Bayshore Nursing & Rehab

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to ensure two (Resident (R) 1 and R9) of four residents reviewed for physical abuse out of the sample of 11 residents were free from physical abuse. Specifically, in a resident-to-resident altercation, R2 hit R1 and R8 hit R9. These failure had the potential to cause harm for residents throughout the facility.

Inspectors wroteBased on record review and interviews, the facility failed to ensure care plans reflected the changing needs of residents to include a plan to maintain communication with family and a plan to be able to volunteer at a soup kitchen for two of 11 sampled residents (Resident (R) 6 and R7) reviewed for care plan revisions. This failure had the potential to cause unmet care needs, distress and a decline in psychosocial well-being.

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to perform medication administration by following accepted standards of identifying the resident prior to administering the medications for one of one resident (Resident (R) 5) reviewed for medication administration in the sample of 11 residents. This failure had the potential to cause decreased quality of life, medication adverse side effects, and exacerbation of health condition.

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to implement interventions to prevent elopement of a resident who eloped from the facility without the guardian's approval for one of three sampled residents (Resident (R) 6) reviewed for accident hazards and supervision in the sample of 11 residents. This failure had the potential for impaired judgments and/or unsafe decision making to cause serious harm to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility was not administered in a manner that enabled it to use its resources effectively to ensure residents attained or maintained their highest practicable physical, mental, and psychosocial well-being. This deficient practice had the potential to affect all 85 residents residing in the facility at the time of the survey.*The facility did not provide skin care treatments based upon accepted standards of practice and assessments. Residents sustained avoidable deterioration in wounds as a result of not being thoroughly assessed, care planned for interventions to prevent decline, and ongoing monitoring with revisions to the care plan. Wounds became infected and necrotic. Hospitalizations were required. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure the medical director followed through on his responsibilities regarding the coordination of care and treatment the residents received in the facility. This has the likelihood to cause serious harm, injury, or impairment to all 85 residents currently residing in the facility. Medical Director (MD)-QQ was not aware of and did not ensure facility residents with wounds had care and treatment necessary to prevent and heal pressure and non-pressure injury wounds. Medical Director-QQ deferred all wound care and treatment to the facility's wound team and Wound MD (Medical Doctor). [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents received treatment and care, based on a comprehensive assessment, in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) for non-pressure injuries, changes of condition, neurological checks after unwitnessed falls, or physician follow up visits for 3 (R97, R98, and R73) of 20 sampled residents. R97 developed an infection in a surgical wound and developed other non-pressure wounds that were not comprehensively assessed by a Registered Nurse (RN) or treated despite physician orders. Due to the severity of the wounds and infections that developed, R97 required both left and right above the knee amputations. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents with pressure injuries 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 5 of 5 residents (R98, R97, R10, R4, and R2) reviewed for pressure injuries. *R98 was admitted to the facility with a history of a stage 2 pressure injury to the right buttock. On 7/3/2025, nursing documented R98 was not able to get wound treatment or measurements completed but does not indicate what wounds required treatment or measurement. On 7/13/2025, nursing documented R98 has a pressure injury to the right lateral coccyx. On 7/16/2025, R98 was assessed by the wound physician and found to have unstageable pressure injuries to the right ischium and sacrum/right buttock. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure 3 (R58, R73, & R40) of 11 residents received adequate supervision and assistance devices to prevent accidents. 1.) R58 suffered a fall on 2/14/25 resulting in left sacrum fracture and right inferior pubic ramus fracture when interventions were not being implemented per R58's care plan. 2.) R73 had three unwitnessed falls, 6/25/2025, 7/1/2025, and 7/3/2025. The falls were not thoroughly investigated with a root cause analysis to determine appropriate interventions to prevent future falls. 3.) R40 did not receive supervision while smoking per R40's smoking care plan.

Inspectors wroteBased on interview and record review, the facility did not use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week and the facility did not ensure full time Director of Nursing (DON) coverage. This deficient practice has the potential to affect all 85 residents residing in the facility. *On 8/30/25, there was no RN who worked for 8 consecutive hours. *The Facility did not provide full time Director of Nursing (DON) coverage from 4/1/25 to 5/12/25 and again 7/31/25 until at least 8/4/25.

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 all 85 residents that eat food prepared by the facility.*In the facility's main kitchen, observations of hair restraints for facial hair not being utilized, scoop used for flour was placed down in the flour bin, and not in the scoop holder and silverware not being stored in sanitary conditions.

Inspectors wroteBased on interview and record review, the facility did not ensure it completed accurate mandatory submission of staffing information based on payroll data in a uniform electronic format to the Centers for Medicare & Medicaid Services (CMS). This had the potential to affect all 85 residents residing in the facility. Staffing information for Quarter 3 (April 1 - June 30 2025) of the Payroll Based Journal (PBJ) was not accurately submitted to CMS.

Inspectors wroteBased on interview and record review, the facility's Quality Assurance Committee did not make a good faith effort to identify and correct systemic deficiencies prior to the survey. This deficient practice has the potential to affect all 85 residents at the facility. During a recertification survey conducted on 9/9/25-9/30/25, it was determined 39 deficiencies existed including the deficient practice at F865, QAPI (Quality Assurance and Performance Improvement) Program/Plan, Disclosure/Good Faith Attempt. Four of the 39 deficiencies have been identified as immediate jeopardies related to wound care at F684, pressure injury care at F686, responsibilities of the medical director at F841 and facility administration at F835. F684 and F686 at the immediate jeopardy scope and severity are also substandard quality of care. [...]

Inspectors wroteBased on observation, interview and record review, the Facility did not establish and maintain an Infection Prevention and Control Program (IPCP) based upon current standards of practice, designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections. This deficient practice has the potential to affect all 85 residents. * The IPCP did not have documentation of an effective water management program (WMP). * The IPCP 2025 surveillance logs were lacking pertinent information and documentation. * The Facility Assessment lacked infection prevention and water management information. * R75 did not have contact isolation initiated when infection was discovered.

Inspectors wroteBased on interview and record review, the facility did not ensure they implemented their antibiotic stewardship program potentially affecting all 85 residents in the facility. Review of the facility infection surveillance logs for residents on antibiotics indicated antibiotic use without documentation of appropriate use of the antibiotic.

Inspectors wroteBased on interview and record review, the facility did not ensure medical records contained documentation related to COVID-19 immunizations for 5 (R6, R33, R40, R65 and R75) of 5 residents reviewed for immunizations and employee records contained documentation related to COVID-19 immunizations for 1 of 1 staff reviewed.*R6's medical record does not contain any documentation as to whether R6 was offered, received, or declined the COVID-19 immunization.*R33's medical record does not contain any documentation as to whether R33 was offered, received, or declined the COVID-19 immunization.*R40's medical record does not contain any documentation as to whether R40 was offered, received, or declined the COVID-19 immunization.*R65's medical record does not contain any documentation as to whether R65 was offered, received, or declined the COVID-19 immunization.*R75's medical record does not [...]

Inspectors wroteBased on observation, interview and record review, the facility did not maintain an effective pest control program to address the flying bugs in the facility. *Surveyors observed active pest activity from flies/flying bugs in multiple areas of the Facility's B Unit. *Surveyors observed active pest activity from flies/flying bugs in multiple areas of the Facility's C Unit.

Inspectors wroteBased on interview and record review, the facility did not ensure that 7 of 8 sampled staff received training on the facility's compliance and ethics program. This has the potential to affect the 85 residents who reside at the facility and have the potential to receive direct and indirect care from these staff. [...]

Inspectors wroteBased on record review and interview, the facility did not ensure 7 out of 8 staff chosen at random received behavioral health training to care for residents diagnosed with a mental, psychosocial, or other behavioral health conditions. This deficient practice has the potential for staff to lack current knowledge to work with the unique challenges mental health illnesses present and has the potential to affect all 85 residents that have the potential to experience behavioral health issues in the facility.

Inspectors wroteBased on interview and record review, the facility did not ensure residents whose Medicare part A benefits ended were provided with written beneficiary protection notifications for 4 (R15, R100, R101, R102) of 5 residents sampled for beneficiary notifications. The facility did not provide 4 Residents (R15, R100, R101, & R102) of 5 sampled residents a written Advanced Beneficiary Notice (ABN), which includes financial liability information and appeal rights, at the time Medicare Part A coverage ended.

Inspectors wroteBased on observation, interview and record review the Facility did not address and resolve grievances conveyed during Resident Council meetings on behalf of 12 of 12 residents who attended the meeting. Per July Resident Council meeting minutes residents expressed concern that staff were not wearing name tags. Surveyor noted no documentation this was thoroughly investigated, along with an appropriate resolution.

Inspectors wroteBased on record review and interview the facility did not ensure that the Minimum Data Set (MDS) assessment accurately reflected the resident's status at the time of the assessment for 12 (R5, R50, R66, R75, R34, R3, R4, R60, R2, R6, R65, and R9) of 20 residents reviewed. * R3, R4, R5, R34, R50, R60, R65, R66, and R75's MDS were inaccurately coded indicating a Preadmission Screening and Resident Review (PASARR) 2 was not required when the resident's PASARR 1 indicated residents having a severe mental illness. * R2's MDS assessment coded R2 having an indwelling foley catheter. R2 does not have an indwelling foley catheter. * R6's MDS did not accurately reflect that R6 had dental issues. * R9's MDS assessment coded anticoagulant use. R9 was not taking an anticoagulant medication.

Inspectors wroteBased on interview and record review, the facility did not ensure 4 (R13, R75, R66, R65) of 20 residents reviewed had a comprehensive care plan developed and implemented so that residents can attain their highest practicable physical, mental and psychosocial well-being. *R13, R75, R66, and R65 have diagnoses and or identification of behaviors that the facility has not established individualized care plan's to include interventions for staff to implement based upon assessments of individual residents needs.

Inspectors wroteBased on observation, interview and record review, the facility did not provide an ongoing program to support residents in their choice of activities, designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident. This deficient practice has the potential to affect all residents residing on the facility's C wing at the time of survey.*Surveyor had observations of residents on facility's C wing not being provided with appropriate activity choices.*Review of the facility's activity calendar indicates that a variety of meaningful activities are not consistently provided at the facility on weekendsFindings Include:Surveyor conducted observation on facility's C wing throughout the survey. On 9/10/25 at 9:00 AM, Surveyor observed R4, R11, R48, R49 and R83 in the C wing dining area around a table. [...]

Inspectors wroteBased on interview and record review, the facility did not complete a performance review at least once every 12 months for 3 of 4 Certified Nursing Assistants (CNA) reviewed. This had the potential to affect all 85 residents who reside in the facility. *The facility was unable to provide a performance review completed within the last year for CNA-JJ.*The facility was unable to provide a performance review completed within the last year for CNA-OO.*The facility was unable to provide a performance review completed within the last year for CNA-PP.

Inspectors wroteBased on interview and record review, the facility did not ensure the physician acted upon recommendations by the pharmacist for 5 (R3, R6, R33, R58, R66) of 5 residents reviewed with pharmacy recommendations. * R3, R6, R33, R58, and R66 had no documented physician response to pharmacist recommendations after the medication regimen was reviewed during the last six months and no indication pharmacist recommendations were followed up on.

Inspectors wroteBased on observation, interview, and record review, drugs used in the facility were not labeled in accordance with currently accepted professional principles, to include the opened on or expiration date when applicable for 1 of 2 medication carts reviewed. Medication cart B contained insulin that was not dated when opened and open stock medications that were not dated when opened.

Inspectors wroteBased on interview and record review, the facility did not ensure residents Pneumococcal immunizations were offered, or refused, as eligible. This was observed with 4 (R6, R33, R65, and R75) of 5 residents whose immunization records were reviewed. *R6, [AGE] years old, has no documentation of Pneumococcal vaccine being offered *R33, [AGE] years old, has no documentation of Pneumococcal vaccine being offered *R65, [AGE] years old, has no documentation of Pneumococcal vaccine being offered*R75, [AGE] years old, has no documentation of Pneumococcal vaccine being offered

Inspectors wroteBased on interview and record review, the facility did not ensure that 2 (R33 & R58) of 5 residents and/or their representative that were reviewed, were provided the risks and benefits for prescribed psychotropic medication. 1. R33 received psychotropic medication with no evidence the risks and benefits were explained, reviewed, or provided. 2. R58 received antipsychotic and antianxiety medications with no evidence of risks and benefits were explained, reviewed, or provided.

Inspectors wroteBased on observation and interview, the facility did not ensure that residents have reasonable access to use the telephone, in a place where calls can be made without being overheard. This concern was expressed by 1 (R35) of 12 residents attending the resident council meeting. Residents with a desire to use a facility phone have the options of the receptionist desk, Social Services office, nurse's station or by the vending and ice machines.

Inspectors wroteBased on observation and interview, the facility did not ensure a resident's right to a clean, comfortable, and homelike environment for 1 (R32) of 85 resident rooms observed. R32's floor was observed to be very sticky over multiple days.

Inspectors wroteBased on interview and record review, the facility did not ensure each resident's drug regimen was free from unnecessary drugs for 1 (R58) of 5 residents reviewed. R58 did not have adequate monitoring while receiving antipsychotic medication.

Inspectors wroteBased on interview and record review, the facility did not report 3 of 3 allegations to the state agency within the required time frame. R58 sustained a fall with fracture that was not reported to the state agency. R66 had an allegation of physical and verbal abuse by a staff member that was not reported to the state agency. R94 had an allegation of verbal abuse by a staff member that was not reported to the state agency within the required 2 hour time frame.

Inspectors wroteBased on interview and record review, the facility did not ensure 3 of 3 allegations of abuse were thoroughly investigated by the facility. R58 sustained a fall with fracture that was not thoroughly investigated by the facility. R66 had an allegation of physical and verbal abuse by a staff member that was not thoroughly investigated by the facility. R94 had an allegation of verbal abuse by a staff member that was not thoroughly investigated by the facility.

Inspectors wroteBased on interview and record review, the facility did not ensure 2 (R2 & R91) of 3 residents reviewed for hospitalizations received the proper notice of transfer or written notice of bed hold policy to include the rate to reserve the resident's bed. *R2 was transferred to the hospital on 5/9/25 and 6/13/25. A bed hold reserve bed payment rate/policy and procedure detail was not provided in writing to R2 upon transfer on 5/9/25, and a transfer notice and bed hold rate was not provided in writing to R2 upon transfer on 6/13/25. *R91 was transferred to the hospital on 7/26/25. A transfer notice and bed hold rate was not provided in writing to R91 upon transfer.

Inspectors wroteBased on interview and record review, the facility did not ensure 1 (R50) of 11 residents reviewed with a completed level 1 Preadmission Screening and Resident Review (PASARR) indicating a need for the completion of a level 2 PASARR had one completed. *R50's PASARR level 1 indicated R50 is suspected of having a serious mental illness and requires a PASARR level 2 screening. R50 did not have a PASARR level 2 screen completed within 30 days of admission to determine need for specialized services. R50's level 2 PASARR was completed almost 2 years post admission.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure 1 (R2) of 1 resident who is dependent with their activities of daily living received the necessary services to maintain their grooming and hygiene. R2's fingernails were observed to be extremely long, and R2's urinal was observed not to be emptied timely.

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R5) of 1 resident reviewed for post traumatic stress disorder (PTSD) received culturally competent, trauma informed care in accordance with professional standards of practice and accounting of resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of R5.* R5 does not have a person centered care plan for triggers and interventions for R5's PTSD diagnosis. R5 has no quarterly trauma assessments completed.

Inspectors wroteBased on observation, interview and record review, the facility did not comprehensively assess a resident before and after applying bed mobility devices. This was observed with 1 (R40) of 1 residents observed with bed mobility devices.*R40 was observed with bilateral bed mobility devices without any attempted alternatives, indication for use, or scheduled maintenance of mobility devices. R40's Bed Rail Assessment was incomplete and documented right bedrail only. R40 does not have a consent signed for mobility devices nor have a mobility device evaluation for installment. R40 does not have a physician order for mobility devices nor a physician order for monitoring of potential residual side effects with a mobility device.

Inspectors wroteBased on observation, interview and record review the facility did not ensure 1 (R6) of 1 residents reviewed for dental concerns had the necessary services for dental care. On 9/9/25 at 10:23 a.m. Surveyor interviewed R6. R6 explained he had broken teeth and was told he could see the dentist and no one from the facility has helped him with this concern. Surveyor observed broken and missing teeth in R6's mouth.

Inspectors wroteBased upon interview and record review, the facility did not ensure the medical records for 1 (R95) of 1 residents was accurate and complete based upon standards of practice. R95 was transferred to a hospital for care. The medical record does not include documentation for the reason for the transfer and where R95 was transferred to.

Inspectors wroteBased on interview and record review, the facility did not ensure that 1 of 4 Certified Nursing Assistants (CNA-JJ) reviewed completed the required annual 12 hours of educational training.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure the most recent State Survey results were readily accessible to residents, family members and legal representatives. This had the potential to affect all 85 residents who resided in the facility at the time of the survey. The facility State Survey results were not readily accessible for review.

Inspectors wroteBased on observation, interview and record review, the Facility did not ensure 1 (R1) of 3 Residents were provided with reasonable accommodations of Resident needs and preferences. R1 does not eat the Facility food and has her meals delivered one time a week. R1 stores her food in her room refrigerator and requests to have her food heated. The Facility was aware R1 does not eat the Facility food and did not heat R1's meal when requested.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents received adequate supervision and assistance devices to prevent elopements or accidents for 2 of 4 residents (R1 and R4) reviewed for elopement and falls. *R1 was discovered on the ground outside the facility’s front door on 5/6/2025 at 3:45 AM. R1’s fall was not thoroughly investigated to determine the root cause of the fall and the elopement out of the building was not investigated. On 7/10/2025 at 3:00 AM, R1 was discovered to be missing from the facility. The police found R1 at 4:55 AM on a bench at a street intersection 1.2 miles away from the facility. R1’s elopement was not investigated. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure residents right to be free from abuse for 1 of 1 (R5) residents reviewed for abuse. Facility staff witnessed a CNA (Certified Nursing Assistant) verbally abuse R5. The verbal abuse was not immediately reported to the Nursing Home Administrator, and the CNA continued to work the remainder of their shift, putting R5 and other residents at risk for additional abuse.

Inspectors wroteBased on interview and record review, the facility did not ensure that allegations of verbal abuse and/or misappropriation were immediately reported to the Nursing Home Administrator for 2 of 3 (R2 and R5) residents reviewed for abuse. R2's allegation of misappropriation of money and property was not reported to the Nursing Home Administrator (NHA)-A-or Social worker, resulting in delay of reporting to the State Agency. R5's (witnessed) verbal abuse was not immediately reported to the NHA-A or Social worker.

Inspectors wroteBased on interview and record review, the facility did not ensure nurse staff postings were accurate. This deficient practice has the potential to affect all 93 residents residing in the facility. Review of the daily nursing schedule and required nurse staff postings revealed inaccuracies with the total number of licensed and non licensed staff working and the number of nursing staff posted on the nurse staffing posting for 20 of 30 days reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents maintained acceptable parameters of nutritional status for 1 (R9) of 1 resident reviewed for weight loss and fluid management. R9 experienced severe weight loss over a period of 3 months, while receiving enteral feeding. The weight loss was not prescribed; no new interventions were implemented, and no assessments were completed to prevent R9's weight loss. R9 experienced fluid deficit resulting in hospitalization after labs were taken that indicated R9 was dehydrated. Starting on 6/18/25, vitals were not taken on R9 even after labs were ordered due to signs of dehydration and lethargy until R9 was sent to the hospital on 6/23/25. The facility's failure to assess R9's weight loss and implement new interventions created a finding of immediate jeopardy that began on 6/23/25. [...]

Inspectors wroteBased on interview and record review, the facility did not employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition services. The facility Dietary Director (DD)-T does not have a qualified certificate to manage the kitchen and is working under the supervision of Registered Dietitian (RD)-Q. RD-Q is working remotely from home and at other facilities and is not on-site full time for supervision. This had the ability to affect 91 of 91 residents.

Inspectors wroteBased on interview and record review, the facility did not implement and maintain an effective training program for facility staff consistent with their expected roles and based on the facility assessment for 5 of 5 facility staff (CNA- L , CNA-M CNA-N, CNA-O, CNA-P). This has the potential to affect the total census of 91 residents.

Inspectors wroteBased on interview and record review, the facility did not ensure that 5 of 5 direct care staff (CNA- L , CNA-M CNA-N, CNA-O, CNA-P) received mandatory training in effective communication. This has the potential to affect the total census of 91 residents.

Inspectors wroteBased on interview and record review, the facility did not ensure that 5 of 5 direct care staff (CNA- L , CNA-M CNA-N, CNA-O, CNA-P) received training on resident rights and facility responsibilities to properly care for its residents. This has the potential to affect the total census of 91 residents.

Inspectors wroteBased on interview and record review, the facility did not ensure that 5 of 5 staff (CNA- L , CNA-M CNA-N, CNA-O, CNA-P) received training regarding abuse, neglect and exploitation and what activities constitute abuse, procedures for reporting and dementia management and resident abuse prevention. This has the potential to affect the total census of 91 residents.

Inspectors wroteBased on interview and record review, the facility did not ensure that 5 of 5 direct care staff (CNA- L , CNA-M CNA-N, CNA-O, CNA-P). received training regarding elements and goals of the facility's QAPI (quality assurance and performance improvement program). This has the potential to affect the total census of 91 residents.

Inspectors wroteBased on interview and record review, the facility did not ensure that 5 of 5 direct care staff (CNA- L , CNA-M CNA-N, CNA-O, CNA-P) received mandatory training on infection control standards, policies and program. This has the potential to affect the total census of 91 residents .

Inspectors wroteBased on interview and record review, the facility did not ensure that 5 of 5 direct care staff (CNA- L , CNA-M CNA-N, CNA-O, CNA-P) received training on compliance and ethics. This has the potential to affect the total census of 91 residents .

Inspectors wroteBased on interview and record review, the facility did not ensure that 5 of 5 Certified Nursing Assistants (CNA- L , CNA-M CNA-N, CNA-O, CNA-P). received the required 12 hours of training per year. This has the potential to affect the total census of 91 residents .

Inspectors wroteBased on interview and record review, the facility did not report 1 of 2 allegations of abuse or neglect to the Nursing Home Administrator (NHA) or State Survey Agency during the required timeframe. * R8 pushed the Urgent Response button on R8's cellphone, which activates 911, when R8 was left on the bedpan for an extended period of time. This allegation of potential neglect was not reported in a timely manner as required to the Nursing Home Administrator (NHA) and the state agency.

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were thoroughly investigated for 1 (R8) of 2 allegations of abuse or neglect that were 1reviewed. R8 pushed the Urgent Response button on cellphone, which activates 911, when R8 was left on the bedpan for an extended period of time. Documentation of an investigation of the alleged incident were not located or provided.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure 2 (R1 and R4) of 9 residents received necessary care and treatment. * R4 was admitted to the facility on [DATE] with a surgical wound to the toes on the left foot. A comprehensive wound assessment was not completed until 1/30/25. R4 was readmitted on [DATE] and a comprehensive wound assessment was not completed until 2/21/25. * R1 had a physician order for an air mattress to be used. Surveyor observed R1 to not have an air mattress. R1 is at high risk for skin impairment.

Inspectors wroteBased on interview and record review, the facility did not ensure that 1 (R5) of 2 residents reviewed for pain management received pain management consistent with professional standards of practice and a resident's goals and preferences related to pain management.* The facility did not provide prescribed needed pain medication or offer non-pharmacological interventions for pain management for R1 on 4/16/25. The facility did not implement recommended pain medication and pain management prescribed by R1's pain clinic on 4/16/25. The facility did not update R5's care plan with person centered interventions for pain management. Findings Include:The facility's policy dated 1/1/25 titled Pain Management documents: [...]

Inspectors wroteBased on interview and record review, the facility did not provide pharmaceutical services to ensure medications were available to be administered as ordered by their physician to meet their medical needs for 1 (R1) of 4 residents.* R1 has an order to receive Oxycodone 5mg (milligrams) 3 times a day for pain related to other chronic pain effective 5/3/25. Prior to 5/3/25, R1 was receiving 7.5 mg of Oxycodone. R1 did not receive this pain medication on 4/26/25, 6/7/25 and 6/8/25 despite voicing pain.

Inspectors wroteBased on observation, record review, interview, and review of facility policy, the facility failed to ensure staff used appropriate personal protective equipment (PPE) for two (Residents (R)1 and R13) of two observed for enhanced barrier precautions (EBP) out of 15 residents reviewed in the sample. This failure had the potential to expose residents to infection.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to inform a resident of a lab draw so the resident could make a decision regarding the procedure for one (Resident (R) 3) of three residents reviewed for self-determination out of a total sample of 15 residents. This had the potential for the resident not be able to make a decision about daily care and services.

Inspectors wrote2. Review of R1's admission Record located in the EMR under the tab titled Profile revealed the resident was admitted to the facility on [DATE] with a diagnosis of gastrostomy (g-tube). Review of R1's Physician Orders dated 03/14/25 located in the resident's EMR under the tab titled Orders revealed the resident was to receive Nepro with Carb Steady at 60 centimeters (cc) from 6:00 PM to 6:00AM for a total of 720 cc. During an observation on 05/27/25 at 9:00AM revealed the resident was in bed positioned on his right side facing the door. The intravenous pole and feeding pump had dried, beige color, formula splatter. During an observation on 05/28/25 at 8:45 AM revealed the resident had tube feeding infusing at 60 ccs an hour with a water bolus bag hanging. The IV pole and feeding pump had dried beige color formula splatter. 3. [...]

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one (Resident (R) 3) of 15 residents whose assessments were reviewed in a total sample of 15 residents. The facility failed to accurately assess the rejection of care for R3. This failure placed the resident at risk of having unmet care needs and services.

Inspectors wroteBased on record review, interview, and review of facility policy, the facility failed to develop a baseline care plan for one Resident (R)1 from a total of 15 residents reviewed for care plans. This failure had the potential to cause staff to not provide the necessary instructions needed to provide effective care and meet the needs of resident.

Inspectors wroteBased on record review, observation, interview, and review of facility policies, the facility failed to revise the care plan of one resident (R2) out of 15 residents reviewed for care plans out of a total sample of 15 residents related to a new medication and a self-administration assessment. This had the potential for staff to not be aware of the resident's ability to administer medication per herself and cause confusion.

Inspectors wroteBased on interview and record review, the facility failed to ensure one (Resident (R) 4) of three residents reviewed for transportation services to outside medical appointments were transported to the correct medical provider out of a total of 15 sampled residents. This failure created the potential for medical needs to remain unaddressed for the resident.

Inspectors wroteBased on observation, record review, interview, and review of facility policy, the facility failed to properly position urinary drainage bag for one resident (R)1 from a sample of three residents with urinary drainage bags out of a total sample of 15 residents reviewed. This failure has the potential to promote reoccurring urinary tract infections (UTIs).

Inspectors wroteBased on observation, record review, interview, and review of facility policy, the facility failed to provide care of oxygen equipment for two residents (R9 and R15) from a sampled fifteen residents. The oxygen tubing for R9 was unlabeled with a date and sticky to the touch. This failure has the potential to provide unsanitary equipment for oxygen therapy.

Inspectors wroteUncorrected on revisit Based on observation, interview and record review, the facility did not ensure the Residents environment was comfortable and homelike. During the survey, the heat was not operational in areas of the facility and did not maintain a comfortable, homelike environment/living temperature for Residents within the facility. This had the potential to effect all 92 Residents residing in the facility at the time of the survey. * During the survey, the internal temperatures of the facility common areas and resident rooms were noted to be cold. Residents expressed they were not warm and comfortable in the facility. Residents were observed wearing winter coats, hats, multiple layers of clothing and using blankets to try to stay warm. Residents shared they were trying to seal out drafts in their rooms themselves instead of facility staff addressing the issues. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure 2 (R32 & R1) of 3 residents were assessed by the interdisciplinary team to determine it was clinically appropriate to self administer medication. * R32's albuterol inhaler was observed on the over bed table next to R32's bed. * On 1/23/25 two aspirin tablets were observed in a medication cup in R1's room. There was also a bottle of Vitamin C 1000 mg (milligrams), a bottle of Vitamin B12 500 mg, three bottles of Potassium Gluconate, and two bottles of Super B Complex observed in R1's room.

Inspectors wroteBased on interview and record review the facility did not ensure a residents physician was consulted with for 2 (R32 & R33) of 3 residents reviewed. * R32's physician was not consulted with when R32 received medication late for medication that were to be received BID/TID/QID (two times daily/three times daily/four times daily) on 12/30/24 to 1/22/25. * R33's physician was not consulted with when R33 received medication late for medication to be received BID/TID on 1/2/25 to 1/22/25.

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R32) of 4 residents reviewed for grievances had their grievances resolved. * R32's grievance regarding missing clothing in September 2024 was not resolved.

Inspectors wroteBased on interview and record review the facility did not provide pharmaceutical services to meet the needs of each resident for 2 (R32 & R33) of 3 Residents. * R32 did not receive scheduled medications one hour before or one hour after the scheduled time 48 times between 12/29/24 & 1/22/25. R32's medication during the day shift on 12/15/24 was not checked and initialed as being administered. * R33 did not receive scheduled medication one hour before or on hour after the scheduled time 27 times between 1/2/25 & 1/22/25.

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 30 opportunities which resulted in a medication error rate of 10%. Medication errors were identified for R44, R45, & R32. * R44 did not receive the correct dose of Folic Acid. * R45 did not receive multivitamin with minerals. * R32 did not receive the correct dose of Vitamin B12.

Inspectors wroteBased on observations, interviews, and review of facility policy, the facility failed to provide a sanitary environment for residents in three of four building wings (A, B, and C wings). This failure had the potential to promote the spread of disease and provide a breeding ground for pests.

Inspectors wroteBased on observations, interviews, and review of facility policy, the facility failed to ensure the facility's garbage was properly stored in two of two dumpsters and one enclosed area and disposed of timely. The failure had the potential to promote a breeding ground for pests and rodents.

Inspectors wroteBased on observations, interviews, review of facility policy, and a review of the facility's contract, the facility failed to maintain an effective pest control program throughout the facility. This had the potential to affect 102 of 102 residents who resided at the facility. During the survey, gnats and flies were observed in resident rooms, common areas, and in the administrative offices. This had the potential to promote the spread of disease and promote unsanitary conditions.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to protect the resident's right to be free from verbal abuse by a staff member for one of four residents (Resident (R) 4) reviewed for abuse out of a total sample of 14. Certified Nursing Assistant (CNA) spoke to R4 using verbally abusive language and had potentially aggressive behavior. Failure to protect residents from abuse has the potential to result in injury to residents.

Inspectors wroteBased upon interview and record review, the facility's governing body failed to fulfill the responsibilities of the governing body to include establishing an implementing policies and procedures regarding the operations of the facility. This has the potential to affect all 101 residents present in the facility at the time of the survey. The facility's governing body did not ensure contracted vendors were reimbursed and paid in accordance with established contracts or invoiced amounts causing the facility's fiscal accounts to be in arrears. This has created the likelihood where good and services necessary to maintain operations of the facility along with care and treatment of the residents may be impacted by the failures of the governing body.

Inspectors wroteBased on observation, interview, and record review the Facility did not dispose of garbage and refuse properly having the potential to affect all 100 residents in the Facility.

Inspectors wroteBased on observation, interviews and record review, the Facility's water management program (WMP) was inaccurate, incomplete and was not consistent with current American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) Guidelines, the Centers for Disease Control and Prevention (CDC) Toolkit, and the Wisconsin State Plumbing Code SPS 382.50, creating a potential for all 100 facility residents to be infected by Legionella or other water born bacteria. In addition, the Facility did not store or process linens to prevent the spread of infection. The WMP did not: ~Include water management team members who were knowledgeable about the facility's water system. ~Describe the building water system using an accurate flow diagram of the system with specific locations. ~Identify all locations where Legionella could grow and spread. [...]

Inspectors wroteBased on observation, interview, and record review the Facility did not maintain mechanical and/or electrical equipment in safe operating condition having the potential to affect all 100 residents in the Facility. Surveyor observed the following outside as a potential fire hazard: *Dryer vent with copious amounts of lint.

Inspectors wroteBased on observation and interview, the facility did not provide a safe, clean, comfortable, and homelike environment for 2 of 4 resident units with the potential to affect 53 residents residing on the units.

Inspectors wroteBased on observation, interview and record review, the facility did not provide reasonably accommodated access to 1 (R16) of 20 sampled residents who did not have equipment repaired timely according to resident's preference. * R16's wall fan was broken and not repaired or replaced timely.

Inspectors wroteBased on Interview and record review the facility did not ensure advanced directives were in the resident's medical record for 1 (R2) of 20 residents reviewed. R2 did not have a State Do Not Resuscitate (DNR) form to indicate if R2 was a full code or DNR. R2 had a facility DNR/ cardiopulmonary resuscitation (CPR) instruction consent form filled out that indicated R2 was a DNR however, a green sheet was located in R2's hard chart that had FULL CODE printed on it.

Inspectors wroteBased on interview and record review the facility did not ensure the 3 of 8 staff reviewed received the necessary background checks every four years. This had the ability to affect all 99 residents. CNA F's last background check was completed on 3/18/20 and the required 4 year check was due 3/18/24 and this was not completed. CNA G's last background check was completed on 3/12/20 and the required 4 year check was due 3/12/24 and this was not completed. CNA H's last background check was completed on 3/111/20 and the required 4 year check was due 3/11/24 and this was not completed.

Inspectors wroteBased on observations, interview, and record review, the facility did not ensure individualized comprehensive care plans were initiated for 1 (R94) of 5 residents reviewed for unnecessary medications and 1 (R94) of 1 resident's reviewed for the use of an indwelling catheter. R94 was prescribed an antidepressant medication and was admitted with an indwelling catheter. R94 did not have a comprehensive plan of care with individualized interventions to address the use of an antidepressant medication or for R94's indwelling catheter.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents received adequate supervision to prevent accidents for 1 (R64) of 5 residents reviewed for falls. R64 had unwitnessed falls on 3/29/2024, 5/6/2024 (4 falls same day), and 5/16/2024. R64 had a habit of moving self to the floor. Fall investigations were not thoroughly investigated to document when R64 was last checked on, toileted, what interventions were in place, or why R64 was lowering self to the floor.

Inspectors wroteBased on interviews and record review, the facility did not ensure residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; for 1 (R34) of 7 residents reviewed for nutrition. R34 sustained a significant weight loss of 9.60% from 2/7/24 to 5/10/24. R34's weights were not obtained in accordance with R34's physician orders.

Inspectors wroteBased on observation, interview and record review the facility did not ensure 1 of 2 medication storage rooms did not have expired stock medications. On [DATE] Surveyor observed 4 bottles of Vitamin B12 stock medication that was expired on 3/24 and 1 bottle of docusate sodium expired 4/24.

Inspectors wroteBased on observation and interview the facility did not provide adequate equipment to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member, or to a centralized staff work area, for 1 residents (R16) out of 20 sampled residents. * R16's call light did not work when pressed and R16 had to pull it out of the wall to get it to work.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure there were enough linens in the facility. This has the potential to affect more than a limited number of residents on any given day. There was a shortage of towels, washcloths, and sheets available for staff to assist residents with cares. As a result of this deficient practice, bath blankets were cut up for resident use as towels, showers were delayed due to no towels, and washcloths were provided as towels for personal care.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a baseline care plan was in place and copy shared with the resident/resident representative within 48 hours of admission for 4 of 5 residents (R11, R13, R14, and R15) reviewed for baseline care plan. As a result of this deficient practice, newly admitted residents may not receive needed nursing care, or interventions as directed by physician orders and resident assessment.

Inspectors wroteBased on observations, interview, and facility policy review, the facility failed to ensure there was consistent application of approved cleaning chemicals for the decontamination and daily cleaning of resident rooms for 2 of 4 resident hallways (Hallway B and C). As a result of this deficient practice, the failure had the potential to cause cross contamination of bacteria and potential to mix bleach with cleaning products causing hazardous fumes within the resident rooms.

Inspectors wroteBased on staff interview and record review, the facility did not designate a person to serve as the director of food and nutrition services who was a certified dietary manager, a certified food service manager, has a national certification for food service management and safety from a national certifying body, or who has an associate's or higher level degree in food service management or hospitality. This had the potential to affect all 105 residents residing in the facility.

Inspectors wroteBased on observation, staff and resident interviews, and record review, the facility did not implement a pest control program that effectively addressed flies and gnats. This had the potential to affect all 105 Residents (R) residing in the facility. Houseflies and gnats were observed in resident rooms and throughout all four wings of the facility.

Inspectors wroteBased on observation, and staff and resident interview, the facility did not ensure a sanitary, comfortable, and home-like environment for 3 Residents (R) (R9, R7, and R10) of 16 sampled residents. Surveyor observed a large, brown, dried spill on R9's floor on 10/9/23 and 10/10/23. Surveyor also observed a leaking toilet in R9's room. Surveyor observed areas of dirt and grime on R7 and R10's floor as well as white-colored splatter on furniture in the room. In addition, R7's bed lacked front wheel supports and the commode in R7's bathroom contained rust.

Inspectors wroteBased on staff and resident representative interview, and record review, the facility did not thoroughly investigate and resolve grievances for 3 Residents (R) (R7, R9, and R6) of 14 sampled residents. The facility did not thoroughly investigate, determine root-cause, document details, and provide satisfactory resolution to a grievance filed by R7's family on 4/20/23. The facility did not thoroughly investigate and document a grievance filed by R9's family on 5/15/23. The facility did not thoroughly investigate, document, and provide resolution to a grievance filed by R6 on 6/1/23.

Inspectors wroteBased on staff interview and record review, the facility failed to to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1105B of the Act for 2 Residents (R) (R15 and R16) of 4 residents reviewed. A facility investigation, dated 5/25/23, determined Certified Nursing Assistant (CNA)-U engaged in verbal abuse of residents on 5/18/23. The incident was not reported to law enforcement.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure the resident environment was as free of accident/hazards as possible for 3 Residents (R) (R1, R13, and R14) of 14 sampled residents. R1 obtained a second to third degree burn from coffee and did not have care plan and safety interventions implemented to prevent burns from hot liquids. R13 did not have care plan and safety interventions implemented to prevent burns from hot liquids. R14 did not have interventions in place to prevent an adverse outcome from ingesting cigarette butts.

Inspectors wroteBased on observation, staff interview and record review, the facility did not ensure food was prepared in a form designed to meet the needs of residents with a mechanically altered diet for 1 Resident (R) (R4) of 1 sampled resident. R4 had a diet order for Dysphagia Level 3 Advanced (smaller than bite-sized pieces/chopped) diet texture. During the lunch meal on 10/9/23, R4 was served spaghetti with whole meatballs and noodles. During the lunch meal on 10/10/23, R4 was served an oatmeal raisin cookie.

Inspectors wroteBased on observation, resident and staff interview, and record review, the facility did not ensure food preferences were honored for 1 Resident (R) (R4) of 1 sampled resident. R4's meal card listed R4's food dislikes which included spaghetti and tacos. During observations on 10/9/23 and 10/10/23, R4 was served spaghetti and taco meat.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure the designated Infection Preventionist (IP), Assistant Director of Nursing C was qualified as an IP to assess, develop, monitor, and manage the Infection Prevention and Control Program. This deficient practice has the potential to affect all 100 residents in the facility. * Director of Nursing (DON) B completed a certification in an infection control program in October of 2022. Corporate Consultant F informed Surveyor, DON B delegates the IP duties to Assistant Director of Nursing (ADON) C. Assistant Director of Nursing (ADON) C and Corporate Consultant F informed Surveyor ADON C is designated as the facility's IP. ADON C has not yet completed a certification in an infection control program. Corporate Consultant F stated Unit Manager Z helps with infection control. [...]

Inspectors wrote3. R2 was admitted to the facility on [DATE] with diagnoses including presence of prosthetic heart valve, schizophrenia, anxiety, depression, malignant neoplasm of prostate and chronic kidney disease stage four. R2's admission MDS (Minimum Data Set) Assessment with an Assessment Reference Date of 12/22/22 documented, R2 had a BIMS (Brief Interview for Mental Status) of 15, indicating R2 is cognitively intact; R2 required two person physical assist for transfers; and R2 had no falls either the last month prior to admission nor the last 2-6 months prior to admission. R2's fall risk assessments document the following scores with a score of 10 or greater meaning the resident is at risk for falls: on 03/17/22 score of 7 (not at risk); 04/26/22 score of 7; 09/19/22 score of 7; 10/07/22 score of 3; 11/03/22 score of 12 (At risk); 12/16/22 score of 9; 03/07/23 score of 8; [...]

Inspectors wroteBased on observation, interview and record review the Facility did not ensure 1 (R2) of 1 resident reviewed for anticoagulation medications were free of significant medication errors. * On 11/25/22 the facility failed to discontinue R2's Enoxaparin/Lovenox (anticoagulant) once R2's INR (international normalized ratio) was therapeutic according to orders. R2 received four additional doses of Lovenox, was hospitalized and needed to have INR reversed with vitamin K while in the hospital. * R2's Warfarin orders stopped from 12/26/22 until 1/10/23 without a reason as to why the Warfarin was stopped. On 2/27/23 R2 did not have a active physician's order for Warfarin or a PT/INR lab draw until 3/7/23. The Nurse Practitioner (NP) reported R2 should have been receiving 4 mg of Coumadin between 2/24 and 3/7/23 with INRs being checked 2 times a week and with INRs to be between 2.5 and 3.5. [...]

Inspectors wroteBased on observation and interviews the facility did not ensure residents right to a safe, clean, comfortable and homelike environment for 3 of 4 units observed with the potential to affect R10, R43, R27, and those residents residing on unit D * R10's window curtain was dirty and contained numerous incontinence brief tabs. * R43's bedroom floor was dirty, and there were paint chips and crumbling drywall observed. * R27's wall behind R27's bed was observed to have scattered chips of paint and dry wall gouged out along with a hole on wall where the dry wall is crumbling * Unit D hallway was observed to have paint chips, markings and and holes in walls. This deficient practice has the potential

Inspectors wroteBased on interview and record review, the facility did not ensure that 6 of 7 Residents (R) (R4, R63, R74, R64, R31 & 2) reviewed for hospitalizations and their responsible parties, received a transfer notice to include date of transfer, reason for transfer, location of transfer, appeal rights and contact information of the State Long-Term Care Ombudsman in writing. Additionally, the facility did not notify the State Long-Term Care Ombudsman of transfers and discharges. *R4 was transferred/discharged to the hospital on [DATE] and there is no indication the Guardian for R4 and the State Long-Term Care Ombudsman were notified of the transfer. *R63 was transferred to the hospital on 1/9/23 and 1/18/23. The State Long-Term Care Ombudsman was not notified of the transfer/discharge from the facility. *R74 discharged to the hospital on 1/6/23. [...]

Inspectors wroteBased on record review and interview, the facility did not provide a bed hold notice upon transfer to the hospital as required for 6 of 7 Residents (R) (R4, R63, R74, R64, R31 & R2) reviewed for hospitalization. *R4 discharged to the hospital on [DATE]. A bed hold notice was not provided to R4 and R4's representative at the time of transfer. *R63 discharged to the hospital on 1/9/23 and 1/18/23. A bed hold notice was not provided to R63 and R63's representative at the time of transfer. *R74 discharged to the hospital on 1/6/23. A bed hold notice was not provided to R74 and R74's representative at the time of transfer. *R64 discharged to the hospital four times. A bed hold notice was not provided to R64 and to R64's representative at the time of transfer. *R31 discharged to the hospital on [DATE], 12/14/22, 12/28/22, and 2/9/23. [...]

Inspectors wroteBased on observation, record review and interview the facility did not prepare food according to professional standards to maintain nutrition. [NAME] H was observed preparing pureed foods without using a recipe. This deficit practice has the potential to affect 5 of 5 residents recieving pureed foods. Fidnings include: On 03/14/2023, at 8:28 AM, Surveyor observed [NAME] H prepare puree food. [NAME] H began scooping cooked, chopped chicken into the food processor with a one cup scoop. [NAME] H put 6 and ½ cup scoops of chicken into the food processor. [NAME] H informed Surveyor she usually adds a little bit of broth at a time until the puree comes to the right consistency. Surveyor asked [NAME] H if she follows a recipe. [NAME] H stated no, I just add the broth to consistency. [NAME] H then placed 3 ounces of thickener into the food processor. [...]

Inspectors wroteBased on observation and interview the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in 1 of 1 kitchen. * Staff were not monitoring the accuracy of the temperatures on the high temperature dishwashing machine. * Staff member was observed touching ready to eat food items with a gloved hand, changing tasks wearing the same gloves, and then continuing to touch ready to eat food items without changing gloves or performing hand hygiene. * Food storage: Items stored in the freezer were observed closer than 6 inches from the floor. The reach in refrigerator had out dated food items. Items in the dry storage were observed to be close to the foil lined vent duck that was lower than the ceiling. [...]

Inspectors wroteBased on interview and record review, the facility did in ensure that an individualized plan of care was developed for 1 (R74) of 20 residents reviewed. *R74 is a diabetic and receives insulin. The facility did not develop an individualized plan of care to address that R74 is a diabetic and receives insulin. R74's plan of care also did not include that R74 often refuses insulin and includes specific interventions to assist R74 is being compliant with physician's orders. Findings Include: The facility's policy and procedure, titled, Comprehensive Care Plans, dated 10/01/22, documents: [...]

Inspectors wroteBased on observation, record review and interviews, 1 Resident (R73) of 1 dependent residents reviewed did not receive required assistance with Activities of Daily Living. * R73 did not receive assistance with toileting in accordance with facility protocol.

Inspectors wroteBased on observations, interviews and record review the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 3 (R301) residents reviewed for an RN assessment after having a fall and for 2 of 3 (R10 and R507) residents reviewed for skin integrity. * R301 fell on [DATE]. R301 reported she fell and the CNA put her back to bed. R301 reported her leg was broken. The CNA did not get an RN to conduct an assessment of R301 prior to placing R301 back into bed. There was no evidence of an RN assessment after R301 reported her leg broken, except for the ordering an X-ray, which confirmed the fracture. * R10 was admitted on [DATE] with current skin issues. R10's skin issues were were not comprehensively assessed or measured until R10 was seen by the would physician on 2/6/23. [...]

Inspectors wroteBased on interviews and record review the facility did not maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for 3 of 6 (R163, R11, R253) residents reviewed for nutrition and weight loss. * R163 was not weighed weekly according to the facility's policy. In additon, R163 had a documented weight loss of 5.2% in 1 month with no interventions. * R11 had oral surgery on 11/2/22 and having all her teeth extracted in preparation for dentures. Surveyor could not locate any Dietary progress notes after 11/2/22 when R11 had her teeth extracted to assess for pain and chewing. On 12/9/22 a significant weight loss was identified with a weight loss of 9% in 1 month with not interventions. [...]

Inspectors wroteBased on observations, interview, and record review, the facility did not ensure 1 (R74) of 1 residents reviewed, received appropriate respiratory care, including monitoring for signs and symptoms of COVID-19 infection. *R74 tested positive for COVID-19 on 3/11/2023. The facility was not monitoring R74 for signs and symptoms daily to ensure R74 did not develop symptoms or that R74's symptoms were improving. Findings Include: Surveyor requested a policy and procedure on monitoring a resident who is positive for COVID-19. Surveyor was provided with a copy of the facility policy Novel Coronavirus Prevention and Response, however, this policy did not address monitoring residents' symptoms who are positive for COVID-19. R74 was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus, Anxiety Disorder, and Pneumonia. [...]

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R63) of 1 residents who receive dialysis had the necessary assessment and care plan. * R63 receives dialysis and there are no assessments of R63's dialysis access site and R63's care plan does not address the care and treatment of R63's dialysis access site.

Inspectors wroteBased on observation and interview the facility did not ensure the accurate monitoring for expiration dates of all drugs and biological's to meet the needs of each resident for 1 of 1 (R69) residents reviewed.

Inspectors wroteBased on record review and interview, the facility did not have an attending physician review and document on an identified medication irregularity for 1 (R2) of 5 residents identified in a pharmacy medication regime report. * The facility did not have documentation the physician addressed R2's Pharmacy Recommendation from October 2022.

Inspectors wroteBased on record review and interview, the facility did not keep 1 (R2) of 5 residents reviewed free from unnecessary drugs. * R2 received Lovenox and Warfarin/Coumadin (anticoagulant) without adequate monitoring by ensuring PT/INR (prothrombin time test and international normalized ration) labs were conducted. R2's INR lab stopped after 12/26/22 until 1/16/23. On 1/16/23 R2's INR was 1.3 subtherapeutic. On 2/15/23 R2 was admitted to the hospital and readmitted on [DATE]. The hospital discharge summary indicated to do an INR on 2/27/23. There was no INR completed from 2/27/23 until 3/7/23. An INR result on 3/7/23 was 1.1 subtherapeutic. The Nurse Practitioner(NP) reported INRs should have been checked 2 times a week and with INRs to be between 2.5 and 3.5. There were no INR lab results between 3/13 and 3/19/23. [...]

Inspectors wroteBased on interview and record review, the facility did not implement individualized behavior monitoring for 2 (R2, R163) of 5 residents receiving psychotropic medications. *R2's behaviors were not monitored in accordance with standards of practice while receiving psychoactive medications. *R163's behaviors were not monitored in accordance with standards of practice while receiving psychoactive medications.

Inspectors wroteBased on observation, interviews and record review the facility did not ensure its medication error rates was not 5 percent or greater. There were 2 errors in 30 opportunities for R38 which resulted in an error rate of 6.67%. * On 3/15/23 at 7:39 AM Surveyor observed Licensed Practical Nurse (LPN)-AA prepare R38's medications. LPN-AA crushed the enteric coated Aspirin. LPN-AA also prepared 2 tablets of Cyanocobalamin Oral Tablet 500 mcg instead of 2 tablets of 1000 mcg as ordered.

Inspectors wroteBased on observation and interview the facility did not ensure drugs and biological's used in the facility were labeled in accordance with currently accepted professional principles, and include the expiration date when applicable for 1 of 2 medication rooms observed with the potential to affect R75. * 2 Insulin pens were observed to have been opened and used, but not dated when opened, one of which did not contain a label with a resident's name.

Inspectors wroteBased on observation and interview the facility did not ensure each resident received food and drink that is palatable, attractive, and at a safe and appetizing temperature for 1 of 1 (R157) residents reviewed. R157 breakfast tray consisting of fried eggs and sausage was observed on the tray table in his room for approximately 3.5 hours while he was at dialysis. R157 consumed the food upon return from dialysis.

Inspectors wroteBased on observations and interview, the facility did not ensure garbage and refuse were properly disposed in the outside garbage storage receptacles. This deficient practice had the potential to affect all 100 Residents residing at the facility during the onsite visit.