Beaver Dam Health Care Center

Inspectors wroteBased on observation and interview, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 75 residents who reside in the facility. Items in the refrigerator were improperly dated.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that they established and maintained an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections and conduct an annual review of its IPCP and update their program, as necessary, this has the potential to affect the census of 75. The facility does not have the IP (Infection Preventionist) on their Water Management Team. The facility has not reviewed all their infection control Policies and Procedures annually. Nurse did not clean the rubber cap of the insulin pen with alcohol before attaching the needle when administering insulin to R36. The facility failed to follow standards of practice during wound care for R1. This is evidenced by: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that services provided by the facility meet professional standards of quality for 4 of 5 residents (R6, R7, R4 and R8) reviewed for unnecessary medications. R6 is receiving Trazodone for insomnia, depression, and anxiety related to depression and did not have a sleep assessment/tracking completed for the insomnia diagnosis. R7 is receiving Melatonin for insomnia and did not have a sleep assessment/tracking completed. R4 is receiving antipsychotic medication and did not have a tardive dyskinesia (a neurological disorder characterized by uncontrollable, repetitive body movements) assessment completed. R8 is receiving antipsychotic medication and did not have a tardive dyskinesia assessment completed. Findings Include: The undated facility policy, Sleep Medication/Hypnotic Medication Monitoring Policy, indicates, in part: . [...]

Inspectors wroteBased on interview and record review the facility failed to ensure each resident had the right to request, refuse, and/or discontinue treatment, and to formulate an advance directive for 1 of 22 sampled residents (R53) and 1 of 1 supplement Residents (R9) reviewed for advance directives. The facility did not have guardianship paperwork on file for R9. The facility did not have a Do Not Resuscitate (DNR) form on file for R53 to match his wishes. This is evidenced by:The facility policy, titled Residents' Rights Regarding Treatment and Advance Directives, dated [DATE], states, in part: It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive. Policy Explanation and Compliance Guidelines:. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident (R11) is free from sexual abuse, from another Resident (R3). R3 was found performing sexual acts on R11. At the time of the event, the facility was unaware whether these two individuals had the capacity to consent to a sexual relationship.

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, are reported immediately to the administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law through established procedures for 2 of 2 incidents involving 3 residents (R3, R11, and R42). R3 was found performing sexual acts on R11 and the facility did not report the event to the State Agency. During a PM shift on 5/1/26, CNA S (Certified Nursing Assistant) and CNA T (Certified Nursing Assistant) reported to LPN U (Licensed Practical Nurse) that R42 has a black eye, an IUO (Injury of Unknown Origin). LPN U states CNA S and CNA T did not report R42's black eye. However, LPN U administered medication twice to R42 during her shift and did not note his black eye. [...]

Inspectors wroteBased on interview and record review the facility failed to have evidence that all alleged violations are thoroughly investigated. Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. and failed to report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident for 1 of 2 incidents involving 2 residents (R3 and R11). R3 and R11 were observed engaging in a sexual act and the facility did not conduct a thorough investigation.

Inspectors wroteBased on interview and record review, the facility did not ensure 1 of 5 residents (R5) reviewed for hospitalizations was provided a bed hold and transfer notice. R5 was hospitalized on [DATE], 5/7/26, and 5/14/26 without a bed hold or transfer notice provided. This is evidenced by: The facility's policy, titled Transfer and Discharge (Including AMA (Against Medical Advice)), dated 10/1/25, states, in part: Policy: It is the policy of this facility to permit each resident to remain in the facility, and not initiate transfer or discharge for the resident from the facility, except in limited circumstances. Policy Explanation and Compliance Guidelines:.12. Emergency Transfers/Discharge - initiated by the facility for medical reasons to an acute care setting such as a hospital, for the immediate safety and welfare of a resident (nursing responsibilities unless otherwise specified).g. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure each resident receives adequate supervision and safety to prevent accidents and hazards for 1 of 5 residents (R79) reviewed for accidents and hazards. On 4/26/26, R79 left the faciity on leave, and upon returning to the facility the following day, admitted to staff that he had used cocaine while he was out of the building. The facility failed to implement any ongoing monitoring for R79's substance use. Evidenced by:The facility policy, Substance Use Disorder, dated 2001, with a last revision date of November, 2022, states, in part: . Policy Explanation and Compliance Guidelines:. 4. The resident's history of substance use disorder and risk for using substances which could lead to an overdose while in the facility are identified to the extent possible and documented in the medical record. 6. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure each resident who was a trauma survivor received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for experiences and preferences in order to eliminate or mitigate triggers that may care re-traumatization for 1 of 2 residents (R79) reviewed for PTSD (Post-Traumatic Stress Disorder). R79 admitted to the facility with a diagnosis of PTSD. The facility failed to include PTSD on R79's comprehensive plan of care, nor were staff aware of any of R79's PTSD triggers. Evidenced by:The facility policy, Trauma Informed Care, dated [DATE], states, in part: [...]

Inspectors wroteBased on interview and record review, the facility did not develop, current up-to-date policies and procedures to ensure that each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized, this affects 1 of 5 residents (R8) reviewed for immunizations. The facilities Pneumococcal Vaccine (Series) dated 3/1/19 does not have the current up-to-date standard of practice involving an adults age. R8 has consent given for pneumococcal vaccine, the facility does not have documentation that the vaccine was offered or administered. This is evidenced by: Example 1The facilities Pneumococcal Vaccine (Series) dated 3/1/19, documents in part: .7. A series of vaccines will be offered to immunocompetent *adults > (greater than or equal to) 65, depending on current vaccination status and practitioner recommendation. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that each resident is offered a COVID-19 immunization, unless the immunization is medically contraindicated or the resident has already been immunized, this affects 1 of 5 residents (R8) reviewed for immunizations. R8 has consent given for COVID-19 vaccine, the facility does not have documentation that the vaccine was offered or administered. This is evidenced by: The facilities Infection Prevention and Control Program Policy and Procedure dated 10/1/25, documents in part: .10. COVID-19 Immunization: a. Residents and staff will be offered the COVID-19 vaccine when vaccine supplies are available to the facility. R8's Immunization Consent or Declination marks yes for COVID-19 vaccine, with verbal consent documented as obtained by POA (Power of Attorney) 11/4/25. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure each resident receives adequate supervision to prevent accidents and hazards for 1 of 3 residents (R1) reviewed for safety. On 2/27/26, a resident (R1) who smokes started a fire in her room using a lighter that she was deemed safe to have in her possession. R1 was not reassessed for safety after igniting material in her room and continued to have smoking materials in her possession without safety interventions being put in place to ensure she does not start another fire within the building. Residents in rooms next to R1 use oxygen. The facility's failure to reassess R1 after she started a fire with smoking materials, and the failure to implement proper safety interventions to prevent accidents created a finding of immediate jeopardy that began on 2/27/26. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that all residents are clinically appropriate to self-administer medications for 1 of 1 resident (R1) reviewed for self-administration of medications. Nursing staff reported to Surveyor that R1 has a backpack full of medications. R1 does not have a completed self-administration of medication assessment. Evidenced by:The facility policy, Self-Administration of Medications, dated 10/24, states, in part;.In order to maintain the residents' high level of independence, residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure each resident receives adequate supervision to prevent accidents/hazards with smoking material. Staff observed R3 to be smoking while using oxygen in his room this had the potential to affect R3 and 12 of 12 residents (R12, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, and R24) who reside on the 100 hall. R4 was observed not to have smoking material secured, R4 handed a cigarette lighter to R5 in the hallway. R3, R12, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, and R24 are cited at a severity level 4 (immediate jeopardy/pattern); R4 and R5 are being cited at a severity level 2 (potential for more than minimal harm). The facility's failure to ensure all staff follow proper safety interventions to prevent accidents created a finding of Immediate Jeopardy that began on 1/6/26. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that each resident is offered sufficient fluid intake to maintain proper hydration and health for 1 of 1 resident (R1) reviewed for hydration. R1 did not consistently meet his required fluid intake goals and was sent to the hospital, where he received IV (intravenous) fluids, on 3 occasions between 12/12/25 and 1/17/26. The facility failed to complete hydration assessments, monitor R1's fluid intake, failed to update the Dietitian and R1's provider when indicated and failed to implement additional interventions to prevent dehydration. Evidenced by:Surveyor requested the facility's hydration policy. No policy was provided. R1 admitted to the facility on [DATE] with diagnoses that included muscle wasting and atrophy (a loss of muscle tissue and mass leading to weakness); morbid obesity; [...]

Inspectors wroteBased on interview and record review, the facility did not ensure CNAs (Certified Nursing Assistants) received the required 12 hours of annual in-service training for 5 of 5 CNAs reviewed for in-service training. This had the potential to affect all residents who reside in the facility. CNA P, CNA/MA DD (Certified Nursing Assistant / Medication Assistant), CNA EE, CNA FF, and CNA GG did not have documentation of 12 hours of annual in-service training.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an effective pest control program so that the facility is free of pests, such as bed bugs for 4 of 4 residents reviewed (R14, R6, R15, R25). R6 indicated she has observed bed bugs in her room this week. Staff indicated they have seen bed bugs in R14's and R25's rooms within the last two weeks and captured one in a closed container to show NHA A (Nursing Home Administrator). Staff indicated they saw a bed bug in R15's room last night/this morning. Director of Maintenance K indicated he was not following manufacturer's guidelines for use of the facility's chemical treatment and does not know when the product was purchased or when it expires. NHA A indicated he was unaware the products were donated to the facility and not purchased. NHA A indicated he is unsure when the product expires or when it was opened. [...]

Inspectors wroteBased on interview and record review the facility failed to have evidence that all alleged violations are thoroughly investigated for 2 of 6 resident-to-resident altercations involving 4 Residents (R9, R10, R2, and R8). Resident to Resident altercation between R9 and R10 was not thoroughly investigated. Resident to resident altercation between R2 and R8 was not thoroughly investigated.

Inspectors wroteBased on observation, interview and record review the facility did not ensure that a resident who needs respiratory care is provided such care consistent with professional standards of practice for 2 of 2 residents (R3 and R1) reviewed for oxygen. R3 had Physician Notes with orders for oxygen therapy. These orders were not in R3's MAR/TAR (Medication Administration Record/Treatment Administration Record). Staff were unsure how many liters of oxygen R3 was supposed to be on. R1 did not have orders for bipap (bilevel positive airway pressure, non-invasive ventilation therapy used to assist with breathing.) and oxygen. Evidenced by: The facility's Oxygen Administration policy, undated, states, in part: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the residents' goals and preferences. 1. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that MAs (Medication Assistants) had 4 hours of medication based in-service training per year for 1 of 1 MA reviewed for in-service training. CNA/MA DD (Certified Nursing Assistant/Medication Assistant) did not have documentation of 4 hours of medication based in-service. Evidenced by:CNA/MA DD has a hire date of 3/20/06. CNA/MA DD's education record dated Year 2025 indicates 1 hour of completed inservice (0.5 hours in Quality Assurance and Performance Improvement and 0.5 hours in Compliance and Ethics. The record shows no medication based in-service. A Medication Administration Education for Nursing Staff form, dated 11/6/25, signed by CNA/MA DD, does not include documentation of credited in-service hours. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure each resident received the necessary care and services in accordance with professional standards of practice to meet each resident's physical needs for 3 of 3 sampled residents (R1, R3 & R2). R1 and R3 did not receive all scheduled wound care treatments as ordered. Facility did not update physician on missed wound care treatments. Facility did not provide residents with risks and benefits due to missing treatments. R2 did not have daily assessments while receiving antibiotic therapy. Evidenced by: The facility policy entitled, Wound Management, dated 2019, states, in part: . To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Policy Explanation and Compliance Guidelines: 1. [...]

Inspectors wroteBased on interview and record review, the facility did not provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 3 residents (R2) reviewed for medications. R2 did not have the correct order for his Gabapentin (medication to treat nerve pain). This is evidenced by:The facility's policy Preventing and Detecting Adverse Consequences and Medication Errors, dated 10/25/14, includes: When a resident receives a new medication, the medication order is evaluated for the following: 1) The dose, rout of administration, duration, and monitoring are in agreement with the current clinical practice, clinical guidelines, and/or manufacturer's specifications for use. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect 2 of 6 sampled residents (R3 and R6's) right to be free from abuse, neglect, or exploitation by a CNA I (Certified Nursing Assistant). R3 stated CNA I was rude to her, yelled at her, and refused to help her put her compression stockings on during morning cares (AM), resulting in a fall, and that she is terrified of CNA I. R6 stated CNA I mocks and belittles her, and often leaves her in a wet incontinence brief for over an hour. Evidenced by: Facility policy entitled Abuse/Neglect/Exploitation, undated, states, in part: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . Definitions: . [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse to the appropriate agencies for 2 of 2 abuse allegations involving Residents (R3 and R6). CNA F (Certified Nursing Assistant) reported an abuse allegation involving CNA I and R3 that occurred on 3/20/25 to NHA A (Nursing Home Administrator). R6 reported multiple incidents of CNA I mocking her accent to NHA A. These incidents were not treated as abuse and were not reported to the state agency. Evidenced by: Facility policy entitled Abuse/Neglect/Exploitation, undated, states, in part: Policy: [...]

Inspectors wroteBased on observation, interview and record review the facility did not ensure that a resident who is fed by enteral means receives the appropriate treatment and services for 1 of 1 resident (R5) reviewed for gastrostomy tube (G/T, or G-Tube) care. R5 had a G-Tube placed 11/8/24 and currently does not use it. R5 does not receive the appropriate care and treatment as ordered to G-Tube to maintain the patency. Evidenced by: The facility policy entitled, Enteral Nutrition, dated January 2025, states, in part: . Policy Statement: Adequate nutritional support through enteral feeding will be provided to residents as ordered. Policy Interpretation and Implementation: . 6. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 3 residents (R6) reviewed for pain. R6 was admitted to the facility with rhabdomyolysis (a condition where muscle tissue breaks down, causing sever muscle pain, tenderness, and muscle cramps). The facility failed to obtain R6's pain medication, and failed to offer R6 any non-pharmacological interventions to treat her pain, resulting in R6 having continued pain. Evidenced by: [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure each resident receives care, consistent with professional standards of practice (SOP), to prevent pressure injuries (PI) and each resident with PIs receives necessary treatment and services, consistent with professional SOP, to promote healing, prevent infection, and prevent new injuries from developing in 3 of 3 sampled residents (R49, R29, R63) and 1 supplemental resident (R5). (R29 is being cited at actual harm) R29 was identified to be at risk for PI development. R29 developed two stage 3 PI's and a stage 2 PI. The facility down staged R29's Pressure injury to a stage 2 when the PI contained slough. Facility staff reported they were not able to turn/reposition R29 every 2 to 3 hours as care planned. [...]

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. This has the potential to affect all 68 residents. Surveyor observed food that had been removed from original containers and not labeled with a use by date. Surveyor observed food that was uncovered and not labeled in the main refrigerator. Surveyor observed opened food without use by dates and expired food in circulation in the facility's kitchenette. Surveyor observed the microwave in the facility's kitchenette to have several multi-colored dried-on splatters on the inside. Evidenced by: Facility policy titled Food Receiving and Storage with a revision date of 1/2025 states in part . 7. Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date) .8. [...]

Inspectors wroteBased on interview and record review, the facility does not have a system for preventing, identifying, reporting, investigating, and controlling infections and communicable disease for all residents. This has the potential to affect the census of 68 residents. The facility's staff surveillance line lists do not include signs and symptoms (s/sx) of illness or specific symptoms, s/sx onset date, date of last s/sx, return-to-work dates, or area last worked. The facility's resident surveillance line lists do not include s/sx or specific s/sx, type of infection, and type of precautions with start and end dates. This is evidenced by: The facility policy titled, Infection Prevention and Control Program, dated 11/17, states, in part: . Policy: [...]

Inspectors wroteBased on interview and record review, the facility did not develop, implement, and maintain an effective emergency training program for all facility and contracted staff consistent with their expected roles and based on the facility assessment. This has the potential to affect the total census of 68 residents and 3 of 3 units. 15 different facility staff were interviewed on 3 of 3 units, who did not know where to locate emergency outlets during a power outage. Staff had not received training on electric power outages or emergency outlet use. Evidenced by: Facility policy titled Power Outage, undated, includes: it is the policy of the facility to protect our residents, staff, and others who may be in our facility from harm during emergency events. [...]

Inspectors wroteExample 6: R10 admitted the facility on 5/11/23. His most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 2/12/25, indicates R10's cognition is intact with a BIMS (Brief Interview for Mental Status) score of 15 out of 15. R16 admitted to the facility on [DATE]. His most recent MDS with ARD of 11/19/24 indicates R16's cognition is intact with a BIMS score of 15 out of 15. R47 admitted to the facility on [DATE]. His most recent MDS with ARD of 1/15/25 indicates R47's cognition is moderately impaired with a BIMS score of 12 out of 15. R36 admitted to the facility on [DATE]. Her most recent MDS with ARD of 11/18/24 indicates R36's cognition is moderately impaired with a BIMS score of 12 out of 15. R7 admitted to the facility on [DATE]. His most recent MDS with ARD of 12/2/24 indicates R7's cognition is intact with a BIMS score of 15 out of 15. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that the residents environment remained as free of accidents and hazards as possible for 2 of 2 sampled residents (R33& R10) and 8 supplemental residents (R47, R36, R16, R38, R59, R4, R13, R60) and 1 of 1 sampled resident (R263) reviewed for oxygen therapy. Surveyor observed a motorized wheelchair being charged in the main dining room with other residents present during meal time. Surveyor observed R263's portable oxygen tank to be on the floor below clothing that was hanging above it. Evidenced by: Facility policy, entitled Electric Wheelchair Policy dated 3/8/20 states in part . Due to the potential for fire or explosion, all electric wheelchairs will be recharged in an area which is not used by the residents for sleeping and which has no oxygen in the vicinity . Example 1: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure drugs and biologicals are labeled in accordance with currently accepted professional standards for 4 of 4 residents who had undated open insulin vials (R41, R48, R63, and R31) and did not ensure 2 medication carts were not left unlocked or with unlocked medications on top of the cart This is evidenced by: The facility policy, Storage of Medications, dated 10/25/14, states in part as follows: When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration (Note: the best stickers to affix contain both a date opened and expiration notation line). [...]

Inspectors wroteBased on interview and record review, the facility did not ensure each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized for 4 of 5 residents (R26, R10, R25, and R9) reviewed for immunizations. R26, R10, R25, and R9 were not offered pneumococcal vaccines. The facility does not have a declination or consent for the pneumococcal vaccine for any of the 4 residents. Evidenced by: The facility policy, titled Infection Prevention and Control Program, dated November 2017, states, in part: . Policy: It is a policy of this facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Policy Explanation and Compliance Guidelines: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that all residents are clinically appropriate to self-administer medications for 1 of 1 Residents (R9) reviewed for self administration. R9 was observed to have her medications left at bedside. This is evidenced by: The facility policy entitled, Self-Administration, undated, states, in part: . Policy: In order to maintain the residents' high level of independence, residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer. Procedures: A. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that a comprehensive person-centered care plan included a sleep assessment and sleep tracking for 1 of 5 residents (R25) reviewed for unnecessary medications and failed to ensure a comprehensive person-centered care plan included how to care for a tube feeding for 1 of 1 residents (R9) reviewed for tube feeding. R25 is receiving Melatonin for sleep and did not have a sleep assessment or sleep tracking completed. R25's care plan does not indicate Melatonin use. R9 is receiving nourishment through a feeding tube and R9's care plan does not indicate how to care for the tube. This is evidenced by: Surveyor requested facility policy for sleep assessments and document was not provided. Example 1 R25 was admitted to the facility on [DATE] with diagnoses that include, in part: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each resident. This has the potential to affect 1 of 2 sampled residents (R264) reviewed for activities. Surveyor observed R264 sitting in recliner in front of the television in R264's room for long periods of time. R264 is legally blind and R264's Preference Evaluation lists it is very important for R264 to keep up with the news and listen to music R264 likes, and somewhat important for R264 to be around animals. Facility has no documentation to show activities were offered to R264. R264's care plan does not list R264's interests. Evidenced by: The facility policy entitled, Activity, dated 11/17, states, in part: . Policy: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure each resident was provided care and services in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for 1 of 1 sampled residents (R43). R43 reported that she had an unwitnessed fall where she hit her head. Facility staff observed a bruise to R43's face, but did not initiate neuro checks or continue monitoring. Evidenced by: Facility policy, titled Falls Management Process, undated, includes: Obtain neurological checks per policy for any unwitnessed fall or any fall with evidence of injury to head. R43's Fall Investigation, dated 2/3/25, includes: On 2/3/25 . staff found a bruise on R43's forehead and hand and does not recall how it happened. Summary of critical information obtained during investigation: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that residents with an indwelling catheter received the appropriate care and services to prevent a urinary tract infection (UTI) for 2 of 2 residents (R26 and R63) reviewed for catheters as catheter bags were observed to be uncovered and resting on the floor. Surveyor observed R63's and R26's indwelling catheter bags to be resting in direct contact with the floor. This is evidenced by: The Centers of Disease Control and the Healthcare Infection Control Practices Advisory Committee - Guidelines for Prevention of Catheter-Associated Urinary Tract Infections 2009. III. Proper Techniques for Urinary Catheter Maintenance B. Maintain unobstructed urine flow. 1. Keep the catheter and collecting tube free from kinking. 2. Keep the collecting bag below the level of the bladder at all times. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure the provision of pharmaceutical services (including procedures that assure that accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 1 sampled resident (R9) reviewed for timing of medications. R9's levothyroxine was left at bedside and R9 self-administered the medication. Levothyroxine is scheduled for 6 AM and R9 took the medication at 11:17 AM. Evidenced by: The facility policy entitled, Medication Administration, dated 2002, states, in part: . Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and are only by persons legally authorized to do so . [...]

Inspectors wroteBased on interview and record review, the facility did not ensure they followed their antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for 1 of 5 (R26) sampled residents and 1 of 1 (R57) supplemental resident reviewed for antibiotic stewardship. R57 was on an antibiotic for a urinary tract infection. Facility did not have documentation of Culture and Susceptibility (C&S). Facility unable to determine if R57 met criteria to be treated with antibiotics. R26 was on an antibiotic for a urinary tract infection without an appropriate indication in December 2024 and January 2025. Facility did not have documentation of urinalysis (UA) and C&S. Facility unable to determine either time if R26 met criteria to be treated with antibiotics. Evidenced by: [...]

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure accurate administration of medication for 1 resident (R) (R2) of 5 sampled residents. R2 did not receive 2 doses of a scheduled intravenous antibiotic. In addition, multiple medication orders were transcribed incorrectly and R2 did not receive the medications as ordered.

Inspectors wroteBased on record review and staff and vendor interview, the Bedrock Corporation governing body did not ensure adequate funds were made available to provide for the safe and efficient management of the facility. The failure to maintain current payment status with service providers and vendors has the potential to affect all 54 residents in the facility. The Bedrock corporate governing body failed to maintain current payment status with several service providers and vendors which resulted in vendors refusing to provide services or providing discontinuation notices until payment is received, the governing body has not paid State bed tax or federal Civil Money Penalties (CMPs), the facility pharmacy provider was abruptly terminated after a past due notice was issued, including potential of disruption of service. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that residents are free of any significant medication error for 1 of 3 (R3) residents reviewed for medication administration. R3 did not receive ordered Nystatin suspension as scheduled on 7/12/24, 7/13/24, 7/14/24, 7/15/24, and 7/16/24. Evidenced by: Facility policy entitled, Medication Reordering dated 4/2023, states in part; It is the policy of this facility to accurately and safely provide or obtain pharmaceutical services including the provision of routine and emergency medications and biologicals in a timely manner to meet the needs of each resident. In the event of new orders, the facility is allowed (24) hours to begin a medication unless otherwise specified by the physician. [...]

Inspectors wroteExample 6: R2 was admitted to the facility on [DATE] and has diagnoses that include paraplegia (paralysis that affects the legs), type 2 diabetes, pressure ulcer of sacral regional stage 3, pressure ulcer of left buttock stage 3, pressure ulcer of other site stage 3, pressure ulcer of other site unstageable and acquired absence of right and left leg below knee (amputation of both legs below the knee). R2's Quarterly Minimum Data Set (MDS) Assessment, dated 3/15/24, shows R2 has a Brief Interview for Mental Status (BIMS) score of 15 indicating R2 has no cognitive impairment. R2's Treatment Administration Record (TAR) from 5/1/24 through 6/10/24 shows: -R (right) lower back/hip wound - Wash with NS (normal saline) or wound cleanser and dry with gauze. Apply border gauze daily, every day shift every other day for wound care. Order date 4/10/24. D/C (discontinue) date 6/11/24. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice when experiencing a change in condition for 2 of 4 sampled residents (R3 and R12). R3 had a change in condition on 5/8/24. R3's respiratory status was not fully assessed, there is no evidence of continuous monitoring of R3's condition or respiratory status, and R3's provider was not updated timely resulting in R3 being sent to the hospital on 5/10/24 for sepsis due to pneumonia. R12 had a change of condition following a fall including increased complaints of leg pain. The facility did complete a comprehensive assessment of R12 resulting in delay of treatment. Evidenced by: The facility's 'Notification of Changes Policy,' implemented 3/1/19, states in part: [...]

Inspectors wroteExample 5: On 6/11/24 at 10:57 AM, Surveyor interviewed R2. Surveyor asked R2 when he uses his call light, do the staff come timely? R2 stated, No, I gotta go to them. Surveyor asked R2 what about when you are in bed? R2 said then I wait 30-45 minutes for my call light to be answered. Example 6: On 6/11/24 at 12:06 PM, Surveyor interviewed FM T (Family Member.) Surveyor asked FM T what concerns she had with R3's care? FM T explained that R3 was admitted for wound care so that was the primary focus for her stay at this facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each resident. This affected 4 of 4 residents reviewed for activities (R5, R8, R9, and R10). The facility failed to create an activity program based on the current residents' interests, preferences, and familiar routines. The facility failed to look at and collect data or activity attendance for R5, R8, R9, and R10 to decide if the program that was in place for each resident was effective or not. Surveyor observed little to no interaction and activities in the location where R5, R8, R9, and R10 reside. Evidenced by: The facility policy titled, Activity, with no date, states, in part; [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that resident(s) and/or their families have the right to voice grievances to the facility, and the facility must make prompt efforts to resolve any grievances the resident may have for 1 of 6 residents (R3) reviewed for grievances out of a total sample of 11. R3's family voiced concerns to the facility that were not filed as grievances and the facility did not have evidence of following up. This is evidenced by: The facility's policy and procedure entitled Grievance dated 3/1/23 documents, in part: It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that 1 of 11 residents (R1) reviewed for Activities of Daily Living (ADL) received the necessary services to maintain personal hygiene. R1 voiced concern that R1 did not receive showers as scheduled. R1 voiced concern that R1 does not receive assistance with oral care, and has not had a toothbrush since admission to the facility. Evidenced by: The facility policy titled, Bathing a Resident, with no date, states, in part; .It is the practice of this facility to assist residents with bathing to maintain proper hygiene and help prevent skin issues. The facility policy titled, Oral Care, with no date, states, in part; .It is the practice of this facility to provide oral care to residents in order to prevent and control plaque-associated oral diseases . [...]

Inspectors wroteBased on interview and record review, the facility did not ensure residents received sufficient fluid intake or meal intake to maintain proper hydration and health for 1 of 4 sampled residents (R3). R3's fluid and meal intakes were not documented daily to ensure she met her fluid and nutrition needs. This is evidenced by: Facility policy entitled 'Hydration,' implemented 5/24/23 states in part: .The facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health. Definitions: Sufficient fluid means the amount of fluid needed to prevent dehydration (output of fluids far exceeds fluid intake) and maintain health. The amount needed is specific for each resident and fluctuates as the resident's condition fluctuates (i.e., increase fluids if resident has fever or diarrhea). [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents received food in the appropriate form for 1 of 4 sampled residents (R7). R7 did not receive a mechanical soft textured diet as ordered by his physician. This is evidenced by: The facility therapeutic spread report for altered texture diets is a spreadsheet that, in part, contains four columns labeled regular menu item, mech (mechanical) soft, finger foods, puree. The therapeutic spread report was printed on June 3, 2024, for week 1 Wednesday. The regular menu item column consists of, in part: . for breakfast Sausage patty 1 each . The mech soft column consists of, in part: .Sausage patty-Grnd (ground texture) 1.5 oz (ounces) . It is important to note, for the mechanical soft diet, ground sausage is to be served. [...]

Inspectors wroteBased on interview and record review the facility did not ensure staff postings were accurate which has the potential to affect 56 out of 56 Residents residing at the facility. Review of staffing schedules and required staff postings revealed discrepancies between the documents. This resulted in inaccuracies with the total number and the actual hours worked for licensed and non-licensed staff directly responsible for resident care each shift. This is evidenced by: Surveyor reviewed the schedules and staff postings from 5/1/24 thru 6/13/24 with the following inaccuracies: On 5/2/24, the Staff Posting indicates on AM (morning) shift that a medication technician (med. tech) was working with four CNA's (Certified Nursing Assistants), and the schedule reflects the Med. Tech for AM shift called off and 5 CNAs were working. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect all 61 residents. Surveyors observed a dusty vent in a food preparation area. A pizza with a questionable use by date was found in a kitchenette refrigerator.

Inspectors wroteBased on interview and record review, the facility has not established an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This has the potential to affect all 61 residents. The facility's resident infection control line lists do not include signs or symptoms (S/Sx), lab reports, culture and sensitivity (C&S) reports, and type of infection for all residents. The facility's policies have not been updated annually. This is evidenced by: The facility policy entitled, Infection Surveillance, dated 10/1/22, states, in part: . Policy: A system of infection surveillance serves as a core activity of the facility's infection prevention and control program. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure they followed their antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for 1 of 5 sampled residents (R12) and 8 of 8 supplemental residents (R164, R17, R128, R155, R29, R26, R2, and R161) reviewed for antibiotic stewardship. R12 was treated for a urinary tract infection (UTI) with no documentation for criteria and C&S. R164 was put on the resident line list for being treated for pneumonia. Hospital discharge states R164 treated for UTI. There is no urinalysis (UA), or culture and sensitivity (C&S) provided. R17 was treated for a UTI per line list with no documentation for criteria or sensitivity. R128 was treated for a UTI with no documentation for criteria and C&S. R155 was treated for E. Coli septicemia with no sensitivity or criteria documentation. [...]

Inspectors wroteBased on interview and record review, the facility did not allow all residents the right to choose their health care provider. This affected 1 of 1 resident's (R45) reviewed for choice of physician. R45 was not allowed to choose his own physician and was assigned a physician determined by the facility. This is evidenced by: R45 admitted to the facility November of 2023. R45 has the following diagnoses: peritoneal abscess, type 2 diabetes mellitus without complications, methicillin resistant staphylococcus aureas (MRSA) infection, and open wound of abdominal wall. R45's most recent Minimum Data Set (MDS) dated [DATE], documents of score of 15 on his Brief Interview of Mental Status (BIMS), which indicates that R45 is cognitively intact. The Facility's Policy and Procedure entitled Choosing a Personal Attending Physician dated 3/26/19, documents in part: .1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not make prompt efforts to document, investigate, and resolve grievances a resident may have for 1 of 2 residents reviewed for grievances (R43). R43 reported to staff that she was missing socks. Evidenced by: The facility's policy titled Grievance implemented on 3/1/19 states in part .The facility will ensure prompt resolution to all grievances, keeping the resident and resident representative informed throughout the investigation and resolution process .G. Response: Any employee of this facility who receives a complaint shall immediately attempt to resolve the complaint within their role and authority. If a complaint cannot be immediately resolved the employee shall escalate that complaint to their supervisor and the facility Grievance Official . [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made in accordance with State law through established procedures. this affected 1 of 17 residents (R38) reviewed for abuse. R38 reported an allegation of verbal abuse, and it was not reported to the State Agency. This is evidenced by: R38 has the following diagnoses: chronic pain syndrome, major depressive disorder, anxiety disorder, bullous pemphigoid, morbid (severe) obesity due to excess calories, and schizophrenia. R38's most recent Minimum Data Set (MDS) dated [DATE], documents of score of 12 on her Brief Interview of Mental Status (BIMS) which indicates that she is moderately impaired cognitively. [...]

Inspectors wroteBased on interview and record review, the facility did not have evidence that all alleged violations were thoroughly investigated. This affected 1 of 1 resident's (R38) reviewed for abuse investigations. R38 reported an allegation of verbal abuse, and it was not thoroughly investigated. This is evidenced by: R38 has the following diagnoses: chronic pain syndrome, major depressive disorder, anxiety disorder, bullous pemphigoid, morbid (severe) obesity due to excess calories, and schizophrenia. R38's most recent Minimum Data Set (MDS) dated [DATE], documents of score of 12 on her Brief Interview of Mental Status (BIMS) which indicates that she is moderately impaired cognitively. The Facility's Policy and Procedure entitled Abuse, Neglect, and Exploitation dated 10/1/19, documents in part: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents who are unable to carry out activities of daily living receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. This has the potential to affected 2 of 2 residents (R31 and R46) reviewed for Activities of Daily Living (ADLs). R31 was observed to have long facial hair, to have food on his gown, and have blood-stained sheets. R46 noted to have long and dirty fingernails and reported long toenails in need of trimming. This is evidenced by: The facility's policy titled Shaving with an Electric Razor implemented on 3/1/19 states in part It is the practice of this facility to assist residents with grooming facial hair to help maintain proper hygiene . [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had complete wound care orders, orders were followed, and proper documentation of wound care completion in Treatment Administration Record (TAR). This affected 2 of 17 residents (R7 and R45) with reviewed Physician orders. R7 has incomplete wound care orders and part of wound care was not completed during observation. R45 has incomplete wound care orders and documentation in R45's TAR is inaccurate. This is evidenced by: The Facilities Policy and Procedure entitled Wound Management undated, documents in part: .1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change .7. Treatments will be documented on the Treatment Administration Record . [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the resident environment remains as free of accidents hazards and each resident receives adequate supervision. This affected 2 of 7 sampled residents (R104 and R454) R104's electric wheelchair charges in his room. R454 has a history of wandering and was not monitored by staff. This is evidenced by: The Facility does not have Policy and Procedure for charging electric wheelchairs. Example 1 On 3/5/24 at 10:17 AM, Surveyor observed R104's electric wheelchair charging in his room. On 3/5/24 at 11:28 AM, Surveyor interviewed R104. Surveyor asked R104 if his electric wheelchair is usually charged in his room, R104 said they usually take it elsewhere to charge but last night I wanted to get into bed. [...]

Inspectors wroteExample 2 R38 was admitted to the facility on [DATE] with diagnoses that include major depressive disorder, anxiety disorder, and schizophrenia. R38 takes the antipsychotic medication Paliperidone ER (Extended Release) oral tablet one time a day for schizophrenia. Surveyor requested that the facility provide a completed Abnormal Involuntary Movement Scale (AIMS) to measure involuntary movements known as tardive dyskinesia- a disorder that develops as a side effect of long-term treatment with antipsychotic medications) for R38. On 3/7/24 Surveyor received an AIMS for R38 that was completed on 3/7/24. On 3/7/24 at 4:07 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if R38 should have had an AIMS completed prior to 3/7/24, DON B stated yes, she probably should have had one. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure the resident's medical record includes documentation that indicates, at a minimum, the following: (A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza and/or pneumococcal immunization; and (B) That the resident either received the influenza and/or pneumococcal immunization or did not receive the influenza and/or pneumococcal immunization due to medical contraindications or refusal. This affected 2 of 5 residents (R7 & R38) reviewed for immunizations. R7 did not sign, date, or check consent or declination for the influenza vaccination for 2023. R38 did not sign, date, or check consent or declination for the influenza vaccine for 2023. This is Evidenced by: [...]

Inspectors wroteBased on interview and observation, the facility did not maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 17 residents (R2) reviewed for appropriately working equipment. R2's shower chair was observed to be broken and facility staff continued using it.

Inspectors wroteBased on interview and record review, the facility failed to provide care consistent with professional standards of nurse practice (N6, Wisconsin Nurse Practice Act) by failing to monitor a resident while the resident was experiencing a change in condition despite an order from the primary physician to monitor for 1 (R2) of 3 residents reviewed for change in condition out of a total sample of 12 residents. R2 experienced a change in condition on 12/17/23. The facility failed to complete ongoing assessments of the resident's condition. R2 continued to decline throughout the day; the facility did not update the physician or complete thorough assessments of resident's condition. Approximately eight hours later, the resident's condition deteriorated significantly, and the resident was sent to the emergency room (ER) and found to be in septic shock. [...]

Inspectors wroteBased on interview and record review, the facility did not implement professional standards of practice to prevent pressure injuries (PIs) from developing and/or worsening or to promote healing of PIs for 1 of 3 residents (R4) reviewed for PIs out of a sample of 12 residents. R4 was admitted to the facility without a PI. R4 was at risk for PI development and had significant co-morbidities including diabetes and right ankle fracture requiring a sugar-tong splint (rigid device that fixes and maintains stability of the ankle). An external fixator was placed on 3/10/23 to the right lower extremity. [...]

Inspectors wroteThe facility failed to complete performance reviews of every nurse aide at least once every 12 months, and failed to ensure every nurse aide (12 hours) and medication technician (4 hours) received their required annual training hours, this affected 3 of 5 Certified Nursing Assistants' (CNAs) annual training, 1 of 1 medication aide training, and 3 of 5 CNAs' performance evaluations. CNA W, CNA X, and CNA Y did not have 12 hours of required annual education. MT V (Medication Technician) did not have 4 hours of required medication education. MT V, CNA W, and CNA Y did not have annual performance evaluations completed. This is evidenced by: The facilities Employee Handbook dated 2/1/24 documents the following, in part: .Annual Training. Annual Training is conducted once a year with a due date determined by the Company. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure the provision of pharmaceutical services (including procedures that assure that accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 4 out of 4 sampled residents (R5, R8, R9\, and R1). R5, R8, R9, and R1 had multiple medication errors related to not receiving medication timely as ordered by the physician. This is evidenced by: The facility policy entitled, Medication Administration, dated 3/1/19, states, in part: .11 . b. Administer with 60 minutes prior to or after scheduled time unless otherwise ordered by physician . Example 1 R5 was admitted to the facility on [DATE]. R5 had the following diagnoses of: [...]

Inspectors wroteBased on interview and record review, the facility did not immediately notify and consult with the resident's physician when a significant change in the resident's physical, mental, or psychosocial status occurred for 1 of 4 residents (R3) of a total sample of 12 residents reviewed. R3 was refusing his antibiotic for an abdominal abscess infected with Methicillin Resistant Staphylococcus Aureus (MRSA) infection. The facility did not continue to notify the Physician of ongoing refusals of antibiotic. As evidenced by The facility does not have a policy for medication refusals and notifying the Physician. R3 was admitted to the facility on [DATE] with diagnoses including, but not limited to: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each resident. This affects 2 (R6 and R7) of 4 residents reviewed for activities. The facility failed to incorporate social history assessment information into R6's and R7's care plans and their current care plan is not person centered. The facility failed to have measurable activity goals and a system in place for measuring R7 and R6's activity involvement to know if the current plan of care is appropriate and if R7 and R6 are meeting their activity goals. Evidenced by: [...]

Inspectors wroteBased on observation and interview, the facility did not ensure that all medications were stored and labeled in accordance with standard of practice in 1 of 4 residents reviewed. Surveyor observed one Lispro Kwik Pen during a medication pass without an open date being administered to R8. Evidenced by: R8 was admitted to the facility on [DATE]. R8 has the following diagnoses of type 2 diabetes mellitus with diabetic chronic kidney disease. R8's Physician Orders: Order date 10/5/23, .Insulin lispro (1 unit dial) 100unit/ml (milliliters) solution pen injector. Inject as per sliding scale: subcutaneously before meals . On 1/10/24 at 12:49 PM, Surveyor observed MT D (Medication Technician) passing medication. Surveyor observed MT D administer Lispro Kwik Pen, subcutaneously to R8. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure hospice collaboration and communication processes were established to ensure continuity of care between hospice and the facility for 1 of 1 hospice residents (R13) reviewed out of a total sample of 5 residents. R13 was admitted to hospice services and the facility did not receive any documentation from the hospice provider in a timely manner. Evidenced by: The facility's policy titled Hospice Services Facility Agreement dated3/1/19 states in part, .5. The facility has designated (the Assistant Director of Nursing or specify the member from the interdisciplinary team) to be responsible for working with hospice representatives to coordinate care to the resident provided by the facility and hospice staff .6. The designated member of the facility working with hospice representative is responsible for: a. [...]

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate and provide education to all staff for six out of seven abuse investigations reviewed for 5 of 7 Abuse investigations involving 8 Residents (R1, R2, R9, R8, R3, R4, R5, & R12). The facility failed to immediately and thoroughly investigate allegations of abuse. The facility failed to educate all staff after multiple abuse allegations were reported. The facility did not report an allegation of abuse to the state agency timely and in its entirety. Evidenced by The facilities Policy and Procedure entitled Abuse/Neglect/Exploitation undated, documents in part: .V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. [...]

Inspectors wroteBased on observation, interview and record review the facility did not ensure that residents who are unable to carry out ADL's (activities of daily living) receive the necessary services to maintain good nutrition, grooming, personal and oral hygiene; for 6 of 7 residents (R2, R5, R8, R9, R10, R11) reviewed for showers and 1 of 9 residents (R5) reviewed for call light placement. R2 has no evidence of receiving showers documented from November to present (12/11/23). R5 has no evidence of receiving showers documented from November to present. R8 states he receives bed baths but requests showers and does not get them. R9 has no evidence of receiving showers documented from November to present. R10 has missed multiple showers prior to room change. R11 has missed multiple showers. R5 did not have her call light within reach. This is evidenced by: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure all allegations of abuse were reported timely to the state survey agency (SSA) for 1 resident (R9) of 9 residents reviewed for abuse. R9 reported an allegation of abuse on 12/4/23. Facility staff completed a grievance form. Facility leadership did not report allegation of abuse to SSA until Surveyor discussed with NHA A (Nursing Home Administrator) on 12/11/23. Evidenced by: The facility policy, titled, Abuse/Neglect/Exploitation, with no date, states, in part; . V11. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. [...]

Inspectors wroteBased on interview and record review the facility did not ensure that Residents receive treatment and care in accordance with professional stanadards of practice, the comprehensive person-centered care pland and the residents choices for 1 of 5 Residents reviewed for wounds (R8). R8 had orders for wound care that were not completed per Physician orders. This is evidenced by: R8 was admitted to the facility on [DATE]. His most recent MDS (Minimum Data Set), dated 11/9/23, shows a BIMS score (Brief Interview for Mental Status) of 15, indicating R8 is cognitively intact. R8 has diagnoses that include right and left below-knee amputations. R8's physician's orders, state in part: *Left and right stump-clean with wound cleaner, apply calcium alginate and cover with abd (abdominal gauze pads) and kerlix, every night shift for wound care. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not ensure that a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable for 2 of 5 residents (R5 & R8) with wounds. R5 developed a heel wound, did not have interventions in place, wound wasn't assessed upon discovery, and is missing a week's worth of measurements. R8 did not have wound care orders completed. This is evidenced by: The facilities Policy and Procedure entitled Pressure Injury Prevention and Management, undated, documents in part: .2. The facility shall establish and utilize a systemic approach for pressure injury prevention and management, including prompt assessment and treatment; [...]

Inspectors wroteBased on interview and record review the facility did not assist the resident in making appointment/transportation arrangements to and from the source of service for 1 of 1 resident (R5) reviewed for appointments. R5 did not have an appointment re-scheduled timely, where a procedure and important lab work was to be completed. This is evidenced by: R5 admitted to the facility in April 2023. R5's most recent MDS (minimum data set), dated 10/27/23, documents a score of 15 on her BIMS (Brief interview of mental status), which indicates she is cognitively intact. R5 is currently experiencing a drastic decline in her condition. R5's Nurse's Notes document the following: 11/9/2023 4:50 PM General Note Note Text: Received an update from R5s guardian . Just wanted to update you on the video meeting we had yesterday with the infectious disease doctor . to discuss the culture results from her test. [...]

Inspectors wroteBased on staff interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with sections 1150B of the Act for 2 Residents (R) (R1 and R2) of 3 sampled residents. On 9/10/23, R2 punched R1 in the right arm. The facility did not report the physical assault to the State Agency (SA) or law enforcement. On 10/16/23, R2 was observed hitting R1. The facility did not report the physical assault to the SA or law enforcement.

Inspectors wroteBased on staff interview, and record review, the facility did not ensure allegations of physical abuse were thoroughly investigated for 2 Residents (R) (R1 and R2) of 3 sampled residents. On 9/10/23, R2 punched R1 in the right arm. The facility did not complete a thorough investigation that included staff and resident interviews. On 10/16/23, R2 was observed hitting R1. The facility did not complete a thorough investigation that included staff and resident interviews.

Inspectors wroteBased on staff and resident interview, and record review, the facility did not ensure appropriate treatment and services related to communication were provided for 1 Resident (R) (R2) of 3 residents reviewed. R2's preferred language of Spanish was not appropriately assessed, documented, or implemented which resulted in ineffective communication between R2 and non-Spanish speaking staff.