Muskego Health and Rehabilitation Center

Inspectors wroteBased on observation, interview and record review, the facility did not ensure residents with pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new pressure injuries from developing for 3 (R1, R15, R16) of 4 residents reviewed for pressure injuries from a sample of 12 residents. *On 2/26/25, R1 was admitted to the facility and assessed to be at high risk for the development of pressure injuries. On 7/23/25 during wound rounds R1was assessed to have developed a facility acquired, unstageable pressure injury to the left heel. R1's care plan did not include an intervention to wear a pressure relieving boot to the left foot until 12/05/25. R1's care plan did not address R1's preference to wear shoes. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that 5 of 5 Certified Nursing Assistants (CNAs) reviewed had an annual performance review completed every twelve months. CNA-E, CNA-G, CNA-H, CNA-I and CNA-J did not have an annual performance review. This deficient practice had the potential to affect all 36 residents residing in the facility as the CNAs work with residents throughout the facility.

Inspectors wroteBased on observation, interview, and record review, drugs used in the facility were not labeled in accordance with currently accepted professional principles, for 1 of 2 medication carts observed.*Surveyor observed 6 expired stock medications and 63 loose medications in the medication carts.

Inspectors wroteBased on observation, interviews, and record reviews, the facility did not ensure each resident was treated with dignity and respect that promoted maintenance or enhancement of quality of life. This occurred for 2 (R22 and R24) of 10 residents reviewed for dignity during mealtime in the dining room.*Director of Nursing (DON)-B and Certified Nursing Assistant (CNA)-F were observed during the lunch meal standing over and feeding R22. CNA-F did not engage in conversation with R22 during the lunch meal.*Certified Nursing Assistant (CNA)-E was observed during the lunch meal standing over and feeding R24. CNA-E did not engage in conversation with R24 during the lunch meal.

Inspectors wroteBased on observation, interview and record review the facility did not ensure 1 (R15) of 12 sampled residents , received necessary care and treatment based on an assessment.*Surveyor observed a border gauze dressing in place to R15's right knee. There was no assessment of the wound and no order for treatment.

Inspectors wroteBased on observation, interviews, and record review, the facility did not ensure 1 (R29) 1 sampled resident with hearing impairment received proper treatment and assistive devices including arrangements for an audiology (ear doctor) evaluation. The facility did not follow up on an audiology consult dated 10/25/25 after recommending wax in both ears be removed to complete a hearing evaluation. Findings Include:The facility policy, entitled Hearing and Vision Services reviewed/revised 7/12/25, documents:Guideline: It is the guideline of this facility to ensure that all residents have access to hearing and vision services and receive adaptive equipment as indicated. Explanation and Compliance Guidelines:2. Staff should refer any identified need for hearing or vision services/appliances to the social worker/social service designee.3. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not ensure a resident received routine dental services for 1 (R29) of 1 resident reviewed for dental services. On 11/11/25 a dental referral for R29 was initiated due to cracked teeth and jaw pain. R29 was not evaluated until 6/15/26 by the dentist. Findings Include:The facility policy, entitled Dental Services reviewed/revised 11/12/24, stated:Policy:It is the policy of this facility to assist residents in obtaining routine and emergency dental care. Policy Explanation and Compliance Guidelines: 1. The dental needs of each resident are identified through the physical assessment and MDS assessment processes and are addressed in each resident's plan of care.a. Oral/dental status shall be documented according to assessment findings.c. [...]

Inspectors wroteBased on interview, record review, and review of the facility policy, the facility failed to document in the medical record family notification for two out of four falls for one resident (Resident (R) 1) in a total sample of five residents. This failure placed the resident at risk of his family not being notified or the resident consented to the notification.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure the medical record was complete and accurate for three residents (Residents (R)1, R2, and R3 in a total sample of five residents. The facility failed to ensure weekly weights, meals, incontinent care, and skin assessments were documented for R1, failed to ensure weekly skin assessments, and incontinent care was documented for R2, and failed to ensure incontinent care was documented for R3. These failures placed residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, are reported immediately to the administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law through established procedures for 1 of 1 abuse investigation involving 1 of 1 Residents (R1). The facility became aware of an abuse allegation on the evening of 10/8/25 at approximately 9:00 PM and did not report to state agency until 10/9/25 at 8:09 PM. Evidenced by:The facility policy entitled Abuse, Neglect and Exploitation, dated 7/01/25, states, in part: . [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not implement professional standards of practice to prevent pressure injuries (PIs) from developing and/or worsening or to promote healing of PIs for 1 of 1 residents (R2) reviewed for PIs out of a sample of 5 residents. R2's treatment orders were not followed and hand hygiene was not performed during wound care for R2's pressure injury. This is evidenced by:The facility's policy Clean Dressing Change, dated 2/14/23, includes: It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. Physician's orders will specify type of dressing and frequency of changes. 7. Wash hands and put on clean gloves. 9. Loosen the tape and remove the existing dressing. 10. Remove gloves, pulling inside out over the dressing. Discard into appropriate receptacle. 11. [...]

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 of 1 sampled resident (R1) reviewed for medications. R1 did not receive medications that included, a blood pressure medication, a thyroid medication and a pain medication 5 days during the months of September and October. Evidenced by: The facility policy entitled Medication Error Reporting and Counseling Procedure, dated 4/09/25, states, in part: . Guideline: It is the expectation of this facility to provide protections for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors. [...]

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 for 1 of 1 residents (R2) observed for wound care. The facility staff did not wear proper PPE (Personal Protective Equipment) when providing wound care to R2. This is evidenced by:The facility's policy Enhanced Barrier Precautions, dated 9/9/25, includes: It is the guideline of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. [...]

Inspectors wroteBased on interview and record review, the facility did not resolve a grievance for 1 (R1) of 3 residents reviewed for grievances.*On 05/23/2025, R1 filed a grievance involving Certified Nursing Assistant (CNA)-E. The Facility documented that CNA-E would not work with R1 moving forward. Surveyor noted, CNA-E cared for R1 since the incident on multiple occasions.

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R1) of 3 residents needing assistance with Activities of Daily Living (ADL), received the necessary services to receive cares.*R1 did not receive weekly showers.

Inspectors wroteBased on record review, and interview, the facility failed to ensure that bilateral heel protectors for one Resident (R7) of three residents reviewed for pressure injuries were worn according to physician orders. This failure had the potential to increase the bilateral heel sores in size for R7 and negatively affect other residents that remain in the facility that have pressure sores.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that the daily nursing staff posting contained accurate information for the skilled nursing facility (SNF). This deficient practice has the potential to affect a pattern of all 37 Residents residing in the facility. The facility nursing staff posting included community based residential facility (CBRF) hours and the skilled nursing facility hours were either blank with no certified nursing assistants (CNAs) assigned on nights or the number of CNAs was inaccurate.

Inspectors wroteBased on interview and record review the facility did not implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of residents property by having a system in place to ensure nurses have a current nursing license and allegations of verbal abuse are reported and investigated and/or investigated timely. * The facility did not have a system in place to check licensed nurses to ensure their license remain valid. Licensed Practical Nurse (LPN)-Q held a multistate license from Texas. On [DATE] the Texas Board of Nursing revoked LPN-Q's license. LPN-Q worked at the facility on [DATE] & [DATE] after her license was revoked. * R7 reported an allegation of verbal abuse by LPN-Q and the allegation of verbal abuse was not reported immediately to Nursing Home Administrator (NHA)-A and to the State Survey Agency. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection for 4 (R3, R4, R7, & R2) of 4 Residents. * There was not an enhanced barrier precaution sign on R3's door, (Licensed Practical Nurse) (LPN)-N did not wear appropriate PPE (personal protective equipment) during a treatment observation and appropriate hand hygiene was not observed during the treatment observation. * R4 was admitted to the facility on [DATE] with multiple non pressure areas. An enhanced barrier sign was not observed on R4's door on 2/20/25 until 2:56 p.m. * Appropriate hand hygiene was not observed during treatment and incontinent cares for R7. [...]

Inspectors wroteBased on interview and record review the facility did not ensure that 1 (R1) of 1 Residents reviewed for a room change within the facility, were provided with prior written notice, including reason for the room change. *R1 transferred to another room on an unknown date and there is no documentation R1 and/or guardian received prior written notice and gave consent for the reason for the transfer. On 2/14/25, R1 was transferred to yet another room and there is no documentation R1 and/or guardian received prior written notice and gave consent for the reason for the transfer. Findings Include: The facility's policy Change of Room or Roommate implemented 3/7/23 documents: .Policy: It is the policy of this facility to conduct changes to room and/or roommate assignments when considered necessary and/or when requested by the Resident or Resident representative. [...]

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R2) of 5 Residents reviewed sought consultation with the physician regarding significant weight loss, possible thrush, and the prescribed formula not being available for administration to R2. Findings Include: The facility's policy and procedure Notification of Changes implemented 10/24/23 and last revised 8/27/24 documents: Policy: .The purpose of this policy is to ensure the facility promptly informs the Resident, consults the Resident's physician; and notifies, consistent within his or her authority, the Resident's representative when there is a change requiring notification. Changes of condition require an evaluation, using the situation, background, assessment, and recommendation (SBAR) Communication Form and Progress Note Evaluation ensures proper documentation and notification has been made. [...]

Inspectors wroteBased on interview and record review, the facility did not protect 1 (R2) of 4 Residents by not implementing their written policies and procedures to prohibit and prevent the right to be free from verbal abuse from Certified Nursing Assistant (CNA)-H. *Staff did not report allegations of verbal abuse immediately of a Resident by CNA-H, and consequently R2 was subjected to verbal abuse a couple of weeks later by CNA-H. Findings Include: The facility's Abuse, Neglect and Exploitation policy and procedure implemented 9/18/23 documents: .It is the policy of this facility to provide protections for health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Policy Explanation and Compliance Guidelines: 1. [...]

Inspectors wroteBased on record review and staff interviews, the facility did not ensure that 3 allegations of abuse/misappropriation involving 3 Residents (R6, R8 and R7) of 4 allegations of abuse/misappropriation were reported immediately to the Nursing Home Administrator (NHA)-A and to the State Survey Agency within the required reporting timeframe . * 3 staff members reported late to Nursing Home Administrator (NHA)-A allegations of Certified Nursing Assistant (CNA)-H being verbally abusive to R6. The allegation of verbal abuse was not reported immediately to Nursing Home Administrator (NHA)-A and to the State Survey Agency. * R8 reported to a CNA that R8 was missing money on 2/19/25. The allegation of misappropriation was not reported immediately to Nursing Home Administrator (NHA)-A and to the State Survey Agency. [...]

Inspectors wroteBased on interview and record review the facility did not ensure 3 (R7, R6, & R2) of 4 allegations of abuse were investigated or thoroughly investigated timely. * The facility did not conduct a thorough investigation timely for R7's allegation of verbal abuse. * The facility did not conduct a thorough investigation timely for R2's allegation of verbal abuse. * The facility did not conduct an investigation for R6's allegation of verbal abuse.

Inspectors wroteBased on interview and record review the facility did not ensure that based on the comprehensive assessment of a resident, residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident's choices for 2 (R3 & R4) of 2 residents. * R3 was admitted to the facility on [DATE] with a left scrotum surgical wound and right fifth digit wound. The facility did not complete weekly assessments on these areas. On 2/20/25 R3's treatment to the right fifth digit was not completed and the left scrotum treatment was not completed according to physician orders. * R4 was admitted to the facility on [DATE] with multiple non pressure areas. These non pressure areas were no assessed until 2/19/25, six days later by Wound Physician-T. [...]

Inspectors wroteBased on observation, interview and record review, the Facility did not ensure that Residents with a pressure injury received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 1 (R7) of 1 Residents reviewed for pressure injuries. On 2/6/25 the facility discontinued the treatment to R7's left fifth toe even though Wound Physician-T continued the treatment of skin prep. On 2/12/25 Wound Physician-T changed treatment orders for R7's left hip pressure injury, left lateral knee pressure injury, & right heel pressure injury. The facility did not pick up these orders until 2/20/25, 8 days later. On 2/20/25 R7's right heel treatment was not completed according to physician orders as the nurse informed R7 her treatment had been discontinued. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure 1 (R1) of 1 Residents reviewed received adequate supervision and assistance devices to prevent accidents. * R1 has been assessed as a high risk for falls. R1 had unwitnessed falls on 1/17, 2/2, and 2/9/25 and a thorough investigation was not completed including a root/cause analysis. R1 is nothing by mouth (NPO) and receives all nutrition through a Peg Tube. On 2/13/25, R1 was given a regular diet with thin liquids on a food tray in the dining room and the facility did not complete an investigation. On 2/14/25, R1 attempted to exit the facility. The facility did not complete a thorough investigation. R1 was not re-evaluated for an elopement risk until 2/18/25 which determined R1 required a wanderguard to be placed. An elopement risk care plan was not implemented until 2/24/25. Findings Include: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure resident (R2) maintained acceptable parameters of nutritional status for 1 (R2) of 1 resident reviewed for weight loss. On 1/24/25, Licensed Practical Nurse (LPN)-E documented in R2's electronic medical record (EMR) that R2 missed 4 bolus feedings due to Nepro not being available. Per R2's Medication Administration Record, there were 7 total missed feedings. R2 had a significant weight loss identified on 1/28/25 times one week of -5.4% (9 pounds). On 2/11/25, R2 was identified as having a significant weight loss times 30 days of -6.9% (11 pounds). The physician was not notified. Cross Reference (F580). On 1/25/25, weights 2 times a week on Tuesday and Saturday were initiated per physician's order. On 2/11/25, weights were recommended by Registered Dietitian (RD)-G to be obtained 3 times a week. [...]

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R3) of 1 residents have consistent pre and post dialysis communication for R3 who receives dialysis three times a week.

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections potentially affecting all 39 residents in the facility and Enhanced Barrier Precautions were not in place or followed for 2 (R37 and R8) of 2 residents observed receiving wound care. *Enhanced Barrier Precautions (EBP) were not posted on doors as required for residents with invasive devices or wounds. *Rates of infection were not calculated and documented monthly to monitor trends of infection. *R37 had an indwelling urinary catheter in place and wound care was completed with no Enhanced Barrier Precautions in place. *R8 had wound care completed and staff did not follow the Enhanced Barrier Precautions.

Inspectors wroteBased on interview and record review, the facility did not ensure that residents remain as free of accident hazards as is possible and that each resident received adequate supervision and assistance devices to prevent accidents for 5 (R8, R12, R23, R29, and R31) of 6 residents reviewed for falls and 1 (R29) of 2 residents reviewed for smoking. * R29 had a fall on 8/31/2024 that was not thoroughly investigated and R29's care plan was not revised until 9/3/2024. * R29 had a smoking evaluation completed on 8/13/2024. The smoking evaluation indicated that the facility holds onto R29's smoking supplies and should be a supervised smoker. R29 did not have a smoking care plan and had smoking supplies located in R29's purse in her room. R29 did not have any additional smoking evaluation assessments completed. * R23 had a fall on 10/29/2024 that was not thoroughly investigated. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 1 (R235) of 1 resident's reviewed for communication were fully informed in a language they can understand of their total health status, including but not limited to, their medical condition and care to be furnished. * R235's primary and only language spoken is Serbian. The facility did not identify methods of communication or provide education to staff related to methods of communication that should be used with R235. The facility depended on R235's family members for translation between the facility staff and R235. The facility documented that R235 to be their own person and a power of attorney for R235 was not activated.

Inspectors wroteBased on interviews and record review, the facility did not ensure 1 (R235) of 2 allegations of neglect were reported to the State Survey Agency. * R235 had an allegation of neglect that occurred during the night shift of 1/8/2025. This allegation of neglect was not reported to the State Agency.

Inspectors wroteBased on interview and record review, the facility did not ensure a resident to resident altercation was thoroughly investigated for 2 (R7 and R30) 3 residents reviewed for abuse and 1 (R235) of 2 allegations of neglect. * The facility did not thoroughly investigate a resident to resident altercation between R7 and R30 that was reported on 12/16/2024 to the State Survey Agency. * R235's family member reported an allegation of abuse to the nursing home administrator on 1/9/2025 and was not thoroughly investigated.

Inspectors wroteBased on interview and record review, the facility did not ensure 2 (R12 and R23) of 2 residents reviewed for hospitalizations received a written transfer/discharge notice that included the date of transfer, reason for transfer, location of transfer, appeal rights and contact information of the State Long-Term Care Ombudsman.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents with pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 1 (R8) of 2 residents reviewed with pressure injuries. * R8 did not receive treatment of R8's lower back pressure injury 20 days out of 71 days. R8 did not have documentation of multiple skin discolorations over boney prominence areas where pressure injuries are likely to occur.

Inspectors wroteBased on observations, interview and record review, the facility did not ensure that 1 (R12) of 1 residents reviewed with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. * R12 has a physician order for a splint to be worn on the right hand. Surveyor observed R12 wearing a palm guard on R12's right hand on the first day of survey. Surveyor had multiple observations of R12 not wearing a splint or a palm guard on R12's right hand during the remainder 2 days of the survey.

Inspectors wroteBased on interviews and record review the facility did not ensure 1 (R5) of 1 residents reviewed for colostomy, urostomy or ileostomy services, received care consistent with professional standards of practice. * R5 was admitted to the facility with a colostomy on 10/25/2024. R5's Physician orders did not contain any orders for the care and treatment of R5's colostomy until an order was placed on January 7th, 2025. There is not consistent documentation that the necessary care and services needed for R5's colostomy were provided between R5's admission to the facility through 1/7/25.

Inspectors wroteBased on interview and record review, the facility did not ensure that residents who require dialysis receive such services, consistent with professional standards of practice, including the ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility for 1 (R485) of 1 residents reviewed for dialysis. * R485 was admitted to the facility needing dialysis and did not have physician orders for hemodialysis and frequency of the dialysis. Assessments were not completed before or after dialysis sessions. No care plan was in place for monitoring and care of R485 related to dialysis and complications. There was no evidence of ongoing communication between the Facility and the dialysis center with each visit.

Inspectors wroteBased on interview and record review the facility did not ensure nursing staff had the specific competencies and skill sets necessary to care for resident's needs affecting 1 (R29) of 12 residents reviewed. R29 indicated Resident Assistant (RA)-T pivots transfers R29 into a wheelchair and takes R29 outside to smoke. RA-T is employed with the community based residential facility (CBRF) and is not a certified nursing assistant (CNA) or certified to care for residents in the long-term care facilities. R29 was assessed to require the use of a sit to stand mechanical lift for transfers.

Inspectors wroteBased on interview and record review, the Facility did not ensure the accurate and safe administration of medication for 1 Resident (R485) of 12 residents reviewed. R485 has a physician order for Epoetin Alfa Injection Solution 4000 UNIT/ML. Inject 1 vial subcutaneously at bedtime every Tue (Tuesday), Thu (Thursday), Sat (Saturday) for anemia related to human immunodeficiency virus [hiv] disease. This medication was not available to be given after R485 admitted to the Facility, resulting in 5 missed doses.

Inspectors wroteBased on interview and record review, the facility did not act upon the pharmacy medication regimen review reports when received. This was observed with 1 (R21) of 5 resident medication reviews. R21's monthly pharmacy reviews noted a recommendation reported on 9/10/2024 and 11/11/2024 (same concern from 9/10/2024 recommendation). There was no documentation the attending physician acted upon the recommendations from pharmacy until Surveyor requested to see the physician signed reviews that were dated the same day requested.

Inspectors wroteBased on interview and record review, the Facility did not ensure monitoring for adverse reactions of high risk medications for 2 residents (R31 and R485) of 5 residents reviewed for unnecessary medications. *R31 has orders for Eliquis (anticoagulant) twice daily for chronic embolism and thrombosis of unspecified deep veins of unspecified lower extremity and Furosemide (diuretic) once daily for hypertension. The Facility did not implement care plans to monitor for any adverse side effects that could result from taking an anticoagulant or diuretic. *R485 has orders for Apixaban (anticoagulant) twice daily for end stage renal disease and Furosemide (diuretic) once daily for hypertension. The Facility did not implement care plans to monitor for any adverse side effects that could result from taking an anticoagulant or diuretic.

Inspectors wroteBased on observation, interview, and record review, the Facility did not ensure residents who receive psychotropic medications had medication side effect monitoring and non-pharmological interventions identified for 1 (R485) of 5 residents reviewed for unnecessary medications. The Facility did not ensure 1 (R21) of 5 residents reviewed did not receive a PRN medication beyond 14 days without a documented rational and indicated duration. R485 did not have orders for monitoring of adverse consequences from the use of Mirtazapine (antidepressant) and SEROquel (antipsychotic) medications or orders for non-pharmacological interventions to improve R485's well being. R21 was prescribed an anti-anxiety medication, Lorazepam oral concentrate 2 mg/ml- give 0.25 ml by mouth every 1 hours as needed without an end date.

Inspectors wroteBased on interviews and record reviews, the facility did not ensure residents received the influenza immunization and the pneumococcal immunization for 2 (R37 and R23) of 5 residents reviewed for immunizations. *R37 consented to the influenza immunization and did not receive it. *R23 consented to the pneumococcal immunization and did not receive it.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that sufficient nursing staff was provided to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. * The facility did not designate a charge nurse for each tour of duty on each daily nursing schedule. This deficient practice has the potential to affect all 39 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that the daily nurse staff posting included all required information. This deficient practice has the potential to affect a pattern of all 39 residents residing in the facility. The facility nurse staff posting did not include the daily resident census as required.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure enhance based precautions (EBP) were implemented for five of five residents (Resident (R)4, R5, R6, R7, R8) reviewed for EBP due to presence of a wound requiring care, indwelling urinary catheter, or gastrostomy tube. The facility failed to ensure that when a resident's incontinence brief change occurred, staff's gloves were changed between cleaning the urine or stool and placing a clean incontinence brief on the resident for one of one residents (R9) observed for incontinence care. As a result of this deficient practice the residents had the potential for harm of cross contamination (from one resident to another) by transmission of multidrug-resistant organisms (MDRO).

Inspectors wroteBased on interview, document review and record review, the facility failed to ensure professional standards of care were provided when transferring physician wound care orders. The failure to ensure physician orders for antibiotics were transcribed and administered for one of three residents (Resident (R)2) reviewed for antibiotic administration. The facility failed to have documentation of skin conditions during nursing assessments for one of three residents (R1) reviewed for skin assessments and treatment. Specifically, the wound physician wrote treatment orders for R1's skin wounds. However, nursing staff failed to review the wound physician's notes and receive clarification of the orders if necessary, prior to documenting the orders in the record. [...]

Inspectors wroteBased on observation, interview and record review the facility did not ensure that all resident rooms have at least 80 square feet of space per resident in multiple rooms. This deficient practice has the potential to affect 10 of 12 residents (R3, R7, R28, R20, R2, R389, R9, R14, R16, R29) currently residing in these rooms. rooms [ROOM NUMBERS] both had 3 residents in each room, were observed to be tight for the residents residing in these rooms. rooms [ROOM NUMBERS] both of these rooms currently had 2 residents in each room along with a an empty bed in each room so that each room could have the capacity of 3 residents. The resident in each of these rooms indicated that when the 3rd bed is occupied, the space in the room is tight.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure the call light was within reach for 1 (R1) of 12 residents reviewed. R1 was observed on multiple occasions in R1's room without a call light within reach.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to protect 1 (R7) of 12 residents of the right to be free from physical abuse by R4 On 7/23/23, R4 attended a church service in which staff were not able to attend. As a result, staff was not able to provide supervision to ensure R4 was an arm's length away from other residents. During this church service on 7/23/23 at 11:45 am, R4 punched R7 in the arm.

Inspectors wroteBased on record review and interview, the facility did not develop and implement a baseline care plan that includes the instructions needed to provide effective and person-centered care for 2 (R20 and R389) of 2 newly admitted residents. R20's baseline care plan did not address hospice services, pressure injuries, or psychotropic medications that R20 was admitted with. R389's baseline care plan did not address the monitoring of psychotropic or anticoagulant medications that were ordered on admission.

Inspectors wroteBased on record review and interview, the facility did not develop and implement a comprehensive person-centered care plan with measurable objectives that were identified in the comprehensive assessment for 1 (R20) of 12 sampled residents. R20 was admitted with an order for an antianxiety medication lorazepam 0.5 mg every hour as needed. The use of lorazepam was not comprehensively assessed on the admission Minimum Data Set (MDS) assessment and no care plan addressing R20's anxiety or use of lorazepam was implemented.

Inspectors wroteBased on interview and record review the facility did not develop and implement a discharge planning process that included preparation for discharge, ensuring discharge needs are identified and incorporated into a discharge planning care plan for 1 (R38) of 1 resident reviewed for discharge planning. * R38 was admitted into the facility with the expectation of discharging to another facility (an assisted living). The facility did not develop a discharge plan for R38. There was no documentation regarding the progress on discharge planning goals. There was no documentation of the assisted living application status or progress. There was no further documentation regarding conversations with R38, the activated Power of Attorney A(POA), or the Assisted Living Facility (ALF) related to discharging from the facility. R38 was discharged on 6/28/23.

Inspectors wroteBased on record review and staff interviews, the facility did not ensure that 1 out of 1 resident (R38) who was discharged from the facility had a discharge summary that included all the pertinent information, a final summary of the resident; status at the time of discharge and a post-discharge plan of care developed with the participation of the resident and/ or representative. R38 was discharged from the facility on 6/28/23. The facility's Discharge summary form which documents a recapitulation of R38's stay was incomplete and the medical record did not include information pertaining to R38's discharge.

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure residents received care consistent with professional standards of practice when admitted with pressure ulcers for 1 (R20) of 2 residents reviewed for pressure injuries. R20 was admitted to the facility with a Stage 4 pressure injury to the right hip, a Stage 4 pressure injury to the left hip, and an Unstageable pressure injury to the sacrum that was not assessed on admission by a Registered Nurse (RN) and treatment was not provided daily as ordered by the Wound Physician.

Inspectors wroteBased on observations, interviews and record reviews the facility did not ensure adequate supervision to prevent falls for 2 (R27 and R36) of 3 residents reviewed for falls. *R27 sustained multiple falls. The facility did not thoroughly investigate 3 of R27's 16 falls. *R36 suffered multiple falls. The facility did not thoroughly investigate R36's falls and did not initiate appropriate interventions.

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R38) of 7 residents reviewed for medication who were receiving psychotropic medication were free from unnecessary drugs. R38's PRN (as needed) Lorazepam/Ativan (antianxiety)) does not have a stop date or rationale to extend the use of this medication past 14 days.

Inspectors wroteBased on interview and record review the facility did not have a comprehensive individualized water management plan having the potential to affect 38 out of 38 residents. * The facility's water management plan did not designate team members nor responsibilities for those team members and the water management plan included areas not relevant to the facility.

Inspectors wroteBased on record review and interview, the facility did not notify the resident and the resident's representative of the transfer or discharge in writing that includes the reasons for the transfer and the statement of the resident's appeal rights including the name, mailing address, email address, and telephone number of the entity which receives such requests, and the name, mailing and email address, and telephone number of the Office of the State Long-Term Care Ombudsman for 4 (R13, R7, R32, and R36) of 4 residents reviewed for discharges. R13 was transferred to the hospital on 1/30/2023 and 4/18/2023. The transfer notices that were provided at those times did not contain the correct contact information for the appeal process. R13 was transferred to the hospital on 7/19/2023. R13 and R13's representative were not provided a transfer notice. [...]