The Alverno Health Care Facility

Inspectors wroteBased on review of the Centers for Medicare & Medicaid Services Certification and Survey Provider Enhanced Report (CASPER), review of the facility Quality Assurance Performance Improvement (QAPI) plan, and staff interviews the facility failed to implement quality assurance practices to prevent the repeat of citations of deficient practices in the area of infection control and pharmacy services. The facility reported a census of 87 residents.

Inspectors wroteBased on observations, record review, staff interviews and facility policy review, The facility failed to ensure staff followed contact precautions for 1 of 1 residents (Resident #103) on contact precautions, failed to utilize Enhanced Barrier Precautions correctly effecting 2 of 2 residents (Resident #16 and Resident #52), failed to follow infection control practices to minimize the potential to spread COVID in the Memory Care unit, and failed to cover wet laundry during transport to an operational dryer. The facility reported a census of 87 residents.

Inspectors wroteBased on clinical record review, review of facility policy, resident and staff interview, the facility failed to determine if a resident was clinically appropriate to self-administer medications for 1 of 1 residents sampled (Resident #33). The facility reported a census of 87 residents.

Inspectors wroteBased on clinical record review, review of facility policy, resident and staff interview, the facility failed to maintain clear, concise determination of a resident's advance directive choice related to receiving cardiopulmonary resuscitation for 1 of 1 residents sampled (Resident #33). The facility reported a census of 87 residents.

Inspectors wroteBased on observation, clinical record review and staff interview the facility failed ensure the secure location of the keys to the double locked compartment to ensure the safety of narcotic medications as required by law to prevent potential loss and/or diversion. The facility reported a census of 87 residents. Review of the facility investigation for the 11/10/25 reported incident regarding a medication discrepancy found on 11/9/25 revealed Staff R, Registered Nurse (RN) was scheduled on first floor. Staff R delivered medications from the pharmacy to the second floor. After delivering medications Staff R, RN proceeded to enter the second floor medication room and was witnessed by at least 3 other employees to be in the medication cart, the nurses office and medication room that she was not assigned to. [...]

Inspectors wroteBased on clinical record review, policy review, and staff and physician interviews, the facility failed to assess a resident's vital signs and neurological status at regular intervals after an unwitnessed fall for 1 of 3 resident records reviewed for post fall assessments (Resident #5). The resident was found unresponsive to painful stimulus 6 hours after the fall that required transfer and assessment at the hospital. The facility reported a census of 85 residents.

Inspectors wroteBased on clinical record review, policy review, and staff interviews, the facility failed to complete a root-cause analysis for three falls in a 4 day period, that started within 48 hours of a resident's admission to the facility, for 1 of 3 residents reviewed for resident safety/nursing supervision (Resident #5). The facility reported a census of 85 residents.

Inspectors wroteBased on observation, clinical record review, pharmacy record review, pharmacy consultant interview, and staff interview, the facility failed to have safeguards and systems in place to control, account for, and periodically reconcile controlled medication in order to prevent potential loss and/or diversion for 1 of 4 residents (Resident #8) reviewed for controlled substance reconciliation. The facility reported a census of 85 residents.

Inspectors wroteBased on observation, clinical record review, pharmacy record review, facility policy review and staff interviews, the facility failed to prevent unauthorized access to the keys to Schedule II narcotic medications stored in a double locked compartment as required by law to prevent potential loss and/or diversion for 1 of 9 residents (Resident #4) reviewed for controlled medication storage and access. The facility reported a census of 85 residents.

Inspectors wroteBased on clinical record review, facility policy review and staff interview the facility failed to follow up on pharmacy recommendations for the monitoring of medications and gradual dose reduction for 4 out of 5 residents reviewed. (Residents #2, #20, #45, and #60) The facility identified a census of 91 residents.

Inspectors wroteBased on observation, food storage guidelines, and staff interviews the facility failed to label food, indicate the opened/prepared date of an item, and dispose of food kept beyond the expiration date in an effort to prevent prevent food borne illness. The facility reported a census of 91 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident's transfer from chair to bed was completed in a safe manner for 1 of 3 residents observed for transfers (Resident #12). The facility reported a census of 91 residents.

Inspectors wroteBased on observations, clinical record review, and staff interviews, the facility failed to ensure an insulin pens was primed and the medication administered prior to the expiration date for 1 of 2 residents reviewed for insulin administration (Resident #45). The facility reported a census of 91 residents.

Inspectors wroteBased on observations, clinical record review, nurse competency checklist and staff interviews, the facility failed to perform the infection control practices of hand hygiene and cleaning the hub of an insulin pen prior to the attachment of the needle for 2 of 2 residents reviewed for insulin administration (Resident #11 and Resident #45). The facility reported a census of 91 residents.

Inspectors wroteBased on observation, resident interviews, staff interviews, and policy review the facility failed to respond to resident's needs within the required fifteen minute time frame when residents activated their call lights. Call light observations revealed 5 of 11 call lights exceeded the fifteen minute response time (Resident #19, #4, #5, #15, and #61). The facility reported a census of 88 residents.

Inspectors wroteBased on observation, interviews, and policy review the facility failed to ensure medications were disposed of in a safe, secure manner. Facility staff missed the medication cup with two pills and disposed of them in the garbage can on the medication cart, giving 18 residents on the floor access to unsecured medication. The facility reported a census of 88 residents.

Inspectors wroteBased on record review, observations, and staff interviews the facility failed to ensure a hand-washing sink was present in 3 of 3 laundry rooms that contained washers and dryers that staff used to transfer presorted clothes from laundry hampers into the washer. The facility reported a census of 88 residents.

Inspectors wroteBased on clinical record review, staff interview, resident interview, and resident handbook review, the facility failed to implement their policy when the Administrator implemented a grievance resolution of assisting the resident to organize his money and gift cards in a locked drawer in the resident's room in regards to missing property and possible theft for 1 of 1 resident reviewed (Resident #43). The facility reported a census of 88 residents.

Inspectors wroteBased on record review and staff interviews the facility failed to ensure 1 of 1 residents newly admitted to the facility Preadmission Screening and Resident Review (PASRR) accurately reflected his admitting diagnosis (Resident #44). The facility reported a census of 88 residents.

Inspectors wroteBased on record review and staff interview the facility failed to ensure 1 of 1 residents as needed (PRN) anti-psychotic medication was reviewed by his Primary Care Provider (PCP) every 14 days or discontinued (Resident #45). The facility reported a census of 88 residents.

Inspectors wroteBased on observations, Kitchen Cleaning Schedule review, and staff interviews, the facility failed to properly maintain a clean kitchen for food preparation, storage and serving to prevent food borne illness. The facility reported a census of 81 residents. Findings Include: On 1/29/24 at 10:54 AM during tour of the kitchen, the following areas were noted not to be clean: a. An ice machine on the right side of the entrance to the kitchen had large amounts of white build up on the drain tray. b. The floor horizontal to the pots and pans dish machine next to the stove and food prep area all had large amounts of debris and brown/black thick substance under and around the mats. c. The refrigerators labeled #5, #6, #7, #8 and #9 noted with a white substance running down the front of them. d. [...]