Edgerton Care Center, Inc

Inspectors wroteBased on interview and record review the facility did not ensure that residents received treatment and care in accordance with professional standards of practice (Wisconsin Nurse Practice Act N6) for 1 of 6 sampled residents (R9) out of a total sample of 16 Residents. R9 had a change of condition that was not assessed properly, communicated to on-coming shifts, nor reported to the resident's medical provider. R9 was sent to the hospital where they remained for 3 days, receiving IV antibiotics. Evidenced by:The Wisconsin Nurse Practice Act states in part .N 6.04 Standards of practice for licensed practical nurses. (1) Performance of acts in basic patient situations. In the performance of acts in basic patient situations, the L.P.N. shall, under the general supervision of an R.N. or the direction of a provider: (a) Accept only patient care delegated acts which the L.P.N. [...]

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 to help prevent the development and transmission of communicable diseases and infections. This has the potential to affect 36 of 36 residents. Infection control concerns:The facility's employee line list is not inclusive and does not document and track employee symptom onset, well date, last day worked, and date may return to work. Surveyor observed NS H (Nursing Scheduler) delivering linens to resident rooms with the cart uncovered. Surveyor also observed boxes of gloves on the same linen cart touching towels, washcloths, chux (washable bed pads), and gowns. As evidenced by:The facility policy, Handling Clean Line, undated, documents in part, as follows: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure written bed holds were completed for 4 of 6 residents (R1, R2, R4 and R19) reviewed for bed holds out of a sample of 16. R1 was transferred to the hospital. The facility did not provide written bed hold notice to R1 and/or R1's resident representative. R2 was transferred to the hospital. The facility did not provide written bed hold notice to R2 and/or R2's resident representative. R4 did not receive a bed hold notice prior to going to the hospital. R19 was sent to the hospital for a change of condition and the facility failed to provide a bed hold.

Inspectors wroteBased on interview and record review, the facility did not ensure their abuse policy was implemented for 1 of 8 employees reviewed for background checks. The facility did not complete the Background Information Disclosure (BID) form, Integrated Background Information System (IBIS) and Department of Justice (DOJ) upon hire and every 4 years thereafter for LPN G (Licensed Practical Nurse).

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 3 of 5 residents (R6, R7, and R27) reviewed for PASARR screening. R6 did not have a level II PASARR screening completed. R7 did not have a level II PASARR screening completed. R27 was admitted with diagnoses that include schizophrenia and anxiety disorder and was prescribed medications to treat the symptoms of schizophrenia and anxiety. No PASARR 1 or PASARR 2 was completed. Evidenced by: The facility policy, Resident Assessment - Coordination with PASARR Program, indicates, in part: Policy: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility for 1 of 2 residents out of a sample of 16 Residents (R40). The facility was not walking R40 in accordance with her plan of care. This is evidenced by: Facility policy titled Restorative Nursing Programs, dated 2025 states, in part: Policy: It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practical level. Policy Explanation and Compliance Guidelines: . 3. Nursing personnel are trained on basic, or maintenance nursing care that does not require the use of qualified therapist or licensed nurse oversight. This training may include but is not limited to: . c. [...]

Inspectors wroteBased on interview, and record review, the facility did not ensure each resident received the necessary respiratory care and services that are in accordance with professional standards of practice for 1 of 1 resident reviewed (R9) out of a total sample of 16. R9 has orders for a BiPAP (a noninvasive ventilatory device that helps patients breathe by delivering two levels of air pressure: higher during inhalation and lower during exhalation) that has not been applied properly and that CNA (Certified Nursing Assistant) staff were not trained to apply, Evidenced by:The facility's policy titled Noninvasive Ventilation (CPAP, BiPAP, AVAPS, Trilogy) no date, states in part .2. The facility will obtain an order for the use of CPAP, BiPAP, AVAPS, or Trilogy device and settings from the practitioner.5. The facility will follow manufacturer's instruction for use of the machine. [...]

Inspectors wroteBased on record review and interview, the facility did not ensure laboratory services were obtained as ordered by the physician for 1 of 3 residents (R19) reviewed for laboratory services out of 16 sampled Residents. R19's laboratory orders were not carried out as ordered. Evidenced by: R19 was admitted to the facility on [DATE] with diagnoses that include alcohol dependence, history of a stroke, toxic encephalopathy, vascular dementia, and adjustment disorder with anxiety. R19 is being seen by a behavioral health Nurse Practitioner (NP). On 6/9/26, the facility had a Quarterly Psychotropic Review. Documentation states in part: Medication.depakote, olanzapine. Target Behavior: 1. Paranoid Behaviors. 2. Agg-Abuse behave (behavior). Paranoia beh- accusatory of theft etc. at home in past. Depakote lab ordered for levels. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide basic life support, including CPR (Cardiopulmonary Resuscitation), to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 of 1 Residents reviewed (R6) this has the potential to affect 25 full code residents that reside in the facility. R6 indicated he wished his code status to be full code. R6 was found to be pulseless and not breathing. Facility staff failed to utilize life-support equipment while providing CPR on R6. Facility staff indicated the facility does not have easily accessible life-support equipment, including a backboard or Ambu bag to provide effective emergency CPR. [...]

Inspectors wroteBased on interview and record review, the facility did not immediately notify and consult with a resident's physician when there was a change in condition. This occurred for 1 of 5 Residents (R3) reviewed for notification of change in condition. On 4/30/26 R3 had no urine output on the NOC (overnight) shift. The facility did not notify the provider of the change of conditionThis is evidenced by:The facility's policy, titled Change of Condition Process, undated, states in part: Unit Nurse Expectations: The unit nurse will identify/assess for changes of condition. All nurses will update the provider and POA (Power of Attorney) immediately of change in condition. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that each resident receives treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 out of 3 total sampled Residents (R1). R1 experienced a change of condition following onset of nasal congestion and a productive cough. R1 was not assessed by a RN (Registered Nurse) prior to being hospitalization for 2 weeks. This is evidenced by:The facility's policy, Change of Condition Process, undated, documents in part, as follows: Unit Nurse Expectations: The unit nurse will identify/assess for changes of condition. All nurses will update the provider and POA (Power of Attorney) immediately of change in condition. The nurse will document the assessment, what the interventions are including any new orders. [...]

Inspectors wroteBased on interview and record review, the facility did not provide evidence that MAs (Medication Aide) had 4 hours of medication based in-service training per year for 1 of 1 MA reviewed for in-service training. MA CC did not have documentation of 4 hours of medication based in-service. Evidenced by:The facility's Continuing Education policy, dated 2/9/26, states, in part: . 1. All levels of employees are expected to complete required trainings within designated time frames. MA CC has a hire date of 8/14/13. MA CC education record for 2025 indicates 2.5 hours of medication related in-service, including:*Medication Administration Pass 1 contact hours*Medication Administration: Antibiotics 0.5 contact hours*Medication Administration: [...]

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 4 residents (R1) reviewed for falls. R1 had a history of falls including one that resulted in multiple rib fractures. The facility did not complete a thorough root cause analysis on the falls or ensure that care planned interventions were in place for R1. As evidenced by:Facility policy, titled Falls - Clinical Protocol, with last revision date of March 2018, states, in part: Assessment and Recognition: 1. The physician will help identify individuals with a history of falls and risk factors for falling. c. While many falls are isolated individual incidents, a few individuals fall repeatedly. Those individuals often have an identifiable underlying cause. 2. In addition, the nurse shall assess and document/report the following: . c. [...]

Inspectors wroteBased on interview and record review, the facility did not always ensure that they implemented written procedures for screening agency staff prior to working with residents at the facility. This has the potential to affect all 51 residents residing with in the facility. On 3/4/26, the facility became aware that an agency Certified Nursing Assistant (CNA S), who had worked 12 previous shifts on various units/floors was working under a false identification as CNA T. The facility did not put new processes in place related to verifying identification of the agency staff prior to orientation and their first scheduled shift. This gave CNA S the continued ability to obtain work while posing as CNA T. This has the potential to affect the safety of all 51 residents of the facility. This is evidenced by:Policy Review: [...]

Inspectors wroteBased on observation and interview, the facility did not dispose of garbage and refuse properly. This has the potential to affect all 54 residents. The facility did not ensure that lids on the dumpster were shut and secured to prevent pests. This is evidenced by: The facility policy titled, Sanitization, states in part: . 14. Garbage and refuse containers are in good condition, without leaks, and waste is properly contained in dumpsters with lids. On 3/26/26 at 10:25 AM Surveyor observed one lid open on recycling dumpster, and one lid open on regular trash dumpster. On 3/26/26 at 11:10 AM Surveyor interviewed DM V (Dietary Manager). Surveyor asked DM V if she knew why the dumpster lids would be open. DM V stated that sometimes the wind will catch them or when the truck comes to dump the trash the lid will remain open. Surveyor asked DM V what days they pick up trash. [...]

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 grooming and personal hygiene for 6 (R6, R7, R8, R9, R10, R11) of 12 residents reviewed for Activities of Daily Living (ADLs). R6, R7, R8, R9, R10, and R11 expressed long call light wait times. Facility documentation shows residents waited an hour or more for ADL care when prompted with their call lights.

Inspectors wroteBased on interview and record review, the facility did not ensure that each resident was free from abuse from another Resident for 1 of 11 residents (R5) reviewed for abuse. R12 had witnessed R1 slap R5 when both R1 and R5's wheelchairs got hung up on each other. R12 reported the incident to staff immediately. R1 has a history of aggressive behaviors towards staff and other residents. R1 has had another known altercation with R12 in the past. Evidenced by:The facility policy entitled Abuse, Neglect and Exploitation, dated 2025, states, in part: . Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. III. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, are reported immediately to the administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law though established procedures for 3 of 3 incidents involving 3 residents (R1, R5 & R6) reviewed for abuse. The facility became aware of a resident-to-resident altercation between R1 and R5 on 2/16/26. The facility failed to do an investigation and report to the state if indicated. Facility did not report a suspicion of a crime when they became aware of a staffing agency CNA (Certified Nursing Assistant) working under false identification. A staff member was alleged to have abused R6, and the facility did not report it to the State Agency. Evidenced by: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that in response to allegations of abuse, neglect, exploitation, or mistreatment, that all alleged violations are thoroughly investigated, and that steps were taken to prevent further abuse for 2 of 3 residents (R1) reviewed. The facility became aware of a resident-to-resident altercation between R1 and R5 on 2/16/26. The facility failed to do a thorough investigation and put interventions into place to prevent future occurrences. Evidenced by:The facility policy entitled Abuse, Neglect and Exploitation, dated 2025, states, in part: . Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. [...]

Inspectors wroteBased on interview and record review, the facility did not complete a performance review of every nurse aide at least once every 12 months for 2 of 5 Certified Nursing Assistants (CNA) reviewed. CNA U did not have an annual performance review. CNA H did not have an annual performance review. Evidenced by:The facility's Performance Evaluations policy, dated 9/2020, states, in part: The job performance of each employee shall be reviewed and evaluated at least annually. 1. A performance evaluation will be completed on each employee at the conclusion of his/her 90-day probationary period, and at least annually thereafter. CNA U was hired 1/28/15. CNA U did not have an annual performance evaluation completed for 2025. CNA H was hired 8/21/19. CNA H did not have an annual performance evaluation completed for 2025. On 3/26/26 at 2:31 PM, Surveyor interviewed CNA H about performance evaluations. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that 1 of 3 Residents (R2) were free from significant medication errors. R2's medication was given late per documentation from 1/14/26 to 2/15/26. Findings Include: A policy titled Administering Medications Revised April 2019 documented:Medications are administered in a safe and timely manner, and as prescribed. Policy interpretation and implementation. Medications are administered in accordance with prescriber orders, including any required time frame. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include:enhancing optimal therapeutic effect of the medication;preventing potential medication or food interactions; andhonoring resident choices and preferences, consistent with his or her care plan. [...]

Inspectors wroteBased on interview and record review, the facility did not assure that the Feeding Assistant Program included annual training and skills review for 2 of 4 feeding assistants reviewed. The facility did not provide annual training or skills monitoring, per state regulations for two Feeding Assistants. This is evidenced by:Wisconsin's State requirements for Feeding Assistants, specified in 42 CFR 483.60(h), includes, in part: . Feeding Assistants must receive an annual in-service on relevant feeding assistant topics (any topic area included in the curriculum is appropriate). [...]

Inspectors wroteBased on record review, interview, and admission packet review, the facility failed to refund a resident's money within 30 days of discharge for one of three residents (Resident (R) 1) reviewed for refunds of eight sample residents. This failure could potentially cause financial hardship for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) for 4 of 17 sampled residents (R6, R2, R24, and R16). R6 and R16 are being cited at severity level 3 (actual harm). R2 and R24 are being cited at severity level 2 (potential for more than minimal harm). R6 has diagnoses of neurogenic bowel (loss of normal bowel function) and constipation. The facility failed to accurately assess and monitor R6 for constipation, decreased fluid intake and output as well as changes in R6's mental status, resulting in frequent visits to the emergency department. The facility failed to notify R6's primary care physician of his level of inadequate fluid intake and significant increases in urine output. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not distribute and serve food in accordance with professional standards for food service safety. This has the potential to affect all 45 residents. Facility staff were observed touching multiple items in the kitchenette while serving and handling food without changing gloves or performing proper hand hygiene. Cook D was observed dishing up lunch from the steam table with gloves on, stepping away from the steam table, touching other surfaces in the kitchenette, returning to the steam table for meal plating and touching ready to eat foods while wearing the same pair of gloves. Surveyor observed visible build on and debris in two ovens. Surveyor observed a visible white substance on inside and outside of a steam kettle. Surveyor observed a visible white substance on the outside of an ice machine. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse to the appropriate agencies for 5 of 5 allegations involving residents (R46, R146, R6, and R3) and 2 of 3 supplemental residents (R18, R19) and failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime. During a NOC (night) shift on 11/28/24 to 11/29/24, CNA H (Certified Nursing Assistant) heard R46 calling for help. CNA H (Certified Nursing Assistant) observed R46 to be bright red and shaking with fresh blood on his right forearm (from a skin tear) and bedding. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that in response to allegations of abuse, neglect, exploitation, or mistreatment, all alleged violations were thoroughly investigated for 3 of 3 sampled residents (R3, R6, R46) and 2 of 3 supplemental residents (R19, R18) reviewed for abuse investigations. On 10/8/24 the facility became aware that R18 had been left in her wheelchair all night without being changed or assisted to bed. The facility completed a grievance form but did not complete a thorough investigation. On 12/15/24 the facility became aware that R19 had her call light on all night, but that staff had shut her door and not assisted her to get changed from her wet brief. The facility completed a grievance form but did not complete a thorough investigation. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a copy of a resident's advance directive was included in the resident's medical record, for 3 of 17 sampled residents (R25, R33, and R146) reviewed for advance directives. The facility did not have advanced directives on file in R25, R33, or R146's medical record. Evidenced by: The facility policy, entitled Advance Directives, dated 2001 with a Revision Date of [DATE], states, in part: . Policy Statement: The resident has the right to formulate an advance directive . Advance directives are honored in accordance with state law and facility policy . Definitions: 1.b. Advance Directive - a written instruction, such as a living will or durable power of attorney for health care, recognized by state law . relating to the provisions of health care when the individual is incapacitated . [...]

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 2 of 17 residents reviewed for grievances (R28 and R6). R28 voiced a grievance to the facility and the facility did not complete appropriate interviews, audits, education, or provide follow up with R28 after the conclusion of the investigation. R6 and his family voiced grievances to the facility. The facility did not complete appropriate interviews, audits, education, or provide follow up with R6 or his family after the conclusion of the investigation. Evidenced by: Surveyor requested a Grievance Policy from the facility; however, one was not provided. Example 1: R28 was admitted to the facility on [DATE], with diagnosis that include, in part: [...]

Inspectors wroteBased on interview and record review, the facility failed to protect a Residents right to be free from physical abuse by a CNA (Certified Nursing Assistant) and LPN (Licensed Practical Nurse) for 1 of 17 residents (R46). During a NOC (night) shift CNA H (Certified Nursing Assistant) heard R46 calling for help. CNA H (Certified Nursing Assistant) observed R46 to be bright red and shaking with fresh blood on his right forearm (from a skin tear) and bedding. CNA H also observed fresh blood on R46's sheets. R46 stated, CNA F (Certified Nursing Assistant) and LPN G (Licensed Practical Nurse), both agency staff, wouldn't let him get up and held his hands down. The police officer documents, he observed significant bruising to R46's right hand and thumb print bruise to his left hand. As evidenced by The State Operations Manual under F600 states in part; [...]

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 2 residents reviewed for restraints (R146). R146 was observed in an power lift recliner with the remote not in reach and thus restricting R146's movement. Evidenced by: The facility policy, Use of Restraints, revision date, April 2017, indicates, in part: Policy Statement: Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls . Policy Interpretation and Implementation: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure each resident received adequate supervision to prevent accidents for 2 of 5 resident (R24 and R2) reviewed. R24 was observed not disposing of cigarette materials properly and not returning materials to staff after returning from smoking. R2 has had eight falls from 1/6/25 - 3/13/25 and has several care planned interventions including Dycem (a non-slip product that grips on both sides placed in a resident's wheelchair to prevent sliding out), gripper socks to be on resident's feet when out of bed, gripper strips on the floor, a mat on the floor by the bed, and shoes to be kept in the wheelchair at bedside when resident was in bed. The facility did not ensure these interventions were in place to prevent R2 from having further falls. Example 1: [...]

Inspectors wroteBased on interview and record review the facility did not ensure that a resident who enters the facility with an indwelling catheter receives appropriate treatment and services 1 of 1 residents (R28) reviewed for indwelling catheters. R28 has an indwelling catheter, and has no physician order for the catheter, including its size and replacement schedule. This is evidenced by: The facility policy, entitled: Catheter Care, Urinary, dated 10/2022, states, in part: .Catheter Evaluation 1. Review and document the clinical indications for catheter use prior to inserting. 2. Nursing and the interdisciplinary team should assess and document the ongoing need for a catheter that is in place . The facility policy, entitled: Medication Orders, dated 11/2014, states, in part: . Supervision by a Physician . 2. A current list of orders must be maintained in the clinical record for each resident . [...]

Inspectors wroteBased on observation, 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 (R10) of 2 residents reviewed for pain management. The facility failed to adequately assess and treat R10's pain while providing wound care, causing R10 to feel pain throughout the dressing change. This is evidenced by: The facility policy entitled, Pain Assessment and Management, dated 10/2022, states, in part: . 2. Pain Management is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals. 3. Pain management is a multidisciplinary care process that includes the following: . b. Recognizing the presence of pain; . f. Identifying and using specific strategies for different levels and sources of pain; [...]

Inspectors wroteBased 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 for 1 of 17 sampled Residents (R15) and 1 of 1 test trays. R15 voiced a concern about hot foods being served cold. Surveyor received a breakfast test tray and the food temperatures were not palatable. Evidenced by: The undated facility policy, Food Temperatures, indicates, in part: Policy: Food temperatures shall be tested & recorded prior to meal service by food service employee. Purpose: To ensure that food is held at safe temperatures to prevent food borne illness and to ensure palatable food temperatures . On 3/25/25 at 2:00 PM, Surveyors interviewed R15 as part of the initial screening process. R15 indicated that the scrambled eggs and vegetables are sometimes cold. [...]

Inspectors wroteBased on interview and record review, the facility failed to immediately consult with a physician when needed to alter treatment for 1 resident (R2) of 4 sampled residents. During a transfer with the EZ stand, the strap/belt to the EZ stand hit R2 in the left eye causing discomfort. Physician was not notified immediately. Facility did not investigate this incident. Evidenced by: The facility policy, entitled Notification of Changes Policy, undated, states, in part: PURPOSE: The facility shall promptly notify the resident and/or the resident representative and his or her physician or delegate of changes in the resident's condition or status in order to obtain orders for appropriate treatment and monitoring and promote the resident's right to make choices about treatment and care preferences. PROCEDURE: 1. [...]

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 1 out of 4 sampled residents (R2). R2 did not receive his Tobramycin-dexamethasone eye drops as scheduled on 5/16/24, 5/17/24, and 5/18/24. R2 did not receive his Maxitrol eye drops as scheduled on 5/18/24 and on 5/19/24. Evidenced by: The facility policy, entitled Medication Pass Protocol, dated 01/2018 states in part . 9. Check all medications against the MAR (medication administration record) prior to administration. 10. Ensure medications that are being administered have a physician's order, medications are administered as ordered . 11. Sign out all medications immediately after administration. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not implement its policy and procedure to prevent abuse, neglect, and mistreatment of residents which had a potential to affect all 13 residents on the unit. The facility did not implement its policy and procedures to safeguard residents by removing CNA D (Certified Nursing Assistant) from patient care when R2 accused CNA D of sexual abuse on 4/20/24. This is evidenced by: The Facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program Policy, revised April 2021, documents in part: Policy Statement -- Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure all alleged violations involving mistreatment, neglect, or abuse were reported to the state agency and other officials, and that the residents were protected during the facilities investigation for 1 of 3 abuse investigations reviewed (R2) of a total sample of 3. On 4/20/24 the facility became aware of an allegation by R2 that a Certified Nursing Assistant (CNA) had touched her breasts. This allegation of abuse was not reported to the state agency and other officials and the facility failed to protect other residents during the investigation. This is evidenced by: The Facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program Policy, revised April 2021, documents in part: [...]

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate an accusation of sexual abuse for 1 of 3 residents (R2) reviewed for abuse. On 4/20/24, the facility became aware of a sexual abuse allegation involving R2 and a thorough investigation was not completed. This is evidenced by: The Facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program Policy, revised April 2021, documents in part: Policy Statement -- Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not implement professional standards of practice to promote healing or prevent pressure injury (PI) development for 1 of 3 residents reviewed for PIs out of a sample of 3 residents (R1). R1 is care planned to be repositioned every two to four hours and facility documentation shows R1 was not being repositioned every two to four hours. Evidenced by: The facility policy, entitled Repositioning, dated 2013, states, in part: . Purpose: The purpose of this procedure is to provide guidelines for the evaluation of resident repositioning needs, to aid in the development of an individualized care plan for repositioning, to promote comfort for all bed- or chair- bound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents. Preparation: 1. [...]

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 40 residents. Cook Q did not allow the thermometer to air dry after sanitizing and before temping resident food. Surveyor observed [NAME] L's personal lunch to be stored in the facility's walk-in refrigerator with resident food. Surveyor observed undated and unmarked food in the unit refrigerator. Surveyor observed facility's mixer to be stored with food particles on it. Surveyor observed facility's ice machine to have a black and a white build up on the piping and the top inside of the ice cube storage compartment. Surveyor observed two (2) dented cans in circulation. Evidenced by: [...]

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 failed to identify a COVID-19 outbreak when DA R (Dietary Aide) tested positive for COVID-19. The facility failed to test and/or exclude staff (Driver S and Housekeeping T) when they were displaying symptoms consistent with COVID-19. This is evidenced by: The facility policy titled COVID-19 Policy, dated September 2023, indicates in part: .Facility staff, regardless of vaccination status, must report any of the following criteria to point of contact designated by the facility so they can be properly managed: [...]

Inspectors wroteBased on interview and record review, the facility the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, are reported immediately to the administrator of the facility and to other officials (including State Survey Agency in accordance with State law though established procedures for 4 of 5 abuse investigations (R21, R31, R17, R45) reviewed of a total sample of 17 residents. R21 had a resident-to-resident incident that was neither reported to NHA A (Nursing Home Administrator) nor the State Agency. R31 had a resident-to-resident incident that was neither reported to the NHA A nor the State Agency. R17 did not have the initial report submitted for a self-report the facility reported. On 12/4/23, the facility became aware of an allegation that R45 felt staff was rough when putting her into bed. [...]

Inspectors wroteBased on interview and record review the facility did not ensure that a resident that is unable to carry out activities of daily living (ADL's) receives the necessary services to maintain personal hygiene for 4 of 6 reviewed for ADL's (R17, R21, R31, R23) of a core sample 12 residents. R17 is not receiving showers per schedule. R21 is not receiving showers per schedule. R31 is not receiving showers per schedule. R23 admitted to the facility on [DATE] and did not receive shower until 1/25/24. R23 went 7 weeks without a shower or bath. This is evidenced by: On 3/27/24 at 11:42 AM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor asked NHA A for a Policy and Procedure for showers, NHA A stated they don't have a Policy and Procedure for showers. [...]

Inspectors wroteBased on observation, interview and policy review the facility did not ensure that each resident was treated with dignity and respect for 1 of 17 sampled residents (R347). R347 expressed concerns regarding LPN U (Licensed Practical Nurse) because he does not explain anything to her and LPN U does not knock on R347's door before entering. As evidenced by: The facility's policy. Resident Rights, revised 2/2021, states, in part, as follows: Copies of our resident rights are posted throughout the facility, and a copy is provided to each employee, provider and contracted staff member. In addition, staff will have appropriate in-service training on resident rights prior to having direct- care responsibilities for residents. Orientation and in- service training programs are conducted quarterly to assist our employees in understanding our resident's rights. [...]

Inspectors wroteBased on observation and interview, the facility did not ensure prompt resolution of all grievances for 1 of 14 residents reviewed for grievances (R47). Resident Representative N and Resident Representative O indicated they voiced concerns regarding R47's care and stay to facility staff and the facility did not provide any feedback to them about their concerns. Evidenced by: The facility policy, entitled Grievances/Concerns/Complaints, undated, includes It is the policy of the facility that each resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. [...]

Inspectors wroteBased on interview and record review the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, are thoroughly investigated for 2 of 5 abuse investigations (R21, R31) reviewed of a total sample of 17 residents. R21 had a resident-to-resident incident that was not investigated. R31 had a resident-to-resident incident that was not investigated. This is evidenced by: The facility's policy and procedure entitled Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated April 2021 documents the following, in part: .1. Protect residents from abuse, neglect, exploitation, or misappropriation of property by anyone including, by not necessarily limited to a. facility staff; b. other residents .8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. 9. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not implement professional standards of practice to promote healing or prevent pressure injury (PI) development for 2 of 3 residents reviewed for PIs out of a sample of 17 residents (R16 and R47). R16 was admitted to facility on 9/28/23 with an unstageable pressure injury (PI) to left lateral foot. R16 did not receive a treatment for PI until 10/5/23. R16's PI was not assessed with measurements or wound description until 10/5/23. R47 is at risk for pressure injury development and Surveyor observed R47 to be sitting in his recliner without a pressure reducing cushion underneath him. Evidenced by: The facility policy entitled Wound Care, with a revision date of October 2010, states, in part: . Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing . Documentation: [...]

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 2 resident (R23 and R1 reviewed for supervision and accidents out of a total sample of 17. R23 had 4 falls from admission on [DATE]. The facility did not identify root/cause for falls or implement interventions to prevent falls for R23. R1 has a history of putting non-food items in her mouth R1's comprehensive care plan does not address the need for supervision or placing non-food items in her mouth. Evidenced by: The facility policy entitled Falls, with a revision date of 3/2018, 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 . Treatment/Management- 1. [...]

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 2 of 5 residents (R37 and R41) reviewed for influenza immunizations. R37's medical record did not show evidence of a declination, consent, or administration for the 2023 to 2024 seasonal influenza vaccine. R41's medical record did not show evidence of a declination, consent, or administration for the 2023 to 2024 seasonal influenza vaccine. This evidenced by: The facility policy, titled Influenza Vaccine, revised August 2023, indicates, in part: Policy Statement: [...]

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure they transcribed physicians' orders for surgical wound care, which resulted in staff not administering treatment as ordered for 1 (Resident #1) of 3 residents sampled for wound care.