacist recommendations to add directions to R90's Arnuity Ellipta inhaled corticosteroid to rinse R90's mouth with water after use, and do not swallow to prevent thrush. The recommendation was not added. *R53 had pharmacist recommendations for a hemoglobin A1C level since an A1C level was not available in R53's medical record in the past 6 months. The lab draw was not completed. *R77 had pharmacist recommendations for R77 to receive a calcium supplement due R77 taking medication to treat osteoporosis. The calcium supplement was not added to R77's medications in a timely matter.

Inspectors wroteBased on interview and record review this facility did not ensure that 1 (R90) of 5 resident's medications reviewed were free from unnecessary drugs. *R90 had a PRN (as needed) order for an anxiolytic medication, Alprazolam, that did not have a documented rationale in R90's medical record that indicated the duration for the PRN order beyond 14 days.

Inspectors wroteBased on observation, interview and record review the facility did not ensure its medication error rate was below 5%. The facility error rate was 7.41% affecting 2 of 4 (R56 and R40) residents observed during the medication pass. R40 received Vitamin B12, however R40's physicians orders did not indicate a dosage of the medication. R56 did not receive Flonase Sensimist Suspension as ordered.

Inspectors wroteBased on observation and interview the facility did not ensure drugs and biologicals used in the facility were not expired and were labeled in accordance with currently accepted professional principles, to include the expiration date for 2 of 2 medications rooms and 1 of 3 medications carts observed. Stock medications were found to be expired and insulin pens were not dated when opened.