Montello Care Center

Inspectors wroteBased on interview and record review, the facility did not provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 2 of 3 residents (R2 & R3) reviewed for medication errors. R3 did not receive her ordered morphine tablet on 5/28/26 (PM), 5/29/26 (AM), 5/29/26 (PM), and 5/30/26 (AM). The morphine was not given as ordered due to the medication being unavailable in the facility. R2 has not received his Trelegy since his admission on [DATE]. This is evidenced by: The facility policy, titled Medication Administration, dated 1/1/26, states in part: .Policy Explanation and Compliance Guidelines: .10. Ensure that the six rights of medication administration are followed: a. Right resident b. Right drug c. Right dosage d. Right route e. Right time f. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure Residents are free of any significant medication errors for 1 of 3 residents (R3) reviewed for medication errors. R3 did not receive her time-sensitive medication during the scheduled administration window 38 times between the dates of 5/1/26 and 6/8/26. This is evidenced by:The facility policy, titled Medication Administration, dated 1/1/26, states in part: .Policy Explanation and Compliance Guidelines: .10. Ensure that the six rights of medication administration are followed: a. Right resident b. Right drug c. Right dosage d. Right route e. Right time f. Right documentation.12. Compare medication source.with MAR (Medication Administration Record) to verify resident name, medication name, form, dose, route and time.b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure therapeutic diets prescribed by the attending physician are entered and followed for 1 of 3 residents reviewed (R1). R1 did not have therapeutic diet entered as ordered. This is evidenced by: The Facilities Policy and Procedure entitled Therapeutic Diet Orders dated 1/1/26 documents in part; The facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician .Therapeutic Diet is a diet ordered by a physician .as part of treatment for a disease or clinical condition. It also may be ordered to eliminate, decrease or increase specific nutrients in the diet. Examples include low salt, diabetic, or low cholesterol diets . R1 was a short-term admission to the facility and was admitted on [DATE]. R1 has the following diagnoses: [...]

Inspectors wroteBased on staff interview and record review, the facility did not provide adequate supervision for 1 resident (R) (R7) of 3 sampled residents who expressed suicidal ideation and threats of self-harm. On 4/19/26, R7 expressed suicidal ideation and was placed on 15-minute checks for 72 hours which the facility failed to complete in full. On 4/22/26, R7 pulled the call light out of the wall and threatened to wrap the cord around R7's neck. The facility failed to implement increased supervision for R7 despite the threats of self-harm. On 4/23/26, R7 was found with the call light cord wrapped around R7's neck. The facility's failure to provide adequate supervision after R7 expressed suicidal ideation and self-harm created a finding of immediate jeopardy that began on 4/22/26. Nursing Home Administrator (NHA)-A was notified of the immediate jeopardy on 5/4/26 at 4:35 PM. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure resident-to-resident altercations and a potential allegation of abuse were thoroughly investigated for 6 residents (R) (R3, R4, R1, R2, R5, and R6) of 6 sampled residents. On 2/16/26, R3 and R4 were involved in a resident-to-resident altercation. The facility did not thoroughly investigate the altercation. On 2/24/26, R1 and R2 were involed in a resident-to-resident altercation. The facility did not thoroghly investigate the altercation. In addition, the facility's investigation indicated R2 would be on 1:1 supervison. The facility did not have documentation that 1:1 supervision was provided for R2. On 4/22/26, R5 and R3 were involved in a resident-to-resident altercation. The facility did not thoroughly investigate the altercation. On 2/21/26, R6 reported a staff member was aggressive during peri-care. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure an appropriate discharge process for 1 resident (R) (R7) of 1 sampled resident. On 4/23/26, the facility called Emergency Medical Services (EMS) after R7 made suicidal statements and had a call light cord wrapped around R7's neck. Crisis was notified and developed a plan to keep R7 safe in the facility. Nursing Home Administrator (NHA)-A told Power of Attorney (POAHC)-K the facility could not meet R7's needs and R7 could not return to the facility. POAHC-K did not receive a written transfer notice. R7's medical record did not contain a bed hold or transfer notice, discharge summary, or recapitulation of stay.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored, prepared, and served in a sanitary manner. This practice had the potential to affect all 29 residents residing in the facility. Staff did not consistently monitor and document food holding and cooking temperatures. Staff did not adhere to temperature requirements when testing parts per million (PPM) of the sanitizing solution. The temperatures of kitchen and unit coolers and freezers were not consistently monitored or documented. The dish machine temperatures and chlorine test strips were not consistently monitored or documented.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 resident (R) (R10) of 4 sampled residents received a written transfer and bed-hold notice, including their right to return to the facility. In addition, the facility did not notify the Office of the State Long-Term Care (LTC) Ombudsman of resident transfers and discharges. This practice had the potential to affect more than 4 of the 29 residents residing in the facility. R10 was transferred to the hospital on 9/22/25, 10/10/25, and 11/18/25. The facility did not provide a written transfer notice to R10 for the hospital transfers. In addition, the facility did not provide bed-hold information for R10's 9/22/25 and 10/10/25 hospitalizations. The facility did not ensure the Office of the State LTC Ombudsman was notified of all transfers and discharges for 4 consecutive months.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure essential equipment was maintained in safe operating condition. This practice had the potential to affect more than 4 of the 29 residents and staff residing or working in the facility. The kitchen oven door was not in working condition.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure a call light was within reach for 2 residents (R) (R8 and R12) of 15 sampled residents. R8 and R12 were observed without access to a call light or a means to notify staff if assistance was needed.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 2 residents (R) (R27 and R38) of 3 sampled residents signed and received copies of a Notice of Medicare Non-Coverage (NOMNC) form which is used to inform residents of their final day of Medicare Part A insurance coverage, potential liability for payment (daily cost of care and services at the facility), and standard claim appeal rights and instructions. The facility did not provide a NOMNC form to R27 or R38 at least two calendar days before their Medicare Part A services ended.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the effectiveness of psychotropic medication was assessed for 1 resident (R) (R25) of 5 sampled residents. R25 was prescribed trazodone (an antidepressant medication) for insomnia. The facility did not complete a sleep assessment for R25 to assess the effectiveness of the medication. In addition, R25 did not have a care plan for insomnia.

Inspectors wroteBased on staff interview and record review, the facility did not implement their abuse policy and procedure for 1 (Certified Nursing Assistant (CNA)-R) of 8 staff reviewed for caregiver background checks. CNA-R was hired through a staffing agency and worked shifts at the facility starting on 7/9/25. The facility did not ensure the staffing agency completed an out-of-state background check for CNA-R who resided outside of Wisconsin within 3 years of hire.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure a potential allegation of abuse was thoroughly investigated for 1 resident (R) (R5) of 1 sampled resident. On [DATE], staff discovered R5 in R5's room between the wall and the bed. Staffs' statements were inconsistent regarding R5's injuries. The facility did not investigate the discrepancy regarding the injuries.

Inspectors wroteBased on staff interview and record review, the facility did not ensure Preadmission Screening and Resident Review (PASRR) requirements were met for 2 residents (R) (R2 and R25) of 4 sampled residents. R2 was admitted to the facility with a diagnosis of epilepsy. The facility did not include the diagnosis on R2's PASRR Level I Screen and did not submit a referral for a PASRR Level II Screen. R25 was admitted to the facility without a diagnosis of mental illness and was not on psychotropic medication. R25 was later prescribed medication for psychosis, anxiety, depression, insomnia, and conduct disorder. The facility did not complete a new PASRR Level I Screen or submit a referral for a PASRR Level II Screen.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure nail care was provided for 2 residents (R) (R7 and R8) of 15 sampled residents. R7 and R8's fingernails were long, jagged, and contained dirt or chipped polish. R7 and R8 were not consistently provided nail care with activities of daily living (ADLs).

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure restorative care was provided for 1 resident (R) (R12) of 3 sampled residents. R12 had limited range of motion (ROM) and had a functional restorative program. Staff did not consistently provide restorative care for R12.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not provide pharmacy services to ensure the accurate administration of medication for 2 residents (R) (R17 and R4) of 8 sampled residents. Staff did not administer a buprenorphine 10 microgram (mcg) per hour transdermal patch or a guaifenesin 600 mg extended release (ER) tablet to R17 in accordance with physician orders. Medications were left at the bedside for R4 to self-administer. R4's last self-administration of medication assessment indicated R4 could not safely and accurately self-administer medication.

Inspectors wroteBased on staff interview and record review, the facility did not ensure monitoring for adverse reactions to a high-risk medication was in place for 1 resident (R) (R19) of 4 sampled residents. R19 was prescribed cefdinir (an antibiotic) for prophylactic measures. R19 was not monitored for adverse reactions to the medication.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 2 residents (R) (R8 and R13) of 2 sampled residents were assessed for safety and had care plans to guide assistance by Paid Feeding Assistants (PFAs). The facility did not assess if R8 and R13 were appropriate to be assisted by PFAs prior to using PFAs to assist R8 and R13 with dining. In addition, R8 and R13 did not have care plans that indicated they could be fed by PFAs.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 1 resident (R) (R3) of 11 sampled residents. R3 had a Foley catheter but was not on enhanced barrier precautions (EBP). Staff provided high-contact care for R3 without wearing a gown. In addition, staff did not complete appropriate hand hygiene during the provision of care.

Inspectors wroteBased on staff interview and record review, the facility did not provide appropriate dementia care to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 Resident (R) (R1) of 8 sampled residents. R1 was admitted to the facility on [DATE] for a 5-day respite stay. R1 had a history of elopement but no physically aggressive behavior. On the evening of 9/25/25, staff attempted to assist R1 to get R1 ready for bed. R1 resisted the care and stated only R1's wife does that. R1 became physically aggressive with staff and stated R1 wanted to leave the facility and go home. R1 attempted to exit multiple doors. Multiple staff pursued R1 through the facility, blocked exit doors from the inside and outside, and put hands on R1 to keep R1 from exiting which increased R1's agitation. Staff called law enforcement due to R1's heightened aggression. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure allegations of abuse were reported to the State Agency (SA) for 1 Resident (R) (R1) of 8 sampled residents. R1 was admitted to the facility for a 5-day respite stay and had a diagnosis of Alzheimer's disease. On the evening of 9/25/25, R1 became agitated when staff tried to help R1 get ready for bed. R1 attempted to leave the facility through multiple doors, however, staff held the doors shut and put hands on R1 to prevent R1 from leaving. A crisis report indicated staff held R1 in a chair. A police report indicated R1 stated that R1 had been attacked by numerous individuals. The facility did not report the allegations of abuse to the SA.

Inspectors wroteBased on staff interview and record review, the facility did not ensure allegations of abuse were thoroughly investigated for 1 Resident (R) (R1) of 8 sampled residents. R1 was admitted to the facility for a 5-day respite stay and had a diagnosis of Alzheimer's disease. On the evening of 9/25/25, R1 became agitated when staff tried to help R1 get ready for bed. R1 attempted to leave the facility through multiple doors, however, staff held the doors shut and put hands on R1 to prevent R1 from leaving. A crisis report indicated staff held R1 in a chair. A police report indicated R1 stated that R1 had been attacked by numerous individuals. The facility did not thoroughly investigate the incident by ensuring all staff involved were interviewed. The facility also did not obtain the police report or county crisis documentation which included allegations of abuse.

Inspectors wroteBased on staff interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 2 residents (R) (R1 and R2) of 2 sampled residents. On 7/14/25, R2 struck R1 in the face. The facility did not notify local law enforcement of the abuse.

Inspectors wroteBased on observation and staff interview, the facility did not provide a safe, functional, and sanitary environment for residents outside the facility. This practice had the potential to affect more than 4 of the 28 residents residing in the facility. On 6/12/25, the front of the facility appeared unkempt which included weeds, dirt and landscaping bark, an open dumpster that contained garbage, a laundry bin that contained items, a plastic chair that contained cardboard, and exposed wires from a missing doorbell. In addition, the front door was reported to be unlocked when it should have been locked. On 6/12/25 from 9:00 AM to 5:45 PM, Surveyor made observations of the front of the facility which faced the main parking lot and public roadway. Surveyor noted long weeds along the front of the facility, under residents' windows, along and under the fencing, and around trees. [...]

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure 1 resident (R) (R2) of 3 sampled residents received the necessary care and services to prevent pressure injuries and/or promote healing. On 5/25/25, staff reported to Director of Nursing (DON)-B that R2's wound vac (negative pressure wound therapy) dressing was not adhered properly. DON-B did not assess the wound vac dressing or ensure R1's wound vac was functioning appropriately.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not provide adequate supervision and assistance to prevent accidents and did not ensure a fall was thoroughly investigated to determine a root cause for 1 resident (R) (R1) of 1 sampled resident. On 4/26/25, R1 fell out of bed and called 911 when staff did not respond to R1's calls for assistance. The facility did not complete a thorough investigation to determine the root cause of R1's fall.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure 1 resident (R) (R1) of 2 sampled residents was provided safe and accurate administration of drugs and biologicals. R1 was not administered a dose of an intravenous (IV) antibiotics on 5/25/25.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 resident (R) (R10) of 1 sampled resident had a medical record that contained complete and accurate information. Director of Nursing (DON)-B did not update R10's medical record when an observation and assessment was completed for R10.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 1 resident of (R) (R2) of 1 sampled resident. Registered Nurse (RN)-C did not complete proper hand hygiene during wound care for R2 and used soiled scissors to trim a clean dressing.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the resident environment was free of abuse for 2 residents (R) (R1 and R2) of 9 sampled residents. R2 had a diagnosis of dementia and an activated Power of Attorney for Healthcare (POAHC). R2 had a history of sexually intimate encounters and sexual comments toward other residents and displayed verbally and physically aggressive behavior. On 1/10/25, 1/29/25, and 2/8/25, R2 made sexual comments, was verbally and physically aggressive toward other residents, and exhibited wandering behavior. The facility did not implement interventions to ensure the safety of R2 and other residents. On 3/18/25, a resident walked past R1's room and observed R2 touching R1's breasts underneath R1's shirt. R1 was cognitively impaired and had an activated POAHC. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure allegations of abuse were reported to the State Agency (SA) timely for 2 residents (R2 and R8) of 8 sampled residents. R2's medical record indicated R2 was sexually inappropriate and/or verbally and physically aggressive toward other residents on 1/10/25 and 1/29/25. In addition, R2 and R8 were involved in a verbal altercation on 2/8/25. The facility did not report the allegations of abuse to the SA.

Inspectors wroteBased on staff interview and record review, the facility did not ensure allegations of abuse were thoroughly investigated for 2 residents (R) (R2 and R8) of 8 sampled residents. Progress notes, dated 1/10/25 and 1/29/25, indicated R2's medical record indicated R2 was sexually inappropriate and/or verbally and physically aggressive toward other residents on 1/10/25 and 1/29/25. In addition, R2 and R8 were involved in a verbal altercation on 2/8/25. The facility did not thoroughly investigate the allegations of abuse.

Inspectors wroteBased on staff interview and record review, the facility did not ensure care plans were revised for 3 residents (R) (R4, R5 and R6 ) of 8 sampled residents. R4, R5 and R6 were assessed as high risk for falls. The facility did not ensure fall interventions were reviewed, revised, or added to R4, R5, and R6's falls care plans in a timely manner.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure staff provided adequate supervision to prevent resident-to-resident altercations for 4 residents (R) (R1, R3, R4, and R5) of 5 sampled residents. On 7/20/24, R1 rolled R1's wheelchair into R2's foot. R2 said ouch and R1 raised R1's fists as if to hit R2. On 7/31/24, R1 was found in R3's room yelling at R3. R1 was placed on 15-minute checks. On 8/20/24, R1 was observed yelling at R4 in the hallway. R1 grabbed R4's shirt and hit R4's chest. R1 was placed on 1:1 supervision until a motion sensor and an audio monitor were in place. On 9/7/24, R1 became agitated and yelled at Med Tech (MT)-C. R5 approached R1 and said, Don't do that . R1 and R5 then hit each other. R1 was not provided 1:1 supervision at the time of the incident.

Inspectors wroteBased on staff interview and record review, the facility did not ensure an allegation of abuse was reported to the State Agency (SA) for 2 residents (R) (R1 and R5) of 5 sampled residents. On 9/7/24, R1 and R5 were involved in a physical altercation that involved hitting and slapping at each other. The resident-to-resident altercation was not reported to the SA.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 30 residents residing in the facility. Cooling logs were not completed for leftover foods. A refrigerator that stored food for resident consumption contained dried food debris and a sticky substance on the interior shelves. Food holding temperatures were not monitored or documented. Food items for resident consumption were not labeled with open or expiration dates and/or were beyond the labeled discard date.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable disease and infection. This practice had the potential to affect all 30 residents residing in the facility. The facility did not maintain monthly and quarterly infection surveillance data. The facility did not implement enhanced barrier precautions (EBP) for 3 Residents (R) (R15, R14, and R11) with a history of multi-drug resistant organisms (MDROs).

Inspectors wroteBased on staff interview and record review, the facility did not implement their abuse policy and complete timely and thorough background checks for 4 of 8 sampled staff. The facility did not obtain Integrative Background Information System (IBIS) or Department of Justice (DOJ) reports for Certified Nursing Assistant (CNA)-T. The facility did not obtain IBIS or DOJ reports for Dietary Aide (DA)-S. The facility obtained Physical Therapist (PT)-R's IBIS and DOJ reports after PT-R's hire date. The facility di not ensure a background check was completed within the last four years for CNA-U. In addition, the facility did not obtain IBIS or DOJ reports for CNA-U.

Inspectors wrote3. On 7/30/24, Surveyor reviewed R15's medical record. R15 was admitted to the facility on [DATE] with diagnoses including cerebral hemorrhage (stroke), hemiplegia, and diabetes. R15's MDS assessment, dated 7/19/24, stated R15's BIMS score was 15 out of 15 which indicated R15 had intact cognition. On 7/30/24, Surveyor reviewed R26's medical record. R26 was admitted to the facility on [DATE] with diagnoses including neurocognitive disorder Lewy bodies and fracture of unspecified part of neck of left femur. R26's MDS assessment, dated 6/18/24, stated R26's BIMS score was 1 out of 15 which indicated R26 had severe cogitative impairment. R26 had a guardian for healthcare decisions. On 7/30/24 at 12:48 PM, Surveyor interviewed R15 who stated R15 was attacked by R26 on 7/20/24 and R15's Family Member ((FM)-L) was not notified. R15 stated R26 made fists and hit R15 in the chest. [...]

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure 5 Residents (R) (R19, R15, R4, R6, and R31) of 6 sampled residents who required assistance with activities of daily living (ADLs) were assisted per their plans of care. R19 was not assisted with meals as indicated in R19's plan of care. R15, R4, R6, and R31 did not consistently receive weekly scheduled showers.

Inspectors wroteBased on observation and staff and resident interview, the facility did not make a prompt effort to resolve a grievance for 1 Resident (R) (R15) of 1 sampled resident. In addition, the grievance was not contained in the facility's grievance file. During an interview on 7/30/24, R15 stated R15 called Family Member (FM)-L and asked FM-L to call the facility for assistance when staff didn't answer R15's call light. FM-L stated FM-L phoned the facility numerous times with no answer or ability to leave a message. R15 told staff the telephone wasn't answered and there was no way to leave a message. The facility did not follow-up with R15 and FM-L or resolve the grievance in a timely manner.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure incidents involving potential abuse were reported to the Nursing Home Administrator (NHA) and the State Agency (SA) for 3 Residents (R) (R24, R15 and R26) of 5 sampled residents. On 4/2/24, staff discovered R24 had an injury of unknown origin. The facility did not report the injury of unknown origin to the NHA and the SA. On 7/20/24, R15 had a physical altercation with R26. The facility did not report the resident-to-resident altercation to the SA.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a written notification of transfer, including the reason for the transfer, location of the transfer, appeal rights, and contact information for the State Long-Term Care Ombudsman was provided for 1 Resident (R) (R6) of 2 sampled residents reviewed for hospitalization. R6 was not provided a written transfer notice when R6 was transferred to the hospital on 5/12/24.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 Resident (R) (R6) of 2 residents reviewed for hospitalization received written information of the duration of the bed hold policy, the reserve bed payment policy, and the right to return to the facility. R6 was transferred to the hospital on 5/12/24 and was not provided a bed hold notice.

Inspectors wroteBased on staff interview and record review, the facility did not ensure Pre-admission Screen and Resident Review (PASRR) requirements were met for 1 Resident (R) (R22) of 5 sampled residents. R22's medical record indicated R22 had a history of mental illness (MI) or mental disorder (MD) diagnosis upon admission and was prescribed psychotropic medication. R22's PASRR Level I Screen was marked no for major mental disorder, yes for psychotropic medication, and no for history of intellectual disability (ID). The facility did not complete a PASRR Level II Screen when R22 remained in the facility for long-term care.

Inspectors wroteBased on staff interview and record review, the facility did not develop a comprehensive plan of care following a smoking assessment for 1 Resident (R) (R25) of 15 sampled residents. R25's plan of care did not address R25's smoking assessment or include interventions specific to smoking at the facility.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure 1 Resident (R) (R14) of 1 resident with an indwelling catheter received the appropriate care and services to prevent a urinary tract infection (UTI). During an observation on 7/29/24, staff did not keep R14's catheter drainage bag below the level of the bladder which prevented the flow of urine.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure 1 Resident (R) (R20) of 3 sampled residents was offered fluid intake between meals. The facility did not provide fluids to R20 between meals.

Inspectors wroteBased on staff interview and record review, the facility did not ensure high-risk medications were monitored for 2 Residents (R) (R6 and R19) of 5 residents reviewed for unnecessary medications. The facility did not monitor R6 for side effects or adverse reactions of insulin and bumetanide. The facility did not monitor R19 for side effects or adverse reactions of apixaban and furosemide.

Inspectors wroteBased on staff interview and record review, the facility did not ensure assessment and rationale for psychotropic medications were completed for 3 Residents (R) (R1, R22, and R19) of 5 residents reviewed for unnecessary medications. R1 was prescribed lorazepam (an antianxiety medication) as needed (PRN) three times daily (TID) on 6/20/24. There was no rationale provided for continued use of the medication beyond 14 days. R22 was prescribed lorazepam 0.5 mg (milligrams) 1 tablet twice daily (BID) PRN on 2/7/24. There was no rationale provided for continued use of the medication beyond 14 days. R19 was prescribed lorazepam PRN TID on 6/20/24. There was no rationale provided for continued use of the medication beyond 14 days.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure medications were stored appropriately for 1 Resident (R) (R4) of 6 residents observed during medication administration. On 7/31/24, Registered Nurse (RN)-N left two bottles of eye drops (fluorometholone and Sil-Optho) and a container of betamethasone valerate topical lotion that were prescribed to R4 and a scopolamine transdermal system 1 mg (milligram)/3 days patch that was not prescribed to R4 on R4's bedside table.

Inspectors wroteBased on observation and staff, resident, and family interview, the facility did not ensure 1 Resident (R) (R15) of 12 sampled residents resided in a clean, comfortable, and home-like environment. This had the potential to affect multiple residents in the facility. During observations on 7/29/24 and 7/30/24, the 100 and 200 wings of the facility smelled of urine. During an interview on 7/30/24, R15 stated the facility smelled like an [NAME].

Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to provide a safe and sanitary environment and prevent the transmission of communicable disease and infection. This practice had the potential to affect all 29 residents residing in the facility. In addition, staff did not perform appropriate hand hygiene during incontinence care for 2 residents (R) (R9 and R6) of 2 residents. The facility did not appropriately monitor for infections and outbreaks. Staff did not perform appropriate hand hygiene during incontinence care for R9 and R6.

Inspectors wroteBased on observation and staff interview, the facility did not ensure medications were properly secured in a medication cart. This practice had the potential to affect multiple residents whose medications were stored in the cart. Surveyor observed R15 open a drawer of an unlocked medication cart in the lobby and remove two medication cards.

Inspectors wroteBased on staff interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 2 residents (R) (R16 and R17) of 10 sampled residents. R16 stated in a resident council meeting that a staff kicked R16's foot off R16's chair on purpose and was rough with R16. The allegation of abuse was not reported to the State Agency (SA) or local law enforcement. R17 stated someone took money out of R17's purse. The allegation of misappropriation was not reported to the SA or local law enforcement.

Inspectors wroteBased on staff interview and record review, the facility did not thoroughly investigate allegations of abuse and misappropriation for 2 residents (R) (R16 and R17) of 10 residents. R16 stated in a resident council meeting that staff kicked R16's foot of R16's chair on purpose and was rough with R16. The allegation of abuse was not thoroughly investigated. R17 stated someone took money out of R17's purse. The allegation of misappropriation was not thoroughly investigated.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure necessary care and services were provided to promote healing and/or prevent pressure injuries from worsening or developing for 1 resident (R) (R6) of 17 sampled residents. R6's medical record indicated R6 had open area(s) on the buttocks on 1/10/24 and 3/27/24. R6's medical record did not contain assessments or proof of monitoring for effectiveness of treatments.

Inspectors wroteBased on observation and staff interview, the facility did not establish and maintain an infection control program designed to provide a safe and sanitary environment to help prevent the development and transmission of disease and infection for 1 Resident (R) (R1) of 3 residents observed during the provision of cares. Staff did not appropriately cleanse hands during the provision of cares for R1.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure safe food handling practices were implemented. This had the potential to affect all 28 residents residing in the facility. Food items for resident consumption were not labeled with open dates and/or expiration dates. A refrigerator with food for resident consumption contained missing daily temperature checks on the temperature log form. An air-handling unit and a condenser in the kitchen/kitchen walk-in cooler contained debris.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program based on current standards of practice and designed to provide a safe environment to help prevent the development and transmission of communicable disease and infection. This practice had the potential to affect all 28 residents residing in the facility. The facility's Water Management Plan (WMP) was not based on current standards of practice and did not: [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure the Infection Preventionist (IP) completed specialized training in infection prevention and control. This had the potential to affect all 28 residents residing in the facility. The facility does not currently have an IP who completed specialized training in infection prevention and control.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the development of a comprehensive person-centered care plan with measurable goals, timeframes, and interventions for 1 Resident (R) (R18) of 2 sampled residents. R18 was diagnosed with a right corneal eye ulcer and bacterial conjunctivitis. R18 was started on antibiotics. The facility did not develop a care plan to address R18's infection or antibiotic use including monitoring and possible side effects.

Inspectors wroteBased on staff interview and record review, the facility did not ensure influenza and pneumococcal vaccinations were reviewed, offered, and administered for 2 Residents (R) (R9 and R20) of 5 residents. The facility did not review R9's vaccination history or offer R9 the PCV20: 20-valent pneumococcal conjugate vaccine (Prevnar 20®). In addition, the facility did not offer R9 an annual influenza vaccine. The facility did not review R20's vaccination history or offer R20 the PPSV23: 23-valent pneumococcal polysaccharide vaccine (Pneumovax23®).

Inspectors wroteBased on staff interview and record review, the facility did not ensure a resident or resident's representative was provided education regarding the risks versus benefits of COVID-19 immunization and did not obtain consent or refusal for COVID-19 immunization for 3 Residents (R) (R9, R18 and R20) of 5 residents reviewed. R9's medical record did not contain documentation to indicate R9 or R9's representative was provided education regarding COVID-19 immunization and offered the opportunity to receive or decline COVID-19 immunization. R18's medical record did not contain documentation to indicate R18 or R18's representative was provided education regarding COVID-19 immunization and offered the opportunity to receive or decline COVID-19 immunization. [...]

Inspectors wrote2. Surveyor reviewed R18's medical record and noted R18 was transferred to the hospital on 5/10/23. R18 had an Activated Power of Attorney for Healthcare (APOAHC). R18's medical record did not include documentation that a transfer notice was provided to R18's resident representative. Based on staff interview and record review, the facility did not ensure a written notification of transfer, including the reason for the transfer, location of the transfer, appeal rights and contact information for the State Long-Term Care Ombudsman was provided for 4 Residents (R) (R12, R18, R9, and R25) of 4 sampled residents reviewed for hospitalization. R12 was not provided a written transfer notice when R12 was transferred to the hospital on 3/6/22 and 3/30/23. R18's resident representative was not provided a written transfer notice when R18 was transferred to the hospital on 5/10/23. [...]

Inspectors wrote2. On 5/30/23, Surveyor reviewed R18's medical record and noted R18 was transferred to the hospital on 5/10/23. R18 had an Activated Power of Attorney for Healthcare (APOAHC). R18's medical record did not include documentation that R18's resident representative was provided a bed hold notice. Based on staff interview and record review, the facility did not ensure 4 Residents (R) (R12, R18, R9 and R25) of 4 sampled residents reviewed for hospitalization received written information regarding the facility's bed hold policy, including the duration of the bed hold, the reserve bed payment policy, and the right to return to the facility. R12 was transferred to the hospital on 3/6/23 and 3/30/23 and was not provided a bed hold notice. R18 was transferred to the hospital on 5/10/23. R18's resident representative was not provided a bed hold notice. R9 was transferred to the hospital on 1/18/23. [...]