Cedarburg Health Services

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure the right to smoke for 1 resident (R) (R9) of 14 sampled residents. R9 expressed a desire to smoke. Staff stated R9 was not allowed to smoke and removed smoking materials from R9's room. The facility did not complete a smoking assessment for R9 following the removal of smoking materials or offer R9 smoking cessation assistance.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure 1 resident (R) (R7) of 4 sampled residents was not free of a physical restraint. R7 had a motorized wheelchair with a seatbelt that R7 could not independently remove. R7 did not have a physician order for use of the seatbelt which was considered a restraint.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure the provision of care and treatment to prevent pressure injuries from developing and/or promote healing for 3 residents (R) (R4, R11, and R25) of 3 sampled residents. R4 had an order (dated 3/11/26) that indicated R4's air mattress should be set at 150 pounds (lbs). The order indicated to check the setting and function every shift. R4's air mattress was set at 50 lbs during multiple observations. R11 had an order (dated 4/1/26) that indicated R11's air mattress should be set at 200 lbs. The order indicated to check the setting and function every shift. R11's air mattress was set at 50 lbs during multiple observations and the low pressure light was on. R25 had an order (dated 2/4/26) that indicated R25's air mattress should be set at 200 lbs. [...]

Inspectors wroteBased on staff interview and record review, the facility did not offer a PCV20 vaccine for 1 resident (R) (R25) of 5 sampled residents. R25 was not offered the recommended PCV20 vaccine. The Facility's Pneumococcal Vaccine policy, dated 3/25/25, indicates: It is our policy to offer residents and staff immunization against pneumococcal disease in accordance with current Centers for Disease Control and Prevention (CDC) guidelines and recommendations .1. Each resident will be assessed for pneumococcal immunization upon admission. Self-report of immunization shall be accepted. Any additional efforts to obtain information shall be documented, including efforts to determine date of immunization or type of vaccine received. 2. Each resident will be offered a pneumococcal immunization unless it is medically contraindicated or the resident has already been immunized. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure a physician was notified of blood sugar levels that were outside the ordered parameters for 1 resident (R) (R20) of 15 sampled residents. R20 had a diagnosis of diabetes and a physician's order that instructed staff to notify the physician if R20's blood sugar level was over 400 (milligrams/deciliter (mg/dL)). On 12/19/24, 12/23/24, and 1/3/25, R20's blood sugar level was over 400 mg/dL. R20's physician was not notified.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure adequate supervision during meals for 2 residents (R) (R24 and R10) of 8 sampled residents observed during mealtime. R24 had a diagnosis of dysphagia (difficulty swallowing). R24's care plan indicated R24 required full assistance with eating and should be cued to take one sip at a time and slow down. On 1/21/25, R24 was observed eating lunch in the dining room without staff assistance. In addition, staff removed R24 from the dining room after R24 coughed, drooled, and appeared to be in distress during the meal. R10's care plan indicated R10 had difficulty swallowing and contained interventions to remind R10 to swallow after each bite and take a drink after every 2-3 bites. On 1/21/25, R10 was observed eating lunch in the dining room without staff assistance.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure the accurate administration of medication for 3 residents (R) (R13, R18, and R19) of 15 sampled residents. R13's physician order for fluticasone (a nasal spray) indicated not to keep fluticasone at the bedside. On 1/21/25, fluticasone was observed at R13's bedside. R18's medication administration record (MAR) did not accurately reflect the time polyethylene glycol (an osmotic laxative) was administered on 1/22/25. Staff administered hydralazine (a vasodilator medication used to lower blood pressure) to R19 on 1/22/25 prior to obtaining R19's blood pressure in accordance with the physician's order. In addition, R19's MAR did not accurately reflect the time polyethylene glycol was administered on 1/22/25.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure it was free a medication error rate of 5% or greater. During medication administration observations, 3 errors occurred during 30 opportunities which resulted in a 10% medication error rate that affected 1 resident (R) (R19) of 5 residents observed during medication administration. During medication administration observations for R19 on 1/22/25, staff did not administer Biofreeze menthol topical analgesic (a pain relieving treatment), cholecalciferol (a vitamin supplement), or levetiracetam (a seizure medication) as ordered.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure all drugs or biologicals were discarded when expired in 1 of 2 medication rooms in the facility. On 1/21/25, expired stock medications were observed in a cabinet and refrigerator in the 400 unit medication room.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 2 residents (R) (R9 and R15) of 4 sampled residents. R9 and R15 had symptoms of an upper respiratory infection and were not placed on precautions in a timely manner.

Inspectors wroteBased on observation and staff and resident interview, the facility did not ensure 2 residents (R) (R13 and R9) of 14 sampled residents had hot water in their bathrooms. During observations on 10/4/24, R13 and R9's bathroom sinks did not have hot water.

Inspectors wroteBased on staff and resident representative interview and record review, the facility did not ensure a grievance was thoroughly resolved for 1 resident (R) (R3) of 14 sampled residents. Resident Representative (RR)-H filed a grievance on behalf of R3 on 8/8/24 that indicated R3 experienced a delayed call light response time and was not attended to in a timely manner. The facility did not resolve the grievance in a timely manner.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure fluids were provided on a consistent basis for 4 residents (R) (R3, R4, R5, and R6) of 4 sampled residents. R3, R4, R5 and R6 did not receive fresh drinking water on a consistent basis or in accordance with their nutritional assessment.

Inspectors wroteBased on staff interview and record review, the facility did not ensure thorough background checks were completed for 2 of 8 sampled staff. The facility did not ensure a Department of Justice (DOJ) letter and State of Wisconsin Department of Health Services (DHS) Governmental Findings Report (GFR) (formerly known as the Integrated Background Information System (IBIS) letter) were obtained for Certified Nursing Assistant (CNA)-C and CNA-E prior to hire.

Inspectors wroteBased on staff interview and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 1 resident (R) (R2) of 1 sampled resident. R2 reported care and treatment concerns. The facility did not thoroughly investigate the allegation of abuse.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure 2 Residents (R) (R17 and R36) of 2 sampled residents had a self-administration of medication assessment, or a physician's order to self-administer medication and keep medication at the bedside. R17 kept a nasal spray and multivitamins on R17's bedside table and stated R17 self-administered both medications. R17 did not have a physician's order to self-administer medication or a self-administration of medication assessment that indicated R17 could safely and accurately self-administer medication. R36 kept a bottle of iron on R36's bedside table and stated R36 self-administered the medication. R36 did not have a physician's order to self-administer medication or a self-administration of medication assessment that indicated R36 could safely and accurately self-administer medication.

Inspectors wroteBased on staff and resident interview, and record review, the facility did not ensure the medical record contained advanced directives for 1 Resident (R) (R25) of 17 sampled residents. R25 was admitted to the facility on [DATE]. R25's medical record did not contain advanced directives, including a Power of Attorney for Healthcare (POAHC) document.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure a safe environment that was free of accident hazards for 1 Resident (R) (R17) of 17 sampled residents. R17 had a space heater in R17's room which was not in accordance with the facility's policy.

Inspectors wroteBased on staff and resident interview, and record review, the facility did not ensure 1 Resident (R) (R3) of 1 sampled resident received catheter care in accordance with their prescribed plan of care. R3 had physician's orders to irrigate R3's Foley catheter with 60 mL (milliliters) of sterile saline 3 times per week (Monday, Wednesday, and Friday) at HS (bedtime) and PRN (as needed), and for catheter care every shift. The orders were not consistently followed.

Inspectors wroteBased on staff interview and record review, the facility did not ensure ongoing communication with a dialysis facility for 1 Resident (R) (R193) of 1 resident who received dialysis care and services. R193 received dialysis three times per week. The facility did not ensure ongoing communication occurred between the nursing facility and the dialysis facility prior to and following R193's dialysis appointments.

Inspectors wroteBased on staff interview and record review, the facility did not thoroughly investigate a medication error for 1 Resident (R) (R38) of 1 resident reviewed. On 11/9/23, R38 had a seizure and was administered Narcan (an opioid antagonist medication used to reverse an opioid overdose) in error.

Inspectors wroteBased on staff an resident interview, and record review, the facility did not ensure an injury of unknown origin was reported to the State Agency (SA) for 1 Resident (R) (R2) of 6 sampled residents. R2 had an injury of unknown origin which was discovered on 8/30/23. The facility did not report the injury to the SA.

Inspectors wroteBased on staff and resident interview, and record review, the facility did not ensure an injury of unknown origin was thoroughly investigated for 1 Resident (R) (R2) of 6 sampled residents. R2 had an injury of unknown origin which was discovered on 8/30/23. The facility did not thoroughly investigate the injury to rule out possible abuse.