Wheaton Franciscan Hc - Terrace at St. Francis

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R1) of 4 residents are treated with respect & dignity and recognizes each resident's individuality. At the end of November, the facility was changing resident's beds that were not changed five or six years ago. R1 was approached about changing her bed and said no. R1's bed was changed on 11/25/25. R1 complained to staff about the bed and being in pain. Surveyor did note an increase in her pain scale and use of prn (as needed) Norco 5/325 mg (pain medication) during the time R1 was provided with the new bed. After a few weeks, the facility agreed to change R1's bed back to an older bed and R1's bed was switched back to an older bed on 12/18/25. For the beds to be switched R1's belongings needed to be removed to the hallway. [...]

Inspectors wroteBased on observation, record review and interview, the facility did not ensure a resident wound was comprehensively assessed weekly, along with interventions to promote healing. This was observed with 1 (R4) of 1 resident observed with a skin wound. R4 developed a skin wound requiring a treatment. This wound was not comprehensively assessed weekly to determine progression of healing.

Inspectors wroteBased on interview and record review the facility did not ensure a resident receives care, consistent with professional standards of practice, to prevent pressure injuries and does not develop pressure injuries unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure injuries receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new injuries from developing for 1 of 1 (R2) residents reviewed for pressure injuries. R2 was assessed to be at risk for the development of pressure injuries and developed a facility acquired pressure injury that was not comprehensively assessed until 1 week later when seen by the wound physician, which then documented an unstageable pressure injury due to necrosis. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure 3 (R3, R1, and R6) of 5 Residents received adequate supervision and assistive devices to prevent accidents. *R3 sustained a left femur fracture when CNA-P transferred R3 alone when R3 was to be a two person transfer and the sit-to-stand lost power. During the survey, R3 was observed not have the leg brace on at all times per physician orders, a follow-up x-ray of the left femur was not obtained, and Certified Nursing Assistants (CNA-F and CNA-G) were observed not operating the mechanical lift correctly when transferring R3. *R1's floor mat was not down next to the bed per care plan during the survey process. *R6's fall interventions were not followed for toileting after meals.

Inspectors wroteBased on interview and record review, the facility did not ensure that all written grievance decisions included the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued for 2 of 2 (R2 and R3) residents reviewed for grievances. R2 and R3's grievances were not thoroughly investigated; no corrective action was taken, and a written decision was not issued.

Inspectors wroteBased on record review and interviews, the facility did not ensure 1 (R3) of 1 allegations of neglect were immediately reported to the Administrator and/or Grievance Officer and submitted to the State Survey Agency. *On 8/27/25, Surveyor reviewed the grievance dated 8/27/25 which documents:-Showers have not been completed, with CNA-F documenting multiple refusals while other staff are able to accomplish the task.-One resident reported needing assistance in cleaning up food that had spilled from her bedside table; she stated that CNA-F refused to help her with the cleanup.-Another resident expressed wanting to get up and be ready for therapy, but CNA-F reportedly came, turned off light and left the room, leaving her unattended. The facility did not submit an Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report to the State Survey Agency. [...]

Inspectors wroteBased on record review and interviews, the facility did not ensure 1(R3) of 1 allegations of neglect were thoroughly investigated and submitted to the State Survey Agency.*On 8/27/25, Surveyor reviewed the grievance dated 8/27/25 which documents:-Showers have not been completed, with CNA-F documenting multiple refusals while other staff are able to accomplish the task.-One resident reported needing assistance in cleaning up food that had spilled from her bedside table; she stated that CNA-F refused to help her with the cleanup.-Another resident expressed wanting to get up and be ready for therapy, but CNA-F reportedly came, turned off light and left the room, leaving her unattended. The facility did not submit an Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report to the State Survey Agency. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure residents who are unable to carry out activities of daily living receive the necessary services to maintain good grooming for 1 (R1) of 6 residents reviewed for ADL's (Activity of Daily Living). On 10/28/25 R1 was not provided with or offered oral care, shaving, or brushing/combing R1's hair.

Inspectors wroteBased on interview and record review, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 1 (R1) of 6 Residents. R1's has a right upper extremity PICC (peripherally inserted central catheter). Upon R1's readmission to the facility on [DATE], the PICC line dressing order was incorrectly entered, and facility staff were only changing the transparent portion of the dressing weekly and not the entire dressing per current standards of care.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that residents with a pressure injury or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 2 (R1 & R3) of 4 residents reviewed for pressure injuries. *R1 has multiple pressure injuries which developed prior to the facility's last recertification survey with an exit date of 8/20/25. R1 was hospitalized from [DATE] to 9/11/25. The assessment for R1's left buttocks does not have the correct stage. Registered Nurse/Interim Unit Manager (RN/IUM)-M assessed R1's left buttock as a Stage 2 with granulation tissue. A stage 2 does not have granulation tissue. R1 was hospitalized from [DATE] to 10/3/25. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not ensure 1 (R1) of 2 residents with indwelling urinary catheter received the appropriate care and services. R1 was observed without a stat lock on R1's catheter tubing per physician orders and CNA-J was observed not clean the end of spigot prior to placing the spigot back in the collection bag.

Inspectors wroteBased on observation, interview, and record review the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection for 1 (R3) of 1 Resident.* Staff did not perform hand hygiene before, during, and after transferring R3 with the mechanical lift. Staff did not wipe down the mechanical lift after transferring R3.

Inspectors wroteBased on interview and record review, the facility did not ensure that 1 of 5 Certified Nursing Assistant (CNA) reviewed received registry verification that the individual has met competency evaluation requirements. CNA-L's Wisconsin Nurse Aide Registry certification expired and CNA-L continued working in the facility. This deficient practice has the ability to affect 41 of 41 residents residing at the facility whom have the potential to and or received cares from CNA-L.

Inspectors wroteBased on observation, interview and record review, the facility did not provide pharmaceutical services that assure proper dispensing of medications, did not ensure drug records are in order, or all controlled drugs are maintained and periodically reconciled.*The facility does not have a process for medications that should be returned to the pharmacy for possible reimbursement or otherwise destroyed; and keeping a log of those medications.*The facility did not ensure that controlled medication logs were accurate and reconciled. This deficient practice has to potential to affect 41 of 41 residents residing at the facility whom have the potential to and or receive pharmaceutical services.

Inspectors wroteBased on interview and record review, the facility did not ensure that 4 (R8, R5, R42 and R11) of 6 residents and/or their representative that were reviewed, were provided the risks and benefits for prescribed psychotropic medication. * R8 received an antidepressant and antipsychotic medication with no evidence that the risks and benefits were explained, reviewed or provided. * R5 received an antidepressant medication with no evidence of risks and benefits were explained, reviewed or provided. * R42 received an antidepressant and antipsychotic medication with no evidence of risks and benefits were explained, reviewed or provided. *R11 received an antipsychotic medication with no evidence of risks and benefits were explained, reviewed or provided. The facility's policy and procedure, Psychotropic Medication, dated 6/2025 documents under Section T, Consents for Psychotropic Medications: 1. [...]

Inspectors wroteBased on interview and record review the facility did not ensure 5 (R1, R2, R5, R33, and R44) of 5 residents reviewed for hospitalizations received the proper notice of transfer, reason for transfer, location of transfer, appeal rights, and name and address (including mail and email) with the telephone number of the Office of the State Long-Term Care Ombudsman, were notified of the reason for transfer/discharge & bed hold policy in writing to the resident & their representative and the rate to reserve the residents bed, and there was no documentation that the ombudsman was being notified of hospitalizations. *R1 was transferred to the hospital on 3/20/2025, 5/20/2025, and 6/27/2025. A transfer notice and bed hold rate was not provided in writing to R1 and/ or R1's representative. There is not evidence that the ombudsman was notified of R1's hospitalizations. [...]

Inspectors wroteBased on interviews and record review, the facility did not complete neurological (neuro) checks in accordance with policy and procedure for 5 (R27, R5, R42, R8 and R11) of 5 residents reviewed for falls. *R27 had an unwitnessed fall on 08/10/2025, no neurological checks were completed. *R5 had 5 unwitnessed falls, 2 of the falls had incomplete neurological checks and 1 fall had no neuro checks documented. *R42 had had 4 falls, 2 of the falls had incomplete or missing neurological checks. *R8 had 1 unwitnessed fall with incomplete neurological checks. *R11 had 1 unwitnessed fall with no documented neurological checks completed.

Inspectors wroteBased on record review and interview, the facility did not timely act upon recommendations based on a pharmacist medication regimen review report for 4 (R6, R5, R8 and R42) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on observation and interview the facility did not ensure resident's right to personal privacy and confidentiality of his or her personal and medical records for 1(R9) of 41 residents reviewed.*On 08/19/2025, at 7:23 AM, R9's personally identifiable information (PII) or Personal Health Information (PHI) was observed to be thrown into the regular garbage during medication pass.

Inspectors wroteBased on interview and record review, the facility did not ensure that an alleged violation involving misappropriation was thoroughly investigated for 1 of 1 Facility Reported Incidents reviewed.*The facility could not provide documentation that weekly audits of narcotic medication counts were preformed, following a narcotic discrepancy identified on [DATE].

Inspectors wroteBased on interview and record review, the facility did not ensure for 2 (R11, R6) of 2 residents reviewed for PASARR (Preadmission Screening and Resident Review) screenings had a PASARR level two screening completed after triggering for it on the level one PASARR. *R11 had a completed level 1 PASARR, which indicated a level 2 was needed and the facility did not ensure a level 2 PASARR was completed within the required time frame after the 30-day extension was exceeded. *R6 had a completed level 1 PASARR, which indicated a level 2 was needed and the facility did not ensure a level 2 PASARR was completed after the 30-day extension was exceeded.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure 1 (R8) of 2 residents reviewed whom is at risk for the development of pressure injuries received the necessary care and services for prevention and healing of pressure injuries/wounds.*R8 was at risk for developing pressure injuries. Surveyor had multiple observations R8 without pressure relieving interventions in place on 8/18/25 and 8/19/25.

Inspectors wroteBased on observation, interview and record review the facility did not ensure 3 (R8, R19 & R27) of 4 residents reviewed were free from accidents and hazards as possible. *R8 was observed without fall interventions in place in accordance with their comprehensive care plan on on 8/18/25 & 8/19/25. *R19 sustained an unwitnessed skin tear to their elbow. The facility did not investigate the root cause of R19's unwitnessed skin tear or implement new interventions to prevent further accidents. *R27 sustained a fall. The facility did not implement comprehensive care plan interventions, including therapy services, to prevent future falls and accidents. Findings Include: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure consistent communication for 1 (R2) of 1 resident who receives dialysis services. R2's dialysis communication tools were missing for 5 days of 14 days reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure the medication rate was not 5 percent or greater. This deficient practice was observed in 2 (R32 and R9) of 6 residents receiving medications. The facility medication error rate was 18.52 percent.*R32 was given 15 milliliters (ml) of liquid Potassium Chloride, but is only ordered to receive 3.75ml. R32 received medication through an enteral feeding tube. The Enteral Tube was not flushed prior to administering the medications and was not flushed after administering the medications, until approximately 1 hour later.*R9 was administered Insulin that was past the discard by date.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that a licensed nurse was designated to serve as a charge nurse on each tour of duty. Surveyor reviewed last 30 days of facility nursing schedules and nurse staff postings. Surveyor noted that the facility did not designate a charge nurse for each tour of duty on each daily nursing schedule. This deficient practice has the potential to affect a pattern of all 41 residents residing in the facility.

Inspectors wroteBased on record review, policy review and interviews, the facility failed to ensure that two residents (Resident (R) R2 and R3) out of a total sample of 13, were protected from abuse when, R2 and R3 were observed holding hands and kissing by staff members.

Inspectors wroteBased on record reviews, policy review and interviews, the facility failed to ensure that two residents (Resident (R)2 and R3) out of a total sample of 13 had accurate care plans. This failure increased the risk of the resident's safety and monitoring. Specifically, R2 had a history of sexually inappropriately touching other residents and was observed kissing/holding hands with R3 on 05/02/25.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents received care consistent with professional standards of practice to prevent development of pressure injuries or received care to promote healing and prevent new ulcers from developing for 4 (R4, R16, R13, and R9) of 4 residents reviewed with pressure injuries. *R4 did not have skin assessments completed timely when readmitted to the facility with the development of pressure injuries. Treatments were not initiated when ordered or completed as ordered, and weekly comprehensive assessments of the pressure injuries were not documented. Surveyor observed R4 with a pressure injury to the right buttock that the facility staff was not aware of. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 1 (R24) of 1 resident reviewed for a suprapubic catheter received appropriate treatment and services related to catheter care. * R24 has physician orders in place for catheter care and the Medication Administration Record (MAR) and Treatment Administration Record (TAR) showed many dates care was not documented as provided. R24 has been treated for urinary tract infections (UTIs) four times in the last six months, in addition to the prophylactic antibiotic R24 has physician orders to receive twice daily to prevent UTIs.

Inspectors wroteBased on review of facility policies, record review, observations, and interviews, the facility failed to ensure transmission based precaution (TBP) and/or Enhanced Barrier Precaution (EBP) procedures were consistently followed by staff for six residents (Resident (R)23, R6, R25, R36, R34, and R27); the facility failed to ensure infection prevention procedures related to the cleaning/sanitizing of glucometers were followed for eight residents (R4, R5, R3, R18, R15, R16, R19 and R20) out of a total of 33 residents reviewed in the sample; and the facility failed to ensure the facility's overall program for infection tracking and trending/data analysis procedures were consistently followed. These failures created the potential for increased risk of infection for all residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents with non-pressure wounds received treatment and care in accordance with professional standards for 3 (R7, R16, and R9) of 3 residents reviewed for non-pressure wounds. Additionally, the facility did not ensure residents had emergency medical equipment available to provide treatment and care in accordance with professional standards of practice due to 3 of 3 crash carts not maintained and fully supplied potentially affecting 39 of the 62 residents that elected to be full code status. * R7 developed a non-pressure wound to the lower mid spine on 2/6/2025. A comprehensive assessment was not completed; no wound measurements or descriptors of the wound were documented. R7 was seen by the wound physician on 2/12/2025 when a treatment was ordered to the wound; [...]

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure medications were secured properly for three of three medication carts (first, second and third floor medication carts). This failure placed residents' medication to be at risk for diversion and/or at risk to be taken by cognitively impaired residents.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to ensure residents' physician was notified when the residents were not administered their medications per the physician's order for 7 of 7 residents reviewed for physician notification Resident (R) R10, R18, R19, R23, R22, R21 and R17. This failure placed the residents at risk for unmet treatment needs and the physician notified to address the resident's treatment.

Inspectors wroteBased on record review, interviews, and review of facility procedure, the facility failed to ensure routine bathing services were provided for one resident (R9) of a total of 33 residents reviewed in the sample. This failure created the potential for R9 to experience hygienic complications related to going without care planned bathing for extended periods of time.

Inspectors wroteBased on review of facility policy, record review and interviews, the facility failed to ensure root cause analysis was conducted and an updated care plan put into place after falls were experienced by three residents (R)13, R14 and R17) out of 33 residents reviewed in the sample. This failure created the potential for these resident to continue to experience falls.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to maintain pharmaceutical services by ensuring medications were available to be administered as ordered by their physician to meet their medical needs for nine of nine residents (R)18, R19, R9, R5, R17, R21, R22, R23 and R24 reviewed for medication availability. This failure placed the residents at risk for unmet pharmacological interventions to maintain or improve their medical conditions. [...]

Inspectors wroteBased on review of facility policy, record review, observations and interviews, the facility failed to ensure three residents (R10, R5 and R24) out of a total of 33 residents reviewed in the sample was free from a significant medication error. This failure created the potential for residents to experience negative physical and/or psychosocial effects related to the omission of necessary ordered medication. * R5 had a physician order to receive one 400mg Imatinib tablet (Per Mayoclinic.org Imatinib is used to treat different types of cancer or bone marrow conditions. It prevents or stops the growth of cancer cells.) daily. R5 did not receive Imatinib between 3/19/2025 and 4/1/2025, nine were marked as Med not administered and five administrations were signed out even though the Facility did not have the medication in stock. [...]

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to ensure a trough level result was received timely from their laboratory for one of one resident reviewed for laboratory results (Resident (R) 18.) R18's physician ordered a laboratory trough level be obtained for R18 for the resident to be able to continue antibiotic infusions; however, there was a delay in the laboratory results and the resident missed four antibiotic infusions. This failure placed the resident at risk of the infection worsening.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure the medication error rate was below 5% for 2 residents (R6 and R7) of 2 residents observed receiving medications. The facility medication error rate was 32%. *R6 received a Folic Acid supplement and the order was discontinued on 12/9/24. Five medications were given more than 60 minutes after the scheduled time. *R7 has an order for Fluticasone Propionate, one spray per nostril, two sprays were observed being given in each nostril. A medication to control blood pressure was also given more than an hour after the scheduled time.

Inspectors wroteUncorrected at Revisit Survey Based on observation, interview, and record review the facility did not ensure 2 (R16, R44) of 3 Residents reviewed for pain management, received pain management consistent with professional standards of practice. *R16 did not receive topical pain relief medication as ordered by the physician. R16 did not have complete pain assessments, or evaluation of the effectiveness of pain interventions. *R44 did not have complete pain assessments, or evaluation of the effectiveness of pain interventions.

Inspectors wroteBased on observation, interview, and record review the Facility did not provide pharmaceutical services that assure the accurate dispensing of medications to meet the needs of residents and did not have sufficient detailed records for controlled drugs to enable an accurate reconciliation for 2 (R369, R44) of 4 residents reviewed. *R44's Medication Administration Record (MAR) did not accurately reflect the controlled medication narcotic count sheet. R44's had an order for Protonix to be administered 30 minutes prior to meals, that order was not transcribed to R44's Medication Administration Record, as ordered. *R369's personal glucose monitor was not properly labeled to identify the glucose monitor belonged to R369.

Inspectors wroteBased on interview and record review, the facility did not ensure that based on the comprehensive assessment of a resident, residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 2 (R13 & R25) of 12 residents. * R13 was admitted to the facility on [DATE]. R13's treatments for surgical pin sites didn't start until 3/31/24 and the left heel did not start until 3/30/24. The facility did not follow the treatment recommended by the hospital for the pin sites and the nurse who wrote the order is no longer at the facility. There are no assessments for the left heel after 4/5/24, the left upper thigh after 4/1/24, and there are no assessment for the left ankle pin site. R13 was transferred to the hospital on 5/14/24 after a wound appointment and was admitted with severe sepsis. [...]

Inspectors wrote*) R11 was admitted to the facility on [DATE] and has diagnoses that include type 2 diabetes mellitus, dementia, Alzheimer's, anxiety disorder, major depressive disorder, heart failure, pulmonary fibrosis, chronic kidney disease stage 3, heart failure, altered mental status, weakness, abnormalities of gait and balance, history of pressure injuries to heels, and chronic respiratory failure with hypoxia. R11's quarterly minimum data set (MDS) dated [DATE] indicated R11 had moderately impaired cognition with a Brief Interview of Mental Status (BIMS) score of 12 and the facility assessed R11 needing maximal assistance with 1 staff member for lower body dressing, bathing, and toileting hygiene and supervision for personal hygiene and upper body dressing and extensive assist with 1 staff member for bed mobility to reposition. [...]

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 3 (R29, R25, and R13) of 4 residents. *R29 had an injury of unknown origin of bruising to left eye on 5/2/24. On 5/16/24, R29 had bruising to right eye and right foot. R29 sustained a laceration requiring 2 stitches between the right big toe and second toe and had an acute fracture in the proximal phalanx of the first digit. On 6/3/24, R29 sustained an acute impacted fracture at the distal femur. The facility stated the injuries were by different safety concerns that were not assessed or thoroughly investigated to prevent future injury. *R25 had a fall on 6/30/24 and the intervention of having a reacher accessible was put in place. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored, prepared and served in a sanitary manner. This practice had the potential to affect 47 of 47 Residents residing in the facility. *On 7/15/24 and 7/16/24, Surveyor observed Food Service Associate (FSA)-C not wearing a beard net while preparing plates and trays for Residents in the second floor kitchenette. *On 7/15/24 and 7/16/24, Surveyor observed the facility's low temperature dish machine not reach the minimum required temperature of 120 F and Food Service Aide (FSA)-C, FSA-D, and FSA-E all stated they do not use test strips to test the sanitizer solution concentration (50-100ppm-parts per million sodium solution hypochlorite [chlorine]), thus not ensuring proper sanitation. Findings Include: The facility's policy Sanitation and Infection Prevention/Control; [...]

Inspectors wroteBased on observations, interviews and record review, the facility did not establish and maintain an infection prevention and control program based upon current standards of practice, designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections. This deficient practice has the potential to affect all 47 residents. The facility's Water Management Plan (WMP) was not based on current standards of practice and did not: ~Reflect changes in program members. ~Include the Facility's Infection Preventionist (IP). ~revise WMP control measures after the closure of wing 1 ~have a defined flush program for little used outlets. ~have logs to monitor water temperatures. ~ include eye washing stations and ice machines in risk assessment. ~measure and record residual (free) disinfectant (Chlorine) levels. [...]

Inspectors wroteBased on interview and record review the facility did not ensure quarterly assessments were completed as required for 6 (R27, R5, R44, R29, R25, & R50) of 12 residents reviewed for MDS (minimum data set). R27, R5, R44, R29, R25, & R50 did not have a quarterly MDS assessment completed within 92 days of their last MDS assessment.

Inspectors wrote2.) R42 was originally admitted to the facility on [DATE] and most recently re-admitted on [DATE]. R42's diagnosis include congestive heart failure, type 2 diabetes, unstageable pressure ulcer to left heel, dependence on supplemental oxygen, weakness and acquired absence of right leg below knee. R42's plan of care states that R42 has diseases and conditions which are treated with medications. The goal is medication will be overseen and managed by the nursing and Physician team during the stay. Will remain free from any adverse effects due to medication over the next review period. Surveyor conducted a review of R42's medication regimen and reviewed the monthly pharmacy reviews. Surveyor requested to review the monthly reviews from pharmacy on 7/16/24. A copy of the June, 2024 pharmacy review was provided. The review was not signed or dated. [...]

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R44) of 12 residents was given the opportunity to be a part of their care planning process in regards to their personal belongings.

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R29) of 12 Residents reviewed, notified R29's representative of R29 being transferred to the emergency room for an x-ray on 6/3/24 and the facility did not have consultation with R29's physician when scheduled pain medications were not being administered and the development of R29's stage 1 pressure ulcer to the coccyx. Findings Include: The facility's policy Change in a Resident's Condition or Status for Residents dated 12/2016 and last revised on 2/2022 documents: .Policy Statement Our community shall promptly notify the Resident, his or her health care provider, and representative of changes in the Resident's medical/mental condition and/or status\. Policy Interpretation and Implementation A. The nurse will notify the Resident's Health care provider or physician on call when there has bee a(an): 1. [...]

Inspectors wroteBased on record review and staff interviews, the facility did not ensure 1 (R29) of 1 Residents with an injury of unknown origin was reported to the State Survey Agency. *Bruising to R29's left eye and left breast was noted on 5/2/24. On 5/16/24, bruising to the right eye, right foot, and a laceration between the right great toe and second toe is noted. R29's x ray documents that R29's right great toe is fractured and R29 required 2 stitches between the right great toe and second toe. The facility did not report the injuries of unknown origin from 5/2/24 and 5/16/24. Findings Include: The facility's policy Abuse Investigation and Reporting for Residents dated 9/2017 and last revised on 11/2023 documents: [...]

Inspectors wroteBased on record review and staff interview, the facility did not ensure all allegation involving potential abuse, neglect, and misappropriation of Resident property were thoroughly investigated for 1 (R29) of 4 reported events to the state survey agency. *Bruising to R29's left eye and left breast was noted on 5/2/24. On 5/16/24, bruising to the right eye, right foot, and a laceration between the right great toe and second toe is noted. R29's x ray documents that R29's right great toe is fractured and R29 requires 2 stitches between the right great toe and second toe. The facility did not report the injuries of unknown origin from 5/2/24 and 5/16/24 and a thorough investigation of the injuries was not completed. Findings Include: The facility's policy Abuse Investigation and Reporting for Residents dated 9/2017 and last revised on 11/2023 documents: [...]

Inspectors wroteBased on record review, interviews, facility document review, and review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, it was determined that the facility failed to complete a comprehensive annual Minimum Data Set (MDS) assessment for 2 (R18 and R21) of 12 Residents reviewed for RAI regulatory timeframe's. *R18's Annual MDS was due 5/15/24, and was not completed and submitted until 7/18/24, during the recertification survey. *R21's Annual MDS was due 5/8/24, and was not completed and submitted until 7/15/24, during the recertification survey

Inspectors wroteBased on observation, interview, and record review the facility did not ensure 1 (R315) of 2 residents reviewed with an indwelling catheter received appropriate treatment and were provided dignity. Surveyor had several observations during survey of R315's catheter bag not covered in a privacy bag and was visible from the hallway. R315's care plan was not revised to indicate if R315 did not mind if R315's catheter bag was visible to others.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure the necessary services to provide respiratory care were consistent with professional standards of practice for 1 (R11) of 2 residents reviewed for respiratory care. R11's oxygen tubing was not labeled during survey. On 7/17/2024 R11's oxygen humidification was dry/empty.

Inspectors wroteBased on interview and record review the facility did not ensure that 1 (R29) of 2 Residents reviewed for pain management received pain management consistent with professional standards of practice and Resident choice related to pain management. R29 was admitted to hospice on 4/24/23. R29 did not receive requested and prescribed pain medication as scheduled during a time that R29 had a right great toe fracture and a right distal femur fracture. Findings Include: The facility was unable to provide a policy and procedure in regards to pain management. R29 was admitted to the facility on [DATE] with diagnoses of Heart Failure, Anemia, Unspecified Dementia and Anxiety Disorder. R29 has an activated Health Care Power of Attorney (HCPOA) effective 9/16/2019. R29 has been receiving hospice service since 4/24/23. [...]

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R5) of 5 residents did not receive unnecessary psychotropic medications. R5 has an order for Ativan 0.5 mg every eight hours as needed. There is no stop date and no documented rationale from the physician as to why it is appropriate to extend the PRN (as needed) order past 14 days.

Inspectors wroteBased on interview, observation, and record review, the facility did not assist 1 (R29) of 1 resident reviewed for obtaining routine dental care. R29 has very few teeth, most are black in color and was not offered and did not receive dental services, resulting in being on a mechanically soft altered diet with tube feeding. Findings Include: The facility's policy Dental Services for Residents dated 6/2016 and last revised on 9/2018 documents: .Policy Statement Routine and emergency dental services are available to meet the Resident's oral health services in accordance with the Resident's evaluation and plan of care. Policy Interpretation and Implementation 1. Oral health services are available to meet the Resident's needs. 3. Our community has a contract with a dentist that comes to the community and provides dental services. 4. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not provide special assistive eating equipment for 1 of 1 sampled resident (R40) reviewed for assistive devices. R40 did not receive special assistive devices needed for assistance when consuming meals to maintain or improve their ability to eat or drink independently.

Inspectors wroteBased on interview and record review the Facility did not ensure hospice services were coordinated for 2 (R5 & R29) of 2 residents reviewed for hospice. * Hospice visit notes were not kept in R5's medical record or in R5's hospice binder which was located in the nurses station. * R29's recertification was not complete and there was not list of assigned staff from hospice with contact information. There is not a designated facility liaison with hospice.

Inspectors wroteBased on interview and record review the facility did not ensure pharmaceutical services including accurate acquiring and administering of medications to meet the needs of each Resident for 1 (R8) of 3 Residents reviewed. R8 returned to the facility from the emergency room (ER) on 2/24/24 with a MD (Medical Doctor) order for Ciprofloxacin HCL (an antibiotic medication used to treat infection) to be given 2 times a day for 10 days. R8 did not receive the morning dose of Ciprofloxacin (Cipro) on 2/25/24. On the morning of 2/26/24, the nurse caring for R8 was an agency nurse and did not have access to the Cubex (automated medication dispensing system) where they could have retrieved the necessary medication. R8 did not receive the morning dose of Cipro on 2/26/24.

Inspectors wroteBased on record review and interviews, the facility did not ensure staff followed a resident's plan of care for transfers for 1 (R5) of 3 residents reviewed for transfers. The facility staff did not report or investigate a resident's fall to determine causative factors and did not implement preventative measures for 1 (R2) of 3 residents reviewed with falls. * On 12/11/23, R5 was transferred with 1 staff instead of 2 staff as identified on R5's care plan, and with a Hoyer lift sling that was not the appropriate size, resulting in a fall from the Hoyer lift and death. R5's plan of care was not followed regarding sling size and the need for 2 staff assistance for transfers. The facility's failure to ensure staff followed the resident's plan of care resulted in a fall, injury, and death, and created a finding of immediate jeopardy that began on 12/11/23. [...]

Inspectors wroteBased on interview, and record review the facility did not ensure a resident's primary provider was notified when there was a change of condition for 1 (R2) of 13 residents reviewed for notification of changes. R2's physician was not notified when facility staff assessed R2 as having upper body bruising, +3 edema to bilateral lower extremities with bilateral lower extremity weeping, swollen body, swollen penis, decline in oral intake, fatigued, cloudy urine with sediment, and jaundice in color. Facility staff did not get a clarifying conflicting orders regarding R2's left hip surgical site to determine if R2's non-removable dressing should stay in place or if R2 should receive a treatment as ordered. R2's family requested R2 be transferred to the hospital on [DATE]. [...]

Inspectors wroteBased on interview, and record review the facility did not ensure residents received treatment and care based on a comprehensive assessment and in accordance with professional standards of practice for non-pressure injuries and a change in medical conditions for 1 (R2) of 13 residents reviewed. -R2 had a left hip surgical wound that was not assessed after admission on [DATE], treatments were not routinely completed as ordered, and it became infected and required intravenous antibiotics on 12/17/2023. -R2 had conflicting treatments for a left hip surgical site. Nursing admission documentation states there is a non-removal dressing, but the admission orders document to clean surgical site with normal saline followed by a dry dressing, change daily and as needed. Staff did not clarify which order to follow. [...]

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure residents at risk for pressure injuries received care consistent with professional standards of practice to prevent pressure injuries from developing for 3 (R4, R7, and R10) of 5 residents reviewed for pressure injuries. *R4 developed a Deep Tissue Injury (DTI) to the right outer ankle and a DTI to the right heel on 10/25/2023. The right heel was documented as an Unstageable pressure injury with characteristics of a DTI. Antibiotics were ordered on 10/25/2023 due to the presentation of the right heel pressure injury with potential for osteomyelitis. The right ankle pressure injury was not comprehensively assessed weekly from 10/25/2023 through 11/21/2023. No revision was made to the Care Plan when the pressure injuries were discovered. The Registered Dietician was not informed of the pressure injuries. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure residents who have indwelling catheters were assessed for removal as soon as possible unless clinical conditions demonstrate catheterization is necessary and received appropriate treatment and services to prevent urinary tract infections for 1 (R2) of 2 residents reviewed for incontinence. R2 was admitted to the facility with a Foley catheter. R2's admission paperwork to the facility recommended a urology follow up appointment for R2's Foley catheter. The facility did not arrange a follow up urology appointment and there was no attempt at a trial removal of R2's Foley catheter. On 12/17/2024, R2's family requested R2 be transferred to the hospital for further evaluation. R2 was diagnosed with a Catheter-Associated Urinary Tract Infection (CAUTI). Antibiotics were administered. [...]

Inspectors wroteBased on record review, and interview, the facility did not ensure residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for 1 (R2) of 5 residents reviewed for weights. R2's weight was not being monitored according to facility policy or dietary technician and R2's edema was not consistently monitored to see if edema was getting worse.

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure residents who are fed by enteral means received the appropriate treatment to prevent complications of enteral feeding for 1 (R4) of 2 residents reviewed for receiving enteral feeding. R4 received a bolus tube feeding and the gastrostomy tube (G tube) was not checked for placement prior to the feeding.

Inspectors wroteBased on interview and record the Facility did not ensure 2 (CNA-S and CNA-T) of 5 randomly sampled CNAs (Certified Nursing Assistant), who are currently employed, had documented annual performance evaluations. This deficient practice has the potential to affect all 53 residents residing in the facility. Findings Include: On 1/17/23, CNA-S and CNA-T's performance evaluations were requested. CNA-S was hired 11/15/23 and did not complete any required performance evaluations, such as dementia training and abuse prevention training. CNA-T was hired on 2/4/19 and did not complete any required annual performance evaluations, such as dementia training and abuse prevention training. On 1/17/24, at 11:00 a.m., Surveyor asked Nursing Home Administrator (NHA)-A if there were any more training or in-services conducted because CNA-S and CNA-T did not have their required evaluations completed. [...]

Inspectors wroteBased on observation, resident and staff interview, and record review, the facility did not ensure appropriate and safe administration of medication for 1 Resident (R) (R3) of 10 sampled residents. On 10/3/23, Surveyor observed Certified Nursing Assistant (CNA)-G apply topical Hydrocortisone (a medication used to treat skin conditions) on R3. In addition, R3 kept the Hydrocortisone in a bag on R3's bed. R3 did not have a physician's order for Hydrocortisone.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure it was free of a medication error rate of 5% or greater. During medication administration observations, 22 errors occurred during 26 opportunities which resulted in a 84.6% medication error rate affecting 3 Residents (R) (R6, R7 and R8) of 3 residents observed during medication pass. R6's 8:00 AM medications (8 medications) were administered at 10:16 AM. R7's 8:00 AM medications (9 medications) were administered at 10:23 AM. R8's 8:00 AM medications (5 medications) were administered at 9:59 AM.

Inspectors wroteBased on observation, staff interview, and record review, staff did not perform proper hand hygiene during the provision of cares for 2 Residents (R) (R3 and R1) of 3 residents. On 10/3/23, Certified Nursing Assistant (CNA)-G did not consistently perform hand hygiene during the provision of care for R3. On 10/5/23, CNA-E did not consistently perform hand hygiene during the provision of care for R3. On 10/4/23, CNA-D did not consistently perform hand hygiene during the provision of care for R1.

Inspectors wroteBased on interview, record review, and policy review, it was determined the facility failed to implement their facility policy and procedure to safeguard residents from abuse by monitoring visitation for 1 (R118) of 3 residents who was previously abused by a visitor.

Inspectors wroteBased on record review, interviews, facility document review, and review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, it was determined that the facility failed to complete a comprehensive annual Minimum Data Set (MDS) assessment for 1 (R32) of 22 residents reviewed for RAI regulatory timeframe's.

Inspectors wroteBased on record review, interviews, and review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, it was determined that the facility failed to complete a significant change in status Minimum Data Set (MDS) assessment for 1 (R275) of 22 residents reviewed for RAI regulatory timeframe's.

Inspectors wroteBased on record review, interviews, facility document review, and review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, it was determined that the facility failed to complete quarterly Minimum Data Set (MDS) assessments for 2 (R12 and R47) of 22 residents reviewed for RAI regulatory timeframe's.

Inspectors wroteBased on observations, interview, and record review, the facility failed to provide timely incontinence care and fingernail care for 2 (R8 and R36) of 5 sampled residents reviewed for activities of daily living (ADL) care.

Inspectors wroteBased on observations, record reviews, interviews, and facility policy review, it was determined the facility failed to ensure physician-ordered medications were provided by the pharmacy and available for administration for 2 (R6 and R274) of 7 residents reviewed for medication administration.

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, it was determined the facility failed to maintain a medication error rate of 5% or less for 2 (R6 and R26) of 7 residents observed during medication administration. Observation of medication passes revealed two medication errors out of 26 opportunities, which resulted in a medication error rate of 7.69%.