Lindengrove Menomonee Falls

Inspectors wroteBased on observation, interview, and record review the facility did not ensure 4 out of 7 residents (R2, R43, R1, R39) who were at risk for falling received the appropriate interventions to prevent further falls from occurring. The facility did conduct a thorough investigation of R2's falls on 5/11/26, 5/23/26, 6/2/26 and 6/4/26. The facility did not update the plan of care with additional interventions that could prevent R2 from future falls and injuries. R43 experienced a fall on 5/21/26 and 6/7/26. The facility did not thoroughly investigate and update R43's plan of care with interventions that could prevent R43 from future falls and injuries. The facility did not conduct a thorough investigation after R1 had a fall on 7/13/26. R39's falls care plan documented a call don't fall sign implemented 12/8/25 which was not observed to be in place. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure injuries of an unknown source were reported immediately, but not later than 24 hours after the event, to the State Agency for 3 of 3 residents (R1, R44, R43) reviewed for injuries of unknown origin from a sample of 12 residents. R1 was found by a family member with bruising and swelling the left ankle. The facility did not report the injury of unknown origin to the State Agency. R44 had an injury of unknown origin reported to staff by a family member on 7/6/26, which was not reported to the Nursing Home Administrator (NHA) until 7/11/26. R43 was found with bruising to the forehead. The facility did not report the injury of unknown origin to the State Agency.

Inspectors wroteBased on interview and record review, the facility did not ensure an alleged violation of mistreatment, including injuries of unknown source, was thoroughly investigated for 2 of 3 (R1, R43) residents reviewed for injuries of unknown origin from a sample of 12 residents. R1 was found by a family member with bruising and swelling of the left ankle. The facility did not investigate the injury of unknown origin. R43 was found with bruising to the forehead. The facility did not investigate the injury of unknown origin or report an investigation.

Inspectors wroteBased on interview and record review the facility did not ensure 3 (R56, R4 and R1) of 3 residents received necessary care and treatment. On 5/28/26 R56 had physician orders from a nephrology consult for daily weights and applying Sequential Compression Device (SCD) for edema. The facility did not obtain daily weights and SCD to monitor. On 12/30/25 R4 sustained an unwitnessed fall. The fall investigation documents neuro (neurological) checks to be conducted. The facility had no evidence neuro checks were completed. On 7/13/26 R1 sustained an unwitnessed fall. The fall investigation documents neuro (neurological) checks to be conducted. The facility had no evidence neuro checks were completed.

Inspectors wroteBased on interview and record review, the facility did not ensure 1 (R39) of 1 resident was free of significant medication errors from a sample of 12 residents. R39 received a different resident's medications on 6/10/26. R39 was prescribed Valbenazine Tosylate for Tardive Dyskinesia without a documented diagnosis of Tardive Dyskinesia or other documented indication to receive Valbenazine Tosylate. R39 was administered 32 doses of Valbenazine Tosylate 60 milligrams (mg) between the dates of 6/16/26 and 7/21/26.

Inspectors wroteBased on interviews, document review, and facility policy review, the facility failed to ensure the timely resolution of grievances raised during monthly Resident Council meetings and failed to document a rationale when grievances were not resolved for repeated concerns with staff attentiveness and call light response times, and housekeeping services for four of seven months of resident council minutes reviewed. This failure placed residents at risk for unmet and delayed care needs, decreased satisfaction with a clean and comfortable living environment, and reduced confidence in the grievance resolution process.

Inspectors wroteBased on observation and staff interview, the facility failed to maintain a safe and homelike environment, including to ensure housekeeping services were conducted as necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, the facility failed to ensure floors were swept and cleaned of dirt and trash in common areas including dining rooms, on two of three units (B and D) hallways and resident rooms during three of three survey days. Specifically, this deficient practice had the potential to affect the residents quality of life in their rooms and common areas.

Inspectors wroteBased on observations, interviews, and document review, the facility failed to ensure that the planned menus were followed as approved, scheduled, and posted. As a result, a pattern of 53 residents who received food prepared by the facility were not provided with the portion size as indicated on the planned menu. These failures placed facility residents at risk for weight loss, malnutrition, and dissatisfaction with their meals.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to report an allegation of abuse for one (Resident (R) 9) of one abuse allegation reviewed in the sample of 12 residents to the State Agency (SA) immediately, but no later than 2 hours after the incident. This failure had the possibility to negatively impact residents currently residing at the facility.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to thoroughly investigate an allegation of abuse for one (Resident (R) 9) of one resident reviewed for abuse in the sample of 12 residents. This failure had the potential to negatively impact all residents currently residing at the facility.

Inspectors wroteBased on the comprehensive assessment of a resident, the facility did not ensure that residents receive care, consistent with professional standards of practice, to prevent pressure injuries and do not develop pressure injuries unless the individual's clinical condition demonstrates that they were unavoidable; and residents receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 2 of 2 (R2 and R4) residents reviewed for pressure injuries. R2 admitted to the facility without pressure injuries and was identified to be at risk for pressure injuries. Care plan interventions to prevent pressure injuries were not implemented. R2 developed a facility acquired unstageable pressure injury and the care plan was not revised. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure adequate supervision and safety to prevent an accident from occurring for 3 of 3 Residents (R1, R3, and R4) reviewed for accidents. *R3 had 10 unwitnessed falls, 3 were not thoroughly investigated for a root cause. On 7/19/25, R3 had an unwitnessed fall in which R3 sustained a left hip fracture. *R1's fall on 10/16/25 was not thoroughly investigated for a root cause. R1's fall interventions of brushing teeth after lunch, toileting schedule, call light in reach, and transferring using a gait belt were observed not to be implemented. *R4's call light was observed to not be within reach and received straws which R4 should not have due to an aspiration risk during the survey process. Findings Include: The facility's undated Falls policy and procedure documents: Policy: [...]

Inspectors wroteBased on record review and staff interviews, the facility did not ensure that allegations of neglect, abuse, and/or misappropriation involving 7 residents (R6, R7, R8, R9,R10, R2 and R1) were reported immediately to the State Survey Agency. *On 8/18/25, R6 initiated a formal grievance to include an allegation of neglect that R6 had not been changed for over 2 hours. On 10/2/25, R6 initiated a formal grievance to include an allegation of neglect of having to wait to be changed until the next shift. The allegation of neglect was not reported to the State Survey Agency. *On 8/12/25, R7's representative initiated a formal grievance to include an allegation of neglect that R7 had to wait a long time to get R7's call light answered. The allegation of neglect was not reported to the State Survey Agency. [...]

Inspectors wroteBased on record review and staff interviews, the facility did not ensure that allegations of neglect, abuse, and/or misappropriation involving 7 residents (R6, R7, R8, R9, R10, R2 and R1) were not thoroughly investigated. *On 8/18/25, R6 initiated a formal grievance to include an allegation of neglect that R6 had not been changed for over 2 hours. On 10/2/25, R6 initiated a formal grievance to include an allegation of neglect of having to wait to be changed until the next shift. The allegation of neglect was not thoroughly investigated. *On 8/12/25, R7's representative initiated a formal grievance to include an allegation of neglect that R7 had to wait a long time to get R7's call light answered. The allegation of neglect was not thoroughly investigated. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 5 of 5 direct care staff chosen at random received Quality Assurance and Performance Improvement (QAPI) training with the potential to affect all 43 residents in the facility. Certified nursing assistant (CNA)-CC, CNA-DD, CNA-EE, CNA-FF, and CNA-GG did not receive QAPI training as a new hire.

Inspectors wroteBased on interview and record review, the facility did not ensure 1 (R3) of 1 resident's representative was notified when there was a need to alter medical treatment.*R3's emergency contact/representative was not notified when R3 had a fall on 6/30/25 and 7/12/25.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure residents who are unable to carry out activities of daily living receive the necessary services to maintain good grooming for 1 (R4) of 1 resident reviewed for ADL's (Activities of Daily Living).*R4 was to have maintained short fingernails per documented skin intervention. R4 fingernails were observed during the survey process to have extremely long fingernails on all fingers of both hands. Findings Include:The facility's undated policy titled STANDARD ADL (activities of daily living) PROTOCOL documents:- ADLS: Dressing, grooming, eating, toileting, bathing, personal hygiene (oral care, face, hands), mobility, transfers- Problem: Individual requires assistance with Activities of Daily Living (ADLs)- Goal: [...]

Inspectors wroteBased on interview and record review the facility did not ensure that based on the comprehensive assessment of a resident, residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident's choices for 3 (R1, R2, & R3) of 4 residents. *R1 receives an anticoagulant twice a day. On 10/16/25 R1 sustained an unwitnessed fall hitting her head. R1 sustained a large purplish hematoma on the left side of the R1's forehead and a skin tear on the left hand. While R1 was laying on the floor, Licensed Practical Nurse (LPN)-N obtained vital signs and Nurse Practitioner (NP)-K assessed R1's range of motion. NP-K informed Surveyor after assessing R1's range of motion she left R1's room as multiple staff were coming into the room. NP-K informed Surveyor she planned on returning to R1's room. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not provide the necessary respiratory care and services for 1 (R1) of 2 residents receiving oxygen therapy. R1did not receive oxygen via nasal cannula per physician orders. On 10/16/25, the ambulance crew observed R1's oxygen tubing was disconnected at the connector and R1's oxygen level was 80%. The facility's intervention to prevent this from occurring in the future was to not use extension tubing. On 11/4/25, R1's oxygen tubing was observed to have extension tubing.

Inspectors wroteBased on interview and record review the facility did not provide routine and emergency drugs and biologicals to its residents (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (R2) of 4 residents reviewed. R2's Mirtazapine was not given as ordered.

Inspectors wroteBased on interview and record review, the facility failed to report an injury of unknown origin (IUO) within required timeframes to the State Survey Agency (SSA) for one of three residents (Resident (R) 2) reviewed for abuse out of a total sample of six. Failure to report injuries of unknown origin places all residents at risk of abuse.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to thoroughly investigate an injury of unknown origin for one of three residents (Resident (R) 2) reviewed for abuse out of a total sample of six. Failure to thoroughly investigate injuries of unknown origin places residents at risk of continued abuse.

Inspectors wroteBased on interview and record review the facility did not provide the opportunity for 1 (R3) of 3 Residents reviewed to participate in the development and implementation of their person-centered plan of care by not facilitating the inclusion of R3 and/or their representative in the care planning process. *R3 was admitted to the facility on [DATE] for short term rehabilitation, and there is no documentation in R3's electronic medical record (EMR) that R3 and/or their representative participated in the development and implementation of R3's person-centered plan of care on a quarterly basis. Findings Include:The facility's Individual Care Plan Conferences policy and procedure last reviewed 3/8/23 documents: . I. Policy: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 1 (R1) of 3 residents reviewed received a prompt resolution of grievances filed, including documentation of steps taken to investigate the grievance, and corrective actions taken by the facility as a result of the grievance. R1's POA filed three grievances with the facility, and there is no evidence of the grievances being thoroughly investigated or a resolution obtained and shared with the complainant.

Inspectors wroteBased on interview and record review, the facility did not ensure 1 (R1) of 3 residents' care plans reviewed were revised as needed based on preferences and needs of the resident. R1's care plan was not revised to include interventions for the safe storage of R1's dentures.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure 1 (R1) of 3 residents reviewed received the appropriate treatment and services to maintain the ability to carry out activities of daily living, including mobility and elimination. R1 was not provided assistance walking in hallways or to the bathroom, was not transferred at the highest practicable level, and was not provided toileting care as indicated in R1's care card and care plan. Findings Include:The facility policy titled Safe Individual Handling Program, with implementation date of 2/8/17 and reviewed date of 5/8/25 documents: . Procedure:A. Transfer Assessment1. Individuals will be assessed according to ability per transfer and movement objective criteria. Nursing will perform this assessment in collaboration with therapy as applicable.2. [...]

Inspectors wroteBased on staff interviews and record review, the facility did not ensure therapy services were provided in a timely manner for 1 (R1) of 1 resident reviewed for therapy services. R1 received orders to start physical therapy (PT) and occupational therapy (OT) dated 4/29/25. PT and OT services were not initiated until 7/14/25. Findings Include: R1 was admitted to the facility on [DATE], with diagnoses that include hemiplegia and hemiparesis (weakness) following cerebral infarction (stroke) affecting right dominant side, anxiety, chronic diastolic (congestive) heart failure, chronic obstructive pulmonary disease, and type 2 diabetes mellitus. R1's most recent Quarterly Minimum Data Set (MDS) assessment completed 4/29/25 documents R1 requires partial assistance for showers, dressing, bed mobility, transfers, and to walk ten feet. [...]

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure 2 (R147 & R350) of 3 residents reviewed with pressure injuries received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new pressure injuries from developing. * R147 developed skin concerns of MASD (moisture-associated skin damage) noted at the facility on 10/28/24. There were no care plan revisions implemented and no comprehensive assessments completed. On 11/04/24, while at the hospital, R147 was found to have an infected sacral wound requiring debridement. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 1 (R297) of 13 residents received treatment and care in accordance with professional standards of practice, the comprehensive person centered care plan and the residents choice. * R297 was admitted to the facility on [DATE] with an order to the left shin which continued until 8/1/24. There is only one skin assessment of this area dated 5/25/24. On 7/22/24 Advanced Practice Nurse Prescriber-FFF progress note documents two dressings on R297 left lower extremity. There are no skin assessments of R297's left lower extremity as to why dressings were applied. On 7/28/24, R297's left forearm was identified as being bruised and red with an indentation from R297's watch being too tight. On 8/1/24 R297's left forearm skin integrity changed from redness to scabbing. There is no skin assessment when R297's skin integrity changed. [...]

Inspectors wroteBased on observation, record review and interview, the facility did not ensure that residents received adequate supervision and assistance to prevent accidents. The facility did not thoroughly assess falls and accidents for causative factors. The facility did not ensure fall interventions were implemented. This was observed with 6 (R12, R23, R36, R39, R346 and R347) of 6 residents reviewed for accidents. * R12's falls were not thoroughly assessed for causative factors. There was not observations of fall preventative interventions * R23's falls were not thoroughly assessed for causative factors. There was not observations of fall preventative interventions * R36 was observed not to have their call light not in reach per his falls plan of care. * R39's falls were not thoroughly assessed for causative factors. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not designate a licensed nurse to serve as a charge nurse on each tour of duty. * The facility did not designate a charge nurse for each tour of duty on each daily nursing schedule. This deficient practice has the potential to affect all 49 residents residing in the facility.

Inspectors wroteBased on review of daily staff postings, staffing schedules, and interview, the facility did not use the services of a RN (Registered Nurse) for at least 8 consecutive hours a day, 7 days a week. * On multiple dates, there was no RN who worked at the facility for 8 consecutive hours. This deficient practice has the potential to affect 49 of 49 residents residing in the building.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure food was prepared, and served, in a sanitary manner. This was observed in 2 of 2 food preparation and serving areas and with the meal tray service to resident rooms on 1 (Unit A) of 4 units. * The facility did not ensure the facility kitchen dish machine was functioning to sanitize dishware. * The dietary staff was observed without hair restraints in the 1st floor kitchen preparation and serving area and the main kitchen. * On Unit A resident meal trays items were not covered during delivery to resident rooms. * The facility kitchen dish machine was not monitored, and checked, to ensure appropriate sanitization of dishware.

Inspectors wroteBased on [NAME], [NAME] & [NAME] [NAME]-Water management program not implemented/not mentioned in facility, Staff not wearing proper PPE for enhanced barrier, No baseline rates of infection for prevalent infections and analysis of 2 outbreaks, The facility assessment does not include information on how facility Infection Preventionist [NAME]'s duties are being fulfilled as she conducts dual roles, [NAME]- [NAME] catheter bag laying on floor, enhanced barrier precautions PPE not followed [NAME] staff lack of hand hygiene during incontinence care [NAME]- Observations of [NAME]'s catheter bag on floor, emptying catheter without proper technique/hygiene Resident #12 FTag Initiation 02/11/25 09:28 AM 11/27/24 significant change mds bims 1 mood 00 no behavior upper & lower extremity one side eating supervision, toileting hygiene, roll left and right, chair/bed to chair transfer & toilet [...]

Inspectors wroteBased on observation, staff interviews and record review, the facility did not ensure a safe, clean, comfortable and homelike environment as evidenced by having a linen shortage in order to properly take care of residents with the potential to affect a pattern of Residents who prefer to wear hospital gowns at night. * R196 informed Surveyor that hospital gowns were not available all weekend, Monday, and Tuesday (2/8-2/11/25) for bedtime and that is R196's preference to wear a hospital gown for bed.

Inspectors wroteFacility not having ability to provide gowns to residents Has ability to effect a pattern of resident who prefer to wear gowns FACILITY FTAGDIR Based on observation, staff interviews and record review, the facility did not ensure a safe, clean, comfortable and homelike environment as evidenced by having a linen shortage in order to properly take care of Residents with the potential to affect 1 of 4 residents interviewed () as well as those residents who receive linens from the linen carts on A,B,C,D units. *R196 informed Surveyor that hospital gowns were not available all weekend, Monday, and Tuesday for bedtime and that is R196's preference to wear a hospital gown for bed.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure 1 (R197) of 1 residents reviewed were assessed by the interdisciplinary team to determine it was clinically appropriate to self administer medication. * R197's as needed (PRN) Albuterol inhaler was observed in R197's drawer without a self-administration assessment and physician order to self-administer.

Inspectors wroteBased on interview and record review, the facility did not develop and implement a baseline care plan that includes the instructions needed to provide effective and person centered care for 2 (R197 and R350) of 5 residents reviewed. * R197 was admitted to the facility on [DATE] and did not have a baseline care plan initiated upon admission. * R350 was admitted on [DATE] and did not have a baseline care plan initiated upon admission.

Inspectors wroteBased on interview and record review the facility did not ensure a comprehensive person centered care plan was developed for 1 (R297) of 13 residents. * R297's foley catheter was discontinued on 6/7/24. The facility did not develop a urinary care plan after R297's foley catheter was discontinued.

Inspectors wrote2.) R23's diagnoses includes obstructive & reflux uropathy and neuromuscular dysfunction of the bladder. R23 is receiving hospice services. R23's admission MDS (minimum data set) with an assessment reference date of 11/8/24 is checked for an indwelling catheter. R23's urinary incontinence and indwelling catheter CAA (care area assessment) dated 11/11/24 documents under the analysis of findings for nature of problem/condition: neurogenic bladder obstructive urop (uropathy) foley cath (catheter) retention. Under the care plan considerations section it documents: Proceed to plan of care. Maintain Foley cath-cath places at risk for infection. Goal for no complications/infections r/t (related to) cath. R23's indwelling catheter care plan initiated 11/1/24 & revised 11/11/24 includes an intervention of monitor and document intake and output as per facility policy. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not provide the necessary respiratory care and services for 1 (R23) of 2 residents receiving oxygen therapy. * R23's oxygen tubing was dated 12/7/24 and was not changed weekly according to R23's physician orders.

Inspectors wroteBased on interview and record review, the facility did not provide dialysis services consistent with professional standards of practice for 1 (R39) of 1 Residents reviewed for dialysis. * R39 receives dialysis three times per week. R39's dialysis center communication records are not being consistently completed by Facility nurses.

Inspectors wroteBased on interview and record review, the facility did not ensure adequate monitoring for adverse reactions of high-risk medications for 1 (R7) of 6 residents reviewed for unnecessary medications in accordance with standards of practice. *R7 has physician's order for Warfarin (an anticoagulant) for chronic embolism and thrombosis of unspecified deep veins of unspecified lower extremity. The facility did not implement care plans to monitor for any adverse side effects that could result from taking an anticoagulant. 1.) R7 was admitted to the facility on [DATE] with diagnoses that includes Atrial Fibrillation, Cerebral Infarction and Hyperlipidemia. R7's Quarterly MDS (Minimum Data Set) Assessment with an assessment reference date of 12/23/2024 indicates that R7 received an Anticoagulant medication during the assessment period. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that 3 (R350, R3 and R36) or 6 residents reviewed for medications were free from unnecessary psychotropic medications. * R350 was prescribed Risperidone (anti-psychotic medication) for bipolar disorder. R350 does not have a diagnosis of bipolar disorder. R350 was prescribed Escitalopram (anti-depressant medication) without a documented diagnosis in the physician order. Facility staff did not document behavior monitoring and side effect monitoring for Risperidone and Escitalopram from 2/6/25 through 2/13/25. * R3 is prescribed an anti-depressant medication. Facility staff did not document side effect monitoring from 1/27/25 through 2/15/25. * R36 is prescribed an anti-depressant medication. Facility staff did not document side effect monitoring from 11/4/24 through 2/15/25.

Inspectors wroteBased on observation, interview and record review, the facility did not provide 3 (R196, R197, and R347) of 3 residents reviewed for dietary services, with food accommodations and preferences as listed on the Resident's meal tickets. * R196 meal ticket states no oatmeal and received oatmeal on 2/11/25 and 2/12/25. R196 did not received the berries for breakfast on 2/13/25. * R197's meal ticket states dislikes eggs but received denver eggs on 2/11/25 for breakfast. *On 2/11/25, residents received a peanut butter cookie instead of the frosted pumpkin bar listed on the posted menu. On 2/12/25, the Residents received beef barley soup instead of french onion soup listed on the posted menu. * R347 did not received a banana per meal ticket on 2/13/25. Findings Include: Surveyor reviewed the facility's dining policies and procedures. The undated Meal Identification policy documents: Policy: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure they followed their antibiotic stewardship program for 1 (R23) of 1 residents reviewed for antibiotic use. * R23 was treated with an antibiotic for a UTI (urinary tract infection) without meeting criteria.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that the daily nurse staff posting included all required information accurately. This deficient practice has the potential to affect a pattern of all 39 residents residing in the facility. The facility's nurse staff posting did not accurately reflect the correct number of staff members on each daily nurse staff posting.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide quality care in accordance with physician orders for one of four sample residents (Resident (R) 2). Specifically, the facility failed to perform a post void residual on R2 every shift as ordered.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to follow the facility's pain policy to ensure effective pain management for one of four residents (Resident (R) 4), reviewed for pain out of a total sample of four residents. This failure resulted in harm when R4 had increased pain and cried and screamed for 3.5 hours awaiting administration of her narcotic pain medication

Inspectors wrote2. R40 was admitted to the facility on [DATE] with diagnoses of type 2 diabetes, bipolar, depression, and spinal stenosis and osteoarthritis. R40 was discharged from the facility on 7/28/23. R40 had a Braden Score completed on 3/14/23 which indicated a score of 20, which is not at risk for pressure injuries. R40 had no other Braden Score completed. The admission MDS (Minimum Data Set) dated 3/30/23 indicates R40 needed extensive assistance with bed mobility, transfers, dressing, and hygiene. It also indicates R40 is occasionally incontinent of urine. It also indicates R40 is at risk for pressure injuries, and has no unhealed Pressure injuries. The MDS indicates R40 only has a pressure reducing device for the chair. The MDS is not checked for a turning/repositioning program. [...]

Inspectors wroteBased on observation and record review, the facility did not maintain documentation of a comprehensive infection control program including infection surveillance and the facility did not have a comprehensive water management plan. This deficient practice has the potential to affect 38 of the 38 residents residing in the facility at the time of the survey. * The facility was not able to show evidence of an infection control surveillance system designed to identify infections before they can spread to others in the facility, prior to December 1, 2023, when the facility identified the deficit and implemented a Performance Improvement Plan. While on survey, the facility was able to provide a line list about the Covid outbreak that occurred around August 7 & 8, 2023. [...]

Inspectors wroteBased on record review and interviews, the facility did not develop a comprehensive plan of care for assessed medical needs. This was discovered with 5 (R25, R3, R43, R32, and R39) of 21 medical record reviews. - R25 was admitted with medication of an antidepressant and anticoagulant. There was not a comprehensive plan of care developed for these medical concerns. -R3 was admitted with anticoagulant medication. There was not a comprehensive plan of care developed for this medical concern. -R43 eloped from the facility. There was no comprehensive plan of care developed for R43's elopement. -R39 is diabetic and receives hospice services. There was no comprehensive plan of care developed for diabetes and hospice care. -R32 receives oxygen for respiratory concerns. There was no comprehensive plan of care developed for oxygen use.

Inspectors wroteBased on observation and interview the Facility did not ensure eye drops and insulin were dated when opened, medications were not expired, medications belonging to residents who no longer resided in the facility were disposed of properly, and the medication refrigerator was being monitored for appropriate temperature. This deficient practice has the potential to affect R1, R29, R4 and a pattern of residents residing on the first floor who utilize refrigerated medications and/or stock medications. *R1, R29 and R4 had medications in the Unit D medication cart that were either not dated and/or expired. *The first-floor medication room contained expired stock medications. *The first-floor medication room refrigerator contained medications belonging to residents no longer in the facility and insulin that was opened but not dated. [...]

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R43) of 7 residents reviewed for discharge received a thorough discharge summary in order to communicate necessary information to the resident *R43 discharged from the facility on 5/19/23. The facility did not complete a discharge summary or a recapitulation of their stay that was available to R43 or R43's representative upon consent.

Inspectors wroteBased on interviews and record reviews the facility did not conduct a root cause analysis of resident falls in order to determine whether current interventions were implemented at the time of the fall, whether current interventions were effective and to determine appropriate ongoing interventions and supervision needed for 2 (R43 and R39) of 6 residents reviewed for falls. *R43 sustained a fall on 5/7/23. The facility did not thoroughly investigate R43's fall. *R39 sustained a fall on 2/28/23. The facility did not thoroughly investigate R39's fall.

Inspectors wroteBased on interview and record review the facility did not offer the pneumonia vaccine for two (R11 and R12) of five residents reviewed for vaccinations.

Inspectors wroteBased on observation, interview, and facility policy review the facility did not ensure the garbage and refuse were properly disposed in the outside garbage storage receptacles. This deficient practice had the potential to affect all 38 residents residing at the facility.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that a resident with a pressure injury received necessary treatment and services, consistent with professional standards of practice, to promote healing for 1 of 7 (R17) residents reviewed for pressure injuries. *R17 was admitted on [DATE] to the facility with a stage III pressure injury on their coccyx and the facility did not initiate the appropriate pressure reducing mattress until 9/13/22.

Inspectors wroteBased on observation, interview and record review the facility did not ensure it's medication error was was not 5 percent or greater, when 2 errors out of 28 opportunities for error was observed affecting R29 & R11, with a medication error rate of 7.14 percent. * R29 was not administered eye drops as ordered. * R11 was administered insulin beyond the expiration date.