Complete Care at Nazareth LLC

Inspectors wroteBased on interview and record review, the facility did not ensure that each resident received adequate supervision to prevent accidents for 2 of 3 residents (R2 and R1) reviewed. On 5/12/26, the facility substituted Brussels sprouts for carrots at the evening meal, without the approval of CD G (Clinical Dietician.) Brussels sprouts were served whole to resident R2 and R1, despite having mechanical soft diets. R2 had a choking episode and was sent to the emergency room (ER) for evaluation. R1 had a choking episode and was sent to the ER for evaluation. R1 expired at the hospital. The facility's failure to ensure appropriate meal substitution, prepare food to the proper consistency for ordered diet, and recognize that inappropriate consistency was served created a finding of immediate jeopardy that began on 5/12/26. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure professional standards were in place to describe the characteristics of food and drink. This has the potential to affect the 65 Residents of the facility. The facility is not following current standards of practice for nutrition by not following IDDSI (International Dysphagia Diet Standardisation Initiative). Evidenced by:Per the SOM Professional standards of quality means that care and all services are provided according to accepted standards of clinical practice. Standards may apply to care provided by a particular clinical discipline or in a specific clinical situation or setting. Standards regarding quality care practices may be published by a professional organization, licensing board, accreditation body or other regulatory agency. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure comprehensive care plans were revised in accordance with the resident's current status and care needs for 1 of 3 residents (R4) reviewed for care planning timing and revision. The facility did not update R4's care plan to prevent future occurrences after he had a resident to resident incident where he grabbed the wrist of another resident (R3). Evidenced by:Facility policy, titled Comprehensive Care Plans, dated 2023, includes: . It is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. [...]

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure meals were served at regular times and in accordance with residents' preferences. This practice had the potential to affect all 64 residents residing in the facility. The facility consistently served meals later than posted mealtimes and residents' preferences.

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 64 residents. The sanitizing solution in the kitchen's three compartment sink did not meet manufacturer parts per million (PPM) requirements. Food items were found to be improperly dated or not dated.

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 64 residents. Surveyor observed the dumpers area to have garbage/refuse around the dumpster. Evidenced by:On 3/30/26 at 8:46 AM, Surveyor and CK J (Cook) observed the following outside on the ground, near and under the facility's main garbage dumpsters:*2 empty egg crates*Empty tissue boxes*Plastic forks, spoons, and knives*Cardboard boxes*Various sauce/condiment packets*An empty plastic bag of coffee*Empty used garbage bags (appeared to have been tied and discolored)*Surgical masksAt this time, CK J stated that the area was Gross. On 4/2/26 at 10:49 AM, DM K (Dietary Manager) stated the task of cleaning the dumpster area is completed regularly but would ensure consistent proper disposal and cleaning is carried out.

Inspectors wroteBased on observation, interview, and record review, the facility did not establish and maintain 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 64 Residents residing in the facility. The facility may have allowed staff to return to work too soon after reporting gastrointestinal/respiratory symptoms. Employee surveillance list is incomplete. It has vague symptoms (i.e.: sick, sick-stomach, not feeling well.), did not accurately report onset date and has no end dates for symptoms, and has no last day worked. [...]

Inspectors wroteNumber of residents sampled:18Number of residents cited:4Based on observation, interview and record review, the facility did not ensure that the menu was followed for 2 of 18 sampled residents (R34, R24) and 2 of 2 supplemental (R54 &R32). R54's diet instructions indicate R54 is to receive gravy to all ground meat. Surveyor observed R54's breakfast ground meat with no gravy. Surveyor observed that R34 received oatmeal instead of cold cereal at breakfast. R34's Meal ticket indicated R34 received cold cereal. Surveyor observed that R24 received oatmeal at breakfast. R24's Meal ticket indicated oatmeal is a dislike of R24. R24's Meal ticket indicated R24 received cold cereal. Surveyor observed that R32 did not receive extra gravy/sauce or fruit per his dietary preferences for his noon meal. Evidenced by: The facility policy entitled Meal Identification, undated, states, in part: . Policy: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that each resident receives food that is palatable. This has the potential to effect 2 of 18 sampled residents (R25 & R5) and 2 of 2 supplemental residents (R32 & R55) reviewed for food palatability. R25, R5, R32, and R55 voiced concerns with their food being not palatable. Surveyor conducted a test tray, and the pork chop was not palatable. Evidenced by: Facility policy titled: Dining Subject: Preparation: states in part: . C. Foods shall be prepared by methods that conserve nutritive value, flavor and appearance and should be served at the proper temperature. Example 1R5 most recent Minimum Data Set (MDS) indicates a Brief Interview for Mental Status (BIMS) of 14/15 indicating R5 is cognitively intact. On 04/01/2026 at12:38 PM Surveyor asked how lunch was. R5 reported it was terrible. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure adequate interventions were in place for safety to prevent accidents from occurring for 1 of 5 residents (R37) reviewed for falls. R37 has had three falls sliding out of her Broda chair. The care planned intervention was to remove the Hoyer sling and not leave it under her in the Broda chair. Surveyor made several observations with the Hoyer sling left under R37 in her Broda chair. The facility did not ensure care planned interventions were followed to prevent R37 from further falls. Evidenced by: The facility's policy titled Facility Fall Protocol and Risk Assessment, dated 1/2025 with last revision date of 1/2026, states, in part: Policy: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents are free of significant medication errors for 1 (R61) out of 14 residents reviewed during the medication administration task. Surveyor observed R61 receiving her roommate's metoprolol. R61 does not have an order for metoprolol. Evidenced by:The facility policy entitled Medication Administration, dated 1/2025, states, in part: . Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: .10. Ensure that the six rights of medication administration are followed: a. Right resident b. Right drug c. Right route d. Right route e. Right time f. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that all drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. This affected 1 of 5 medication rooms. During the medication storage observation task, there were five medications found to be with expired dates. Evidenced by:The facility policy entitled Medication Storage, dated 1/2026, states, in part: . Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations. Policy Explanation and Compliance Guidelines: .8. Unused Medications: [...]

Inspectors wroteBased on interview and record review the facility did not provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 4 residents (R5) reviewed for equipment. R5 requested a referral for a new wheelchair for use out of the building. The facility did not follow up with the outside vendor in a timely manner. Evidenced by: The facility's Social Worker Job Description, undated, states, in part: .The Social Worker will also assist residents and their representatives in locating and accessing financial, legal, and other community resources. Accurately and completely document social service actions and interactions in each resident's medical record . Surveyor requested facility policy for requisition of wheelchairs. No policy provided. [...]

Inspectors wroteExample 5: On 1/6/25 at 11:02 AM, Surveyor interviewed R58. Surveyor asked R58 how the food is at the facility, R58 said not good. Surveyor asked R58 if his hot foods are hot and cold foods are cold. R58 stated hot foods are lukewarm and cold foods are warm. Surveyor asked R58 if there was anything else about the food he wanted to share. R58 replied all the meat is mysterious. Example 6: On 1/6/25 at 2:50 PM, Surveyor interviewed R31. Surveyor asked R31 how the food is at the facility, R31 said it's ok. Surveyor asked R31 what would make it better? R31 said if the vegetables weren't cold. Based 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 all 65 residents residing at the facility. [...]

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 65 residents who reside in the facility. FSD D (Food Service Director) was taking temperatures of lunch on 1/6/25. Surveyor observed FSD D wearing gloves touching items in FSD D pocket, thermometer, alcohol wipes, hot pad, lids on pans, and then directly touch chicken with same pair of gloves. Surveyor observed FSD D then go to dishwashing room and touch items, use cell phone, and touch steam table with same pair of gloves on. Surveyor observed no changing of gloves or hand washing. Evidenced by The facility policy, General Food Preparation and Handling, dated 2023, states, in part; [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that residents with pressure injuries receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new injuries from developing for 2 of 3 residents (R34 and R51) reviewed for pressure injuries. R34 did not have wound care treatments documented as completed in October and December. R51's pressure injury was left open to air for approximately 2 hours. This is evidenced by: The facility policy and procedure entitled Documentation of Wound Treatments dated 9/19/24, documents the following in part: .3. Wound treatments are documented at the time of each treatment. If no treatment is due, an indication on the status of the dressing shall be documented each shift (i.e., clean, dry, intact) . [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure they provided adequate supervision and assistance to prevent accidents for 1 (R11) of 4 residents reviewed for accidents and supervision. R11's care plan indicates R11 needs supervision for all meals. Surveyor observed R11 eating meal in his room alone. R11 indicated it was difficult to eat the meal. Evidence by The facility policy, Activities of Daily Living, dated 8/24, states, in part; .2. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . [...]

Inspectors wroteBased on interview and record review the facility did not ensure that 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, this affected 2 of 2 residents reviewed for med errors, 1 sampled resident (R38) and 1 supplemental resident (R50). R38 had the wrong pain medication administered on 8/15/24 and 8/16/24. R38's narcotic count was not accurate on 9/26/24. RN G (Registered Nurse) used a contaminated pill cutter to cut an unscored tablet for R50. This is evidenced by: The Facilities Policy and Procedure entitled Medication Administration dated 10/2024 documents in part: .9. Ensure that the six rights of medication administration are followed: a. Right resident, b. Right drug, c. Right dosage, d. Right route, e. Right time, f. Right documentation .16. [...]

Inspectors wroteBased on observation, interview and record review the facility must establish and maintain 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 RN F touched items within resident room with dirty gloves. R319 was admitted with a pressure injury (PI) and previous wound infection. During observation of wound care, the facility failed to utilize standard infection control practices. This is evidenced by: The facility policy Clean Dressing Change dated 10/2024, states, in part: .17. Discard disposable items and gloves into appropriate trash receptacle and wash hands. 18. Return resident to a comfortable position . Example 1 On 1/7/25 at 10:53 AM, Surveyor observed RN F (Registered Nurse) perform wound care for R51. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure each resident received adequate supervision to prevent accidents for 4 of 5 residents (R1, R2, R3, and R5) reviewed for wandering and elopement potential. R1 is severely cognitively impaired and has an Activated Power of Attorney for Health Care (APOAHC). R1 eloped from the facility on 9/1/24 and fell outside the facility, resulting in a fracture of his jaw. The facility did not have adequate supervision to ensure they were aware of R1's whereabouts and did not have security measures and monitoring in place to ensure R1 could not access various locations in the building, allowing him to exit the rear of the facility. [...]

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 a potential to affect all 71 (R) residents who reside in the facility. During kitchen walk through, Surveyor observed the following: * 1 gallon of [NAME] Real Mayo with no receive date or expiration date in the dry storage area. * 1 gallon of Dusseldorf Mustard with no receive date or expiration date in the dry storage area. * Container of prepared Gluten Free Chicken [NAME] with a prepared date of 11/26/23 and no use by date in the refrigerator * An opened 1-gallon French Dressing with a receive date of 4/20/23 with no use by or open date in the refrigerator. * An opened 1-gallon Buttermilk Ranch Dressing with a receive date of 4/22/23 with no use by or open date in the refrigerator. [...]

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 71 residents (R) in the facility. The facility's infection control line lists for staff are incomplete. The facility's monthly infection control rates were not calculated according to current standards of practice. This is evidenced by: The facility policy titled, Infection Prevention and Control Program, with a reviewed/revised date of 10/23, includes, in part: Policy: [...]

Inspectors wroteBased on observation and interview, the facility did not ensure residents received food that is palatable and at a safe and appetizing temperature for 1 of 1 resident's (R12) and 1 of 1 test tray affecting 24 residents out of a total census of 71. Surveyor received a food test tray, and the food was cool. Surveyors viewed grievance log to find grievance of food being cold when trays are delivered. R12 informed surveyor during initial screening that hot food is served cold. Evidenced by: The Wisconsin Food Code reads that hot food foods should be served at 135* degrees Fahrenheit (F) or above. Guidance 483.60(i);(1) -(2) in the State Operations Manual states the following: Tray line and Alternative Meal Preparation and Service Area- A resident's meal tray may consist of a combination of foods that require different temperatures. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that self-administering of medications was determined to be clinically appropriate for 1 of 1 resident (R128) reviewed for self-administration of medications out of a total sample 71. R128 was observed with medication sitting on the bedside table. R128 does not have an order to self-administer medications. This is evidenced by: The facility policy titled, Medication Administration, reviewed/revised date, 10/23, indicates, in part: Policy: Medications are administrated by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice . The facility policy titled, Resident Self-Administration of Medication, reviewed/revised date 10/23, indicates, in part: Policy: [...]

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 2 of 5 residents (R19 & R56) reviewed for falls out of a sample of 25 for supervision and accidents. R19 is a fall risk and has had multiple falls. R19's care planned fall interventions that were not in place. Root causes were not identified for one of R19's falls on 7/16/23. The facility did not follow a care plan intervention after a fall for R56. Evidenced by: The facility policy, entitled Clinical Protocol: Falls, dated 10/2023, states, in part: . Cause Identification: 1. For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall . 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure medication error rates are not 5% or greater during medication administration, this affected 1 of 3 Residents (R12) observed for medication pass. The facility medication error rate was 10.71%, for 3 errors out of 28 opportunities. The facility did not follow a physician order to administer medication before breakfast and was administered after breakfast. The facility did not administer two (2) medications as ordered and documented as administered. This evidenced by: Example 1 The facility's policy titled Medication Administration, dated 10/2023, states in part: . 11. Compare medication source (bubble pack, vial, etc.) with MAR (Medication Administration Record) to verify resident name, mediation name, form, dose, route, and time . b. [...]

Inspectors wroteBased on interview and record review, the facility must develop policies and procedures to ensure that residents and/or resident 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 1 of 5 residents (R39) reviewed for pneumococcal immunizations. R39 had an incomplete pneumococcal vaccine consent form and no evidence the vaccine was administered. This evidenced by: The facility policy, titled, Pneumococcal Vaccine (Series), with a reviewed/revised date of 10/23, indicates, in part: Policy: It is our policy to offer our residents and staff immunization against pneumococcal disease in accordance with current CDC (Centers for Disease Control) guidelines and recommendations. [...]