Avina of Milwaukee

Inspectors wroteBased on interviews and record review, the facility failed to protect the resident's right to be free from neglect, including the failure to provide timely incontinence care by staff, resulted in the deprivation of necessary services, prolonged exposure to urine, compromised dignity, and caused mental anguish and emotional distress for 1 (R105) of 2 residents reviewed. *R105 informed Surveyor that 2 or 3 months ago, an unknown facility Certified Nursing Assistant (CNA), CNA-Q, left R105 in urine-soaked bed linens and incontinence brief. R105 went the entire day shift without incontinence cares despite R105 asking CNA-Q to change and clean R105. R105 tearfully informed Surveyor that this made R105 feel like garbage and useless and R105 felt like R105 had been physically abused. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure the accurate and safe administration of medication for 1 (R68) of 7 residents reviewed for medication administration.*Surveyor observed Medication Technician (MT)-J deliver R68 an afternoon medication. MT-J left the medication on R68's bedside table and exited R68's room. R68 did not have a self-administration of medication assessment completed, did not have a physician's order to self-administer medication and did not have a care plan regarding self-administration of medication.

Inspectors wroteBased on interview and record review, the facility did not ensure 2 (R102 and R109) of 4 residents reviewed for grievances had their grievances resolved.*A grievance filed for R102 on 11/13/25 documents R102 was not provided incontinence cares on day shift of 11/12/25. There is no documentation that the grievance was investigated and that steps were taken to investigate the grievance, a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued and/or communicated to the resident and/or representative filing the grievance.* A grievance filed for R109 on 3/31/26 documents R109 was served a lunch tray with a fly on it and was not receiving a salad with lunch. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse or neglect were reported to the Administrator and the State Agency within the required reporting timeframe for 2 (R105 and R108) of 2 residents reviewed with an allegation of abuse. *R105 informed Surveyor that 2 or 3 months ago, an unknown facility Certified Nursing Assistant (CNA), CNA-Q, left R105 in urine-soaked bed linens and incontinence brief. R105 went the entire day shift without incontinence cares despite R105 asking CNA-Q to change and clean R105. R105 tearfully informed Surveyor that this made R105 feel like garbage and useless and R105 felt like R105 had been physically abused. CNA-G informed Surveyor that when CNA-G went into R105's room on second shift that same day, CNA-G noted that R105's bed linens and incontinence brief were soaked with urine. [...]

Inspectors wroteBased on interviews and record review, the facility did not ensure all allegations of abuse or neglect were thoroughly investigated for 2 (R105 and R108) of 2 residents reviewed for an allegation of abuse. *R105 informed Surveyor of an allegation of neglect. R105 told Surveyor that after the incident occurred, R105 spoke to Certified Nursing Assistant (CNA)-G, Assistant Director of Nursing (ADON)-E and Social Worker (SW)-R of the allegation of neglect. This allegation was not immediately reported to Nursing Home Administrator (NHA)-A and an investigation into the allegation of neglect was not completed. *R108 reported to Surveyor an allegation of abuse that was not thoroughly investigated by facility staff.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure that food was palatable, attractive and at a safe and appetizing temperature. This has the potential to affect 2 (R102 and R109) out of 5 residents receiving meals by the facility kitchen.*R102 was served peaches that appeared to be moldy and had a fly on R102's meal.*R109 filed a grievance documenting R109 received a lunch tray with a fly on it. Findings Include:The facility's undated Food Storage policy and procedure documents: Policy: Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure 2 (R96 & R19) of 6 sampled residents had adequate supervision to prevent accidents. *R96 had an unwitnessed fall on 10/19/25 and was diagnosed with a right hip fracture. R96 had care plan interventions to wear hip protectors and to be in high traffic areas in line of sight of nursing staff to prevent falls. The facility did not provide any evidence that these interventions were in place at the time of R96's fall on 10/19/25. The facility did not conduct thorough investigations of R96's falls on 9/22/25, 10/4/25, 10/18/25, and 10/19/25. *R19 is a smoker, the facility lacked ongoing smoking supervision and assessments.

Inspectors wroteBased on observation and interview, the facility did not ensure food was stored, prepared and served in a sanitary manner in accordance with professional standards for food safety requirements. *Dietary staff was observed with no a hair net or beard/mustache guard in food preparation areas. *Observations of no labeling, dating or use by date for opened food items located in the cooler and freezer. *An ice scoop was observed resting inside of the ice bucket touching the ice on the third-floor dining area. This deficient practice has the potential to affect residents residing on the third floor of the facility who receive ice in their water. This deficient practice has the potential to affect 87 out of 88 residents whom receive food from the main kitchen in the facility.

Inspectors wroteBased on interview and record review, the Facility did not ensure the medical record contained signed advanced directive election forms for 4 (R4, R8, R60, and R82) of 18 residents reviewed. R4's medical record showed no evidence of being offered the option to formulate an advance directive. R8's medical record showed no evidence of being offered the option to formulate an advance directive. R60's medical record showed no evidence of being offered the option to formulate an advance directive. R82's medical record showed no evidence of being offered the option to formulate an advance directive.

Inspectors wroteBased on interview and record review, the facility did not consistently provide or offer a substantial evening snack to residents within a timeframe greater than 14 hours between evening supper meal and breakfast. *R67 is not offered a substantial snack routinely between meals as care planned which created a gap of more than 14 hours between the supper and breakfast meals. *The facility failed to provide a nourishing snack at bedtime to residents between the dinner meal and breakfast the following day. This resulted in a 14.5 hour time-lapse in meals for second floor residents and a 15.5 hour time-lapse in meals for third floor residents. This deficient practice has the potential to affect 87 out of the 88 residents residing at the facility.

Inspectors wroteBased upon observation, interview and record review, the facility did not ensure 1 Resident (R45) in a sample of 18 residents received activities offered based upon assessment of individual preferences and interests. R45 was observed sitting in the dining room with no activities being offered to R45 during that time other than music playing in the background. Interviews indicate R45 has interest in music and preferences for activities and routines based on history that were not assessed or care planned for R45.

Inspectors wroteBased on observation, interview and record review the facility did not ensure 1 (R12) of 1 residents at risk for diabetic wounds received the necessary services to prevent diabetic wounds. R12 was admitted to the facility on [DATE]. On 1/22/26 diabetic wounds were identified to R12's bilateral heels. There are no documented interventions that were in place to prevent diabetic wounds from developing despite R12 having a diagnosis of diabetes type 2.

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R43) of 6 residents had necessary interventions to monitor weight. R43's physician order dated 1/27/26 documents that R43 is to be weighed Monday, Wednesday and Friday for two weeks and then weekly thereafter. R43's medical record reveals R43 has a documented weight on 1/21/26, 2/2/26 and 2/3/26. Weights were not obtained per physician orders.

Inspectors wroteBased on interview and record review, the facility did not ensure that residents who require dialysis receive such services, consistent with professional standards of practice, including the ongoing communication with the dialysis center before and after dialysis treatments, for 1 (R82) of 2 residents reviewed for dialysis. R82 has a physician order for dialysis on Monday, Wednesday and Friday. Communication between the facility and the dialysis center was not being shared with each dialysis visit.

Inspectors wroteBased on observation, interview and record review the facility did not ensure its medication error rate was not 5 percent or greater. The medication error rate was 14.81%.

Inspectors wroteBased on observation and interview, the facility did not ensure that drugs and biologicals used in the facility were stored under proper temperature controls, were labeled in accordance with currently accepted professional principles, and include the expiration date when applicable for 1 of 2 medication rooms and 2 of 6 medication carts observed. Insulin was not dated when opened and/or was expired and the medication refrigerator temperature was above the recommended temperature.

Inspectors wroteBased on interview and record review, the facility did not ensure that a resident continued to receive specialized rehabilitative services for 1(R67) of 1 residents reviewed for rehabilitation services. R67 was discharged from Occupational Therapy services on 3/3/26 when goals were not met and R67 was cooperative in participation.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure a resident's hospice notes were readily available for communication and collaboration of care in accordance with professional standards of practice for 1 (R60) of 2 residents reviewed for hospice services.*Hospice visit notes were not updated or ready available in R60's medical record or in R60's hospice binder until Surveyor requested the information.

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to provide a safe and sanitary environment to reduce the development and transmission of communicable diseases and infections for 2 (R4 & R7) of 2 residents reviewed during medication pass. *Medication Technician (MT)-H was observed dropping a medication cup onto floor, picking it up then using the same medication cup, and placing R7's medications into MT-H's bare hand when administering R7's medications.*Registered Nurse (RN)-F did not wear a gown when administering R4's medication through a gastrostomy tube.

Inspectors wroteBased on interview and record review, the facility did not ensure 3 (R1, R5, & R3) of 4 residents had the right to participate in the development and implementation of their person-centered plan of care. R1, R5, & R3 did not have evidence of quarterly care plan meetings and facility staff did not know when their last quarterly care conference meetings occurred.

Inspectors wroteBased on interview and record review, the facility did not report 1 (R1) of 1 incident reviewed to the State survey agency and Nursing Home Administrator during the required timeframe. On 1/1/26, Registered Nurse (RN)-G's nurses note documents R1 had complaints regarding the two-night Certified Nursing Assistants (CNAs) who performed ADL (activities daily living) cares for him. RN-G attempted to resolve it but R1 said he wanted it reported. On 2/2/26, R1 informed Surveyor he didn't want to be changed but staff said they had to and R1 alleged his wrists were held down when the staff members provided cares. R1's allegation of potential abuse was not reported to the State agency and Nursing Home Administrator.

Inspectors wroteBased on interview and record review, the facility did not have evidence that all alleged violations of mistreatment were thoroughly investigated for 1 (R1) of 1 resident. On 1/1/26, Registered Nurse (RN)-G's nurses note documents R1 had complaints regarding the two-night Certified Nursing Assistants (CNAs) who performed ADL (activities daily living) cares for him. RN-G attempted to resolve it but R1 said he wanted it reported. On 2/2/26, R1 informed Surveyor he didn't want to be changed but staff said they had to and R1 alleges his wrists were held down. The facility did not thoroughly investigate R1's allegation as R1 was not interviewed, CNA-K & CNA-D were not interviewed, and a statement was not received from RN-G. The facility did not interview any residents to see if there were any concerns regarding care provided to them.

Inspectors wroteBased on interview and record review, the facility did not ensure a person-centered baseline care plan was developed and implemented containing the minimum of required healthcare necessary to care for a resident within a resident's admission for 1 (R4) of 1 Resident reviewed for new admissions.*A person-centered baseline care plan was not developed with interventions necessary to care for R4 upon admission to the facility on 1/6/26.

Inspectors wroteBased on interviews and record review, the facility did not complete neurological checks in accordance with policy and procedure for 1 (R4) of 3 residents reviewed for unwitnessed falls.*R4 sustained two unwitnessed falls on 1/7/26. Facility staff did not complete neurological checks in accordance with the facility's policy and procedure.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure each resident received adequate supervision and assistance to prevent accidents for 2 (R4 and R2) of 3 residents reviewed for falls. *On 1/7/26, R4 had two unwitnessed falls on 1/7/26 and one witnessed fall on 1/8/26. The facility did not thoroughly investigate the falls and did not establish a root/cause analysis. *On 1/27/26, R2 had an unwitnessed fall, and the facility did not thoroughly investigate the falls and did not establish a root/cause analysis.

Inspectors wroteBased on observation, interview, review of the Food and Drug Administration (FDA) guidelines, and review of Manufacturer's Instructions for Use (MIFU), the facility failed to document inspections and maintenance per the MIFU recommendations of bed frames and bed rails, if present, for any of the 77 resident beds and did not perform FDA entrapment risk measurements for any of the 36 residents the facility identified as having bed rails, mobility bars, or assist bars. These failures created the potential for bed malfunctions and or resident injury.

Inspectors wroteBased on observations, record review, interviews, and policy review, the facility failed to maintain and serve food at safe temperatures. This failure created the potential for foodborne illness and compromised nutritional safety for five cognitively impaired residents who were able to self-propel to the activities room/dining area, as well as residents receiving meal trays in their room.

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to provide meal set-up assistance for one (Resident (R) 17) of three residents reviewed for activities of daily living (ADLs) out of a total sample of 17 residents. This failure could negatively impact residents' psychosocial wellbeing and overall quality of life and may contribute to unintended weight loss.

Inspectors wroteBased on record review and interviews, the facility failed to administer a prescribed medication to stabilize post-meal blood glucose as ordered for one resident (Resident (R) 5) of 17 sample residents reviewed. This failure had the potential to impair carbohydrate absorption and increase the risk of hypoglycemia (low blood sugar).

Inspectors wroteBased on interview and record review, the facility did not ensure 1 (R7) of 1 resident reviewed received a prompt resolution of 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.*R7 called the main facility phone number to express concern of the need for incontinence care and had been on the call light for 4-5 hours. Facility staff were aware of the concern but did not initiate a formal grievance in writing and investigate the concern thoroughly.

Inspectors wroteBased on interview and record review, the facility did not ensure residents are accurately screened for a mental disorder prior to the expiration of a 30-day exemption for 1 (R3) of 1 resident reviewed for the PASARR (Preadmission Screening and Resident Review).*R1 did not have a PASARR level 1 screen resubmitted prior to the expiration of the 30-day exemption documented on the original PASARR level 1.

Inspectors wroteBased on observations, record review and staff interviews, the facility did not ensure 1 out of 2 residents (R5) reviewed for being at high risk for falls, received adequate supervision and assistance devices to prevent accidents.*R5 is at high risk for falls and had 3 unwitnessed falls at the facility. The facility did not ensure they thoroughly investigated each fall to determine the root cause and to assure that all interventions were in place at the time of the fall and were effective.

Inspectors wroteBased on interview and record review the facility did not ensure that each resident maintained acceptable parameters of nutritional status, such as usual body weight unless the resident's clinical condition demonstrates that this is not possible, or resident preferences indicate otherwise for 1 of 1 (R1) resident reviewed for weight loss. R1 sustained a weight loss of 10.1 pounds / 6.61% over a period of 3 weeks with no physician or dietician notification.

Inspectors wroteBased on interview and record review, the facility did not report to the State survey agency and/or Law Enforcement in a timely manner timely for 1 (R2) of 1, abuse allegations reviewed.* On 6/2/2025, R2 reported an incident to Physical Therapy (PT)-D of inappropriate touching from R1. Staff did not report the allegation to Nursing Home Administrator (NHA)-A until 6/3/25.

Inspectors wroteBased on interview and record review, the facility did not ensure residents received the necessary behavioral health care and services to maintain the highest practicable mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for 1 (R1) of 1 resident reviewed for related to the residents emotional and mental well-being.*Surveyor reviewed a facility self-report from 6/13/2025, which pertained to behaviors of inappropriate touching with R1 being the aggressor. Nurse Practitioner (NP)-E, stated that currently R2's, psychiatric services are being managed by NP-E. NP-E indicated not being updated regarding alleged behaviors of R1's hands going inside of R2's shorts. There was no documentation that R1's POA was contacted in attempt to obtain consent for psychiatric services.

Inspectors wroteBased on observation, document review, interview and facility policy review, the facility failed to prevent misappropriation of resident property for five of five sampled residents (Resident (R) 9, R10, R11, R16, and R17). The facility failed to ensure security resulting in narcotic drug diversion by one of one staff (Registered Nurse 1). Failure to protect residents' property has the potential to affect the residents mental, emotional and financial status.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to notify the resident representative of a fall for one of three residents (Resident (R) 7) reviewed for notification out of a total sample of 17. This has the potential to cause family members to not have the opportunity to be involved in the resident's care.

Inspectors wroteBased on review of facility policy, record review, and interview, the facility failed to ensure the right to be free from verbal and potential sexual abuse for two residents (Residents (R) 3 and R12) of four residents reviewed for abuse/neglect out of a total sample of 17. The facility failed to ensure R3 was protected from verbal abuse by Certified Nursing Assistant (CNA1). The facility failed to protect R12 from potential sexual abuse from R13. These failures had the potential to cause physical harm, pain, or mental anguish.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to ensure that allegations of injury of unknown origin, verbal abuse, and neglect were reported to the State Survey Agency (SSA) in a timely manner for three residents (Resident (R) 2, R3, and R5) reviewed in a total sample of 15 residents. Specifically, the facility failed to report timely an allegation of injury of unknown origin involving R2; an allegation of verbal abuse involving R3; and an allegation of neglect involving R5. This failure had the potential for other allegations to not be reported in a timely manner.

Inspectors wroteBased on review of facility policy, record review, and interview, the facility failed to ensure two resident (Resident (R) 3 and R5) out of a sample of three residents reviewed for abuse allegations, had a thorough investigation completed for R5 and the five-day report was not submitted timely to the State Agency (SA) for R3. This failure had the potential to lead to continued episodes of abuse.

Inspectors wroteUNCORRECTED AT REVISIT Based on record review and interviews, the facility did not ensure they thoroughly investigated and attempted to find the root cause of a fall for 1 (R361) of 3 residents reviewed for being at risk for falls. R361 experienced an unwitnessed fall in her room on 11/12/24. When family entered the room, the wardrobe/dresser was observed to be on top of R361 who was lying on the floor of her room. R361 stated that she lost her balance while attempting to ambulate to the bathroom by herself after calling for help from staff with no response. Post fall, the facility did not review the wardrobe dressers utilized by facility residents to ensure they were safely secured to prevent other residents from having the wardrobe/dresser fall over creating a safety concern. [...]

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R38) of 1 sampled resident's potential allegation of misappropriation of property was reported to the State Survey Agency or the Nursing Home Administrator within 24 hours. *R38's family reported a missing necklace on 11/29/24 to a facility staff member. R38's missing gold necklace was not reported to the Nursing Home Administrator until 12/2/24. The investigation into R38's missing gold necklace did not start until 12/2/24.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents 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 2 of 2 residents (R5 and R48) reviewed for pressure injuries. * On 4/16/2024, R5 was noted to have an area of concern that was not comprehensively assessed and R5's pressure injury care plan was not revised until two days later on 4/18/2024. The area was then staged as an unstageable wound to R5's sacrum. Surveyor made observations on 10/1/2024 and 10/2/2024 of R5's care plan not being followed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure 3 of 4 residents reviewed (R38, R29, and R43) received adequate supervision and assistance, and that interventions were in place to prevent accidents. R38 sustained multiple falls resulting in injuries. A thorough investigation after every fall was not completed to determine root cause analysis. R38's care plan was not revised with recommended fall prevention interventions. R29 had a fall in their room on 9/24/24. Fall interventions were not in place at the time of the fall. R43's fall on 9/9/24 was not thoroughly investigated to determine the root cause.

Inspectors wroteBased on observation, interview, and record review, the facility did not store and prepare food in accordance with professional standards for food service safety potentially affecting 65 of the 66 residents in the facility. *Observations were made in the main kitchen of food open to air in the freezer, boxes of food stored on the floor, milk in the refrigerator past the expiration date, the dishwasher was in disrepair, and staff not wearing beard coverings while working in the kitchen preparing food.

Inspectors wroteBased on observations, interviews, and record review the facility did not establish and 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 for 4 of 4 (R24, R44, R48 and R60) residents reviewed for infection control. * The shared glucometer on Medication Cart A & D was not cleaned between residents' use. * R48's catheter bag was observed lying on floor on 10/2/2024.

Inspectors wroteBased on interview and record review the facility did not report 3 (R5, R111, R45) of 5 allegation to the State Survey Agency, Nursing Home Administrator, or local law enforcement during the required timeframe. R5 had an allegation of abuse and it was not reported to the Nursing Home Administrator until two days later, the alleged employee continued to work at the facility during those two days, and law enforcement was not contacted about R5's potential abuse allegation. R111's family members had a physical altercation in front of R111 and other resident's in the facility main dining room during meal service. Local law enforcement was notified and removed 1 of the individuals involved. The Nursing Home Administrator was not notified about the altercation until two days later at which time it was reported to the State Agency. R45's allegation of abuse was not reported timely.

Inspectors wroteBased on interview and record review, the facility did not ensure all allegations involving potential abuse, neglect, and misappropriation of resident property were thoroughly investigated for 3 (R5, R111, R45) of 5 Facility self-reports reviewed. R5's allegation of abuse reported on 7/8/2024 was not thoroughly investigated and residents were not protected from potential abuse during the abuse investigation. R111's family's verbal and physical altercation which occurred in the main dining room during meal time was reported on 6/22/2024 and was not thoroughly investigated. R45's allegation of abuse reported on 6/17/2024 was not thoroughly investigated.

Inspectors wroteBased on interview and record review, the facility did not complete a Preadmission Screening and Resident Review (PASARR) for individuals with a mental disorder for 2 (R4 and R52) of 2 residents reviewed for PASARR screening. *R4 was admitted [DATE] and the Level I PASARR was completed indicating R4 would be in the skilled nursing facility for less than 30 days. R4 discharged from the facility 2/21/2024. A Level I PASARR was not resubmitted/updated indicating R4 was going to be at the facility longer than the 30 exemption period triggering a Level II PASARR to be completed. R4 was admitted again to the facility on 4/4/2024 and a Level I PASARR was not completed. *R52 was admitted [DATE] to the facility and the PASARR Level I was not completed accurately to reflect R52's mental illness or psychotropic medications and a Level II PASARR was not completed.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure residents had an individualized comprehensive plan of care. This was observed with 3 (R48, R55, and R57) of 17 resident comprehensive care plan reviews. * R48 did not have a comprehensive care plan for R48's oxygen/respiratory monitoring/needs. * R55 did not have a comprehensive care plan for bowel monitoring. * R57 did not have a comprehensive care plan for bowel or bladder incontinence.

Inspectors wroteBased on interview and record review, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 1 (R55) of 2 residents reviewed. * R55 had concerns with feelings of abdominal pain and bloating and is on several bowel medications for management of constipation and diarrhea. The facility was not assessing or monitoring or assessing R55's bowel regimen.

Inspectors wroteBased on interview and record review, the facility did not ensure residents with urinary incontinence were comprehensively assessed to receive appropriate treatment and services to prevent complications and restore continence to the extent possible for 1 (R57) of 2 residents reviewed for incontinence. *R57's admission, quarterly, and significant change Minimum Data Set (MDS) assessments documented R57 was incontinent of bowel and bladder. No comprehensive bowel or bladder assessments were completed to determine a toileting program to decrease incontinence and no care plan was initiated to provide incontinence care on a scheduled basis.

Inspectors wroteBased on interview and record review the facility did not ensure that residents maintained acceptable parameters of nutritional status, such as usual body weight for 1 of 2 (R40) residents reviewed for weight loss. * R40 sustained weight loss which was not identified by the facility and the Dietician was not notified. Findings Include: The facility policy, entitled Weight Monitoring dated revised 1/2023 documents (in part) . . It is the policy of (facility) that appropriate nutritional care shall be provided to residents who have a significant weight change. A significant weight change is identified as a weight loss or gain of 5% in 30 days, 7.5% in 90 days or 10% in 180 days. Policy interpretation and implementation states: [...]

Inspectors wroteBased in observation, interview, and record review the facility did not ensure the necessary services to provide respiratory care were consistent with professional standards of practice for 1 (R48) of 1 resident reviewed for respiratory care. * R48's oxygen tubing and humidification were not labeled and dated. On 10/1/2024, R48's humidification was below the line/tubing so R48 was unable to benefit from humidification while R48's oxygen was running, R48's oxygen was set for 3 L (liters)/minute (Liters per minute) during survey and R48 order was for 2L/minute, and R48 did not have orders in place for care of oxygen supplies.

Inspectors wroteBased on interview and record review, the facility did not ensure that based on the comprehensive assessment of a resident, residents (R4, R1, and R3) received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and residents' choices. *R4 admitted to the facility on [DATE] and was to have admission lab work completed on [DATE] to get a baseline and because his labs on [DATE] at the hospital had some significant results. The facility did not obtain this lab work until [DATE]. The after hours Nurse Practitioner (NP) was notified of the lab results on [DATE] and ordered a repeat a CBC (complete blood count) on [DATE]. On the afternoon of [DATE], R4 fell in the parking lot while working with therapy and complained of hip pain after he was brought to his room. [...]

Inspectors wroteBased on record review and staff interviews, the facility did not ensure Certified Nursing Assistants (CNA) had annual performance reviews at least once every 12 months for 5 of 5 CNA staff reviewed (CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W). This had the potential to affect all 72 residents in the facility as staff assignments float throughout the facility. Findings Include: The facility was unable to provide a policy and procedure in regard to annual performance reviews. The facility's 2023 MyLearning-Required Annual Training Assignment Schedule documents that there should be Year End Review (All annual education needs to be done no later than 12/31/23). In-Person Annual Performance Review with follow up training for areas of weakness and special needs of residents. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure staff received annual Resident Rights training: Dietary (DIET)-Y, Certified Nursing Assistants (CNA), CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W. This practice had the potential to affect all 72 residents in the facility. The facility did not provide staff with the required annual Resident Rights training.

Inspectors wroteBased on staff interview and record review, the facility did not ensure staff received annual QAPI training: Dietary (DIET)-Y, Physical Therapist (PT)-X, Registered Nurse (RN)-N, Certified Nursing Assistants (CNA), CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W. This practice had the potential to affect all 72 residents in the facility. The facility did not provide staff with the required annual QAPI training.

Inspectors wroteBased on staff interview and record review, the facility did not ensure all employed staff received annual training on written policies and procedures of the facility's Infection Control Program. Dietary (DIET)-Y, Physical Therapist (PT)-X, Certified Nursing Assistants (CNA), CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W employee files were reviewed. This practice had the potential to affect all 72 residents in the facility. The facility did not provide the above staff with the required Infection Control training.

Inspectors wroteBased on staff interview and record review, the facility did not ensure staff received annual Compliance and Ethics training: Physical Therapist (PT)-X, Dietary (DIET)-Y, Registered Nurse (RN)-N, Certified Nursing Assistants(CNA), CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W. This practice had the potential to affect all 72 residents in the facility. The facility did not provide staff with the required annual Compliance and Ethics training.

Inspectors wroteBased on staff interview and record review, the facility did not ensure staff received annual Behavioral Health training: Physical Therapist (PT)-X, Dietary (DIET)-Y, Registered Nurse (RN)-N, Certified Nursing Assistants (CNA), CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W. This practice had the potential to affect all 72 residents in the facility. The facility did not provide staff with the required annual Behavioral Health training.

Inspectors wroteBased on observation and interview, the facility did not ensure privacy and confidentiality of personal health information for 9 (R13, R14, R15, R16, R17, R19, R1, R6, & R18) of 9 residents. On 6/18/24 Cluster C report sheet for R13, R14, R15, & R16 dated 6/17/24, Cluster D report sheet for R17, R19, R1, R6, & R18 dated 6/17/24 and CNA (Certified Nursing Assistant) worksheet dated 6/12/24 for R6, R18, R14, R17, R19, & R1 were observed on the round table in the dining area located on the D unit during multiple observations. These report sheets and CNA worksheets contained personal resident information.

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. (Physical Therapist (PT)-X, Dietary (DIET)-Y, Registered Nurse (RN)-N, Certified Nursing Assistants (CNA), CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W. The facility does not have an effective training program and does not maintain documentation of staff completing the required training's.

Inspectors wroteBased on interview and record review, the facility did not ensure 6 of 6 direct staff chosen at random received communication training. Registered Nurse (RN)-N, Certified Nursing Assistants (CNA) CNA-O, CNA-T, CNA-U, CNA-V and CNA-W did not receive communication training. This has the potential to affect the 8-10 residents who reside on each unit where RN-N, CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W are typically assigned.

Inspectors wroteBased on staff interview and record review, the facility did not ensure staff received annual Abuse/Neglect/Exploitation and Dementia training: Dietary (DIET)-Y, Certified Nursing Assistants (CNA), CNA-T, CNA-U, CNA-V, and CNA-W. This practice had the potential to affect 8-10 residents who reside on each unit where CNA-T, CNA-U, CNA-V, and CNA-W are typically assigned. The facility did not provide staff with the required annual Abuse/Neglect/Exploitation and Dementia training.

Inspectors wroteBased on record review and staff interview, the facility did not ensure that 5 of 5 CNAs (Certified Nursing Assistants) reviewed completed the required annual 12 hours of educational training hours. (Certified Nursing Assistants (CNA) (CNA-O, CNA-T, CNA-U, CNA-V and CNA-W did not receive annual 12 hours of educational training. This has the potential to affect the 8-10 residents who reside on each unit where CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W are typically assigned.

Inspectors wroteBased on record review and interviews, the Facility did not ensure that an allegation of abuse involving 1 (R5) of 3 Residents reviewed for allegations of abuse were reported immediately to the Nursing Home Administrator and State Survey Agency. *On 4/19/24 R5 informed the facility of an allegation of abuse involving Certified Nursing Assistant (CNA)-M. The facility did not report the allegation of abuse to the State Survey Agency until 4/22/24. The Nursing Home Administrator was not notified of the allegation until 4/22/24. Findings Include: The facility's policy entitled, Abuse Prevention, dated 9/2017 and last revised on 6/2020 documents: . Investigation A. The community will investigate and report any allegations of abuse within timeframe's as required by federal, state, and local requirements. Protection A. [...]

Inspectors wrote3.) R5 was admitted to the facility on [DATE] with diagnoses of Hypertensive Chronic Kidney Disease, Stage 3, Hyperlipidemia, Pulmonary Hypertension, and Pleural Effusion. R5 is currently her own person. R5's Annual Minimum Data Set(MDS) completed on 4/10/24 documents R5's Brief Interview for Mental Status(BIMS) score of 14, indicating R5 is cognitively intact for daily decision making. R5's MDS also documents that R5 has range of motion impairment of upper extremity on one side. R5 requires partial/moderate assistance with upper and lower body dressing. Substantial to maximum assistance for sit to lying, and lying to sitting. R5 requires supervision for transfers and mobility. The facility was informed by R5 on 4/19/24 that R5 requested assistance from Certified Nursing Assistant (CNA)-M. R5 stated that CNA-M responded in a rude and aggressive manner. [...]

Inspectors wroteBased on observation, interview, and record review the Facility did not ensure proper foot care for 1 (R3) of 3 Residents. R3's toenails were very long and in need of trimming.

Inspectors wroteBased on electronic medical record(EMR) review, and interview, the facility did not ensure adequate supervision and assistance devices, or ensure the environment remained free of accident hazards to prevent accidents for 1 (R4) of 2 Residents reviewed for falls. *R4 had a fall on 4/11/24 where the root cause of the fall was not determined, the facility did not complete documentation of the fall including witness statements and a registered nurse (RN) assessment and interventions were not not reviewed or initiated. Findings Include: The facility's Fall policy dated 12/2017 and last revised 7/2023 documents: .The licensed nurse shall document the fall in the Resident's clinical record. The documentation of the identified interventions should be maintained in the Resident clinical record and available to the direct care associates. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not ensure 1 (R1) of 1 residents received medically related social services to attain or maintain their highest practicable physical, mental and psychosocial well being. R1 was admitted to the facility on [DATE] with an order for Seroquel. The Facility was not monitoring the effectiveness of multiple medication changes with R1's Seroquel, Buspar & Depakote. The Facility did not determine the root cause of R1's anxiety and did not develop patient center approaches to help R1 with her anxiety.

Inspectors wroteBased on interview and record review, the facility did not maintain records that were complete and accurately documented for 3 (R12, R8, & R9) of 6 residents reviewed who expired in the facility. * R12 expired in the facility on [DATE] and there is no documentation in R12's medical record regarding R12's death. * R8 expired in the facility on [DATE] and there is no documentation in R8's medical record regarding R8's death. * R9 expired in the facility on [DATE] and there is no documentation in R9's medical record regarding R9's death.

Inspectors wroteBased on interview and record review, the facility did not ensure each resident was offered a COVID 19 immunization for 2 (R6 & R10) of 11 residents reviewed for their COVID 19 immunization.

Inspectors wroteBased on interview and record review the facility did not have a system in place to outline staff response in the event of a resident requiring cardiopulmonary resuscitation (CPR) and the facility did not have a system in place to maintain records documenting agency staff are qualified to perform CPR. This had the potential to affect 34 of 78 residents residing in the facility who have elected their code status to be full code (receive CPR). * On [DATE] R1 had a change in condition which led to CPR being performed. Registered Nurse (RN)-D left R1 to get the automated external defibrillator (AED) and other nursing staff were not aware of R1's change in condition and need to receive CPR until emergency medical technician (EMT) staff arrived at the facility. RN-D did not have a up to date CPR certification on file at the facility at the time of R1's event.

Inspectors wroteBased on observation and staff interview, the facility did not ensure all drugs and biologicals were stored in accordance with the facility's policy. One of 4 medication carts was observed unlocked and not under direct supervision of the nurse in charge of the cart. This had the potential to affect 14 residents whose medications were stored in the cart. The third floor medication cart was observed unlocked and against the wall for approximately 2 minutes. During that time, Resident (R) (R32) was observed opening the unlocked draws. The unlocked medication cart was not in direct supervision of the nurse on duty.

Inspectors wroteBased on staff and provider interview, and record review, the facility did not notify a provider of a significant weight loss for 1 Resident (R) (R67) of 4 residents reviewed for weight loss. R67 lost a significant amount of weight (defined as 10% loss in 6 months; 7.5% loss in 3 months; 5% loss in 1 month) between 7/5/23 and 7/26/23. R67's provider was not notified of the weight loss.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a written notification of transfer, including the reason for the transfer, location of the transfer, appeal rights, and contact information for the State Long-Term Care Ombudsman was provided for 3 Residents (R) (R14, R21, and R26) of 3 residents reviewed for hospitalization. R14 was not provided a written transfer notice when R14 was transferred to the hospital on 5/9/23. R21 was not provided a written transfer notice when R21 was transferred to the hospital on 6/18/23. R26 was not provided a written transfer notice when R26 was transferred to the hospital on 7/23/23.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 3 Residents (R) (R14, R21, and R26) of 3 residents reviewed for hospitalization received written information regarding the facility's bed hold policy, including the duration of the bed hold, the reserve bed payment policy, and the right to return to the facility. R14 was transferred to the hospital on 5/9/23 and was not provided a bed hold notice. R21 was transferred to the hospital on 6/18/23 and was not provided a bed hold notice. R 26 was transferred to the hospital on 7/23/23 and was not provided a bed hold notice

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 Resident (R) (R42) of 5 residents reviewed for unnecessary medications was monitored for adverse reactions to an antipsychotic medication. R42 was prescribed aripiprazole (an antipsychotic medication). The facility did not complete a tardive diskinesia (TD) (movement disorder characterized by uncontrollable, abnormal, and repetitive movements of the face, torso, and/or other body parts caused by prolonged use of treatments that block dopamine receptors in the brain, such as antipsychotic use) screening assessment to monitor for adverse reactions to the medication.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not establish and maintain an infection control program designed to provide a safe and sanitary environment to help prevent the development and transmission of disease and infection for 2 Residents (R) (R6 and R21) of 7 residents observed during the provision of cares. During the provision of cares for R6, Licensed Practical Nurse (LPN)-G did not appropriately remove gloves and cleanse hands. During the provision of cares for R21, Certified Nursing Assistant (CNA)-H did not appropriately remove gloves and cleanse hands.