Beloit Health and Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision and assistive devices to prevent accidents for 3 of 3 residents (R10, R13, and R12) reviewed for supervision. R10 was found smoking in his room. R10 was deemed to be an elopement risk on admission but deemed to be safe to smoke unsupervised. R13 was found smoking in her room. R13 was observed smoking in an undesignated smoking area, and the smoking areas was unkept. R12 was observed eating food that was not in accordance with her physician ordered diet.

Inspectors wroteBased on observation, interview, and record review, 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 59 residents who reside at the facility. Surveyor observed staff in the kitchen not wearing hair restraints. Cook E touched ready to eat food with contaminated gloves. CNA M did not wash or sanitize her hands after assisting one resident and before assisting another resident with their meal. Evidenced by: The facility policy, Food Safety Requirements, dated 10/2022.states, in part;.1. Food safety practices shall be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with delivery of the food to the resident. Elements of the process including the following.f. Employee hygienic practices.7. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure garbage and refuse was disposed of properly. This has the potential to affect all 59 residents who reside at the facility. Garbage was found outside the dumpsters at the facility. Evidenced by:The facility policy, Disposal of Garbage and Refuse, revised on 3/2025.states, in part. The facility shall properly dispose of kitchen garbage and refuse.8. Dumpsters shall be emptied according to the facility contract. Garbage should not accumulate or be left outside the dumpster. On 1/27/26 at 9:44 AM, during the initial walk through of the kitchen, Surveyor observed garbage on the ground next to the facility dumpsters. Surveyor observed cardboard, food wrappers, and used gloves on the ground. Dietary Manager D (DM) indicated garbage should not be left on the ground. [...]

Inspectors wroteBased on interview, and record review, the facility did not ensure 1 of 4 residents (R12) received the necessary services for acceptable nutrition. R12 triggered for significant weight change with a weight loss of 7.4% in the last thirty days. The Registered Dietician recommended a scheduled snack of choice at HS (bedtime) on 1/20/26. The order was not started until 1/28/26. Evidenced by:The facility policy, Nutritional Management, revised on 4/2024, states, in part;.The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition. A systematic approach is used to optimize each resident's nutritional status:.c. Developing and consistently implementing pertinent approaches. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure Physician progress notes were maintained in a physical chart or Electronic Health Record (EHR) for 1 of 3 supplemental residents reviewed (R61). R61 reported that they would like to schedule an appointment with their doctor; Surveyor was unable to locate documentation of physician visits in their physical chart or EHR.Evidenced by:The facility's policy titled Physician Visits and Physician Delegation last reviewed on 10/16/24 states in part .1. The Licensed Nurse, Medical Records, or Facility Designee should: .f. Remind the physician to date and sign all orders and write a progress note.h. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not ensure each resident receives food prepared in a form designed to meet individual needs for 1 of 4 Residents (R40 ) reviewed for nutrition. R40 has an order for ground meat and received general texture meats. Evidenced by:The facility's Therapeutic Diet Orders policy, dated 3/26/25, states, in part: The facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician. Definitions: Mechanically Altered Diet is one in which the texture or consistency of food is altered to facilitate oral intake. Examples include soft solids, pureed foods, ground meat, and thickened liquids. Therapeutic Diet is a diet ordered by a physician.as part of treatment for a disease or clinical condition. Explanation and Compliance Guidelines: .2. [...]

Inspectors wroteBased on interview and record review, the facility did not implement an established process of assessing a resident's cognitive ability to understand an arbitration agreement before obtaining a signature for residents; and did not ensure the staff responsible for the arbitration agreement was able to thoroughly explain the agreement for complete understanding. This deficient practice had the potential to affect all 1 of 3 sampled residents (R44) RR J (R44's Resident Representative and Power of Attorney (POA)) and RR K voiced concerns of having signed an arbitration agreement while filling out admission paperwork and not fully understanding what she had signed. [...]

Inspectors wroteBased on record review and interviews, the facility did not include accurate potential financial liability to residents whose Medicare coverage was ending when issuing the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) for 3 of 3 residents reviewed (R43, R54, and R72). R43 was receiving Medicare A benefits. R43 was not provided accurate potential financial liability when the SNFABN was issued. R54 was receiving Medicare A benefits. R54 was not provided accurate potential financial liability when the SNFABN was issued. R72 was receiving Medicare A benefits. R72 was not provided accurate potential financial liability when the SNFABN was issued. Evidenced by:The facility's policy titled Policy and Procedure: Advanced Beneficiary Notice dated 2/1/22 states in part .2. When determined that services are no longer necessary a. Social Services or Social Services back up i. [...]

Inspectors wroteBased on interview and record review, the facility did not promptly notify and consult with a physician when a resident missed their medications for 1 of 1 resident's (R2) reviewed for medication administration. R2's physician was not notified when R2 did not receive antipsychotic medication over several days. This is evidenced by: The facility's policy titled Notification of Changes, dated 10/24/23, includes the following: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. The facility must inform the resident, consult with the resident's physician and/or notify the resident's family or legal representative when there is a change requiring such notification. [...]

Inspectors wroteBased on interview and record review the facility did not ensure based on the comprehensive assessment of a resident, the resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents/choice for 1 of 2 residents (R1) reviewed for non-pressure wounds. R1 had dates his wound care was not signed out in the TAR (Treatment Administration Record). R1 returned from the hospital and did not have a full assessment completed for his non-pressure wounds. This is evidenced by: The Facilities Policy and Procedure entitled Wound Treatment Management dated 2/14/23 documents in part: .Policy Explanation and Compliance Guidelines: 1. Wound treatments will be provided in accordance with physician orders .7. Treatments will be documented on the Treatment Administration Record or in the electronic health record. 8. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure each resident received care, consistent with professional standards of practice, to prevent pressure injuries (PI) for 1 of 3 residents (R2) reviewed for pressure injuries. The facility did not complete wound care as ordered for R2. This is evidenced by: The facility's policy titled Wound Treatment Management, dated 2/14/23, includes: 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. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. Treatments will be documented on the Treatment Administration Record or in the electronic health record. [...]

Inspectors wroteBased on interview, and record review, the facility did not ensure each resident received adequate supervision to prevent accidents for 1 of 1 resident's (R2) reviewed for smoking/vaping. The facility failed to re-assess and update R2's care plan for safety after being observed vaping in the facility. This is evidenced by: The facility's policy titled Resident Smoking, dated 7/10/25, includes the following: It is the guideline of this facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and non-smoking residents. Smoking is prohibited in all areas except the designated smoking area. Electronic cigarettes (e-cigarettes/vape/vapor pen) can catch on fire and/or explode if not handled and stored safely. [...]

Inspectors wroteBased on interview and record review the facility did not ensure residents are free of any significant medication errors for 1 of 1 resident's (R2) reviewed for medications. The facility did not ensure R2 was provided his Seroquel (Antipsychotic medications) for several days. This is evidenced by: The facility policy titled Medication Error Reporting and Counseling Procedure, dated 12/12/23, includes the following: Medication errors .should be reviewed for the potential of a negative outcome. When a medication error occurs, the licensed nurse/employee needs to be able to report the error .to Nursing Management. The facility should consider reporting the error to their contracted pharmacy provider for any desired information or needed follow-up. A prompt assessment of the resident(s) involved to be completed to determine harm or the potential risks to the resident. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that residents were free of any significant medication errors for 1 of 1 resident (R57) reviewed for significant medication errors. R57 did not receive scheduled insulin at 8:00AM on 7/24/24 and did not have blood glucose monitoring in place. R57 was hospitalized on the evening of 7/24/24 with acute hyperglycemia (a medical emergency that occurs when blood sugar levels are extremely high) requiring treatment with insulin drip (administration of insulin through intravenous line.) Evidenced by: Facility policy entitled Medication Administration, dated 05/2024, states in part: Policy: Medications are administered by licensed nurses .as ordered by the physician and in accordance with professional standards of practice . 20. Sign MAR (Medication Administration Record) after administered . [...]

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 2 of 6 sampled residents (R16 and R34) and 1 supplemental resident (R612) reviewed for antibiotic stewardship. R16 is being cited at severity level 3 (actual harm). R34 and R612 are being cited at severity level 2 (potential for more than minimal harm). The facility did not follow Standards of Practice for Antibiotic Stewardship: R16 has a history of antibiotic resistance and was prescribed antibiotics without meeting criteria. R16 was prescribed antibiotics for five events between March 26, 2024 and July 5, 2024, for asymptomatic bacteremia (presence of bacteria that does not cause symptoms thus not requiring antibiotic treatment). [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure each resident received meals at their desired time in accordance with resident needs, preferences, or requests. This has the potential to affect all 58 residents residing at the facility. Residents (R8, R41, and R35) voiced concern regarding meals being served over an hour after the scheduled time. Surveyors observed meals being served 1-1.5 hours after the scheduled mealtimes. Evidenced by: The facility policy, Frequency of Meals, dated, 7/17, states, in part: .The following mealtimes have been established by our facility for residents, Breakfast 7:45AM, Lunch 11:45AM, Dinner 4:45PM . Example 1: R8 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure accurate reporting of the mandatory submission of staffing information based on payroll data to the Centers for Medicare & Medicaid Services (CMS.) This has the potential to affect all 58 residents residing within the facility. The facility failed to enter accurate data in their Payroll Based Journal (PBJ) reporting and triggered for five fiscal year quarters, dated 4/1/23 - 6/30/24, for inadequate weekend staffing. This is evidenced by: Centers for Medicare & Medicaid Services (CMS) Electronic Staffing Data Submission Payroll-Based Journal, Long-term Care Facility Policy Manual, dated June 2022, states in part: Chapter 1: Overview, 1.1 introduction .(U) mandatory submission of staffing information based on payroll data in a uniform format. [...]

Inspectors wroteBased on observation, 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 such as COVID-19. This has the potential to affect the census of 58 residents (R). The facility infection prevention and control policies have not been updated annually. The facility did not ensure contact tracing and testing was completed accurately and timely during a COVID outbreak. Surveyor observed cares for R35 with breaches in infection control technique. Evidenced by: The facility policy titled Infection Prevention and Control Program dated 5/16/23, states, in part: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure each resident had the right to a safe, clean, comfortable, and homelike environment for 3 of 3 sampled Residents (R35, R52, & R15) and 1 of 1 supplemental (R49). R35 and R49's floor in their room had not been cleaned and had visible dirt on the floor. R15's room was not homelike with visible repairs needed. R52 voiced concern that R52 is unable to use closet in bedroom because of roommate thinking R52 is stealing clothes. R52 voiced concern that her dresser is broken as well. R52 indicated she has to keep all of her clothes and items in boxes in R52's room. Surveyor observed R52 to have boxes stacked up in her room. This is evidenced by: Facility Policy entitled 'Routine Cleaning and Disinfection,' dated 8/2022, states in part: Policy: [...]

Inspectors wroteBased on observation, interview, and record review the facility did not ensure that a resident who is unable to carry out activities of daily living (ADLs) receives the necessary services to maintain good nutrition, grooming, personal and oral hygiene for 4 of 24 total sampled Residents (R48, R38, R15 & R16). R48 did not receive her showers twice a week every week. R38 did not receive the appropriate oral hygiene care recommended by the dentist. R15 did not receive oral hygiene daily R16's nails were visibly long and staff did not assist R16 in trimming them. Evidenced by: Facility policy entitled 'Oral care,' dated 8/22, states in part: Policy: It is the practice of this facility to provide oral care to residents in order to prevent and control plaque- associated oral diseases. Equipment and supplies. soft- bristle tooth brush, toothpaste; tongue depressor; penlight; [...]

Inspectors wroteExample: 2 R23 was admitted to the facility on [DATE] with diagnoses that include in part: polyosteoarthritis (arthritis where at least 5 joints are affected), Polyneuropathy, Lymphedema (A buildup of lymph fluid that causes swelling), Difficulty in walking, and Low back pain. R23's chart indicates she is her own decision maker. R23's ADL (Activities of Daily Living) Care Plan, with a revision date of 5/2/23, indicates R23 requires staff intervention to complete ADL's. Interventions include, in part: .Hoyer (full body lift) sling with hole cut out for bed side commode toileting needs. On 9/9/24 at 3:00PM Surveyor interviewed R23 who indicated about once a month she waits an hour to get assistance with toileting. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure grievances were documented and thoroughly resolved for 1 of 24 sampled residents (R23). R23 reported a grievance regarding her Hoyer (full body lift) transfers, and this was not documented or thoroughly resolved. R23 reported a grievance regarding an interaction with a staff member and this was not documented or thoroughly resolved. Evidenced by: The facility policy, Grievance Guideline, revised on 5/31/23, indicates, in part: Purpose: To provide a process to voice grievances (such as those about treatment, care .or violation of rights) and respond with prompt efforts to resolve while keeping the resident and/or representative appropriately apprised of progress toward resolution . Guideline: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that information from the baseline care plan was reviewed with the resident/resident representative and a copy of or summary of the care plan was provided to the resident/resident representative within 48 hours of admission for 1 of 3 residents (R27) reviewed for baseline care plan out of a sample of 24 residents. R27 did not have a baseline care plan review within 48 hours of admission. Evidenced by: The facility policy, entitled Baseline Care Plan dated February 2023, states, in part: .The baseline care plan will be developed within 48 hours of the resident's admission. A written summary of the baseline care plan shall be provided to the resident and representative . R27 was admitted to the facility on [DATE] with diagnoses that include anoxic brain damage and personal history of traumatic brain injury. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not develop a comprehensive person-centered care plan for 1 of 3 (R54) residents reviewed for person-centered care plans out of 24 total sampled residents. R54's Activities of Daily Living (ADL) care plan was reviewed by Surveyor. The care plan does not contain R54's individualized preferences in regard to her left arm. Evidenced by: The facility policy, Comprehensive Care Plans, implemented 1/2024, indicates, in part: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. .Definitions: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure each resident (R), or their representative had the right to participate in the care planning process for 2 of 24 total sampled Residents (R48 & R14). R48 indicated she does not have quarterly care plan meetings to discuss her care. R14's care plan was not revised to address her change in code status. This is evidenced by: Facility policy entitled 'Comprehensive Care Plans,' dated 8/22, states in part: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframe to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: 1. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure that services provided by the facility meet professional standards of quality for 1 of 21 residents (R45) reviewed for orders out of a total sample of 24. R45 received orders and those orders were not transcribed for two (2) days. This is evidenced by: The Facility's Policy and Procedure entitled Medication Orders dated 4/16/24, documents the following in part: .a. Handwritten Order Signed by the Physician- The charge nurse on duty at the time the order is received should note the order and enter it on the physician order sheet or electronic order format, if not written by the physician . R45's wound documentation shows that R45's right heel wound was healed on 6/21/24 with placement of graft. Documentation from R45's Physician dated 6/26/24 includes the following orders: [...]

Inspectors wroteBased on interview and record review the facility did not ensure that residents with pressure injuries receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new injuries from developing for 3 of 5 (R34, R45 and R14) residents reviewed for pressure injuries out of a total sample of 24. R34 did not have his wound treatments completed as ordered. R45 did have her wound treatments completed as ordered. R14 did not have wound treatments completed as ordered. This is evidenced by: The Facility's Policy and Procedure entitled Wound Treatment Management dated 2/14/23, 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. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not ensure each residents environment was free of accidents and hazards for 3 of 24 total sampled Residents (R48, R34 and R52.) R48 indicated she smokes. R48 did not have a smoking assessment or care plan completed for smoking even though nursing staff were aware that she smoked occasionally. R34's electric wheelchair was charging in his room. R52 indicated she would use her electric scooter and go out in the community on her own. Therapy did not complete an assessment for safe operation of electrical wheelchairs/scooters until after R52 went out in community by herself. Evidenced by: Facility policy entitled 'Smoking Policy,' (no date), states in part: when the resident requests to smoke, the interdisciplinary team will assess the resident capabilities and deficits to determine appropriate supervision and assistance. [...]

Inspectors wroteBased on observation, 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 biological's to meet the needs of each resident for 1 of 1 Supplemental Resident (R32). On 9/10/24 R32 had a lidocaine patch still on her arm that was not removed the night before. Evidenced by: Facility policy entitled, Medication Administration General Guidelines, dated 01/24, states in part: .medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so . Procedures: Medication Preparation: .3. Prior to administration, review and confirm medication orders for each individual resident on the medication administration record. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that it was free of medication error rates of 5% or greater. There were 3 errors out of 28 opportunities that affected 2 out of 4 supplemental residents (R32 & R31) included in the medication pass task, which resulted in an error rate of 10.71%. RN H (Registered Nurse) did not give R31 the correct dosing of his Sevelamer (phosphate binder to prevent low levels of calcium) LPN I (Licensed Practical Nurse) omitted R32's lidocaine patch and dispensed R463s medication into R32's medication cup. Evidenced by: Facility policy entitled, Medication Administration General Guidelines, dated 01/24, states in part: .medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so . Procedures: [...]

Inspectors wroteBased on observation, interview, and record review the facility did not ensure drugs and biological's are labeled in accordance with currently accepted professional standards for 1 of 2 Medication carts and 1 of 1 medication rooms reviewed for medication storage. Medication room had 5 bottles of expired liquid Tylenol on the shelf. Medication room fridge had an undated open insulin vial for R57. Needlepoint medication cart had three bottles of artificial tears that did not have the residents full name or date opened on them. Evidenced by: Facility policy entitled, Medication Administration General Guidelines, dated 01/24, states in part: . Medication administration: 1. Medications are administered in accordance with written orders of the prescriber . 8. Check expiration date on package/container. No expired medications will be administered to a resident.b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that all residents receive food at a palatable temperature for 1 of 1 sampled (R467) and 1 of 1 supplemental residents (R41) and 1 of 1 test trays. Residents R467 and R41 voiced concerns with receiving hot foods cold. Test tray was observed to have hot foods served cold and food not palatable. Evidenced by: The facility policy, Record of Food Temperatures, dated 3/24, states, in part; .It is the policy of this facility to record food temperatures daily to ensure food is at the proper serving temperatures before trays are assembled .11. No food will be served that does not meet the food code standard temperatures . Example 1 R467 admitted to the facility on [DATE] with diagnoses that include, in part, Type 2 Diabetes Mellitus, Essential Hypertension, atherosclerotic heart disease. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not ensure food was stored or labeled in accordance with professional standards for 1 of 2 medication room refrigerators. Three cartons of thickened liquids and two half gallons of chocolate milk were opened and expired in the medication room refrigerator. Evidenced by: Facility policy entitled 'Food Safety Requirements,' states in part: .Policy explanation and compliance guidelines: .3. Facility staff shall inspect all food, food products, and beverages for safe transport and quality upon delivery/receipt and ensure timely and proper storage.c. Refrigerated storage - foods that require refrigeration shall be refrigerated immediately upon receipt or placed in freezer, whichever is applicable. Practices to maintain safe refrigerated storage include: .iv. [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure medication administration was provided according to professional standards for one resident (R) out of nine sampled (R4). Specifically, the facility failed to follow physician insulin orders in the electronic medical record (EMR) and document the rationale for not administering the insulin. This failure had the potential to cause R4 not to receive the necessary care for treatment of R4's diabetes.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents receive and consume foods in the appropriate therapeutic diet for 1 (R4) of 3 residents sampled for altered special diets out of 4 total sampled residents. R4 did not receive a controlled carbohydrate diet as ordered by her physician. This is evidenced by: The facility policy entitled, Food and Nutrition Services, undated, states in part: . 1. The multidisciplinary staff, including nursing staff, the attending physician and the dietitian will assess each resident's nutritional needs, food likes, dislikes and eating habits, as well as physical, functional, and psychosocial factors that affect eating and nutritional intake and utilization. 2. A resident-centered diet and nutrition plan will be based on this assessment . 7. [...]

Inspectors wroteBased on interview and record review, the facility did not immediately consult with a resident's physician when there was a need to alter treatment for 1 of 7 residents (R63) that resulted in actual harmy, and 1 of 7 residents (R61) that had potential for minimal harm. The facility did not consult with R63's Medical Doctor (MD) per Physician Orders and as her condition changed resulting in actual harm when R63 was hospitalized and aggressive diuresis. Evidenced by: Facility policy, entitled Notifications of Change, date implemented 12/2022, states in part .the purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification . [...]

Inspectors wroteBased on record review and interview, the facility did not offer and/or administer the influenza immunization to each resident, and the resident's medical record does not include documentation the resident either received, refused, or was educated on the risks and benefits of the influenza and immunization for 1 of 6 (R64) residents reviewed for immunizations that resulted in actual harm, and 2 of 6 residents (R34 and R27) reviewed for immunizations that resulted in the potential for harm. R64 consented to have the influenza immunization upon admission to the facility. R64 did not receive the immunization and then contracted Influenza A which resulted in a complex hospitalization. Evidenced by: The facility's policy titled Influenza Vaccination dated 12/2022, states in part: Policy: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that the food was stored, distributed, and served in accordance with professional standards for food service safety. This has the potential to affect all 52 residents residing at the facility. Surveyor observed: -facility staff personal items in food preparation workstations -dirty floors in the dry storage, walk-in cooler, and walk-in freezer -dirty hood vent -undated and uncovered foods and beverages -milk served that were not on ice and not within safe zone -wet stacking

Inspectors wroteBased on observation, interview, and record review, the facility has not 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. This has the potential to affect the census of 52 residents. The duct work over the top of a folding table was observed to be leaking onto the table while the laundry aide was folding clean linens on the table. This is evidenced by: The facility policy entitled Laundry, dated 12/22, states in part: . Policy: The facility launders linens and clothing in accordance with current CDC (Centers for Disease Control) guidelines to prevent transmission of pathogens . The facility policy, entitled Infection Prevention and Control Program, dated 6/16/23, states, in part: . Policy: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use was in place for 1 of 21 residents (R47) and 4 of 5 supplemental residents (R14, R28, R26, & R19). R47 was treated with antibiotics for a urinalysis culture and sensitivity (UA & C/S) that was not susceptible to the bacteria. R14 was treated with antibiotics for UA & C/S without documentation of a sensitivity report. R28 was treated with antibiotics for UA & C/S without meeting McGeers criteria. R28 had no signs and symptoms (s/sx.) of a urinary tract infection (UTI). R26 was treated with antibiotics for UA & C/S that was not susceptible to the bacteria. R19 was treated with antibiotics for UA & C/S without documentation of a sensitivity report. This is evidenced by: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that all residents are clinically appropriate to self-administer medications for 2 of 2 residents (R53 and R65) of the total sample of 21 residents observed. R53 was observed to have an analgesic ointment cream in his room on his bedside table. R65 had medications located at the bedside. R65 did not have an order to self-administer medications. This is evidenced by: The facility policy entitled, Resident Self-Administration of Medication, dated 12/22, states in part: . Policy: It is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely . 4. [...]

Inspectors wroteBased on interview and record review, the facility did not implement their written policy which includes completing background checks for 3 of 8 employees. The facility did not implement their written policy which includes completing reference checks for 8 of 8 employees reviewed. CNA P (Certified Nursing Assistant), CNA S, and Dietary Aide V's personnel files did not contain Background Information Disclosure (BID) checks and reference checks. CNA O, CNA Q, CNA R, RN T (Registered Nurse), and LPN U's (Licensed Practical Nurse) personnel file did not contain reference checks. Evidenced by: The facility policy, Background Investigation, dated 12/22, states, in part; Policy: [...]

Inspectors wroteBased on interview and record review, the facility did not report an alleged violation of abuse to the State Survey Agency for 1 of 21 sampled residents (R38). R38 alleged he was told by a staff member you can get f****d and the facility did not report this to the State Survey Agency. This is evidenced by: The facility policy entitled, Abuse, Neglect and Exploitation, dated 12/22, states in part: .VII. Reporting/Response A. The facility will have written procedures that include: Reporting of all alleged violation to the Administrator, state agency . within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury . [...]

Inspectors wroteBased on interview and record review, the facility did not have evidence that all alleged violations are thoroughly investigated for 1 of 21 sampled residents (R38). R38 alleged he was told by a staff member you can get f****d and the facility did not conduct a thorough investigation into this allegation. This is evidenced by: The facility policy entitled, Abuse, Neglect and Exploitation, dated 12/22, states 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. Written procedures for investigations include: 1. Identifying staff responsible for the investigation; . 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents who are unable to carry out activities of daily living (ADLs) receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene, this has the affected 1 of 6 residents (R1) reviewed for activities of daily living out of a total sample of 21. R1 was noted to have chin hairs that were approximately 1/4- 1/2 long. Evidenced by: The facility's policy titled Activities of Daily Living (ADLs) dated 12/2022, states in part: .Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care .Policy Explanation and Compliance Guidelines: .3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that residents who require dialysis receive such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents out of a sample of 21 residents (R66) resulting in R66 in missing dialysis. R66 missed dialysis on 6/10/23 due to the facility not ensuring the transport service provider was available to transport R66 to scheduled dialysis appointment. According to <Gray, K. P., [NAME], D., & [NAME], S. M. (2017). In-center hemodialysis absenteeism: prevalence and association with outcomes.>Clinic Economics and Outcomes Research, Volume 9, 307-315. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure medication error rates are not 5% or greater during medication administration. This affected 1 of 6 residents (R4) observed for medication pass. The facility medication error rate was 6.67%, for 2 errors out of 30 opportunities. R4's first medication error was administered 30 minutes late making this a timing error. The second medication error was administered without a complete physician order. The order was not found on the current Medication Administration Record (MAR) and was signed as administered under a different medication order that had been discontinued. This is evidenced by: Example 1 The facility's policy titled Medication Administration, dated 12/22, states in part: . 11. [...]