Avina of Weyauwega

Inspectors wroteBased on interview and record review, the facility did not provide the necessary care and services to maintain the highest practicable physical well-being for 3 residents (R) (R29, R24, and R28) of 18 sampled residents. R29 had a diagnosis of chronic heart failure which was not included on their facility diagnoses list or care plan. In addition, the facility did not provide cardiac monitoring assessments for R29 or nursing interventions for heart failure and staff did not notify the provider of a significant weight change. R24 had a diagnosis of chronic heart failure. Staff did not weigh R24 as ordered or notify the provider of a significant weight change. R28 had a non-pressure injury on the left foot. R28's Treatment Administration Record (TAR) contained multiple missing entries for treatments in April and May of 2026.

Inspectors wroteBased on staff interview and record review, the facility did not provide pharmacy services to ensure the accurate administration of medication for 1 resident (R) (R1) of 3 sampled residents. R1 did not receive insulin, intravenous (IV) cefepime, levofloxacin, or blood sugar checks as ordered.

Inspectors wroteBased on staff interview, record review, and policy review, the facility did not ensure documentation that medications were administered was accurate for 1 resident (R) (R3) of 7 sampled residents. R3 was sent to the emergency room (ER) on 2/23/26 when staff indicated R3 was lethargic, sweaty, and difficult to arouse. Documentation sent with R3 indicated R3's bedtime (HS) medications were administered; however, the medications were not administered.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure an active physician order was in place for an indwelling catheter for 1 resident (R) (R1) of 3 residents reviewed for catheters. R1 had an indwelling catheter for which staff provided care. R1 did not have an active physician order for the catheter or for catheter care.

Inspectors wroteBased on staff interview and record review, the facility did not make a prompt and thorough effort to resolve a grievance for 1 resident (R) (R7) of 1 resident. R7's Guardian ((GD)-F) reported to Former Nursing Home Administrator (FNHA)-E that R6 provided R7 with illegal drugs and alcohol. FNHA-E did not file a grievance on behalf of R7 and the facility did not investigate the concern or follow-up with GD-F.

Inspectors wroteBased on staff interview and record review, the facility did not ensure care plans were updated for 2 residents (R) (R6 and R7) of 4 sampled residents. R6 and R7 had a history of drug and/or alcohol abuse. R6 and R7's care plans were not updated after R6 and R7 tested presumptive positive for cannabinoids.

Inspectors wroteBased on staff interview and record review, the facility did not develop a plan of care to address a mental health diagnosis and meet the psychosocial and emotional health needs of 1 resident (R) (R2) of 2 sampled residents. The facility did not accurately assess R2's mental health, which included a diagnosis of paranoid schizophrenia, to ensure R2's plan of care addressed R2's psychosocial and emotional health requirements. The facility's Treatment/Services for Mental/Psychosocial Concerns policy, dated 9/29/22, indicates: [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 3 residents (R) (R10, R4 and R5) of 3 residents observed during the provision of cares. R10 was on enhanced barrier precautions (EBP). On 6/27/25, staff exited R10's room without removing personal protective equipment (PPE) and transferred R10 with a lift without donning the appropriate PPE. In addition, staff did not sanitize the lift after use. During an observation of pericare for R4 on 6/27/25, staff did not appropriately remove gloves and complete hand hygiene and touched items in R4's room with soiled gloves. In addition, a used bed pan was stored on R4's floor. On 6/27/25, staff put clean wash clothes in an unsanitized sink and used them to complete pericare for R5. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for 2 residents (R) (R19 and R27) of 5 sampled residents which had the potential to affect more than 4 of the 49 residents residing in the facility, including 3 residents who shared a bathroom with R19. The facility did not ensure R19 smoked cigarettes in a safe manner consistent with the facility's smoking policy. R19 smoked in R19's room with no revisions to R19's care plan to ensure the safety of R19 or other residents in the vicinity. On one occasion, a hot cigarette butt had singed trash in a garbage can in R19's bathroom. R27 exited the building unsupervised on multiple occasions. [...]

Inspectors wrote3. From [DATE] to [DATE], Surveyor reviewed R300's medical record. R300 was admitted to the facility on [DATE] and had diagnoses including bacteremia, osteomyelitis of left ankle and foot, gangrene, diabetes, epilepsy, amputation of left toes, and right below-the-knee amputation. R300's MDS assessment, dated [DATE], had a BIMS score of 15 out of 15 which indicated R300 was not cognitively impaired. R300 was responsible for R300's medical decisions. On [DATE] at 2:02 PM, Surveyor reviewed R300's [DATE] MAR and noted R300's 10:00 AM 2 gm dose of ceftriaxone (an antibiotic medication) was not administered via R300's peripherally inserted central catheter (PICC) line on [DATE]. Code 2 was documented on R300's MAR which indicated away from home without medications. The order for 2 gm of ceftriaxone administered via PICC line daily was started on admission for osteomyelitis of the foot. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 49 residents residing in the facility. Kitchen staff did not complete appropriate hand hygiene. Logs for testing the parts per million (PPM) of the sanitizing solution in the sanitizer buckets were not completed. Staff did not appropriately test and maintain dishwasher temperatures. Staff completed unsanitary dishwashing.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection. This practice had the potential to affect all 49 residents residing in the facility. The facility's gastrointestinal illness (GI) outbreak line lists did not include last symptom dates or times for affected employees and residents. R24 should have remained on contact precautions related to GI illness until after 7:39 AM on 4/8/25. The facility removed R24 from contact precautions on 4/7/25. R44 should have remained on contact precautions related to GI illness until after 10:00 AM on 4/9/25. The facility removed R44 from contact precautions on 4/7/25. [...]

Inspectors wroteBased on staff and Ombudsman interview and record review, the facility did not ensure 2 residents (R) (R11 and R18) of 5 sampled residents received a written transfer notice that included the date of the transfer, the reason for the transfer, the location of the transfer, and appeal rights. In addition, the facility did not notify Ombudsman (OMB)-PP of hospital transfers and an involuntary 30-day discharge notice for 5 residents (R11, R18, R19, R24, and R49) of 5 sampled residents. R11 was transferred to the hospital on [DATE] and 1/3/25. R11 was not provided with a written transfer notice for either transfer. In addition, OMB-PP was not notified of the transfers. R18 was transferred to the hospital on 2/17/25. R18 was not provided with a written transfer notice. In addition, OMB-PP was not notified of the transfer. R19 was transferred to the hospital on 1/23/25. [...]

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure the provision of sufficient nursing staff to meet residents' needs. This practice had the potential to affect more than 4 of the 49 residents residing in the facility. R24, R29, R44, R3, and R53 expressed concerns with staffing and call light response times. In addition, R24's call light was activated for 1 hour and 19 minutes on 4/9/25. Two other residents' call lights were activated for 35 minutes and 55 minutes. On 4/8/25, Certified Nursing Assistant (CNA)-DD was the only staff present in the dining room. R23 and R402 require feeding assistance and had to wait until all other residents were served. R41 asked for water twice but was not provided water. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure drugs and biologicals were stored in accordance with the facility's policy in 1 of 1 medication storage room and 2 of 3 medication carts. In addition, unsecured narcotic medication was stored at the nursing station. This practice had the potential to affect more than 4 of the 49 residents residing in the facility. Medication carts on the B wing and near the nurses' station were left unlocked and unattended. In addition, seven medication cards, including schedule two narcotic medications, were observed in an unlocked desk drawer at the nurses' station. The E wing medication cart contained improperly labeled, undated, and/or expired medications. The D wing medication storage room contained expired medication and medical supplies and unlabeled medication.

Inspectors wroteBased on staff and resident representative interview and record review, the facility did not ensure an Advance Directive was followed for 1 resident (R) (R37) of 20 sampled residents. R37 had an activated Power of Attorney for Healthcare (POAHC) when R37 returned from the hospital and signed multiple consent forms on [DATE]. The facility did not request and obtain a capacity evaluation when R37's cognition improved after recovering from sepsis. In addition, R37's POAHC was not notified until [DATE] that R37 was deemed to b incapacitated on [DATE].

Inspectors wroteBased on staff interview and record review, the facility did not ensure Preadmission Screening and Resident Review (PASRR) requirements were met for 2 residents (R) (R9 and R19) of 6 sampled residents. R9's PASRR Level I Screen indicated R9 had a mental illness (MI) and a 30-day hospital discharge exemption. The facility did not obtain form F-20822 for R9's 30-day exemption and did not submit for a PASRR Level II Screen in a timely manner. R19's PASRR Level I Screen indicated R19 had an MI and a 30-day hospital discharge exemption. The facility did not obtain form F-20822 for R19's 30-day exemption and R19's medical record did not include a PASRR Level II Screen.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure the appropriate care and treatment was provided for 2 residents (R) (R53 and R44) of 5 residents reviewed for wound care. R53 was admitted to the facility with multiple wounds. The facility did not complete timely skin assessments or wound care for R53. The facility did not ensure R44 had a treatment order for an open area on R44's left lower shin and received timely wound care.

Inspectors wroteBased on staff interview and record review, the facility did not ensure physician visits were completed timely for 1 resident (R) (R36) of 5 sampled residents. Regulation allows for a physician to delegate alternating visits to a physician extender, such as a Nurse Practitioner (NP). R36 was not seen by a physician in February 2025 based on an alternating schedule.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not provide pharmaceutical services to meet the needs of 3 residents (R) (R300, R24 and R29) of 5 sampled residents. On 4/7/25, Surveyor observed a bottle of 60 milligram (mg) melatonin gummies on R300's bedside table. R300 did not have a physician order to keep medication at the bedside and did not have a self-administration of medication assessment that indicated R300 could self-administer medication. In addition, R300 did not receive bedtime (HS) medications on 4/3/25. On 4/7/25, Surveyor observed a bottle of bovine collagen pills, a bottle of liquid Imodium, and two albuterol inhalers on a table in R24's room. R24 did not have a physician order to keep Imodium at the bedside or a self-administration of medication assessment that indicated R24 could self-administer Imodium. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure sleep assessments or sleep monitoring was completed for 1 resident (R) (R29) of 5 sampled residents. R29 had an order for trazodone 25 milligrams (mg) at bedtime to promote sleep. The facility did not ensure sleep assessments or sleep monitoring logs were completed for R29 per the facility's policy.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 2 residents (R) (R27 and R36) of 5 sampled residents were provided influenza or pneumococcal vaccines as indicated. R27's Power of Attorney for Healthcare (POAHC) gave consent for R27 to receive the influenza vaccine. The facility did not administer the vaccine. R36 was eligible for and signed consent to receive a pneumococcal vaccine. The facility did not administer the vaccine. Findings Include: The facility's Influenza, COVID, and Pneumococcal Immunizations for Residents policy, dated 2/4/21, indicates: The facility's policy ensures that the resident receives influenza and pneumococcal immunizations per state and federal regulations and national guidelines .5. Influenza immunization will be offered in accordance with the Centers for Disease Control and Prevention (CDC) .5. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 resident (R) (R9) of 5 sampled residents was offered a COVID-19 vaccine as indicated. R9's Power of Attorney for Healthcare (POAHC) gave consent for R9 to receive a COVID-19 vaccine. The facility did not administer the vaccine.

Inspectors wroteBased on staff interview and record review, the facility did not ensure staff received required Quality Assurance Performance Improvement (QAPI) training. This practice had the potential to affect all 49 residents residing in the facility. The facility did not provide staff with required annual training on the facility's QAPI program.

Inspectors wroteBased on staff and resident interview and record review, the facility did not provide the necessary care and services to promote healing and/or prevent pressure injuries from developing for 1 resident (R) (R53) of 5 sampled residents. R53 was admitted to the facility with a pressure injury on the right buttock. The facility did not ensure thorough, accurate, and timely skin assessments were completed and did not ensure a treatment was provided.

Inspectors wroteBased on staff interview and record review, the facility did not provide timely access to a medical record for 1 resident (R) (R2) of 1 sampled resident. R2 requested a copy of R2's medical record in writing on 1/3/25. R2's medical record was mailed on 1/28/25 (25 days later) which was not in accordance with the facility's policy that indicated the facility would provide a copy within 7 days.

Inspectors wroteBased on staff interview and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 2 residents (R) (R5 and R6) of 3 sampled residents. R5 had a suprapubic catheter and was on enhanced barrier precautions (EBP). On 2/18/25, Certified Nursing Assistant (CNA)-D did not wear a gown during personal hygiene and catheter care for R5. On 2/18/25, CNA-E did not complete hand hygiene or change gloves appropriately during an observation of care for R6.

Inspectors wroteBased on staff interview and record review, the facility did not ensure adequate monitoring and administration for 1 resident (R) (R7) of 3 sampled residents who received psychotropic medication. R7 had an order for clozapine 25 milligrams (mg) twice daily (BID) for psychosis related to Parkinson's disease and a weekly complete blood count (CBC) with differential (diff) for monitoring. On 11/19/24, staff did not ensure the correct lab was drawn. R7 did not receive clozapine from 11/23/24 to 11/26/24 and was sent to the emergency room (ER) on 11/26/24 for symptoms of psychosis.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure they had sufficient nursing staff to provide care and services to meet the needs of 6 residents (R) (R1, R13, R11, R10, R2, and R12) of 13 sampled residents. R1, R13, R11, R10, and R2 reported cares were not completed timely due to staffing shortages. Multiple staff stated resident cares (including for R12) were not provided timely due to staffing shortages.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a Neurologist was notified when medication was not administered for 1 resident (R) (R7) of 4 sampled residents. R7 had an order for clozapine (an antipsychotic medication used to treat psychosis) twice daily. R7 did not receive clozapine from 11/23/24 through 11/26/24. R7's Neurologist was not informed that clozapine was not administered. R7 was hospitalized on [DATE] for psychosis symptoms, including attempting to ingest lotion.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not provide care and treatment to ensure the highest practicable well being for 3 residents (R) (R7, R3, and R5) of 13 sampled residents. R7 was admitted to the facility with a deep brain stimulator (DBS) for Parkinson's disease. Staff did not appropriately apply or charge the DBS as ordered. R3's care plan indicated R3 had an intimate relationship with R2. When R3 had a change of condition, including a decreased level of cognition, staff did not complete an updated assessment. R5 had a diagnosis of fungal candidiasis (a type of yeast infection). Oral care was not provided per R5's care plan.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for 1 resident (R) (R6) of 13 sampled residents. On 1/3/25, R6 fell when staff transferred R6 incorrectly and did not follow R6's care plan. In addition, the facility did not provide staff education in a timely manner. Batteries used for motorized wheelchairs were charged in a vacant resident room which did not have appropriate ventilation. The room was used for storage and did not have a door closure in place.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure accurate administration of medication for 2 residents (R) (R4 and R10) of 13 sampled residents. R4 was administered multiple scheduled medications late in December 2024 and January 2025. R10's scheduled pain medication was not administered on the 1/13/25 night (NOC) shift. In addition, R10's medications were left with R10 to take without staff supervision. R10 did not have a self-administration of medication assessment that indicated R10 could safely and accurately self-administer medication.

Inspectors wroteBased on staff interview and record review, the facility did not implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 1 resident (R) (R3) of 6 sampled residents. On 8/11/24, Certified Nursing Assistant (CNA)-C reported an allegation of verbal abuse involving CNA-D and R3. The facility did not report the allegation of abuse to local law enforcement.

Inspectors wroteBased on staff interview and record review, the facility did not ensure appropriate care and treatment was provided consistent with N6 Wisconsin Nurse Practice Act when 1 resident (R) (R2) of 9 sampled residents experienced a change of condition. On 5/16/24, R2 experienced a change of condition and indicated to staff that R2 was having difficulty breathing and felt like R2 was having a stroke. Certified Nursing Assistant (CNA)-D and CNA-J reported R2's change of condition to nursing staff on 5/16/24. Registered Nurse (RN)-C and Licensed Practical Nurse (LPN)-K did not adequately assess R2 or report R2's concerns to a physician. In addition, R2's change of condition was not reported to night shift staff on 5/16/24. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure competent staff completed nail care for 1 resident (R) (R3) of 9 sampled residents. In addition, the facility did not ensure competent staff completed vital signs which had the potential to affect multiple residents residing in the facility. Hospitality Aide (HA)-E was asked to complete nail care for R3 under the direction of Registered Nurse (RN)-C. HA-E and HA-L were asked to complete vital signs for multiple residents by RN-C. HA-E and HA-L were not enrolled in a Certified Nursing Assistant (CNA) course.

Inspectors wroteBased on staff interview and record review, the facility did not ensure protective placement was obtained for 2 Residents (R) (R21 and R35) of 4 sampled residents. R21 had a legal guardian at the time of admission on [DATE]. The facility did not obtain court-ordered protective placement for R21. R35 had a legal guardian at the time of admission on [DATE]. The facility did not obtain court-ordered protective placement for R35.

Inspectors wroteBased on staff interview and record review, the facility did not ensure written notification of Medicare Non-Coverage appeal rights were provided to 2 Residents (R) (R20 and R202) of 3 residents. In addition, the facility did not ensure written notification of financial liability was provided for 1 (R20) of 3 residents who remained in the facility when their Medicare Part A benefits ended. The facility did not provide an Advanced Beneficiary Notice (ABN) or Notice of Medicare Non-Coverage (NOMNC) form to R20 when R20's Medicare Part A benefits ended on 10/27/23 and R20 remained in the facility. The facility did not provide an ABN to R202 when R202's Medicare Part A benefits ended on 12/8/23 and R202 discharged home.

Inspectors wroteBased on staff interview and record review, the facility did not ensure timely transmittal of Resident Assessment Information (RAI)/Minimum Data Set (MDS) assessments for 2 Residents (R) (R28 and R41) of 72 sampled residents. R28's Comprehensive Assessment was completed 17 days late. In addition, R28's Death in Facility Tracking Record was completed 24 days late and transmitted 10 days late. R41's Quarterly Assessment was completed 32 days late. In addition, R41's Discharge Assessment was completed 4 days late.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure 1 Resident (R) (R21) of 16 sampled residents received the necessary care and services to maintain personal hygiene. R21 was dependent on staff for oral care. During an observation on 2/13/24, staff did not offer or provide oral care.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure a resident who was fed via enteral feeding (a way of sending nutrition right to the stomach or small intestine via tube) received care and services to avoid complications for 1 Resident (R) (R21) of 1 sampled resident. On 2/13/24, the head of R21's bed was lowered to less than 30 degrees while R21's tube feeding was being administered.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not provide appropriate care and services for 2 Residents (R) (R31 and R153) of 2 residents reviewed for respiratory care. R31's respiratory equipment was not sanitized and stored in a manner to maintain infection control standards. R153's respiratory equipment was not sanitized and stored in a manner to maintain infection control standards. In addition, R153 did not have a physician order for tracheostomy suctioning.

Inspectors wroteBased on staff interview and record review, the facility did not ensure vaccinations were reviewed, offered, or administered for 3 Residents (R) (R30, R23 and R153) of 5 residents reviewed for vaccines. The facility did not review R30's vaccination history or offer R30 the PCV20 (Prevnar 20®) vaccine. The facility did not review R23's vaccination history or offer R23 the PPSV23 (Pneumovax23®) or PCV20 vaccine. The facility did not review R153's vaccination history or offer R153 the PCV20 vaccine.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not develop and/or implement an individualized comprehensive care plan for 2 Residents (R) (R21 and R43) of 16 sampled residents. R21 needed assistance with activities of daily living (ADLs). The facility did not develop a comprehensive care plan that included interventions related to grooming and oral hygiene. In addition, R21's self-care performance deficit care plan contained an intervention that indicated R21 preferred to wear a gown and R21's potential for pressure ulcer care plan contained an intervention for a foot cradle to bed. The interventions were not consistently implemented. R43 incurred falls on 1/26/24 and 1/30/24. Following R43's fall on 1/26/24, interventions were to place R43's bed against the wall and use a Broda chair. [...]

Inspectors wroteBased on staff interview and record review, the facility did not provide the necessary care and services to maintain the highest practicable physical well being for 1 Resident (R) (R1) of 3 sampled residents. A Dermatology recommendation, faxed to facility on 6/13/23, recommended R1's provider consider discontinuing medications that could be causing bullous pemphigoid (BP) (a rare skin condition that mainly affects older people and usually starts with an itchy, raised rash. As the condition develops, large blisters can form on the skin.) The facility did not contact R1's provider, and R1's condition worsened. During a follow-up Dermatology appointment on 9/6/23, a second recommendation was issued to consider discontinuing medications that could be causing BP. The second recommendation was sent to R1's provider who implemented some of the recommendations, and R1's condition improved.

Inspectors wroteBased on resident and staff interview, and record review, the facility did not ensure the necessary care and services were provided to prevent pressure injuries from developing or worsening and/or promote healing for 1 Resident (R) (R2) of 3 sampled residents. R2 was admitted to the facility on [DATE] with a pressure injury to right ischium, full thickness stage four. The facility did not follow wound consultation recommendations for an antibiotic on 9/20/23 and 9/27/23. R2 was hospitalized on [DATE] due to a change of condition with diagnoses including osteomyelitis and sepsis.

Inspectors wroteBased on record review and staff interview, the facility did not ensure staff who cared for 2 Residents (R) (R40 and R346) (and potentially other residents) of 15 sampled residents had the competencies and skills to provide nursing-related services to assure resident safety. This had the potential to affect multiple residents in the facility who required assistance, including transfers, toileting, personal care, wound care and ostomy care. Former Social Services (SS)-C (who did not have a Nurse Aide Certification or Nursing License) and Civilian (CIV)-D (who was SS-C's spouse and was not employed by the facility) provided care to R40 (and potentially other residents) on [DATE]. In addition, SS-C provided care to residents on [DATE], including wound care for R346.

Inspectors wroteBased on observation, record review and staff interview, the facility did not ensure safe food handling practices were implemented. This had the potential to affect 51 residents residing in the facility. Dish machine water temperature gauges indicated water did not rise to required temperatures for rinse and/or wash cycles and surface temperature monitoring of dishes used to serve residents' food was not routinely conducted during dishwashing. Kitchen walls, ceilings, shelving, cooking surfaces, vents, air exchange units and a microwave were dirty with debris, food splatters, dust and/or a mildew-like substance. In addition, ceiling vents contained rusty areas. Ceiling vents and areas around the walk-in freezer also contained peeling paint. [...]

Inspectors wroteBased on record review and staff interview, the facility did not establish and maintain an infection surveillance program designed to help prevent the development and transmission of disease and infection which had the potential to affect all 51 Residents in the facility. The facility did not consistently maintain Infection Surveillance/Tracking Logs designed to assist with the detection of disease transmission patterns.

Inspectors wroteBased on staff interview, the facility did not ensure a staff person designated as the Infection Preventionist completed specialized training in infection prevention and control which had the potential to affect all 51 residents in the facility. Director of Nursing (DON)-B was the facility's designated Infection Preventionist (IP) in addition to performing full-time DON duties. DON-B did not complete specialized training for infection prevention and control before assuming the role of IP.

Inspectors wroteBased on record review and staff interview, the facility did not ensure COVID-19 testing was completed in accordance with the Centers for Disease Control and Prevention's (CDC's) recommendations for staff. This had the potential to affect all 51 residents in the facility. The facility did not consistently implement their process to track staff compliance with COVID-19 testing.

Inspectors wroteBased on record review and staff interview, the facility did not ensure all allegations of abuse and neglect were reported to Nursing Home Administrator (NHA)-A and the State Agency (SA) for 4 Residents (R) (R40, R346, R38 and R45) of 15 sampled residents. Former Social Services (SS)-C and Civilian (CIV)-D (SS-C's spouse who was not an employee of the facility) provided care to R40 despite the fact neither SS-C or CIV-D held a Nursing Assistant Certification or a Nursing License. The facility did not report the allegation to the SA. In addition, it was alleged SS-C provided care to R346's wound vac (a machine which assists in healing complex wounds) and assisted an unknown resident with ostomy (a surgical opening in the abdomen which alters the way stool is passed) care. NHA-A was not made aware of the allegation of colostomy care. [...]

Inspectors wroteBased on record review and staff interview, the facility did not ensure all allegations of abuse and neglect were thoroughly investigated for 4 Residents (R) (R40, R346, R38 and R45) of 15 sampled residents. Former Social Services (SS)-C and Civilian (CIV)-D (SS-C's spouse who was not an employee of the facility) provided care to R40. Neither SS-C or CIV-D held a Nursing Assistant Certification or a Nursing License. In addition, it was alleged SS-C provided care to R346's wound vac (a machine which assists in healing complex wounds) and assisted an unknown resident with ostomy (a surgical opening in the abdomen which alters the way stool is passed) care. The facility did not conduct a thorough investigation. The facility did not thoroughly investigate an allegation that R38 was inappropriately touched by R45.

Inspectors wroteBased on resident and staff interview, and record review, the facility did not notify a medical provider when 1 Resident (R) (R305) of 15 sampled residents experienced a significant change in physical status. Staff did not obtain a baseline weight when R305 was admitted to the facility on [DATE]. R305's weight was last obtained in the hospital and documented as 171.11 pounds on 1/5/23. On 1/11/23, staff weighed R305 and documented a weight of 148.4 pounds which was a 13.27 % weight loss since admission. The facility did not notify R305's Provider of the significant weight change.

Inspectors wroteBased on staff interview and record review, the facility did not ensure written notification of financial liability via an Advanced Beneficiary Notice (ABN) was provided for 2 Residents (R) (R4 and R19) of 2 residents who remained in the facility at the end of their Medicare Part A benefit period. The facility did not provide an ABN to R4 when R4's Medicare Part A benefits ended on 1/5/23 or R19 when R19's Medicare Part A benefits ended on 10/13/22. Both R4 and R19 remained in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure 1 Resident (R) (R6) of 15 sampled residents was free from falls. R6 had a history of falls. R6's current care plan interventions were not consistently implemented by the facility.

Inspectors wroteBased on resident and staff interview and record review, the facility did not ensure 1 Resident (R) (R305) of 15 sampled residents received a comprehensive assessment to address weight loss. Upon admission to the facility on 1/6/23, R305's weight was documented as 171.11 pounds which was obtained in the hospital on 1/5/23. The facility did not obtain a baseline weight for R305 upon admission. On 1/11/23, a weight of 148.4 pounds was obtained after Surveyor asked to have R305 weighed. Surveyor noted R305 incurred a 13.27% weight loss since admission.