Oak Park Place of Janesville

Inspectors wroteBased on interview and record review the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (R33) reviewed for accidents out of a sample of 17 Residents. R33 received a laceration (that required 10 stitches) during a transfer that was done with 1 assist and R33 required 2 assist. This is evidenced by: The Facility's Policy and Procedure entitled Safe Lifting and Movement of Residents dated July 2017 documents in part: .3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. R33 was admitted to the facility on [DATE] with the following diagnoses: [...]

Inspectors wroteBased on interview and record review the facility did not document grievance or document prompt efforts by the facility to resolve grievances for 1 of 1 Residents (R1) reviewed for grievances. R1's AHCPOA (Activated Health Care Power of Attorney) voiced concerns to the NHA (Nursing Home Administrator) via email communication. The facility failed to follow their grievance policy by thoroughly investigating, following up, and documenting the concerns and resolution. Evidenced by:The facility policy, Grievance Program, hand dated, 5/15/24, indicates, in part: .Process: 1. Grievances - grievances are formal written or verbal complaints made to the facility when prompt or bedside resolution to the satisfaction of the person making the objection was not possible. When there is a grievance, it will be: Documented on the facility Comment/Concern Forms. Routed to the Grievance official. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect 24 of 25 residents. Surveyor observed staff going into the main kitchen and kitchenette without hairnets on. Surveyor observed food that had been removed from original containers and not labeled with a use by date. Surveyor observed a dented can to be in circulation. Surveyor observed food that was uncovered and/or not labeled in a kitchenette freezer and refrigerator. The freezer temperature in one of the kitchenettes is not being consistently monitored or recorded. Surveyor observed shelves with dried on substances, food particles, pieces of candy without wrappers, opened food without use by dates and expired food in circulation in the facility's kitchenette. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents were treated with dignity and respect in an environment that promotes an enhanced quality of life which affected 6 of 15 sampled Residents (R174, R1, R172, R13, R223, and R73), 3 of 5 supplemental Residents (R173, R16, and R6), and 1 of 1 dining room. Surveyors observed residents who were dining in the main dining room to have Styrofoam cups instead of regular glasses. Surveyors observed meal trays for residents dining in their rooms to contain plastic silverware instead of metal silverware and Styrofoam cups instead of regular glasses. R73 was observed using plastic silverware and foam cups while eating breakfast in her room. R1 was observed using plastic silverware and foam cups in her room while eating breakfast. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure each resident had the right to a safe, clean, comfortable, and homelike environment for 4 of 12 sampled residents (R12, R172, R223, and R224) and 2 supplemental residents (R5 and R171). R5, R171, and R172's room were not clean. Surveyor observed R12's bed to be unmade, dust bunnies under the bed, and flakes of debris on the floor near the wall. Surveyor observed R223's bed to be unmade and garbage can to be full. Surveyor observed the bed unmade, dust bunnies under the bed, a garbage can overflowing with a glove on the floor, and dried stool on the back of the toilet seat. This is evidenced by: The facility's policy titled Cleaning and Disinfection of Environmental Surfaces, dated 8/19, includes the following: 9. [...]

Inspectors wroteBased on interview and record review, the facility did not develop a discharge plan for 1 of 3 residents (R13) reviewed for discharge planning. R13 does not have a discharge care plan, nor has he had a care conference to discuss his discharge goals. Evidenced by: The facility's policy titled Care Plans, Comprehensive Person- Centered revised 12/2016 states in part .4. Each resident's comprehensive care plan will be consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to: a. participate in the planning process .e. participate in establishing the expected goals and outcomes of care .5. The resident will be informed of his or her right to participate in his or her own treatment . [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that residents with an indwelling catheter received the appropriate care and services for 2 of 2 residents (R1 and R174) reviewed for catheters. R1 had a catheter placed without an appropriate diagnosis and does not have a care plan for the catheter. R174's catheter bag was uncovered and viewable from the hallway. Evidenced by: The facility's policy titled Indwelling Catheter Evaluation/ Removal revised on 6/27/16 states in part Policy: It is the policy of [Facility Name] to ensure that residents receive care and services to prevent the use of an indwelling catheter, unless clinically necessary .4. When there is not supporting diagnosis for the use of the indwelling urinary catheter, the nurse will obtain an order from the physician or physician extender to remove. [...]

Inspectors wroteBased on record review and interview, the facility did not ensure 1 of 1 resident (R13) who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. R13 has a diagnosis of PTSD (Post Traumatic Stress Disorder) and does not have a complete trauma assessment or a care plan addressing triggers, resident specific approaches, or interventions. This is evidenced by: The facility's policy titled Trauma- Informed and Culturally Competent Care revised 8/2022 states in part .Resident Assessment: 1. Assessment involves an in- depth process of evaluating the presence of symptoms, their relationship to trauma, as well as the identification of triggers. 2. [...]

Inspectors wroteBased on observation, interview and record review the facility did not ensure that all drugs and biologicals used in the facility were labeled with an open date or expiration date in 1 of 1 medication rooms. The facility failed to ensure an open vial of tuberculin solution located in the medication room contained an open date and/or expiration date. Evidenced by: The facility's policy titled Medication Labeling and Storage dated 2/2023 states in part .5. Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date. On 6/2/25 at 2:11 PM Surveyor and RN P (Registered Nurse) went to the medication room. Surveyor observed an open vial of Tuberculin solution in the refrigerator, in a bag without an open date or expiration date. Surveyor interviewed RN P. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 1 resident (R1) reviewed for hospice. R1 was receiving hospice services, and the facility failed to obtain hospice documentation. Evidenced by: The facility policy titled Hospice Program revised date 7/2017 states in part .12. Our facility has designated (Name) (Title) to coordinate care provided to the resident by our facility staff and the hospice staff .He or she is responsible for the following: .d. Obtaining the following information from the hospice: (1) The most recent hospice plan of care specific to each resident; (2) Hospice election form; (3) Physician certification and recertification of the terminal illness specific to each resident .13. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to 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, for 2 of 2 resident (R4 and R174) with observed breeches in transmission-based precautions. Staff entered R174, who is COVID-19 positive, without proper personal protective equipment (PPE). Surveyor observed staff perform tracheostomy care on R4 without proper hand hygiene and not using enhanced barrier precautions. This is evidenced by: The facility's policy titled Isolation - Categories of Transmission-Based Precautions, dated 9/22, includes the following: 5. [...]

Inspectors wroteExample 2 R4 was admitted to the facility on [DATE] and has diagnoses that include cellulitis of left lower limb (potentially serious skin infection) and acute respiratory failure (occurs when the lungs can't properly exchange gases, causing abnormal levels of carbon dioxide and/or oxygen in the arteries). R4's admission Minimum Data Set (MDS) Assessment, dated 1/8/25, shows R4 has a Brief Interview of Mental Status score of 14 indicating R4 is cognitively intact. R4's Physician Orders, dated 1/25/25 include: -Pain monitoring every shift using 1-10 narrative or FACE scale. Resident Pain Goal is: (4) every shift for pain. Order Date: 1/03/25. Start Date: 1/03/25. -Acetaminophen ER (extended release) Oral Tablet Extended Release 650 mg (milligrams)- Give 2 tablets by mouth every 4 hours as needed. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for three of three residents (R3 and R1) of 8 sampled residents. The facility failed to assess and monitor R3's diuretic medication and provide supplemental medication to prevent critical laboratory values which caused R3 to be hospitalized due to the critically low blood levels. In addition, the facility failed to monitor and document R1 and R3's physician ordered weights. These failures placed the residents at increased risk of health complications and hospitalization. R3 is being cited at severity level 3 (actual harm). R1 is being cited at severity level 2 (potential for more than minimal harm).

Inspectors wroteBased on interviews, record review, and document review, the facility failed to ensure sufficient nurse staffing to provide nursing and related services to assure resident safety and to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 4 of 4 residents and/or representatives (R8), Family Member (FM1) FM2, and FM3 out of a census of 20 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a hospital transfer was documented in the medical record and appropriate information was communicated to the receiving hospital for 1 of 1 resident (R1) of eight sample residents.

Inspectors wroteBased on observations, interviews, record review, and review of the facility procedure, the facility failed to ensure activities of daily living (ADLs) were provided according to the plan of care for 1 of 3 residents (R5) of 8 sampled residents.

Inspectors wroteBased on interview and record review the facility failed to consistently assess and monitor pressure ulcers and wounds. In addition, the facility failed to inform the provider upon admission and when wound care was refused for 1 of 2 residents (R4) reviewed for wounds out of 8 sampled residents.

Inspectors wroteBased on interview and record review the facility must provide pharmaceutical services to meet the needs for 1 (R6) of 8 sampled residents. R6 did not receive his Trazadone per R6's preference and physician's orders resulting in a timing error. Review of R6's admission Record located in the Profile tab of the EMR. revealed R6 was admitted to the facility on [DATE] with diagnoses that included a left leg fracture, Parkinson's disease, and dementia. Review of the admission MDS located in the MDS tab of the EMR with an ARD of 11/15/24 revealed R6 had a BIMS score of 13 out of 15 which indicated he was cognitively intact and was administered an antidepressant medication during the seven-day observation period. Review of the Physician Orders located in the Orders tab of the EMR revealed Trazadone (an antidepressant medication) 50mg. Give one tablet my mouth in the evening at 1800 [6:00 PM]. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain a complete and accurate medical record for 2 (R1 and R4) of 8 sample residents. The facility failed to ensure the daily Medicare and/or Skilled Charting documentation contained skin/wound documentation for R1. In addition, the daily Medicare and/or Skilled Charting assessments were not completed daily, as required for R4. This failure placed the residents at risk of unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 12 residents who reside in the facility. Facility staff were observed working in the kitchen without beard nets on. Chef Q was observed placing dirty pans in a rack and then removing and organizing clean metal pans without wearing gloves or washing his hands. The metal pans were wet stacked on a drying rack. Thermometer probe was not being sanitized between temping resident food. Chef Q was observed putting garbage and gloves in the garbage can without washing his hands prior to going back to cooking dinner. KM P (Kitchen Manager) observed dishing up lunch from the steam table with gloves on. KM P stepped away from the steam table and made a phone call. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure accurate reporting of the mandatory submission of staffing information based on payroll data to the Centers for Medicare & Medicaid Services (CMS). This has the potential to affect all 12 residents residing within the facility. The facility failed to enter accurate data in their Payroll Based Journal (PBJ) reporting and triggered for two fiscal year quarters for failure to have licensed nursing coverage 24 hours a day and one fiscal year quarter for failure to have Registered Nurse (RN) hours each day. Evidenced by: According to https://www.cms.gov/medicare/quality/nursing-home-improvement/staffing-data-submission Example the Centers for Medicare & Medicaid Services (CMS) has long identified staffing as one of the vital components of a nursing home's ability to provide quality care. [...]

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 has the potential to affect the total census of 12 residents and 1 out of 2 hand hygiene opportunities (R2). The facility allowed staff to return to work too soon after reporting gastrointestinal symptoms and did not place staff with respiratory symptoms on the line list. The facility did not accurately document employees' symptom onset. Staff performed catheter care on R2 and applied barrier cream without appropriate hand hygiene. Evidenced by: [...]

Inspectors wroteExample 4 R65 admitted to the facility on [DATE] with diagnoses, including Parkinson's disease, dysarthria following nontraumatic subarachnoid hemorrhage (weakness in muscles used for speech), dysphagia (condition that makes it hard to swallow), conversion disorder (mental condition that causes sensory or motor problems), cognitive communication deficit, and other voice and resonance disorders. R65's CNA Care Card, dated 5/17/24, includes transfer- 2 assist with Hoyer lift . dressing- 2 assist . hygiene: 2 assist . mobility- 2 assist with wheelchair . toileting- indwelling foley catheter, bed pan 2 assist . diet/fluids- regular pureed diet, thin liquids in Kennedy cup, provide 1 on 1 supervision and feeding assist, allow resident to participate as much as possible . [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each resident. This affects 7 of 12 residents (R1, R9, R113, R4, R6, R2, R64) reviewed for activities. The facility failed to incorporate social history assessment information into R1, R9, R113, R4, R6, R2, and R64 care plans and their current care plan is not person centered. R64 voiced concerns with the facility's lack of activity programming. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents were treated with dignity and respect in an environment that promotes an enhanced quality of life which affected 3 of 12 residents in the dining area (R65, R113, and R9). RR W (Resident Representative) indicated R65's appearance is important to him, and he depends on the facility staff to advocate and care for R65 as he resides out of state. Surveyor observed R65 being pushed into the dining room by CNA F (Certified Nursing Assistant) and his hair was uncombed, his face was not shaven, and his catheter bag was not covered, exposing the urine inside. R65 was seated at a table with other residents who were eating in front of him. After 11 minutes, his plate of food was delivered but he was not given silverware. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure each resident (R), or their representative had the right to participate in the care planning process for 1 of 12 sampled residents (R2). R2 attended a care plan conference where she voiced an intervention that would aid in her pain management during transfer, bed mobility and toileting. This intervention was not considered when revising R2's care plan. R2 indicated she does not get out of bed at all anymore due to staff not following this intervention. SW T did not add the suggested intervention to R2's care plan and did not tell front line staff about this intervention. Evidenced by: [...]

Inspectors wroteBased on interview and record review the facility failed to weigh a new admission per recognized standards of practice for 1 of 12 residents (R4) reviewed for weights. R4 voiced concern of losing seven (7) pounds in less than a month. The facility did not obtain weights per standards of practice. Evidenced by: The facility policy, entitled Weight Management, dated 2/14/14, states, in part: . Policy: It is the policy of the facility based on the resident's comprehensive assessment to ensure each resident maintains acceptable parameters of nutritional status, such as body weight, unless the resident's clinical condition demonstrates this is not possible. Procedure: 1. All new admissions and readmissions will be weighed the morning of the first full day after admission, then daily for two days. 2. Residents will then be weighed for the first four weeks . 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not implement professional standards of practice to promote healing or prevent pressure injury (PI) development for 1 of 1 resident reviewed for PIs out of a sample of 12 residents (R64). R64 admitted to the facility on [DATE] with a stage 3 PI of the sacral region. On 5/20/24, during wound care, improper hand hygiene technique was observed. R64's Baseline Care Plan dated 5/20/24 does not include interventions or goals related to his Stage 3 PI putting R64 at risk of worsening PI and/or developing more PIs. Evidenced by: The facility policy, entitled Handwashing/Hand Hygiene, dated August 2019, states, in part: . Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation: . 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure a resident with a catheter receives appropriate treatment and services to prevent urinary tract infections for 2 of 4 residents (R113, R9) reviewed for catheter care out of total sample of 12. R113's catheter was dragging on floor during a transfer in wheelchair. Surveyor observed R9's catheter make direct contact with the facility's dining room floor. Evidenced by: Example 1 R113 was admitted to the facility on [DATE] and has diagnoses that include malignant neoplasm of bladder (bladder cancer) and benign prostatic hyperplasia without lower urinary tract symptoms (age-associated prostate gland enlargement that can cause urination difficulty). [...]

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 in part ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility), the Comprehensive Person-Centered Care Plan, and the resident's goals and preferences for 1 of 1 dialysis residents (R6) sampled out of a total of 18 sampled residents. The facility did not provide monitoring of R6's arm fistula/access dialysis site, have emergency interventions in place, and staff were not competent on what to do if they found R6 to be bleeding out of her fistula. Evidenced by: Facility policy, entitled Hemodialysis Catheters- Access and Care, revised 2/2023, includes . [...]

Inspectors wroteBased on interview and record review, the facility did not ensure adequate supervision and safety to prevent accidents from occurring for 1 of 3 residents (R1) reviewed for falls. R1 has a history of multiple falls. Facility staff did not implement appropriate fall interventions and provide adequate supervision. R1 had a fall that resulted in a displaced right inferior pubic ramus fracture (a break in part of the pelvis). Evidenced by: The facility's policy titled, Falls Policy and Prevention Program dated 6/29/21, states in part; .all residents will receive adequate supervision, assistance, and assistive devices to aid in the prevention of falls . [...]

Inspectors wroteBased on interview and record review, the facility did not ensure adequate supervision and safety to prevent accidents from occurring for 1 of 4 residents (R2) reviewed for falls. R2 has a history of multiple falls. Facility staff did not implement appropriate fall interventions and provide adequate supervision. R2 had a fall that resulted in a head laceration requiring seven (7) sutures. This is evidenced by: The facility's policy titled Falls Policy and Prevention Program dated 6/29/21 states in part, .All residents will receive adequate supervision, assistance, and assistive devices to aid in the prevention of falls . According to Superior Health Quality Alliance, Root Cause Analysis (RCA) is a problem-solving method to investigate an actual or potential problem, incident or concern. A team looks beyond an immediate solution to understand the underlying cause(s) of the problem. [...]

Inspectors wroteBased on interview and record review, the facility did not have evidence that all alleged violations are thoroughly investigated for 1 of 3 residents reviewed for abuse (R1). The facility became aware of an allegation of abuse during an investigation involving R1. The facility did not complete a thorough investigation that included interviews of other residents.

Inspectors wroteBased on interview and record review, the facility did not ensure a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement was in place. This has the potential to affect all 16 residents. The facility does not have a Pneumococcal Vaccine Policy and Procedure that includes all the new guidance from April 2022 regarding options for pneumococcal vaccines. The facility does not have a staff call-in process to ensure appropriate signs and symptoms (S/Sx) are known, length of time off is adequate, and that staff are testing for COVID when they have S/Sx that may be indicative of COVID prior to coming back to work after calling in. [...]