Dove Healthcare - St. Croix Falls

Inspectors wroteBased on observation and interview, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 47 residents who reside in the facility. Surveyor observed staff in the food preparation area without donning hair restraints. Surveyor observed frozen drips on the ceiling inside of the facility's freezer and on and inside of boxes of food that were no longer sealed by the manufacturer. Surveyor observed a stored mixer to be stored unclean. Surveyor observed [NAME] Y with his personal beverage on the food preparation counter. Surveyor observed opened boxes of juice without an open date. Evidenced by: Example 1 Facility policy, titled Dietary Employee Personal Hygiene, effective 4/2025, includes: Hair Restraints: [...]

Inspectors wroteBased on interview and record review, the facility has not established an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This has the potential to affect all 47 residents (R) in the facility. The facility failed to test staff who displayed COVID-19 and norovirus symptoms. The facility failed to ensure staff wore appropriate PPE (personal protective equipment) while handling soiled linens and laundry. This is evidenced by: The facility policy, titled, Covid-19 Prevention, Response and Reporting, dated 1/2025, includes in part: Policy: It is the policy of this facility to ensure that appropriate interventions are implemented to prevent the spread of Covid-19 and promptly respond to any suspected or confirmed Covid-19 infections. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 1 (R13) of 12 resident's right to be informed of, and participate in, his or her treatment was honored. The facility offered R13 the Respiratory Syncytial Virus (RSV) Vaccine but did not administer the vaccine when R13 indicated her preference for receiving it.

Inspectors wroteBased on interview and record review, the facility did not ensure the resident's right to request, refuse, and/or discontinue treatment and to formulate an advanced directive for 2 of 12 residents (R27 and R32) R27 and R32's charts did not contain current copies of their advanced directive and/or did not contain evidence of advanced care planning, other than code status, for a time when they are not able to make their own healthcare decisions. Evidenced by: The facility policy titled, Advance Directives, revision date 7/10/24, indicates, in part: Policy: It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate advance directive. Definitions: [...]

Inspectors wroteBased on interview and record review the facility did not document a thorough investigation and did not resolve grievances as outlined in the facility policy for 2 of 12 Residents (R32 and R20) reviewed for grievances. R32 voiced a concern to a staff member and the facility failed to follow their grievance policy by thoroughly investigating, following up, and documenting the concern. R20 voiced a grievance regarding wound care and the facility did not follow the grievance process. Evidenced by: The facility policy, “Grievance Policy,” revision date 11/2019, indicates, in part: Policy Statement: …grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their long-term care facility stay. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving injuries of unknown origin are reported immediately to the administrator of the facility and to other officials, including to the State Agency, in accordance with State law for 1 of 12 residents (R1) reviewed for abuse. R1 was noted to have an area of swelling to right hip and dark purple bruising to right shoulder and arm. The origin of this injury was unknown and was not reported to the Nursing Home Administrator (NHA) or the State Agency (SA). Evidenced by:The facility's Resident Abuse, Neglect, Misappropriation of Property, and Exploitation Prevention Program policy, dated 10/2023, states, in part: .Definitions: . Injuries of unknown source an injury should be classified as an injury of unknown source when all of the following are met: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that each resident receives adequate supervision and assistive devices to prevent accidents in 2 of 2 (R6 and R17) residents reviewed for falls. R17 was assessed and care planned for 2-person assist with an EZ stand to meet her needs for transfers. CNA E (Certified Nursing Assistant) did not follow manufacturer’s recommendations for the EZ stand lift and did not fasten the harness’ safety strap around R17’s waist. R17 had a change in plane when she was lowered to the floor. R6 has diagnoses repeated falls, has been assessed by the facility to be at risk for falling, and has experienced multiple falls since admission. Surveyor observed R6 without his care planned intervention in place related to fall prevention. This is evidenced by: [...]

Inspectors wroteBased on interview and record review the facility failed to ensure they followed standards of practice for an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for 1 (R44) of 5 residents reviewed for antibiotic stewardship. R44 was diagnosed with an acute urinary tract infection. The physician ordered the antibiotic ciprofloxacin (Cipro) 500 milligram (mg) tablet. There was no susceptibility testing done to ensure that R44's antibiotic treatment would be effective. Evidenced by:The facility's Antimicrobial Stewardship Procedure policy, dated March 2012, with last revision date of March 2024, states, in part: Policy: To ensure judicious use of antibiotics, optimize clinical outcomes while minimizing unintended consequences of antimicrobial use including toxicity, to prevent the development of pathogenic organisms. [...]

Inspectors wroteBased on record review, interview, and policy review, the facility failed to thoroughly investigate an allegation of staff to resident abuse for 2 of 3 residents (R3 and R2) reviewed for abuse out of five sampled residents.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure 1 of 3 residents (R) reviewed for pressure injuries (PI) received care consistent with professional standards of practice to prevent the development of a new pressure injury and promote healing of existing PIs (R1). R1 was admitted to the facility without a PI and was assessed to be at risk for PI development. R1 developed one PI a deep tissue injury (DTI) on 01/22/25. The facility did not have preventive measures of heel boots in place prior to the development of the DTI. The facility did not complete a comprehensive assessment with staging of the PI upon discovery and did not care plan new interventions timely to promote healing. This is evidenced by: Facility's policy titled Pressure Injury Prevention and Management with last reviewed date of 09/24, read in part, 2. [...]

Inspectors wroteBased on interview and record review, the facility did not complete comprehensive weekly wound assessments for 1 of 3 residents (R)1 to ensure that residents receive treatment and care in accordance with professional standards of practice. R1 did not receive comprehensive assessment of a skin injury upon discovery and did not initiate timely interventions to promote healing. This is evidenced by: Facility's policy titled Documentation of Wound Treatments with the last reviewed date of 09/24, read in part, 1. Wound assessments are documented upon admission, weekly, and as needed if the resident or wound condition deteriorates. 2. The following elements are documented as part of a complete wound assessment: a. Type of wound .b .if non-pressure (partial or full thickness) c. measurements; height, width, depth, undermining, tunneling d. Description of wound characteristics . [...]

Inspectors wroteBased on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 of 2 residents (R) (R1) observed when cares were provided. Facility staff did not conduct appropriate hand hygiene when providing personal cares. Facility staff did not wear personal protective equipment (PPE) for R2 who is on Enhanced Barrier Precautions (EBP). This is evidenced by: Facility's policy titled Hand Hygiene dated 12/24, read in part, 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. [...]

Inspectors wroteBased on interview and record review, the facility did not promptly notify and consult with a resident's physician when there was a significant change in a resident's clinical condition when blood sugar levels exceeded the threshold. This occurred for 1 of 3 residents (R) R4, reviewed for insulin use. This is evidenced by: The facility's STANDING ORDERS for SKILLED NURSING FACILITIES with the revised date of 2024, read in part, Diabetic Management .If DMII (diabetic mellitus type 2): Notify provider if two BG (blood glucose) results are <(less than) 70 or > (greater than) 400 in a 24-hour timeframe and/or change in condition; if no condition change, notify provider on the next business day . R4 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that a resident who is unable to carry out daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Residents were not receiving regular weekly showers. This affects two of five residents reviewed, R1 and R7.

Inspectors wroteBased on interview and record review, the facility failed to have a system in place to ensure the code status of residents (R), as indicated in their advance directives, was followed. This affected 1 of 1 resident reviewed (R1) whose Cardiopulmonary Resuscitation (CPR) wishes were not followed. R1's Critical Care Plan indicated R1 wanted CPR. On [DATE], R1 was found not breathing and without a pulse. Staff did not promptly begin CPR per resident's wishes. When CPR was initiated, it was not performed according to current standards resulting in ineffective procedure. The facility's failure to ensure R1 received basic life support, including CPR, in accordance with preferences on signed Critical Care Plan, created a finding of Immediate Jeopardy (IJ) beginning on [DATE]. Director of Nursing (DON) B was notified of the immediate jeopardy on [DATE] at 1:30 p.m. [...]

Inspectors wroteBased on observations and interviews, the facility did not distribute and serve food with professional standards for food service safety. This has the potential to affect all 43 residents in the facility. Observations of handling ready to eat foods with contaminated gloves. Observed dirty air conditioner blowing on clean dishes. Dirty, unsanitary condition in dish room.

Inspectors wroteBased on interview and record review, the facility did not establish an Infection Control Program under which it investigates, controls, and prevents infections in the facility, and a system for recording incidents identified under the facility's Infection Control Program, including corrective action in a timely manner, for both residents and staff. This has the potential to affect all 43 residents in the facility. -The facility did not a have a clear water management process or plan in effect to prevent transmission of Legionella infection. This has the potential to effect 43 of 43 residents reviewed. -The facility did not have a tracking program in place for the early detection of infected and exposed residents (R) and staff for COVID-19 during an outbreak. -Observations were made of the facility not implementing Enhanced Barrier Precautions (EBP) for 2 of 5 sampled residents on EBP. [...]

Inspectors wroteBased on interview, the facility failed to ensure the Infection Preventionist (IP) is trained in special education and training in infection prevention and control. This has the potential to affect all 43 residents. This is evidenced by: Registered Nurse (RN) D was the facility's Infection Preventionist (IP) until 06/08/24. On 07/17/24 at 9:30 AM, Surveyor asked RN D if RN D had specialized training in Infection Control (IC) and prevention. RN D stated, No, I never did finish the infection control instructional class to become certified but that there was a corporation person for IC who oversaw the infection control program sometimes. [...]

Inspectors wroteBased on interview, medical record review and facility document review, the facility did not have a comprehensive system for ensuring residents received influenza and/or pneumococcal immunizations, for 9 of 13 sampled residents, (R). (R40, R24, R11, R1, R2, R21, R42, R37, and R31) This is evidenced by: The CDC Influenza Vaccine Timing for Adults reads, in part: One dose of Influenza vaccine is recommended for adults each flu season . The CDC Pneumococcal Vaccine Timing for Adults reads, in part: Administer 1 dose of PCV13 at least 1 year after the most recent pneumococcal vaccine dose. Administer a second dose of PPSV23 at least 8 weeks after PCV13 and at least 5 years after the previous dose of PPSV23 . Surveyor requested a list of current residents and their influenza and pneumococcal immunization dates. R40 was admitted on [DATE]. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure 8 residents (R) of 13 sampled were offered a COVID-19 vaccine as indicated. (R40, R24, R1, R2, R21, R42, R37, and R31) This is evidenced by: The CDC COVID-19 vaccine Timing for Adults reads, in part: One dose of COVID-19 vaccination booster is recommended for adults every 6 months unless immunocompromised . Surveyor requested a list of current residents and their COVID-19 immunization dates. R40 was admitted on [DATE]. R40's immunization record stated that COVID-19 vaccinations were recommended. Facility did not have documentation that the facility offered or educated R40 of the COVID-19 vaccination recommendation. The facility did not have a declination form in R40's record of the COVID-19 vaccination being declined. R24 was re-admitted on [DATE]. R24's immunization record stated COVID-19 vaccination recommended. [...]

Inspectors wroteBased on interview and record review, the facility failed to consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status that is a deterioration in heath, mental, or psychosocial status in either life-threatening conditions or clinical complications. Staff did not contact physician when blood sugar levels exceeded the threshold that orders specified a physician to be contacted. This has the ability to effect 1 of 3 residents (R) R2 investigated for insulin use.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure resident safety through assessment and that the environment remains as free of accident hazards as is possible for 2 of 2 residents (R301 and R25) reviewed. - R301 was evaluated by the facility to be a fall risk. R301 was observed self-ambulating to R301's car in the parking lot and driving to a neighboring community in R301's personal vehicle. -Facility staff did not follow the plan of care for safety with smoking for 1 of 3 residents (R25) reviewed for smoking.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that parenteral medications were administered consistent with professional standards of nursing practice for 1 of 1 (R24) resident reviewed. R24 was admitted to the facility on [DATE], with a Peripherally Inserted Central Catheter (PICC) line, which is a soft, thin, flexible tube in a vein used to administer IV medications and fluids. Staff did not complete appropriate assessment before administration of IV antibiotics. Staff were observed not applying alcohol-based connector locks after the administration of IV antibiotics.

Inspectors wroteExample 3 R1 was admitted to the facility on [DATE] with the following diagnoses in part, cerebrovascular disease, hemiparesis and hemiplegia following cerebral infarction affecting left dominant side, Alzheimer's disease with late onset. Record review identified R1 was hospitalized from [DATE] to 04/23/24 due to signs and symptoms of a possible stroke. On 07/15/24 at 4:08 PM, Surveyor interviewed R1's Power of Attorney for Health Care, who stated they did not remember if they received a written notice of transfer when R1 was transferred to the hospital. Surveyor was unable to locate a written notice of discharge/transfer form for this hospitalization on R1's medical record. On 07/17/24 at 8:29 AM, Surveyor requested a copy of the written notice of discharge or transfer and documentation of Ombudsman notification for R1's transfer to the hospital on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The facility did not ensure that potentially hazardous foods were served at temperatures that would reduce the chance of illness for residents. This has the potential to affect all 47/47 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility did not ensure 1 of 12 nurses reviewed had the proper licensure in accordance with Wisconsin state law licensing requirements. This had the potential to affect all 47 residents in the facility. This is evidenced by: On [DATE], Surveyor requested and received licensure information for 12 nurses at the facility. Upon reviewing nursing licensures, Surveyor reviewed documentation for Licensed Practical Nurse (LPN) N. The facility did not have documentation of a Wisconsin license for LPN N. The facility did provide documentation for ACT 10 (temporary licensure), which stated LPN N started employment at the facility on [DATE]. The form was not signed by the Director of Nursing (DON) B until [DATE]. ACT 10 expired [DATE]. [...]

Inspectors wroteBased on record review and staff interviews, the facility did not provide pharmaceutical services, including services that assure the accurate dispensing and administering of all drugs and biologicals, to meet the needs of 4 of 4 residents reviewed for medication administration (R) (R1, R2, R5, R6). This is evidenced by: Example 1 On 05/14/24, Surveyor reviewed R1's medical record. [...]

Inspectors wroteBased on record review and interview, the facility did not provide care and treatment in accordance with professional standards of practice related to resident assessment after a fall incident for 1 resident (R) (R7) of 3 residents reviewed for falls. R7 sustained a fall, and when reported, the facility's licensed nursing staff did not assess R7. This is evidenced by: On 05/14/24, Surveyor reviewed R7's medical record concerning a fall. R7's nurse's notes state on 3/10/2024 at 1:14 p.m., R7 verbalized to staff that R7 fell. R7 complained of left hip pain to the nurse on 03/10/24. R7 said R7 fell yesterday, 03/09/24. R7 said R7 was transferring from the wheelchair to the bed. R7 went to grab the arm of the wheelchair and fell to the ground on R7's left side. R7 stated, The blonde girl went and got the cherry picker, then hooked R7 up, and then staff lifted R7 back to the wheelchair. [...]

Inspectors wroteBased on observation, interviews and record reviews, the facility did not ensure the resident environment remained as free of accident hazards as possible. The facility did not assess the resident's ability to use cigarettes after determining the resident used nicotine products. This occurred for 1 of 3 residents (R) 7 reviewed for assessments related to nicotine use. This is evidenced by: The facility policy, entitled Smoking - Residents & Visitors which was not dated, did not have any information regarding assessing residents who chose to smoke while attending the facility. Surveyor requested a policy for nicotine use. Facility had no policy related to nicotine use. On 05/14/24 at 5:30 PM, Surveyor observed R7 smoking out in the parking lot as they were leaving for the day. R7 was able to smoke without any concerns to safety of the resident. [...]

Inspectors wroteBased on interview and record review, the facility did not report a reasonable suspicion of a crime to law enforcement or report an allegation of misappropriation of narcotic medications to the state agency for 5 of 8 residents (R16, R14, R8, R7, and R13) reviewed. This is evidenced by: The facility policy, entitled Controlled Substance Administration and Accountability, revised February 01, 2024, states: 10. Discrepancy Resolution: a. Any discrepancy in the count of controlled substances or disposition of the narcotic keys is resolved by the end of the shift during which it is discovered. c. Resolution can be achieved by review of dispensing and administration records and consulting with all staff with access. e. Any discrepancies which cannot be resolved must be reported immediately as follows: i. Notify the DON, charge nurse, or designee and the pharmacy; ii. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure to complete thorough investigations for misappropriation of narcotics form pharmacy emergency kit and Residents (R7 and R13). The facility did not complete a thorough investigation for potential abuse or neglect for R1. This occurred for 3 of 9 residents reviewed for investigations. This is evidenced by: Example 1 The facility policy Controlled Substance Administration and Accountability, revised February 01, 2024, states .10. Discrepancy Resolution: a. Any discrepancy in the count of controlled substances or disposition of the narcotic keys is resolved by the end of the shift during which it is discovered. c. Resolution can be achieved by review of dispensing and administration records and consulting with all staff with access. e. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure proper reconciliation, disposition, or accurate records of controlled medications for 7 of 8 residents (R) and from emergency kit (E-KIT). (R16, R14, R8, R3, R15, R7, and R13)

Inspectors wroteBased on observation, interview and record review, the facility did not serve palatable hot foods for 7 of 43 residents residing in the facility. (R12, R7, R8, R6, R4, R2, and R13). This is evidenced by: On 02/22/24 at 9:30 AM, staff reported residents eat meals in their rooms, due to a COVID outbreak. R1, R3, and R5 require assistance with eating meals and may eat in the dining room with staff assist. On 02/22/24 at 9:40 AM, Surveyor reviewed Resident Council minutes for November, December, and January and noted the following: -November food concerns: Noodles are crunchy over overcooked. -December food concerns: Pancakes not cooked in the middle. Noodles are dry and need more sauce. -January food concerns: Pork is too tough, too many noodles. On 02/22/24 at 9:49 AM, Surveyor reviewed facility grievances related to food and noted the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure activities of daily living (ADLs) of meal set-up, repositioning, incontinence cares, bed baths, and obtaining body weight were provided for 2 of 11 residents (R9 and R13) reviewed. This is evidenced by: Example 1 R9 was admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD), trochanteric bursitis bilaterally, muscle weakness, morbid severe obesity, and depressive disorder. R9's minimum data set (MDS) assessment, completed on 01/17/24, confirmed R9 scored 15/15 during Brief Interview for Mental Status (BIMS), indicating cognitively intact. R9 makes his own healthcare decisions. R9 is incontinent of urine and frequently incontinent of bowels. R9 requires set-up assistance with eating and oral hygiene. [...]

Inspectors wroteBased on observation, interview and record reviews, the facility staff failed to adequately assess and treat pain and provide necessary care and services to attain or maintain the highest practicable physical wellbeing for 3 (R8, R12, R9) of 7 residents (R) reviewed for pain. This is evidenced by the following: Example 1 R8 was admitted to the facility on [DATE], with diagnoses including pressure ulcer of sacral region, trochanteric bursitis bilaterally, type 2 diabetes mellitus, dysphagia, osteomyelitis of vertebra, reduced mobility, and anemia. R8's Minimum Data Set (MDS) assessment, completed on 01/02/24, confirmed R8 scored 9/15 during Brief Interview for Mental Status (BIMS), indicating moderate cognition impairment. R8 is dependent on staff for personal hygiene, showering/bathing, toileting, transferring, dressing upper and lower body, and putting on/taking off footwear. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 1 of 5 nurses reviewed had the proper licensure in accordance with Wisconsin state law licensing requirements. This had the potential to affect all 44 residents in the facility. Licensed Practical Nurse (LPN) C, who is a current employee, has worked at the facility as an LPN since 4/17/23 to date of survey without a Wisconsin nursing license.

Inspectors wroteBased on interview and record review, the facility did not ensure services were provided by individuals who had proper certification, skills, experience, and knowledge to do a particular task for 1 of 4 (R3) residents reviewed.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety. This had the potential to affect all 37 residents in the facility. Facility did not ensure milk was kept at a safe temperature of 41 degrees or lower during lunch service on 7/10/23. Facility did not ensure refrigerator and freezer in the TCU kitchen were monitored for appropriate temperatures and did not ensure resident foods brought in from outside were labeled with date opened and discarded when expired.

Inspectors wroteBased on observation and interview, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections during 4 observations. Staff did not assist residents (R) with hand hygiene prior to meals in the main dining room during observations of lunch meal on 07/10/23 and breakfast meal on 07/11/23. This affected R13, R4, R35, R24, R11, R20, R19, R10, R239, R1, R33, R18, R28, R6, R25, R17, R13, R21, R27, and R12. Staff did not perform hand hygiene and did not sanitize mechanical lifts before or after transferring. This affected 2 of 2 residents (R26 and R4). [...]

Inspectors wroteBased on record review and interview, the facility did not implement policy and procedures related to screening employees for a prior history of abuse, neglect, exploitation of residents, or misappropriation of resident property for 3 of 8 staff reviewed. This had the potential to affect all residents. Facility did not complete criminal background checks every four years for 3 of 8 employees reviewed.

Inspectors wroteBased on interview and record review, the facility did not complete the required Preadmission Screen and Resident Review (PASRR) screen for 2 of 3 residents reviewed, (R17, R28). R17 was admitted to the facility and had a PASRR screen which indicated that they would remain in the facility for under 30 days. When this resident's stay exceeded 30 days, a new PASRR screen was not completed. R28 was admitted to the facility and had a PASRR screen which indicated that they would remain in the facility for under 30 days. When this resident's stay exceeded 30 days, a new PASRR screen was not completed. This is evidenced by: Example 1 R17 was admitted to the facility and has diagnoses including adjustment disorder, post-traumatic stress disorder, and depression, for which the resident takes Wellbutrin. R17's medical record included a PASRR level 1 screen which was completed on 03/29/22. [...]

Inspectors wroteBased on record review and interview, the facility did not develop a medical care plan for 1 of 13 resident (R12) care plans reviewed. The facility did not develop a diabetic plan of care for R12. This is evidenced by: R12 was admitted to the facility on [DATE] and has diagnosis that include type 2 diabetes, chronic obstructive pulmonary disease (COPD), atrial fibrillation and major depressive disorder. Surveyor reviewed R12's comprehensive care plan and identified a diabetic plan of care was not developed. On 07/12/23 at 10:34 AM, Surveyor interviewed Certified Nursing Assistant (CNA) R and asked how they know if a resident is a diabetic. CNA R indicated that it is on the resident's [NAME]. Surveyor asked CNA R when doing bathing do you clip nails of someone that is diabetic. CNA R indicated no that the nurses do that. [...]

Inspectors wroteBased on interview and record review, the facility did not revise care plans to include non-pharmacological interventions for 3 of 5 sampled residents (R17, R35, and R28) for psychotropic medications. R17's care plan was not updated to identify non-pharmacological individualized interventions for insomnia and depression related to current use medications of Trazadone and Wellbutrin. R35's care plan was not updated to identify non-pharmacological individualized interventions for depression related to current use medication of Wellbutrin. R28's care plans was not updated to include non-pharmacological interventions for generalized anxiety disorder and major depressive disorder, severe with psychotic symptoms. This is evidenced by: Example 1 R17 was admitted on [DATE] with diagnoses which include, in part, Parkinson's disease, and post traumatic disorder. [...]

Inspectors wroteBased on record review and interviews, the facility did not ensure that 2 (R26 and R33) of 4 sampled residents who are unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming and personal and oral hygiene. R26 and R33 did not receive a weekly shower.

Inspectors wroteBased on record review, observation and interview, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (R4). Facility staff did not follow R4's plan of care to ensure fall interventions were in place.

Inspectors wroteBased on record review and interview, the facility did not ensure that 1 of 5 staff reviewed for verification of a current Nurse Aide Registry were on the Wisconsin registry before starting work in the facility. Certified Nursing Assistant (CNA) H was not on the Wisconsin Nurse Aide Registry and was working in the facility at the time of the discovery.

Inspectors wroteBased on observation and interview the facility did not provide pharmaceutical services, including procedures that assure that accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident, for 2 of 2 medication rooms reviewed, or ensure accurate administering of insulin. The facility did not ensure destruction of medication occurred timely after Resident (R9 and R31) were discharged from the facility. The facility did not ensure safe and secure storage for controlled substances and emergency/contingency medications. Licensed Practical Nurse (LPN) V administered insulin medication without checking the expiration date for R2 and R17.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure psychotropic drugs are not given unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 5 residents (R17) reviewed. The facility did not complete a sleep assessment to determine adequate indication for use of an antidepressant medication (Trazadone) for R17 to promote sleep. This is evidenced by: R17 was admitted on [DATE] with diagnoses which include, in part, Parkinson's disease, and post traumatic disorder. R17's Minimum Data Set (MDS) dated [DATE] indicates Brief Interview for Mental Status (BIMS) of 15, which means R17 is cognitively intact and Patient Health Questioner (PHQ-P) with score of 8, which means mild depression severity. R17's care plan, dated 06/02/23, with a target date of 09/30/23 states, in part: [...]

Inspectors wroteBased on observation, record review and interview, the facility did not ensure a medication error rate of 5% or less for 2 of 5 residents (R2 and R17) observed for medication pass. The facility had 48 opportunities and 3 medication errors resulting in a 6.25% error rate. Licensed Practical Nurse (LPN) V administered insulin medication without checking the expiration date for R2 and R17. This is evidenced by: According to the Food and Drug Administration (FDA), insulin pens should be discarded 28 days after opening the pen to ensure effectiveness of the medication. Surveyor reviewed policy Administering Medications which states in part, under number 12 bulletin point, The expiration/beyond use date on the medication is checked prior to administering . [...]

Inspectors wroteBased on staff interview and record review, the facility did not provide Advanced Beneficiary Notice (ABN) of non-coverage for residents (R) whose Medicare Part A coverage was discontinued with benefit days remaining for 2 (R3 and R25) of 3 residents reviewed. R3 and R25 were discharged from Medicare Part A services with benefit days remaining and remained in the facility. The facility did not provide an ABN.