Resolve at West Allis Respiratory and Rehab

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that 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 4 (R1, R8, R10 and R25) of 7 residents reviewed for pressure injuries. *R1 was readmitted to the facility on [DATE] with an unstageable Deep Tissue Injury (DTI) to R1's left heel. Surveyor observed R1's heels to not be offloaded on 3 separate occasions (4/26/2026, 4/27/2026 and 4/28/2026). On 4/27/2026, R1's wound has nearly doubled in size since initial assessment. The example regarding R1 is being cited at a scope and severity of a G (actual harm/isolated). The examples regarding R8, R10, and R25 are examples at the scope and severity of a D (potential for harm/isolated). [...]

Inspectors wroteBased on interview and record review, the facility did not ensure it completed accurate mandatory submission of staffing information based on payroll data in a uniform electronic format to the Centers for Medicare & Medicaid Services (CMS). This had the potential to affect all 79 residents residing in the facility. Staffing information for Quarter 1 (October 1 - December 31, 2025) of the Payroll Based Journal (PBJ) was not accurately submitted to CMS.

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 for 1 of 4 resident unit refrigerators in the facility and 1 of 1 meat/dairy cooler. *Observations of black, moldlike substances in the kitchen walk in cooler.*Ice buildup in the kitchen freezer*Condiments in kitchen walk in cooler were expired and/or not dated. This deficient practice has the potential to affect 62 of 79 residents whom receive food from main kitchen.

Inspectors wroteBased on observation and interview, the facility did not ensure a safe, clean, comfortable, and homelike environment for 1 (R49) of 18 residents.*The facility experienced water damage to the ceiling in R49's room causing R49 to be concerned of ceiling integrity and organic growth. The facility did not remediate the water damage to R49's ceiling in a timely manner.

Inspectors wroteBased on interview and record review, the facility did not ensure all alleged violations of neglect were reported immediately to the State Agency, but not later than 24 hours after the allegation was made for 1 of 2 Facility Reported Incidents (FRI) reviewed. The facility received notification that R10 made an allegation of neglect on 1/23/26 at 7:00 PM and did not report the allegation to the State Agency until 1/26/26 at 3:14 PM.

Inspectors wroteBased on interview and record review, the facility did not ensure 2 (R25 & R57) of 2 residents were notified of the reason for transfer/discharge & bed hold policy in writing to the resident & their representative and the rate to reserve the resident's bed was not documented in the Transfer, Bed hold Notice form. * There is no evidence R25 and/or R25's representative was provided a copy of the bed hold/ transfer notice for R25's hospitalization on 7/19/2025 and the bed hold notice did not document the bed hold rate for R25's hospitalization on 10/27/2025. * R57 was transferred to the hospital on 3/25/2026 and 4/10/2026. The bed hold and transfer notices for the two separate transfers were combined and not individualized for each transfer.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure dependent residents received the necessary services to maintain nail care for 1 (R5) of 5 residents reviewed for activities of daily living (ADLs). R5, an ADL dependent resident, was observed with long and dirty fingernails from 4/26/26 to 4/28/26.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure 1 (R25) of 18 residents received treatment and care in accordance with professional standards of practice.*R25 had a peripherally inserted central catheter (PICC) line placed on 4/13/26. R25 has an MD order for the PICC line dressing to be changed every 7 days. Surveyor observed R25's PICC line dressing on 4/26/26 and 4/28/26. During observation, R25's PICC line dressing was dated 4/13/26, indicating that R25's PICC line dressing was not changed from 4/13/26 to 4/28/26. R25's IV medication care plan was not initiated until 4/27/26, which is 2 weeks after the PICC line was placed.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure staff followed infection control procedures for 1 (R25) of 2 residents reviewed with an indwelling catheter.* R25's catheter bag was observed lying directly on the ground without a barrier. R25 is considered high risk for infection with a history of urinary tract infections (UTIs) with sepsis.

Inspectors wroteBased on observation, interview and record review the facility did not ensure 1 (R1) of 3 residents reviewed for falls received adequate supervision and assistive devices to prevent accidents. R1 was admitted to the facility on [DATE] with recommendations to wear a helmet when out of bed or chair to prevent brain injury from falling or head trauma after having a craniotomy (a surgical procedure in which a neurosurgeon temporarily removes a section of the skull). R1's care plan for activities of daily living (ADLs) identifies the need for R1 to wear a helmet; dated 1/2/26. The facility assessed R1 being at risk for falls and did not place orders for R1's helmet until 1/20/26. The facility did not verify recommendations/orders with the physician to determined when R1 is to wear a helmet until 1/27/26.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure the medication error rate was below 5% for 1 resident (R5) of 3 observed receiving medications. The facility medication error rate was 6.89%. *R5 received one ergocalciferol oral capsule 1.25mg. R5's physician order documents ergocalciferol oral capsule 1.25mg, give 2 capsule by mouth in the morning every Wed (Wednesday) for vitamin D deficiency. *R5 received one zinc 50mg tablet. R5's physician order documents zinc-220 oral capsule, give 1 capsule by mouth one time a day.

Inspectors wroteBased on interview and record review the facility did not ensure 3 (R2, R3, and R4) of 3 residents and/or representative were notified of the reason for transfer/discharge in writing and the rate to reserve the residents' bed was not documented in the Bed Hold and Notice of Transfer. *R2 was discharged to the hospital on [DATE] and 12/28/25. The facility's transfer and discharge notice was not provided in writing and in a language understood to R2 and/or R2's representative. R2's bed hold notices did not document the facility per diem daily rate. *R3 was discharged to the hospital on [DATE], 12/2/25, 12/7/25 and 12/11/25. The facility's transfer and discharge notice was not provided in writing and in a language understood to R3 and/or R3's representative. R3's bed hold notices did not document the facility per diem daily rate. *R4 was discharged to the hospital on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review the Facility did not ensure there was a medication error rate below 5 percent. There were 2 medication errors in 31 opportunities which resulted in a medication error rate of 6.45%. Medication errors were identified for R7 & R9.*R7's Prednisolone Acetate Ophthalmic Solution 1% was not shaken prior to administration.*R9 was administered two drops of Cromolyn Sodium 4% eye drops into each eye without waiting one minute between drops.

Inspectors wroteBased on observation, interview and record review the facility did not ensure 1 (R7) of 1 resident were free of significant medication errors. R7 was admitted to the facility on [DATE]. R7's has an order for Acetaminophen 1000 mg (milligrams) by mouth every 6 hours for pain/discomfort with a start date of 8/21/25. This order was not entered correctly, and Acetaminophen 1000 mg did not appear on R7's monthly medication administration records resulting in R7 not receiving Acetaminophen 1000 mg every six hours daily. R7 missed 48 doses in August 2025, 120 doses in September 2025, 124 doses in October 2025, 120 doses in November 2025, 124 doses in December 2025, and 53 doses in January 2026. R7 was not administered 589 doses of Acetaminophen 1000 mg.

Inspectors wroteBased on observations, interviews, 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, for 1 (R11) of 3 residents reviewed for medication administration via Enteral Tube (ET) (a tube that is connected to the digestive system and is used to deliver hydration, nutrition, or medications.) R11 was on Enhanced Barrier Precautions (EBP), a staff member placed a graduated cylinder and syringe, from R11's room that's used for R11's ET cares, on the nurse's medication cart leaving residual fluid on the cart. The staff member did not sanitize the cart but then began preparing the next medication administration for another resident by placing cups on the contaminated cart/fluid. [...]

Inspectors wroteBased on observation, record review, observation, and policy review, the facility failed to determine one of five sampled residents (Resident (R) 5) was safe in the self-administration of physician ordered medications. This failure had the potential for R5 not to take his medication and experience adverse effects of not taking the physician ordered medications.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to ensure medication administration was timely for two of three residents (Resident (R)1 and R5) reviewed for late medications out of five sampled residents. This failure had the potential to interfere with the medication effectiveness.

Inspectors wroteBased on observation, record review, interview and document review, the facility failed 1. to prime an unused insulin pen prior to the injection of insulin as well as 2. failed to ensure the insulin was administered as ordered for one of five sampled residents (Resident (R)5). This failure had the potential for R5 not to receive the physician ordered amount of insulin to R5 and the potential to have uncontrolled blood sugars as a result of this action.

Inspectors wroteBased on observation, record review, interview and document review, the facility failed to follow infection control guidelines during a wound care observation for two of three residents (Resident (R)1 and R4) observed out of five sampled residents. This failure had the potential for R1 and R4 to be exposed to infections.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that 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 (R3) of 4 residents reviewed for pressure injuries. *R3 is dependent for all cares and mobility, is at high risk for developing pressure injuries and has a history of pressure injuries. On 5/2/25, facility documented that R3 had developed a pressure injury to R3's left ear. The pressure injury was not comprehensively assessed and there is no documentation that R3's MD was contacted until 5/4/25 when a treatment order was put in place. From 5/7/25 through 5/14/25, R5 was admitted to the hospital for a different change of condition. [...]

Inspectors wroteBased on observations, interviews, 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 for 1 (R5) of 3 residents observed with Enhanced Barrier Precautions (EBP). *R5 has a facility acquired pressure injury to the sacral area. On 6/26/25 Surveyor observed R5's wound treatment. Facility staff did not wear the proper Personal Protective Equipment (PPE) while performing R5's wound treatment.

Inspectors wroteBased on record review, document review and staff interviews, the facility failed to ensure one of one (Resident (R) 2) family member (F1) was provided with a timely refund for paying privately prior to the approval of R2's Medicaid application for long-term care services.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure one (Resident (R)1) care plan out of a survey sample of 15, accurately reflected the resident's current status. This failure created an increased risk for the resident to receive care and services not appropriate for their current clinical condition.

Inspectors wroteBased on observations, interviews, record review, facility policy review, and Centers for Disease Control (CDC) guidance, the facility failed to adhere to infection control practices and policies during wound care related to staff failing to perform hand hygiene during glove changes for one of two residents (Resident (R) 6) observed for wound care in the sample of 15 residents. In addition, the Respiratory Therapist (RP)1 failed to apply appropriate Personal Protective Equipment (PPE) prior to performing a respiratory treatment for one of one resident (R1) with a tracheostomy in the sample of 15 The deficient practice increased the risk for cross contamination and infections.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to notify the representative of a hospital transfer for one of two residents (Resident (R) reviewed for hospital transfer out of a total sample of 17.

Inspectors wroteBased on review of facility policy, record review, and interviews, the facility failed to protect the resident's right to be free of staff to resident abuse for two of 17 residents (Resident (R ) 2 and R7) reviewed for abuse out of a total sample of 17. This failure created the potential for these and other residents to experience further abuse.

Inspectors wroteBased on review of facility policy, record review, and interviews, the facility failed to ensure timely reporting of potential abuse for one out of 17 residents (Resident (R) R7) reviewed for abuse out of a total sample of 17. This failure created the potential for this and other residents to experience further abuse.

Inspectors wroteBased on review of facility policy, record review, and interviews, the facility failed to ensure one out of 17 residents (Resident (R) R2 reviewed in the sample received his medication routinely as ordered by his physician. This failure caused multiple medication errors during the resident's medication administration, which created the potential for this resident to experience significant negative physical effects related to the errors.

Inspectors wroteBased on observation, interview, and record review., the facility did not ensure that 1 (R79) of 2 residents reviewed for discharge, had a discharge plan that was developed or implemented in an effective discharge planning process that focuses on the resident's discharge goals and resident safety. *R79 stated a desire to return home after being admitted to the facility. R79 was scheduled for discharge on [DATE] and 12/2/2024. R79's care plan was developed without including measurable objectives or defined interventions consistent with R79's needs and goals.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure residents who are unable to carry out activities of daily living receive the necessary services to maintain good grooming for 1 (R50) of 19 resident's reviewed for ADL's (Activities of Daily Living). *R50's request for nail trim and face shave was not completed. The explanation for why R50 did not receive a beard trim and nails trimmed is that R50 refuses baths. R50 did not have a plan of care to address R50's refusals. The facility did not assist in providing personal hygiene that did not require a full bath to complete.

Inspectors wroteBased on observation, interviews and record review, the facility did not ensure 1 (R57) of 1 residents reviewed for Dialysis received Dialysis care in accordance with professional standards of practice. *R57 did not have a MD (Medical Doctor) order for monitoring R57's Arterio-Venous (AV) Fistula for bruit (whooshing sound of blood flow) or thrill (palpable vibration of the blood flow) until 12/2/24, which was after the current Recertification Survey began. There is no evidence staff were monitoring R57's AV fistula site for bruit or thrill from the end of the last Recertification Survey (6/11/24) through 12/2/24.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure a sanitary environment was maintained to help prevent the potential development of infections for 1 (R71) of 7 residents observed during wound care. R71 was incontinent of liquid stool prior to Licensed Practical Nurse (LPN)-C doing a dressing change to R71's Stage 4 pressure injury to the coccyx. LPN-C did not provide incontinence care to clean the buttocks or intergluteal cleft prior to completing the dressing change potentially contaminating the dressing and introducing fecal matter into the Stage 4 pressure injury.

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R4) of 1 Residents reviewed for grievances has the right to voice grievances in writing, in a manner they prefer, and receive written grievance decisions. On 4/29/24 the facility issued a letter to residents and/or their representatives informing them they would not accept grievances emailed to the facility. Resident's grievances do not include whether their issues were confirmed or not confirmed and the date written decisions were issued to the individual with the grievance/concern

Inspectors wroteBased on interview and record review the facility did not report 1 (R6) of 3 incidents to the State survey agency and/or Nursing Home Administrator during the required timeframe. An allegation of verbal abuse and possible neglect on 7/10/24 was not reported to NHA (Nursing Home Administrator)-A or the State agency until 7/16/24 which was 6 days after the incident occurred.

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R2) of 2 Residents received prescribed medication as ordered by the physician. On 7/10/24 the medication cart and narcotics drawer were observed open & unlocked. RN (Registered Nurse) Supervisor-D removed 2 medication cards from the narcotics drawer of the unlocked medication cart for R2. R2 did not receive her Tramadol HCL 50 mg (milligrams) and Lorazepam 0.25 mg as ordered by the physician during the evening medication pass.

Inspectors wroteBased on observations, interviews and record review, the facility did not establish and maintain an infection prevention and control program based upon current standards of practice, designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections. This deficient practice has the potential to several of the 79 residents. The facility's Water Management Plan (WMP) was not based on current standards of practice and did not: ~Include water management team members who were knowledgeable about the facility's water system. ~Identify all locations where Legionella could grow and spread. ~Identify where control measures should be applied based on where Legionella could grow and spread and identify how to monitor the control measures and risks. [...]

Inspectors wroteBased on observations, interviews and record review, the facility did not ensure that residents who entered the facility 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 for 1 of 1 (R47) residents reviewed for range of motion. R47 was not wearing her palm protectors during survey.

Inspectors wroteBased on observation, interview and record review the facility did not ensure it's medication error rate is not 5 percent or greater. The facility had a medication error rate of 6.45% affecting 1 of 4 (R76) residents observed during medication pass. R76 was administered medications crushed, which is contraindicated.

Inspectors wroteBased on observation, interview and record review the facility did not ensure that drugs and biological's used in the facility were labeled in accordance with currently accepted professional standards of practice, to include the expiration date when applicable for 2 of 2 (R50 and R84) residents' insulin observed. Open and used insulin belonging to R50 and R84 were not dated when opened.

Inspectors wroteBased on interviews and record review, the facility did not ensure 1 (R4) of 2 allegations involving potential abuse, neglect, misappropriation, injuries of unknown origin or exploitation were reported to the State Survey Agency. On 3/16/24 an unknown Certified Nursing Assistant (CNA) informed R4 of rumors being spread in the facility. The rumors were that R4 was in a romantic relationship with Licensed Practical Nurse (LPN-D) and that R4 was buying gifts for LPN-D. These rumors caused R4 to call the police. On 3/18/24, R4 reported to the Director of Nursing (DON-B) that R4 had bought various gifts for LPN-D. The facility did not identify this as an allegation of exploitation and did not report this allegation to the State Survey Agency.

Inspectors wroteBased on record review and interviews, the facility did not ensure all allegations involving potential abuse, neglect, misappropriation, injuries of unknown origin and exploitation were thoroughly investigated for 1 (R4) of 2 allegations of abuse. R4 was told by a Certified Nursing Assistant (CNA) of rumors that R4 had a romantic relationship with and was buying gifts for Liscenced Practical Nurse (LPN)-D. R4 reported this to a staff member who did not report it to administration. After R4 heard that LPN-D was suspended because of these rumors, R4 called the police. At this time the admiistration became aware of all the rumors about R4 and LPN-D. The facilty did not investigate this as an allegation of abuse or exploitation.

Inspectors wroteBased on interview and record review the facility did not ensure that 4 ( R3, R4, R5, R2) of 4 Residents reviewed were provided medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being. * R3 is assessed to be severely cognitively impaired for daily decision making skills and has a court appointed legal guardian. R3's capacity to consent to engage in sexual relationships was not regularly evaluated and documented on R3's plan of care. On 1/28/24 an allegation was made of R3 having oral sex with R5 in her room. R3's care plan was not updated to reflect parameters of male visitation in her room after 8:30 pm. There was no psychological evaluation to establish and/or support the capacity for consent for engaging in intimate relationships. [...]

Inspectors wroteBased on interviews and record review, the facility did not ensure 1 of 1 resident's right (R8) to be treated with dignity and respect in an environment that enhances R8's quality of life. R8 is assessed to have severe cognitive impairment with daily decision-making skills and requires assistance for dressing. On 12/20/23 at approximately 2:15pm, R8 was in the common area wearing a T-shirt and sweater and just a towel covering R8's waist area. R8 had no pants or brief on and was naked from the waist down. An allegation was made that 2 Residents (R5 and an additional unknown Resident) were laughing and pointing at R8. CNA-P was notified of the situation and removed R8 from the common area. CNA-P brought R8 to R8's room. R5 followed where R5 entered through R8's closed door without permission, was yelling and pointing in a threatening manner. [...]

Inspectors wroteBased on interviews and record review, the facility did not ensure the right of a Resident to receive visitors at the time of their choosing for 1 (R2) of 1 Resident reviewed for visitation rights. The facility restricted R2's husband immediate access to R2 unless R2's husband was accompanied either by their daughter who lives in Minnesota or son who has his own business.

Inspectors wroteBased on observation and interview, the Facility did not ensure to provide a safe, clean, and homelike environment for 3 (R2, R10, & R11) of 5 Resident's reviewed for their environment. * The base of R2's tube feeding pole was splattered with dried tube feeding and there was dried feeding on the floor. This was observed on 2/19/24, 2/20/24, 2/21/24, & 2/22/24. * There is a piece of wall paper missing on the wall to the left of R10's bed measuring approximately two feet in length by 4 inches in width. The cove base is missing next to the bathroom door. * There are two wall tiles that have come off the wall and are laying on the floor on the right side in R11's bathroom.

Inspectors wroteBased on interview and record review the Facility did not promptly resolve a grievance for 1 (R1) of 1 grievance reviewed. On 1/20/24 R1's son filed a grievance that R1's echo show 8 (3rd generation) was missing. The date of resolution on the January grievance log is documented as 1/25/24. On 2/6/24 SSD (Social Service Director)-G indicated she was just informed the Facility needs a receipt for the item in order to submit for reimbursement. On 2/7/24 R1's son provided SSD-G with the order information from [Amazon] and this information was then provided to provided to Assistant Administrator-C on 2/7/24. As of 2/19/24 when Surveyor inquired about R1's son's grievance, R1's son was not provided with reimbursement for the missing echo show 8. R1's grievance was not resolved on 1/25/24.

Inspectors wroteBased on record review and interviews, the facility did not ensure that 3 of 3 allegations of abuse (R5, R3, and R4) reviewed was reported no later than 2 hours and 1 of 1 allegation of misappropriation of funds(R3) was reported no later than 24 hours to the State Survey Agency and other officials in accordance with State law through established procedures. The facility did not report results of the investigations to the State Survey Agency within 5 working days of the incident and if the alleged violation required corrective action. *On 12/20/23, it was reported to administration that R5 had a physical altercation with certified nursing assistant (CNA-P). CNA-P and CNA-I provided written statements of the altercation between R5 and CNA-P and in which CNA-P ended up calling the police. [...]

Inspectors wroteBased on record review and staff interviews, the facility did not ensure all allegations involving potential abuse, neglect and misappropriation of Resident funds (R3) were thoroughly investigated for 3 Residents(R) (R5, R3, and R4,) of 3 Residents reviewed for all abuse, neglect, and misappropriation of Resident property investigations. The facility did not thoroughly investigate the allegations and the facility did not report the results of the investigations to the State Survey Agency within 5 working days of the incident and if the alleged violation required corrective action. * On 12/20/23, it was reported to administration that R5 had a physical altercation with certified nursing assistant (CNA-P). The facility did not complete a thorough investigation as evidenced by obtaining only 4 staff statements. [...]

Inspectors wroteBased on observation, interview, and record review, the Facility did not ensure that Residents at risk for pressure injuries received necessary treatment and services to prevent the development of pressure injuries for 1 (R2) of 2 Residents reviewed for pressure injuries. * On 2/20/24 and 2/21/24, R2 was observed in bed without the pressure relieving boot on R2's left foot per plan of care.

Inspectors wroteBased on observation, interview and record review, the Facility did not ensure the necessary care and services to provide respiratory care for 3 (R2, R12, & R11) of 4 Residents receiving oxygen care. * R2 was readmitted to the facility on [DATE] and was receiving oxygen via nasal cannula. There was no physician's order for R2's oxygen until 2/20/24. * The filter on R12's oxygen concentrator had dust and white particles throughout. * R11's oxygen concentrator had a coating of dust on the back vent portion, there was dust on the front of the concentrator throughout and under the humidifier bottle there was a large accumulation of dust & dirt.

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure residents at risk for pressure injuries, and with pressure injuries, were comprehensively assessed in order to implement an individualized plan of care. This was observed with 6 (R95, R101, R107, R100, R68, and R88) of 6 residents reviewed with pressure injuries and at risk for pressure injuries. * R95 was admitted to the facility on [DATE] and identified as being high risk for pressure injuries. R95 was not comprehensively assessed in order to implement an individualized plan of care for prevention of pressure injuries or implement care plan revisions with pressure injury onset. R95 developed a facility acquired unstageable pressure injury to the sacrum on 6/15/23 which deteriorated. On 7/21/23, R95 was hospitalized with sepsis secondary to sacral wound infection with a stage 4 pressure injury to the sacrum. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility did not ensure residents were comprehensively assessed for bowel and bladder function to prevent infections and skin impairment. This was observed with 4 (R101, R95, R100, and R15) of 5 residents reviewed with bowel and bladder incontinence upon admission to the facility. -R101 was admitted to the facility with both bowel and bladder incontinence. An individual assessment of R101's continence status was not completed to develop an individualized plan of care. On 8/14/23, R101 was determined to have a urinary tract infection (UTI). On 8/16/23, R101 was determined to have an unstageable pressure injury and was started on antibiotics for the UTI. On 8/18/23, a Foley catheter was placed for R101 without an individualized plan of care or for clear justification for the use of the Foley catheter. [...]

Inspectors wroteBased upon interview and record review, the facility did not ensure the facility wide assessment developed by the facility included all relevant details to ensure the facility provided care and services to residents to meet their individual needs within the facility's identified resources. This has the potential to affect all 99 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility did not ensure that the mandatory staffing data that had been submitted from 4/1/23-6/30/23 was complete and accurate. This has the ability to affect all of the 99 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observation and interview the facility did not ensure residents the right to a safe, clean, comfortable and homelike environment. This deficient practice has the potential to affect all 54 residents residing on the second floor. R63's room had multiple black half circle marks, missing paint and exposed dry wall next to bed. The South 2 hallway has two areas on floor tiles with large cracks/gaps. The second-floor dining room was observed to have a loveseat that was buckled down the middle and a metal screen frame on a window was bent. The corner of R2's nightstand is broken.

Inspectors wrote9.) R15 was admitted to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary disease, vascular dementia, hemiplegia, sequelae following unspecified cerebrovascular disease, depressive disorder, heart failure, peripheral vascular disease and paralytic syndrome. R15's Quarterly Minimum Data Set (MDS) dated [DATE] indicates R15 is moderately cognitively impaired. R15 understands and is understood by others and is able to make their needs known. R15 is totally dependent on staff for transfers with a mechanical lift and requires extensive staff assistance with bed mobility, toileting and dressing. Review of R15's Care Plan documents R15 uses anti-anxiety medications (Lorazepam) due to anxiety, date initiated 7/8/22 and revised on 7/11/22. Switched from Buspirone to Lorazepam, date initiated 7/11/22. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure each resident is treated with dignity and ensured an environment that promotes enhancement of their quality of life. This occurred for 1 (R15) of 20 residents reviewed for dignity. R15 requested staff assistance to be changed and was told they would be changed later when it was time for their shower. R15 waited over two hours to be changed out of a urine-soaked brief. Just prior to receiving incontinence care, staff answered their personal cell phone while in the resident room and held a conversation for several minutes. R15 requested to have the bed linen changed as they were soiled and wet from laying in a urine-soaked brief for a prolonged period of time. Staff was observed telling R15 the bed linen was fine and proceeded to make the bed.

Inspectors wroteBased on observations, record review and interviews, the facility did not ensure residents had an individualized comprehensive plan of care. This was observed with 3 (R101, R95 and R55) of 20 resident comprehensive care plan reviews. -R101 was admitted to the facility with bowel and bladder incontinence and there was no comprehensive plan of care with individualized interventions to address bowel and bladder incontinence. -R95 was admitted to the facility with bowel and bladder incontinence and there was no comprehensive plan of care with individualized interventions to address bowel and bladder incontinence. - R55 was admitted with oxygen and there was no comprehensive plan of care with individualized interventions to address oxygen management.

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R34) of 5 residents reviewed for discharge received a thorough discharge summary in order to communicate necessary information to the resident, continuing care provider, and other authorized persons at the time of the anticipated discharge. *R34 discharged from the facility on 10/02/23. R34 had lab work drawn on 10/02/23 prior to discharge. R34's discharge summary did not include the results of the lab work and there was no documentation R34 or R34's representatives were aware of the lab results.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure the medication error rate was below 5%, with 4 errors of 29 opportunities, affecting 1 supplemental resident (R99) of 4 residents observed receiving medications. The facility medication error rate was 13.79%. *R99's placement of g-tube was not confirmed before medication administration, medications were combined and crushed together, and the doctor's order to flush with 30mL between each individual medication was not followed. *R99 did not have her Lidocaine patches applied per order and the patches were signed out on Medication Administration Record (MAR). *R99 did not receive her Pantoprazole Sodium Powder which was signed out on the MAR. *R99 was given Carvedilol 25mg after Surveyor observation completed and should have been held per doctor's order to hold for heart rate under 60.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure the nurse staff posting was accurate for the previous eight months having the potential to affect all 99 residents residing in the facility at the time of the survey.