Wi Veterans Hm Ainsworth Hall

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect more than 4 of the 105 residents residing in the facility. Food items for resident consumption were not appropriately labeled and/or were beyond the discard date. Equipment in the main kitchen and unit 2 kitchenette was not in clean condition and/or covered.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection. This practice had the potential to affect more than 4 of the 105 residents residing in the facility. During two care observations, staff did not adhere to enhanced barrier precautions (EBP) for R8. Hand hygiene was not offered or completed for multiple residents prior to or after dining.

Inspectors wroteBased on observation, resident and staff interview, and record review, the facility did not provide a safe, clean, comfortable, and home-like environment for 1 resident (R) (R97) of 26 sampled residents. The third floor day room, dining room, and hallway contained several missing and broken floor tiles. Staff indicated the missing and broken floor tiles were a potential safety hazard. R97 indicated the tiles were unsightly and should be fixed.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 resident (R) (R22) of 2 residents reviewed for hospitalization received a transfer notice that included the date of the transfer, the reason for the transfer, the location of the transfer, and appeal rights. R22 was transferred to the hospital on 9/23/24 and 11/28/24. R22 was not provided with a written transfer notice on 9/23/24 or 11/28/24. In addition, the Ombudsman was not notified of R22's 9/23/24 hospital transfer.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 resident (R) (R22) of 2 sampled residents received written information of the duration of the facility's bed hold policy, the reserve bed payment policy, and the right to return to the facility. R22 was transferred to the hospital on 9/23/24 and 11/28/24. Neither R22 or R22's Guardian were provided with a written bed hold notice for either transfer.

Inspectors wroteBased on staff interview and record review, the facility did not ensure Minimum Data Set (MDS) assessments were coded correctly for 3 residents (R) (R30, R49, and R1) of 26 sampled residents. R30's MDS assessment, dated 2/26/25, contained diagnoses of long term (current) use of anticoagulant medication and long term (current) use of aspirin; however, R30 was not prescribed anticoagulant medication or aspirin. The MDS assessment also indicated R30 received hypnotic medication; however, R30 was not prescribed hypnotic medication. In addition, MDS assessments, dated 6/5/24, 6/21/23, 4/13/23, and 4/20/22, indicated R30 did not have a Preadmission Screening and Resident Review (PASRR) Level II Screen; however, a PASRR Level II Screen was completed and indicated R30 had a mental illness. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure Preadmission Screening and Resident Review (PASRR) requirements were met for 1 resident (R) (R16) of 7 sampled residents. R16 had a mental illness (MI) diagnosis. R16's PASRR Level I Screen stated No to MI. R16 did not have a PASRR Level II Screen.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a comprehensive care plan to meet psychosocial needs was developed and implemented for 1 resident (R) (R30) of 26 sampled residents. R30 was identified as having a serious mental illness of post-traumatic stress disorder (PTSD). R30 did not have a a care plan or interventions in place to address the diagnoses.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for 2 residents (R) (R22 and R31) of 2 sampled residents. R22 and R31 were known smokers. Staff did not follow R22 and R31's assessments and care plans for safe smoking.

Inspectors wroteBased on staff interview and record review, the facility did not ensure monitoring interventions for adverse reactions to antipsychotic medication were in place for 1 resident (R) (R104) of 6 sampled residents. R104 was prescribed quetiapine (an antipsychotic medication) 50 milligrams (mg) once daily with a start date of 11/22/24. The facility did not ensure an Abnormal Involuntary Movement Scale (AIMS) assessment was completed when R104 started the medication.

Inspectors wroteBased on observation, staff interview and record review, the facility did not ensure kitchen equipment was monitored appropriately to ensure food safety. This practice had the potential to affect all 164 residents residing in the facility. Mechanical warewashing wash, sanitization, and internal surface temperature logs were not consistently completed. Cooking and cooling temperature logs for food cooked in the oven were not consistently completed. Logs that documented parts per million (PPM) of the sanitizing solution in sanitizer buckets and sanitization levels in the 3 compartment sink were not consistently completed.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was prepared and served in a sanitary manner. This practice had the potential to affect all 151 residents. The Warewashing machine (dishwasher) sanitizing rinse did not meet the required minimum temperature of 180 degrees Fahrenheit (F) during observation and per monitoring logs in November and December of 2022. In addition, the internal surface temperature monitoring device did not meet the required 160 degrees F during observation. The kitchen floor was visibly soiled and not cleanable in multiple areas.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain appropriate infection control procedures to ensure residents' clothing, pillows and linens were protected from contamination in the facility's laundry area. This practice had the potential to affect all 151 residents. The floor in the facility's kitchen kettle room was in disrepair and contained numerous divots and areas of missing flooring. The kettle room was located above the facility's clean storage and laundry labeling area. The laundry area contained a plastic bin that collected approximately 37 gallons of liquid per day that drained from the kitchen floor through a membrane in the ceiling that contained hoses and funnels. The plastic bin was located in an area that contained residents' clothing, labeling equipment, spare pillows and linens.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure a safe and sanitary environment for staff. Kitchen floor disrepair caused tripping or injury to at least 4 (Dietary [NAME] (DC)-H, Dietary Aide (DA)-F, Dietary Supervisor (DS)-E, and DC-I) dietary staff and had the potential to be unsafe for 48 dining services staff. DC-H and former DA-F submitted injury reports related to the unsafe state of the kitchen floor. DS-E and DC-I both verbalized tripping on the unsafe kitchen floor.