Ingleside Manor

Inspectors wroteBased on observation, interview, and record review, the facility did not implement professional standards of practice to prevent pressure injuries (PIs) from developing and/or worsening or to promote healing of PIs for 2 of 6 residents (R28 and R4) reviewed for PIs out of a sample of 19 residents. R28 was admitted to the facility with four (4) Stage 1 PIs. R28 was at risk for further PI development and had significant comorbidities. The facility failed to complete a readmission skin assessment, accurately complete all wound assessments and measurements, notify the provider of changes to the PI, offload pressure, and follow standards of practice during wound care. R28 developed an Unstageable PI which deteriorated to a Stage IV (4) PI with osteomyelitis. R4 was admitted [DATE] without any pre-existing pressure injuries. [...]

Inspectors wroteBased on 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. This has the potential to affect the census (48). The facility is not monitoring the temperature of their water heater as part of their control measures for Water Management Program. The August 2025 line list does not include symptom monitoring. Evidenced by:The facility's Legionella Water Management Program policy, dated 9/2022, states, in part: Our facility is committed to the prevention, detection, and control of water-borne contaminants, including Legionella.5. The water management program includes the following elements: .e. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure grievances and recommendations discussed during resident group meetings (Resident Council) were acted upon promptly, for 3 of 11 supplemental residents (R12, R46, R52) and 2 of 18 sampled residents (R26 & R42). During Resident Council Task, three months of Resident Council Minutes were reviewed to find 3 (R12, R46, R52) residents had voiced concerns regarding facility phone issues. R12 and R42 voiced concerns to Surveyors regarding concerns with no one answering the facility phone. Evidenced by: The facility policy entitled, Ingleside Manor Resident Council Policy and Procedure, dated 5/26/2021, states, in part: . Policy: It is the policy of this facility to support and assist in the formulation of a Resident Council which provides a formal, structured process for communication among residents, staff and administrator. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure the resident's right to request, refuse, and/or discontinue treatment and to formulate an advanced directive for 5 of 18 residents (R8, R7, R3, R26, R67) reviewed for advanced directives. R8, R7, R3, R26, and R67's charts did not contain current copies of their advanced directive and/or did not contain evidence of advanced care planning, other than code status, for a time when they are not able to make their own healthcare decisions. Evidenced by: The facility's Advance Directives policy, dated 9/2022, states, in part: .Determining Existence of Advance Directive 1. Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure each resident had the right to a safe, clean, comfortable, and homelike environment for 1 of 3 shower room affecting a pattern of residents who use the shower room and 1 (R67) of 19 sampled residents. Surveyor observed the Whirlpool Shower Room (Note just shower) to not be homelike with the following visible repairs needed: Example 1: Opening in floor covered by a loose piece of tile and a board laying over a large open area Example 2: Tiles missing on the wall next to the shower with exposed rusty metal protruding from the wall Example 3: Missing tiles on the shower floor Example 4: Dark substance along the inside right where the shower wall meets the floor. Tiles are broken and worn in this area as well. Example 5: Vent above shower coated with dust; dust is visibly hanging off the vent Example 6: [...]

Inspectors wroteBased on interview and record review, facility staff did not provide care and treatment in accordance with professional standards of practice for 3 of 4 sampled residents (R51, R6 & R23) and 1 of 1 Supplemental Residents (R69). R51 was admitted to the facility with a surgical wound. R51's wound treatments were not completed as ordered by the physician. R6 had a change of condition and did not have documented assessments through the course of antibiotic treatment. R23 had a change of condition and did not have documented assessments through the course of antibiotic treatment. R69 admitted to the facility on antibiotic for infection and did not have documented assessments through the course of antibiotic treatment. This is evidenced by: The facility policy titled, Wound Care, dated 10/2010, states, in part: . [...]

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 through established procedures for 1 of 48 residents (R42) reviewed for abuse. Facility did not report an abuse allegation involving R42 within the required two hours to the state agency (SA). Evidenced by:The facility policy entitled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated 9/2022, states, in part: . Policy Statement: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure a resident with a catheter receives appropriate treatment and services to prevent urinary tract infections for 1 of 2 residents (R42) reviewed for catheter care. Staff attached a dirty leg bag with urine in the bag and the tube after removing R42's catheter bed bag. Evidenced by:The facility policy entitled, Urinary Leg Drainage Bags, dated October 2010, states, in part: . Purpose: The purpose of this procedure is to provide guidelines to decrease the likelihood of nosocomial urinary tract infections associated with the intermittent use of leg drainage bags with foley catheters. General Guidelines: .3. A new sterile drainage bag should be used every time the regular straight drainage tubing is disconnected, and the leg bag is used.6. Do not wash or disinfect leg bags in an attempt to reuse them. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who receives nutrition and hydration and maintains acceptable parameters of nutritional status unless the resident's clinical condition demonstrates otherwise for 1 of 4 residents (R19) reviewed for nutrition. Facility staff were aware R19 was prescribed a vegetarian diet and failed to provide a source of protein on his daily meal trays to accommodate R19's likes. R19 went 3 months without an adequate source of protein provided on his daily meal trays or a supplemental protein source R19 experienced a weight loss of 16%, a severe weight loss, in 3 months. Evidenced by:The National Council on Aging (NCOA) states, The first step in managing diabetes through diet as an older adult is to understand how different nutrients affect blood glucose levels. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that it was free of medication error rates of 5% or greater. There were 4 errors out of 31 opportunities that affected 2 out of 6 residents (R16 & R54) included in the medication pass task, which resulted in an error rate of 12.9%. R16's ordered Miralax was omitted. R16 received Simethicone without an order and received 2 tablets of Senna Plus and order was for 1 tablet. R54 was to receive 2 tablets of Senna Plus and it was omitted. Evidenced by:The facility policy entitled Medication Errors, dated 9/01/10, states, in part: . Applicability: This section 10.1 sets forth procedures relating to medication errors. Procedure: .4. Administration Errors: . Examples of administration errors include, but are not limited to: .4.4 Dose Error: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that all drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. This affected 1 of 2 medication carts. Surveyor observed medication on top of an unsupervised medication cart in hallway while nurse administered medications to a resident. The medication cart had an expired open bottle of Milk of Magnesia (laxative medication). Evidenced by: The facility policy entitled Administering Medications, dated 4/2019, states, in part: . Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: . 19. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not provide food that accommodates resident preferences; appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice for 1 of 18 sampled resident's (R19). R19 was known to be a vegetarian and was not given foods of similar nutritive value to replace the meat options on the menu to maintain his assessed protein goals. Evidenced by:R19 was admitted to the facility from the hospital on 6/3/25 with diagnoses of cerebral infarction, type 2 diabetes, and congestive heart failure. His most recent MDS (Minimum Data Set), dated 9/8/25 includes a BIMS (Brief Interview for Mental Status) score of 15, indicating he is cognitively intact. R19 has physician's orders, dated 6/4/25, for a vegetarian diet, no dairy. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure hospice collaboration and communication processes were established to ensure continuity of care between hospice and the facility for 1 of 1 resident (R28) reviewed for hospice. R28's current hospice plan of care and visit notes were not available to facility staff. The facility did not designate a staff member to coordinate the plan of care with the hospice provider. This is evidenced by: The facility's Hospice Program policy, revised July 2017, states, in part: .9. In general, it is the responsibility of the hospice to manage the resident's care as it relates to the terminal illness and related conditions. 10. [...]

Inspectors wroteBased on interview and record review, the facility did not identify issues to which quality assessment and assurance activities are necessary or develop and implement appropriate plans of action to correct identified quality deficiencies for 2 of 2 Residents (R28 & R4). The facility has failed to identify key areas of deficient practice and implement action plans to correct these deficient practices or identify areas needing improvement to develop, implement, monitor, and evaluate action plans to achieve specific goals to improve quality of care for Pressure Injury care and prevention. Evidenced by:The facility's Quality Assurance and Performance Improvement (QAPI) Program-Feedback, Data, and Monitoring policy, dated March 2020, states, in part: The QAPI program is based on the collection of information obtained from data, self assessment and systems of feedback. [...]

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 2 of 5 residents (R9 and R2) reviewed for immunizations. R9 and R2 were not offered pneumococcal vaccination. Evidenced by:The facility's Pneumococcal Vaccine policy, dated 2001, states, in part: All residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. 1. Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered the vaccine series within 30 days of admission to the facility unless medically contraindicated or the resident has completed the current recommended vaccine series. 2. Routine vaccination consists of the following: a. [...]

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 1 of 4 sampled residents (R2). R2 was admitted to the facility with a wound on her left abdomen. The facility failed to complete ongoing comprehensive wound assessments throughout her stay. While at the facility, R2's wound increased in size and developed a foul odor. No physician notification was made. R2 was readmitted to the hospital with a diagnosis of a wound infection. Evidenced by:According to the Wisconsin Nurse Practice Act, N6.03(1), An R.N. (Registered Nurse) shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. [...]

Inspectors wroteBased on observation, interview and record review, 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 4 of 4 residents (R6, R4, R12 and R13) reviewed for cleanly environment. R6's room had dried substances and crumbs on the floor and staff identified fecal matter on the outside of the toilet in R6's bathroom. R4 indicates staff come in to clean her room once a week if she is lucky. R12's room was observed to be unclean. R13's room was observed to be unclean. This is evidenced by: The facility policy titled, Cleaning and Disinfecting Residents' Rooms, dated August 2013, states in part… Purpose: The purpose of this procedure is to provide guidelines for cleaning and disinfecting residents' rooms. General Guidelines: 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 5 out of 16 sampled residents (R14, R9, R6, R3, & R17). R14 did not receive scheduled medications for 8:00 AM & 2:00 PM on 8/28/25 due to the facility's internet being down. R9 did not receive scheduled medication for 4:00 PM on 8/28/25 due to the facility's internet being down. R3 did not receive all of her medications as ordered on 8/20/25, 8/21/25, 8/22/25, 8/23/25, 9/8/25. R17 had medications not administered as ordered. R6 did not receive her 9/11/25 medications within the allowed time frame. Evidenced by: The facility policy titled, “Medication Errors”, dated 9/1/10, states, in part: “… 3. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility did not ensure each Resident is treated with dignity and respect that promoted maintenance or enhancement of quality of life for 1 of 1 residents (R6) reviewed for choices. R6 expressed she chooses to eat in the dining room and the facility did not ensure R6's choices were honored. This is evidenced by:The facility's policy titled Resident Rights, version 2/21, includes: Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: e. self-determination; f. communication with and access to people and services, both inside and outside the facility; h. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure each resident received care, consistent with professional standards of practice, to prevent pressure injuries (PI) for 1 of 1 Residents (R6) reviewed for pressure injuries. R6 has a stage 2 pressure injury and pressure injury prevention devices were observed not in place. This is evidenced by:The facility's policy Prevention of Pressure Injuries, dated 4/20, includes: The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Use a standardized pressure injury screening tool to determine and document risk factors. Select appropriate support surfaces based [sic] the resident's risk factors, in accordance with current clinical practice. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that a resident with urinary catheters receive appropriate treatment and services for 1 of 1 residents (R6) reviewed for catheters as catheter bags were observed resting on the floor. Surveyor observed R6's urinary catheter bag resting on the floor. This is evidenced by:The facility's policy titled Catheter Care, Urinary, dated 9/14, includes: The purpose of this procedure is to prevent catheter-associated urinary tract infections. Infection control 2. b. Be sure the catheter tubing and drainage bag are kept off the floor. R6's active physician orders, dated 9/11/25, include: SP Catheter (Suprapubic Catheter, a thin, flexible tube inserted directly into the bladder through a small incision in the lower abdomen): cleanse daily with mild soap and water; pat dry with soft towel. [...]

Inspectors wroteBased on interview and record review, the facility did not provide behavioral health services to ensure a resident received the highest practicable mental and psychosocial well-being. The facility did not create a comprehensive assessment and plan of care to address a substance use disorder (SUD) for 1 of 1 residents (R17) reviewed for SUDs and 1 of 1 Residents reviewed for suicidal ideations (R1). R17 has a SUD. The facility failed to create a care plan related to R17's alcohol consumption and failed to implement interventions for behaviors associated with R17's alcohol consumption. R1's record indicates R1 had a history of suicidal ideation and suicidal attempts. The facility did not develop a Plan of Care with goals and interventions for R1's history of suicidal attempts and ideations. [...]

Inspectors wroteBased on interview and record review the facility did not ensure residents are free of any significant medication errors for 2 of 17 Residents (R14 & R3) reviewed for medications. R14 had 2 seizure medications not administered on 8/28/25 due to the facility's internet being down. R3 did not receive all of her medications as ordered on 8/20/25, 8/21/25, 8/22/25, 8/23/25, and 9/5/25 This is evidenced by: The facility policy entitled, “Administering Medications,” dated 4/2019, states, in part: … “Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: … 4. Medications are administered in accordance with prescriber orders, including any required time frame… 6. Medication errors are documented, reported… 7. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure effective pest control in the facility dining area, hallways and resident rooms for 8 of 10 sampled residents (R4, R6, R11, R12, R13, R14, R15 and R16). Residents voiced concerns with flies in the facility. Surveyor made observation of 6 flies on R4's left lower leg while interviewing R4. Evidenced by: The facility policy, entitled Pest Control, dated 2023, states, in part: . Policy Statement: Our facility shall maintain an effective pest control program. Policy Interpretation and Implementation: 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. 2. Pest control services are provided by Professional Pest Control monthly and as needed. 6. Maintenance services assist, when appropriate and necessary, in providing pest control services. [...]

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 10 residents (R9) reviewed for notification of change in condition. R9 had blood sugars above the ordered parameter of 350 without notification of a physician. This is evidenced by: The facility's policy titled Medication and Treatment Orders, revised in July 2016 states in part, Policy Statement: Orders for medications and treatments will be consistent with principles of safe and effective order writing. Policy Interpretations and Implementation: .9. Orders for medications must include: a. name and strength of the drug; b. number of doses, start and stop date, and/or specific duration of therapy; c. dosage and frequency of administration; d. route of administration; e. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving misappropriation of resident property are reported immediately to the administrator of the facility in accordance with State law for 1 of 1 allegation reviewed. LPN H (Licensed Practical Nurse) did not report a suspicion of misappropriation of medication. As evidenced by:The facility's Loss or Theft of Medications policy, dated 9/1/10, states, in part: .Procedure 1. Where the community staff suspect theft or loss of medications, community staff should take such actions as required by Applicable Law and community policy. Appropriate actions should include, but not limited to: 1.1 Immediately reporting suspected theft or loss of medications to a supervisor/manager, the Director of Clinical Services or designee for appropriate investigation and follow-up. [...]

Inspectors wroteBased on interview and record review, the facility did not provide showering assistance for residents requiring assistance for 1 of 6 residents (R2) reviewed for showers. R2 did not receive weekly showers. This is evidenced by:The facility's policy titled Bath, Shower/Tub, dated 2/18, includes: The purpose of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Documentation 1. The date and time the shower/tub bath was performed. 2. The name and title of the individual(s) who assisted the resident with the shower/tub bath. 3. All assessment data (e.g., any reddened areas, sores, etc., on the resident's skin) obtained during the shower/tub bath. 4. How the resident tolerated the shower/tub bath. 5. If the resident refused the shower/tub bath, the reason(s). [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 1 residents (R5) reviewed for bowel management. R5 was sent to hospital emergency department for constipation. Facility did not monitor bowels and perform abdominal assessments per facility protocol. Evidenced by:The facility's Bowel Management Protocol, undated, states, in part: 1. NOC (night shift) nurse will run the Resident Bowel Management Report in Matrix each NOC shift . 2. Identify all residents who have not had a bowel movement in the last 2 or more days and add them to the Nurse's Daily Bowel Report.5. Follow this procedure for residents with 2 or more days since last bowel movement Day #2 (number) No Bowel Movement-. Day #3 No Bowel Movement . [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (R5) reviewed for falls. R5 was evaluated to be transferred with 2 assist and [NAME]-Steady (transfer device) and was transferred with 2 assist (with no device). Evidenced by:The facility's Safe Lifting and Movement of Residents policy, dated 7/2017, states, in part: In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. 1. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents.3. [...]

Inspectors wroteBased on interview, and record review, the facility did not ensure residents with G-Tubes (gastrostomy feeding tube) were assisted with nutrition and hydration for 1 of 3 Residents (R2) reviewed for nutritional status. R2 did not receive his G-Tube feeding as ordered. This is evidenced by:The facility policy titled Enteral Tube feeding via Gravity Bag, dated11/18, includes: The purpose of this procedure is to provide nourishment to the resident who is unable to obtain nourishment orally. 1. Verify that there is a physician's order for this procedure. 3. Check the following information: a. Resident name, ID and room number. b. Type of formula. f. Method (pump, gravity, syringe). 5. Check the order to verify the type, amount, method and rate of administration. 9. When correct tube placement has been verified, flush tubing with at least 30 ml warm water (or prescribed amount). 5. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure residents were seen by a physician every 30 days for the first 90 days after admission and every 60 days thereafter for 1 of 15 resident (R4) reviewed. R4 was not seen by a physician once every 30 days for the first 90 days after admission. Evidenced by:The facility policy, entitled Physician Services, dated 2/21, states, in part: . Policy Statement: The medical care of each resident is supervised by a licensed physician. Policy Interpretation and Implementation: .7. Physician visits, frequency of visits, emergency care of residents, etc. are provided in accordance with current OBRA (Omnibus Budget Reconciliation Act) regulations and facility policy. According to OBRA '87, OBRA regulations mandate specific frequencies for physician visits in nursing homes. [...]

Inspectors wroteBased on interview and record review, the facility did not provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 7 residents (R5 and R10) reviewed for medications. R5 had medications not administered as orderedR10 had medications not administered as ordered This is evidenced by:The facility's policy titled Providing Pharmacy Products and Services, revised on 6/1/2018, states in part: .1. The Pharmacy will provide the community with a community-specific information sheet that details how community staff can contact the Pharmacy twenty-four (24) hours a day, seven (7) days a week. The facility's policy titled Medication Errors, revised on 9/1/10, states in part: .Omission error: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure residents are free of any significant medication errors for 1 of 7 residents (R8) reviewed for medications. The facility did not ensure R8 was provided all doses of her buprenorphine-naloxone (combination medication used to treat opioid addiction) and her cephazolin (antibiotic). This is evidenced by: The facility's policy titled Providing Pharmacy Products and Services, revised on 6/1/2018, states in part: .1. The Pharmacy will provide the community with a community-specific information sheet that details how community staff can contact the Pharmacy twenty-four (24) hours a day, seven (7) days a week. The facility's policy titled Medication Errors, revised on 9/1/10, states in part: .Omission error: [...]

Inspectors wroteBased on interview and record review, the facility has not established an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 Residents (R4 & R15) of 2 opportunities for hand hygiene. Staff did not perform proper hand hygiene per standards of practice during wound care on R4. CNA K had a breach in infection control when performing pericare (cleansing of the genital area). Evidenced by: The facility policy entitled “Handwashing/Hand Hygiene,” undated, states, in part: … “Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Policy Interpretation and Implementation: -Administrative Practices to Promote Hand Hygiene: 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (R6) reviewed for elopement, 2 of 3 residents (R8 and R10) who smoke, 1 of 1 resident’s (R18) who voiced suicidal ideations, and 1 of 3 residents (R13) at risk for falls. The facility’s failure to supervise a resident who was known to be an elopement risk, created a finding of immediate jeopardy that began on [DATE]. Surveyor notified NHA A (Nursing Home Administrator) of the immediate jeopardy on [DATE] at 4:19 PM. The immediate jeopardy was removed on [DATE], however, the deficient practice continues at a scope/severity of E (potential for more than minimal harm/pattern) as evidenced by the following examples: R8 has no smoking assessment or care plan for smoking. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who receives assisted nutrition and hydration maintains acceptable parameters of nutritional status unless the resident's clinical condition demonstrates otherwise for 1 of 4 residents (R14) reviewed for nutrition and hydration. R14 has diagnoses including severe protein malnutrition, severe weight loss, and adult failure to thrive (FTT). R14 was admitted to the facility on [DATE]. R14's discharge physician orders included an order indicating NPO (Nothing by Mouth). R14 was to receive enteral feedings. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure the facility crash cart was checked by facility staff to ensure appropriate BLS (Basic Life Support) could be provided to any resident requiring such care prior to arrival of emergency medical personnel in accordance with current standards of practice for 2 of 2 crash carts with the potential to effect 34 of 34 full code (R) residents residing in the facility. The facility did not ensure the necessary supplies and equipment were readily available for residents of the facility who have chosen to receive basic life support if needed. Evidenced by:The facility was not able to provide a crash cart policy. On [DATE] at 11:22AM Surveyor interviewed LPN L (Licensed Practical Nurse). [...]

Inspectors wroteBased on interview and record review the facility failed to complete a performance review of every nurse aide at least every 12 months and failed to provide regular in-service education based on the outcome of these reviews for 5 of 5 staff for evaluations and 4 of 5 staff for education. All 5 staff chosen did not have performance evaluations completed every 12 months. Four of five staff did not have regular in-service education completed every 12 months. This is evidenced by:The Facility's 5.6 Performance Evaluation/Review Policy from the Employee Handbook, undated, documents in part: Performance evaluations/reviews are generally scheduled once a year based on the employee's anniversary date or upon change in assignments The Facility does not have a Policy or Procedure specific to required in-service education. [...]

Inspectors wroteBased on interview and record review, the facility did not maintain a Quality Assessment and Assurance Committee consisting of at a minimum, the Director of Nursing Services, the Medical Director, or his/her designee, at least three other members of the facility's staff at least one of whom must be the administrator, owner, a board member or other individual in a leadership role, and the Infection Preventionist, which met at least quarterly. This has the potential to affect all 48 Residents residing within the facility. Quality Assurance and Performance Improvement (QAPI) meetings did not consist of the required attendees/members for the months of June 2024 and July 2025. Two of the meetings over the last 4 quarters did not occur within the appropriate timeframe. [...]

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, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 3 of 5 reportable incidents. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure that all alleged violations are thoroughly investigated and report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken this affected 2 of 4 investigations (R18 and R2, R18 and R19) reviewed. There is no investigation for the resident-to-resident altercation between R18 and R2. There is no investigation for the resident-to-resident altercation between R18 and R19. This is evidenced by:The Facilities Policy and Procedure entitled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating dated September 2022 documents in part: .1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents who receiving nutrition and medication by G-tube (Gastrostomy tube, a thin flexible tube inserted through a small incision in the abdomen and into the stomach, used to provide nutrition and fluids) receive the appropriate treatment and services 3 of 4 Residents reviewed for tube feedings (R15, R16 and R17). R15 has a G-tube (Gastronomy tube) is not being checked for placement prior to use. R16 has a G-tube that is not being checked for placement prior to use. R17 has a G-tube that is not being checked for placement prior to use. Evidenced by:Facility policy entitled 'Confirming Placement of Feeding tubes,' states in part: .The purpose of this procedure is to ensure proper placement of an existing feeding tube prior to administering enteral feedings or medication. Preparation 1. [...]

Inspectors wroteBased on interview and record review the facility did not maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized for 1 of 1 sampled residents (R7) for change of condition. R7's medical record is missing documentation of her change of condition and subsequent passing away on 6/19/25. R18 has no nursing documentation following suicidal ideations documented by Activities. R19 has no documentation regarding the resident-to-resident altercation with R18. Evidenced by:The Facility policy Charting and Documentation, indicates, in part: Policy Statement: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. [...]

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure a resident's safety during a transfer when one Resident (R1) of three residents reviewed for accidents sustained a minor injury after falling out of a Hoyer lift during a transfer.

Inspectors wroteBased on interviews, record review, and policy review the facility failed to notify hospice and the resident's representative timely with a change in condition for 1 of 12 sampled residents (R4). R4 had a change in condition evidenced by a change in her eating habits, this was not communicated to hospice or R4's representative.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure a resident-to-resident abuse allegation was reported to the administration and the State Agency within two hours for an allegation involving 2 of 12 sampled Residents (R1 & R2). An allegation of resident to resident abuse between R1 and R2 was not reported within the required timeframe.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to interview all staff who may have had knowledge of a resident-to-resident abuse allegation involving 2 of 12 sampled Residents (R1 & R2). Facility did not thoroughly investigate a resident-to-resident abuse allegation involving R1 and R2.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to administer medications as scheduled for 1 of 12 Residents (R3) reviewed for medication administration. R3's medications were documented as not being administered and/or documented as being administered late.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure a medication error rate of 5% or less. During the medication administration task, Surveyors observed 18 errors out of 28 medication opportunities, resulting in an error rate of 64.28% This affected 3 out of 4 Residents (R) observed for medication administration (R10, R11 & R12). R10, R11 and R12 received their 8:00 AM medications more than an hour past their scheduled administration time. Evidenced by: Review of the facility's Administering Medications policy, dated April 2019, revealed Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions and Medications are administered in accordance with prescriber orders, including any required time frame. In addition, Medications are administered within one hour of their prescribed time, unless otherwise specified. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that a resident received treatment and care to prevent hospitalization in accordance with professional standards of practice for 1 of 6 residents (R18) that were reviewed for hospitalizations out of a total sample of 16. R18 had a change in condition and the facility did not complete full assessments and monitor symptoms. R18's condition continued to decline and R18 was hospitalized with atrial flutter (an abnormal heart rhythm in the heart's upper chambers (atria) when the atria beats too fast. This may cause dizziness and fatigue,) acute decompensated heart failure with preserved ejection fraction (Decompensated heart failure is a phase in the progression of chronic heart failure where symptoms worsen and become more severe. The heart cannot pump enough blood to meet the body's needs under this condition. [...]

Inspectors wroteBased on observation, interview and record review the facility did not ensure that the ice machine was cleaned and disinfected properly. This has the potential to affect all 56 residents. On 7/8/24, Surveyor observed a layer of black film on the inside of the ice machine lid. Evidenced by: Facility Ice Machine Policy dated 2/22 with last revision date of 1/24 states in part: Ice Machine and Equipment will be cleaned and sanitized on a regular basis .Maintenance will deep clean the ice machine quarterly and as needed . On 7/8/24 at 9:02 AM, during the initial tour of the kitchen, Surveyor and Dietary Manager (DM) F observed a layer of black film on the inside lid of the ice machine in the right-hand corner. DM F indicated that maintenance was responsible for cleaning the air filter, but she was unsure who was responsible for cleaning the ice machine itself. [...]

Inspectors wroteBased on observation, interview and record review the facility did not ensure that garbage and refuse was disposed of properly. This has the potential to affect all 56 residents. On 7/8/24, Surveyor observed garbage not properly contained in the dumpsters. Evidenced by: Facility Trash Disposal and Dumpster Area Policy dated 1/22 with last revision date of 1/24 states in part: Garbage will be disposed of as needed throughout the day and at the end of each day .Trash will be deposited into a sealed container outside the premises. The garbage storage area must be maintained in a sanitary condition to prevent the harborage and feeding of pests. Maintenance will routinely check the premises and keep the dumpster area free of debris . [...]

Inspectors wroteBased on interview and record review, the facility has not established an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This has the potential to affect all 56 residents (R) in the facility. The facility does not maintain a staff infection control line list for illnesses/infections other than Covid-19. The facility's policies have not been updated annually. This is Evidenced by: The Facility's provided the policy, Surveillance for Infections, with a reviewed date of 4/1/24, indicates, in part: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure 2 (R19 and R25) of 16 sampled residents and 2 (R17 and R23) of 4 supplemental residents had a call light within reach or a means to call staff for assistance. Surveyor observed R19's and R23's call lights not within reach. R25 and R17 voiced concern that their call lights are not always within reach, making it difficult to call for staff assistance. Evidenced by: The facility policy titled, Call System, Residents, dated 9/23, states, in part; .Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station .1. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor . [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide a comfortable and homelike environment for 1 of 16 total sampled residents (R38) and 3 of 4 supplemental residents (R13, R27, and R17) reviewed. R38 voiced concern that the water in R38's bathroom is always cold. R38 indicated that R38 is not able to take a shower so his main form of washing up and showering is done at his bathroom sink. R13, R27, and R17 indicated that they have had cold showers and that the water in the shower room does not warm up. Evidenced by: The facility policy titled, Water Temperatures, Safety of, dated 12/2009, states, in part; .2. Maintenance staff is responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log . [...]

Inspectors wroteBased on interview and record review, the facility did not immediately consult with the resident's physician when there was a need to alter treatment for 2 of 7 residents (R49 and R18) reviewed for physician notification out of a total sample of 16 Residents. R49's provider was not notified of a positive urine culture and sensitivy result therefore delaying a treatment decision by the provider. R18 missed medications and R18's physician was not notifed. This is evidenced by: The facility's policy Lab and Diagnostic Test Results - Clinical Protocol with a review date of 11/27/23, indicates, in part: .Identifying Situations that Warrant Immediate Notification - 1. Nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic tests results: [...]

Inspectors wroteBased on interview and record review the facility did not develop a comprehensive, person-centered care plan for 1 of 16 sampled Residents (R14) reviewed for person centered care plans. The facility failed to develop and implement a care plan that addressed monitoring for side effects such as bruising or bleeding for R14, who is taking Eliquis (Apixaban). Evidenced by: The facility's policy titled Care Plans, Comprehensive Person-Centered with a revision date of March 2022, states in part .3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment .7. The comprehensive, person-centered care plan: a. includes measurable objectives and time frames .e. reflects currently recognized standards of practice for problem areas and conditions . [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure a resident receives care, consistent with professional standards of practice to prevent pressure injury (PI) development for 1 of 2 residents reviewed for PIs out of a total sample of 16 residents (R49). R49 was assessed to be at risk for pressure injury on 4/28/24. The facility did not implement a repositioning plan. Evidenced by: The facility policy, entitled Pressure Ulcers/Skin Breakdown, dated April 2018, states, in part: Assessment and Recognition 1. The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcer(s) . Cause Identification 1. The physician will help identify factors contributing or predisposing residents to skin breakdown; [...]

Inspectors wroteBased on interview and record review, the facility did not ensure a resident maintains acceptable parameters of nutritional status and weight. This affected 1 of 3 Residents (R49) reviewed for nutrition and hydration out of a total sample of 16 residents. The facility failed to monitor R49's meal intake after R49 was assessed at risk for malnutrition and experienced weight loss. Evidenced by: The facility policy, titled, Weight Assessment and Intervention Policy, revised 2/2024, states, in part: Policy: Resident weights are monitored for undesirable or intended weight loss or gain. Procedure: 1. Residents are weighed upon admission and at intervals established by the interdisciplinary team. 2. Weights are recorded in the residents' vitals. 3. Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. 4. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure all residents receive scheduled medications on time per physician orders for 1 (R18) of 14 residents reviewed for medications. R18 did not receive night time medications on 6/16/24. Evidenced by: The facility policy titled, Administering Medications, dated 4/19, states, in part; .Medications are administered in a safe and timely manner, and as prescribed. 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) . The facility policy titled, Documentation of Medication Administration, states, in part; .The facility shall maintain a medication administration record to document all medications administered .1. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that drug regimes are free of unnecessary psychotropic medications, and that a resident taking a psychotropic medication has a care plan that includes targeted behaviors for 1 of 5 residents (R11) reviewed for unnecessary medications. R11 was started on Bupropion (antidepressant) for Other symptoms and signs involving cognitive functions and awareness, Quetiapine (antipsychotic) for Bipolar disorder, and Sertraline (antidepressant) for Bipolar Disorder and the care plan contained no behavior monitoring to assess the effectiveness of these medications, Evidenced by: The facility policy, entitled Psychotropic Medication Use, dated 7/2022, states, in part: Policy Statement. Residents will not receive medications that are not clinically indicated to treat a specific condition. Policy interpretation and Implementation. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that it was free of medication error rates of 5% or greater. There were 2 errors out of 25 opportunities that affected 1 out of 5 residents (R46) included in the medication pass task, which resulted in an error rate of 8%. RN D (Registered Nurse) did not administer R46's medications according to Physician orders. This is evidenced by: Facility policy entitled 'Adverse Consequence and Medication Errors,' states in part: 1. Residents receiving any medication that has a potential for an adverse consequence will be monitored to ensure that any such consequences are promptly identified and reported.4. The staff and practitioner shall strive to minimize adverse consequences by: a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents are free of significant medication errors for 2 of 2 Residents out of a total sample of 16 Residents (R7 and R18). R7 had an order for Midodrine (medication used to constrict blood vessels to increase blood pressure) 5 mg (milligrams) to be administered three times per day by mouth and to hold this medication for a systolic blood pressure over 130. This medication was administered with a systolic blood pressure over 130. R18 did not receive nighttime medications on 6/16/24. R18 did not receive insulin per ordered on 6/16/24. Evidenced by: The facility policy titled, Administering Medications, dated 4/19, states, in part; .Medications are administered in a safe and timely manner, and as prescribed. 7. [...]

Inspectors wroteBased on interview and record review the facility must develop policies and procedures to ensure that residents and/or resident 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 1 of 5 residents (R41) reviewed for pneumococcal immunizations. R41 received the Pneumococcal 23 vaccine on 7/5/22. R41 became eligible for further pneumococcal vaccinations one year after this date and was not offered the additional vaccines by the facility. Evidenced by: The facility's policy, titled, Pneumococcal Vaccine, with a revised date of, October 2023, states, in part: Policy Statement - All residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. [...]

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 2 of 3 residents reviewed for falls (R3 and R1). R3 is being cited as actual harm/isolated. R3 experienced multiple falls with fractures and the facility did not assess or find the root cause to prevent additional falls from occurring. R3's comprehensive care plan does not include interventions as written in fall reports. R1 had smoking materials in his room despite the facility being aware of his noncompliance with smoking.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure snacks were offered at bedtime daily when there is more than 14 hours between the evening meal and breakfast. This has the potential to affect 56 of 57 residents and 4 of 4 units. R48, R31, R38, R34, R17, R1, R4, and R39 voiced concerns that residents were not consistently being offered a snack at bedtime. R162 complained of not receiving snacks between meals. There was more than 14 hours between the evening meal and breakfast and the facility staff were not offering snacks to all residents. Evidenced by: Facility policy, entitled Snacks, reviewed 3/23, includes, in part: Snacks will be provided to increase hydration and prevent episodes of hunger. Snacks will be provided between meals in adherence with the resident's diet order . Nursing will be responsible for the delivery of snacks to the residents . [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is stored and distributed in accordance with professional standards for food service safety. This has the potential to affect 56 of the 57 residents who reside in the facility. Surveyor observed the following: - Food mixer to have cream colored food particles on it. - Microwave has missing coating on the door. - Dirty scoop in drawer. - Walk in freezer ice buildup on the floor, shelves, and on boxes of food. Boxes of food were not factory sealed and ice chips were inside of box. - One dented can of chocolate pudding left in circulation. - Temperature logs for dishwasher had temperatures that were not in accordance with the manufacture's recommendations for January, February, and March 2023. Evidenced by: [...]

Inspectors wroteBased on interview, and record review the facility did not provide feedback as to the steps taken to address Residents' prior concerns voiced at the Resident Council Meetings for 2 of 15 sampled residents (R4 and R31) and 11 supplemental residents (R35, R43, R34, R13, R38, R17, R36, R48, R39, R1, and R109) R4, R31, R43, R35, R1, R34, R13, R38, R17, R36, R48, R39, and R109 voiced concerns in Resident Council with no follow up. Evidenced by Facility policy, entitled Grievances, reviewed 2/6/18, includes, in part: Resident Council the facility will review the grievance policy and procedure with the resident council on annual or as needed basis. the grievance official or designee well attend the resident council meeting as agreed upon by the resident council members. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure all grievances were promptly resolved for 1 of 15 residents reviewed for grievances (R4) and 3 supplemental residents (R13, R35, and R43). R4, R13, R35, and R43 voiced concerns regarding missing items and the facility did not promptly follow up on concerns. Evidenced by: Facility policy, entitled Grievances, includes, in part: it is the facility policy 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. such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their stay. [...]

Inspectors wroteBased on interview and record review, the facility has not established an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This had the potential to affect more than a limited number of residents in the facility. The facility could not produce complete documentation regarding testing for residents during an outbreak of COVID-19. The facility did not thoroughly screen a staff member who reported symptoms that could be associated with COVID-19 for the [DATE] COVID outbreak. The facility's infection control line list for staff contained inaccurate and/or missing information. A staff member with signs and symptoms consistent with COVID-19 returned to work without 2 negative COVID-19 tests completed 48 hours apart. This is evidenced by: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that self-administration of medications was determined to be clinically appropriate for 1 of 1 supplemental resident (R34) reviewed for self-administration of medications out of a total sample 15. R34 was observed unsupervised with medication sitting on the bedside table. This is evidenced by: The facility policy entitled, Administering Medications, revised date, December 2012, indicates, in part: Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 1. Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so . 24. [...]

Inspectors wroteBased on interview and record review, the facility did not notify the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 15 sampled residents (R18). R18's Activated Power of Attorney for Health Care (APOAHC) was not notified promptly of changes with Physician's orders. Evidenced by: The facility's policy titled Change in a Resident's Condition or Status, dated February 2021 states in part, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/ mental condition and/ or status . R18 was re-admitted to the facility on [DATE] following a hospitalization. [...]

Inspectors wroteBased on observation and interview, the facility did not ensure residents who are unable to carry out activities of daily living receive the necessary services to maintain good nutrition, this has the potential to affected 1 of 15 residents (R26) reviewed for Activities of Daily Living (ADLs). R26 was observed to have a thick film on her teeth and around her mouth. R26 is dependent on staff for oral care. R26 does not have a comprehensive care plan that includes oral care. The facility failed to develop and implement individualized, patient specific care plans that addressed providing oral care or interventions for when R26 refuses oral care. This is evidenced by: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide assistive devices and care plan the interventions to ensure safety and prevent accidents for 1 (R5) of 3 residents reviewed for accidents out of a sample of 15 residents. R5 has a history of falls. The facility failed to create a robust person-centered Comprehensive Care Plan to support R5. The facility failed to ensure all staff are educated on interventions to best support R5. Evidenced by: The facility policy titled, Fall Prevention, with a revision date of 3/10/17, includes, in part: It is the policy of this facility to identify residents at risk for fall, develop plans of care that address the risk and implement procedures to assist in preventing falls. [...]