Waunakee Valley Senior Living

Inspectors wroteBased on interview and record review, the facility did not ensure each resident received the necessary care and services in accordance with professional standards of practice to meet each resident's physical needs for 1 of 2 (R52) sampled residents. R52 had a diagnosis of CHF (Congestive Heart Failure). The facility failed to complete comprehensive assessments for R52 including daily weights, failed to consult the physician regarding R52's weight gain resulting in R52 having a change in condition requiring hospitalization for exacerbation of his CHF.Evidenced by:According to an article from The National Library of Medicine titled Congestive Heart Failure (Nursing) last updated 11/5/23, .Monitoring: Patients with HF require frequent monitoring of vital signs, including oxygen saturation .Frequent assessment and monitoring for symptoms is also indicated. [...]

Inspectors wroteBased on staff interview and record review, the facility did not provide the necessary respiratory care and services 1 of 1 (R52) sampled residents. R52 had orders to use Bilevel Positive Airway Pressure (BIPAP), BIPAP settings were not transcribed, and the facility did not ensure staff had the right settings for usage, did not ensure it was being worn, and did not contact R52's physician after refusals to wear the BIPAP, no evidence of Risk. Vs benefits being provided regarding refusals resulting in R52 being sent to the hospital for exacerbation of acute respiratory failure with hypoxia (low oxygen levels in the body tissues) and hypercarbia (elevated levels of carbon dioxide in the blood). [...]

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 infection. This has the potential to affect the census of 59 residents. The facility does not have monthly Infection Control Rates documented accurately and does not have Infection Control Rates documented by infection type. This is evidenced by:The facility policy Infection Prevention and Control Program (IPCP), dated 11/19/25, includes: The campus has a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases that: a. Covers all residents, staff. c. Follows accepted national standards. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that all residents are clinically appropriate to self-administer medications for 1 of 1 sampled residents (R10) reviewed for self- administration of medications. R10 was observed to have 3 cups of medications left on their bedside table for them to take independently. R10 does not have an assessment for self-administration of medications indicating that they are safe to administer medications independently. Evidenced by:The facility's policy titled Guidelines for Self-Administration of Medications last reviewed on 12/16/25 states in part .Procedure 1. Residents requesting to self-medicate or has self-medication as a part of their plan of care shall be assessed using the observation [Facility's Corporation Name]- Self Administration of Medication withing the electronic health record. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure adequate supervision and safety to prevent accidents from occurring for 1 of 1 resident reviewed (R8) for smoking. R8 began smoking at the facility and the facility was not able to provide documentation indicating that R8 was assessed to be a safe, independent smoker, once the facility was made aware. Evidenced by:The facility's policy titled Smoke Free Environment last reviewed on 11/20/25 does not address steps taken if a resident starts smoking once they are admitted to the facility. R8 was admitted to the facility on [DATE] with diagnoses that include malignant neoplasm of overlapping sites of right breast (breast cancer), secondary malignant neoplasm of bone (bone cancer), major depressive disorder, and bipolar disorder. [...]

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 (R48) reviewed. R48 did not have a PASRR level II completed. This is evidenced by: Per the facility, they do not have a PASRR Policy and Procedure, but they follow the Wisconsin PASRR QRG (Quick Reference Guide) process. Surveyor was also given the Forward Health Update dated November 2023 that the facility references. The Wisconsin PASRR QRG documents the following in verbiage and a flow diagram: What is a PASRR: Preadmission Screening and Resident Review (PASRR) is a federal requirement established to identify individuals with mental illness and/or intellectual developmental disability to ensure appropriate placement in the community or a nursing facility. Purpose: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure residents receive treatment and care in accordance with professional standards of practice when experiencing a change in condition for 2 of 2 residents (R52 and R305) reviewed for quality of care. R52 and R305 has documented nursing assessments completed and signed by Licensed Practical Nurse (LPNs), which are required to be completed or signed off by a Registered Nurse (RN). Evidenced by: Surveyor requested a facility policy outlining RN assessments, facility staff stated they were unable to provide this policy. N9 Wisconsin Nurse Practice Act states, in part: N6.03 Standards of practice for registered nurses. An R.N. shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. [...]

Inspectors wroteBased on interview and record review, the facility did not provide behavioral health services to ensure the highest practicable mental and psychosocial well-being for 1 of 2 residents (R11) reviewed. R11 admitted to the facility with a history of depression. The facility failed to offer R11 services related to this diagnosis even after R11's husband passed away in [DATE]. This is evidenced by: The National Institutes for Health states, in part: .Depression, even severe depression, can be treated. It's important to seek treatment as soon as you begin noticing signs . A doctor can rule out medical possibilities through a physical exam, learning about your health and personal history, and lab tests. If a doctor finds there is no medical condition that is causing the depression, he or she may suggest a psychological evaluation and refer you to a mental health professional . [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents are free of significant medication errors for 1 of 1 out of 14 sampled residents (R52). R52 had an order for abiraterone (used to treat prostate cancer that has spread to other parts of the body) 1000 mg (milligrams) to be administered once a day by mouth. This medication has precise administration instructions, that it needs to be taken with a full glass of water and on an empty stomach. Residents are instructed not to eat anything for at least two hours before and one hour after taking this medication. This medication was administered late on 11/30/24 and 12/1/24. Evidenced by: The facility policy, titled, Medication Administration Times, dated 12/17/24, states, in part: . Purpose: To ensure medication is administered in resident centered fashion and documented in medical record. Procedures . [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure all drugs and biologicals were stored in accordance with currently accepted professional principles. This occurred for 1 of 3 medication carts observed. During the three-day survey, 1 of 3 medication carts was left unattended, unlocked, and out of view of staff. Evidenced by: The facility policy titled Medication Storage in the Facility revised 10/2019 states in part .B. Only licensed nursed, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) are permitted to access medications. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access . On 1/21/25 at 9:18 AM, Surveyor observed the medication cart located on A wing to be sitting in the hallway unlocked. [...]

Inspectors wroteBased on record review and interviews, the facility did not ensure each resident received adequate supervision to prevent accidents from elopements for 1 of 3 residents (R4) reviewed for accidents. R4 was identified as a risk for wandering and has a Wanderguard attached to her walker. R4 eloped from the facility on 10/26/24 and the Wanderguard alarm system did not activate. The facility did not know R4 had left the building until local law enforcement contacted the facility. R4 traveled four (4) blocks and crossed a busy intersection. 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 10/26/24. NHA A (Nursing Home Administrator) was notified of the immediate jeopardy on 10/30/24 at 12:54 PM. The immediate jeopardy was removed on 10/27/24 and corrected on 10/30/24. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure Certified Nursing Assistant (CNA) staff received a performance review at least every 12 months for 5 of 5 staff members selected for review. CNA T was hired on 3/1/23 and has not had an evaluation in the past 12 months. CNA U was hired on 3/1/23 and has not had an evaluation in the past 12 months. CNA S was hired on 3/1/23 and has not had an evaluation in the past 12 months. CNA R was hired on 3/1/23 and has not had an evaluation in the past 12 months. CNA H was hired on 8/17/23 and has not had an evaluation in the past 12 months. Evidenced by: The facility does not have a Policy and Procedure in place for CNA performance evaluations. Example 1 CNA T was hired on 3/1/23 and has not had an evaluation in the past 12 months. CNA T was due for an evaluation on or around 3/1/24. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that all residents receive food at a palatable temperature for 1 of 1 test trays. A test tray was found to outside of acceptable temperature range and not palatable. Evidenced by: The facility policy, Food Production Guidelines, dated 1/24, states, in part; .Procedures 5. Food is served as soon after preparation as possible and is held at the following temperature: Hold food- HOT= 135F or above. Hold food- COLD= 41F or below . On 10/28/24 at 1:20 PM, Surveyor requested to temp the last tray on the meal cart. Meat and noodles temped at 123.8°F, corn temped at 125.8°F and milk 41.7°F. The meat was difficult to chew, and meat and noodles were cold. The corn was cold and milk was warm. On 10/28/24 at 1:30 PM, Director of Food Services J indicated hot foods should be served hot and cold foods served cold. [...]

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 for 1 of 4 residents reviewed (R3). R3 did not receive Acetaminophen, Aspirin, and Lacosamide medications as scheduled on 10 separate days in August 2024. Evidenced by: The facility policy, Preparation and General Guidelines IIA2: Medication Administration-General Guidelines, revised date 11/18, indicates, in part: .B. Administration .2) Medications are administered in accordance with written orders of the prescriber .11) .Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the facility .C. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure each resident receives cares, consistent with professional standards of practice to prevent pressure injuries (PIs) for 2 of 2 residents (R) sampled out of a total sample of 13 (R4 and R6). R4 was admitted on [DATE], without a pressure injury or catheter. Resident was hospitalized on [DATE], returning on [DATE] with a foley catheter in place. The facility failed to ensure interventions to prevent medical device-related pressure injuries were implemented correctly to prevent PI development, failed to complete weekly measurements and assessments, and failed to complete treatments as ordered. R4 subsequently developed a full thickness wound that extended from the tip of the penis where the catheter is placed, through the meatus, and down to the shaft. [...]

Inspectors wroteBased on record review and interview, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, not later than 24 hours if the events that cause the suspicion do not result in serious bodily harm for 4 of 10 sampled residents reviewed (R1, R10, R11 and R7.) According to §483.12(c)(1) of the State Operations Manual; [...]

Inspectors wroteBased on record review and interview, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment were thoroughly investigated for 4 of 10 residents reviewed (R1, R10, R11 and R7). R1 reported to NHA A (Nursing Home Administrator) that CNA E (Certified Nursing Assistant) was rude and yelled at R1. This allegation was not thoroughly investigated. R10 was found to have a black eye. This allegation was not thoroughly investigated. R11 reported to NHA A (Nursing Home Administrator) that staff refused to assist R11 with wiping his bottom when using the toilet. The staff indicated she did not need to wipe R11 was not R11's wife and does not have to do that. This allegation was not thoroughly investigated. R7 reported to staff that she was missing a white ski jacket and a pair of Jordashe jeans. R7 alleged the jacket and jeans were stolen. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure each resident received the necessary care and services in accordance with professional standards of practice to meet each resident's physical needs for 1 (R2) of 4 sampled residents. The facility failed to complete a focused assessment for R2 when he presented with a change in condition on 9/17/24. R2 had reported not feeling well and had a gray emesis the morning of 9/17/24. The nurse took a set of vital signs and did not assess R2 thoroughly. R2 was found in his room that afternoon expired in his bed with black liquid emesis in the bed and on the floor. Evidenced by: The facility policy entitled Notification of Change in Condition, dated 12/31/23, 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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect all 52 residents. The facility was not manually monitoring the internal temperature of their dishwasher. Surveyor observed staff serving expired milk during meal time. Surveyor observed staff working in and around open food with facial hair and without hair restraints. Surveyor observed staff put on a pair of unclean gloves and then use them while preparing food. Surveyor observed opened food, removed from original containers, without an open date, expiration date, or a use by date. Surveyor observed Mighty Shakes to be stored thawed for more than 14 days. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not always serve food that was palatable and served at the right temperature. This has the potential to affect 2 of 13 sampled Residents (R20, R44) and 3 of 3 supplemental residents (R17, R37, R16) residing in the facility, and 1 of 1 test trays. R20, R44, R37, R17, and R16 voiced concerns of their hot meals being served to them at cold and undesirable temperatures. Surveyor performed a test tray, and the results were not palatable. Evidenced by: Facility policy; entitled Hot and Cold Temperature Holding Guideline states in part: .hot food in steam table should be at least 135 or higher degrees Fahrenheit and arrive approximately at greater than or equal to 120 degrees Fahrenheit when the resident is served. This is a guideline as certain foods like hot breads and eggs will not be this hot. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that 1 (R33) of 2 residents reviewed for Activities of Daily Living (ADL) out of a total sample of 13 received the necessary services to maintain good nutrition grooming, personal and oral hygiene. R33 voiced concern of not receiving showers, and morning (AM) and evening (PM) cares. Evidenced by: The facility policy, entitled Nursing ADL (Activities of Daily Living) Documentation Guidelines, 12/31/22, states, in part: . Purpose: To document the type and amount of assistance provided to the resident for activities of daily living. Procedures: 1. Completion of ADL services will be validated through the use of the CARE ASSIST ADL reports . 2. ADL services will be conducted and documented by the CNA each shift at the point of care or as reasonably possible after caret . [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (R40) reviewed for supervision and accidents out of a total sample of 13. R40 has a history of falling and has had multiple falls since admission. R40 was care planned to have dycem in wheelchair and recliner. Surveyor observed R40 in wheelchair with no dycem under her. Evidenced by: The facility policy, entitled Falls Management Program Guidelines, dated 3/16/22, states, in part: . Purpose: (Corporation Name) strives to maintain a hazard free environment, mitigate fall risk factors and implement preventative measures. (Corporation Name) recognizes even the most vigilant efforts may not prevent all falls and injuries Procedures: . 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for 1 of 1 resident (R50) reviewed for nutrition out of a sample of 13 residents. R50 experienced significant weight loss and the facility did not ensure that dietary and physician orders were carried out, monitored, and assessed for effectiveness. The facility did not notify R50's physician when additional weight loss occurred. This resulted in a significant weight loss of 7.26% in less than 1 month.

Inspectors wroteBased on interview and record review, the facility did not ensure that a resident who displays or is diagnosed with a mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder (PTSD), receives appropriate treatment and services to correct the assessed problem or attain the highest practical mental and psychosocial well-being for 1 of 1 resident's reviewed out of 13 sampled residents (R44). R44 voiced concerns with having PTSD (Post Traumatic Stress Disorder) and wished the facility would do more to help him with this. R44's Comprehensive Care Plan does not contain goals, triggers, or interventions related to R44's PTSD. This is evidenced by: Facility policy entitled Trauma Informed Care, includes, in part: . [...]