Oak Park Nursing and Rehab Center

Inspectors wroteBased on interview and record review, the facility did not ensure each resident received the necessary care and services in accordance with professional standards of practice to meet each resident's physical needs for 1 of 5 sampled residents (R1). R1's surgical dressing was not monitored or assessed. R1's surgical wound was not care planned. This is evidenced by:The facility's policy Acute Condition Changes - Clinical Protocol, dated 3/18, includes: 5. The physician and nursing staff will review the details of any recent hospitalization and will identify complications and problems that occurred during the hospital stay that may indicate instability or the risk of having additional complications. 1. The staff will monitor and document the resident/patient's progress and responses to treatment. The facility's policy Charting and Documentation, dated 7/17, includes: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 5 sampled residents (R1). R1 had multiple wounds on his feet with physician orders for dressing changes and treatment. These treatments were not completed on the AM (morning) shift of 1/18/26. This is evidenced by:The facility policy entitled, Wound Care, dated October 2010, states, in part: . Documentation. The following information should be recorded in the resident's medical record. 2. The date and time the wound care was given. 9. If the resident refused the treatment and the reason(s) why. 10. The signature and title of the person recording the data. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure all drugs and biologicals were disposed of in accordance with currently accepted professional principles for 1 of 3 residents (R2) observed. Surveyor observed R2 in their wheelchair with a nitroglycerin patch stuck to the wheel. R2 does not have an order for a nitroglycerin patch. Evidenced by:According to Enokon article titled How Should a Nitroglycerin Patch Be Disposed of? A Step-By-Step Safety Guide dated 12/2025 states in part .The Step-by-Step Removal and Disposal ProcessFollowing a precise procedure for removing your nitroglycerin patch is essential for safety and consistent treatment. Each step is designed to protect you and others from unintended contact with this potent medication. Step 1: Peel the Patch from the SkinPress down on the center of the patch with one finger. [...]

Inspectors wroteBased on record review, observations, interviews, and facility policy review, the facility failed did not establish and maintain an infection prevention and control program designed to provide a safe environment and to help prevent the development and transmission of communicable disease and infections. This has the potential to affect all 70 residents. The facility failed to ensure adequate infection control processes were followed to ensure containment of Influenza, Respiratory Syncytial Virus (RSV), and COVID during a concurrent facility outbreak of all three infections. This failure created the potential for all residents, staff, and visitors to the facility to become infected with one or more of these viruses, potentially leading to serious illness, hospitalization, and or/death, thus leading to a finding of immediate jeopardy. [...]

Inspectors wroteBased on observations, interviews, and document review, the facility failed to designate a qualified infection preventionist (IP) to develop, implement, and monitor the facility's infection prevention program. This has the potential to affect all 70 residents residing at the facility. The facility failed to monitor residents and staff with signs and symptoms of an acute respiratory illness and protect residents and staff from contracting an acute respiratory illness during a concurrent outbreak of influenza, RSV and COVID in January 2026 The facility's failure to have an infection preventionist who developed, implemented and monitored infectious illnesses placed 70 of 70 residents and facility staff at risk for development of an infectious illness which could result in serious harm and/or death, thus leading to a finding of immediate jeopardy. [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to protect 2 of 22 sampled residents' (R2 and R3) right to be free from verbal abuse by a Registered Nurse (RN1). RN1 referred to R2 as a (drug) addict and told R3 to Stop your damn crying while administering the resident's eye drops.

Inspectors wroteBased on interview and record review, the facility did not implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 3 residents (R1) reviewed for abuse. The facility did not implement their Abuse policy when the facility was made aware R1 was verbally abused by a family member. The facility did not put interventions in place to prevent further abuse, the facility did not report nor investigate the allegation of abuse. This is evidenced by:The facility's policy Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated 4/21, includes: Residents have the right to be free from abuse. This includes but is not limited to freedom from .verbal.abuse. 1. Protect residents from abuse.by anyone including, but not necessarily limited to: f. family members; 2. [...]

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, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse to the appropriate agencies for 1 of 1 abuse allegations involving a resident (R1). On 10/22/25, an allegation of verbal abuse toward R1 from a family member was reported to the facility and the facility did not report the allegation of abuse. This is evidenced by:The facility's policy Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated 4/21, includes: Residents have the right to be free from abuse. This includes but is not limited to freedom from .verbal.abuse. 1. Protect residents from abuse.by anyone including, but not necessarily limited to: f. family members; 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported to the administrator and other officials in accordance with State law through established procedures for 1 of 3 residents (R1) reviewed for abuse. On 10/22/25, an allegation of verbal abuse toward R1 from a family member was reported to the facility and the facility did not thoroughly investigate the allegation of abuse. This is evidenced by:The facility's policy Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated 4/21, includes: Residents have the right to be free from abuse. This includes but is not limited to freedom from .verbal.abuse. 1. Protect residents from abuse.by anyone including, but not necessarily limited to: f. family members; 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that each resident received treatment and care in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) for 1 out of 19 residents (R74) reviewed for change of condition. R74 had orders to update the physician with pulse greater than 119. R74 had a pulse of 140 and the facility did not complete a nursing assessment, recheck the pulse, consult with the physician, or complete ongoing monitoring of R74. R74 was found pulseless and non-breathing. The facility's failure to recognize a change in condition and perform a thorough nursing assessment along with ongoing assessments and monitoring of a resident created a finding of immediate jeopardy that began on [DATE]. Surveyor notified the NHA A (Nursing Home Administrator) of the immediate jeopardy on [DATE] at 2:03 PM. [...]

Inspectors wroteBased on interview, and record review, the facility did not ensure a resident's environment remained free of accidents and hazards for 1 of 3 residents reviewed for falls (R48) and 1 of 3 residents reviewed for supervision (R37). R48 is being cited at severity level 3 (actual harm). R48 sustained three falls. The facility failed to identify a root cause analysis (RCA) or patterns with R48's three falls. Without identifying the RCA, the interdisciplinary team (IDT) did not implement resident specific interventions or identify patterns which could have contributed to her falls and/or prevent future falls, such as a plan to anticipate her toileting needs when she stated she was trying to go to the bathroom. R48 was found to have a C1 fracture (a break in the first vertebra or the cervical spine, located at the base of the skull) and left seventh rib fracture after the second fall. [...]

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 67 of 68 residents. Surveyor observed food that was not sealed or labeled with a use by date in the main kitchen freezer. Surveyor observed food that was not labeled or dated in a kitchenette refrigerator. Surveyor observed microwaves in the three kitchenettes to have several multi-colored dried on splatters and stains on the inside microwaves. The refrigerator and freezer temperatures in two of the kitchenettes are not being consistently monitored or recorded. Evidenced by:Example - Unsealed and unlabeled packages of food in main kitchen freezerFacility policy entitled, Food Receiving and Storage with a revision date of April 2019 states, in part: .8. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This had the potential to affect all 68 residents. Three staff members returned to work too soon after experiencing gastrointestinal (GI) symptoms. The facility's infection control line lists for staff and residents are incomplete and inaccurate. The facility did not ensure daily infection control surveillance for staff and residents. The facility failed to recognize commonalities with staff who called in with similar symptoms in February 2025 and did not rule out a GI or COVID-19 outbreak. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure each resident had a safe, clean, comfortable and homelike environment or ensure housekeeping provided necessary services to maintain a sanitary, orderly and comfortable area for 3 of 22 sampled residents (R33, R37, and R47), 4 supplemental residents (R57, R76, R26, R30) and 1 of 4 units. R33 and R26 voiced concerns related to the cleanliness of the unit. Surveyor observed R33's, R37's, R57's, R76's, and R30's rooms to be unclean with dirt and debris build up in the corners, urine dried around floor and bottom of toilet, and food and paper particles spattered on floor throughout room. [...]

Inspectors wroteBased on observation, resident interview, staff interviews, and record review, the facility did not ensure Minimum Data Set (MDS) assessment information accurately reflected resident's status for 3 residents (R) of 19 sampled residents (R8, R23, R37) and 1 supplemental resident (R48). R8's, R23's, R37's, and R48's MDS (Minimum Data Set) assessments have conflicting data and are inaccurate as section C indicates they are rarely or never understood, while section B indicates they are understood, have clear speech, and make themselves understood by others. R48's MDS indicates she discharged with return anticipated and that she had a fall with major injury. R48's emergency department notes indicate she had a fall with fracture. Her reentry assessment indicates she did not have a fall with major injury. [...]

Inspectors wroteBased 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 4 (R82, R51, R3 and R1) of 19 sampled residents and residents eating in 1 of 3 dining rooms (10 residents out of a census of 68). R82 and R51 voiced concerns with hot foods not being hot. R3 and R1 voiced concerns regarding food temperatures. Surveyor conducted 1 test tray for the dining room which was not palatable. Evidenced by: Example 1 On 8/20/25 at 2:38 PM, Surveyor interviewed R82 during the initial screening process. During the interview R82 was asked if there were any concerns with meals. R82 indicated about 5 times a week the food is dry, tasteless, has no spices and the hot foods are not hot. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not ensure that residents were ensured a dignified existence and self-determination for 2 of 17 sampled residents (R45 and R37). R45 voiced concerns that his catheter bag was not covered, including when he went to the dining room for meals. R37's wheelchair was observed to be dirty and undignified. As evidenced by: The facility policy titled, Resident Rights, dated 2001, states, in part: .Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. to be treated with respect, kindness, and dignity. e. self-determination. h. be supported by the facility in exercising his or her rights. The facility policy titled, Dignity, dated 2001, states, in part: Policy Statement: [...]

Inspectors wroteBased on interview and record review the facility did not document a thorough investigation and did not resolve grievances as outlined in the facility policy for 1 of 1 Residents (R2) reviewed for grievances. R2 had voiced a concern to a staff member and the facility failed to follow their grievance policy by thoroughly investigating, following up, and documenting the concern. Evidenced by: The facility policy, Grievances/Complaints, Recording and Investigating indicates, in part: Policy Statement: All grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievance(s). Policy Interpretation and Implementation: 1. The administrator has assigned the responsibility of investigating grievances and complaints to the grievance officer. 2. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving misappropriation of resident funds/personal property are reported immediately to the administrator of the facility, the State agency, and to other officials, including local law enforcement, in accordance with State law through established procedures for 1 of 22 sampled residents (R48) reviewed for abuse. The facility did not report allegations of abuse to the state agency in accordance with facility policy and federal regulations for an incident involving R48. Evidenced by:Facility policy, titled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, revised 9/2022, includes, in part: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that in response to allegations of abuse, neglect, exploitation or mistreatment, that all alleged violations are thoroughly investigated and residents are protected pending a thorough investigation for 1 of 22 residents reviewed (R48). The facility did not thoroughly investigate R48's allegations of abuse by a staff member. The facility did not remove the alleged staff from patient care to protect residents while conducting a thorough investigation. Evidenced by:Facility policy, titled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, revised 9/2022, includes, in part: [...]

Inspectors wroteBased on interview and record review, the facility did not provide the proper discharge documentation for 3 of 4 residents reviewed for discharge (R2, R5, and R73). R2 was transferred to the hospital, and no bed hold notice was provided. R5 was not provided a bed hold. R73 was transferred to the hospital, and no bed hold notice was provided. Evidenced by: The facility policy, Bed-Holds and Returns includes, in part: Policy Statement: Residents and/or representatives are informed (in writing) of the facility and state (if applicable) bed-hold policies. Policy Interpretation and Implementation: All residents/representatives are provided written information regarding the facility and state bed-hold policies, which addresses holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). [...]

Inspectors wroteBased on interview and record review the facility did not ensure that a resident who requires dialysis receives such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 1 sampled resident (R1) reviewed for dialysis. The facility failed to provide ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. The facility staff were not fluent in the emergency plan for a resident bleeding from their dialysis fistula site. This is evidenced by:The facility's policy titled Hemodialysis Catheters - Access and Care Of, dated 2001, with a Revision Date of February 2023, states, in part: . Care of Arterio-venous fistula (AVF)s. 4. To prevent infection and/or clotting: a. [...]

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 in 28 opportunities that affected 2 out of 6 residents (R53 & R16) included in the medication pass task, which resulted in an error rate of 7.14%. R53 received Lasix (Furosemide) 10 mg tablet outside of the medication administration window. R16 received Metoprolol Extended Release (ER) 25 mg tablet that had been crushed. Evidenced by: The facility policy entitled, Administering Medications, dated 2001, states, in part: Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: . 4. Medications are administered in accordance with prescriber orders, including any required time frame. 7. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents are free of significant medication errors, for 1 of 6 residents reviewed in the medication administration task (R16). R16 received a Metoprolol Succinate Extended Release (ER) 25 mg tablet (a medication used to treat high blood pressure and chest pain) that had been crushed. This is evidenced by:The facility policy, Adverse Consequences and Medication Errors, revised in February 2023, states in part, .Medication Errors - 1. A 'medication error' is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. 2. Examples of medications errors include: .h. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not ensure drugs and biologicals are stored in accordance with currently accepted professional standards for 1 of 2 medication rooms reviewed for medication storage. The medication room on the first floor contained an expired single-dose COVID vaccine and 4 urinary catheter kits that were expired. This is evidenced by: Facility policy entitled, Medication Labeling and Storage with a revision date of February 2023 states, in part. Medication Storage.3. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. On [DATE] at 10:36 AM, Surveyor conducted medication storage observation of the medication room on the first floor with RN P (Registered Nurse). [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure snacks were offered at bedtime daily when there is more than 14 hours between the evening meal and breakfast for 1 resident (R3) of total census of 68 reviewed for snacks. R3 voiced concerns of snacks not being offered at bedtime. The facility is not offering all residents nourishing snacks at bedtime when their supper meal and breakfast meal are more than 14 hours apart. Evidenced by:Facility policy, titled Frequency of Meals, dated 2001, states, in part: . Policy Interpretation and Implementation: 1. The facility will serve at least three (3) meals or their equivalent daily at scheduled times. There will not be more than a fourteen (14) hour span between the evening meal and breakfast. 5. Nourishing snacks will be available for the residents who need or desire additional food between meals. 6. [...]

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 1 of 5 residents (R33) reviewed for immunizations. R33 signed a consent form to receive the 2024-2025 influenza vaccine but never received it. This is evidenced by:The facility policy entitled Influenza Vaccine, with a revision date of March 2022, states in part: Policy Statement: [...]

Inspectors wroteBased on 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 Resident (R1) of 6 observed for Enhanced Barrier Precautions (EBP) and 1 (R1) of 8 opportunities for hand hygiene. Staff did not apply PPE (Personal Protective Equipment) appropriately while completing a treatment to R1 who was on EBP. Staff did not perform hand hygiene for appropriate amount of time during treatment. The facility policy entitled Handwashing/Hand Hygiene, dated October 2023, states, in part: . Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure each resident had a safe, clean, comfortable, and homelike environment or ensure housekeeping provided necessary services to maintain a sanitary, orderly, and comfortable area for 1 of 16 residents reviewed for homelike environment out of a total sample of 17 residents (R31). R31 voiced concerns related to the cleanliness of her room. Evidenced by: Resident Handbook, revised 6/8/08, includes: the facilities housekeeping staff will clean and mop resident rooms daily or more often as needed to ensure a clean, safe, and home-like environment. The facility reserves the right to clean any area or room and to remove items that prevent us safe and sanitary environment. Periodically the housekeeping department will do seasonal cleaning and floor care in resident rooms . [...]

Inspectors wroteBased on interview and record review the facility did not develop a comprehensive person-centered care plan for 2 of 5 residents (R9 and R42) reviewed for unnecessary medications. The facility did not develop a care plan for R9 and R42's use of Melatonin (a medication used to help with sleep) for insomnia. This is evidenced by: The facility policy, titled Care Plans, Comprehensive Person-Centered, dated December 2016, states in part: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents received the necessary treatment and services consistent with professional standards of practice for 2 (R7 and R12) of 5 residents reviewed with non-pressure injuries. *R7 had non-pressure injuries to the left distal shin, the left dorsal foot, and the left calf. The wounds were not comprehensively assessed weekly and the facility documentation for the location and etiology of the non-pressure injuries were not consistent with the Wound Physician. * R12 developed a non-pressure injury to the right buttock on 7/8/2024 that was not comprehensively assessed until 7/12/2024 when R12 was seen by the Wound Physician.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents received the necessary treatment and services consistent with professional standards of practice for 2 (R7 and R12) of 3 residents reviewed with pressure injuries. *R7 had a Stage 4 pressure injury to the left heel, a Stage 4 pressure injury to the left lateral foot, and a Stage 3 pressure injury to the left first toe. The wounds were not comprehensively assessed weekly and the facility documentation for the staging of the pressure injuries were not consistent with the staging by the Wound Physician. *R12 developed a Stage 2 pressure injury to the sacrum on 5/24/2024 that was not comprehensively assessed until 5/31/2024 when R12 was seen by the Wound Physician. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not ensure adequate supervision and safety to prevent accidents from occurring for 1 of 3 residents (R5) reviewed out of a sample of 17 residents. R5 was assessed to be at risk for falls with care plan interventions of a low bed and fall mat while in bed. The facility did not ensure interventions were in place when R5 was in bed. Evidenced by: The facility policy, titled Assessing Falls and Their Causes, dated March 2018, states in part: .4. Residents must be assessed upon admission and regularly afterward for potential risk of falls. Relevant risk factors must be addressed promptly .the following information should be recorded in the resident's medical record: .6. Appropriate interventions take to prevent future falls. [...]

Inspectors wroteBased on interview and record review the facility did not ensure that residents that use psychotropic drugs have appropriate assessments, diagnoses, and consent. This affected 2 of 5 residents (R9 and R42) reviewed for unnecessary medications. R9 receives an antipsychotic for dementia. R42 receives an antipsychotic for anxiety. R42 is receiving an antidepressant and does not have active consent. This is evidenced by: The facility policy, titled Psychotropic Medication Use dated July 2022, states in part: Residents will not receive medications that are not clinically indicated to treat a specific condition .Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: a. anti-psychotics; b. anti-depressants; c. anti-anxiety medications; and d. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure residents are free of significant medication errors for 1 of 1 resident's reviewed for significant medication errors (R1). On 3/4/24, the facility received orders for R1 to receive Humalog sliding scale insulin. This order did not specify the frequency of administration. Two Registered Nurses (RN's) signed off on the order, but did not clarify how frequently the insulin was to be administered. Facility staff entered to administer the Humalog four times daily on R1's Medication Administration Record (MAR) without a clarification order from R1's physician. Additionally, R1 did not receive the Humalog insulin as ordered on 3/4/24, 3/5/24, 3/6/24, and 3/7/24. This is evidenced by: R1 was admitted on [DATE] with diagnoses including, but not limited to: [...]

Inspectors wroteBased on interview and record review the facility did not ensure that all alleged violation involving neglect are reported immediately to the State Survey Agency for 1 resident (R1) of 3 reviewed of a total sample of 6 residents. The facility failed to immediately report an allegation of neglect to the State Survey Agency. This is evidenced by: The facility policy titled, Abuse, Neglect, Mistreatment and Misappropriation-Reporting and Investigating, with a revision date of 9/22, states, in part: All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. [...]

Inspectors wroteBased on interview and record review the facility failed to thoroughly investigate an allegation of neglect for 1 (R1) of 3 sampled Residents. The facility failed to complete a thorough investigation into R1 allegation. This is evidenced by: The facility policy titled, Identifying Types of Abuse, with a revision date of 9/22, states, in part: . 'Abuse' is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. a. Abuse also includes the deprivation by an individual, including a caretaker, or goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being . The facility policy titled, Abuse, Neglect, Mistreatment and Misappropriation-Reporting and Investigating, with a revision date of 9/22, states, in part: 7. [...]

Inspectors wroteBased on interview and record review, the facility did not provide care consistent with professional standards of practice to prevent pressure injuries (PI) from developing or worsening for 2 of 5 residents reviewed for PIs (R68 and R66.) R68 was admitted to the facility with a stage 2 PI on his spine. The facility did not complete weekly wound assessments and measurements and R68's PI worsened. The facility did not ensure an initial assessment, weekly measurements, and interventions were in place to prevent the PI from developing or worsening for R66's left buttock pressure injury. Evidenced by: [...]

Inspectors wroteBased on observation and interview, the facility did not ensure each resident has a safe, clean, comfortable, and homelike environment or ensure housekeeping provided necessary services to maintain a sanitary, orderly, and comfortable area for 4 (R57, R10, R17, and R27) of 25 residents R10 and R27 voiced concerns with the cleanliness of bedrooms. Surveyor observed concerns with cleanliness for R57, R10, R17, and R27's bedrooms. Evidenced by: The facility did not provide a housekeeping policy. Example 1: R57 was admitted to the facility on [DATE] with diagnoses including: unspecified dementia without behavioral disturbance, cognitive communication deficit, difficulty in walking, kidney failure, anxiety disorder, and major depressive disorder. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that residents who are unable to carry out Activities of Daily Living (ADLs) receive the necessary services to maintain good nutrition, grooming, and personal hygiene for 5 of 19 residents (R25, R48, R57, R66, and R68) reviewed for ADLs. R66 had long facial hair and long toenails that are thick and discolored. R66 requires assistance with shaving and nailcare. R25 had long facial hair and requires assistance with ADLs. R48 was not provided assistance with eating and requires assistance. R68 had long nails and nail care had not been provided R57 Surveyor observed R57 not receive assistance with eating meals. Surveyor observed R57's fingernails long with a dark substance underneath fingernails. This is evidenced by: [...]

Inspectors wroteBased on observation, interview, 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 designed to meet their interests and support their physical, mental, and psychosocial well-being. This affected 3 (R5, R10, and R57) of 19 sampled residents and 1 of 1 (R3) supplemental residents reviewed for activity participation. The facility failed to offer a variety of activities that meet the interests and support all residents' physical, mental, and psychosocial well-being. The facility failed to ensure resident's activity care plans were personalized to meet the needs of residents physical, mental, and psychosocial well-being. The facility failed to create personalized goals and develop a tracking/monitoring system for resident's activity attendance. Evidenced by: [...]

Inspectors wroteBased on interview and record review the facility did not assess a resident using the quarterly review instrument specified by the State and approved by CMS (Centers for Medicare and Medicaid Services) not less frequently than once every 3 months for 1 of 19 sampled residents (R38). R38 did not have a quarterly Minimum Data Set (MDS) completed. This is evidenced by: Per R38's MDS record, she had assessments completed on the following dates: 3/11/22 Quarterly 6/11/22 Quarterly 8/30/22 Quarterly 11/30/22 Annual R38 was due for a Quarterly assessment end of February 2023 or beginning of March 2023. There were no completed or in progress assessments noted in R38's medical record. With R38's Quarterly assessment not being done, the facility could have missed critical indicators of gradual change in a resident's status. [...]