Rivers Edge Nursing and Rehab

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, including injuries of unknown source, are reported immediately for 1 of 16 sampled residents (R) reviewed for abuse (R14). R14 made an allegation she was emotionally and sexually abused at the facility. The facility was aware on 6/9/26 of R14's allegations and did not report to the state agency timely. This is evidenced by: The facility's policy Abuse/Neglect/Exploitation, undated, includes: VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies. within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse. [...]

Inspectors wroteBased on interview and record review the facility did not have evidence all allegations of abuse were thoroughly investigated for 1 of 16 sampled residents (R14). R14's allegation of emotional, psychical, and sexual abuse was not thoroughly investigated. This is evidenced by:The facility's policy Abuse/Neglect/Exploitation, undated, includes: V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation; 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure each resident received adequate supervision to prevent accidents for 1 (R3) of 3 residents reviewed for falls out of a sample of 16. R3 had four falls within a month's time. R3 has frequent falls. The facility has not completed root cause analysis for three of the falls to implement appropriate fall interventions. Evidenced by:The facility policy entitled Accidents and Supervision- [NAME] Edge Nursing and Rehab, dated 1/2026, states, in part: . Policy: The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1) Identifying hazard(s) and risk(s). 2) Evaluating and analyzing hazard(s) and risk(s). 3) Implementing interventions to reduce hazard(s) and risk(s). [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that each resident who was a trauma survivor received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for experiences and preferences in order to eliminate or mitigate triggers that may care re-traumatization for 1 of 1 residents reviewed (R9) for PTSD (Post-Traumatic Stress Disorder). R9's Psychosocial Assessment and Trauma Informed Care Assessment indicated R9 has a history of childhood physical abuse by father while growing up. The facility did not implement a Trauma Informed Care Plan for R9. Evidenced by:The facility policy entitled Trauma Informed Care- [NAME] Edge Nursing and Rehab, dated 1/2026, states, in part: . Policy: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, are reported immediately to the administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law through established procedures for 2 of 8 residents (R3 & R4) reviewed for abuse involved in1 of 4 self-reports. The facility did not contact law enforcement on a resident-to-resident altercation regarding R3 and R4 on 12/23/25. Evidenced by:The facility policy entitled Abuse/Neglect/Exploitation, dated 11/2017, states, in part: . Policy: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure each resident received adequate supervision to prevent accidents for 1 (R2) of 8 sampled residents. R2 was at risk for falls and had three falls while residing at the facility. R2 had a care planned intervention to remain in line of sight while up in her broda chair (wheelchair that tilt and reclines). R2 experienced a fall from her broda chair while not in line of sight of staff. Neurological checks following the fall were not completed. This is evidenced by: The facility policy entitled, Fall Management Process, dated 2011, states, in part: 1. In the event a resident has fallen and/or is found on the ground, a complete head-to-toe assessment must be performed prior to moving the resident unless life-threatening safety concerns are present. 8. [...]

Inspectors wroteBased on interview and record review the facility did not provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 1 resident (R3). Facility did not follow up on psycho-social needs with R3 after a resident-to-resident altercation involving R3 being slapped by another resident (R4). Evidenced by:The facility's policy Abuse/Neglect/Exploitation, dated 11/2017, states, in part: . Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. [...]

Inspectors wroteBased on interview, and record review, the facility did not ensure residents are free of significant medication errors for 1 of 8 sampled residents (R5). R5 has an order for Metoprolol Succinate (medication that slows the heart rate and force of contraction of the heart which decreases blood pressure) 150 MG (milligrams) to be administered one time a day by mouth and to hold this medication for a systolic blood pressure (blood pressure when the heart contracts) below 110 and a heart rate less than 55 beats per minute. This medication was administered 14 times in December 2025 and 6 times from 1/1/26 through the survey date with a systolic blood pressure less than 110. As evidenced by The facility policy entitled, Medication Errors, undated, states, in part: . Definitions: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident (R) received adequate supervision to prevent accidents for 1 of 4 sampled residents (R3) reviewed for falls. Surveyor observed R3's fall intervention not in place. R3 had a fall on 9/30/25 and facility failed to complete a falls investigation and update the physician on the fall. Evidenced by: The facility policy entitled Falls Management Process, undated, states, in part: . 1. In the event a resident has fallen and /or is found on the ground.11. The nurse will complete an event documentation report, fall risk assessment, pain assessment, and obtain witness statements.12. The nurse will determine the most appropriate intervention, implement, and update care plan.[12] Contact physician and family and document in the medical record, including time and person spoken with.13. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that each resident receives food that is palatable and at a safe and appetizing temperature. This has the potential to affect all 37 residents who reside in the facility. Food being held in the steam table, did not meet the required hot holding temperature. Four residents (R26, R 31, R36, R46) voiced concerns about food being cold. Evidenced by: Facility policy, entitled Food Preparation and Service, last revised January 2025, includes in part: . Food Preparation, Cooking and Holding Temperatures and Times. 1. The danger zone for food temperatures is between 41 degrees F and 135 degrees F. The temperature range promotes the rapid growth of pathogenic microorganisms that cause food borne illness. [...]

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 all 39 residents who reside in the facility. Surveyor observed hairlike dust built up in the frame of the drop ceiling, along the electrical covers, and on top of the outlets in the main kitchen, in the freezer unit, and in the refrigerator unit. Surveyor observed Mighty Shakes to be in the refrigerator thawed with no thaw dates. Surveyor observed a cup left in the sugar bin that had been used as a scoop. Surveyor observed cereal in large plastic containers with a use by date that had passed. Surveyor observed frozen drips in and on boxes of food that is no longer sealed by the manufacturer and ice built up inside of the facility's walk-in freezer over opened boxes of food. [...]

Inspectors wroteBased on 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 census (39). The facility has no documentation of Infection Control Surveillance prior to August of 2025. The facility does not have documentation that Infection Control Policies and Procedures were reviewed annually. The facility does not have Infection Control rates documented. The facility has not been completing Legionella testing per their Water Management Plan. The facility has not completed their monthly NHSN (National Healthcare Safety Network) reporting since July. This is evidenced by: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure they maintained medical records on each resident in accordance with professional standards of practice. This has the potential to affect 1 of 16 sampled residents (R3) and 3 of 3 supplemental Residents ((R27, R28, & R44) reviewed for medical records. R27's medical information was observed accessible in an unsecured area on 9/24/25. R28's medical information was observed accessible in an unsecured area on 9/24/25. R44's medical information was observed accessible in an unsecured area on 9/24/25. R3's medical information was observed accessible in an unsecured area on 9/24/25.

Inspectors wroteBased on interview, observation, and record review, the facility did not provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals, to meet the needs for 1 of 16 sampled Residents (R31). R31 was observed with a cup of pills sitting on her bedside table. R31 did not have an order to self-administer medications, nor did she have an assessment completed to determine her competency for self-administering medications. This is evidenced by:The facility policy titled, Self-Administration of Medications, dated 10/25/14, states, in part: Policy: . residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer. [...]

Inspectors wroteBased on record review and interview the facility did not provide the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) and did not provide the accurate potential financial liability to residents whose Medicare coverage was ending for 3 of 3 residents reviewed (R2, R8, and R50). R2 was receiving Medicare A benefits. R2 was not provided the SNFABN form thus not provided with the accurate financial liability. R8 was receiving Medicare A benefits. R8 was not provided the SNFABN form thus not provided with the accurate financial liability. R50 was receiving Medicare A benefits. R50 was not provided the SNFABN form thus not provided with the accurate financial liability. Evidenced by:The facility's policy titled Advance Beneficiary Notice dated 10/01/22 states in part .5. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are reported to the State Survey Agency for 1 (R12) of 5 investigations reviewed. R12 indicated the nurse threw him on R12's bed. Facility did not report incident to state agency and did not contact law enforcement. The facility policy, Abuse/Neglect/Exploitation, with no date, states, in part;.1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure that all alleged violations are thoroughly investigated and report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken this affected 1 (R12) of 5 investigations reviewed. R12 reported an allegation of abuse. The facility did not complete a thorough investigation. Evidenced by:The facility policy, Abuse/Neglect/Exploitation, no date, states, in part;.A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. [...]

Inspectors wroteBased on record review and interview the facility did not complete the PASRR Level II (Preadmission Screening and Resident Review) for residents having a major mentalDisorder and are receiving psychotropic medications to treat behaviors or symptoms of a major mental disorder affecting 1 of 3 residents (R8) reviewed for PASRR. R8 admitted to the facility with a major mental disorder and is receiving psychotropic medications. The facility did not ensure that a PASRR level 2 screen was performed by the PASRR contractor. Evidenced by: The Preadmission Screen and Resident Review Level 1 Screen directions include, in part, the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a person-centered comprehensive care plan to meet personal preferences and goals, or address the resident's medical, physical, mental and psychosocial needs for 1 or 16 sampled residents (R1). R1 displayed behaviors of making sexual remarks to a staff member and the facility failed to develop a behavior care plan with goals and interventions related to R1's behavior. Evidenced by:Facility policy, titled Comprehensive Care Plan, dated 3/1/23, includes: . it is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessments. [...]

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 (N6, Wisconsin Nurse Practice Act) for 2 of 3 sampled residents (R29 and R4). On 9/19/25, R29 was being pushed in his wheelchair by staff when his foot came off the foot pedal and was run into by the wheelchair wheel. There is no indication that R29's foot was assessed by an RN (Registered Nurse). R4 has a diagnosis of CHF (Congestive Heart Failure) and experienced a 23 pound weight increase in a week. The facility failed to notify R4's Medical Doctor, failed to assess R4 for symptoms of complications related to CHF, failed to provide continued close monitoring of CHF exacerbation such as checking for edema and listening to lung sounds, and the facility failed to notify R4's Registered Dietician timely for consultation. [...]

Inspectors wroteBased on interview and record review, the facility did not recognize, evaluate and address the nutritional and hydration needs of 1 of 3 Residents (R35) to reduce the risk of continued weight loss, dehydration and malnutrition. R35 did not have appropriate interventions put into place to prevent continued weight loss. R35 had a weight loss of 22.6 pounds/13.9% over 1 month, indicating a severe weight loss, and a 32 pound/18.6% weight loss in 6 months, indicating a severe weight loss. This is evidenced by:Facility policy titled, Weight Monitoring, undated, states in part, Purpose: . the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range. Compliance Guidelines: Weight can be a useful indicator of nutritional status. Significant unintended changes in weight. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that a resident's drug regimen was free from unnecessary medications for 3 of 5 residents reviewed for unnecessary medications (R7, R1, and R3). R7 is on sleep medication and the facility failed to assess and document sleep pattern and routinely monitor the medication. R1 is on sleep medication and the facility failed to assess and document sleep pattern and routinely monitor the medication. R3 is receiving Ambien for sleep disorder. The facility failed to complete a sleep assessment and have continued monitoring for sleep behaviors. Evidenced by: The facility policy, Hypnotic Medication, no date, states, in part;.It is the policy of this facility to: Use hypnotic medications only when clinically necessary and after non-drug interventions have been attempted and documented. Prior to initiating a hypnotic: [...]

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 2 of 7 sampled residents (R4 and R5) reviewed for change of condition. R4 experienced a change in condition as evidenced by a change in mental status, decrease in intake, and change in urine color and output. Certified Nursing Assistants (CNAs) reported these changes to nursing staff. R4’s nurse did not complete an assessment, monitor resident, or report change in condition to the provider. R4 continued to deteriorate over the weekend and was found to be unarousable and then sent to ER. R4 was admitted to the hospital on [DATE] with bacteremia UTI (bacteremia presence of bacteria in the blood stream; [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, are reported immediately to the administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law through established procedures for 1 of 16 residents (R10) reviewed for abuse. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that in response to allegations of abuse, neglect, exploitation, or mistreatment, that alleged violations are thoroughly investigated for 2 of 4 residents reviewed for abuse (R4 & R6). CNA C (Certified Nursing Assistant) reported an allegation of verbal and sexual abuse to NHA A (Nursing Home Administrator). The facility failed to conduct a thorough investigation of the allegations made regarding R6. R4 experienced a change in condition that resulted in his unexpected death. The facility failed to conduct a thorough investigation to rule out neglect of R4. Evidenced by: Facility policy, titled Abuse Neglect Exploitation, undated, 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 12 sampled residents (R9). R9 voiced concern of being transferred with a Hoyer lift and only one staff present. This is evidenced by: Facility policy titled, Transfer Status dated 1/2025, states in part: It is a policy to ensure safe, consistent, and resident-centered transfer practices for all long-term care residents, minimizing risk of injury to residents, staff, and visitors, while maintaining dignity and compliance .Hoyer Lift - A mechanical lift used when resident requires full or partial support. All mechanical lifts require the assistance of 2. Example 1: R9 was admitted to the facility on [DATE] with diagnoses that include: [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that its medication error rate was 5% or less for 24 medication pass opportunities and 2 of 2 residents observed (R12 and R5). The facility's medication error rate was 100% with 24 errors observed for R12 and R5. This is evidenced by:The facility policy, Medication Administration, dated 3/1/19, states in part, as follows: Compare medication source (bubble pack, vial, etc.) with MAR (Medication Administration Record) to verify resident name, medication name, dose, route, and time. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. Example 1R12's Physician Orders, signed 8/7/25, include, in part, the following medications:1. Vitamin C (Ascorbic Acid) - Give 500 mg (milligrams) by mouth two times a day to promote wound healing. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure Residents are free of significant medication errors, for 1 of 2 residents reviewed for significant medication errors (R5). Surveyor observed RN J (Registered Nurse) crush R5's Divalproex (Depakote) extended- release and administered it to R5. Evidenced by:The facility policy, entitled, Medication Administration, dated 3/1/19, states in part: Administer medication as ordered in accordance with manufacturer specifications. Crush medications as ordered. Do not crush medications with do not crush instructions. R5's Physician Orders, signed 8/7/25, include, in part, the following medication:Divalproex Sodium ER (Extended Release) Oral Tablet 24-hour 250 mg (milligrams) - Give 1 tablet by mouth in the morning for seizures. [...]

Inspectors wroteBased on interview, and record review the facility did not provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, this affected 5 of 5 sampled residents (R1, R2, R3, R4, R5). R1 had medications not documented as administered. R2 had medications not documented as administered. R3 had medications not documented as administered. R4 had medications not documented as administered. R5 had medications not documented as administered. This is evidenced by:The Facilities Policy and Procedure entitled Medication Administration dated 3/1/19 documents in part: .17. Sign MAR (Medication Administration Record) after administered .Example 1R1 is long resident of the facility. R1 has the following diagnoses: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents are free of any significant medication errors, this affected 4 of 5 sampled residents (R1, R2, R4, R5). R1 had medications not documented as administered which resulted in a significant medication error. R2 had medications not documented as administered which resulted in a significant medication error. R4 had medications not documented as administered which resulted in a significant medication error. R5 had medications not documented as administered which resulted in a significant medication error. This is evidenced by:The Facilities Policy and Procedure entitled Medication Administration dated 3/1/19 documents in part: .17. Sign MAR (Medication Administration Record) after administered . Example 1R1 is long term resident of the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect residents' right to be free from neglect. This had the potential to affect all affected 43 residents who reside in the building. CNA M (Certified Nursing Assistant) stated she was the only CNA for PM shift on 6/20/25. Residents did not receive care on 6/20/25 between the hours of 2:00 PM and 9:00 PM. R16, R18, R14, R15, and R17 voiced concerns regarding care. This is evidenced by:The facility's policy titled Abuse, Neglect, and Exploitation, dated 10/1/22, states in part; it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures to prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to have sufficient staffing to ensure resident safety and attain or maintain each resident's highest practicable physical, mental, and psychosocial well-being as determined by resident assessments and individual plans of care and considering the number, acuity, and diagnoses of the facility's resident population in accordance with the required facility assessment. This has the potential to affect all 43 residents residing in the facility. R16 stated she did not receive any cares on a PM shift (evening shift). R18 stated she had concerns regarding the long wait times when using the call light. R14 did not get up for dinner due to low staffing. R15 complained of long wait times when using her call light and her plan of care was not followed due to low staffing. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, are reported immediately to the administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law through established procedures for 1 of 9 abuse investigations reviewed regarding misappropriation of medications. The facility submitted a Facility Reported Incident to the State Agency involving misappropriation of medications, but did not notify the police. Evidenced by: The facility's policy titled Abuse, Neglect, and Exploitation, dated 10/1/22, states in part POLICY: [...]

Inspectors wroteBased on interview and record review, the facility did not provide the proper discharge documentation for 3 of 4 residents reviewed for discharge (R8, R12, and R13). R8 and R12 transferred out of the facility (resident-initiated discharge) and both residents had incomplete discharge documentation. R8's discharge was delayed. R13 was transferred to the hospital and had incomplete discharge documentation.

Inspectors wroteExample 2: R6 was admitted to the facility on [DATE] and has diagnoses that include infection and inflammatory reaction due to indwelling urethral catheter, hydronephrosis (condition characterized by excess fluid in the kidney due to a backup of urine) and type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). R6's Minimum Data Set Quarterly Assessment, dated 3/25/25, shows R6 has a brief interview if mental status score of 14 indicating R6 is cognitively intact. R6's physician's orders, dated 6/25/25, states, in part: .Perform foley catheter care every shift. Order Date: 2/07/2024 03:39 . Enhanced Barrier Precautions (EBP) in place for indwelling urinary catheter every shift. Order Date: 5/22/2025 10:16 . On 6/25/25 at 10:25 AM, Surveyor observed CNA C (certified nursing assistant) perform catheter cares on R6. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure the accurate administration of medication for 1 of 3 sampled residents (R8). R8 did not receive her morning medications on a day she left the facility for a pre-scheduled appointment, was missing documentation for medications on her Medication Administration Record (MAR) in May 2025, received a dose of her morning and afternoon medications at the same time, and received medications outside of the recommended time window.

Inspectors wroteBased on interview and record review, the facility did not ensure residents are free of any significant medication errors for 1 of 3 residents (R3) reviewed for medications. R3 did not receive his time sensitive medication timely 83 times, received 2 doses at once on 10 occasions, and was given doses too close together 8 times between the dates of 6/1/25 and 6/15/25. This is evidenced by: The facility's provided an untitled and undated document covering their medication policy. The document includes: 3. Best practices in timely medication administration and steps to address potentially late administration. Timely medication administration is essential for ensuring therapeutic effectiveness, preventing complications, and maintaining patient safety. Administer medications within the recommended time window . Prioritize time-critical medications . [...]

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 1 of 1 resident (R1) reviewed for transmission-based precautions. R1 had a sign posted on his door that he was under Enhanced Barrier Precautions (EBP), however a staff member entered R1's room and performed personal cares without following the EBP protocol or wearing the appropriate PPE (Personal Protective Equipment). This is evidenced by: The facility policy, titled Enhanced Barrier Precautions dated 3/25/24, with no revision or review date, states, in part: Policy: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure staff postings were accurate which has the potential to affect 43 out of 43 residents residing at the facility. Review of staffing schedules and required staff postings revealed discrepancies between the documents. This resulted in inaccuracies with the total number and the actual hours worked for licensed and non-licensed staff directly responsible for resident care each shift. This is evidenced by: Surveyor reviewed the schedules and staff postings from 6/10/25 thru 6/23/25 and noted the following inaccuracies: On 6/10/25, the Staff Posting indicates for AM shift, 4 CNAs (Certified Nursing Assistant), 2 Med Techs (Medication Technician), and 1 RN (Registered Nurse). The schedule indicates 3 CNA's, and 2 LPNs (Licensed Practical Nurse) worked. Of note, the Staff Posting indicates the RN was DON B (Director of Nursing). [...]

Inspectors wroteExample 3 The facility's policy titled Wound Management, undated, states in part: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidenced-based treatments in accordance with current standards of practice and physician orders. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. Dressing changes may be provided outside the frequency parameters in certain situations: feces has seeped underneath the dressing, the dressing has dislodged, the dressing is soiled otherwise or is wet. Treatment decisions will be based on a. etiology of the wound: i. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure each resident received adequate supervision to ensure each residents' environment remains free of accidents and hazards for 2 of 5 sampled residents (R17 and R1.) R17 is being cited at a scope and severity level 3 (actual harm.) R17 requires staff assistance to, in part, stand, transfer, and toilet. On 2/5/25, PT Y (Physical Therapist) recommended R17 be provided with: 1:1 supervision required due to falls and history of seizures. The facility did not implement 1:1 supervision. On 3/2/25, R17 fell and fractured his hip while self transferring from his wheelchair to bed. Surveyor observed R1's motorized wheelchair charging in his room and not behind a fire safe door. As evidenced by: The facility's policy, Falls Management Process, undated, indicates in part as follows: [...]

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 41 residents who reside in the facility. Surveyor observed food that had been removed from the original box to be undated and unlabeled. Surveyor observed milk to be opened with no open date. Surveyor observed magic cups to be thawed and without a thaw date. Evidenced by: Facility policy titled Date Marking for Food Safety, undated, includes: the food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. [...]

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 8 of 14 sampled Residents (R1, R3, R8, R9, R10, R11, R12, R13). Surveyor observed in R1's room visibly soiled linens on the bed, dirty towels and washcloths on the floor, food, clothing, and other items scattered on the floor. Surveyor observed R3's wheelchair to be dirty. Resident Representative Q voiced concerns of R3's wheelchair being unclean. Surveyor observed dried food particles, a white chalk-like substance, and 2 different colors of dried drips on the seat and arms of R3's wheelchair. Surveyor observed a used Kleenex and a piece of gauze on the floor by the head of R8's bed. Surveyor observed food, other items, footprints and wheelchair marks on the floor in R9's room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure other alternatives were tried prior to installing/utilizing side rails. The facility failed to have a system in place to assess for risk of entrapment between the mattress and side rail and failed to identify and recognize that the use of side rails with an air mattress increases the risk for entrapment for 6 of 6 (R3, R7, R10, R6, R5, and R4) residents reviewed for bed rails. R4, R5, and R6 have an air mattress with enabler bars/bedrails. The facility did not complete all requirements as listed in F700 of the State Operations Manual prior to installing bed rails/enabler bars. [...]

Inspectors wroteBased on observation, interview, and policy 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 more than a minimal number of Residents (R). 2 of 2 test trays were served outside of temperature range. Evidenced by: The facility policy, titled Food Safety Requirements, dated 10/1/22, includes in part: .Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety . Police Explanation and Compliance Guidelines . 4. When preparing food, staff shall take precautions in critical control points in the food preparation process to prevent, reduce, or eliminate potential hazards . d. [...]

Inspectors wroteBased on interview and record review, the facility did not make prompt efforts to document, investigate, and resolve grievances a resident may have for 1 of 1 resident's reviewed for grievances (R10). R10 voiced a grievance to the facility regarding a missing clothing item. The facility did not document the grievance or follow through with their grievance policy. This is evidenced by: The facility's policy entitled Grievance Policy, dated 3/1/19, states in part .F. Grievances may be given to any staff member who will forward the grievance to the Grievance Official. G. Response Any Employee of this facility who receives a complaint shall immediately attempt to resolve the complaint within their role and authority. If a complaint cannot be immediately resolved the employee shall escalate that complaint to their supervisor and the facility Grievance Official . [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, for 1 of 3 sampled residents (R15). R15 was hospitalized from [DATE] through 4/4/25 and from 4/7/25 through 4/9/25, and did not have a skin assessment completed by the facility upon return from these hospitalizations. Evidenced by: The facility's Skin Assessment policy, dated 3/1/29, states, in part: It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment. Policy Explanation and Compliance Guidelines: 1. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that residents are provided foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s) for 2 of 2 residents (R15 and R16) reviewed for diabetic foot checks. R15 was not provided routine diabetic foot checks. R16 was not provided routine diabetic foot checks. Evidenced by: The facility's Skin Integrity-Foot Care policy, dated 10/1/24, states, in part: It is the policy of this facility to ensure residents receive proper treatment and care within professional standards of practice and state scope of practice, as applicable, to maintain mobility and good foot health. This policy pertains to maintaining the skin integrity of the foot.2. Assessment of Risk . e. Diabetic foot checks will be performed daily by the licensed nurse. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure residents are free of any significant medication errors for 1 of 1 residents (R16) reviewed for medications. R16 was prescribed an antibiotic for right third toe cellulitis. The facility delayed entering the order into R16's Medication Administration Record (MAR) and delayed starting the antibiotic. This is evidenced by: The facility's policy titled Non-Controlled Medication Order Documentation dated 10/25/14 states in part; Documentation of Medication Order: Each medication order is documented in the resident's medical record with the date, time, and signature of the person receiving the order. [...]

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 infection for 2 of 2 residents (R2 and R15) reviewed for enhanced barrier precautions. Staff did not follow Enhanced Barrier Precautions (EBP) of wearing personal protective equipment (PPE) when providing high-contact resident care activities for R2. Staff did not follow EBP of wearing a gown when removing a wound dressing for R15. This is evidenced by: The facility's policy titled Enhanced Barrier Precautions, dated 3/25/24, states, in part: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. [...]

Inspectors wroteBased on interview and record review the facility did not document a thorough investigation and did not resolve grievances as outlined in the facility policy for 1 of 1 Residents (R1) reviewed for grievances. R1's Activated Power of Attorney voiced concerns via email. Facility failed to follow their grievance policy by thoroughly investigating, following up, and documenting the concerns. Evidenced by: The facility policy, Grievance, dated 3/19, states, in part; .b. The Grievance Official will complete a written response to the resident or resident representative which includes: 1. Date of grievance/concern. ii. Summary of grievance. iii. Investigation steps. iv. Findings. v. Resolution outcome and actions taken and date decision was issued. I. The Grievance Officer will maintain a log of all grievances for a period of 3 years including: i. Date of the Grievance ii. [...]

Inspectors wroteBased on interview and record review, the facility did not complete a thorough investigation in response to allegations of abuse and/or did not report the results of all investigations to the State Agency (SA) within 5 working days of the incident for 2 of 4 (R3 and R2) residents reviewed for abuse. On 2/13/25, the facility became aware of an alleged violation of abuse between R3 and R4. The facility did not interview other residents about the allegation and did not report the results of investigation timely to SA. On 2/16/25, the facility became aware of an alleged violation of abuse between CNA E and R2. The facility did not complete an assessment of R2 and did not report the results of investigation timely to SA. On 3/12/25, the facility became aware of an alleged violation of abuse between a staff member and R2. The facility report the results of the investigation timely to the SA. [...]

Inspectors wroteBased on interview and record review the facility did not ensure that residents are free of significant medication errors for 1 of 3 residents (R5) reviewed for medication administration. R5 did not have all her medications administered to her in February and March. This is evidenced by: The facility's policy entitled, Administration Procedures for all Medications, states, in part: .Oral Medication AdministrationPurpose: To administer oral medications in a safe, accurate, and effective manner .Procedures: .I. Chart medication administration on Medication Administration Record Immediately following each resident's medication administration . R5 has the following diagnoses: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 1 of 4 residents (R2) reviewed was able to choose their physician. R2 was not given the right to select a new physician due to the facility's lengthy requirements requested from the new physician which prohibited R2's choice in a physician. Evidenced by: The facility policy entitled Choosing a Personal Attending Physician, dated 3/26/19, states, in part: . Policy: It is the policy of the facility to support the resident's right to choose his or her attending physician. All physicians treating residents within the facility must meet requirements set forth by State and Federal laws to guarantee provision of appropriate and adequate care and treatments. Definition: Attending Physician refers to the primary physician who is responsible for managing the resident's medical care . Policy Explanation and Compliance Guidelines: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect 1 of 3 residents (R1) right to be free from verbal abuse from a housekeeper. R1 was verbally abused by a housekeeper and facility staff did not intervene and protect the resident. Evidenced by: The facility policy titled Abuse, neglect, and Exploitation, dated 10/1/2022, states, in part: .It is the policy of this facility to provide protections for the health, welfare and rights of each resident . to prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . Definitions: 1. Abuse: means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish . It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology . Willful: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, are reported immediately to the administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law though established procedures for 2 of 4 abuse investigations reviewed involving (R3 and R4). Facility became aware of an abuse allegation involving R3 on 1/23/25 at 11:36 PM and did not report it to the State Agency until 1/24/25 at 4:53PM. The facility was aware of an allegation of abuse involving R4 and the facility failed to report it to the State Agency. Evidenced by: The facility policy, entitled Abuse, Neglect, and Exploitation, dated 10/1/22, states, in part: . POLICY: [...]

Inspectors wroteExample 2 R3 admitted to the facility on [DATE] and has diagnoses that include schizoaffective disorder (a mental health condition including schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and mood symptom, such as depression or bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). R3's admission Minimum Data Set (MDS) Assessment, dated 11/21/24, shows that R3 has a Brief Interview of Mental Status (BIMS) score of 11 indicating R3 has moderate cognitive impairment. The facility's Grievance/Concern Form, dated Thursday January 23, 2025, states, in part: . Date of Occurrence: January 23, 2025, 11:36PM. Location of Occurrence: Nurse Station. Staff or Residents Involved: CNA M (certified nursing assistant) and R3 Summary of Concern: Resident came up to nurses' station. [...]

Inspectors wroteBased on interview and record review the facility did not ensure residents are free of any significant medication errors for 1 of 4 residents (R2) reviewed for medications. R2 had 9 medications not administered for 2 days in month of January, and 1 medication not administered on 1 day in the month of January including a cancer medication and pain medication. This is evidenced by: The facility's policy entitled, Administration Procedures for all Medications, dated 10/25/14, states, in part: . Oral Medication Administration Purpose: To administer oral medications in a safe, accurate, and effective manner . Procedures: . I. Chart medication administration on Medication Administration Record Immediately following each resident's medication administration . [...]

Inspectors wroteBased on observation, record review, and interviews, the facility did not ensure each resident received adequate supervision to prevent accidents from elopements for 1 of 3 residents (R8) reviewed for accidents. R8 has a guardian and is protectively placed at the facility. R8 has a history of dementia and made comments about his desire to leave the facility. R8 left the faciity on [DATE] and hitch hiked from the facility to Prairie [NAME] and then to La [NAME]. La [NAME] is approximately 70 miles away from the facility. Facility staff were not aware R8 left the building until R8's guardian notified the facility. R8 left the building around 2:00 PM and was not located until around 7:30 PM by law enforcement. The facility's failure to provide adequate supervision created a reasonable likelihood for serious injury or harm leading to a finding of immediate jeopardy that began on 10/30/24. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure residents are free of significant medication errors for 4 of 6 total sampled residents (R5, R7, R8 and R3). R5 received Milk of Magnesia 296 ml instead of Magnesium Citrate 296 ml. R7 did not receive Anastrozole (a hormone-based chemotherapy) 4 days in November and Ribociclib (a cancer growth blocker) 1 day in November. R8 did not receive ordered Suboxone Sublinqual Film as ordered from 11/9/24 through 12/4/24 (total of 26 days/doses). R3 did not receive amphetamine-dextroamphet (Adderall) until 3 days after admission (missed 5 doses). This is evidenced by: The facility policy titled, Medication Administration, dated 3/1/20, states, in part: [...]

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 affected 1 of 3 halls and 1 of 1 test tray. Surveyor requested a test tray. Hot foods tempted cold and cold foods tempted warm. This is evidenced by: The facility policy titled, Food Safety Requirements, dated 10/1/22, states, in part: .Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety .staff shall monitor food temperatures while holding for delivery to ensure proper hot and cold holding temperatures are maintained . food that is cooked and cooled must be reheated so that all parts of the food reach an internal temperature of 165oF. Ready-to-eat foods that require heating before consumption must be heated to at least 135oF. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 5 residents (R1) reviewed was free from abuse/exploitation by a Certified Nursing Assistant (CNA). CNA C took humiliating and exploitative pictures on her phone of R1 and other unidentified residents without their knowledge or consent and sent or showed them to other staff members. Using the reasonable person concept a resident would feel humiliated and dehumanized to have someone take embarrassing and degrading pictures of them and send or show them to another staff member. According to the Social Security Act [Sections §§1819(c)(1)(A)(ii) and 1919(c)(1)(A)(ii)], every resident has the right to be free from mental or physical abuse. A reasonable person would not expect that they would be harmed in his/her own home or a health care facility and would experience a negative psychosocial outcome (e.g. [...]

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 5 Residents (R1) reviewed for abuse/exploitation. Several staff were aware of an allegation of abuse/exploitation and did not immediately report it to the Nursing Home Administrator (NHA) or the State Agency within the required time frames. Evidenced by: Facility policy entitled Abuse, neglect, and Exploitation, dated 10/1/2022, states, in part: .It is the policy of this facility to provide protections for the health, welfare and rights of each resident . to prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . Reporting/Response. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure a thorough investigation of abuse/exploitation was completed for 1 of 5 Residents (R1) reviewed for abuse/exploitation. On 11/21/24, the facility became aware of an allegation of abuse/exploitation by a Certified Nursing Assistant (CNA). The facility did not ask residents questions related to the allegation of taking pictures of residents without their consent. Evidenced by: Facility policy entitled Abuse, neglect, and Exploitation, dated 10/1/2022, states, in part: .It is the policy of this facility to provide protections for the health, welfare and rights of each resident . to prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . Exploitation: means taking advantage of a resident . Mistreatment means inappropriate treatment or exploitation of a resident . [...]

Inspectors wroteBased on interview and record review, the facility did not develop and implement a discharge planning process ensuring discharge needs are identified and incorporated into a discharge planning care plan for 1 of 4 residents (R7) reviewed for discharge planning. R7 does not have discharge care plan. This is evidenced by: The facility policy titled, Discharge Planning Process, undated, states in part: It is the policy of this facility to develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions . [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that residents (R) receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident's physician orders for 1 of 1 resident (R7) reviewed for treatments. R7 did not have her tubigrips (elasticated tubular bandage used for edema) applied daily per her physician orders and comprehensive care plan. This is evidenced by: The facility policy titled, Comprehensive Care Plans, dated 3/1/19, states, in part: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . [...]

Inspectors wroteBased on interview and record review, the facility did not complete a performance review at least every 12 months for 1 (CNA S) of 5 staff reviewed for performance reviews. CNA S (Certified Nursing Assistant) was hired on 9/21/23 and has not had a performance review in the last year. This is evidenced by CNA S was hired on 9/21/23. The facility has no evidence of a performance review being completed in the last year. On 12/16/24 at 12:20 PM, Surveyor interviewed DON B (Director of Nursing) regarding performance evaluations. DON B stated she did not recall completing a performance evaluation for CNA S in the last year.

Inspectors wroteBased on interview and record review, the facility did not provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident (R) for 2 of 2 residents (R7 and R8). In November, R7 did not receive: Nystatin Powder 1 time; B12, Cetirizine, Farxiga, Metformin, Azelastine nasal spray, Buspirone, Potassium Chloride, and Senna-Docusate Sodium 4 times each; Lidocaine patch 5 times; and Lasix and Gabapentin 6 times. R7 did not receive medications timely in November 2024. R8 did not receive his scheduled medications. This is evidenced by: The facility policy titled, Medication Administration, dated 3/1/20, states, in part: [...]

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 was 1 error out of 6 opportunities that affected 1 out of 4 residents (R10) observed for medication administration, which resulted in an error rate of 16.67%. LPN I (Licensed Practical Nurse) did not prime R10's insulin pen before administration. (Of note, if insulin pens are not primed the resident may not receive the correct dose of insulin.) This is evidenced by: The facility policy entitled, Medication Administration, dated 3/1/19, states, in part: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice . [...]

Inspectors wroteBased on observation, interview and policy review, the facility did not ensure that staff followed standards of practice for infection prevention and hand hygiene during 2 of 3 hand hygiene observations for 2 (R6 and R9) of a total sample of 11 residents. On 12/3/24, R6's cares were not conducted in a manner to prevent cross contamination. Hand hygiene was not completed according to standards of practice. On 12/3/24, R9's cares were not conducted in a manner to prevent cross contamination according to standards of practice. This is evidenced by: The facility's Handwashing/Hand Hygiene Policy, implemented 10/1/23, includes, in part: . Policy: All staff perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Policy Explanation and Compliance Guidelines: 1. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure CNA C received education on resident rights and the responsibilities of a facility to properly care for its residents. CNA C (Certified Nursing Assistant) did not have resident rights education in the last year. This is evidenced by: On 12/16/24, Surveyor reviewed CNA C's annual education. CNA C did not have evidence of completing resident rights education in the last year. On 12/16/24 at 12:20 PM, Surveyor interviewed DON B (Director of Nursing) and NHA A(Nursing Home Administrator) regarding CNA C's annual education. DON B stated they have sent information to the staff regarding completing their annual education and CNA C was one who had not yet completed the required training.

Inspectors wroteBased on interview and record review the facility did not ensure CNA C completed mandatory infection control training which includes the written standards, policies, and procedures for the program. CNA C (Certified Nursing Assistant) did not complete the required annual infection control training in the last year. This is evidenced by: On 12/16/24 Surveyor reviewed CNA C's annual training. CNA C did not complete infection control training. On 12/16/24 at 12:20 PM Surveyor interviewed DON B (Director of Nursing) and NHA A(Nursing Home Administrator) regarding CNA C's annual education. DON B stated they have sent information to the staff regarding completing their annual education and CNA C was one who had not yet completed the required training.

Inspectors wroteBased on interview and record review, the facility did not ensure CNA R received behavioral health training. CNA R (Certified Nursing Assistant) did not have evidence of completing annual behavioral health training in the last year. This is evidenced by: On 12/16/24, Surveyor reviewed CNA R's annual training. There was no evidence CNA R had completed behavioral health training. On 12/16/24 at 12:20 PM, Surveyor interviewed DON B (Director of Nursing) and NHA A(Nursing Home Administrator) regarding CNA R's annual education. DON B stated she was not aware CNA R did not complete behavioral training in the last year.

Inspectors wroteBased on interviews and record review, the facility did not ensure that the services provided by nursing personnel met the professional standards of quality for 1 of 3 residents (R1) reviewed. R1 received an order for bilateral ankle-foot orthotics and the facility did not promptly facilitate the procurement of the orthotics. Evidenced by: The facility's policy titled Physician/ Practitioner Orders dated 3/1/20, states in part .2. For consulting physician/ practitioner orders received in writing or via fax, the nurse in a timely manner will: a. Call the attending physician to verify the order. b. Follow the facility procedures for verbal or telephone orders including noting the order, submitting to pharmacy, and transcribing to medication or treatment administration record . [...]

Inspectors wroteBased on interview and record review, the facility did not ensure each resident received adequate supervision to prevent accidents for 1 of 1 residents (R1) reviewed for suicidal ideations out of a total sample of 3. R1 was noted to have suicidal ideations and was placed on 15-minute checks. The 15-minute check log was incomplete.

Inspectors wroteBased on interview and record review, the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice for 2 (R46 and R32) of 16 residents reviewed for change of condition. R46 is being cited at severity level 3 (actual harm). R32 is being cited at severity level 2 (potential for more than minimal harm). R46 experienced a change of condition on 4/27/24 and received STAT (urgent or rush) orders for ultrasound (diagnostic testing which shows the structures inside the body). The facility failed to notify the physician when the STAT testing was not completed timely. Two days later, while still waiting for testing, the resident was taken to the hospital by family. R46 was admitted to the hospital from [DATE] through 5/2/24 with treatment of IV (intravenous) antibiotics for diagnosis of cellulitis of the left arm. [...]

Inspectors wroteBased on interview and record review, the facility did not establish an Infection Prevention and Control Program (IPCP) that must include, at a minimum, the following elements: An Antibiotic Stewardship Program that includes antibiotic use protocols and a system to monitor antibiotic use for 1 resident (R37) of 9 sampled residents reviewed. The facility did not thoroughly review R37's culture and sensitivities, and therefore, did not recognize R37 had resistance to antibiotics ordered for Urinary Tract Infections (UTIs). The facility did not follow Standards of Practice (SOP) for Antibiotic Stewardship. R37 was treated for a urinary tract infection three times within 6 weeks according to the Culture and Sensitivity (C&S; a lab test that distinguishes the bacteria in the urine and the appropriate antibiotic to use.) R37's C&S indicated R37 had resistance to two different antibiotics. [...]

Inspectors wroteBased on interview and record review, the facility did not provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident. This has the potential to affect all 46 residents residing in the facility. CNA J (Certified Nursing Assistant) worked at the facility as a Medication Technician (MT), administering medications to residents on both units of the facility, from 10/31/2023 through 7/23/2024 without having the certification required of a MT for the state of Wisconsin. The facility did not verify eligibility to work as a MT. R98 had an order for oxycodone as needed; [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that all residents receive food at a palatable temperature. This has the potential to affect all 46 residents residing at the facility. R32 voiced concern that the food is served cold. On Surveyor's test tray, hot food was served cold and cold food was served warm. Evidenced by: The facility policy, Food Safety Requirements, dated 10/1/22, states in part: .It is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state, and local authorities. Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety .d. Holding-staff shall monitor food temperatures while holding for delivery to ensure proper hot and cold holding temperatures are maintained. [...]

Inspectors wroteBased on 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 all 46 residents residing at the facility. Staff reported the facility dishwasher was not reaching correct temperatures a few months ago due to issues with the boiler. Staff was instructed by previous administrator to wash pots and pans 3 times through the dishwasher, even if it was not reaching correct temperature, and that would suffice. Evidence by The facility policy, Dishwasher Temperature, dated 3/1/23, states, in part; .It is the policy of this facility to ensure dishes and utensils are cleaned under sanitary conditions through adequate dishwasher temperatures .1. All items cleaned in the dishwasher will be washed in water that is sufficient to sanitize any and all items. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility does not have a system for preventing, identifying, reporting, investigating, and controlling infections and communicable disease for all residents. This has the potential to affect the census of 46 residents. The staff surveillance lists contain vague symptoms or no symptoms (sx), unknown infections, and no return to work (RTW) dates. All staff call-ins are not on the staff surveillance lists. Staff calling in with symptoms of COVID are not being tested. Resident surveillance lists vague sx or does not include sx. Facility did not have documentation for urinalysis (UAs) and culture and sensitivities (C&S) for all residents. During COVID outbreak the facility did not ensure all staff were fit tested for N95 masks. Facility did not follow their process to ensure all new staff and current staff were fit tested. [...]

Inspectors wroteBased on interview and record review, the facility did not assist in the facilitation of a new Power of Attorney document when one was requested for 1 of 13 Residents (R35) reviewed for Advanced Directives. R35 requested to change her Power of Attorney.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure grievances were documented and thoroughly resolved for 1 (R25) of 13 sampled residents. R25 reported a missing key to staff and the concern was not documented and thoroughly resolved. Evidence by The facility policy, Grievance, dated 3/1/19, states, in part; .The facility will ensure prompt resolution to all grievances, keeping the resident and resident representative informed throughout the investigation and resolution process .G. Any employee of this facility who received a complaint shall immediately attempt to resolve the complaint within their role and authority . R25 was admitted to the facility on [DATE]. On 7/24/24 at 1:00 PM, R25 indicated R25 has a locked drawer on her bedside table. R25 is able to put important items in the locked drawer and has a key that R25 keeps in her purse. [...]

Inspectors wroteBased on interview and record review, the facility did not develop a comprehensive, person-centered care plan for 2 (R32 and R25) of 16 sampled residents reviewed for person-centered care plans. R32's care plan states R32 may yell and have outbursts. R32's care plan does not include person-centered interventions for when R32 becomes anxious and has outbursts towards staff. R25 has an indwelling urinary catheter. R25 is not care planned for an indwelling urinary catheter. Evidence by The facility policy, Comprehensive Care Plans, dated 10/1/22, states, in part; [...]

Inspectors wroteBased on interview and record review, the facility did not ensure each resident received adequate supervision to prevent accidents for 1 of 12 sampled residents (R38). R38 left the facility without his Healthcare Power of Attorney's (HCPOA) notification or permission. R38's friend did not sign R38 per facility policy. This is evidenced by: The facility's policy entitled, Accidents and Supervision, dated 3/1/2023, states in part: . Each resident will receive adequate supervision and assistive device to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2 Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). 4. Monitoring for effectiveness and modifying interventions when necessary . 5. Supervision- Supervision is an intervention and a means of mitigating accident risk. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 1 (R2) of 4 residents reviewed for oxygen use received such respiratory services consistent with professional standards of practice, comprehensive person-centered care plan, and the resident's goals and preferences. R2 has orders to administer oxygen if her oxygen saturation is below 90%. However, the facility continuously administered oxygen and failed to assess R2's oxygen saturation on room air. This led to a failure to properly assess the resident's oxygen level. This is evidenced by: The facility policy entitled, Oxygen Administration, undated, states in part: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the residents' goals and preferences . 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 13 residents (R35) reviewed for pain. R35 had consistent complaints of pain and the facility failed to incorporate non-pharmacological interventions, assess R35's pain accurately, and did not address scheduling her pain medications or make a referral to pain management. This is evidenced by: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 (R2) of 3 out of a sample of 16 reviewed for behavioral health. R2 has a history of bipolar disorder and depression. Staff report R2 has periods of highs and lows related to her diagnosis of bipolar disorder and R2 has made statements of wanting to die. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 3 residents (R35) reviewed out of a total sample of 16 residents. R35 reported that she wanted to change her Power of Attorney (POA) paperwork and was documented to have several behavior concerns. Social Services Director (SSD) did not follow up with R35 to ensure that her needs were met. This is evidenced by: The facility policy titled Social Services dated 3/1/23 states in part, .2. The facility, regardless of size, will provide medically related social services to each resident, to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 3. [...]

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 4 errors out of 37 opportunities that affected 2 out of 3 residents (R1 and R98) included in the medication pass task, which resulted in an error rate of 10.81%. CNA J (Certified Nursing Assistant), acting as a Med Tech, without proper licensure from the State of Wisconsin, crushed 3 of R1's extended-release medications. LPN I (Licensed Practical Nurse) omitted R98's B-12 medication. This is evidenced by: Facility policy entitled, Medication Administration, dated 3/1/20, states in part: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician an in accordance with professional standards of practice . 14. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents are free of significant medication errors for 1 of 3 residents reviewed in the medication pass task (R1). R1 has an order for Metoprolol Succinate (medication used to lower blood pressure by decreasing how strong the heart contracts and lowers the heart rate) and Sinemet CR (Complete Response; medication used to treat symptoms of Parkinson's Disease such as tremors, stiffness, difficulty moving). Both medications are labeled and ordered as extended-release medications and they were both crushed prior to administration to the resident. This is evidenced by: The facility policy entitled, Medication Administration, dated 3/1/2020, states in part: [...]

Inspectors wroteBased on observation and interview, the facility did not provide a bed and mattress of proper size to ensure the safety and convenience of the resident for 1 (R98) of 1 resident reviewed out of a total sample of 12. R98 slept in a recliner, which was too small for her size, for the first 7 nights after admission to the facility, as the facility did not place the bariatric bed and air mattress in R98's room. R98 was admitted to the facility on [DATE] with diagnoses which include, in part: secondary malignant neoplasm (a cancer that has spread from where it first started to another part of the body), neoplasm related pain, morbid obesity due to excess calories, and muscle wasting and atrophy (decrease in size). R98's Minimum Data Set (MDS) dated [DATE] states Brief Interview for Mental Status (BIMS) of 13, indicating R98 is cognitively intact. [...]

Inspectors wroteBased on record review and staff and vendor interview, the Bedrock corporation governing body did not ensure adequate funds were made available to provide for the safe and efficient management of the facility. The failure to maintain current payment status with service providers and vendors has the potential to affect all 45 residents in the facility. The Bedrock corporate governing body failed to maintain current payment status with several service providers and vendors that resulted in delays in getting equipment being fixed, vendors holding facility property after service work and declining to provide additional service work due to (d/t) outstanding bills, vendors refusing to provide further service until payment is received, and the facility aquarium/fish and aviary birds were removed d/t non-payment. [...]

Inspectors wroteExample 2 On 6/27/24 10:00 AM, R7 informed staff he had been Raped by two black women. On 7/10/24 at 4:30 PM, Surveyor asked NHA A (Nursing Home Administrator) if Law Enforcement was contacted when R7 had made the allegation of being raped by two black women. NHA A stated no, Law Enforcement had not been contacted. Surveyor asked NHA A if the allegation had been reported to the State Agency. NHA A stated no, the allegation had not been reported to the State Agency. NHA A stated she had consulted with Corporate Staff and was informed that Law Enforcement did not need to be called and the allegation did not need to be reported to the State Agency. NHA A was to put the information in a soft file. NHA A stated that Law Enforcement should have been contacted when R7 made the allegation and the allegation should have been reported to the State Agency. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect 1 of 10 residents (R13's)right to be free from verbal/mental abuse by a CNA (Certified Nursing Assistant). The facility's current NHA A (Nursing Home Administrator) previously worked as the SW (Social Worker) prior to becoming the current NHA A. While in the role of SW, NHA A verbally reported observing two (2) allegations of abuse to the previous NHA. There is no documentation that the previous NHA documented or investigated the allegations. The previous NHA A did not protect R13 as well as other residents. R13 stated, CNA D (Certified Nursing Assistant) Didn't treat me bad at first, but then it got bad. and He threw me in bed and treated me bad. R13 added, CNA D would call me names. R13 is severely cognitively impaired and has difficulty remembering events. This is evidenced by: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that in response to allegations of abuse, neglect, exploitation, or mistreatment all alleged violations were thoroughly investigated, and that steps were taken to prevent further potential abuse for 3 of 5 residents (R13, R7, and R2) reviewed for abuse. The current NHA A (Nursing Home Administrator) verbally reported two (2) allegations of abuse towards R13 to the previous NHA. The previous NHA did not document the allegations, investigate the incidents, and educate all staff to prevent future reoccurrence. R7 told staff he had been raped by two black women on 6/27/24. The allegation was not fully investigated. R2 told staff that two staff members on the night shift were rough with him and now he has pain in his right shoulder. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision to ensure safety and prevent accidents for 2 of 4 residents (R1, R8) reviewed for resident-to-resident incidents out of a total sample of 13. At the time R1 and R8 were roommates, R1 struck R8 on the head, unprovoked. R1 is able to propel his wheelchair while R8 is in a Broda chair and unable to lift his arms. CNA C (Certified Nursing Assistant) stated to Surveyor she observed R1 attempt to hit R8 prior to the resident-to-resident altercation that took place on 7/8/24. CNA C stated, during the initial altercation she moved R1 away from R8 and she was struck by R1. The facility failed to provide supervision to prevent resident-to-resident incidents from occurring. Evidenced by: The facility's policy and procedure, Abuse/Neglect/Exploitation, undated, documents in part, the following: [...]

Inspectors wroteBased on interviews, record review, document review, and facility policy review, the facility failed to ensure money that belonged to 1 (Resident #2) of 4 sampled residents reviewed for misappropriation of resident property was not misappropriated by the facility.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to complete a fall risk assessment (evaluation) after 1 (Resident #3) of 3 sampled residents reviewed for falls had a fall.

Inspectors wroteBased on interview and record review, the facility failed to provide dependent residents with activities of daily living (ADL) assistance when residents used their call lights to signal for staff to come assist, affecting 4 of 7 sampled residents (R1, R4, R6, and R7). R4 filed a grievance related to his concern of staff deactivating his call light and exiting room without assisting him with ADL cares. R1 filed a grievance regarding putting her call light on, staff entering the room and deactivating her call light, then exiting the room without meeting her ADL needs. R6 voiced concerns related to staff coming in to answer his call light and then leaving his room without providing the needed services to meet his ADL needs. R7 voiced concerns of staff deactivating her call light and leaving the room without meeting her ADL needs and then having to call over and over. This is evidenced by: [...]

Inspectors wroteBased on interview and record review, the facility did not implement their written policies and procedures to prohibit and prevent abuse, neglect, injuries of unknown origin, and misappropriation of resident property by conducting a thorough background check for 1 Certified Nursing Assistant (CNA H) of 1 employee reviewed for background checks. CNA H was hired on 6/27/23. CNA H's National Background Screen Report revealed CNA H was convicted of disorderly conduct on 6/11/2022. The facility did not have additional information from the County Clerk of Courts regarding the disposition of the case and the facts of the incident.

Inspectors wroteBased on interview and record review, the facility did not ensure that alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made, for 1 of 7 Residents (R2) reviewed for abuse. The facility failed to report an abuse allegation timely to the state agency. Evidenced by: The facility policy titled, Abuse/Neglect/Exploitation, with no date, states, in part; V11. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specific timeframes: a. Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. [...]

Inspectors wroteBased on interview and record review, the facility did not have evidence that all alleged violations including injuries of unknown origin (IUO) and allegations of mistreatment are thoroughly investigated for 1 of 7 residents reviewed for abuse (R2). The facility was made aware of an IUO and allegation of mistreatment on 7/17/23. The facility failed to complete a timely investigation into this allegation. Evidenced by: The facility policy titled, Abuse/Neglect/Exploitation, with no date, states, in part; Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .V. Investigation of Alleged Abuse, Neglect and Exploitation A. [...]

Inspectors wroteBased on interviews, record reviews, and facility policy review, it was determined that the facility failed to accurately code a Minimum Data Set (MDS) for 1 (Resident 27) of 24 residents reviewed for MDS accuracy. Specifically, Resident 27 received dialysis treatment while residing in the facility and their admission MDS did not reflect this treatment.

Inspectors wroteExample 2 A review of an admission Record indicated the facility admitted Resident 10 from another nursing home or swing bed with diagnoses that included delusional disorders, Alzheimer's disease, severe dementia with behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident 10 was unable to complete a Brief Interview for Mental Status (BIMS) due to being rarely or never understood. The Staff Assessment for Mental Status indicated the resident had both short-term and long-term memory problems. The MDS indicated the resident required extensive assistance from staff with bed mobility, transfers, dressing, toilet use, and personal hygiene. [...]

Inspectors wroteExample 2 A review of an admission Record indicated the facility admitted Resident 1 with diagnoses that included morbid obesity and acute and chronic respiratory failure with hypoxia (a low blood oxygen level). The quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident 1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS indicated the resident required extensive assistance of two or more staff with bed mobility, transfers, dressing, toilet use, and personal hygiene. The MDS indicated the resident had an indwelling catheter and received oxygen therapy. [...]

Inspectors wroteBased on observations, interviews, record review, and facility policy review, it was determined that the facility failed to assist dependent residents with activities of daily living (ADLs) for 2 (Resident 1 and Resident 34) of 3 residents reviewed for ADL care. Specifically, the facility failed to assist Resident 1 and Resident 34 with removing their facial hair.

Inspectors wroteBased on record review, interviews, and facility policy review, it was determined that the facility failed to ensure the use of an indwelling urinary catheter was medically necessary and physician orders were obtained prior to the use an indwelling urinary catheter for 1 (Resident 1) of 2 residents reviewed for indwelling urinary catheters.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, it was determined that the facility failed to provide respiratory care according to standards of practice for 1 (Resident 1) of 3 residents reviewed for respiratory care. Specifically, the facility failed to have physician's orders for the use of a bi-level positive airway pressure (BiPAP) machine (a machine used for non-invasive ventilation) for Resident 1.

Inspectors wroteBased on observations, record review, interviews, and facility policy review, it was determined that the facility failed to store medications in a secured manner for 2 (Resident 1 and Resident 6) of 3 residents reviewed who had medications in their rooms. Specifically, the facility failed to ensure staff did not leave medications unsecured and unattended in resident rooms.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, it was determined that the facility failed to have an effective infection control program to prevent the spread of infection for 3 (Residents 1, 6, and 22) of 3 residents reviewed for respiratory services. Specifically, the facility failed to clean/store Resident #1's BiPAP (bilevel positive airway pressure) tubing and mask and oxygen tubing after use, and clean/store Resident 6 and Resident 22's CPAP (continuous positive airway pressure) tubing and mask after use.