Careview Health and Rehab of Minocqua

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 of 3 residents (R) out of a sample size of 6 residents reviewed for conveyance of resident funds, had funds returned to the Power of Attorney (POA), family, or estate within 30 days of resident death. The facility did not refund R6's funds to POA within 30 days of discharge from facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure that each resident's drug regimen was free from unnecessary drugs for 1 or 7 residents (R2). R2 has a history of an elevated international normalized ratio (INR) blood test for blood clotting time while taking an anticoagulant (blood thinner) medication. R2 did not receive adequate monitoring while receiving the anticoagulant medication in conjunction with an antibiotic. Registered Nurse (RN) C assessed R2 and found a large amount of blood in R2's stool, on an incontinent pad, and when R2 was rolled a large amount of blood expelled from R2's rectum. R2 was transferred to the emergency room and found to have a critical INR level of 9.3. R2 was given vitamin K and Kcentra to reverse the anticoagulation and prevent further bleeding. [...]

Inspectors wroteBased on record review and interview, the facility did not ensure that residents are free of significant medication errors for 4 of 5 residents (R) [R2, R3, R5, and R9] reviewed for medication administration. R5 is being cited at severity level 3 (actual harm). R2, R3, R9 are being cited at severity level 2 (potential for more than minimal harm). -R5 has a history of pancreatic and kidney transplant and receives antirejection medications. R5 did not receive his antirejection medications Mycophenolate Mofetil (medications that prevents the body from rejecting a transplanted organ) for 37 days and Tacrolimus (medication that prevents body from rejecting a transplant) for several days. [...]

Inspectors wroteBased on interview, and record review, the facility did not ensure a resident is free from verbal abuse perpetrated by a resident for 1 (R12) of 5 residents reviewed for abuse. On 3/29/26, R11 was heard verbally yelling and threatening R12 to shut up and if R12 did not shut up R11 would help R12 to shut up.

Inspectors wroteBased on interview and record review, the facility did not ensure a thorough investigation of an allegation of abuse for 1 of 1 abuse investigations reviewed involving (R11 and R12). On 3/29/26, the facility was made aware that R12 yelled at R11 to shut up and if R12 did not shut up R11 would help R12 to shut up.~ There was no formal investigation of the incident.~ There was no care plan intervention to protect R11 from R12 from further verbal abuse.

Inspectors wroteBased on observation, interview and record review, 1 of 3 residents (R5) at risk of falls did not receive adequate supervision and assistance devices to prevent potential accidents from occurring. R5 required the assistance of 2 staff for transfers with mechanical Hoyer lift. Staff continued to transfer R5 with a mechanical sit-to-stand lift, then to assist of 2 stand-pivot transfer.

Inspectors wroteBased on interview and record review, the facility did not ensure the resident (R) maintained acceptable parameters of nutritional status for 1 out of 3 residents reviewed. (R1)~ Facility did not implement daily weights per admission orders for R1. R1 experienced a 11-pound weight loss, 9.55% in the first 17 days. ~ Facility did not ensure a registered dietician assessment of the nutrition status and diet orders for resident with tube feeding with admission.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 resident (R3) of 1 resident reviewed for intravenous therapy received intravenous care consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences. R3 was re-admitted to the facility on [DATE] with a PICC (Peripherally Inserted Central Catheter) which is a soft, thin, flexible tube in a vein used to administer IV (Intravenous) medications. The facility did not administer IV medications or complete PICC line care as physician orders state.

Inspectors wroteBased on interview and record review, the facility did not ensure that residents who require dialysis receive such services, consistent with professional standards before and after dialysis treatments the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 1 dialysis residents (R3) sampled out of a total of 9 sampled residents. The facility did not provide monitoring of R3's fistula access dialysis site, monitoring of R3 post dialysis treatments, and R3's vitals as ordered. This is evidenced by:The facility policy, titled Care of a Resident with End-Stage Renal Disease dated October 2009, states: .Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure a medication error rate of 5% or less for 1 error out of 10 medication opportunities, resulting in an error rate of 10%. This had the potential to affect 1 of 1 resident (R) observed for medication administration. (R10) ~ R10 received topical medication without prior measurement for correct dosing. This is evidenced by: The facility policy titled, Administering Medications, dated December 2009, states: Medications shall be administered in a safe and timely manner, and as prescribed. The facility policy titled Administering Topical Medication, undated, states: Purpose: To ensure the safe, accurate, and compliant administration of topical medications in accordance with Wisconsin nursing home regulations, promoting resident safety and preventing medication errors. [...]

Inspectors wroteBased on observations, interview, and record review, the facility did not treat each resident with respect and dignity and care for each resident in a manner that promotes their quality of life. This occurred for 2 of 2 residents (R3 and R29). R3 and R3's representative were not informed of audio and visual surveillance that had been placed in his room for his roommate, R29. R3 and R29, or their resident representatives, did not consent to the audio and visual surveillance. R3 was admitted to the facility on [DATE], after a hospitalization for altered mental status and falls at home. R3's Brief Interview for Mental Status (BIMS) confirmed R3 scored 08/15, indicating moderate cognitive impairment. R3 was appointed a guardian to assist with decision making. R3 was admitted to a room with R29. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure care plans were revised to reflect residents' current needs and to provide the needed direction to staff in providing necessary care and services. The facility practice affected 1 of 4 resident (R2) care plans reviewed. The facility did not revise R2's care plan after each fall. R2 was admitted to the facility on [DATE] after a hospitalization for increased confusion and falls at home. An elopement assessment was conducted on 02/05/26 and indicated no elopement risk. A fall assessment was conducted on 02/05/26 and indicated low fall risk. R2 scored 08/15 during Brief Interview for Mental Status (BIMS), indicating moderately impaired cognition. R2's power of attorney (POA) was activated to assist with decision making. Surveyor reviewed R2's record and noted the following falls:-02/14/26, fall with major injury. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 5 residents (R43) received care, consistent with professional standards of practice, to prevent pressure injuries and received necessary treatment and services to promote healing, prevent infection and prevent new pressure injuries (PI) from developing. R43 was at risk for pressure injury development. The facility failed to implement aggressive interventions to prevent PI development, ensure treatment orders were completed as ordered, and failed to complete a comprehensive assessment upon discovery of a new PI on R43's left heel. R43 developed an avoidable pressure injury (PI) that deteriorated to stage IV with osteomyelitis requiring hospitalization and intravenous antibiotic therapy. This created a finding of immediate jeopardy that began on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility did not develop and implement policies that prohibit and prevent abuse, neglect, exploitation of residents, and misappropriation of resident property and includes the screening of prospective employees and residents. 16 out of 17 sampled staff (Certified Nursing Assistant (CNA) O, CNA P, CNA Q, Social Worker (SW) F, Dietary Manager (DM) E, Activities Director (AD) I, and Licensed Practical Nurse (LPN) R), CNA W, CNA GG, CNA HH, CNA G, CNA II, Dietary Aide (DA) JJ, Business Office (BO) KK, Registered Nurse (RN) LL, and LPN K did not receive a full background check, which includes the Background Information Disclosure (BID), Department of Justice (DOJ) criminal background response and State of Wisconsin Caregiver Background Check - Government Findings Reports (previously IBIS) reviewed. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure a registered nurse (RN) worked at the facility for at least eight (8) consecutive hours a day, seven days a week, on 3 of 92 days reviewed. This deficient practice had the potential to affect all 47 residents. The facility was unable to provide documentation to support that an RN was working in the facility for at least 8 consecutive hours on 08/15/25, 09/08/25, and 09/09/25. This is evidenced by:Surveyor reviewed the PBJ Staffing Data Report for fiscal year Quarter 4 2025 (July 1 - September 30) which triggered for 4 or more days within the quarter with no RN hours on 08/15/2025, 09/08/25, 09/09/25 and 09/14/25. Surveyor reviewed the facility staff scheduled and nurse posting for the last 92 days of Quarter 4 2025 (July 1- September 30). [...]

Inspectors wroteBased on observation and interview, the facility did not ensure safe storage and labeling of foods in accordance with professional standards for food service safety for 47 of 47 residents which could result in residents consuming unsafe foods with biological, chemical, or physical contamination. Facility's dry storage area contained packages of food opened, not in labeled containers and without a use by date identified on packaging. Refrigerator in resident common area contained opened dishes of food without resident identification, date opened or use by dates. This is evidenced by: The facility policy, titled Food Receiving and Storage, revised 12/2008, states in part: Dry foods that are stored in bins will be removed from original packaging, labeled and dated ('use by' date) .All foods stored in the refrigerator or freezer will be covered, labeled and dated ('use by' date). [...]

Inspectors wroteBased on observation and interview, the facility did not ensure all garbage and refuse was properly contained inside dumpsters to prevent the harborage and feeding of pests. This has the potential to affect all 47 residents residing at facility. This is evidenced by: On 01/11/2026 at 9:27 AM, Surveyor observed several bags of garbage on the ground next to dumpsters located outside and near kitchen back door. On 01/11/2026 at 9:27 AM, Surveyor asked Dietary Manager (DM) E what facility policy was for disposal of garbage. DM E stated none of the bags observed on the ground was disposal from the kitchen. DM E stated the bags observed were left there by other staff, namely nursing, and it happened every day. DM E stated administration has been made aware on several occasions this was happening.

Inspectors wroteBased on observation, interview, and record review, the facility did not provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections which had the potential to affect all 47 residents.-Staff did not sanitize mechanical lift after transferring a resident on enhanced barrier precautions.-Hand hygiene not offered to residents prior to meals.-Lack of Personal Protective Equipment (PPE) worn in isolation rooms.-No Enhanced Barrier Precautions (EBP) for resident with indwelling catheter.-No droplet precautions for resident COVID positive.-Improper hand hygiene with cares-Dirty linens placed on the floor-Urinary catheter lying on the floorFindings include: Facility policy titled, Policies and Practices-Infection Control, last revised July 2014, reads in part: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure abuse training was provided at hire and annually for 9 of 9 staff reviewed. This deficient practice had the potential to affect all 47 residents in the facility who are cared for by staff who did not receive ongoing training on recognizing and reporting abuse, neglect, exploitation, and misappropriation. Certified Nursing Assistant (CNA) W was hired 10/1/20 and no abuse, neglect, exploitation, and misappropriation training was provided to the Surveyor for CNA W upon hire or annually. CNA GG was hired 10/20/25 and no abuse, neglect, exploitation, and misappropriation training was provided to the Surveyor for CNA GG upon hire. CNA HH was hired 1/5/26 and no abuse, neglect, exploitation, and misappropriation training was provided to the Surveyor for CNA HH upon hire. [...]

Inspectors wroteBased on record review and interview, the facility did not ensure residents/representatives received notice of bed-hold policy indicating reserve payment and did not receive notice before indicating specific reason for the transfer/discharge for 5 of 5 residents (R2, R7, R8, R14, and R43). Example 1 R43 was admitted to the facility on [DATE]. On 10/10/25, R43 scored 15/15 during Brief Interview for Mental Status (BIMS), indicating intact cognition. R43 was transferred to the hospital on 1/5/26. Surveyor noted a summary that was sent with R43 upon transfer. On 1/12/25 at 12:11 PM, Social Worker F reported she does not have bed-hold notice for R43's hospital transfer. Example 2 R8 was admitted to the facility on [DATE]. On 01/05/26, Brief Interview for Mental status score was 9/15, indicating moderate cognitive impairment. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not maintain a system to account for disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for 25 residents (R25, R7, R34, R48, R22, R30, R21, R14, R26, R50, R62, R60, R44, R4, R16, R23, R36, R20, R15, R5, R19, R61, R2, R45, R55) of 25 residents reviewed for controlled substance reconciliation in a sample of 47 residents at facility. The facility's narcotic count reconciliation for the month of January 2026 does not have documentation of oncoming and outgoing nursing staff reconciling controlled substances at each shift change. The facility's policy, titled Controlled Substances, revised 4/2007, states in part: Nursing staff must count controlled drugs at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. [...]

Inspectors wroteBased on record review and interview, the facility did not obtain written consents, explaining medication risks and benefits, options, and alternatives when psychotropic medications were initiated. The facility practices affected 2 of 5 residents (R) reviewed for unnecessary medications, R26 and R50. This is evidenced by:Example 1R26 was admitted to facility on 12/19/25 with diagnoses that include dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. R26 has an activated power of attorney. R26's physician orders include the following psychotropic medications: Quetiapine Fumarate Oral Tablet 25 MG (Antipsychotic). Give 1 tablet by mouth three times a day initiated on 12/23/2025. Sertraline HCl Oral Tablet 100 MG (Antidepressant). [...]

Inspectors wroteBased on observation, interview and record review, the facility did not determine if self-administration of medications is clinically appropriate for 1 resident (R65) of 4 residents reviewed for medication administration in a sample of 16 residents. R65's medical record did not have documentation by an interdisciplinary team (IDT) determining R65, or a family representative, was safe to self-administer medications, or had demonstrated self-administration of medications. R65 did not have a physician's order to self-administer medications. R65's care plan did not have interventions in place for self-administration of medications, or a family member to administer medications to R65. R65's medications were not in a locked box while being stored in R65's room. This is evidenced by:The facility policy, titled Administering Medications, revised 12/2009, states in part: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure residents were free from misappropriation for 1 of 1 resident (R29).-On 01/07/26, the facility was made aware R29 was missing personal property, including $80.00.-The facility did not protect R29 from misappropriation.-The facility did not report this to the State Agency (SA).-The facility did not begin an investigation until 01/09/26.-The facility did not conduct a thorough investigation of R29's missing property.-The facility was unable to locate R29's missing property. The facility policy titled, Abuse prevention, read in part, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation.3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents.4. [...]

Inspectors wroteBased on record review and interview, the facility must ensure each resident is free from unnecessary drugs as evidenced by completing adequate drug monitoring for 2 of 5 residents (R) (R26 and R50) reviewed for unnecessary medication reviews. The facility is not accurately monitoring resident-specific targeted behaviors for R26 or R50's psychotropic medication use. This is evidenced by: Example 1R26 was admitted to facility on 12/19/25 with diagnoses that include dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. R26 has an activated power of attorney. R26's physician orders include the following psychotropic medications: Quetiapine Fumarate Oral Tablet 25 MG (Antipsychotic). Give 1 tablet by mouth three times a day initiated on 12/23/2025. Sertraline HCl Oral Tablet 100 MG (Antidepressant). [...]

Inspectors wroteBased on interview and record review, the facility did not report a reasonable suspicion of a crime to law enforcement or report an allegation of misappropriation to the state agency for 1 of 1 resident (R29) reviewed. -On 01/07/26, the facility was made aware R29 was missing personal property, including $80.00.-The facility did not report this to the State Agency (SA).-The facility did not begin an investigation until 01/09/26.-The facility did not report an allegation of misappropriation to law enforcement or the Ombudsman. The facility policy titled, Abuse prevention, read in part, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation.3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents.4. [...]

Inspectors wroteBased on interview and record review the facility did not ensure a thorough investigation of an allegation of abuse for 2 of 2 residents (R8 and R29).-On 01/07/26, the facility was made aware R29 was missing personal property, including $80.00. -The facility did not begin an investigation until 01/09/26.-The facility did not conduct a thorough investigation of R29's missing property, by conducting staff or resident interviews.-The facility was unable to locate R29's missing property.-R8 was found to have a pelvic fracture and no root cause.-The facility did not investigate the cause by conducting further staff interviews and interviewing R8 or representative.-The facility did not complete education to all staff per intervention related to incident. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure each resident receives necessary care and services upon admission for 2 of 2 residents reviewed (R58, R27).-Orders for wound care were not implemented upon admission-Orders for Cochlear Implants not followed upon admissionFindings include:Example 1R58 was admitted to the facility on [DATE].admission orders include:Lower spine-Cleanse with normal saline, apply foam dressing to spine for protection once a day on AM shift. Sacrum-Clean with normal saline or wound cleaner, pat dry, apply leptospermum honey, cover with border gauze dressing once a day on AM shift. On 01/12/26 at 7:40 AM, Surveyor interviewed R58. R58 stated the bandages were not changed the first few days since admission. Surveyor reviewed physician orders in R58's electronic health record (EHR). [...]

Inspectors wroteBased on record review and interview, the facility did not ensure a second Preadmission Screening and Resident Review (PASRR) was completed for 1 of 1 resident reviewed (R9).-R9's PASARR I indicated R9 has a serious mental illness and has exceeded the 30-day exemption period requiring a PASARR II.

Inspectors wroteBased on interview and record review, the facility did not develop and implement a baseline care plan for each resident to include instructions needed to provide effective and person-centered care of the resident for 1 resident (R65) of 1 resident reviewed for baseline care plans in a sample of 16 residents. R65 did not have a baseline care plan in place within 48 hours of admission to include the minimum healthcare information necessary to properly care for him, including, but not limited to, the ability for R65 to self-administer medications. This is evidenced by: State Operations Manual (SOM) 42 CFR 483.21 (a)(1), effective 11/28/2017, states in part: The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. [...]

Inspectors wroteBased on interview and record review, the facility did not develop and implement a person-centered care plan for each resident consistent with resident rights including services to attain or maintain the resident's highest or practicable physical, mental or psychosocial needs for 2 of 15 residents reviewed (R2 and R27).-R2's care plan was not developed after R2 had a significant weight loss.-R27's care plan did not include possible complications of using R27's left arm for blood pressure, labs, etc. due to dialysis graft. Example 1 The facility's policy titled, Care Plans-Comprehensive, read in part, 3. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems; c. Build on the resident's strengths; d. Reflect the resident's expressed wishes regarding care and treatment goals; e. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure 2 of 15 residents (R61, R27) who are unable to carry out activities of daily living received the necessary services to maintain good nutrition.-R61 did not receive set up assistance for meal while in bed.-R27 did not receive supervision or set up assistance with meal while in bed.

Inspectors wroteBased on interview, observation and record review, the facility failed to provide weekend activities, which has the potential to affect all 47 residents. No activities offered on the weekend.

Inspectors wroteBased on interview and record review, the facility did not provide care and treatment by professional standards of practice to maintain a resident's highest practicable level of physical well-being for 2 of 15 residents (R29 and R62).-The facility did not follow physician orders to monitor R29's blood pressure.-The facility did not follow orders to assess and provide dressing changes to R62's lower extremities. R62 was admitted to the facility on [DATE] with pertinent diagnosis including chronic osteomyelitis, right ankle and foot, type 2 diabetes mellitus with foot ulcerations, sepsis, non-pressure chronic ulcer of other part of right foot with necrosis of bone, and non-pressure chronic ulcer of other part of left foot with necrosis of bone. On 1/9/26, a Minimum Data Set (MDS) assessment indicated R62 did not have a Brief Interview for Mental Status (BIMS) completed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure a resident's environment remains free of accident hazards and each resident receives adequate supervision and assistive devices to prevent accidents for 2 of 4 residents (R3 and R50) reviewed. -R3 was assessed as an elopement risk and care planned to have a wanderguard on her left wrist. It was observed R3 did not have a wanderguard on. -R50 was observed being transferred without a gait belt as care planned. Example 1 The facility policy titled, Wandering, Unsafe Resident, read in part, 1. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement). 3. The resident's care plan will indicate the resident is at risk for elopement or other safety issues. 4. Interventions to try and maintain safety will be included in the resident's care plan. [...]

Inspectors wroteBased on observation and interview, the facility did not provide appropriate care and treatment to prevent complications for 2 out of 4 residents (R) reviewed for bowel and/or bladder. (R60, R35)-R60's indwelling urinary was not secured and catheter drainage bag was connected to bed frame. Catheter tubing was pulled tightly during repositioning of the resident lying in the bed.-R35 was not toileted in a timely manner and according to care plan. Example 1 Facility policy titled, Catheter Care, Urinary, revised April 2010, states in part, Infection Control . b. Be sure the catheter tubing and drainage bag are kept off the floor. 2. Ensure that the catheter remains secured with a securement device such as a leg strap to reduce friction and movement at the insertion site. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure a resident maintained acceptable parameters of nutritional status for 1 out of 4 residents (R2) reviewed for nutrition. -The facility did not notify R2's provider or a registered dietician of R2's weight loss. Surveyor reviewed the facility's policy titled, Weight Assessment and Intervention, which read in part, Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietician in writing. R2 was admitted to the facility on [DATE] with diagnoses including depression, anxiety, chronic pain, vitamin D deficiency, reduced mobility, chronic kidney disease, and adult failure to thrive. [...]

Inspectors wroteBased on interview and record review, the facility did not implement appropriate interventions for 1 of 1 resident reviewed (R27) to ensure resident receives care and services as it relates to dialysis consistent with professional standards of practice.-R27 did not have orders/care plan instructions in place related to the left arm fistula regarding blood pressure.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure a medication error rate of 5% or less for 2 residents (R65, R61) of 4 residents reviewed for medication administration in a sample of 16 residents. R65 received a medication after breakfast was eaten that was ordered to be given before breakfast. R61 received an incomplete dose of insulin based on physician orders for sliding scale insulin according to blood glucose levels. A medication error rate of 8% occurred on 01/12/2026 during observation of medication administration. This is evidenced by: The facility policy titled, Administering Medications, revised 12/2009, states in part: Medications must be administered in accordance with the orders, including any required time frame. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure 4 of 4 residents (R10, R55, R58, R61) reviewed were free from significant medication errors.-R58 who has multiple upper respiratory concerns, did not receive nebulizer treatments on time/as ordered.-R61 did not receive insulin and other medications at the correct time.-R10 and R55 were given medications late.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure all drugs for resident self-administration was stored in a locked compartment in resident room for 1 resident (R65) of 4 residents reviewed for safe medication administration in a sample of 16 residents. R65 kept prescription medications in a closet in room, which is not a locked unit, for self-administration. R65's care plan has no interventions in place for safe and secure storage of personal medications in roomThis is evidenced by: The facility policy, titled Storage of Medication, revised 4/2007, states in part: Compartments (including but not limited to, drawers, cabinets, rooms.boxes) containing drugs.shall be locked when not in use. Wisconsin State Legislature, DHS 132.65(6)(b)(1) Storage and labeling medications, states in part: [...]

Inspectors wroteBased on interview, observation, and record review, the facility did not ensure accurate documentation in accordance with accepted professional standards and practices for 1 of 2 residents reviewed (R58).-Respiratory Assessments were documented completed and were not.-Documentation air mattress was checked/working and no air mattress on bed.

Inspectors wroteBased on interview and record review, the facility did not maintain documentation of screening, education, offering and/or declination of the influenza and pneumococcal vaccines to 2 residents (R44, R65) of 5 residents reviewed for immunizations in a sample of 17 residents. R44 had no documentation of screening, education on, or acceptance/declination for receiving influenza and pneumococcal vaccinations. R65 had no documentation of screening, education, or acceptance/declination for receiving influenza and pneumococcal vaccinations. This is evidenced by: The facility policy, titled Influenza Vaccine, revised 08/2008, states in part: All residents and employees who have direct contact with residents will be offered the influenza vaccine annually. Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not maintain documentation of screening, education, offering and/or declination of the Coronavirus 19 (COVID) vaccination to 2 residents (R44, R65) of 5 residents reviewed for COVID immunization in a sample of 17 residents. R44 had no documentation of screening, education on, or acceptance/declination for receiving a COVID vaccination when known positive cases of COVID were present in facility at time of admission. R44 tested positive for COVID 10 days after admission. R65 had no documentation of screening, education, or acceptance/declination for receiving a COVID vaccination when known positive cases of COVID were present in facility at time of admissionFacility did not develop and implement policies and procedures regarding the COVID 19 vaccine immunizationThis is evidenced by: [...]

Inspectors wroteBased on record review and interviews, the facility did not ensure 2 out of 5 Certified Nursing Assistants (CNA), (CNA W, CNA G), employed at the facility for more than one year received a minimum of 12 hours of in-service training each year. This has the potential to affect all 47 residents in the facility. CNA W's date of hire is 10/01/20, and the facility did not provide 12 hours of in-service training. CNA G's date of hire is 07/02/24, and the facility did not provide 12 hours of in-service training. This is evidenced by: S483.95 Training Requirements state:Training topics must include but are not limited to-S483.95(g) Required in-service training for nurse aides. In-service training must-S483.95(g)(1) Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure staff postings were posted daily and included total number of hours and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift which has the potential to affect 47 out of 47 residents residing at the facility. Review of staff postings did not reflect the accurate staffing numbers each day. On 01/11/2026 at 9:07 AM, upon entrance to facility Surveyor noted the Facility's Direct Care Report posted in lobby dated December 19, 2025: Census 47. On 01/13/2026, Surveyor received and reviewed the facility's schedules and staff postings from 12/01/25 through 01/13/26 and noted: Print date and actual time stamped at bottom of each page for time frame. [...]

Inspectors wroteBased on interviews and record reviews, the facility did not consult with a physician when unable to obtain a wound VAC (vacuum assisted closure) and vancomycin solution, as ordered per hospital discharge instructions, for 1 of 3 residents reviewed (R1). R1 was admitted to the facility on [DATE] at approximately 2:30 PM, after a hospitalization for sepsis related to necrotizing fasciitis and Fournier's gangrene (gangrene affecting the external genitalia or perineum), of the right groin. R1 scored 12/15 during Brief Interview for Mental Status (BIMS), indicating moderately impaired cognition. R1 was hospitalized from [DATE]-[DATE]. R1 suffered a stroke during her hospitalization, was intubated, and required mechanical ventilation, R1 was successfully extubated prior to her discharge from the hospital. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure a baseline care plan was developed and implemented for each resident (R) within 48 hours of admission for 1 of 3 residents reviewed (R1). R1 was admitted with a non-pressure related wound and wound care orders; a baseline care plan for wound care was not developed. R1 was admitted to the facility on [DATE] at approximately 2:30 PM, after a hospitalization for sepsis related to necrotizing fasciitis and Fournier's gangrene (gangrene affecting the external genitalia or perineum), of the right groin. R1 scored 12/15 during Brief Interview for Mental Status (BIMS), indicating moderately impaired cognition. R1 was hospitalized from [DATE]-[DATE]. R1 suffered a stroke during her hospitalization, was intubated, and required mechanical ventilation, R1 was successfully extubated prior to her discharge from the hospital. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure residents received care and treatment in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 3 residents (R) reviewed for quality of care (R1).-R1 did not receive wound care as ordered.-The facility did not order R1's wound VAC (vacuum assisted closure), as ordered.-The facility did not implement a baseline care plan related to R1's wounds. R1 was admitted to the facility on [DATE] at approximately 2:30 PM, after a hospitalization for sepsis related to soft tissue injury of necrotizing fasciitis and Fournier's gangrene (gangrene affecting the external genitalia or perineum), of the right groin. R1 scored 12/15 during Brief Interview for Mental Status (BIMS), indicating moderately impaired cognition. R1 was hospitalized from [DATE]-[DATE]. [...]

Inspectors wroteBased on interview, observation and record review, the facility did not designate a registered nurse to serve as the Director of Nursing. This had the potential to affect all 48 residents in the facility. The facility's Director of Nursing is not a registered nurse.

Inspectors wroteBased on interview and record review, the facility did not request a waiver when unable to meet the requirements of recruiting appropriate personnel. This had the potential to affect all 48 residents in the facility. The facility did not request a waiver when unable to recruit a registered nurse for the Director of Nurse's position.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure all portions of the call light system were working properly. This had the potential to affect all 48 residents. The facility's call light system was not working at the nurse's station. The call light system's auditory alarms were not working.

Inspectors wroteBased on interviews, record review, and policy review, the facility licensed staff failed to ensure that cardiopulmonary resuscitation (CPR) was provided when resident was found unresponsive for one of three residents (Resident (R)1) reviewed for deaths out of a total sample of 11 residents. This failure had the potential to decrease the chance of survival for residents who required CPR.

Inspectors wroteBased on interviews, record reviews, and policy reviews, the facility failed to enter orders and/or document routine flushes, dressing changes, and monitoring for complications of a peripherally inserted central catheter (PICC) single lumen line (a thin, flexible tube that delivers treatments through a vein) for one of one resident (Resident (R)1) reviewed for intravenous (IV) medication out of a total of 12 residents. This failure had the potential to increase the risk of line occlusion, infections, and unnoticed complications.

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to administer medications as scheduled for two of five residents (Resident (R)2 and R5) reviewed for pharmacy services out of a total sample of 11 residents. Failure to administer medications at the prescribed intervals between doses had the potential for increased side effects for residents who were administered the same medication several times a day.

Inspectors wroteBased on interviews, record reviews, and policy reviews, the facility failed to ensure Vancomycin (antibiotic used to treat serious bacterial infections) was administered as ordered resulting in two missed doses for one of five residents (Resident (R)1) reviewed for significant medication errors out of a total sample of 11 residents. This failure had the potential to increase the risk of serious complications from untreated sepsis such as organ damage and/or death, especially in critically ill patients.

Inspectors wroteBased on interviews, record reviews, and policy review, the facility failed to identify and investigate an adverse event and develop a corrective plan to include staff education after one of one residents (Resident (R) 1) reviewed for an adverse event of an unwitnessed fall was found with a potential injury of unknown origin with her chin and neck against the bed frame and her lower body on the floor, unresponsive, and required Cardiopulmonary Resuscitation (CPR) per her code status out of a total sample of 11 residents. This failure had the potential to affect the health and well-being of residents susceptible to accidents, incidents, and injuries from unknown origins.

Inspectors wroteBased on interview and record review, the facility did not ensure residents (R) with indwelling Foley catheters received care and treatment consistent with professional standards of practice to prevent complications or urinary tract infections (UTI) from the catheter for 3 of 3 residents (R4) reviewed.-R4's suprapubic catheter output was not monitored per physician's order and assessments not completed per professional standards of practice. R4 was transferred to the hospital on [DATE] after 2 days of increased incontinence, and hospitalized for four days with a Urinary Tract Infection. This example is cited at actual harm.-R2's Foley catheter output was not monitored per physician orders.-R5's suprapubic catheter output was not monitored per physician orders. This is evidenced by:Facility policy titled, Catheter Care, Urinary, with a revised date of 04/2010, states in part: [...]

Inspectors wroteBased on record review and interview, the facility did not provide Notice of Bedhold, Notice of Transfer and did not notify the Ombudsman of residents who transferred from the facility to a hospital for 3 of 3 residents (R) (R1, R3 and R4). Example 1 R1 was admitted to the facility on [DATE] and has an Activated Power of Attorney. On 07/23/25, R1 had a change in condition as a result of a fall resulting in need to be transferred to the hospital for evaluation. A Bedhold, Notice of Transfers was not provided to R1's representative and the facility did not notify the Ombudsman of transfer. On 08/17/25, R1 had a change in condition as a result of a fall resulting in need to be transferred to the hospital for evaluation. A Bedhold, Notice of Transfers was not provided to R1's representative and the facility did not notify the Ombudsman of transfer. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure all drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 of 3 residents (R) reviewed (R1).-Medication storage room had R1's lorazepam, with an opened date of 12/01/24, stored in unlocked refrigerator.-Medication storage room had 2 open, unlabeled bottles of eye drops in refrigerator.-Medication storage room had 4 opened boxes of expired intermittent catheters. This is evidenced by:Facility policy titled, Storage of Medications, with a revised date of 04/2007, states in part: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. 7. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure continued monitoring of food's internal temperature. This has the potential to affect all 58 residents (R) in the facility. The facility policy, titled Food Temperatures, states: The temperature of all food items will be taken and properly recorded prior to service of each meal. Under the section labeled Procedures it states: 1. All hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 degrees Fahrenheit. On 07/15/25, Surveyor reviewed the facility Resident Council Meeting Minutes from May 13, 2025, which indicated concerns with food coming out late. Surveyor reviewed kitchen food logs, which show food temperatures are taken at the beginning and end of service with no concerns noted. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not provide pharmaceutical services that ensure the accurate administering of all drugs and biologicals reviewed for 2 or 4 sampled residents (R), R1 and R2The facility did not ensure that medication orders were transcribed accurately. R1 received wrong dose of medication. The facility did not ensure that medication was given according to physician orders. R2 did not receive medications on 2 occasions in the last 45 days. This is evidenced by:The facility policy, titled Administering Medication by MED-PASS, last revised December 2009 states, 3. Medication must be administered in accordance with the orders, including required time frame. 15. [...]

Inspectors wroteBased on record review and interview, the facility did not ensure the physician was notified of laboratory results for 1 of 2 residents (R), R7, reviewed for lab results. -A urinalysis (U/A) determined R7 had a urinary tract infection (UTI). The facility did not update R7's primary provider or urologist with the results; four days later R7 was hospitalized due to sepsis.

Inspectors wroteBased on record review and staff interview, the facility did not ensure the facility-wide assessment was updated to reflect current resident care needs or the resources needed to support the resident care needs. The facility did not use the facility assessment to inform staffing decisions to ensure there are a sufficient number of staff with the appropriate competencies and skill sets necessary to care for its residents' needs prior to increasing the census. This had the potential to affect all 48 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice (N6 Wisconsin Nurse Practice Act,) the comprehensive person-centered care plan, and the resident's choice for 2 of 12 sampled residents (R6 and R21.) R21 did not have comprehensive Congestive Heart Failure (CHF) assessments completed or labs completed to determine worsening CHF. R21 was hospitalized with exacerbation of CHF and Non-ST segment elevation myocardial infarction. This example is cited at actual harm. R6 has multiple non pressure wounds that were not assessed weekly and had missed wound care appointments.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure proper sanitization and food handling practices to prevent the outbreak of foodborne illness for all 28 residents (R). Serving utensil was left in thickener powder. Cooks were observed grabbing ready to eat food with gloved hands, after touching non-sanitized food surfaces, and placing the ready to eat food on plates for residents to eat. Cooks were observed not changing gloves and washing hands after touching non-sanitized food surfaces. Cooks did not perform hand hygiene between glove changes during food service. Cook did not wear hair restraint and/or correctly when entering kitchen, preparing, or serving food. Food (milk) placed in kitchen refrigerator had been opened but was not labeled with an opened date, resulting in the potential for foodborne illnesses to spread. [...]

Inspectors wroteBased on interview and record review, the facility did not immediately report to the resident's physician when a resident had difficulty breathing and was transferred via Emergency Medical Services (EMS) to the Emergency Department (ED). This occurred for 1 of 1 resident (R) reviewed, (R21).

Inspectors wroteBased on record review and interview, the facility did not conduct a Preadmission Screening Resident Review (PASRR) Level II screen for R7, who has a serious mental disorder and is taking psychotropic medication to treat symptoms of major mental disorder to ensure he received care and services to meet his needs. The facility practice affected 1 of 3 residents (R7) reviewed. This is evidenced by: According to the State of Wisconsin Department of Health Services (DHS), PASRR is a federal requirement that all applicants to Medicaid-certified nursing facilities be assessed to determine whether they might have an intellectual/developmental disability (ID/DD) and/or mental illness. This is a Level I Screen. The purpose of a Level I Screen is to identify individuals whose total needs require they receive additional services for their ID/DD and/or mental illness. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that 1 of 1 resident (R) reviewed for pressure injuries (PI) (R21) received care consistent with professional standards of practice to promote healing of PIs. R21 was at risk for PI development and has existing PIs. The facility failed to apply purple boots for off-loading heels as ordered and did not do thorough admission and weekly PI skin assessments.

Inspectors wroteBased on observation, record review and interview, the facility did not provide the needed services in attempt to maintain R10's mobility. The facility practice has the potential to affect 1 of 3 residents (R), R10, reviewed for limited range of motion and mobility. This is evidenced by: Surveyor requested the facility policy regarding restorative or maintenance programs at the facility. Director of Nursing (DON) B informed surveyor the facility does not have a maintenance or restorative program at the facility and has not for some time due to various reasons. The facility does not have a policy specific to maintenance or restorative programing. Surveyor reviewed R10's most recent Minimum Data Set (MDS) which was a quarterly (MDS) completed on 8/22/24. The MDS notes R10 understands and is understood. R10 does not reject care. [...]

Inspectors wroteBased on record review and interview, the facility did not ensure a resident with an indwelling catheter was assessed for removal of the catheter as soon as possible for 1 of 1 resident (R) R19, reviewed with indwelling catheters.

Inspectors wroteBased on random observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and help to prevent the development and transmission of communicable diseases and infections for 2 residents (R) (R17 and R25). Example 1 The facility policy entitled F880 Multidrug-Resistant Organisms (MDRO) and Enhanced Barrier Precautions (EBP) last revised on 3/2024, states under definition of EBP, The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. [...]

Inspectors wroteBased on record review and interview, 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 section 1150B of the Act when an allegation of verbal abuse was not reported immediately but not later than 2 hours after the allegation is made to local law enforcement in accordance with state law through established procedures. The facility practice affected 1 of 1 resident (R) reviewed. (R1). This is evidenced by: Surveyor requested and reviewed the facility policy regarding reporting suspicion of a crime. The policy titled Reporting Abuse Allegations which was dated as last approved on 11/2023 indicated the following: Policy: [...]

Inspectors wroteBased on interview and record review, the facility did not thoroughly investigate an allegation of abuse. The facility practice affected 1 of 1 resident reviewed (R1). Findings Include: Surveyor reviewed the facility policies for the abuse prohibition program as follows: Abuse Prevention Program, Training which was dated 9/2023. The policy does not address the facility's investigation process. Abuse Prevention Program which was dated 9/2023. The policy in part reads: Abuse as the willful infliction of injury, unreasonable confinement, intimidation or punishment . Comprehensive policies and procedures have been developed to aid the facility administration in preventing abuse, neglect or mistreatment. The abuse prevention program provides policies and procedures that govern at a minimum: timely and thorough investigations of all reports of abuse including reporting of crimes. [...]

Inspectors wroteBased on record review and staff interview, the facility did not ensure a Registered Nurse (RN) worked at the facility for at least eight consecutive hours a day, seven days a week, on 3 of 5 days reviewed on Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Year (FY) Quarter 3 2023 (April 1-June 30, 2023). This has the potential to affect all residents in the facility. The facility did not have a RN working in the facility for at least eight consecutive hours on 04/25/23 (Tuesday), 05/13/23 (Saturday), and 05/14/23 (Sunday). This is evidenced by: The Code of Federal Regulation (CFR) 483.35 (b) states, in part: . except when waived, the facility must use the services of a registered nurse for at least 8 hours a day; 7 days a week. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that the mandatory staffing data that had been submitted from 04/01/23-06/30/23 was complete, accurate, and auditable. This has the ability to affect all 30 residents in the facility. The submitted data from 01/01/22-03/31/23 was not complete, accurate, or auditable. This is evidenced by: The Payroll Based Journal (PBJ) Staffing Data Reports that were generated quarterly document that the facility triggered No RN Hours for the dates of 04/25 (TU); 05/13 (SA); 05/14 (SU); 05/28 (SU) 06/03 (SA) Failed to have Licensed Nursing Coverage 24 Hours/Day for the dates of 04/01 (SA); 04/02 (SU); 04/03 (MO); 04/04 (TU); 04/06 (TH); 04/07 (FR); 04/08 (SA); 04/09 (SU); 04/10 (MO); 04/11 (TU); 04/12 (WE); 04/14 (FR); 04/15 (SA); 04/16 (SU); 04/17 (MO); 04/18 (TU); 04/20 (TH); 04/21 (FR); 04/22 (SA); 04/23 (SU); 04/24 (MO); 04/25 (TU); [...]

Inspectors wroteBased on interview and record review, the facility did not identify issues to which quality assessment and assurance activities are necessary or develop and implement appropriate plans of action to correct identified quality deficiencies. This has the potential to affect all 30 residents. The facility does not have a QAPI system in place and has failed to identify key areas of deficient practice and implement action plans to correct these deficient practices or identify areas needing improvement to develop, implement, monitor, and evaluate action plans to achieve specific goals to improve quality of care. This is evidenced by the following: The policy titled Quality Assurance & Performance Improvement (QAPI,) was reviewed. [...]

Inspectors wroteBased on interview and record review, the facility did not provide dementia management and abuse prevention training to all staff. This deficient practice had the potential to affect all 30 residents (R) residing in the facility. The facility did not implement and maintain a dementia training program for all staff, as determined by the facility assessment.

Inspectors wroteBased on record review and staff interviews, the facility did not implement procedures for reporting an injury of unknown origin for 1 of 1 resident (R9). R9's record confirmed three separate incidents of an injury of unknown origin not reported to the Nursing Home Administrator or the state Survey Agency (SA).

Inspectors wroteBased on record review and interview, the facility did not conduct a Preadmission Screening and Resident Review (PASARR) for R5, who has a serious mental disorder to ensure he receives care and services in the most integrated setting appropriate to his needs. The facility practice affected 1 of 2 residents reviewed (R5). R5 was admitted on [DATE] with diagnoses that included Schizoaffective disorder and cognitive and communication deficit. The facility did not complete a Preadmission Screening and Resident Review (PASARR) prior to his admission to ensure he receives care and services in the most integrated setting appropriate to his needs. This is evidenced by: Surveyor reviewed R5's record and noted he was admitted [DATE] with diagnoses that included Schizoaffective disorder and cognitive and communication deficit. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure care plans were updated for 1 of 12 residents (R22) reviewed. R22's care plan was not updated after two hospitalizations related to gastrointestinal bleed. This is evidenced by: R22 was admitted to the facility on [DATE]. R22's diagnoses include failure to thrive, malnutrition, atrial fibrillation, and weakness. R22's MDS completed on 10/04/23 confirmed R22 scored 15 during BIMS, indicating intact cognition. R22 was admitted to the hospital on [DATE] and 09/25/23 for gastrointestinal (GI) bleed. Surveyor reviewed R22's record which did not include a care plan related to bleeding or GI bleeding. Surveyor reviewed R22's [NAME] and certified nursing assistant (CNA) tasks and noted no care or monitoring related to bleeding or GI bleeding. On 10/24/23 at 3:29 PM, Surveyor interviewed Director of Nursing (DON) B. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure the resident's environment remained as free of accident hazards as possible, and residents received adequate supervision and assistive devices to prevent accidents for 4 of 7 residents (R20, R27, R9, and R18) reviewed. R20 was observed to be maintaining her smoking materials, not using a smoking apron, or being provided supervision with smoking. R20's smoking assessment and care plan identify R20 is at risk for burns and requires supervision with smoking and R20's smoking materials to be secured. R27 was transferred by Certified Nursing Assistant (CNA) E without use of a gait belt. R27's Minimum Data Set (MDS) indicates R27 requires extensive assistance of 2 staff for transfers. Facility standard of practice indicates staff should use a gait belt with transfers. [...]

Inspectors wroteBased on observation, record review and interview, the facility did not monitor resident weight status consistent with current standards of practice. The facility practice has the potential to affect an appropriate and prompt response to potential resident weight loss affecting 3 of 3 residents reviewed for weight loss (R81, R131 and R22). R81's weights were not obtained per the facility policy and standards of practice to ensure nutritional parameters were maintained. R81 did not have evidence of snacks being provided. R22 has a diagnosis of malnutrition and was identified by Registered Dietician (RD) C as having significant weight loss and was to be weighed weekly. R22's last weight was obtained on 10/12/23. R131 is a new admission to the facility on [DATE]. R131's last weight was obtained on 10/10/23. This is evidenced by: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure residents received pharmaceutical services (accurate acquiring, dispensing, and administering of all drugs and biologicals) to meet the needs of 2 of 12 residents (R18 and R22). R18 had a physician's order to administer D-Mannose. After R18 ran out of his medication the facility made no effort to obtain a new supply and reported this medication was brought in by family. R22 had a physician's order to administer Lidocaine Viscous Mouth solution. The facility did not receive the medication from the pharmacy and no efforts were made to obtain the medication for five days. This is evidenced by: Example 1 Surveyor reviewed facility policy titled Pharmacy Services, dated 09/2023. The policy reads in part . The facility shall contract with a licensed pharmacist to help obtain and maintain timely and appropriate pharmacy services. [...]

Inspectors wroteBased on record review and interview, the facility did not provide residents who had a continued stay at the facility after their Medicare benefits were terminated, the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) and did not provide the Medicare Part A Skilled Services Episode Start Date for 3 of 3 residents (R) R2, R11, R20 reviewed for notices. R2 did not receive an SNF ABN. Medicare Part A Skilled Services Episode Start Date not provided. R11 did not receive an SNF ABN. Medicare Part A Skilled Services Episode Start Date not provided. R20 did not receive an SNF ABN. Medicare Part A Skilled Services Episode Start Date not provided. On 10/24/23, Surveyor reviewed three records for Centers of Medicare and Medicaid Services (CMS) 10123 (Notice of Medicare Non-Coverage- NOMNC) and CMS 10055 (Advance Beneficiary Notice) as follows: [...]

Inspectors wroteExample 2: Surveyor reviewed R12's record and noted the following: 08/07/23 at 8:30 AM R12's Nurses Notes show resident breathing hard, nausea and vomiting episode, temp 97.1 with other vitals refused. NP (Nurse Practitioner) here and ordered transfer to ER (emergency room). 08/16/23 Resident returned to the facility. Surveyor could not locate a notice of transfer in R12's record. On 10/25/23 at 2:23 PM, Surveyor spoke with Registered Nurse/Care Coordinator (RN) D about the facility process for providing written notice of transfer to residents/resident representative and informing the office of the State Long-Term Care Ombudsman. RN D indicated she is responsible for notifying the ombudsman of transfers and was sending a report of residents who discharged from the facility but not hospital transfers thus the ombudsman has not been notified of resident transfers. [...]