Middleton Village Nursing and Rehab

Inspectors wroteNumber of residents sampled:5Number of residents cited:5Based on observation, interview, and record review, the facility did not ensure that each resident receives food and drink that is palatable and at a safe and appetizing temperature. This has the potential to affect all residents who resident at the facility. Residents (R45, R18, R76, R15, R65, R3, R58, R74, R34, R54) on 5 of 5 hallways voiced concerns regarding food temperatures and palatability of food served. Surveyor received a test tray, and hot foods were served cold. Evidenced by: The facility policy, Food Preparation and Service, dated 7/14, states, in part;.Food service employees shall prepare and serve food in a manner that complies with safe food handling practices.3. The temperature of foods held in steam tables will be monitored by food service staff. Example 1: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 73 residents who reside in the facility. Surveyor observed dietary aide directly touching food with dirty gloves. Evidenced by:The facility policy, Food Preparation and Service, 7/14, states, in part. Food service employees shall prepare and serve food in a manner that complies with safe food handling practices.5. Food preparation staff will adhere to proper hygiene and sanitary practices to prevent the spread of food borne illness.6. Bare hand contact with food is prohibited. Gloves must be worn when handling food directly. However, gloves can also become contaminated and/or soiled and must be changed between tasks. [...]

Inspectors wroteBased on 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 73 residents residing in the facility. The facility assessment does not include information on staffing levels needed for specific shifts. This is evidenced by:Surveyor requested a facility assessment policy; however, staff reported to Surveyor that the facility does not have a facility assessment policy. Surveyor reviewed the facility assessment, last updated 2/26/26, as part of a resident investigation. Surveyor found that the facility assessment does not contain information on staffing levels needed for specific shifts. The facility assessment states, in part: [...]

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 3 of 3 shower rooms, in use, affecting a pattern of residents who use the shower rooms and 3 (R3, R51, and R58) of 23 sampled residents. R3 refuses his showers because the showers are too cold. R51 stated the shower is cold. R58 has not showered in 3 months because the shower does not have hot water. The water temperature in 3 shower rooms that are in use, did not have adequate hot water. This is evidenced by:The facility policy Water Temperatures, Safety of, dated 12/09, includes: Maintenance staff is responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not ensure that a resident who is unable to carry out activities of daily living (ADLs) receives the necessary services to maintain good nutrition, grooming, personal and oral hygiene for 5 of 23 sampled Residents (R3, R14, R29, R48, and R58). R3 refuses his showers because the showers are too cold. R58 has not showered in 3 months because the shower does not have hot water. R29 did not receive all showers as scheduled. R14 did not receive all showers as scheduled. R48 did not receive all showers as scheduled and has not been shaved. This is evidenced by: The facility's policy Activities of Daily Living (ADLs), dated 5/7/20, includes: [...]

Inspectors wroteBased on observation, interview, and record review the facility did not ensure drugs and biologicals are labeled in accordance with currently accepted professional standards for 3 of 3 out of 5 medication carts reviewed for medication storage. The Harbor Hall medication cart had an undated open insulin pen for R36. Additionally, Surveyor located a box of 3 warm, undated GLP-1 pens without a resident label fixed to the box or the pens. The St. [NAME] Hall medication cart had an illegible date on R67 inhaler. The Depot Hall medication cart had an open and undated ophthalmic solution (eye drops) for R62. Additionally, there was an undated, open insulin pen for R19 and an open, undated inhaler for R17. As evidenced by:The facility policy entitled, Storage of Medications, dated 4/2007, states, in part: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure each resident has the right to be fully informed in a language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition for 1 of 23 sampled residents (R84). The Facility does not ensure R84 is receiving communication in a language he can understand. As evidenced by:On 3/3/26 at 3:27 PM, Surveyor interviewed R84. Surveyor asks R84 if he is concerned about anything. R84 indicated he has trouble communicating with staff and wants them to speak with him in Spanish. R84 also indicated he only speaks a little English.(Of note: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure the residents' right to formulate an advanced directive in 1 of 23 sampled residents reviewed (R76) for advanced directives. R76 is a full code with corresponding paperwork in the medical chart. She has no advanced directive in the medical chart. No evidence of discussions regarding advanced care planning, other than code status, was noted to be in R76's medical record. This is evidenced by: The facility policy Advance Directives revised 4/2013 states in part: The interdisciplinary team will review annually with the resident his or her advance directive to ensure that such directives are still the wishes of the resident. Such reviews will be made during the annual assessment process and recorded on the resident assessment instrument (MDS). [...]

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 in accordance with accepted professional standards and practices for 1 resident (R18) of 23 residents sampled. R18 experienced an incident involving a transfer and sustained a fracture. Staff did not document this incident in the medical record. Evidenced by:The Facility Policy titled, Charting and Documentation includes, in part:Policy Statement: Any changes to the residents' medical or mental condition shall be documented in the residents' medical chart. All incidents, accidents, or changes in the residents' condition must be recorded. [...]

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 (R11) reviewed for hospice. R11's current hospice plan of care and visit notes were not available to facility staff. As evidenced by:R11 was administered to the facility on 2/13/25 with diagnoses including end stage renal disease (kidney failure in which the kidney's no longer function well enough to sustain life), type 2 diabetes mellitus, infection and inflammatory reaction due to indwelling urethral catheter, obstructive and reflux uropathy (urine flow is blocked and backs up into the kidneys), and retention of urine. [...]

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 1 of 1 reportable incidents involving 1 of 3 residents reviewed for abuse (R1). [...]

Inspectors wroteBased on interview and record review, the facility did not have evidence that all alleged violations are thoroughly investigated and did not report the results of all investigations to officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident for 1 of 1 allegations of abuse involving 1 of 3 residents reviewed for abuse (R1). An allegation of sexual abuse was made in which a staff member was accused of inappropriately touching R1's genitals and the facility did not conduct a thorough investigation and report the results to the state survey agency. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure the preparation, storage, and serving of food in a clean and sanitary environment. This has the potential to affect all 67 residents in the facility. Surveyor observed partially eaten meal trays from the previous meal sitting on tables in the dining room while residents were eating breakfast. Surveyor observed 3 wall dispensers of hand sanitizer in the dining room to not be in working order. Surveyor observed a table in the dish room to be covered with stacked boxes mixed with a tray of glasses, a dirty towel, dirty coffee pots, and a fleece jacket laying on top of a metal pot which was inside of a box of white aprons. Surveyor observed a microwave in the kitchen which was covered with multi-colored splatters all over the inside walls. [...]

Inspectors wroteExample 3 On 5/5/25 at 2:49 PM Surveyors interviewed R5 who indicated she had a shower that morning and that she feels the shower room is cluttered, congested, not clean, and does not feel homelike. R5 indicated she does not always get her shower on Depot and sometimes is taken to [NAME] hall. R5 indicated last week was the last time she had been to the one on [NAME] and indicated it is more homelike than depot but still cluttered and indicated they need to take some of that stuff down to the basement. Example 4 On 5/5/25 at approximately 8:15 AM Surveyors began observations of the facility shower rooms and completed staff interviews regarding the shower rooms which included the following: [NAME] Hall shower room: 1) Two lifts and Multiple shower chairs were present with some shower chairs being stacked on top of each other. [...]

Inspectors wroteBased on interview and record review the facility failed to 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 for 2 of 6 residents (R2 and R5) reviewed for abuse. R2's POA (Power of Attorney) reported an alleged sexual abuse allegation and did not report this to the State Agency or Law Enforcement. R5 reported an allegation of abuse that was not reported to other officials (including to the State Survey Agency) within two hours of discovery. This is evidenced by: The Facilities Policy and Procedure entitled Abuse, Neglect, and Exploitation dated 1/5/24 documents, in part: [...]

Inspectors wroteBased on interview and record review the facility did not thoroughly investigate an allegation of abuse this has the potential to affect 1 of 6 investigations reviewed affecting resident (R5). R5 reported an allegation of abuse that was not thoroughly investigated by the facility. R5's most recent Minimum Data Set (MDS), target date 3/8/25, indicates a Brief Interview of Mental Status (BIMS) of 13. Indicating that R5 is cognitively intact. On 5/5/25 at 2:49PM Surveyors interviewed R5 who indicated last week when she was in activities R9 said to her If I had a gun, I'd shoot you. R5 indicated she did not believe any staff witnessed the event. R5 indicated she did not tell anyone until the next day when she reported it during her therapy session to OT K (Occupational Therapist) who told her she would report it to NHA A (Nursing Home Administrator). R5 indicated it makes her feel anxious. [...]

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 3 residents (R2) reviewed for elopement. R2 did not have an order to check the function of his elopement device. This is evidenced by: The Facilities Elopement/Unsafe Wandering Policy and Procedure dated 1/4/24 does not speak to monitoring the function of the elopement device. R2 is short-term resident of the facility. R2 has the following diagnoses: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that they provided pharmaceutical services (including procedures that assures the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. This affected 1 (R2) of 6 residents reviewed for medication administration. R2 had 2 dates in May 2025 that were blank for his thyroid medication. This is evidenced by: The Facilities Administering Medications Policy and Procedure dated 12/24 documents, in part: .3. Medications must be administered in accordance with the orders, including any required time frame .19. The individual administering the medication must initial the resident's MAR (Medication Administration Record) on the appropriate line after giving each medication and before administering the next ones . R2 is short term resident of the facility. [...]

Inspectors wroteExample 7 The facility policy titled, Change in a Resident's Condition or Status, revised November 2015, states, in part: . 3. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the SBAR (Situation, Background, Assessment, and Recommendation) (Interact Version 4.0) Communication Form . 7. The Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status . The facility policy, Falls Investigation Guideline, undated, states in part: .It is the practice of this facility to evaluate a resident following every fall . 2. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure each resident receives care, consistent with professional standards of practice (SOP), to prevent pressure injuries (PI) and each resident with PIs receives necessary treatment and services, consistent with professional SOP, to promote healing, prevent infection, and prevent new injuries from developing in 1 of 2 sampled residents (R41). R41 developed an in house acquired, stage 3 pressure injury on her coccyx. Surveyor observed R41 to be lying directly on her wound and to have her heels directly on the mattress/not floating several times during survey. The facility delayed changing out R41's bed to a mattress designed to treat pressure injuries stage 3 or higher. The facility did not perform wound care per physician orders. Evidenced by: [...]

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 1 of 2 residents (R26) reviewed for pain management resulting in R26 experiencing uncontrolled pain. R26 was experiencing breakthrough pain at 9 out of 10 severity and the facility staff did not provide her with pain medication over a period of 5 hours on 10/22/24. The facility had R26's as needed pain medication in contingency stock, however R26 was told the facility was out of her medication. R26's comprehensive care plan does not include individualized non-pharmacological interventions, and the medical record does not indicate any of these interventions being performed. This is evidenced by: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect all 75 residents. Moldy food was found in a resident's room. Food items were found without dates in multiple locations. A scoop was observed in an ice machine.

Inspectors wroteBased on observation and interview, the facility did not ensure that garbage and refuse was disposed of properly. This has the potential to affect all 75 residents. On 10/21/24 at 10:10 AM, surveyors observed the facility's main dumpster (located outside) lid open and the following on the ground near the dumpster: *Surgical Masks *8 sealed condiment packets *2 pre-made condiment containers with lids *Numerous used disposable gloves *Plastic straws and plasticware *Paper towels *Various pieces of scattered cardboard On 10/21/24 at 10:11 AM, DM Y (Dietary Manager) stated that facility tries to keep the area clean whenever garbage is brought out and stated it should be cleaned up and it would get done immediately.

Inspectors wroteBased on interview and record review, the facility did not ensure that staff background checks were completed thoroughly or timely for 3 of 8 staff (Medication Technician K, Certified Nursing Assistant R (CNA), and CNA S) background/Background Information Disclosure (BID) checks reviewed. MT K's (Medication Technician) BID had not been run since her initial one on 12/10/19. CNA R's (Certified Nursing Assistant) BID had not been run since his initial one on 11/25/19 and this did not include the Wisconsin results. CNA S's BID was dated 8/15/24, however, there were no questions on this document that were answered. This is evidenced by: The Facilities Policy and Procedure entitled Background Screening Investigations dated 2008 documents, in part: .1. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility for 1 of 1 resident's reviewed for mobility (R58). The facility was not walking R58 in accordance with his plan of care.

Inspectors wroteBased on interview and record review, the facility did not ensure that residents (R) receiving psychotropic medication were free from unnecessary medication for 1 of 5 residents (R23) reviewed for unnecessary medications. R23 receives psychotropic and antipsychotic medications. R23 does not have an appropriate diagnosis for antipsychotic medication. Consent was not obtained prior to administration of psychotropic and antipsychotic medications. Verbal consent was obtained without follow up signature.

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 26 opportunities that affected 1 out of 12 residents (R477) included in the medication pass task, which resulted in an error rate of 7.69%. LPN HH (Licensed Practical Nurse) did not give R477 the correct dosing of his calcium carbonate (antacid). LPN HH omitted R477's Pyridoxine HCl (Vitamin B6). This is evidenced by: The facility policy entitled, Administering Medications, dated 12/2012, states in part: Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: . 3. Medications must be administered in accordance with the orders, including any required time frame. R477's Physician Orders state, in part: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, affecting 1 of 21 sampled residents (R41). Surveyor observed CNA KK (Certified Nursing Assistant) don gloves (put on), assist R41, and then exit R41's room. CNA KK went into the clean linen storage, gathered an armful of bedding, and enter another resident's room wearing the same pair of gloves. Surveyor observed dirty linens to be stored in R41's room on the floor. R41 voiced concerns regarding the cleanliness of her room. Evidenced by: Facility policy, titled Handwashing/Hand Hygiene, dated 8/2014, includes: all personnel shall follow the hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. [...]

Inspectors wroteBased on interview and record review, the facility did not develop, implement, and maintain an effective emergency training program for all facility and contracted staff consistent with their expected roles and based on the facility assessment for 8 of 8 facility staff and 1 of 1 contracted staff. Eight facility staff and one contracted staff had not received training on electric power outages and emergency outlets. Staff stated they have not received emergency training regarding severe thunderstorm or tornado warnings. 3 of 8 Residents stated the staff where rattled, scurrying, and struggled during the severe weather and power outage. This is evidenced by: The facility's policy, revised 1/2011, titled Disaster Training states in part; [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure a Resident (R) who is fed by enteral means receives the appropriate treatment and services for 1 of 1 Residents (R) with a tube feeding (R7). R7 had two different enteral feeding orders that were being signed out as administered and R7's enteral feeding bottle was observed to be without a name, date, and time it was hung for use. This is evidenced by: Facility policy entitled Enteral tube Feeding via continuous pump, revised March 2015, states in part: .General guidelines: .3. Check the enteral nutrition label against the order before administration. Check the following information: a. Resident name, ID, and room number. b. Type of Formula. C. Date and time formula was prepared .g. Rate of administration (ml/hour). Initiate feeding .5. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure Continuous Positive Airway Pressure (CPAP) orders were obtained or transcribed upon admission and consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 2 (R5 and R8) of 4 residents reviewed for CPAP use. R5's hospital discharge orders dated 4/18/22 state OSA (obstructed sleep apnea) continue CPAP. R5 did not have an order for CPAP in her medical record until 5/24/24. Orders for R8's CPAP were not obtained or entered upon admission. This is evidenced by: Example 1 R5 was admitted to the facility 4/18/22 with diagnoses of morbid obesity, Obstructed Sleep Apnea (OSA), and general weakness. R5's hospital discharge orders dated 4/18/22 state in part; OSA continue with CPAP. R5's care plan dated 4/18/22 Focus: [...]

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 though established procedures for 1 of 7 abuse investigations (R2) reviewed of a total sample of 10 residents. Facility became aware of an abuse allegation on 4/18/24 and did not report to state. Evidenced by: The facility policy, entitled Abuse, Neglect and Exploitation, dated 1/5/24, states, in part: . Policy: [...]

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate an accusation of verbal abuse for 1 of 7 residents (R2) reviewed for abuse out of a total sample of 10 residents. Facility became aware of an abuse allegation on 4/18/24 and did not report to state. Evidenced by: The facility policy, entitled Abuse, Neglect and Exploitation, dated 1/5/24, states, in part: . Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation and misappropriation of resident property . Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that 3 (R3, R10, R5) of 5 residents reviewed for Activities of Daily Living (ADL) out of a total sample of 10 received the necessary services to maintain good nutrition grooming, personal and oral hygiene. R3 voiced concern of not receiving showers as scheduled. R10 voiced concerns of not receiving showers as scheduled. R5 did not receive showers as scheduled. Evidenced by: The facility policy entitled, Shower/Tub Bath, dated October 2010, states, in part: . Purpose: The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin . Documentation: The following information should be recorded on the resident's ADL record and/or in the resident's medical record: 1. The date and time the shower/tub bath was performed. 2. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 3 of 10 residents reviewed for quality of care (R1, R3, and R5). R1 was noted to have a history of aspiration pneumonia and refusal to comply with thickened liquid recommendations and the facility did not care plan his refusals or need to assess R1 more frequently due to increased risk of aspiration pneumonia. Facility staff were not monitoring R5's bowel movements. R3 did not receive wound care two times in one week for two wounds.

Inspectors wroteBased on interviews, record review, and review of professional standards of practice, the facility did not ensure that the services provided by nursing personnel met the professional standards of quality for 1 of 6 residents (R1). R1 was admitted to the facility with orders for Point of Care glucose testing (POCT) 4 times daily before meals and at bedtime. Facility did not monitor blood glucose levels while R1 was a resident in facility. Evidenced by: The facility's policy entitled, Diabetes Management, dated 6/29/17, states, in part: . Purpose: To develop a practice in which our facility consistently provides care for the resident with diabetes . Admission, Quarterly and Change in Condition Evaluations . Individualized approaches for protection must be initiated upon admission .Additional evaluations to be included upon admission and throughout stay: Upon admission and Throughout Stay: [...]

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 1 out of 3 sampled residents (R1). R1 did not receive her ordered amlodipine on 3/23/24. R1 did not receive her ordered Ezetimibe on 3/23/24. R1 did not receive her ordered dose of carbamazepine on 3/23/24. Evidenced by: The facility policy, entitled Administering Medications, with a revision date of December 20212, states, in part: . Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: . 3. Medications must be administered in accordance with the orders, including any required time frame. 4. [...]

Inspectors wroteBased on staff interview, record review, document review, and policy review, the facility did not ensure staff responded appropriately to an alarm and provided adequate supervision to 1 of 2 (R5) residents reviewed for elopement. R5 was assessed by the facility to be at risk for elopement. He did wear a WanderGuard. On 12/18/23, R5 eloped from the facility and was found on facility grounds by staff. On 02/25/24, at approximately 04:26am, R5 eloped from the facility through an alarmed door. Staff responded to the alarm but did not look outside the door to determine if anyone was outside. Staff did not begin a room-by-room search until approximately 30 minutes later when it was noted R5 was not in the building. Law Enforcement was not notified of the missing resident for 2 hours. [...]

Inspectors wroteBased on record review, interview and policy review, the facility failed to prevent staff to resident abuse for 1 (Resident (R) 4) of 1 resident reviewed for physical abuse when allegedly Licensed Practical Nurse (LPN)3 physically grabbed R4's arm and removed a dab/vape pen from R4's hand.

Inspectors wroteBased on record review, interview and policy review, the facility failed to report 1 of 1 allegations to the State Agency (SA) that Licensed Practical Nurse (LPN)3 physically grabbed R4's arm and removed a dab/vape pen from R4's hand.

Inspectors wroteBased on record review, interview and policy review, the facility failed to thoroughly investigate 1 of 1 allegation's that Licensed Practical Nurse (LPN)3 physically grabbed R4's arm and removed a dab/vape pen from a resident's hand for one (Resident (R 4) of one resident reviewed for physical abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 10 residents (R8) was using a continuous positive airway pressure (CPAP) machine as ordered by R8's Physician.

Inspectors wroteBased on interview and record review, the facility did not immediately report alleged violations of abuse to the State Agency for 1 of 3 reports incidents (R1). On 1/28/24 at 11:47 AM, R1 and his Activated Power of Attorney for Health Care (APOAHC) contacted the police department regarding a theft of R1's backpack which contained his wallet, identification card, debit card, and FoodShare/[NAME] card (a public assistance card used to purchase food). R1's APOAHC reported this allegation to NHA A (Nursing Home Administrator), the Grievance Officer, told R1's APOAHC he was unable to do anything about this. NHA A failed to report this Suspicion of a Crime to law enforcement and the State Agency. This is evidenced by: The facility's policy and procedure, Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property, dated 9/11/20, documents in part, the following: Purpose: [...]

Inspectors wroteBased on interview and record review the facility failed to thoroughly investigate an allegation of abuse for 1 out of 3 sampled Residents (R1). On 1/28/24 at 11:47 AM, R1 and his Activated Power of Attorney for Health Care (APOAHC) contacted the police department regarding a theft of R1's backpack which contained his wallet, identification card, debit card and FoodShare/[NAME] card (a public assistance card used to purchase food). R1's APOAHC reported this allegation to NHA A (Nursing Home Administrator), the Grievance Officer, who told R1's APOAHC he will be unable to do anything about this. NHA A failed to investigate this Suspicion of a Crime. This is evidenced by: The facility's policy and procedure, Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property, dated 9/11/20, documents in part, the following: Purpose: [...]

Inspectors wroteBased on observation, record review, review of facility policy, and staff interviews, the facility failed to develop a person-centered comprehensive plan of care with measurable goals and plans for one of 18 residents (Resident (R) 2) reviewed for care plans.

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 70 residents who reside at the facility. Surveyor observed the following: - Food items were not dated to reflect open and/or use by date. - Crumbs, debris, and spilled food on the floor of the kitchen. - 2 garbage cans with no lids near the food prep area. - Microwave splattered with substance and crumbs. - Scoops left in the flour and sugar bins. - A bag of onions directly on the floor with 3 moldy onions. - Observation of staff not wearing beard nets and entering the kitchen without a hair net on. - Improper hand hygiene during dishwashing, going from dirty items to clean items. - Food items not labeled or dated in the nourishment room refrigerator. [...]

Inspectors wroteBased on observation and interview, the facility did not ensure that garbage and refuse was disposed of properly. This has the potential to affect all 70 residents. On 10/23/23, Surveyor observed garbage not properly contained in the dumpsters. Evidenced by: On 10/23/23, at 8:30 AM, during the initial tour of the kitchen, Surveyor and [NAME] R observed the following outside, on the ground near the facility's main garbage dumpster: Used gloves. Wet cardboard boxes A garbage bag that was ripped open and debris laying on ground. Plastic spoons Plastic wrap and used food containers. Cook R indicated she was not sure who was responsible for ensuring garbage was disposed of properly. On 10/24/23 at 9:22 AM, DM J (Dietary Manager) indicated the kitchen is responsible for ensuring garbage is in the dumpsters. [...]

Inspectors wroteBased on interview and record review, the facility does not have a system for preventing, identifying, reporting, investigating, and controlling infections and communicable disease for all residents. This has the potential to affect the census of 70. The facility's line lists for Infection Control are not being completed contemporaneously as the dates are not in any order. The line lists only include residents receiving antibiotic therapy, no residents with only signs or symptoms (S/Sx) are on the line lists. August through October line lists are not accurate compared to the McGeer's documentation (i.e., HAI or CAI, type of infection, etc.) and all are documented as Healthcare Associated Infection (HAI), none are Community Associated Infection (CAI). The line list does not contain any S/Sx, organism, or colony counts. [...]

Inspectors wroteBased on interview and record review the facility did not ensure that residents that use psychotropic drugs have appropriate assessments, behavioral interventions, and consent. This affected 4 of 5 residents (R18, R26, R60, R36) reviewed for unnecessary medications. R18 receives medication for insomnia and has no sleep assessment. R18 does not have specific individualized targeted behaviors in place for staff to monitor to ensure the effectiveness of her psychotropic medications. R18 does not have the appropriate consents for her psychotropic medications. R26 receives medication for insomnia and has no sleep assessment. R26 does not have the appropriate consents for her psychotropic medications. R60 does not have the appropriate consents for her psychotropic medications. R36 does not have the appropriate consents for his psychotropic medications. This is evidenced by: [...]

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 5 of 14 supplemental residents (R226, R23, R3, R225, R272). R226 treated for Urinary Tract Infection (UTI) per line list, no urinalysis (UA) culture and sensitivity (C/S) provided. R23 per line list received antibiotic for prophylaxis but did not indicate for what. R3 treated for respiratory illness when CT chest did not show infectious process. R225 treated for UTI when C/S results indicate probable contamination and antibiotic treated with in same family as antibiotic listed as resistant. R272 McGeer's documentation indicates there is physician diagnosis or lab confirmation; neither was provided. This is evidenced by: [...]

Inspectors wroteBased on interview and record review, the facility did not facilitate resident self-determination through support of resident choice for 1 of 15 supplemental residents (R24). R24 did not know the facility's menu choices and was not given the opportunity to choose his meals before receiving them.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure the environment was safe, clean, comfortable, and homelike for 1 (R51) of 20 sampled residents during mealtime out of a total sample of 27 Residents. Surveyors observed R51 during lunch time on 10/23/23. R51 was sitting at the table closest to the dishwashing room. Kitchen staff had the dishwashing door propped open during mealtime. Kitchen staff was standing outside of the dishwashing room next to R51. Kitchen staff had a garbage can, a cart with stacks of dirty plates, and the staff was scraping off food from the dirty dishes into the garbage can. As kitchen staff was doing this, R51 was flinching. R51 is unable to verbally indicate if there is something that bothers R51. Evidenced by: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure allegations of abuse were reported to the State Survey Agency for 1 of 27 sampled residents (R65.) R65 shared an allegation of abuse with Surveyor. R65 alleged CNA V (Certified Nursing Assistant) was verbally abusive to him and would throw his meal trays on his over bed table for three (3) days after he reported a concern to her. R65 also reported this concern to CNA H. Neither CNA V nor CNA H reported this allegation of abuse to the facility. Subsequently, the facility did not report this allegation of abuse to the State Agency until Surveyor brought this allegation to the attention of facility. Evidenced by: The facility's Policy and Procedure entitled Abuse and Neglect dated 9/11/20, documents in part: .Internal Reporting: a. [...]

Inspectors wroteBased on interviews and record review, the facility did not provide an ongoing, individualized, and meaningful program to support the residents in their choice of activities, which was designated to meet their interests and support their physical, mental, and psychosocial well-being. This affected 1 of 2 residents (R51) out of a sample of 20 residents reviewed for activity participation out of a total sample of 27 Residents (R). The facility failed to offer a variety of activities that meet the interests and support all residents' physical, mental, and psychosocial well-being. Evidenced by: The facility policy, Activity Programs, with a revised date of 8/06, states, in part; .1. Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs. 2. [...]

Inspectors wroteBased on interview, and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 2 of 27 total sampled residents (R37 and R27). R37 has diagnosis of congestive heart failure and facility staff did not complete daily weights as ordered, nor did they update the Nurse Practitioner when R37 had a weight gain. R27 has diagnoses of Adult Failure to Thrive and Severe Protein-Calorie Malnutrition and facility staff did not complete weights as ordered. Evidenced by: The facility's policy titled Weight Monitoring Guideline last revised on 7/1/2019, states in part: .Residents will be weighed; documentation will be recorded in PCC (Point Click Care): *Upon admission and re-admission. Hospital weights should be verified and compared to facility admission/ re-admission weight. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure a resident (R) with a pressure injuries/ulcers receives necessary treatment and services, consistent with professional standards of practice. The facility did not implement immediate robust care plan interventions for 1 (R73) of 4 residents reviewed for pressure ulcers out of a total sample of 27. R73 admitted to the facility with pressure ulcers. The facility did not implement a robust care plan in place for R73. This is evidenced by: The facility policy, entitled Wound Care, dated October 2010, states, in part: . Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation: . 2. Review the resident's care plan to assess for any special needs of the resident. a. [...]

Inspectors wroteBased on observation, interview and record review the facility did not ensure that a resident with limited range of motion (ROM) receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 1 Resident's (R57) reviewed for limited range of motion of 27 sampled residents. R57 is not receiving his walking program. This is evidenced by: The facility does not have a Restorative Program. The facility has a binder labeled Daily Skilled Schedule - Walking Program Schedule - Section GG The facility's Walking Program, dated 10/3/23, that indicates the following: CNAs (Certified Nursing Assistants) to assist resident to ambulate once during each AM and PM shift daily using 2ww (wheeled walker), gait belt and wheelchair to follow (1 assist). Distance as tolerated. Please see therapy staff with any questions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure the resident environment remains as free of accident hazards as is possible for 1 of 1 resident (R39) reviewed for smoking out of a total of 27 sampled residents. R39 requires supervision while smoking. Surveyor observe R39 put out his cigarette on the wheel on his wheelchair, on a leaf he had picked up off the ground, and then placed the used butt back in the empty pack of cigarettes. CNA N (Certified Nursing Assistant) who was supervising the smoking session did not notice how R39 put out his cigarette nor how he disposed of it. As evidenced by The facility's policy, Smoking Guideline, dated 11/28/17, states in part, the following: Residents who want to smoke are evaluated and assessed for smoking safety. Each facility establishes its own smoking policy that addresses how, when, and where to allow smoking. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that a resident with an indwelling catheter receives services and assistance. This affected 1 of 4 residents with catheters (R48) out of a sample of 27 Residents (R). R48's catheter was leaking on 9/2/23; the facility did not have the size catheter that R48 needed. A different size catheter was inserted, and no Provider notification was done. This is evidenced by: The Facilities Policy and Procedure entitled Urinary Indwelling Catheter Management Guideline dated 11/28/17, documents in part: .Medically justified indwelling catheters will require physician orders for: Catheter size and type- Current standards indicate catheterization should be accomplished with the narrowest, softest tube that will serve the purpose of draining the bladder. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that a resident who is fed by enteral means receives the appropriate treatment and services. This affects 1 of 1 resident (R51) reviewed for G/T (gastrostomy tube) out of a total sample of 27 residents. The facility did not properly check placement of R51's gastronomy tube (G/T; surgically placed device used to give direct access to the stomach for supplemental feeding, hydration, or medicine). This is evidenced by: The Facilities Policy and Procedure entitled Tube Feeding dated 6/29/21, documents in part: .Refer to [NAME] Clinical Nursing Skills and Techniques (or alternated facility evidence-based standards for practice guide) for: Site Care, Observation, Flushing Feeding, Placement Checking: NOTE Auscultation is no longer recommended for checking placement of the feeding tube. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that it provided 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, this affected 1 of 27 sampled residents (R48). R48 did not receive her Actos medication on 10/8/23 and 10/9/23. R48 did not receive her Glipizide medication on 8/5/23, 8/6/23, and 9/9/23. R48 did not receive her Oxycodone medication on 10/6/23. This is evidenced by: The Facilities Policy and Procedure entitled Adverse Consequences and Medication Errors dated 4/14, documents in part: .5. [...]

Inspectors wroteBased on record review and interview, the facility did not ensure laboratory services were obtained as ordered by the physician for 1 of 20 residents (R37) reviewed for laboratory services out of a total sample of 27 residents (R). R37's laboratory orders were not carried out as ordered. Evidenced by: R37 was admitted to the facility on [DATE] with diagnoses that include: congestive heart failure (impairment of the heart's blood pumping function), major depressive disorder, type 2 diabetes mellitus, and fracture of neck of right femur (leg bone). On 10/19/23, R37 was seen by the NP (Nurse Practitioner). The NP's note states in part: .Upon entering room, foul odor noted. Overall patient reports feeling well but spouse is concerned that she may have a UTI (Urinary Tract Infection). She endorses foul odor, dysuria, frequency, and urgency. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure the resident's medical record includes documentation that indicates, at a minimum, the following: (A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza and/or pneumococcal immunization; and (B) That the resident either received the influenza and/or pneumococcal immunization or did not receive the influenza and/or pneumococcal immunization due to medical contraindications or refusal. This affected 3 of 5 residents (R36, R57, R60) reviewed for immunizations. R36 did not receive influenza vaccine consent or declination for last year, 2022. R57 was not offered next dose of pneumococcal vaccine. R60 was not offered pneumococcal vaccine. This is evidenced by: [...]