Edenbrook of Platteville

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 53 residents who reside in the facility. Surveyor observed dust coating the light fixtures and sprinkler heads within the facility's stove hood unit. Surveyor observed [NAME] D sanitizing the food prep area with a bucket of sanitizer that did not test the correct parts per million and was no longer warm. [NAME] D was unsure how long the sanitizer is good for before it needs to be changed out. Surveyor observed Corporate Maintenance Man E who has a full head of hair and a full beard to be in the food preparation/clean dishware area without donning hair restraints. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not provide toileting assistance for dependent residents for 1 of 1 supplemental resident (R39) reviewed for Activities of Daily Living (ADLs) assistance. Staff did not assist R39 with toileting assistance after an incontinent episode. Evidenced by: Facility policy, entitled Activities of Daily Living (ADL), dated 3/15/21, with revision date of 2/25/25 states in part: Policy: Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services . Procedure: .2. The facility will provide care and services for the following activities of daily living: . Toileting: Assisting with using the bathroom and maintaining cleanliness . [...]

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 3 residents (R253) reviewed for pressure injuries. R253 is at risk for PI (pressure injury) development. R253 was admitted with two stage 3 PIs. Staff did not confirm accurate measurements were taken of R253's PI upon admission and weekly to ensure that R253's PIs did not deteriorate. Evidenced by: The AMDA (American Medical Directors Association) clinical practice guideline titled, 'Pressure Ulcers and Other Wounds,' dated 2017, states in part: .A pressure ulcer (Injury) is localized damage to the skin or underlying soft tissue, usually over a bony prominence or related to a medical or other device. The ulcer may present as intact skin or as an open ulcer and may be painful. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 1 sampled resident's (R19) reviewed for dialysis and 2 of 2 supplemental residents reviewed for dialysis (R28, R49). R19, R28, and R49's care plans did not include emergency actions for any staff; no Nurses, CNA's (Certified Nursing Assistants) or any Ancillary staff (i.e. housekeeping, dietary, therapy, etc.). Staff were not able to voice the appropriate procedure if they encountered bleeding from a dialysis site. R19 and R49 did not have a soft clamp present in room to aid in a bleeding emergency. This is evidenced by: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not have sufficient staff with appropriate competencies and skill sets to provide direct nursing and related services to assure resident safety and for each resident to attain or maintain their highest practicable physical, mental, and psychosocial well-being for 1 of 1 resident's (R) reviewed (R253) who have a mental health diagnosis as well as a history of self-harm statements. R253 verbalized suicidal ideation which was not recognized by the facility and was not taken seriously. R253's statement was not documented in his medical record, interventions were not put in place, R253's POA (Power of Attorney) and PCP (Primary Care Physician) were not notified, increased monitoring was not initiated, and R253's care plan was not updated.

Inspectors wroteBased on interview and record review, the facility did not ensure the provision of 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 3 out of 3 supplemental residents (R24, R30, R303). R24 received a full tab of Hydrocodone-Acetaminophen Oral Tablet 5-325 mg (milligrams) instead of a half tab as ordered on 3/8/25, 3/9/25, 3/10/25, 3/12/25, 3/17/25, 3/18/25, 3/20/25, and 3/21/25. R30 received 1 mg of lorazepam instead of the 0.5 mg ordered on 2/1/25. R303 received Hydrocodone-Acetaminophen Oral Tablet 7.5-325 mg instead of the Hydrocodone-Acetaminophen Oral Tablet 5-325 mg as ordered on 4/6/25. Evidenced by: The facility policy, entitled Medication Error and Drug Interactions, dated 8/1/15 with last revision date 2/12/24, states in part: . [...]

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, for 1 of 15 residents (R253) reviewed for infection control. The facility failed to recognize CDC (Centers for Disease Control) guidance that all residents with wounds would meet the criteria for Enhanced Barrier Precautions. This is evidenced by: The facility policy titled Enhanced Barrier Precautions, dated 3/6/24, indicates in part: . Overview: Enhanced Barrier Precautions (EBP) will not only focus on residents with infection or colonization with MDRO's (Multi Drug Resistant Organism) but will also address residents at risk for developing or becoming colonized. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure each resident received adequate supervision to prevent accidents for 1 of 3 sampled residents (R2). R2 is at risk for falls and was left unsupervised in a bathroom, still connected to a mechanical lift, and experienced a fall while unsupervised. R2 was also observed to not have an anti-rollback device installed on his wheelchair as stated in his care plan. This is evidenced by: The facility policy entitled, Sit-to-Stand Mechanical Lift-SNF, dated 8/22/23, states, in part: . Purpose: To assist residents with transfers who are able to bear weight with some assistance. Employees will use the sit to stand mechanical lift per policy to ensure safety for the resident and the employee. Procedure: 1. Sit to stand mechanical lift will be used with two caregivers .8. [...]

Inspectors wroteBased on interview and record review, facility staff did not adequately assess and treat pain and provide necessary care and services to attain or maintain the highest practicable physical well-being for 1 of 1 resident (R1) reviewed for pain. R1 complained of pain during pericare. R1 was observed to wince and cry due to the pain. At no point during this interaction did staff stop care and let R1 take a break, or immediately notify the nurse of R1's pain. Evidenced by: The facility policy, Pain Management and Assessment, revised 4/27/22, indicates in part the following: The purpose of this policy is to develop a standardized method for assessing, monitoring, evaluating, managing, and documenting pain in both cognitively intact and impaired residents. [...]