Sun Prairie Senior Living

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 34 residents who reside in the facility. Surveyor observed cereal spilled on the floor and an open container for storing dry pasta in the kitchen pantry. Surveyor observed milk temperatures to be out of range on room trays being delivered to residents for lunch. Surveyor observed sanitizing solution to test outside of the recommended range for parts per million (ppm) concentration. Surveyor observed male staff to have facial hair and to be working with resident food without hair restraints in place. Surveyor observed a refrigerator for resident snacks to be broken with melted, warm food inside of the refrigerator and freezer. This is evidenced by: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure each resident had a safe, clean, comfortable, and homelike environment or ensure housekeeping provided necessary services to maintain a sanitary, orderly, and comfortable area for 2 of 16 sampled residents (R4 & R44). R4 reported to Surveyor that their divider curtain was soiled and that their carpet had not been vacuumed. R44 reported that their toilet overflows and no one will fix it. Evidenced by: Facility did not provide a policy on housekeeping. Example 1: R4 was admitted to the facility on [DATE] with diagnoses that include end stage renal disease, congestive heart failure, and type 2 diabetes mellitus. R4's most recent Minimum Data Set (MDS) dated [DATE] states that R4 has a Brief Interview of Mental Status (BIMS) of 15 out of 15, indicating that R4 is cognitively intact. [...]

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 2 residents reviewed for grievances (R26). R26's Activated Power of Attorney (APOA) expressed concerns regarding R26 not getting out of bed for activities and that R26 had a broken wheelchair. The facility failed to provide a written resolution to R26's APOA. Evidenced by:The facility policy titled Resident Concern Process last reviewed 12/16/24 states in part .4. The facility staff will follow these basic steps in response to a complaint: [...]

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 (R43) reviewed for abuse. R43 and FM G (Family Member) reported an allegation of abuse and the facility did not submit a report to the State Agency (SA). Evidenced by:The facility's Abuse and Neglect Procedural Guidelines policy, dated 8/29/19, states, in part: Facility has developed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident abuse and neglect. 1. The facility has implemented processes in an effort to provide a comfortable and safe environment. 2. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure it had evidence that an alleged violation was thoroughly investigated for 2 of 16 Residents (R27 and R34) reviewed for abuse. Facility did not thoroughly investigate an allegation of abuse (resident-to-resident) for R27 and R34. Evidenced by: Facility Policy entitled 'Abuse, Neglect and Exploitation Procedural Guidelines, states in part: .The facility has developed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident abuse and neglect. Procedures: The facility has implemented processes in an effort to provide a comfortable and safe environment. The Executive Director (also known as NHA A, Nursing Home Administrator) and Director of Health Services are responsible for the implementation and ongoing monitoring of abuse standards and procedures. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that the assessments must accurately reflect the resident's status for 1 of 16 residents' (R5) Minimum Data Sets (MDS) reviewed for accuracy. R5's MDS dated [DATE] does not have her pressure injury (PI; localized damage to skin and underlying tissue caused by prolonged pressure) coded correctly. This is evidenced by: The Facility does not have a Policy and Procedure for MDS accuracy. The Facility follows the Resident Assessment Instrument (RAI) manual. Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated 10/23, documents the following, in part: .The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR (Code of Federal Regulations) 483.20 (b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident's status . [...]

Inspectors wroteBased on interview and record review, the facility did not follow through with the appropriate steps of the Preadmission Screening and Resident Review (PASRR) process for 1 of 5 residents (R43) reviewed for PASRR screening. R43 did not have a PASRR Level I (1) completed. This is evidenced by: The facility provided the Wisconsin Department of Health Services Forward Health Update, volume 2023-37, dated 11/2023, for their PASRR policy. The Forward Health Update states, in part: Federal regulations.require that all individuals seeking admission to a Medicaid-enrolled nursing facility be screened to determine the presence of a major mental illness and/or developmental disability. Nursing facilities fulfill this requirement by conducting a preadmission Level I screen for anyone who meets the definition of a 'new admission.'. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not ensure that a resident who is unable to carry out activities of daily living (ADLs) receives the necessary services to maintain good nutrition, grooming, personal and oral hygiene for 2 of 5 sampled Residents (R4 & R41). R4 reported that they have only had 1 shower since their admission to the facility. R41 reported that they have only had 1 shower since their admission to the facility. R41 has facial hair that is approximately 1/4- 1/2 long and facility staff has not shaved R41. Evidenced by:The facility does not have a policy for ADLs (Activities of Daily Living). Example 1R4 was admitted to the facility on [DATE] with diagnoses that include end stage renal disease, congestive heart failure, and type 2 diabetes mellitus. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that the resident environment remains as free of accident and hazards as possible for 2 of 4 sampled residents (R27 & R26). Surveyor observed R27's motorized wheelchair (Motorized Assistive Devices) being charged in the conference room. NHA A (Nursing Home Administrator) states the wheelchair should be charged in the Conference Room. Surveyor observed the Conference Room to not have a fire safe door. R26 has an order to be supervised at meals. The facility was not providing supervision with breakfast. Evidenced by The facility did not have a policy for charging electric wheelchair batteries. The facility also did not have a policy for Motorized Assistive Devices. On 3/31/26 at 8:30 AM, Surveyor observed R27's wheelchair battery charging in the conference room while Surveyors were in the conference room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure a resident who requires BiPAP respiratory support was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 of 1 resident (R4) reviewed with BiPAP.R4 was admitted to the facility with an order for BiPAP; the order was never transcribed and R4 has not received the BiPAP since admission. Evidenced by:The facility does not have a policy for respiratory care. R4 was admitted to the facility on [DATE] with diagnoses that include end stage renal disease, congestive heart failure, OSA (Obstructive Sleep Apnea), and type 2 diabetes mellitus. R4's most recent MDS (Minimum Data Set) dated 2/25/26 states that R4 has a BIMS (Brief Interview of Mental Status) of 15 out of 15, indicating that R4 is cognitively intact. [...]

Inspectors wroteBased on interview and record review the facility did not ensure that a resident who requires dialysis receives such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 1 sampled resident (R4) reviewed for dialysis. R4 receives dialysis and the facility staff were not fluent in the emergency plan for a resident bleeding from their dialysis access site. This is evidenced by: The facility's policies titled Pre-Dialysis Patient Assessment and Post-Dialysis Assessment dated 12/1/2022 does not include an emergency plan. According to Clinical Journal of the American Society of Nephrology article titled Diagnosis, Treatment, and Prevention of Hemodialysis Emergencies dated February 2017, .Vascular Access Hemorrhage: [...]

Inspectors wroteBased on observation, 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 for 1 (R33) resident based on the review of medication storage in 2 of 3 medication carts. R33 was given oxycodone after the printed expiration date on the medication card. This is evidenced by:The facility's policy, titled General Guidelines for Administration of Medication, effective 12/1/22, states in part: Purpose: To maintain the safety and comfort of the patient regarding the administration of medication. Procedure:.20. Expiration dates for all medication in inventory are recorded and the inventory must be monitored on a monthly basis. This ensures that medication is replaced prior to the expiration date. [...]

Inspectors wroteBased on observation and interview, the facility did not ensure that all drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles for 2 residents (R5 and R33) based on the review of medication storage in 2 of 3 medication carts. R5's lorazepam tablets were expired. R33's oxycodone tablets were expired. This is evidenced by:The facility's policy, titled Medication Storage, revised on 11/1/22, states in part: .6. SOP (Standard Operating Procedure) Details. E. Inspection of Storage Areas i. The pharmacy must inspect every medication in the pharmacy on a monthly basis for expiration dating, package integrity and storage area cleanliness. ii. Outdated or otherwise unusable medications must be immediately pulled from active inventory and segregated to an area to prevent unintentional use. [...]

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 1 of 1 Resident (R24) observed for wound care and 1 of 1 Resident (R35) on transmission based precautions. IP/WN C (Infection Preventionist / Wound Nurse) had breaches in infection control when IP/WN C did not perform hand hygiene after cleansing R24's wound prior to touching clean dressings. R35's is on contact precautions; staff removed a used cup from R35's room. Evidenced by: The facility's Guideline for Handwashing/Hand Hygiene policy, dated 11/18/25, states, in part: The purpose of this policy is to: [...]

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 of 3 residents (R1). R1's comprehensive care plan does not include approaches for staff to follow for R1's care This is evidenced by: The facility's policy titled Comprehensive Care Plan Guideline, dated 5/22/18, includes the following: Purpose To ensure appropriateness of services and communication that will meet the resident's needs, severity/stability of conditions, impairment, disability, or disease in accordance with state and federal guidelines. Care plan interventions should be reflective of risk area(s) or disease processes that impact the individual resident. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that the resident environment remained as free of accident hazards as possible for 2 of 6 residents (R6 and R5) reviewed. CNA C reported performing solo transfers for residents requiring assist of two staff members. Evidenced by The facility's Resident Transfers policy, dated 12/16/24, states, in part: Overview To ensure the safety of residents and staff when performing mobility/transfer tasks.3. Campuses determine the amount of assistance required for transfers and record this on the Nursing admission Observation, the Care Assist profile, and the Resident Care Plan to provide communication to all staff regarding safe transfers. The facility's Guidelines for Resident Utilizing a Lift policy, dated 12/17/24, states, in part: Purpose To ensure the safety of residents and staff when performing lift transfer tasks.3. [...]

Inspectors wroteBased on record review and interview, the facility did not ensure a Registered Nurse (RN) worked for 8 consecutive hours in a day, 7 days a week. This has the potential to affect all 33 residents (R) residing within the facility. On Wednesday, January 1, 2025, the facility did not have an RN in the building 8 consecutive hours on any of the three shifts. Evidenced by: On 1/8/25 at 9:43 AM, Surveyor reviewed nursing staff schedules and postings from 12/23/24 to 1/6/25. Surveyor observed no RN on the schedule for 1/1/25 and the posting which shows hours worked for nursing staff was filled with zeros for all three shifts under RN column for 1/1/25. On 1/9/25 at 2:40 PM, Surveyor interviewed DON B (Director of Nursing) regarding RN coverage. Surveyor asked DON B if he would expect an RN to be in the building every day for at least 8 consecutive hours; DON B stated yes. [...]

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 33 residents who reside in the facility. Surveyor observed male staff to have facial hair and to be working with resident food without hair restraints in place. The facility did not keep a record of when staff manually monitored the internal temperature of the facility's dishwasher. Surveyor observed food to be in circulation passed the use by date. Surveyor observed dented cans to be in circulation. Surveyor observed food that had been removed from the original packaging to be unlabeled and undated. Evidenced by Example 1 The Food and Drug Administration (FDA) Food Code 2022, includes in part: [...]

Inspectors wroteBased on observation, interview, and record review, the facility has not established an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This has the potential to affect the entire census of 33 residents. The facility was in a COVID-19 outbreak and the facility failed to do contact tracing and complete appropriate testing of residents and staff. The facility is not placing all staff that call in sick on the employee line list. The line list does not include last day worked, or area worked in. Staff was observed not wearing appropriate personal protective equipment (PPE) when administering eye drops to resident (R) R16. Surveyor observed staff providing care for a resident who was in enhanced barrier precautions without proper PPE. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that every resident was treated with dignity and respect when providing activities of daily living (ADLs) for 1 of 12 residents (R13) reviewed for resident rights. R13 indicated to Surveyor that staff had transferred R13 to the dining room for breakfast in her pajamas after she informed them, she preferred not to go to the dining room in her pajamas. The facility did not ensure that R13 was treated with dignity and respect when transferring R13 to breakfast. Evidenced by: The facility's New admission Packet with Resident Rights, undated, states, in part: . Resident Rights: -Resident Rights. The resident has the right to a dignified existence, self-determination . inside and outside the facility . -Respect and dignity. The resident has a right to be treated with respect and dignity . [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure each resident had a safe, clean, comfortable environment or ensured housekeeping provided necessary services to maintain a sanitary, orderly, and comfortable area for 1 out of 33 residents (R18). R18 voiced concern her room does not get cleaned often. R18 pointed out to Surveyor her dresser being dusty, and floor does not get vacuumed. Surveyor observed dusty areas in R18's room. Surveyor observed tiny pieces paper/debris and lint particles on the carpeting. This is evidenced by: The facility's New admission Packet with Resident Rights, undated, states, in part: . Resident Rights: . -Safe environment. The resident has a right to a safe, clean, comfortable, and Homelike environment, including but not limited to receiving treatment and supports for daily living safely . [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that residents with pressure ulcers receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 2 residents (R382) reviewed for pressure injuries. R382 spent approximately 5 hours sitting in a wheelchair without a pressure relieving cushion. An air mattress was inflated and placed onto R382's bed without facility staff having knowledge of the manufacturer's recommendations for amount of air necessary for beneficial use. Evidenced by: Facility's Guidelines for Pressure Prevention policy, dated 12/17/24, states, in part: Purpose: To maintain good skin integrity and avoid development of pressure ulcers. Procedures: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure each resident (R) received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents reviewed for falls (R16). R16 fell at the facility on 12/27/24 and staff failed to document details related to R16's fall, failed to update R16's medical doctor and failed to update R16's activated power of attorney failed to initiate neuro checks according to facility policy, and failed to record a Registered Nurse Assessment post fall. The facility did not identify root causes of R16's falls and did not implement individualized interventions. [...]

Inspectors wroteBased on 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 2 residents (R182) reviewed for pain. R182 was admitted to the facility with a right humerus fracture (a break in the upper arm bone). The facility failed to obtain R182's ordered narcotics and obtain a new order when R182 began refusing the acetaminophen, resulting in R182 having continued pain. Evidenced by: The facility policy titled Guidelines for Pain Observation and Management last reviewed on 12/17/24 states in part, .1. Observation of resident pain will be completed as part of the admission Observation and Data Collection form. a. Review other system observations for pain indicators. [...]

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 3 errors in 25 opportunities that affected 3 out of 11 residents (R11, R14, & R5) included in the medication pass task, which resulted in an error rate of 16%. R11 received her Tylenol that was ordered for 7:00 AM at 8:42 AM resulting in a timing error. R14 received Vitamin B-12 and Vitamin D3 that was ordered for 7:00 AM at 8:51 AM resulting in a timing error. R5 received her short acting insulin and did not receive her meal within the required 15 minutes resulting in a medication error. Evidenced by: Facility policy entitled Medication Administration- General Guidelines, dated 11/18, states, in part: . [...]

Inspectors wroteBased on record review and interview, the facility did not offer each resident influenza immunizations, and the resident's medical record does not include documentation the resident either received, refused, or was educated on the risks and benefits of the influenza immunization for 1 of 5 residents (R16) reviewed for immunizations. R16 refused the influenza vaccine upon admission and was not offered the vaccine during the current flu season. Evidenced by: The facility's policy titled Guidelines for Influenza, Pneumococcal, & COVID-19 Immunizations last reviewed on 12/17/24 states in part, .4. Each resident/ responsible party will be provided annually with information regarding the risk and benefits of influenza vaccine and receive the immunization per their request, unless medically contraindicated. 5. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that 1 (R19) of 12 residents out of a total sample of 14 residents received assessment and appropriate and timely medical care with a change in medical condition. R19 had an unwitnessed fall on 10/21/23 at 6:15 PM. R19 experienced change of condition and the facility failed to properly assess range of motion (ROM)/change in ambulation ability on 10/21/23. The facility failed to identify change in resident when resident experienced the inability to move right leg and increased weakness on 10/21/23 and the morning of 10/22/23. R19 went to emergency room on [DATE] at 11:00 AM and was diagnosed with a right hip fracture. Evidenced by The facility policy titled, Notification of Change in Condition, with a revision date of 12/31/22, states, in part; .PURPOSE to ensure appropriate individuals are notified of change in condition. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that the food was stored, distributed, and served in accordance with professional standards for food service safety. This has the potential to affect all 23 residents residing at the facility. Surveyor observed dirty hood vent and equipment, undated, unlabeled, and expired foods and beverages, and opportunity for cross contamination. The facility failed to ensure adequate dinnerware sanitization and document temperature of refrigerator and freezer.

Inspectors wroteBased on interview and record review, the facility did not ensure the mandatory submission of staffing data based on payroll data was completed. This has the ability to affect all 23 residents residing in the facility. Payroll Based Journal (PBJ) data was not submitted for the 3rd quarter of 2022.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents with complications related to range of motion receives appropriate services and assistance to prevent further complications related to decrease in range of motion, for 1 of 12 resident's (R5) reviewed for ROM. The facility did not ensure R5's Physicians orders and care planed functional maintenance program was being followed.

Inspectors wroteBased on interview and record review, the facility did not off each resident an influenza immunization. This affected 1 of 5 residents (R21) reviewed for immunizations of a total sample of 14. R21 did not receive influenza immunization. This is evidenced by: The Facilities Policy and Procedure entitled Guidelines for Influenza, Pneumococcal, & COVID-19 Immunizations dated 7/12/23 documents, in part: .1. Upon admission each resident/resident representative will be provided with information regarding the risk and benefits of influenza, pneumococcal, and COVID-19 immunization .4. Each resident/resident representative party will be provided annually with information regarding the risk and benefits of influenza vaccine and receive the immunization per their request, unless medically contraindicated .10. [...]