Complete Care at Grande Prairie

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure that food was prepared, distributed, and served in accordance with professional standards for food service safety (Wisconsin Food Code) in the main kitchen. This deficient practice has the potential to affect all 79 residents who receive food from the main kitchen. *Dietary Manager (DM)-C, Dietary Aide (DA)-D, and DA-E were observed in the main kitchen preparing and handling food without wearing hair restraints that covered facial hair. DA-E was observed wearing a hat that did not fully restrain hair.

Inspectors wroteBased on interview and record review, the facility did not ensure it submitted accurate mandatory staffing information based on payroll data in a uniform electronic format to the Centers for Medicare & Medicaid Services (CMS). This had the potential to affect all 79 residents residing in the facility. Staffing information for Quarter 1 (October 1 - December 31, 2025) of the Payroll Based Journal (PBJ) was not accurately submitted to CMS.

Inspectors wroteBased on observation, interview, and record review, drugs used in the facility were not labeled in accordance with currently accepted professional principles. *Surveyor observed 6 expired stock medications and 63 loose medication pills in 2 of 3 medication carts. This deficient practice has the potential to affect more than 3 residents residing on the units that utilize the medication carts for medication administration.

Inspectors wroteBased on observation, interview and record review the facility did not ensure residents who are fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding, including risk for dehydration for 1 (R8) of 2 residents reviewed for enteral feeding.*R8 has an order for 12 hours continuous feed from 8PM to 8AM. Surveyor observed that on 5/11/2026, 5/12/2026 and 5/13/2026 that R8's tube feeding was not administered as ordered.

Inspectors wroteBased on interview and record review, the facility did not ensure 3 (R7, R12, & R91) of 3 residents reviewed for post-traumatic stress disorder (PTSD) received trauma informed care in accordance with professional stands of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization. R7, R12, and R91 were admitted to the facility with a diagnosis of PTSD, and the facility did not develop a person-centered care plan identifying triggers, interventions, or monitoring for PTSD.

Inspectors wroteBased on interview and record review, the facility did not thoroughly investigate 2 of 4 allegations of abuse involving residents (R) (R5 and R1) and did not take steps to prevent further potential abuse while an investigation was in progress. The facility was made aware of an incident involving allegations of abuse that occurred involving R5 and two staff members. The facility did not investigate the incident causing R5 to be fearful and cautious. R5 sought evaluation and treatment for left knee pain following the incident. The staff member alleged to have abused R5 was allowed to work approximately 46 shifts following the incident, resulting in R5 and other residents to not be safeguarded from additional potential abuse. [...]

Inspectors wroteBased on interviews and record review, the facility failed to protect the residents' right to be free from verbal and or physical abuse by Certified Nursing Assistant (CNA)-J. *R5 reported that R5 was attacked in the doorway of the kitchen, in the dining room, at the facility resulting in R5 to be fearful and cautious in the facility. R5 reported left shoulder, left rib and left knee pain following the incident. R5 sought evaluation and treatment for R5's left knee pain on 01/13/2025 resulting in R5 requiring an invasive injection into R5's left knee.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents received adequate supervision and assistive devices to prevent accidents for 1 (R6) of 2 residents reviewed for falls. R6 was assessed as needing bilateral enabler bars on the bed to assist with positioning and bed mobility. An enabler bar was placed on the left side of the bed. No enabler bar was placed on the right side of the bed. R6's care plan had the intervention of bilateral enabler bars until 1/7/2025 when the care plan was revised to reflect what was actually in place, the left enabler bar only. On 3/10/2025, Certified Nursing Assistant (CNA)-C was providing cares to R6 and rolled R6 away from CNA-C. R6 continued to roll to the right and fell out of bed sustaining a right hip fracture requiring surgical intervention. [...]

Inspectors wrote2.) Surveyor reviewed a facility investigation regarding a resident to resident physical altercation between R3 and R4. This incident was reported to the state agency. R3 was admitted to the facility on [DATE] with diagnoses of quadriplegia, type 2 diabetes, and anxiety. R3's annual MDS (minimum data set) dated 2/8/25 indicates R3 is cognitively intact and is dependent for ADLs (activities of daily living). R4 was admitted to the facility on [DATE] with diagnoses of ESRD (end stage renal disease), type 2 diabetes, and PTSD (post traumatic stress disorder). R4's quarterly MDS dated [DATE] documents that R4 is cognitively intact and independent for ADLs. The facility investigation dated 1/24/25 documents that R3 was in bed and thought R4 was trying to climb in bed with him. R3 then threw water at R4 and R4 retaliated by throwing a fan at R3 hitting R3 in the shin. [...]

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to assess two of 18 sampled residents (Resident (R) 11 and R45) for self-administration of medications. This failure led to medications being left at the bedside where they could be accessed by other residents.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure leftovers were cooled properly, over easy eggs were pasteurized or cooked thoroughly for one (Resident (R)55) of one resident, and the ice machine was routinely cleaned in one of one kitchen reviewed for food handling practices. This deficient practice had the potential to cause food-borne illness and affect 32 of 33 residents who received meals prepared in the facility's only kitchen.

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to ensure two of two Licensed Practical Nurses (Licensed Practical Nurses (LPN) 3 and LPN 5) followed Enhanced Barrier Precautions (EBP) during medication administration for two of two residents (Resident (R) 68 and R231).

Inspectors wroteBased on interview and record review, the Facility did not ensure the medical record contained advanced directives for 1 (R5) of 5 residents. On 10/2/23 SW (Social Worker)-F received physician's statement of incapacity form from Physician-H for R5. As of 1/4/24 there has been no follow up from the Facility for a 2nd physician signature to activate R5's healthcare power of attorney.

Inspectors wroteBased on interview and record review the Facility staff did not report to the Administrator & the Facility did not self report to the State agency an allegation of neglect for 1 (R1) of 2 Residents. R1's allegation of not receiving cares during the morning of 11/4/23 was not reported to the Administrator or State agency.

Inspectors wroteBased on interview and record review the Facility did not investigate an allegation of neglect for 1 (R1) of 2 Residents reviewed for abuse. On 11/4/23, R1 alleged not being changed all morning. R1's allegation of neglect was not investigated.

Inspectors wroteBased on observation, interview and record review the facility did not provide adequate supervision and interventions to prevent accidents for 2 (R4 and R6) of 3 sampled Residents identified by the facility to be at risk for falls. *On 11/10/23, R4 had a fall from the toilet resulting in a skin tear to the left elbow. The facility did not complete a thorough investigation and determine a root cause analysis for R4's fall. *On 1/4/24, R6 was not transferred per plan of care (including the care sheet), which indicates the use of 2 staff assist and the use of a sit to stand. Findings Include: On 1/4/24, the facility provided Surveyors with the Incidents and Accidents policy and procedure implemented 7/23/23. Surveyor reviewed the policy and procedure and notes the following applicable: .Policy: [...]

Inspectors wroteBased on observation, interview, and record review the Facility did not obtain and provide medications to meet the needs of each resident for 2 (R5 & R1) of 3 Residents reviewed for medications. * R5's scheduled twice daily Hydrocodone-Actaminophen 5-325 mg (milligram) tablet was not available for multiple days from 10/28/23 to 11/1/23. * R1 did not receive Ertapenem Sodium (antibiotic) injection solution reconstituted 1 gram intravenously on 10/29/23 at 1:00 p.m.

Inspectors wroteBased on observation and interview the facility did not ensure residents the right to a safe, clean, comfortable and homelike environment. This deficient practice has the potential to affect 2 of 3 units where residents were observed eating in the dining room on Garden Hall and [NAME] Hall lounge on 9/7/23 and on 9/11/23. Ten residents were served and ate their meals on delivery trays and staff was observed assisting with feeding while standing next to the resident which was not homelike.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that self-administration of medications was determined to be clinically appropriate for 3 (R68, R7, and R66) of 3 residents reviewed for self- administration of medications out of a total sample of 18. * R68 had Voltaren gel and Clobetasol located in room but did not have an assessment or doctors order to determine if R68 was safe to self-administer medications. * R7 had Voltaren gel located in room but did not have an assessment or doctors order to determine if R7 was safe to self- administer medications. * R66 had glucose tablets on the dresser but did not have an assessment or doctors order to determine if R66 was safe to self-administer medications.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure 1 (R20) of 19 sampled residents were free of from accident hazards and were provided supervision and assistive devices to prevent avoidable accidents. R20's call light was observed laying on the floor and not within reach and their bed was not at the lowest level as identified as a fall prevention intervention in R20's care plan. Findings Include: R20 was admitted to the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis Following Cerebral Infarction, Type 2 Diabetes, Aphasia Following Infarction, Dysphasia, and Cognitive Communication Deficit. R20's Quarterly Minimum Data Set (MDS) dated [DATE] indicates that a BIMS (Brief Interview for Mental Status) could not be performed for R20 due to cognitive deficits. [...]

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure psychotropic medications had a gradual dose reduction or documentation that a gradual dose reduction was clinically contraindicated, had behavior monitoring that was reflective of the resident behaviors, and were given for specific diagnosed conditions for 2 (R52 and R10) of 5 residents reviewed for unnecessary medications. *R52 did not have timely gradual dose reductions of aripiprazole, an antipsychotic, or duloxetine, an antidepressant, or documentation stating the gradual dose reduction was clinically contraindicated for those medications, and behavior monitoring was not individualized for R52 with behaviors that R52 presented with. *R10 did not have an appropriate diagnosis for the use of quetiapine.