Complete Care at Care Age

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure food was served in accordance with professional standards for food service safety potentially affecting 45 of 67 residents who eat their meals in their room. Observations were made of staff delivering meal trays to residents in their room with uncovered dessert items and beverages.

Inspectors wroteBased on interview and record review, the facility did not ensure each resident receives the necessary care and services in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) after experiencing a change of condition for 1 of 11 residents reviewed (R20). R20 had an unintended sudden change of plane while being transferred by a sit to stand lift by a lone Certified Nursing Assistant (CNA). While in the lift sling, the lift's battery died, and resident ended up in a squatting position with her buttocks touching the foot pads of the lift. This sudden change of plane resulted in a hip fracture. Staff did not follow R20's plan of care which included using 2 staff for transfers with a sit to stand lift, and staff moved resident twice without a Registered Nurse (RN) assessment after the change of plane. [...]

Inspectors wroteExample 2 R35 was admitted to the facility 4/24/23 with diagnoses including, but not limited to, the following: Dementia (a group of thinking and social symptoms that interferes with daily functioning), diabetes mellitus type 2 (a long-term condition in which the body has trouble controlling blood sugar), abnormal gait (walking different than normal), chronic kidney disease (disease of the kidneys that will eventually lead to kidney failure), and hypertension (high blood pressure). On 4/24/23, the facility's Treatment Administration Record (TAR) documents the following: Monitor feet to ensure skin is intact and free from s/sx (signs/symptoms) of developing skin alterations. Notify MD (Medical Doctor) with any change in skin integrity. Every evening shift for prevention of skin impairment. R35's Braden's are as follows: 4/24/24: 19 (Not At Risk) 7/24/24: 20 (Not at Risk) 10/25/24: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents in 1 of 2 residents (R20) reviewed for falls resulting in actual harm, 1 of 1 resident (R31) reviewed for motorized wheelchair charging, and 2 of 4 units reviewed for lithium battery charging. R20 is being cited at Actual Harm/Isolated. R31 and 2 of 4 units is being cited at Potential for Harm/Isolated. R20 was care planned to be a two person assist with a sit to stand transfer. CNA L transferred R20 alone when the lift lost battery power. R20 ended up sitting on the ground, had a sudden drop from the lift, and a change of plane/fall. [...]

Inspectors wroteBased on observation and interview, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 57 residents who reside in the facility. The facility did not have a system in place for manually monitoring the internal concentration of the chemical dishwasher. Surveyor observed staff prepping food and in food preparation areas without hair restraints. Surveyor observed food in circulation to be opened and undated or pass the expiration date. Evidenced by: Example 1 Facility's policy, titled Recording Dish Machine Temperatures, undated, includes: Dishwashing staff will monitor and record dishwasher machine temperatures to assure proper sanitizing of dishes. The food service manager will train dishwashing staff to monitor dish machine temperatures throughout the dishwashing process. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that each resident receives food and drink that is palatable and at a safe and appetizing temperature. This has the potential to affect 4 of 4 sampled residents (R56, R23, R37, R29) reviewed for food palatability and 4 of 4 supplemental residents (R2, R8, R14, and R5). R56, R23, R37, R29, R2, R8, R14, and R5 voiced concerns with their food not being palatable. Surveyors conducted 2 test trays and both test trays were not palatable. Evidenced by: Facility policy, titled Record Food Temperatures, implemented 5/28/25, includes: . Hot foods will be held at 135 degrees Fahrenheit or greater . Potentially hazardous cold food temperatures will be kept at or below 41 degrees Fahrenheit. Example 1 R29 admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility has not established an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 19 sampled residents (R49, R23, and R41) and 1 of 1 supplemental residents (R19) observed for hand hygiene. Staff did not perform proper hand hygiene per standards of practice during wound care on R49 and R23. A nurse had a breach in infection control during medication adminstration observation for R19 when a nurse did not perform hand hygiene following a blood glucose test. A nurse had a breach in infection control during wound care for R41. Evidenced by: The facility policy entitled Hand Hygiene, dated 5/28/25, states, in part: . Policy: [...]

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 sampled residents (R36, 31) and 1 of 1 supplemental resident's (R24) reviewed for self- administration of medications. R36 was observed to have a cup of medications left on his bedside table for him to take independently. R36 does not have an assessment for self-administration of medications indicating that he is safe to administer medications independently. R31 had containers of medication at bedside and had scheduled medications left on her bedside table for longer than 1 hour. R31's self-administration assessment only allows Lactaid at bedside and requires nurses to follow up with R31 after 1 hour. R24 had an inhaler at his bedside. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that a comprehensive person-centered care plan included a sleep assessment and sleep tracking for 3 of 5 residents (R6, R18, and R43) reviewed for unnecessary medications. R6 is prescribed melatonin and does not have a sleep assessment or sleep tracking. R18 is prescribed melatonin and does not have a sleep assessment or sleep tracking. R43 is prescribed melatonin and does not have a sleep assessment or sleep tracking. This is evidenced by: The facility's policy titled Use of Psychotropic Medication(s), dated 5/28/25, includes: Adequate indications for use refers to the identified, documented clinical rationale for administering a medication that is based upon an assessment of the resident's condition and therapeutic goals and after any other treatments have been deemed clinically contraindicated. 5. [...]

Inspectors wroteExample 2 R28 admitted to the facility on [DATE] with diagnoses including urinary tract infection (2/25/25) , urine retention, and neuromuscular dysfunction of bladder. On 6/10/25 at 10:56 AM Surveyor observed R28 being pushed in his wheelchair down the hallway. Surveyor heard something rubbing as R28 passed. Surveyor observed R28's catheter bag dragging on the floor. On 6/10/25 at 10:59 AM LPN Y (Licensed Practical Nurse) indicated R28's catheter bag should not be in contact with the floor. LPN Y stated, I will fix this. On 6/10/25 12:03 PM NHA A (Nursing Home Administrator) indicated residents' catheters should not be touching the floor. On 6/10/25 at 1:53 PM DON B (Director of Nursing) indicated R28's catheter should not be in contact with floor. On 6/11/25 at 1:26 PM during wound care observation, Surveyor observed R28's catheter bag to be resting in contact with the floor. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure residents are free of any significant medication errors for 2 of 2 residents (R31 and R41) reviewed for medications. The facility did not ensure R31 took her evening medications as prescribed. R41 did not receive one dose of the intravenous (IV) antibiotic ordered for wound infection. This is evidenced by: The facility's policy titled Medication Errors, dated 5/28/25, includes: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors. Medication error means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order; [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not provide food that accommodates resident preferences; appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice for 3 of 17 sampled resident's (R23, R31, & R37). R23 was being served foods that were listed on his meal ticket as disliked food. R23's food preferences were not being honored. R31 was being served gravy that was listed on her meal ticket as disliked food. R31's food preferences were not being honored. R37's received foods that are on the R37 has indicated she should not have. Evidenced by: The facility policy entitled Resident Food Preferences, dated 5/28/25, states, in part: . Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility did not provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 5 (R3, R5, R6, R7 and R8) of 7 residents reviewed for medications. *R3, R5, R6, R7 and R8 had MD orders for narcotic pain medication. Facility staff did not consistently document the administration time of the pain medication directly after administering the pain medication as outlined in the facility policy. The late documentation could result in duplication of pain medication administration. *R5 had duplicate Medical Doctor (MD) orders for Oxycodone (a narcotic pain medication). Facility staff were using both MD orders for documenting the administration of Oxycodone.

Inspectors wroteBased on interview and record review the facility did not report 1 (R2) of 2 incidents to the State Survey Agency and/or Nursing Home Administrator during the required timeframe. On 12/7/24 NHA (Nursing Home Administrator) was informed of a skin tear on R2's left wrist which CNA (Certified Nursing Assistant)-G reported to LPN (Licensed Practical Nurse)-E as occurring when taking off R2's sweat shirt. NHA-A was not informed on 12/7/24 of R2's allegation the skin tear occurred when CNA-G grabbed her arm. The allegation of CNA-G grabbing R2's arm was reported to DON (Director of Nursing)-B on 12/7/24 but DON-B did not report this to the State agency. The allegation of physical abuse was not reported to NHA-A or the State agency until 12/9/24.

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R2) of 4 residents care plans were revised. R2's care plan was not revised after an allegation on 12/7/24 of a CNA grabbing R2's wrist causing a skin tear.

Inspectors wroteBased on interview and record review, the facility did not ensure that in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. This had the potential to effect 19 of 19 residents on the 400 hallway. On 4/2/24 while providing cares, R1 accused Certified Nursing Assistant (CNA)-D of slapping her. CNA-D reported this to Licensed Practical Nurse (LPN)-C. LPN-C did not immediately report the allegation of abuse to administration resulting in CNA-D not being removed from the resident care area immediately pending investigation and was allowed to work the rest of the shift.

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, are reported immediately to the administrator of the facility and to the State Survey Agency in accordance with State law through established procedures. The staff did not report the incident to the administration immediately after the incident and did not contact law enforcement to report this reasonable suspicion of a crime for 1 (R1) of 3 residents reviewed for abuse and neglect. On 4/2/24 while providing cares, R1 accused Certified Nursing Assistant (CNA)-D of slapping her. CNA-D reported this to Licensed Practical Nurse (LPN)-C. LPN-C did not immediately report the allegation of abuse to administration. Law enforcement was not called to report this reasonable suspicion of a crime.

Inspectors wroteThe facility did not ensure grievances and recommendations discussed during resident group meetings (Resident Council) were acted upon promptly and with feedback provided by the Facility. R2, R4, R20, and R51, expressed concern the Facility did not resolve grievances or provide feedback of steps taken to resolve grievances discussed at Resident Council Meetings. The grievance documents generated from Resident Council Meetings do not identify how the grievances were investigated, if interviews with staff/residents were completed, or the outcome of the investigation. Resident Council Minutes did not include actions taken regarding the concerns voiced by residents. Findings Include: Surveyor reviewed the facility's Resident Council Meetings policy and procedure implemented 2/20/23 and notes the following: . Policy: [...]

Inspectors wroteBased on interview and record review the Facility did not thoroughly investigate a possible misappropriation of property for Residents receiving liquid morphine. This has the potential to affect 7 hospice residents who received liquid morphine on the 300 & 400 units in October 2023.

Inspectors wroteBased on interview and record review the Facility did not report 2 of 2 incidents to the State Survey Agency and/or Nursing Home Administrator. * A possible diversion of liquid morphine was not reported to the Nursing Home Administrator and State Agency. * R25's ankle fracture was not reported to the State Agency as an injury of unknown origin.

Inspectors wroteBased on observation, interview, and record review the Facility did not ensure 1 (R2) of 1 Resident's reviewed for communication received proper treatment and assistive devices to maintain hearing ability. R2 had an audiology consult on 2/19/24 for a lost hearing aid. Under recommendations for attending M.D. (medical doctor)/Nursing Staff documents Medical consult to obtain medical clearance for comprehensive evaluation for hearing aids. As of 3/20/24 medical clearance was not obtained and R2 does not have a right hearing aid.

Inspectors wroteBased on observation, interview and record review, the Facility did not ensure Residents with a pressure injury received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 1 (R2) of 5 Residents reviewed for pressure injuries. R2 has a stage 2 right buttock pressure injury with an intervention for an air cushion on R2's wheelchair. Observations were made on 3/18/24 & 3/19/24 of the air cushion not on. Facility staff were not aware the air cushion was off until brought to their attention by the Surveyor.

Inspectors wroteBased on interview and record review the Facility did not ensure 1 (R30) of 4 Residents reviewed for falls received the supervision and assistance to prevent accidents. On 11/16/23 R30 fell out of bed during incontinence cares as CNA-I rolled R30 away from her and not towards her.

Inspectors wroteBased on record review and interview, the facility did not ensure potential side effects of psychotropic medications were monitored and consents were provided for 1 (R25) of 5 residents reviewed for unnecessary medications. *R25 received an order for Seroquel 25 mg (milligrams) on 12/18/2023. R25's activated Power of Attorney (POA) did not sign the medication consent for use of the Seroquel until 3/19/2024 after Surveyor inquired about the consent and no monitoring was documented for potential adverse side effects of the Seroquel until 3/19/2024.

Inspectors wroteBased on observations, record review and staff interviews, the facility did not always ensure that 3 out of 4 residents ( R37, R2, R360) reviewed for pressure ulcers received the necessary care and treatment to promote healing of existing pressure ulcers and to avoid the development of new pressure ulcers. R37 developed a Stage #3 pressure ulcer to his middle finger of the right hand. R37's range of motion to the right hand had deteriorated and a contracture developed. R37 was not provided with pressure relief for the contracture to the right hand and developed the stage #3 pressure ulcer. R2 had a history of resolved pressure ulcers to the right ankle and left buttocks. On [DATE] R2 developed a new pressure ulcer to the right buttocks (stage 2) and an order was given to obtain an alternating air mattress to provide additional pressure relief. [...]

Inspectors wroteBased on interview, observation, and record review, the facility did not ensure a Resident with limited range of motion received the appropriate treatment and services to prevent further decrease in range of motion for 1 (R37) of 1 Residents reviewed for limited range of motion. On 5/25/22, R37 was transferred from the hospital to the facility. R37 had been hospitalized following a fall which resulted in a right hip fracture and right humerus fracture. There was no surgical repair of the right humerus and R37 was advised to keep the right arm in a sling. R37 was admitted to the facility with the supportive services of hospice care. The facility did not document the interventions to address R37's limited arm Range of Motion (ROM), or identity interventions to prevent further decline in the right arm ROM until after R37's right hand became contracted.

Inspectors wroteBased on interview and record review, the facility did not ensure 2 Certified Nursing Assistants (CNA-G and CNA-H) of 5 reviewed for abuse training and 5 (CNA-D, CNA-E, CNA-F, CNA-G, and CNA-H) of 5 reviewed for dementia training who had been employed for over a year or providing direct care received dementia management & resident abuse prevention training. This has the potential to affect all 62 residents residing at the facility as staff work throughout the facility.

Inspectors wroteBased on observation, interview and record review, the Facility did not utilize proper infection control techniques to prevent and control the spread of infections such as COVID-19. The facility did not ensure all necessary staff were fit tested for N95's. The facility's last recording of staff having a fit test for N95's was 5/6/21 where 18 of the 175 staff members were noted to be fit tested.

Inspectors wroteBased on record review, observation and interview the facility did not provide care and services related to Restorative Nursing Services for dependent residents for 1 (R26) of 1 resident reviewed for therapy services. * R26 was discharged from Physical Therapy (PT) on 11/9/22. On 11/18/22 an order was written to begin Restorative Nursing Rehabilitation and was not completed per order and plan of care.

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R29) of 5 resident reviewed for weight loss received the necessary services to assist with nutritional maintenance. R29 experienced a 9.4 pound weight loss (5.9%) from 11/23/22- 12/14/22 without having a comprehensive assessment or further interventions put into place to help R29 not to loose any further weight. This is evidenced by: Policy review: Weighing and Measuring the Resident revised March 2011. Purpose: The purposes of this procedure are to determine the resident's weight and height, to provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident, and to provide a baseline height in order to determine the ideal weight of the resident. Reporting: 1. Report significant weight loss/ weight gain to the nurse supervisor. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure 1 (R13) of 5 residents reviewed for unnecessary medications had adequate behavior monitoring while receiving psychotropic medications. * R13 received psychotropic medications without adequate behavior monitoring.