Madison Health and Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review the facility did not Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This has the potential to affect all 67 residents. Surveyor observed open food in the refrigerator, undated and unlabeled food in the freezer, staff food and beverages stored in the same cooler as resident food, ice accumulation in the freezer, and a freezer temperature of positive 8 degrees. Evidenced by: Facility policy, titled Food Safety Requirements, dated 3/26/25, includes the following, in part: Guideline: . Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety. Definitions: . Food service safety refers to handling, preparing, and storing food in ways that prevent foodborne illness. Explanation and Compliance Guidelines: 1. [...]

Inspectors wroteBased on observation, and interviews, 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 6 shower rooms and 1 (R6) of 9 residents rooms reviewed for cleanliness of a total sample of 67 residents. R6 voiced concerns related to the cleanliness of their room. Surveyor observed brown smears on the floor, dirt and grime crusted in the corners, sticky floors, accumulated soap/shampoo scum on the wall, and overflowing waste baskets and linens carts in the shower rooms. Evidenced by: Facility Housekeeping Schedule indicates that public bath and shower rooms need to be deep cleaned on the weekends. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that all residents are clinically appropriate to self-administer medications for 1 of 1 residents (R6) observed with medications at bedside out of 9 sampled residents. R6 was observed to have medications left on her bedside table for her to take independently. R6 does not have an assessment for self-administration of medications indicating that she is safe to administer medications independently. This is evidenced by:The facility's policy Medication Administration, dated 4/9/25, includes: Medications are administer by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. 18. Observe resident consumption of medication. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure each resident's right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility is changed for 1 of 3 residents reviewed for room changes (R8) out of a sample of 9. R8 was moved to another room without notice and without reason for the change.

Inspectors wroteBased on record review and interview, the facility did not complete the Preadmission Screening and Resident Review (PASARR) Level II when it was realized that a resident would reside in the facility for more than 30 days for 1 of 1 resident (R6) reviewed for PASARR out of 9 sampled residents. R6 resided in the facility for longer than 30 days and required a PASARR Level II screen, but the facility failed to complete the screening. This is evidenced by: The facility's policy, Resident Assessment - Coordination with PASARR Program, dated 1/9/26, includes: If a resident who was not screened due to an exception above and the resident remains in the facility longer than 30 days: a. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure each resident receives adequate supervision to prevent accidents and hazards for 1 of 1 residents (R6) reviewed for smoking out of 9 sampled residents. R6 was observed smoking in her room after she was deemed safe to have her smoking materials in her possession. R6 was not reassessed timely for safety after being observed smoking in her room. R6 was reassessed to be a supervised smoker and continued to have smoking materials in her possession without safety interventions being put in place. This is evidenced by: The facility's policy Resident Smoking, dated 12/1/23, includes: 1. Smoking is prohibited in all areas except the designated smoking areas. 4. Residents and resident representatives will be notified of this policy during the admission process and as needed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not provide the necessary respiratory care and services 1 of 1 (R6) reviewed for CPAP (Continuous Positive Airway Pressure) usage out of 9 sampled residents. R6 stated she cannot use her CPAP machine because the mask was missing. This is evidenced by: The facility's policy Noninvasive Ventilation (CPAP, BiPAP, AVAPS, Trilogy), dated 1/9/26, includes: It is the policy of this facility to provide noninvasive ventilation as per physician's orders and current standards of practice. CPAP, or continuous positive airway pressure, is a respiratory therapy intervention used to provide a patent airway during periods of sleep apnea. It uses air pressure generated by a machine, delivered through a tube into a mask that fits over the nose or mouth. 3. The CPAP. device must be set up and maintained. 5. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 3 residents (R1) reviewed for accidents. On 3/9/26, CNA C (Certified Nursing Assistant) was providing perineal care to R1. CNA C had R1 positioned on her left side which has paralysis from a stroke and toward the left side of the mattress versus the middle. Per NHA A (Nursing Home Administrator), CNA C turned to get more wipes and removed her hand from R1 for two (2) seconds. R1 fell from the bed onto the floor. R1's fall was unwitnessed as CNA C did not observe R1's fall from bed. R1 was not positioned toward CNA C for added stability nor did R1 have anything to hold onto with her right hand while positioned on her left side. On 3/10/26 an x-ray was obtained indicating No acute fracture or dislocation. [...]

Inspectors wroteBased on observation, staff interview, and record review the facility did not provide special assistive eating equipment for 1 of 3 sampled residents (R6) reviewed for assistive devices. The facility did not provide R6 with a built-up utensil (adaptive eating tools with thickened handles, designed for residents with limited gripping strength or hand tremors) as indicated per plan of care. Evidenced by: R6 was admitted with diagnoses of cerebral palsy (a neurological disorder affecting movement and muscle tone) and epilepsy (a chronic neurological disorder characterized by seizures causes by abnormal electrical activity in the brain). R6's meal ticket on 4/7/26 (breakfast) states in part, as follows: Built up utensils R6's comprehensive care plan documents as follows: Focus: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. This has the potential to affect the census of 63. DA D (Dietary Aid) was observed stacking wet dishes without allowing them ample time to dry. Evidenced by: Facility policy entitled Warewashing, states in part: .All dishware, serviceware, and utensils will be cleaned and sanitized after each use. Procedures 1. The dining services staff will be knowledgeable in the proper technique for processing dirty dishware through the dish machine, and proper handling of sanitized dishware .4. All dishware will be air dried and properly stored. On 2/16/2026 at 1:03 PM, Surveyor observed dishwashing. [...]

Inspectors wroteBased on interview and record review, the facility did not follow through on a recommendation from the Audiologist for hearing aides/amplification for a resident who expressed not being able to hear for 1 (R60) of 24 residents reviewed for hearing. R60 received an order for hearing aids, and this order was not fulfilled. This is evidenced by: Facility policy: Hearing and Vision Services, revised 3/2025 states in part: . Guideline: It is the guideline of the facility to ensure all residents have access to hearing services and receive adaptive equipment as indicated. R60 was admitted to the facility on [DATE] and has diagnoses that include Type II Diabetes Mellitus, Schizophrenia, and Major Depressive Disorder. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that: (i) The agreement is explained to the resident and his or her representative in a form and manner that he or she understands, including in a language the resident and his or her representative understands; (ii) The resident or his or her representative acknowledges that he or she understands the agreement for 2 of 2 Residents (R2 and R72) reviewed for arbitration agreements. R2 indicated the arbitration agreement was not fully explained and he/she would not have signed if he/she knew there would no longer be the right to use the judicial system to resolve a dispute with the facility. R72 indicated the arbitration agreement was not fully explained and he/she would not have signed if he/she knew there would no longer be the right to use the judicial system to resolve a dispute with the facility. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not ensure that every resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility for 1 (R4) of 6 sampled residents. R4 prefers staff to wear a mask when entering his room. Surveyor observed staff entering R4's room without a mask. Evidenced by: The facility's Resident Rights admission Document states, in part: . Resident rights. The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. 2. Planning and implementing care. The resident has the right to be informed of, and participate in, his or her treatment, including: . b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that each resident has a safe, clean, comfortable and homelike environment for daily living for 1 of 6 sampled Residents (R2). Surveyor observed a commode in R2's room with a brown substance on the seat and arm. Findings Include:The facility policy, Safe and Homelike Environment, revised 7/1/25, indicates, in part: Guideline: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment. Definitions: . Sanitary includes, but is not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored. Resident care equipment includes, but is not limited to, equipment used in completion of the activities of daily living. R2 was admitted on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the results of all investigations of alleged violations were reported to the resident 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 for 1 of 2 Facility Reported Incidents reviewed. An initial Facility Reported Incident alleging possible misappropriation of property was submitted to the State Agency on 12/7/25. The facility submitted the results of their internal investigation to the State Agency on 12/15/25, which is outside of the required timeframe of 5 working days. This is evidenced by:The facility policy entitled Abuse, Neglect, and Exploitation with a review date of 5/25 states in part: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect 72 of 72 residents. Surveyor observed left over food items not properly covered, labeled, or dated. Surveyor observed cleanliness concerns in main kitchen. Surveyor observed staff in kitchen not wearing beard restraints. Surveyor observed food being stored on the floor in the dry storage, walk in refrigerator, and walk in freezer. Surveyor observed staff touching the inside surface of a container used to hold food with their bare hands. Surveyor observed staff prepare food without using a recipe. This is evidenced by: The facility's policy Food Preparation Guidelines, dated 12/17/24, includes: [...]

Inspectors wroteBased on observation, interview and record review, the facility has not established an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This has the potential to affect 3 of 6 hallways. Surveyor observed 2 staff members incorrectly wearing PPE (Personal Protective Equipment) on the Covid-19 positive hallway. RN V (Registered Nurse) did not perform hand hygiene between glove changes. This is evidenced by: The facility's policy Personal Protective Equipment, dated 6/11/25, includes: This facility promotes appropriate use of personal protective equipment to prevent the transmission of pathogens to residents, visitors, and other staff. [...]

Inspectors wroteNumber of residents sampled: 2Number of residents cited: 1Based on observation, interview, and record review, the facility did not ensure that all residents are clinically appropriate to self-administer medications for 1 of 2 residents (R48) reviewed for self-administration of medications. Surveyor observed R48 to have a cup of medications left on her bedside table on her meal tray for her to take independently. R48 did not have an assessment for self-administration of medications and did not have an active physician's order. R48's care plan does not indicate R48 can self-administer medications. This is evidenced by: The facility's policy Resident Self-Administration of Medication dated 4/17/25, includes it is the guideline of this facility to support each resident's right to self-administer medication. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure that every resident had an Advance Directive, including Code Status (Do Not Resuscitate or Full Code (resuscitate)), this affected 1 of 21 residents (R58). R58 did not have a code status determination in her medical record. This is evidenced by:The Facilities Policy and Procedure entitled Resident's Rights Regarding Treatment and Advance Directives dated [DATE], documents in part: 1. On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive .9. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure adequate supervision and safety to prevent accidents from occurring for 2 of 3 residents reviewed (R53 and R85). R53 began smoking at the facility and was not assessed to be a safe, independent smoker once the facility was aware R53 began smoking. R85 was assessed to be at risk for falls. The facility did not assure that the care plan interventions were in place for R85. Evidenced by: The facility's policy titled Resident Smoking dated 12/15/23 states in part .6. Residents who smoke will be further evaluated using the Smoking Evaluation to determine supervision need and intervention.10. All safe smoking measures will be documented on the care plan and communicated to all staff, visitors, and volunteers who will be responsible for supervising residents while smoking. [...]

Inspectors wroteBased on observation, interview and record review the facility did not ensure the provision of routine biologicals for 1 of 9 residents observed for medication pass (R15). RN V (Registered Nurse) did not prime R15's insulin pen prior to administering 2 units of insulin. Evidence by:Facility policy entitled 'insulin pen,' states in part: .it is the guideline of this facility to use insulin pens in order to improve the accuracy of insulin dosing provide increased resident comfort and serve as a teaching aid to prepare residents for self-administration of insulin therapy upon discharge. Explanation and compliance guidelines: .2. Insulin pens must be clearly labeled with the resident name, physician name, date dispensed, type of insulin, amount to be given, frequency and expiration date.6. insulin pens will be primed prior to each use to avoid collection of air in the insulin reservoir.9. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure food allergies, intolerances and preferences were accommodated and/or individualized meal tickets were followed for 2 residents (R90 and R70) reviewed for food allergies/intolerances. R90 is allergic to eggs and milk. Staff served R90 an egg muffin sandwich and offered milk for breakfast on 8/21/25. R70 is lactose intolerant. Staff did not provide a milk alternative on 8/21/25. This is evidenced by: The facility's policy Food Preparation Guidelines, dated 12/17/24, includes: It is the policy of this facility to prepare foods in a manner to preserve or enhance a resident's nutrition and hydration status. Staff shall accommodate resident allergies, intolerances, and preferences, providing appropriate alternatives when needed. The facility's policy Menus and Adequate Nutrition, dated 5/26/24, includes: [...]

Inspectors wroteExample 3 R65 was admitted to the facility 11/4/24 with diagnoses including, but not limited to, the following: cerebral infarction (stroke), contractures bilateral knees (when muscles, tendons, joints tighten or shorten causing a deformity), reduced mobility (inability to move freely), osteoarthritis (degenerative disease that worsens over time causing pain and stiffness) of knee. R65's most recent Minimum Data Set (MDS) dated [DATE] documents, a score of 13 on his Brief Interview of Mental Status (BIMS), which indicates R65 is cognitively intact. R65 is his own person. R65's comprehensive care plan states, in part, as follows: Focus area: (Date Initiated: 11/4/24; Date Revised: 3/9/25) The resident has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) CVA (cerebrovascular accident); Goal: [...]

Inspectors wroteExample 2 R65 was admitted to the facility 11/4/24 with diagnoses including, but not limited to, the following: cerebral infarction (stroke), contractures bilateral knees (when muscles, tendons, joints tighten or shorten causing a deformity), reduced mobility (inability to move freely), osteoarthritis (degenerative disease that worsens over time causing pain and stiffness) of knee. R65's most recent Minimum Data Set (MDS) dated [DATE] documents, a score of 13 on his Brief Interview of Mental Status (BIMS), which indicates R65 is cognitively intact. Section M indicates R62 does not have any pressure injuries (PIs) upon admission and is at risk of PI's. R65 is his own person. R65's care plan indicates the following Focus area: (Date Initiated: 11/4/24; Date Revised: [...]

Inspectors wroteExample 3 The facility's policy titled Wound Treatment Management dated 2/14/23 states in part . 2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse . R37 was admitted to the facility on [DATE] with diagnoses that include chronic diastolic heart failure (a type of heart failure that occurs when the heart's left ventricle stiffens and cannot relax properly, preventing it from filling with enough blood), morbid obesity, depression, anxiety disorder, and history of stroke. R37's most recent Minimum Data Set (MDS) dated [DATE] states that R37 has a Brief Interview of Mental Status (BIMS) of 15 out of 15, indicating that R37 is cognitively intact. On 3/5/25 at 2:48 PM, Surveyor interviewed R37. [...]

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. R223 had a multi-drug resistant organism (MDRO) in her urine. R32, R44, and R47 later tested postived for the same MDRO. Hand hygiene was not performed per standards of practice for (R25 and R74). Residents (R223, R32, R44, & R47) are being cited at severity level 3 (actual harm), and (R25 and R74) are being cited at severity level 2 (potential for more than minimal harm). R223 had extended-spectrum beta-lactamase (ESBL) a MDRO, in R223's urine. ESBL is spread easily through hands and surfaces. The facility failed to ensure R223 was placed in proper transmission-based precautions. [...]

Inspectors wroteBased on observation, record review, and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. This has the potential to affect all 66 residents. Nutritional supplements were observed without the appropriate thaw dates. Dietary staff did not report when the dishwasher did not reach the necessary PPM (Parts Per Million).

Inspectors wroteBased on observation and interview, the facility did not ensure garbage and refuse was disposed of properly. This has the ability to affect all 66 residents. Garbage and litter was found near the facility's main dumpster area.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure the facility-wide assessment developed by the facility included all relevant details to ensure the facility provided care and services to residents to meet their individual needs within the facility's identified resources. This has the potential to affect all 66 residents residing at the facility. The facility assessment must reflect the resident population, the resources needed to care for this population as well as staff competencies to care for the resident population residing within the facility. The facility has several residents who do not speak English as their primary language, the staff did not have the competencies to communicate with these residents or to ensure their ethnic, cultural, and activity needs were being met. The facility has residents who require dialysis; [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that each resident has a safe, clean, comfortable and homelike environment for daily living for 1 of 24 sampled Residents (R51), 2 of 2 supplemental residents (R424 & R67) and 5 of 6 shower rooms. This had the potential to affect more than a limited number of residents in the facility. Surveyor observed R51's footboard on her bed and the wall next to her bed to contain many dried particles and not homelike. R424 and R67 voiced concerned about the shower cleanliness. Surveyor observed 5 out of 6 shower rooms as being unkept with visible black and brown substance in the shower area. As evidenced by: The facility policy, Safe and Homelike Environment, dated 10/23/24, indicates, in part, as follows: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that a review of the residents' total program of care to include signing monthly physician orders were completed for 9 of 11 residents (R17, R9, R20, R65, R6, R24, R2, R25, and R61) reviewed. R17 did not have Physician Orders signed monthly. R9 did not have Physician Orders signed monthly. R20 did not have Physician Orders signed monthly. R65 did not have Physician Orders signed monthly. R6 did not have Physician Orders signed monthly. R24 did not have Physician Orders signed monthly. R2 did not have Physician Orders signed monthly. R25 did not have Physician Orders signed monthly. R61 did not have Physician Orders signed monthly. This is evidenced by: The Facilities Policy and Procedure entitle Physician Visits and Physician Delegation dated 10/16/24 documents the following, in part: f. [...]

Inspectors wroteBased on interview and record review, the facility did not complete a performance review of every nurse aide at least once every 12 months for 4 of 5 Certified Nursing Assistants (CNAs) reviewed. CNA ZZ did not have an annual performance evaluation completed. CNA AAA did not have an annual performance evaluation completed. CNA BBB did not have an annual performance evaluation completed. CNA CCC did not have an annual performance evaluation completed. This is evidence by: The Facilities Policy and Procedure entitled Annual Employee Evaluation dated 5/2/23 documents, in part: Purpose: To comply with federal regulations, all employees will receive an annual evaluation of their work performance . Example 1 CNA ZZ's hire date was 11/28/22. CNA ZZ did not have an annual performance evaluation completed. Example 2 CNA AAA's hire date was 12/29/22. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that all residents are clinically appropriate to self-administer medications for 1 of 2 sampled residents (R25) and 1 of 1 (R7) supplemental residents reviewed for self- administration of medications. R7 was observed during medication administration to have his medications put into a Mighty Shake and left with R7 in the dining room to take independently. R7 does not have an assessment for self-administration of medications. R25 was observed to have a cup of medications left on her bedside table for her to take independently. R25 does not have an assessment for self-administration of medications. Evidenced by: The facility's policy titled Resident Self- Administration of Medication dated 5/1/24 states in part, .3. [...]

Inspectors wroteBased on interview and record review, the facility did not immediately notify and consult with the resident's physician when a change in the resident's physical, mental, or psychosocial status occurred for 1 of 24 residents (R71) reviewed for change in condition. R71 was was sent to the ED (Emergency Department) with a change in condition. The ED documented, Skin: Severe candidal rash around SP (suprapubic) cath (catheter) and into bilateral groin. R71 was diagnosed with Candidiasis intertrigo (a fungal infection that occurs in skin folds) involving the groin and area around SP (suprapubic) catheter and prescribed Nystatin. The facility did not document the rash nor notify the provider. As evidenced by The facility policy, Notification of Change, dated 10/24/23, documents, in part, as follows: [...]

Inspectors wroteBased on interview and record review, the facility did not make prompt efforts to document, investigate, and resolve grievances a resident may have for 1 of 8 residents reviewed for grievances (R73). R73 and her family voiced grievances to the facility. The facility did not complete appropriate interviews, audits, education, or provide follow up with to R73 or her family after the conclusion of the investigation. Evidenced by: The facility's policy titled Resident and Family Grievances, no date, states in part .10. Procedure: .d. The Grievance Official will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form. i. Steps to resolve the grievance may involve forwarding the grievance to department manager for follow up .g. [...]

Inspectors wroteBased on observation, interview and record review, the facility must ensure the assessment accurately reflects the resident's status, this affected 2 of 20 residents (R17 and R8) reviewed for Minimum Data Set (MDS). R17's most recent MDS indicates that R17 is receiving hospice services. R17 has not signed up for nor received hospice services. R8's MDS indicated that R8 had a pressure injury. R8 has not had a pressure injury since being admitted to the facility. This is evidenced by: The facility policy titled MDS 3.0 Completion dated 1/18/23 states in part: Policy: Residents are assessed, using a comprehensive assessment process to identify care needs and to develop an interdisciplinary care plan .4. Care Plan Team Responsibility for Assessment Completion: a. Interdisciplinary Responsibility for Completion of MDS Sections: i. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that a resident who is unable to carry out Activities of Daily Living (ADL's) received the necessary services to maintain personal hygiene for 1 of 20 residents (R51) reviewed for ADLs. R51 is scheduled to receive a shower on Mondays and Thursdays. The facility has no documentation that R51 was offered or declined a shower on the following dates: 2/6/25, 2/24/25, 3/3/25, and 3/6/25. Evidenced by: R51 was admitted to the facility on [DATE] with diagnoses including, but not limited to, the following: Alzheimer's disease, dementia, delusional disorders, restlessness and agitation. R51's most recent Minimum Data Set (MDS) dated [DATE] documents R51 is severely cognitively impaired. R51 has an Activated Power of Attorney for Health Care (APOAHC). R51's comprehensive care plan documents the following: (Date Initiated: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each resident. This has the potential to affect 1 of 21 sampled residents (R74) reviewed for activities. R74 does not speak English, Spanish only. Facility does not offer R74 activities appropriate for R74's culture/ethnicity. Evidenced by: The facility policy entitled, Activities, dated 12/23/22, states, in part: .Policy: It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that the residents environment remained free of accidents and hazards for 1 of 7 residents (R61) reviewed for accidents. Surveyor observed R61's bed was not in the lowest position and staff reported the bed was broken. Surveyor observed R61's fall mats and call light not in place. Evidenced by: The facility policy, Accidents and Supervision, dated 12/22, states, in part; .The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents .3. Implementing interventions to reduce hazard(s) and risk(s) . R61 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, stroke, anxiety disorder, and other seizures. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that residents with an indwelling catheter received the appropriate care and services to prevent a urinary tract infection (UTI) for 1 of 2 residents (R65) reviewed for catheters as catheter bags were observed to be uncovered and resting on the floor. Surveyor observed R65's indwelling urinary catheter bag to be resting in direct contact with the floor. Evidenced by: The Centers of Disease Control and the Healthcare Infection Control Practices Advisory Committee - Guidelines for Prevention of Catheter-Associated Urinary Tract Infections 2009 indicate in part: . III. Proper Techniques for Urinary Catheter Maintenance . B. Maintain unobstructed urine flow. 1. Keep the catheter and collecting tube free from kinking. 2. Keep the collecting bag below the level of the bladder at all times. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that a resident who requires dialysis receives such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 1 sampled resident (R24) reviewed for dialysis. The facility failed to provide ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. The facility staff were not fluent in the emergency plan for a resident bleeding from their dialysis fistula site. This is evidenced by: The facility's policy titled Hemodialysis with an implementation date of 2/15/23, includes, in part: Policy: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that residents were seen by a physician or physician extender (NP- Nurse Practitioner, PA- Physician Assistant) for 3 of 11 residents (R9, R20, and R2) reviewed. R9 did not have Provider visits timely. R20 did not have Provider visits timely. R2 did not have Provider visits timely. This is evidenced by: The Facilities Policy and Procedure entitled Physician Visits and Physician Delegation dated 10/16/24 documents, in part: .h. Ensure a progress note is present to reflect the date and time of the physician visit, an indication as to whether new orders were written or no new orders were received and any special discussions between the resident and/or family and physician during the visit .2. The Physician should .d. Date, write and sign progress note for each visit .h. [...]

Inspectors wroteBased on observation, interview and record review, the facility does not have nursing staff with the appropriate cultural competencies to communicate effectively while providing care to residents with communication needs and ensuring that devices are utilized per the care plan. This has the potential to affect 2 of 20 sampled residents (R74 & R423) and 1 of 12 supplemental residents (R9). The Facility does not ensure R74 is receiving communication in a language she can understand. The Facility does not ensure R423 is receiving communication in a language she can understand. The Facility does not ensure R9 is receiving communication in a language she can understand. Evidenced by: The facility policy entitled, Non-Discrimination-Language Assistance Services, dated 2/1/25, states, in part: .Policy: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure they followed their antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for 2 of 10 sampled Residents (R11 and R21) and 1 of 1 supplemental (R73) reviewed for antibiotic stewardship. R73 was treated with an antibiotic for a urinary tract infection (UTI) and urinalysis (UA) showed R73 did not have a UTI. R11 and R21 were treated prophylactically with antibiotics. Evidenced by: The facility policy entitled, Antibiotic Stewardship Program, dated 12/23/22, states, in part: . Policy: It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure adequate supervision, monitoring, and evaluation for 2 of 4 sampled residents (R2 and R3) after the residents had a fall. R2 had a fall on 11/1/24 at 1:00 PM (day shift). The facility did not document post-fall clinical findings or new fall intervention effectiveness after R2's fall. R3 had a fall on 10/28/24 at 4:55 PM (evening shift). The facility did not document relevant post-fall clinical findings or new fall intervention effectiveness after R3's fall. This is evidenced by: The facility policy titled Accidents and Supervision dated 12/29/22, states, in part: .Each resident will receive adequate supervision and assistive devices to prevent accidents . Monitoring for effectiveness and modifying interventions when necessary . Ensuring the interventions are put into action . [...]

Inspectors wroteBased on interview and record review, the facility did not ensure each resident received adequate supervision to prevent accidents for 1 of 3 residents (R3) reviewed for wandering and elopement potential. R3 eloped from the facility on 7/6/24 and the facility did not know his whereabouts for approximately seven (7) hours. Facility staff let R3 out of the building but did not know who he was or ensure he was monitored for safety. Police contact was made and a community silver alert was issued due to R3's unknown whereabouts. The facility's failure to provide adequate supervision to R3 and ensure adequate supervision created a finding of Immediate Jeopardy that began on 7/6/24. NHA A (Nursing Home Administrator) was notified of the immediate jeopardy on 8/21/24 at 3:30 PM. The Immediate Jeopardy was removed on 7/12/24; [...]

Inspectors wroteBased on observation, interviews, and record review, the facility did not ensure that residents had the right to receive visitors of their choosing at the time of their choosing for 1 of 19 residents (R5) reviewed for visitation rights. This resulted in R5 experiencing depression, financial hardship, and disinterest in participating in activities of daily living (ADLs). R5's husband is limited by the facility to visiting between the hours of 8:00 AM to 4:30 PM, regardless of the resident's wishes.

Inspectors wroteBased on observation, interviews, and record review, facility staff did not ensure that each resident who required pain management received such services according to the comprehensive person-centered care plan and the resident's goals and preferences for 2 of 19 residents (R6 and R5) reviewed for pain management. R6 asked for her as needed pain medication and did not receive it for almost 22 hours resulting in emotional distress, agitation, becoming physically hostile, and throwing objects. R5 was experiencing breakthrough pain at an 8 out of 10. R5 consistently takes her as needed (PRN) Hydromorphone every 4 hours for breakthrough pain. The facility ran out of R5's hydromorphone and R5 went several hours without her PRN medication which resulted in increased verbalizations of pain and uncontrolled pain. [...]

Inspectors wroteBased on interview and record review the facility did not ensure 1 of 19 residents (R4) were treated with respect and dignity. The facility did not provide laundry services timely for R4. R4's personal laundry was in the laundry department for three weeks before being returned to R4. Evidenced by: The Resident Rights in the facility's admission packet, states, in part: . Resident rights. The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility . 4. Respect and dignity. The resident has a right to be treated with respect and dignity, including: . b. The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents. c. [...]

Inspectors wroteBased on interview and record review, the facility did not immediately consult with a resident's physician or update resident's guardian when there was a change in resident's condition and need to alter treatment for 1 resident (R4) out of 3 reviewed for notification of changes. R4 was sent to the emergency department on 5/4/24 and R4's guardian was not immediately notified. R4 had three falls on 5/11/24 and R4's guardian was not notified of one of those falls. Evidenced by: The facility policy entitled Notification of Changes, dated 10/22/23, states, in part: . Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification . Compliance Guidelines: [...]

Inspectors wroteBased on photographic evidence and interview, the facility failed to keep residents' personal health information confidential for 1 of 3 residents reviewed for health information (R18). R18's private health care information was found in R4's room. Evidenced by: The facility policy entitled Confidential of Personal and Medical Records, dated 5/15/24, states, in part: . Policy: This facility honors the resident's right to secure and confidential personal and medical records. This includes the right to confidentiality of all information contained in a resident's records, regardless of the form of storage or location of the record. Policy Explanation and Compliance Guidelines: . 2. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that each resident had a baseline care plan developed and implemented, within 48 hours, with needed instructions to provide effective and person-centered care for 1 of 18 residents (R3) reviewed. R3 did not have a baseline care plan completed. This is evidenced by: The facility policy, entitled Baseline Care Plan, dated 11/2023, states in part: the facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan will be developed within 48 hours of the residence admission, will include the minimum health care information necessary to properly care for a resident including, but not limited to: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that 2 residents (R4 & R15) reviewed for Activities of Daily Living (ADL) out of a total sample of 19 received the necessary services to maintain good nutrition, grooming, personal and oral hygiene. R4 did not receive weekly scheduled showers in April, May, and June 2024. R15 did not receive weekly showers as scheduled in April, May, and June 2024. Evidenced by: The facility policy entitled Activities of Daily Living, undated, states, in part: Policy: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs (activities of daily living) do not deteriorate unless deterioration is unavoidable. Cares and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care . 3. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the resident environment remains as free of accident hazards as is possible. This affected 2 of 19 sampled residents (R5 and R14) R5's electric wheelchair charges in her room with her roommate, R14, also present. This is evidenced by: Facility policy, entitled Power Mobility Device, reviewed 1/1/24, includes, in part: Battery charging installations shall be located in areas designated for that purpose . Example 1 R5 admitted to the facility on [DATE]. R5's most recent Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 6/7/24, indicates R5 is impaired on both sides of her upper and lower extremities and utilizes an electric wheelchair for mobility. On 6/18/24 at 3:21 PM, Surveyor observed R5's wheelchair power charging cable plugged in next to her nightstand. [...]

Inspectors wroteExample 2 R5 consistently takes her as needed (PRN) Hydromorphone every 4 hours for breakthrough pain. The facility ran out of R5's hydromorphone. R5's progress notes indicate that this facility ran out of R5's medications twice in the span of four days. R5 was admitted to the facility on [DATE], and has diagnoses that include: multiple sclerosis (degenerative disorder causing nerve damage which leads to paralysis, vision loss, fatigue, and mood disturbance) , sickle cell disorder with acute chest syndrome (red blood cells become crescent-shaped causing severe pain with occlusion of arteries and veins around the lungs), idiopathic aseptic necrosis of right femur (death of bone tissue related to loss of blood supply), idiopathic aseptic necrosis of left femur, and other chronic pain. [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to notify the physician of elevated blood glucose levels for 1 of 3 residents (Resident (R) 9) reviewed for diabetes in a total sample of 25 residents.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure a resident was free from misappropriation of the resident's property when Registered Nurse (RN)1 diverted the resident's Oxycodone for 1 of 6 residents (Resident (R) 19) reviewed for misappropriation in a total sample of 25 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable for 1 (R1) of 3 residents reviewed for pressure ulcers (PU). R1 was a risk for PU development. The facility failed to implement aggressive interventions to prevent PU development. R1 developed a stage 2 PU which worsened to an unstageable PU. The facility failed to ensure R1 had aggressive offloading, failed to complete all physician ordered treatments, and failed to ensure physician prescribed offloading orders were followed. This is evidenced by: The facility policy entitled, Pressure Injury Prevention and Management undated, states in part: . Definitions: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and serve food in accordance with professional standards for food service safety for 1 (R1) of three residents reviewed for food storage. Surveyor observed 6 unopened Magic Shakes on R1's windowsill. This is evidenced by: The facility policy entitled, Food Safety Requirements, dated 3/20/23, states in part: . 1. Food safety practices shall be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with delivery of the food to the resident. Elements of the process include the following: . b. Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms . [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure all residents who smoke did so safely for 4 of 4 (R4, R6, R7, and R8) residents reviewed. R4's Smoking Assessment and Care Plan indicated they required supervision while smoking and that all smoking material should be stored by the facility. R4 uses oxygen. On 12/8/23, R4 was allowed to keep their smoking materials in their possession. Staff observed R4 smoking in their room. Staff observed R4's oxygen running, with the nasal cannula sitting on the bedside table thereby enriching the room with oxygen. R4 admitted to Surveyor that she had smoking materials on her person prior to being deemed safe to smoke independently. This created an unsafe environment for R4 as well as other residents of the building as a fire could have started much easier with the oxygen enriched air in the room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure for 9 of 12 residents (R12, R15, R16, R17, R18, R19, R13, R14, and R15), each resident received food with at a palatable temperature. Residents have voiced concerns related to cold food. Test tray found food was not served hot. Evidenced by Facility policy, Record of Food Temperatures, revised 12/1/23, states, as follows: It is the policy of this facility to record food temperatures daily to ensure food is at the proper serving temperature(s) before trays are assembled. 2. Hot foods will be held at 135 degrees Fahrenheit or greater. 4. Potentially hazardous cold food temperatures will be kept at or below 41 degrees Fahrenheit. The facility has dining in two (2) dining rooms and residents also eat in their rooms. [...]

Inspectors wroteBased on interview and record review, the facility did not maintain medical records on each resident that are complete and accurately documented in accordance with accepted professional standards and practices in 1 of 6 residents reviewed (R3). R3's Medication Administration Record (MAR) did not have all medications administered documented. This is evidenced by: The facility policy titled, Medication Administration, with a reviewed/revised date of 12/4/23, indicates, in part: .Policy Explanation and Compliance Guidelines: .11. Compare medication source (bubble pack, vial, etc) with MAR to verify resident name, medication name, form, dose, route and time .17. Sign MAR after administered . R3 was admitted to the facility on [DATE] with diagnoses that include, in part: schizophrenia, weakness, and other specified forms of tremors. [...]