Complete Care at Hales Corners

Inspectors wroteBased on record review, observation, interviews, and facility document review, the facility failed to maintain a resident's dignity by failing to close the door and curtains while providing care for one resident (Resident (R) 3) out of total sample of six residents. This failure had the potential to compromise the resident's dignity.

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to document a thorough investigation into the allegation of neglect for one resident (Resident (R) 4) and did not evaluate a Certified Nursing Assistant's (CNA's) history of concerning interactions with residents during an investigation of neglect reported by R2 for two of three facility reported incidents reviewed for abuse or neglect. This failure created the potential for similar incidents to recur.

Inspectors wroteBased on observation, interview and record review the facility did not allow residents and/or residents representative to obtain a copy of personal and medical records or any portions thereof (including in an electronic form or format when such records are maintained electronically) upon request for 1 of 1 (R1) resident reviewed. R1's daughter/POA (power of attorney) requested copies of his medical record were not provided.

Inspectors wroteBased on interview and record review the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 1 (R2) of 3 Residents. On 7/21/25 R2's left facial mass was observed with organism maggot looking like moving all over its surface. R2 was transferred to the hospital and hospitalized until 7/25/25. Hospital course includes documentation of chronic left facial mass for the past 2 years which apparently the patient has refused treatment which has grown bigger in size fungating with maggots' infestation. The facility did not investigate R2's maggot infestation, did not monitor the maggots and did not develop a plan of care for maggots and R2's refusals.

Inspectors wroteBased on interview and record review the facility did not maintain an effective pest control for 1 (R2) of 1 resident. On 7/21/25 R2 was identified with having maggot looking like organisms moving all over R2's left facial mass. The facility did not increase their pest control services to treat R2's room for flies.

Inspectors wroteBased on interview and record review, the facility did not ensure 1 (R20) of 2 residents reviewed for investigations regarding allegations of abuse, that lawn enforcement was notified of potential allegations of abuse. On 4/20/25, R20 told RN (registered nurse) Supervisor-D that CNA (certified nursing assistant)-C pushed R20. The facility immediately placed CNA-C on suspension pending the investigation. The investigation was conducted immediately. The facility failed to notify the police of this allegation of abuse.

Inspectors wrote2.) R19 was hospitalized on [DATE] with a change in condition and returned to the facility on 3/11/25. After R19 was readmitted to the facility, on 3/11/25, R19 was sent back to the hospital for increased pain in her knee. R19 was readmitted to the facility on [DATE]. On 6/17/25 Surveyor requested the transfer and bed hold notice for R19 hospitalization from 3/5/25 to 3/11/25 and from 3/11/25 to 3/12/25. On 6/17/25 at 1:52 p.m. NHA (Nursing Home Administrator)-A explained to Surveyor that the facility has not been doing the transfer and bed hold notices since they switch over to a new EMR (electronic medical record) in January 2025. NHA-A stated the nurses had been doing the notices when the facility had the old EMR system. No additional information was provided. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 1 (R1) of 12 sampled residents reviewed for a change of condition. *R1 was diagnosed with a wound on 03/09/2025. The facility did not ensure that at the time of R1's initial assessment and diagnosis of a skin wound, a clinician assessed the wound to determine the wound type. The facility did not document the evaluation, assessment, treatment and treatment outcomes for R1's wound. The facility did not have a skin care plan or risk for pressure injuries care plan for R1 until the discovery of R1's wound. R1's Orthopedic specialist was not consulted in the change of condition regarding the orthopedic hardware protruding from R1's skin. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not ensure 2 (R19 and R35) of 2 residents received the necessary services for acceptable nutrition. * R19 had a 7.65% weight loss in one month. The weight loss was not communicated to the physician and dietician. A comprehensive assessment was not completed regarding the weight loss. The care plan was not reviewed and updated regarding the weight loss. Interventions were not implemented for R19's weight loss. * R35 required supervision during meals and was observed on two occasions not to receive assistance with meals as per care plan.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure that food was prepared to conserve nutritive value and flavor. This has the potential to effect 3 (R5, R9 and R250) of 3 residents residing at the facility whom receive a puree diet. *Cook-C was observed not following a recipe for preparing texture and modified consistency food for puree diets.

Inspectors wroteBased on observation, interview, and record review the facility did not provide special assistive eating equipment for 1 (R250) of 1 sampled resident reviewed for assistive eating devices. R250's emergency contact and family member (FM)-E, informed Surveyor that R250 does not always get the adaptive equipment placed on R250's meal tray so that R250 can eat independently. Surveyor observed R250's meal tray ticket and noted that the adaptive equipment listed on the meal tray ticket did not match what was provided on R250's meal tray.

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure residents at risk for pressure injuries or those admitted with pressure injuries received care consistent with professional standards of practice to prevent pressure ulcers from developing for 2 (R43 and R19) of 3 residents reviewed for pressure injuries. *R43 was admitted to the facility with an Unstageable pressure injury to the right elbow that required antibiotics for a wound infection and developed pressure injuries to the left heel and right Achilles. Wound documentation was not an accurate description of staging, measurements, and characteristics of the wound. *R19 was admitted to the facility with a Stage 3 pressure injury to the right outer ankle. Wound documentation was not an accurate description of staging, measurements, and characteristics of the wound.

Inspectors wroteBased on record review and interview, the facility did not thoroughly investigate an allegation of misappropriation affecting 1 (R147) of 1 residents in a Facility Reported Incident that was reviewed. R147 reported a missing wallet. The facility administration did not interview residents in the facility at the time of the report to determine if any other residents were affected by potential theft.

Inspectors wroteBased on observations and record review, the facility failed to ensure the facility developed and followed the menus and that the menus met the nutritional needs of the residents. This failure placed all 38 facility residents at risk of nutritional problems and dissatisfaction with their meals.

Inspectors wroteBased on interview, record review, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) website, the facility failed to implement staff COVID-19 testing in the presence of a COVID-19 outbreak in the facility. This failure affected all 134 who worked in the facility and all 38 residents. This failure had the potential to contribute to spread of COVID-19 within the facility.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure that one resident (Resident (R) 28) of three residents reviewed for accidents received adequate interventions to prevent the resident from sustaining continued falls.

Inspectors wroteBased on interviews, record review, and review of the facility's policy, the facility failed to develop and implement their policy for additional infection control precautions for unvaccinated staff. These failures had the potential to reduce efforts to mitigate COVID-19 transmission, consequently placing all staff and all current clients receiving care at this facility at risk of exposure to COVID-19.