Complete Care at Maple Grove LLC

Inspectors wroteBased on observation, interview, and record review, 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 103 residents who reside in the facility. Surveyor observed food not properly covered in the walk-in refrigerator. Surveyor observed a scoop left in the flour bin. Surveyor observed a kitchen staff with facial hair not wearing a beard restraint. Surveyor observed food brought in by family members not properly labeled and dated. Evidenced by:The facility policy, Food Safety requirements, dated 1/26, states, in part;.labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date.keeping foods covered or in tight containers. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal hygiene for 5 of 21 residents reviewed for accommodation of needs out of a sample of 25. R15 was observed in bed without access to a call light. R41 was observed in bed without access to a call light. Surveyor observed R11 to not have a call light within reach. Surveyor observed R24 to have long facial hair. R75 was observed in bed without access to a call light. Evidenced by: The facility's Call Lights: Accessibility and Timely Response policy, dated 1/26, states, in part: [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that all residents are clinically appropriate to self-administer medications for 1 of 1 residents (R2) observed with medications at bedside out of a sample of 25. R2 was observed on 2 separate occasions to have medications left on her bedside table for her to take independently. R2 does not have an assessment for self-administration of medications indicating that she is safe to administer medications independently. This is evidenced by:The facility's policy, Resident Self-Administration of Medication, dated 1/26, includes: A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. [...]

Inspectors wroteBased on interview and record review, the facility did not make prompt efforts to document, investigate, and resolve grievances a resident may have for 1 of 3 residents (R121) from a total sample of 25 residents reviewed for grievances. R121 voiced a grievance to the facility. Staff did not write his concern up as a grievance, complete an investigation, or follow up with the complainant. This is evidenced by:The facility's policy, titled Resident and Family Grievances, reviewed/revised in 2/2026, states in part: Policy: It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal, or fear of discrimination or reprisal. Policy Explanation and Compliance Guidelines: 1. The Administrator has been designated as the Grievance Official. [...]

Inspectors wroteBased on interview and record review, the facility did not follow through with the appropriate steps of the PASARR (Preadmission Screening and Resident Review) process for 1 of 9 residents (R2) reviewed for PASARR screening out of a sample of 25. R2 did not have a level II PASARR screening completed. This is evidenced by:The facility's policy, Specialized Rehabilitative Services, dated 1/26, includes: It will also ensure that residents with Mental Disorder (MD), Intellectual Disability (ID) or related conditions receive services as determined by their Preadmission Screening and Resident Review (PASARR). R2 admitted to the facility on [DATE] with diagnoses including major depressive disorder. R2's quarterly MDS (Minimum Data Set) assessment, accepted date 6/12/26, has a BIMS (Brief Interview for Mental Status) score of 15. This indicates R2 is cognitively intact. [...]

Inspectors wroteBased on interview, and record review, the facility did not ensure that Residents receive treatment and care in accordance with professional standards of practice for 1 (R5) of 6 residents reviewed for assessments out of a sample of 25 residents. R5 fell and facility did not complete on-going monitoring and assessments, and the following evening R5 went to ER by ambulance. The facility policy, Fall Prevention Program, dated 1/25, states, in part;.monitor for changes in resident's cognition, gait, ability to rise/sit, and balance.monitor vital signs in accordance with facility policy.document all assessments and actions. R5 was admitted to the facility on [DATE], with a diagnoses including stroke, difficulty in walking, and unspecified fall. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure each resident received care, consistent with professional standards of practice (SOP), to prevent pressure injuries (PI) for 1 of 1 residents (R1) reviewed for pressure injuries of a total of 25 sampled residents. R1 is at risk for PI (pressure injury) development and has a history of pressure injuries. Staff did not obtain measurements for two weeks of a newly developed pressure injury, and failed to ensure that care planned interventions were in place to prevent worsening of the pressure injury. Evidenced by:The AMDA (American Medical Directors Association) clinical practice guideline titled, 'Pressure Ulcers and Other Wounds,' dated 2017, states in part: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure each resident receives adequate supervision and assistance devices to prevent accidents from occurring for 1 of 4 residents (R31) of 25 sampled residents reviewed for safety concerns. R31's Care Plan instructed that he was to be given plastic silverware at meals; however, he was repeatedly observed to be given regular silverware at meals. This is evidenced by:The facility's policy, titled Accidents and Supervision, reviewed/revised in 3/2026, states in part: Policy: The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that residents with an indwelling catheter received the appropriate care and services to prevent infections or complications for 1 of 1 resident (R95) reviewed for catheters out of 25 sampled residents. Surveyor observed R95's suprapubic indwelling catheter bag to be resting in direct contact with the floor. This is evidenced by:The facility's policy, titled Catheter Care, implemented 11/2025, states in part: Policy: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy while indwelling catheters are in use. Policy Explanation: .2. Privacy bags will be available and catheter drainage bags will be covered at all times while in use. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 3 residents (R102) reviewed for trauma informed care out of a sample of 25 residents. R102 disclosed trauma and does not have a complete trauma assessment or a care plan addressing triggers, resident specific approaches, or interventions. This is evidenced by:The facility's policy, Trauma Informed Care, dated 1/26, includes: It is the policy of this facility to provide care and services. and address the needs of trauma survivors by minimizing triggers and/or re-traumatization. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that the hospice services meet professional standards and principles that apply to individuals providing services in the facility for 1 of 1 resident (R44) reviewed for hospice services out of sample of 25 residents. R44 was receiving hospice services and the facility failed to obtain hospice care plan and notes. Evidenced by: The facility policy titled Coordination of Hospice Services, dated 1/26, states, in part: Policy: When a resident chooses to receive hospice care and services, the facility will coordinate and provide care in cooperation with hospice staff in order to promote the resident's highest practicable physical, mental, and psychosocial well-being. Policy Explanations and Compliance Guidelines: . 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure Residents are free of significant medication errors for 1 of 10 sampled Residents (R3) Facility staff did not administer R3's scheduled Parkinson's medications as ordered.

Inspectors wroteBased on interview and record review, the facility did not ensure that the resident environment remains as free of accident hazards as is possible for 1 of 1 incident reviewed. RN C (Registered Nurse) burned sage in the facility and the facility did not verify that the sage was extinguished and did not provide education to the staff regarding safety. Evidenced by:Surveyor requested policy related to fire safety / flames in building. No policy provided. Facility email from RN D to NHA A (Nursing Home Administrator) and DON B (Director of Nursing), dated 7/18/25, states, in part: .came into work today, 7/17/25.at about 11:30 PM, smelled marijuana so strong, so I started to walk through all the units, but the smell remained at the atrium.asked RN C about the smell and RN C admitted stating it is me don't say nothing please I am burning sage the smell will go away. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure fall interventions were in place per the care plan and each residents received adequate supervision to prevent accidents for 3 of 23 sampled Residents (R27, R59, & R82) reviewed for falls and supervision. R27 is being cited at scope/severity level 3 (isolated/actual harm). R27 was a fall risk and has had 23 falls since admission on [DATE]. R27's falls typically occurred in the dining room or resident room; there were similarities to the falls including location and time of day. The facility completed a root cause analysis (RCA) and collected data on the falls; however, there is no evidence the interdisciplinary team (IDT) comprehensively reviewed the data or considered increasing R27's supervision. R27 fell resulting in a head injury requiring sutures. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect all 94 residents who reside at the facility. Surveyor observed staff taking temperatures of food during lunch meal. Staff did not take temperatures of all foods on steam table. Surveyor observed staff taking temperatures of food during lunch meal. Staff did not allow time for thermometer to dry after using alcohol wipe and placed directly into food. Evidenced by: The facility policy, Record of Food Temperatures, dated, 2/25, states, in part; .6. Measure and record the temperatures for each food product and milk at all meals. Record temperature on temperature log. 7. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that every resident was treated with respect and dignity for 2 of 2 sampled Residents (R71 & R146) and 2 of 2 supplemental Residents (R13 & R67) reviewed for Resident rights. R13, R67, R71, and R146 expressed concerns about R82 wandering into their private rooms uninvited. This is evidenced by: The facility policy titled Promoting/Maintaining Resident Self-Determination dated 4/22/25 states: It is the practice of this facility to protect and promote resident rights by facilitating resident self-determination through support of resident choice. The facility will ensure that each resident has the opportunity to exercise his/her autonomy regarding those things that are important in his/her life such as food, interests, and preferences. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure drugs and biological's used in the facility were stored and labeled in accordance with currently accepted professional practices and include the expiration date when applicable for 1 of 3 medication carts reviewed for compliance. Surveyor observed the following: R36's fluticasone propionate nasal spray did not have an open date and R36's Systane Ultra Ophthalmic Solution 0.4- 0.3% eye drops had an open date of 3/15/25. R45's PRN (as needed) Hydralazine card expired on 2/22/25. R32's PRN Chest Congestion Relief card expired 2/27/24 and PRN ondansetron card expired on 2/22/25. R48's PRN stimulant laxative card expired on 2/27/24. R194's PRN calcium antacid card expired on 2/25/24. R16's PRN ondansetron card expired on 2/22/25. Evidenced by: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that all residents are clinically appropriate to self-administer medications for 1 of 1 residents (R17) reviewed for self- administration of medications. R17 was observed to have a cup of medications left on her bedside table for her to take independently. R17 does not have an assessment for self-administration of medications indicating that she is safe to administer medications independently. Evidenced by: The facility's policy titled Resident Self- Administration of Medication dated 4/17/25 states in part, .3. When determining if self- administration is clinically appropriate for a resident, the interdisciplinary team should, at a minimum consider the following: a. The medications appropriate and safe for self- administration; b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not document a thorough investigation and did not resolve grievances as outlined in the facility policy for 1 of 4 residents (R26) reviewed for grievances. R26 voiced concern about staff being on their cell phones. The facility failed to follow up on the grievance. Evidenced by: The facility policy, Resident and Family Grievances, dated 10/23, states, in part; .3. The Grievance Official is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances and notifying the person filing the grievance of the decisions and outcome . Surveyor reviewed January 2025 Resident Council Minutes. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that each resident is free from physical restraints that are not required to treat the resident's medical symptoms for 1 of 3 residents reviewed for restraints (R27). R27 was placed in a low Broda chair (a specialty wheelchair that assists with positioning) that has brakes located on the back of the wheels at the bottom of the chair. R27's brakes were engaged while R27's was at the dining table, not allowing R27 to move the chair. Evidenced by: The facility's policy titled Restraint Free Environment dated 2/2025 states in part .Physical Restraint refers to any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a person-centered comprehensive care plan to meet personal preferences and goals, or address the resident's medical, physical, mental, and psychosocial needs for 3 of 23 residents (R53, R70, and R28). R53's care plan does not include a focus, goal, or interventions for religious preferences. R70's care plan does not include a focus, goal, or interventions for religious preferences. R28's care plan was not followed for using the interpretive services to communicate with R28 in her preferred language. Evidenced by: The facility policy titled, Comprehensive Care Plans states, in part: Policy: [...]

Inspectors wroteBased on interview and record review, the facility did not develop a discharge plan that reflected the resident's goals for 1 of 23 residents (R76) reviewed for discharge planning. R76's discharge care plan did not match his discharge goals. Evidenced by: The facility's policy titled Discharge Planning Process dated 2/28/25 states in part . Procedure: 1. The facility will support each resident in the exercise to participate in his or her care and treatment, including planning for discharge. 2. The facility will determine the resident's expected goals and outcomes regarding discharge upon admission, routinely in accordance with the MDS (Minimum Data Set) cycle, and as needed .b. Subsequent assessment information and discharge goals will be included in the resident's comprehensive plan of care .5. [...]

Inspectors wroteBased on interview and record review the facility did not ensure that 2 of 19 Residents (R53 and R70) received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing in accordance with their comprehensive assessment and plan of care. R53 is a Muslim whose custom is to pray seven times a day. R70 is a Muslim whose custom is to pray seven times a day. Evidenced by: The facility policy, titled Quality of Care dated 2/28/25, states, in part: Policy: Based on comprehensive assessments, the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered care plans, and the residents'' choices . Policy Explanation and Compliance Guidelines: 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not provide toileting assistance for dependent residents for 2 of 19 residents (R37 & R293) reviewed for Activities of Daily Living (ADLs) assistance. Staff did not assist R37 with toileting assistance after several incontinent episodes despite R37 requiring toileting assistance per his plan of care. R293 was observed sitting in the dining room in his pajamas with his hair sticking up, and scraggly (not neat or even) whiskers on his face approximately 1/4 inch long. Evidenced by: Facility policy, titled Activities of Daily Living (ADLs), dated 2/25, states, in part: Policy: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate . [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure a resident with a pressure injury (PI) received necessary treatment and services, consistent with standards of practice to promote healing for 1 of 3 residents (R40) reviewed for PIs. R40 has a stage 4 pressure injury, with physician orders to not be in her wheelchair for more than an hour at a time, to be repositioned every 30 minutes while in her wheelchair and to not lay on her left hip while in bed. R40's interventions were not completed as ordered. Evidenced by: Surveyor requested the facility's policy regarding Pressure Injury's; however, none was provided. R40 was admitted to the facility on [DATE] with diagnoses including: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 5 residents (R31) reviewed for pain. R31 was admitted to the facility with chronic pain that became exacerbated with the use of the EZ stand lift. The facility did not address her pain needs or seek alternative transfer options. Evidenced by: The facility policy titled Pain Management, dated 2/8/25, states in part, The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents goals and preferences . Recognition: . [...]

Inspectors wroteBased on interview, record review, and policy review the facility failed to ensure that the facility was free of accident hazards in 1 of 7 residents R9 reviewed for accident hazards of 14 sample residents. The facility failed to prevent a fall for R9

Inspectors wroteBased on observations, record review, interviews, and policy review, the facility failed to follow the prescribed easy to chew diet for 1 of 1 resident (R6) reviewed for proper diet texture out of 14 sampled residents. R6's diet orders stated Level & easy to chew. R6 had several snacks in R6's room that did not follow this diet order. The facility failed to have an order in R6's medical record indicating exceptions to the diet order or a risk and benefit to consume items outside the diet order.

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to ensure medical records were complete and accurate for 1 out of 14 sample residents (R5) reviewed for medical records. R5's plan of care had confliciting information regarding R5's ability to self-administer medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure correct installation, use, and maintenance of bed rails for 4 of 5 (R3, R6, R7, and R8) residents reviewed. R3, R6, R7, and R8's bedrails were installed without a Bed System Measurement Device Test ompleted to ensure proper installation to reduce the risk of entrapment. Findings Include: The Facility policy, Bed Devices and Device Assessment, date of issue, March 21, 2024, indicates, in part: Policy .2. Physical devices will be reviewed for safety and used according to manufacturer's recommendations. 5. Physical devices include, but are not limited to, side rails (half or full); grab bars, halo bars, positioning poles . The Facility policy, Bed Inspection, date of issue, March 21, 2024, indicates, in part: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that each resident environment remains as free of accident hazards as is possible for 1 of 3 residents reviewed for accidents (R1). R1 fell out of bed due to facility staff''s failure to follow R1's plan of care and the facility did not ensure all staff were trained to help ensure a similar event did not occur.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (R5) reviewed for supervision and accidents. R5 was served coffee while in his bed and dropped the coffee cup in the bed on his right side which pooled up against him. R5 sustained superficial partial thickness burns to right flank and right buttocks, estimated approximately 7% Total Body Surface Area (TBSA). Facility had no process in place regarding safety to residents with hot liquid temping or any type of safety assessment. After the incident occurred, coffee brewers were temped at 185° Fahrenheit. Evidenced by: The facility policy titled Food Safety: Preventing Burns dated 2021, states, in part: Policy: Hot food and beverages will be served at a safe temperature that prevents burns. Procedure: 1. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure residents (R) receiving a psychotropic medication, were free from unnecessary medications for 1 of 1 residents (R1). R1 receives psychotropic and antipsychotic medications. The facility is not tracking quantitative measurements during behavior tracking, which is required to measure efficacy of medication therapy, nor are side effects of psychotropic medications being adequately monitored. R1 does not have an appropriate diagnosis for antipsychotic medication. This is evidenced by: Facility policy entitled Unnecessary Medication - Psychotropic Medication, Dated April 1, 2008, with last revision date September 22, 2017, states in part: .A. 2. Antipsychotic drugs should not be used unless the resident's medical record clearly indicates that the resident has one of more of the following specific conditions: . i. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident (R) received adequate supervision to prevent accidents for 1 of 3 residents (R2) reviewed for altered diets out of a total sample of 6. R2 has had two choking episodes within a month's time. On 7/27/24, R2 choked on a hot dog. The Heimlich maneuver was performed, and R2 was sent to the emergency room and admitted to the hospital for acute hypoxic respiratory failure, aspiration event/choking on a hot dog, and aspiration pneumonitis. On 8/13/24, R2 was to receive a Level 6: soft and bite sized (no hot dogs), thin liquids consistency diet. CNA G (Certified Nursing Assistant) provided R2 a bowl of chunked honeydew that was not part of a Level 6 soft and bite sized diet with his supper, resulting in an aspiration event and another hospitalization. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 3 of 5 randomly sampled Certified Nursing Assistants (CNAs), who had been employed at the facility for over a year, had documented performance reviews (CNA J, CNA K, and CNA L). CNA J, CNA K, and CNA L's annual performance evaluations were not conducted yearly. This is evidenced by: The facility's policy titled Competency Assessment and Validation, dated 6/12/2024, states, in part: SSM Health (SSM) will ensure all employees are competent to perform their assigned responsibilities and to establish a consistent and effective process to measure staff competence unique to job classifications, duties and responsibilities .II. Competency Process . B. Validation . 2. Competency should be assessed annually. On 9/12/24, Surveyor reviewed the list of CNAs that had worked for the facility longer than one year. [...]

Inspectors wroteBased on interview and record review, the facility did not immediately consult with the resident's physician when there was a need to alter treatment for 1 of 4 residents (R5) reviewed for physician notification. The facility did not update R5's physician when a medication was not administered as ordered. This is evidenced by: The facility's policy Notification of Change with a revision date of 11/2022, indicates, in part: Policy - The community will consult the resident's physician, nurse practitioner, or physician assistant and notify the resident representative or an interested family member when there is: .Acute illness or a significant change in the resident's physical, mental, or psychosocial status (i.e., deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). [...]

Inspectors wroteBased on interview and record review, the facility did not ensure prompt resolution of all grievances for 1 of 4 reviewed (R8) out of a sample size of 8 residents. R8 said that R8's recent concern was not followed up on. R8 indicated about a week ago an agency CNA (Certified Nursing Assistant) became frustrated with R8 because R8 needs help with setting up her meal. R8 stated the CNA was frustrated and left R8 sitting in bedroom unable to eat her meal. Evidenced by The facility policy, Grievance Process, dated 11/22, states, in part; .It is the policy to support each resident's right to voice grievances and to assure that after receiving a complaint or grievance to seek a resolution and keep the resident appraised of progress. Prompt reporting is encouraged so that constructive action can be taken. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported to the administrator and other officials in accordance with State law through established procedures for 1 of 5 residents (R1) reviewed for abuse of a total sample of 8. R1's daughter emailed NHA A (Nursing Home Administrator) a verbal abuse allegation that the facility did not report to the State Agency. This is evidenced by: The Facility's Abuse, Neglect, and Exploitation Policy and Procedure, dated November 2023, documents in part: [...]

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate accusations of abuse for 2 of 5 residents (R1 and R2) reviewed for abuse. On 6/6/24, the facility became aware of an allegation of neglect involving R2 and a thorough investigation was not completed. R1 did not have a thorough investigation completed for a reported verbal abuse allegation. This is evidenced by: The Facility policy titled Caregiver Misconduct, Patient Abuse, Neglect, Misappropriation of Property, and Harassment, revised 11/17/23, indicates in part: Outcome Statement: To ensure timely and thorough investigations and reporting of all incidents in a healthcare setting where patients are abused, neglected, harassed, or where their property is misappropriated. To ensure compliance with Federal and State laws and regulations .Definitions: .II. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not implement professional standards of practice to promote healing, prevent infection, and prevent pressure injury (PI) development for 1 of 3 residents (R3) reviewed for pressure injury out of a sample of 8 residents. R3 is at risk for PI. The facility did not implement PI interventions to prevent PI development. R3 developed an avoidable PI to her left foot bunion (a bony bump that forms on the joint at the base of the big toe). R3's PI became infected requiring oral antibiotics. Evidenced by: The facility policy, titled Pressure Injury/Skin Integrity with a revision date of 5/24, states in part: It is the policy of this facility to enable nursing staff to manage wounds and select appropriate interventions according to the National Pressure Injury Advisory Panel (NPUAP). [...]

Inspectors wroteBased on interview and record review, the facility did not ensure residents (R) received treatment and care in accordance with professional standards of practice for diabetic foot care for 1 of 3 (R3) residents reviewed for diabetic foot out of a sample of 8 residents. The facility did not provide diabetic foot checks to R3 daily in accordance with the current standards of practice. Evidenced by: Facility policy, titled Foot Care - Diabetic with a revision date of 10/22, states, in part: The community will ensure that residents receive proper treatment and care to maintain mobility and good foot health. For those residents with the diagnosis of diabetes: .2. Provide foot care daily . The current standard of practice per the American Diabetes Association copyright 1995-2024, https://diabetes.org, includes, in part: .1. Check your feet daily for sores, cuts, cracks, blisters, or redness . [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure adequate supervision and safety to prevent accidents from occurring for 1 of 3 residents reviewed for accidents/supervision (R6). R6 had a fall on 6/27/24 and staff failed to maintain 1:1 supervision that had been implemented for safety concerns. Evidenced by: The facility policy, Accidents/Falls ., with a review date of November 2023, indicates, in part: Policy - The facility strives to promote safety, dignity, and overall quality of life for its residents by providing an environment that is free from any hazards for which the facility has control and by providing appropriate supervision and interventions to prevent avoidable accidents . R6 was originally admitted to the facility on [DATE], with diagnoses that include, in part: [...]

Inspectors wroteBased on interview and record review, the facility did not provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological's to meet the needs of each resident for 1 of 4 residents reviewed (R5). R5 had a physician order for Vitamin B Complex-C Oral Capsule (B Complex with C) and the facility did not ensure this medication was available for administration. This is evidenced by: Facility policy titled, Pharmacy Services (General) with a reviewed date of May 2020, includes in part: The community pharmacy provides routine and emergency drugs and biologicals to the residents .The community provides pharmaceutical services (including procedures that assure the accurate acquisition, receipt, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. [...]

Inspectors wroteBased on observation, 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. This has the potential to affect all 106 residents (R) in the facility. The facility did not ensure daily infection control surveillance for staff. The facility's infection control line lists for staff and residents are incomplete. The facility's monthly infection control rates were not calculated according to current standards of practice. The facility's March 2024 COVID outbreak summary was incomplete and inaccurate. CNA G did not disinfect R80's bedside table after placing a urinal on it without a barrier in place. This is evidenced by: [...]

Inspectors wroteBased on record review and interview, the facility did not complete the Preadmission Screening and Resident Review (PASARR) Level II when it was realized that a resident would reside in the facility for more than 30 days. This affected 2 of 2 sampled residents reviewed for PASARR out of a total sample of 27 (R89, R41) and 2 supplemental residents (R36, R103). R89, R41, R36, and R103 stayed longer than 30 days in the facility and required a PASARR Level II screen, but the facility failed to complete. Evidenced by: Facility policy, entitled Pre-admission Screening and Resident Review (PASARR), revised 1/2017, includes: . Complete a PASARR Level I screen on all new admissions . [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each resident. This affects 3 of 3 sampled residents (R41, R79, R24) reviewed for activities out of a total sample of 27 and 4 supplemental residents (R42, R53, R22, and R59). R41, R79, R24, R42, R53, R22, and R59 voiced concerns during Resident Council of the facility's activity program. Evidenced by: (It is important to note the facility has two separate resident neighborhoods, one is called long term care and the other is a semi-locked unit called memory care.) The facility policy, entitled Activities, issued February 2021, includes, in part: . Policy: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional practices and include the expiration date when applicable in 1 of 2 medication rooms and 4 of 7 medication carts reviewed for compliance. Surveyor observed the following: --undated, open stock medication in medication room. --medications that should be refrigerated were in the medication carts and not refrigerated. --undated, open eye drops in a medication cart. --different medication administration routes co-mingled in the same bag. --unlabeled medications in medication carts. --expired medications in medication carts. --medications with illegible expiration dates in medication cart. This is evidenced by: Surveyor reviewed the facility Medication Storage policy with a reviewed date of 1/24. [...]

Inspectors wroteExample 3 R83 was admitted to the facility on [DATE]. On 2/14/24, R83's Nurse Practitioner (NP) ordered a urinalysis due to dysuria with urination. Records indicate the urinalysis was collected on 2/14/24 at 7:50 PM. A nursing home visit note, dated 2/15/24, states, .Ampicillin 500 QID started--culture still pending . Results returned on 2/16/24 at 10:14 AM that stated, >=100,000 CFU/mL mixed gram-positive flora. No further workup performed .suggest recollection if clinically indicated. R83's NP again visited him on 2/19/24 with the NP noting, Patient treated for UTI due to gross hematuria and positive UTI, culture showed mixed morphology. Plan to stop treatment--he will have had a 5 day plus one tablet coarse. Continue to monitor. Facility Medication Administration Record (MAR) for R83 indicates the Ampicillin order was 4 times per day for 10 days, starting 2/15/24. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported to the administrator and other officials, and that the residents are protected during the facilities investigation for 2 of 3 abuse investigations reviewed (R43 and R41) of a total sample of 27 residents. During R43's investigation, the alleged staff member named in allegation was not suspended per the facility's Abuse Policy and Procedure. On 4/17/24 the facility became aware that R41's narcotic pain patch was unable to be located and this was not reported to the administrator. This is evidenced by: The Facilities Abuse, Neglect, and Exploitation Policy and Procedure, dated November 2023, documents in part: [...]

Inspectors wroteBased on interview and record review, the facility failed to investigate a potential misappropriation of a narcotic medication for 1 of 2 residents (R41) reviewed for abuse. On 4/17/24 the facility became aware of a potential misappropriation involving R41's narcotic pain patch and this was not reported to the Nursing Home Administrator so that an investigation could be completed. This is evidenced by: The Facility Policy, titled Abuse, Neglect, and Exploitation, with a reviewed date of November 2023, indicates, in part: Policy: it is the policy of this community to take appropriate steps to prevent the occurrence of Abuse, Neglect, Misappropriation of resident property .The community investigates each such alleged violation thoroughly .Procedure: .Investigation: a. [...]

Inspectors wroteBased on record review and interview, the facility did not ensure comprehensive assessments were completed as required for 1 of 3 closed records reviewed for Minimum Data Set (MDS) assessments (R12). R12 passed away on [DATE] and the facility failed to complete a discharge MDS assessment. Evidenced by: Facility policy, entitled MDS (Minimum Data Set) Timing, dated [DATE], includes It is the policy of this community to follow the guidance for the RAI (Resident Assessment Instrument) Manual when determining the timing of MDS assessments. Centers for Medicare and Medicaid Services' RAI Version 2.0 Manual, includes: Factors Impacting the Skilled Nursing Facility Medicare Assessment Schedule: . Resident expires or transfers .If a resident dies or is discharged . whatever portions of the RAI that have been completed must be maintained in the resident's discharge record . [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that the assessments must accurately reflect the resident's status for 1 of 1 (R43) Minimum Data Set reviewed for accuracy of a total sample of 27. R43's MDS dated [DATE] does not have her Continuous Positive Airway Pressure (CPAP; machine that uses mild air pressure to keep breathing airways open while you sleep) coded correctly. This is evidenced by: The Facility does not have a Policy and Procedure for MDS accuracy. The Facility follows the Resident Assessment Instrument (RAI) manual. Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated 10/23, documents the following, in part: .The RAI process has multiple regulatory requirements. [...]

Inspectors wroteBased on observation, staff interviews, and record review, the facility did not ensure treatment and care in accordance with professional standards of practice for 1 of 1 resident's reviewed for wound out of a total sample of 27 residents (R85). R85 does not have weekly measurements documented for left stump wound. This is evidenced by: Facility policy titled Pressure Ulcer/Skin Integrity with a reviewed date of 4/2022 contains, in part: Policy .A resident receives care, consistent with professional standards of practice . Procedure: 6. Documentation a. Routine ongoing documentation should be conducted related to the resident's skin condition and the resident's response to the care and treatment of the skin. The frequency of documentation shall be determined based on the resident's individual needs in accordance with accepted standards of practice. b. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that residents are free of significant medication errors for 1 of 1 supplemental resident's (R19) reviewed for medication errors. R19 was not administered two doses of an antipsychotic medication in April as directed by the physician order. This is evidenced by: The facility policy entitled, Medication Administration, dated 1/23, states, in part: . Policy: Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. Procedures: Medication Preparation: .3. Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record . [...]

Inspectors wroteBased on observation and interview, the facility did not ensure that food and drink that is palatable, attractive, and at a safe and appetizing temperature for 1 of 27 residents observed during dining (R7). R7 was given cold food.

Inspectors wroteBased on interview and record review, the facility must develop policies and procedures to ensure that residents and/or the resident's responsible party receives education regarding the benefits and potential side effects of the immunization prior to offering the immunization and documentation is noted in the medical record on whether the resident received or declined the immunization. This affected 3 of 5 residents (R41, R63, and R102) reviewed for pneumococcal immunizations. R41's medical record contained a consent form titled Pneumococcal Vaccine (Prevnar 20) Consent/Declination without evidence of administration. R63 and R102's medical records did not contain evidence of a declination, consent, or administration of Pneumococcal Vaccinations. This evidenced by: The facility policy titled, Immunization: Pneumococcal with a review date of 4/4/2024 indicates, in part: Policy: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure the nurse staffing posting was accurate and posted in an accessible area which has the potential to affect the census of 106. Multiple daily staff postings did not reflect the actual hours of the nursing staff. The posting was posted up high on the wall with small text making it difficult to read.

Inspectors wroteBased on interview and record review the facility did not provide pharmaceutical services to meet the needs of each resident for 6 of 15 (R4, R5, R7, R13, R18 and R21) residents reviewed for medications. R4, R7, R18 and R21 did not receive their medications as ordered. R5 did not receive her scheduled Lasix on 2/28/24. R13 did not receive her scheduled Tylenol Claritin, melatonin, and trazodone on 2/21/24. R13 did not receive her scheduled calcium on 3/2/24 and 3/5/24. R13 did not receive her scheduled magnesium on 3/25/24, 3/26/24, and 3/30/24. R21 did not receive scheduled Seroquel on 3/4/24 and did not receive scheduled lamotrigine on 3/8/24. Evidenced by:

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that each resident was treated with dignity and respect for 1 of 6 sampled residents (R1). R1's APOAHC (Activated Power of Attorney for Health Care) has chosen for R1 to see physicians outside of the facility. The facility failed to provide a support person to assist R1 so that she may attend medically necessary physician appointments. As evidenced by The facility's admission Resident Rights, undated, indicates the following: The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights to be supported by the facility in the exercise of his or her rights. The resident representative has the right to exercise the resident's rights to the extent those rights are delegated to the resident representative. [...]

Inspectors wroteBased on interview and record review, the facility did not make prompt efforts to resolve resident grievances for 1 resident (R1) out of 7 residents reviewed for grievances, out of a total sample of 24 Residents. R1's APOAHC (Activated Power of Attorney for Healthcare) expressed concerns to the previous DON (Director of Nursing) regarding the way CNA C (Certified Nursing Assistant) treated R1. The facility did not record details regarding the grievance, has no documentation that the grievance was investigated, or any details regarding the allegation. This is evidenced by: The facility Policy and Procedure, Grievance Process, with a revised date of 11/2022, includes, in part: Residents have the right to voice grievances to the community or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure care plans were reviewed and revised for 1 (R1) of 20 sampled residents. Facility staff did not revise R1's care plan to address her need for a support person while out of the facility at appointments.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that residents who are unable to carry out Activities of Daily Living (ADLs) received the necessary services for assistance with incontinent cares for 3 of 6 residents (R16, R23, & R24) reviewed for ADLs. R16 indicates she has double briefs on almost every night due to being a heavy wetter. R23 indicated she has a blue liner and a pullup on due to being a heavy wetter. Surveyor observed a blue liner and pullup placed on R23 during am cares. R24 indicates she gets double briefed at times due to being a heavy wetter. This is evidenced by: Facility unable to provide policy on incontinence products. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that it was free of medication error rates of 5% or greater. There was 1 error in 12 opportunities that affected 1 out of 2 residents (R21) included in the medication pass task, which resulted in an error rate of 8.3%. R21 received the wrong dose of Venlafaxine. This is evidenced by: The facility policy entitled, Medication Administration, dated 1/23, states, in part: . Policy: Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. Procedures: Medication Preparation: . 3. [...]

Inspectors wroteUNCORRECTED AT VERIFICATION VISIT. See SOD for Event ID OC8I11. Based on observation, interview, and record review, the facility did not ensure adequate supervision or fall interventions were in place for residents who required increased supervision to prevent accidents/hazards from occurring for 2 of 5 sampled Residents (R5 and R7). R5 did not have fall interventions in place. R5's care plan documents: Do not leave unattended in the Bathroom. R5 ambulated independently to the bathroom and her alarm was sounding. CNA N (Certified Nursing Assistant) heard the alarm sounding and identified that R5 ambulated independently to the toilet. CNA N turned the alarm off, exited the room, and shut the door leaving R5 unattended in the bathroom. CNA N did not assist R5 or alert other staff that she had self-transferred on the toilet. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure all residents have a means of directly contacting caregivers while in their room for 1 (R6) out of 11 sampled residents. The facility failed to ensure R6 had call light pendent in working condition and near R6 while in R6 was in his room. Evidenced by: The facility policy, titled, Resident Call System, dated 5/20, states, in part; .All residents have call system access while in bed or while sitting at their bedside or in the bathroom. Residents who are unable to use their call system, due to decreased physical or mental ability, are so identified with needs anticipated to best of abilities. All staff responds promptly when the call system is activated. R6 was admitted to the facility on [DATE] with diagnoses including: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that each staff implemented proper safety interventions as directed by a resident's plan of care and did not ensure residents were free from accidents and hazards for 1 of 3 residents (R1) reviewed for falls. On [DATE], a Certified Nursing Assistant (CNA) attempted to provide care to R1 without maintaining the proper safety interventions as directed in R1's care plan. R1 rolled off the bed and fell approximately 2 feet to the floor, hitting her head. R1 suffered multiple fractures and a subarachnoid hemorrhage (bleeding in the space surrounding the brain), resulting in death. This created a finding of immediate jeopardy that began on [DATE]. The facility's failure to to ensure all staff follow proper safety interventions to prevent accidents created a finding of Immediate Jeopardy that began on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility did not have evidence that all alleged violations are thoroughly investigated for 4 of 7 sampled residents (R2, R3, R5, R7). R2's self report, dated 10/22/23, was not thoroughly investigated. The facility did not ensure residents were protected when an allegation of abuse was reported for R3. R5 did not have thorough follow-up after responding to interview questions. R7 did not have thorough follow-up after responding to interview questions. Evidenced by: The facility policy, Abuse, Neglect, and Exploitation, dated 1-2023, states, in part; .c. Allegations of abuse, neglect, or exploitation will be thoroughly investigated. The investigation will be initiated upon receipt of the allegation. The administrator, or designee, will complete the investigation process. d. The investigation can include, but is not limited to: i. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure all allegations of abuse were reported timely to the state survey agency (SSA) for 1 resident (R3) of 8 sampled residents. The facility failed to timely report to the SSA when an allegation of abuse was reported to administration. Evidenced by: The facility policy titled, Abuse, Neglect, and Exploitation, revision date 1-23, states, in part: .It is also the policy of this community to take appropriate steps to ensure that all alleged violations of federal or state laws which involve mistreatment, neglect, abuse, injuries of unknown source, and misappropriation of resident property are reported immediately to the administrator of the community. [...]

Inspectors wroteBased on record review, interviews, and policy review it was determined the facility failed to ensure that physicians' orders were accurately implemented for 5 out of 8 residents Resident (R23, R6, R22, R24, R21) reviewed for medication errors. A review of the facility's Incident Audit report indicated at least five residents were administered medications incorrectly by facility staff. This failure placed these residents and potentially other residents at risk of harm.

Inspectors wroteBased on observations, record reviews, and interviews, it was determined the facility failed to report a resident's missing pain patch, as outlined in their abuse policies related to the misappropriation of residents' property, for 1 (R11) out of 4 residents prescribed Fentanyl patches for pain. This failure placed R11 and other residents requiring the use of a pain patch at risk of breakthrough pain and for the unlawful use of the residents' property without their permission. Note: Fentanyl is a schedule II pain medication that is unlawful to use without a physician's prescription and the facility did not ensure that all alleged violations involving abuse, neglect, mistreatment, and including injuries of unknown source are reported to the State Survey Agency for 1 of 3 residents reviewed for abuse (R28).

Inspectors wroteBased on observations, record reviews, and interviews, it was determined the facility failed to investigate a resident's missing pain patch, as outlined in their abuse policies related to the misappropriation of residents' property, for one out of four residents Resident (R11) prescribed Fentanyl patches for pain. This failure placed R11 and other residents requiring the use of a pain patch at risk of breakthrough pain and for the unlawful use of the residents' property without their permission. Note: Fentanyl is a schedule II drug that is unlawful to use without a physician's prescription.

Inspectors wroteBased on observation, interview, and record review, the facility did not implement professional standards of practice to prevent pressure injuries (PI) from worsening for 1 of 5 residents reviewed for PIs, out of a sample of 34 residents (R104). The facility did not ensure weekly measurements/assessments and treatments were being completed to R104's sacral PI. MD (Medical Doctor) notifications were not done when changes were noted to the wound. R104 was admitted to the facility with a stage 2 PI which progressed into a stage 4 PI causing R104's PI to become infected and R104 was placed on antibiotics. This is evidenced by: The facility's policy, entitled Pressure Injuries (Management/Treatment,) with a revision date of 12/22, states, in part: [...]

Inspectors wroteBased on observation, interview, and record review the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. This has the potential to affect all 104 residents. Raw hamburger was not being thawed in accordance with standards of practice. Clean dishes were found undried and stacked.

Inspectors wroteBased on observation and interview, the facility did not ensure that garbage and refuse was disposed of properly. This has the potential to affect all 104 residents. On 2/15/23 at 9:28 AM, Surveyors observed the following outside, on the ground near the facility's main garbage dumpster: *8 gloves *A face shield *plastic CPAP/oxygen mask *Numerous broken plastic bottle caps *Opened/used feminine hygiene products *paper towels *Various pieces of scattered cardboard On 2/15/23 at 10:40 AM, NHA A (Nursing Home Administrator) observed the garbage area and reported to Surveyors that the facility could use some improvements as it pertains to disposing of garbage and refuse properly. NHA A stated the task of cleaning the dumpster area is completed regularly but would be added to the monthly cleaning list to ensure consistent proper disposal and cleaning is carried out.

Inspectors wroteExample 15 R25 has the following diagnosis: Alzheimer's Disease, Osteoarthritis, Polyosteoarthritis, Anemia, Urge Incontinence, and Unsteadiness on Feet. R25's most recent Minimum Data Set (MDS) dated [DATE], section B0700 indicates R25 is rarely or never understood. In R25's most recent MDS, section G0110 indicates extensive assist of two staff is needed with bed mobility and dressing. R25 is total dependent of 2 plus staff members for physical assist for transfers, hygiene and toileting. R25's Alteration in elimination care plan documents, in part: . check and change schedule: AM- 7am, 10am, 1pm and as needed . On 2/16/22 from 7:37 AM- 11:02 AM, Surveyor observed R25 sitting at the breakfast table and staying in the dining room area. At 9:30AM, Surveyor noted the smell of stool. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 6 of 26 residents reviewed for staffing (R25, R32, R45, R60, R35 and R83), as determined by resident assessments and individual plans of care and considering the number, acuity and diagnosis of the facility's resident population in accordance with the facility assessment. R25 was observed not receiving incontinent cares per her individualized care plan. Facility staffing census documentation indicates fewer staff hours than the Staffing Plan in the Facility Assessment for specified shifts. R32, R45 and R60 complained of long call light wait times. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that feeding assistants completed a state approved training course for 4 of 34 sampled residents (R83, R19, R38, & R24). A staff member reported to Surveyor that she assists R83, R19, R38 & R24 with dining and she has not completed a Certified Nursing Assistant Course or a state-approved paid feeding assistant training course and who, otherwise by Wisconsin law, should not be allowed to feed residents. FM V (family member) reported to Surveyor that her and a staff member assists residents with dining due to short staffing at the facility. This is Evidenced by: Facility unable to provide policy on paid feeding assistants as the facility does not offer a paid feeding assistant training course. [...]

Inspectors wroteBased on interview and record review, the facility did not make prompt efforts to resolve resident grievances for 1 of 26 residents (R265) reviewed for grievances out of a total sample of 34 Residents. R265's family voiced a concern to the facility staff regarding R265's hearing aid being lost. The facility did not file a grievance or follow-up with the family to resolve these concerns. This is evidenced by: The Facility's grievance policy, titled, Grievance Process, with most recent revision dates of 3/2018 and 11/2022, includes, in part: Policy: Residents have the right to voice grievances to the community or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment .and other concerns regarding their stay in the community. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure each resident's right to be free from physical restraints for 1 of 1 resident reviewed for restraints (R97) out of a total sample of 34 residents. The facility employed a full body-length pillow on the edge of R97's bed without an assessment for its use.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that residents with an indwelling catheter received the appropriate care and services to prevent a urinary tract infection (UTI) for 1 of 2 sampled residents (R104) and 1 of 1 supplemental resident's (R14) reviewed for catheters out of a total sample of 34 Residents. Surveyor observed R14's catheter bag uncovered and in direct contact with the floor. CNA L (Certified Nursing Assistant) did not perform proper hand hygiene during catheter/peri care on R104. Evidenced by: Facility policy & procedure entitled Catheter/Urinary Daily Care, undated, does not contain any information, approaches, and interventions for infection control. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 1 of 6 residents (R96) of a total of 24 residents reviewed had a drug regimen free from unnecessary drugs. R96 did not meet criteria for collection of a urinalysis or meet criteria for antibiotic thearapy. As evidenced by The facility policy, Antibiotic Stewardship, undated, indicates in part, the following: The facility has established, implements and maintains an Antibiotic Stewardship Program designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. The program includes prevention, overall oversight, tracking and reporting antibiotic use and outcomes, and education. The facility recognizes that antibiotic stewardship is a continuous process. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that it was free of medication error rates of 5% or greater. There were 2 errors in 40 opportunities that affected 2 out of 4 residents (R54 & R19) included in the medication pass task, which resulted in an error rate of 5%. *R54 was administered nasal spray incorrectly. *MT (Medication (Med) Tech) administered R19 an enteric coated (ec) bisacodyl crushed. (enteric coating is a special coating that prevents the medicaiton from breaking down in the stomach) This is evidenced by: The facility policy, entitled Nasal Medications, dated 1/1/22, states, in part: . Nasal medications may be installed with drops, spray, or aerosol (nebulizer) . PROCESS: . V. Atomizer (Nasal Spray): A. Resident should be sitting upright with head tilted back slightly. B. Occlude one nostril with finger. C. [...]