Hope Health and Rehab

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 32 residents who reside in the facility. Surveyor observed [NAME] E use the same dirty alcohol wipe to sanitize a thermometer while testing the temperature of several foods. Surveyor observed DA D (Dietary Aide) washing dirty dishes causing his clothing to get wet and then Surveyor observed DA D carrying clean dishes up against his dirty/wet clothing to put them away. Surveyor also observed DA D to not wash his hands after cleaning dirty dishes and before putting away clean dishes. Surveyor observed food in the resident refrigerator to be undated and unlabeled. Staff were unsure of when the food was placed in the refrigerator. Evidenced by: Example 1: [...]

Inspectors wroteBased on interview and record review the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made to the State Agency, this affected 1 of 18 residents (R18). R18 voiced concern on 2/10/26 that CNA F (Certified Nursing Assistant) was rough with her, this was not reported to the State Agency. R18 voiced concern on 2/21/26 that Agency CNA H was rough with her, this was not reported to the State Agency. This is evidenced by: The Facilities Policy and Procedure entitled Abuse Prevention, Investigation, and Reporting Policy dated 2/16/26, documents in part: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure each resident received the necessary care and services in accordance with professional standards of practice to meet each resident's physical needs for 1 of 3 sampled residents (R1). R1 had a change in condition. The facility did not assess or have ongoing monitoring of R1's change in condition. R1 was eventually sent to the hospital with a distal fracture of the left femur (leg bone). This is evidenced by: On 12/2/25 at 12:28 PM, Surveyor spoke to DON B (Director of Nursing) and requested the facility's change in condition policy and procedure. DON B stated the facility does not have a change in condition policy and procedure. DON B indicated the facility follows the standard of practice for nursing. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that each resident received treatment and care in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) for 1 of 3 residents identified in closed records review (R31). R31 presented with a change in condition (COC) on [DATE]. Facility staff did not document all R31's symptoms in R31's medical record and did not complete a thorough and ongoing RN (Registered Nurse) assessment related to the COC. R31's condition continued to decline. R31's vital signs warranted immediate MD (Medical Doctor) notification/consultation and the facility did not notify the MD. R31 continued to deteriorate and was sent to the hospital where R31 became pulseless and nonbreathing (PNB) and expired due to a critical potassium level. [...]

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 26 of 27 residents. Surveyor observed dust in the facility's stove hood, over open food being prepared for resident meals. Surveyor observed food to have been removed from the original packaging and not sealed or dated with an expiration date, an open date, or a use by date. Surveyor observed a box of potatoes on the floor in the dry food storage area. Evidenced by: Example 1 Facility's Cooks Weekly Cleaning Tasks sheet, undated, states in part: Sunday, Hood cleaning above stove, AM cook, take vent down run thru dishwasher. Clean all nozzles free of dust or dirt . On 4/21/25 around 9:30 AM, Surveyor and DM G (Dietary Manager) observed facility stove hood. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each resident. This affects 1 sampled resident (R6) and 5 supplemental residents (R5, R15, R17, R23, R25) reviewed for activities. R5, R6, R15, R17, R23, and R25, voiced concerns during Resident Council of the facility's activity program regarding evenings and weekends. Evidenced by: The facility does not have a policy for activity programming. Example 1 On 4/22/25 at 3:00 PM, Surveyor reviewed the activity calendars from December 2024 through March 2025. The facility activity calendar for December 2024 states, in part: Fridays: [...]

Inspectors wroteBased on interview and record review, the facility did not immediately notify and consult with a resident's physician when there was a significant change in condition. This occurred for 1 of 16 residents (R8) reviewed for notification of change in condition. R8 had blood sugars below ordered parameter of 70 without notification of physician. Evidenced by: The facility's Physician Notification policy, dated 4/12/17, states, in part: Purpose: To provide guidance to licensed nurse as to when and how to notify a physician/practitioner of changes in resident status. Procedure: .Take into consideration: immediate notification includes any symptom, sign, or apparent discomfort that is acute or sudden in onset, and a marked changed in relation to usual symptoms and signs . Surveyor requested a blood sugar parameter policy. No policy was provided. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that residents are provided foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s) for 1 of 3 residents (R8) reviewed for diabetic foot checks. R8 was not provided routine diabetic foot checks. Evidenced by: The facility did not provide a policy for diabetic foot checks. R8 admitted to the facility on [DATE] and has diagnoses that include: acute osteomyelitis, left ankle and foot (infection in the bone); type 2 diabetes mellitus (a disorder which affects the body's ability to produce enough insulin or to effectively use the insulin it produces which can raise blood sugar levels); [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure each resident received adequate supervision to prevent accidents for 1 of 1 residents (R334) reviewed. R334 was observed smoking in the street, not disposing of cigarette materials properly, and not returning materials to staff after returning from smoking. Evidenced by: The facility policy, Smoking Policy, effective date 11/27/2024, included, in part: Policy: It is the policy .to not allow smoking, including e-cigarettes, vapes, cigars etc. on .property. Procedure: *No residents are permitted to smoke in the facility or on the facility property, including the facility side walk [sic], courtyard or other green spaces, driveway, parking lot, or entrances to the parking lot. [...]

Inspectors wroteBased on interview and record review, the facility did not provide a suitable, nourishing snack to residents who want to eat outside of scheduled meal service times for 1 of 1 resident (R8) reviewed for nightly snacks. R8 had blood sugars below ordered parameter of 70 and was not receiving a routine nightly snack. Evidenced by: The facility's Resident Diet policy, dated 1/14/25, states, in part: Purpose: To outline how the dietary department provides each member a nourishing, palatable, well-balanced diet that meets daily nutritional and special dietary needs.dining program for residents includes service of three meals per day , and a snack program. Snacks If not prohibited by the resident's diet, condition or physician order, bedtime snacks are offered routinely to all residents. Snacks will conform to the residents' therapeutic or texture modified diet. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 1 of 1 residents (R8) reviewed for infection control with personal cares. CNA K (Certified Nursing Assistant) had a breach in infection control when performing pericare (cleansing of the genital area). Evidenced by: The facility's Standard Precautions policy, dated 4/10/24, states, in part: Purpose: The objectives of this policy is to communicate the requirements and expectations regarding the use of standard precautions to prevent the transmission of infection throughout the facility. Standard: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated, or the resident has already been immunized for 1 of 5 residents (R7) reviewed for immunizations. R7 was not offered the pneumococcal vaccination. Evidenced by: The facility's Pneumococcal Conjugate Immunization policy, dated 4/9/24, states, in part: It is the goal of facility to reduce morbidity and mortality related to pneumonia through various measures, including by educating all residents on pneumococcal conjugate vaccination and offering the opportunity for vaccination in accordance with current Centers for Disease Control and Prevention (CDC) recommendations and CMS regulatory requirements . [...]

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 34 residents. Surveyor observed Mighty Shakes to be in the refrigerator for more than the manufacturer's recommendations of 14 days. Surveyor observed hairlike dust moving in the air exchange, in the facility's stove hood, over open food being prepared for resident meals. Surveyor observed a dented can in circulation. Surveyor observed food to have been removed from the original packaging and not dated with an expiration date, an open date, or a use by date. Evidenced by: Example 1 Hormel Mighty Shakes manufacturer's recommendations for storage and handling, includes Store frozen. Thaw at or below 40 degrees Fahrenheit. Used thawed product within 14 days. [...]

Inspectors wroteBased on observation and interview, the facility did not ensure each resident had a safe, clean, comfortable, and homelike environment or ensure housekeeping provided necessary services to maintain a sanitary, orderly, and comfortable area for 1 of 15 sampled residents (R31). R31 voiced concerns regarding the wall in her room needing to be repaired and painted. Surveyor observed R31's tan painted wall, alongside R31's bed, to have large white patched areas and some small holes where screws used to sit. Evidence by: R31 admitted to the facility on [DATE]. Her most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 1/30/24, indicates R31's speech is clear with distinct intelligible words. R31's MDS also indicates she can make herself understood with her ability to express ideas and wants verbally and nonverbally and she usually understands verbal content. [...]