Heritage Lakeside

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that each resident receives treatment and care in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) for 1 of 12 residents (R) reviewed (R46.) Beginning 03/03/26, R46 presented with a change of condition including shortness of breath, difficulty breathing, and continuous use of a Continuous Positive Airway Pressure (CPAP) machine. The facility failed to assess R46 with the change in condition, failed to notify the provider of R46's change in condition, failed to complete respiratory assessments as per provider order, and failed to implement new care plan interventions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare and distribute food under sanitary conditions. This has the ability to affect all 38 of the facility's residents. Staff were observed to not complete hand hygiene during food preparation and service or maintain sanitary storage. Food was not labeled with identifying information. Open food is not labeled with open or use by dates and no manufacturer's label with use by date. Food was not stored in refrigerator with a cover. A scoop was found in food container, increasing food's risk for contamination. Safe food temperatures for food service were not ensured. Food was not cooled in a way to prevent contamination. Staff washing dishes contaminated their uniform with dirty water sprayed off dishes and then returned to the duty of food preparation and service with the same uniform, no barrier. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 resident (R) (R6) of 5 residents reviewed had documentation the resident and/or legal representative had been informed in advance of the risks and benefits of prescribed psychotropic medications. R6 was prescribed Escitalopram Oxalate (a psychotropic medication). The facility did not obtain written consent from R6 or R6's legal representative.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's (R) R20) right to be free from verbal abuse by staff for 1 out of 2 residents reviewed. R20 reported Registered Nurse (RN) V grabbed R20's arm. RN V yelled at R20 and stood in front of R20's wheelchair stopping him, as he attempted to get away from RN V.

Inspectors wroteBased on record review and interviews, the facility did not ensure that an alleged violation involving abuse by a resident (R20) was reported immediately to the Nursing Home Administrator (NHA) and to the State Survey and Certification Agency. An incident which R20 reported Registered Nurse (RN) V grabbed R20's arm, yelled at R20, and stood in front of R20's wheelchair stopping him as he attempted to get away from RN V, was reported to on call Nurse Manager, who did not report it to the NHA and thus the facility did not report the abuse to the State Survey and Certification Agency.

Inspectors wroteBased on interview and record review, the facility did not ensure the prevention of further potential abuse from occurring while an investigation was in progress for 1 out of 2 residents (R) investigated for abuse (R20). Facility did not protect R20 when allowing Registered Nurse (RN) V to continue to work with R20 when accused of verbal and physical abuse.

Inspectors wroteBased on interview and record review, the facility did not ensure 3 residents/resident representative (R) (R6, R46, and R48) of 5 residents reviewed for hospitalization received the proper notice of transfer, reason for transfer, and bed hold notice.-Facility did not have a specific reason on the transfer notice for R6, R46, and R48.-Facility did not provide R6 and R46 a bed hold notice.-Facility did not notify the ombudsman of R6 and R46's transfers to the hospital. Per the Long-Term Care State Operations Manual (SOM), dated 7-23-25, regulation 483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must- (i) notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. 483.15(c)(5) Content of Notice. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not provide care consistent with professional standards of practice to promote the healing of existing pressure injuries (including prevention of infection to the extent possible) and prevent development of additional pressure injuries for 1 resident (R26) of 5 residents reviewed for pressure injuries in a sample of 12 residentsThe facility did not provide repositioning at a minimum of every 2 hours for R26, or document refusals by R26 to be repositioned at a minimum of every 2 hours, which potentially led to development and exacerbation of a pressure injury to R26's coccyx/sacral (lower back/tailbone) area.

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 and to help prevent the development and transmission of communicable diseases and infections. Licensed Practical Nurse (LPN) F, LPN G and Registered Nurse (RN) H did not perform hand hygiene prior to administering medication. This affected 5 out of 5 residents (R) (R6, R34, R20, R19, R2). LPN F did not wipe off blood pressure cuff and machine prior to RN H taking and using with another resident (R33). This was evidenced by:On 3/24/26, Nursing Home Administrator (NHA) A stated that Surveyor had all the policies related to hand hygiene. Policy received is specifically related to food preparation. [...]

Inspectors wroteBased on interview, record review, and facility document review and policy review, the facility failed to submit an initial report of an allegation of misappropriation to the state survey agency within 24 hours and failed to notify law enforcement for 1 (Resident #1) of 4 residents reviewed for misappropriation. Specifically, the facility failed to report an allegation of a missing wallet and identification cards for Resident #1 to the state agency within the required time for reporting and failed to notify the law enforcement of the allegation.

Inspectors wroteBased on interview, record review, and facility document and policy review, the facility failed to complete a thorough investigation for 1 (Resident #1) of 4 residents sampled for allegations of misappropriation. Specifically, the facility failed to conduct interviews and/or obtain statements from staff regarding Resident #1's missing wallet and identification cards.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure care plans met medical needs and included preferences for 1 of 3 residents (R) reviewed. R1 had a fall out of wheelchair and there was no intervention added. R1 was sitting on multiple items in the wheelchair per preference that was not noted in the care plan. CAM boot was ordered from the doctor on 09/26/25 and was not added to the care plan.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure resident's environment was free from accidental hazards to prevent accidents for 1 of 3 residents reviewed. R1 was sitting on multiple items in a wheelchair, which contributed to R1 falling off the wheelchair seat during transport.

Inspectors wroteThe facility did not ensure licensed nurses had the specific competencies and skill sets necessary to care for residents' needs, which had the potential to affect all 42 residents. -Licensed Practical Nurse (LPN) G performed a venous blood draw from R1's foot without evidence of training. -The facility did not have a system in place to evaluate licensed nurse competencies.

Inspectors wroteBased on interview and record review, the facility did not develop and implement a person-centered care plan for each resident consistent with resident rights including services to attain or maintain the resident's highest or practicable physical, mental or psychosocial needs for 2 of 4 residents reviewed (R3 and R4). R3 and R4 did not have a care plan for an anticoagulant or risk for bleeding.

Inspectors wroteBased on observations, interviews and record review, the facility failed to protect the residents' right to be free from sexual abuse. The facility did not implement interventions to protect other residents (R) from exposure of R3's genital area. This affected 2 of 3 residents reviewed for sexual abuse. (R1 and R2) On 03/21/25, R3 exposed his penis in proximity to R1 and R2 in the west dining room. No new interventions were implemented and the previous intervention of placing a blanket on R3's lap was not effective.

Inspectors wroteBased on observation, interview and policy review, the facility did not ensure they stored, prepared, distributed, and served food in accordance with professional standards for food policy safety. The facility failed to label and date perishable items found in the refrigerator. This has the potential to affect all 33 of 33 residents residing in the facility.

Inspectors wroteBased on observations and record review, the facility did not ensure drugs and biologicals were stored in accordance with currently accepted professional practice. This had the potential to affect 7 out of 7 residents (R) (R2, R14, R17, R20, R32, R33, R136) for proper storage and 1 of 1 resident (R) (R18) for proper labeling. 16 new unopened insulin pens and one bottle of Humalog were found in an out of temperature range refrigerator. R18 did not have an accurate label for insulin.

Inspectors wroteBased on observation, record review and interview, the facility did not ensure 1 resident (R) of 12 sampled residents (R21) was reasonably accommodated for personal needs. R21's room is set up so that he cannot access or use his sink. This is evidenced by: R21 was admitted to the facility on [DATE] and has diagnoses that include but are not limited to: Parkinson's disease with dyskinesia, with fluctuations; difficulty in walking, not elsewhere classified. R21's Minimum Data Set (MDS) assessment, dated 11/19/24, indicated that R21 uses a wheelchair and a 4 wheel walker for mobility. R21's care plan, dated 11/26/24, states: ADL: The resident has an ADL self-care performance deficit r/t Parkinson's disease, weakness, encephalopathy. Ambulation: [...]

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 (ADLs) receive the necessary services to maintain safety and personal hygiene (hand hygiene) for 1 out 4 residents (R). R21 does not receive hand hygiene services after toileting or when in his room. This is evidenced by: The policy, titled Handwashing/Hand Hygiene, dated August 2019, states, This facility considers hand hygiene the primary means to prevent the spread of infections. R21 was admitted to the facility on [DATE] and has diagnoses that include but are not limited to: Parkinson's disease with dyskinesia, with fluctuations; non-Alzheimer's dementia; needs assistance with personal care; weakness; difficulty in walking, not elsewhere classified. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. The facility did not implement orders received for a resident with a foot wound upon reception of the order. Resident (R) 137 did not see a decline with the wound. This has the potential to effect 1 of 3 residents investigated for wound care.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure the residents' safety through adequate supervision or use of safety devices in 2 of 4 residents, (R)21 and R30. Staff did not use a gait belt when transferring R21, and R21 was left unsupervised during cares. R30 had a recent fall with the new intervention to prevent falls not updated on the care plan. This is evidenced by: Example 1 The policy, titled Policy NO: 007-004 Subject: Gait Belts, dated April 2023, states, It is the policy to require the use of transfer belts for resident transfer and walks as indicated in the resident's plan of care or as needed to ensure resident's safety. R21 was admitted to the facility on [DATE] and has diagnoses that include but are not limited to: Parkinson's disease with dyskinesia, with fluctuations; encephalopathy, unspecified; non-Alzheimer's dementia; [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. The facility was not able to produce a reason to have Resident (R) 24's catheter changed on a monthly basis. This had the potential to affect 1 of 1 resident observed for catheter care (R24).

Inspectors wroteBased on interview and record review, the facility failed to ensure that services for a resident who needs respiratory care, is provided such care, consistent with professional standards of practice, for 1 of 1 residents (R) R18 reviewed for respiratory assessment related to medication administration. R18 was administered a nebulizer treatment without a lung assessment completed prior to and after treatment.

Inspectors wroteBased on record review and interview, the facility did not ensure 1 of 1 resident ((R)27) who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. This is evidenced by: R27 was admitted to the facility on [DATE] with current diagnoses of protein-calorie malnutrition, difficulty walking, attention deficit hyperactivity disorder (ADHD), post-traumatic stress disorder (PTSD), and major depression. Minimum Data Set (MDS) dated [DATE] a quarterly assessment documented R27's Brief Interview of Mental Status score of 11, indicating moderate cognitive impairment. R27's depression screen PHQ -9 score of 12, indicating moderate depression severity. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to have a policy identifying those circumstances when loss or damage of dentures is the facility's responsibility. This has the potential to affect all 33 residents residing in the facility. The facility failed to promptly, within 3 days, refer residents with lost or damaged dentures for dental services for 1 of 1 (R5) resident reviewed for missing dentures. R5's partial upper denture was lost on 11/01/24. They were not replaced and dental services were not provided after dentures were missing.

Inspectors wroteBased on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections for 2 out of 4 residents (R18, R22) during care observations. Staff did not complete hand hygiene during personal cares for 1 of 4 residents (R18) during personal cares. Staff did not disinfect reusable medical equipment after use with R18. R22 did not have enhanced barrier precautions (EBP) in place.

Inspectors wroteBased on policy review and interview, the facility failed to ensure facility's admission packet did not request or require residents to waive potential facility liability for losses of personal property. This failure had the potential to affect all 33 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility did not ensure they notified the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. All residents investigated for hospitalizations did not receive a notice of transfer. Four of four residents (R) investigated (R21, R22, R24, R20) did not receive notice of transfer.

Inspectors wroteBased on observation, interview and record review, the facility did not post the required daily information correctly. The facility did not ensure to include the resident census and facility name on all daily postings in the last 30 days. This has the ability to affect all 33 of 33 residents.

Inspectors wroteBased on interview and record review, the facility failed to report to the State Agency, an allegation of abuse immediately but not later than 2 hours after the allegation was made. This occurred for 1 of 1 resident (R1). R1's family member reported an allegation of staff bending R1's fingers back to cause pain to try and get R1 to stand up. The facility did not report this allegation of abuse to the State Agency.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice (N6 Wisconsin Nurse Practice Act), the comprehensive person-centered care plan, and the resident's choice for 1 of 13 sampled residents (R1). R1 had a change in condition; staff did not complete comprehensive neurological assessments or have a Registered Nurse assess R1 as the change of condition continued. R1 was sent to the emergency room several hours later and had suffered a stroke, and as a result was put on hospice services. The facility's failure to assess R1 and provide appropriate treatment for stroke symptoms created a finding of immediate jeopardy that began on [DATE]. Surveyor notified Nursing Home Administrator of the immediate jeopardy on [DATE] at 11:55 a.m. The immediate jeopardy was removed on [DATE]; [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents received adequate fluid and food intake to maintain acceptable parameters of hydration and nutrition for 3 of 3 residents (R) (R2, R1, R19). R2 was admitted to the facility on [DATE]. R2 was sent to hospital on [DATE] and returned on 03/23/24 with diagnosis of failure to thrive and laboratory results of elevated blood urea nitrogen (BUN) and creatinine indicating dehydration. R2 was hospitalized on [DATE] with elevated BUN, creatinine, and albumin levels, resulting in R2 being transferred to another critical care hospital and expiring on 05/27/24. The facility failed to ensure R2 received adequate fluid intakes to maintain acceptable parameters of hydration to include the following: * failure to assess daily fluid intake; [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents with pressure injuries received necessary treatment and services to promote healing and prevent infection, and did not ensure residents received care and treatment to prevent development of pressure injuries. This occurred for 2 of 5 residents (R) reviewed for pressure injuries. (R1 and R11). R1 did not have a care plan with interventions in place to prevent a pressure injury and developed a deep tissue injury on the left heel, causing actual harm. R1 was not repositioned to prevent the development of pressure injuries. R11 did not have weekly assessments documented for a stage 4 pressure injury. Example 1: According to the National Pressure Injury Advisory Panel (NPIAP) Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline, 2019: [...]

Inspectors wroteBased on record review and interviews, the facility did not ensure 2 out of 5 Certified Nursing Assistants (CNA), (CNA BB, CNA DD), employed at the facility for more than one year received a minimum of 12 hours of in-service training each year. This has the potential to affect all 43 residents in the facility. This is evidenced by: On 09/23/24, Surveyor requested in-service training hours for CNA BB and CNA DD for review. CNA BB's date of hire is 09/16/22, and the facility did not provide 12 hours of in-service training, which included communication, behavioral health, and dementia care. CNA DD's date of hire is 12/22/15, and the facility did not provide 12 hours of in-service training, including communication, behavioral health, and dementia care. CNA BB and CNA DD have the potential to work with all residents in the facility. [...]

Inspectors wroteBased on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. The facility did not ensure staff used proper hand hygiene when distributing food. This has the ability to affect 5 of 43 residents (R11, R14, R15, R16, R17) residing in the facility. Findings Include: The facility policy, entitled, Food Preparation and Service, dated April 2019, states, Bare hand contact with food is prohibited. Gloves are worn when handling food directly and changed between tasks. Disposable gloves are single use items and are discarded after each use. On 09/16/24 at 11:52 AM, Surveyor observed the serving of food by Dietary Aide (DA) S. DA S was touching the meal tickets which were not a cleanable surface and then touching ready to eat foods. [...]

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. Staff did not sanitize the mechanical lift after use in another resident room, prior to using it for resident (R)11. Staff did not perform hand hygiene with glove changes during incontinent cares for R11 and R1 Staff did not wear proper personal protective equipment (PPE) when entering a resident room (R9) labeled Droplet Precautions. Staff did not wear gloves when obtaining a blood sample for blood glucose monitoring for R11. Staff did not wear proper personal protective equipment for enhanced barrier precautions when providing care for R18 and R3.

Inspectors wroteBased on interview and record review, the facility did not promptly notify and consult with a resident's physician when there was deterioration in a resident's clinical condition. R12 presented with symptoms of low blood pressure. R12's physician was not notified for all low blood pressure occurrences as was instructed by orders. This occurred for 1 of 4 residents (R12), reviewed for change in condition.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure 1 (R1) of 13 residents was provided privacy during personal cares. *Surveyor observed staff leave the window drapes and privacy curtain open while providing cares to R1. *Surveyor observed R1's breasts exposed from hallway.

Inspectors wroteBased on observation, record review and interviews, the facility did not ensure that 1 of 7 sampled residents (R) who are unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene. (R1)

Inspectors wroteBased on interview and record review, the facility did not ensure the resident was assessed for removal of the catheter and had no orders in place for a foley catheter. For 1 of 1 residents (R) R1 reviewed with urinary catheters. R1 has an indwelling foley catheter without a physician order to direct the care and treatment for the catheter. Staff did not assess and prevent complications of catheter during R1's care.

Inspectors wroteBased on observation and interview, the facility did not ensure staff followed procedures for the accurate administration of insulin. Staff did not complete a safety check by priming the needle on two insulin pens to ensure the injectable pens were dispensing insulin before administration for 2 of 3 residents (R), (R8 and R11).

Inspectors wroteBased on observation and interview, the facility did not ensure all drugs and biologicals were stored and labeled in accordance with currently accepted professional. Staff did not ensure that medications that could be potentially harmful were secured. This occurred for 1 of 1 resident's (R13) rooms observed.

Inspectors wroteBased on observation, interviews, and record review, the facility did not ensure 1 of 1 resident (R3) at high risk for pressure ulcer development received the necessary treatment and services needed to prevent the development of a pressure injury (PI) or to prevent worsening of an existing PI. -R3 developed a facility acquired unstageable PI to right foot on 07/10/24 which became larger with a macerated center on 07/16/24 resulting in actual harm. The facility did not complete weekly comprehensive assessments of R3's PI. The facility did not ensure preventative pressure relieving measures were implemented. The PI of the right foot is cited at actual harm. -R3 acquired a PI to right buttock stage II, due to shearing on 06/12/24. Interventions to prevent friction and shearing were not put into place. The facility did not complete weekly comprehensive assessments of R3's PI.

Inspectors wroteBased on interview and record review, the facility did not report an incident of potential misconduct to the state agency immediately upon learning of the incident and did not submit the 5 day investigation within 5 days as required. The facility practice had the potential to affect 1 of 12 residents reviewed for abuse (R7). The facility administration learned of the incident when Certified Nursing Assistant (CNA) E flushed R7's feeding tube on 06/28/24. The facility did not report the incident to the state agency until 07/10/24 via a Misconduct Incident Report (5-day Investigation). No immediate initial reporting was submitted.

Inspectors wroteBased on interview and record review, the facility did not conduct a thorough investigation and complete appropriate actions to correct an alleged violation affecting 1 of 12 residents (R) reviewed for potential abuse (R7). Certified Nursing Assistant (CNA) E flushed R7's feeding tube with warm water to make sure it was patent when she found R7's feeding tube not attached. The facility investigation included limited staff interviews, no resident interviews, and no post incident education to staff as a corrective action in attempts to prevent further incidents.

Inspectors wroteBased on interview and record review, the facility did not ensure services were provided by a qualified person in accordance with resident's written plan of care. The facility practice had the potential to affect 1 of 12 sampled residents (R7). Certified Nursing Assistant (CNA) E flushed R7's feeding tube with warm water to make sure it was patent when she found R7's feeding tube not attached to R7.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure residents received the necessary treatment and services consistent with professional standards of practice for 2 of 2 residents (R2 and R4) reviewed with non-pressure injuries. -On 07/07/24, R4 developed a facility acquired non-pressure injury to his left heel. Documentation indicated staff was checking R4's heels and feet twice daily for skin issues. Weekly wound assessment on 07/08/24 is not accurate and indicated R4 had no skin concerns. On 07/16/24, R4 had developed two additional facility acquired non-pressure injuries to left and right foot and his previous non-pressure injury had worsened, this was not documented in a weekly wound assessment.

Inspectors wroteBased on observation, interview and record review, the facility did not provide the needed supervision to prevent accidents for 2 of 3 residents reviewed for accidents (R6 and R11). Facility staff did not provide supervision while R6 was eating breakfast. Speech Therapy caregiver instructions and care plan indicated R6 requires supervision to eat. Facility staff did not provide supervision while R11 was eating breakfast. R11's caregiver instructions and care plan indicated she requires supervision to eat. This is evidenced by: Example 1 R6's most recent Minimum Data Set (MDS) completed 06/30/24 notes R6 eats independently. Follow-Up Caregiver Instructions: Referred by: Speech therapy (ST) dated 09/09/23 indicated: Issue: Swallowing Strategies: .Soft bite sized foods, thin liquids Activities to be performed with Resident: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to adequately assess and provide necessary care and services to attain or maintain the highest practicable physical wellbeing for 1 of 2 residents (R1) reviewed for pain management. R1 expressed increased pain utilizing a pain scale. The facility did not administer as needed medications when R1's pain was elevated. The facility did not document the effectiveness of as needed pain medications, when used. The facility did not follow R1's care plan to provide maximum comfort related to hospice care and terminal diagnosis.

Inspectors wroteBased on interview and record review, the facility did not ensure licensed nurses had the specific competencies and skill set necessary to care for a resident's needs, as identified through resident assessment, and described in the plan of care, for 1 of 1 resident (R2) reviewed for negative pressure wound therapy (NPWT). R2's NPWT malfunctioned, and staff were unable to continue R2's NPWT.

Inspectors wroteBased on observations, interviews and record review, the facility did not ensure 3 of 3 residents (R7, R5, and R1) reviewed with pressure injuries (PI) and at high risk of pressure injury development received the necessary treatment and services to promote healing of existing skin impairments or prevent new pressure injuries from developing. R7 developed a stage 2 PI to the right gluteus on 03/27/24, a stage 2 PI to spine on 05/01/24, and a stage 3 PI to the left heel on 05/13/24 which became unstageable on 5/29/24 resulting in actual harm. The facility did not initiate preventative pressure relieving measures, complete weekly comprehensive assessments of the PI, and no treatment changes or physician notification for increasing size of the PIs. This example is cited at actual harm. [...]

Inspectors wroteBased on observations and interviews, the facility did not ensure staff performed proper handwashing during personal cares for 1 (R3) of 8 sampled residents. This is evidenced by: The facility policy titled Hand Washing/Hand Hygiene, dated 04/2024, states: Indications for Hand Hygiene: 1. Hand hygiene is indicated: a. Immediately before touching a resident; b. Before performing an aseptic task (for example, placing an indwelling device or handling an invasive medical device); c. After contact with blood, body fluids, or contaminated surfaces; d. After touching a resident; e. After touching the resident's environment; f. Before moving from work on a soiled body site to a clean body site on the same resident and g. Immediately after glove removal. 3. Wash hands with soap and water: a. When hands are visibly soiled; b. [...]

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not have sufficient nursing staff to ensure the highest practicable physical, mental, and psychosocial well-being for five residents (R6, R7, R10, R11, and R12). R6, R7, R10, and R11 were not out of bed or prepared to eat meal when trays were delivered. R6, R7, R10, R11, and R12 waited over 40 minutes to eat after meal trays were delivered to floor. R6 and R7 were not provided adequate assistance with meal. R12 did not receive a meal tray.

Inspectors wroteBased on interview and record review, the facility did not ensure care plans were updated for 1 of 3 residents reviewed (R6). R6's care plan did not include areas for skin/wounds, pain, and refusal of cares.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that medications ere administered in a manner to prevent a medication error in technique Medication technique errors were identified for residents (R4 and R9). R4 was not instructed to rinse and spit after receiving an inhalation medication. R9 was not instructed to or assisted with applying pressure to the inner corner of the eye after receiving medicated eye drops.

Inspectors wroteBased on record review and interview, the facility did not use the services of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week. This has the potential to affect all 34 residents that reside in the facility. This is evidenced by: On 12/13/23 at 9:30 AM, Surveyor completed an interview with Corporate Administrator (CA) F about PBJ submissions. CA F stated during that time period there was a change in the Business Office Manager and that he himself would have been responsible to submit the PBJ for the 3rd quarter. Surveyor then requested and reviewed the staff schedules for that time period (April 1 - June 30, 2023) and compared the data with time punches. There were no concerns uncovered related to licensed staff coverage or certified nursing assistant coverage. [...]

Inspectors wroteBased on interviews and record review, the facility failed to submit Centers for Medicare and Medicaid Services (CMS) mandatory Payroll Based Journal (PBJ) data for the third quarter of 2023 (April 1-June 30). This has the potential to affect all 34 residents. This is evidenced by: Surveyor noted the facility failed to submit PBJ data for Fiscal Year Quarter 3. On 12/13/23 at 9:30 AM, Surveyor completed an interview with the Corporate Administrator (CA) F about the PBJ submissions. CA F stated during that time period there was a change in the Business Office Manager and that he himself would have been responsible to submit the PBJ for the 3rd quarter. CA F stated that he missed it and did not submit the data for the third quarter. CA F stated that the facility was staffed adequately and there was no shortage of staffing during that time period. [...]

Inspectors wroteBased on 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. This had the potential to affect 34 of 34 residents (R) residing in the facility. -Legionella Water Management plan did not include a team that meets regularly, a flow diagram indicating potential areas of opportunity, control measures, or monitoring. -Infection control line listing of infections was not completed accurately or thoroughly.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure practices were not used to restrict a resident's freedom of movement when staff were observed locking resident's wheelchair brakes. The facility practices affected 1 of 1 resident (R139). This is evidenced by: Surveyor requested and reviewed the facility policy titled Use of Restraints dated as revised on April 2017. The policy indicates: Policy Statement: Restraints shall only be used for the safety and well-being of the residents . Restraints shall only be used to treat resident's medical symptoms and never for discipline or staff convenience . Policy Interpretation: Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot easily remove, which restricts freedom of movement . [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility did not ensure 1 of 4 residents reviewed (R18) for pressure injuries (PI) received necessary treatment and services, consistent with professional standards of practice to prevent new ulcers from developing. This is evidenced by: According to the National Pressure Injury Advisory Panel (NPIAP) 2019, page 115, . Repositioning and mobilizing individuals is an important component in the prevention of pressure injuries. The underlying cause and formation of pressure injuries is multifaceted; however, by definition, pressure injuries cannot form without loading, or pressure, on tissue. Extended periods of lying or sitting on a particular part of the body and failure to redistribute the pressure on the body surface can result in sustained deformation of soft tissues and, ultimately, in tissue damage . [...]

Inspectors wroteBased on observation, interview and record review, the facility did not provide the needed supervision to prevent accidents for 1 of 5 residents reviewed for accidents (R17). This is evidenced by: On 12/11/23 at 12:04 PM, Surveyor observed R17 sitting at a table in the small lounge/dining area on the rehabilitation wing. Staff brought R17's meal tray over to the table. Surveyor observed staff exit the dining room. Certified Nursing Assistant (CNA) D was observed at the nurse's station with her back to the dining room where R17 was eating. There were no other staff present in the dining room. R17 consumed most of the chicken alfredo and beverages. At 12:21 PM, R17 stood from table, used her walker, and exited the dining room. There were no staff present in the lounge/dining room to cue or prompt R17 while she ate. Surveyor reviewed R17's record and noted a physician order that read: [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility did not ensure 1 of 4 residents reviewed (R18) for pain control, received necessary treatment and services consistent with professional standards of practice to manage pain. This is evidenced by: R18 has medical diagnoses that include but are not limited to, cerebral vascular accident (CVA) due to unspecified occlusion or stenosis of the left carotid arteries, cerebral infarction with hemiparesis and hemiplegia affecting the right dominant side, aphasia, metabolic encephalopathy, primary osteoarthritis, a current stage II PI of the right medial ankle, recent fracture of the left hip (08/06/23), muscle weakness, rhabdomyolysis and severe right leg contracture at the knee. On 12/11/23 at 10:30 AM, Surveyor interviewed R18 asking about her pain control. R18 stated that she . [...]

Inspectors wroteBased on record review and interview, the facility did not identify specific targeted behaviors with individual behavioral goals and approaches or have a system in place to monitor the effectiveness of medications for 1 of 5 residents reviewed for unnecessary medications (R26). This is evidenced by: Surveyor reviewed the facility policy titled Antipsychotic Medication Use dated as revised on December 2016 which indicates the following: Policy Statement: Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-re-review. Policy Interpretation and Implementation: ~Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 1 resident (R) (R1) out of 1 sampled resident who was reviewed for behaviors, received adequate supervision, or had interventions implemented to prevent behaviors of exposing genitals to female residents. *R1 displayed sexually inappropriate behavior by exposing self to R2 in the facility library. *R1 displayed sexually inappropriate behavior by exposing self to R3 upon entering R3's room.