Careview Health And Rehab Of Minocqua

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not ensure that resident funds were returned to the Power of Attorney, family, or estate within 30 days of discharge or death for 1 of 3 residents reviewed for conveyance of resident funds. R6 was admitted under Hospice Private Pay, and the facility received an $8,500 check at admission. R6 discharged from the facility to home under the care of an outside Hospice entity on 04/08/26. A complaint was later received from the spouse on 06/22/26 regarding delay in receiving reimbursement for the one-day admission after the deposit had been provided. During interview on 07/09/26, the NHA stated that reimbursement requests are sent to corporate accounts payable, that the billing cycle can take 30 to 60 days, and that a check was cut on 06/12/26 and cashed on 06/22/26. The NHA stated the reason for the delay was unknown, but noted changes in accounts payable personnel and the facility's business office manager during that period.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure a resident’s drug regimen was free from unnecessary drugs and appropriately monitored, specifically related to warfarin therapy. The resident had chronic atrial fibrillation and was discharged from the hospital on warfarin 2.5 mg orally once daily with explicit instructions for repeat INR testing and follow-up with an anticoagulation clinic (ACC). At discharge, the resident’s INR had been supratherapeutic at 5.6, warfarin was held, and then the INR decreased to 3.2 prior to discharge, with recommendations for repeat INR testing on specified dates. The facility did not correctly transcribe the hospital’s warfarin order; instead, staff entered an order for 2.5 mg (two tablets) on Mondays and Fridays and 2.5 mg (one tablet) on the remaining days, effectively giving extra warfarin doses on Mondays and Fridays based on the resident’s previous regimen rather than the new discharge instructions. The facility also failed to implement and carry out INR monitoring orders and communication with the ACC as indicated in the hospital discharge summary and as described by facility practitioners. Although the discharge summary directed ongoing INR monitoring and follow-up with the ACC, no INR orders were transcribed into the resident’s record, and no INR tests were obtained during the resident’s stay. Progress notes from the NP and PA referenced that nursing should contact the ACC for warfarin dosing and INR monitoring, and the NP documented being assured by the DON that nursing had reached out to the ACC. However, there was no documentation of ACC orders, INR results, or any INR/warfarin log entries for this resident during the relevant period. An order for PT/INR every Monday and Thursday was later entered with a start date backdated to the admission date, but this was created after the resident had already been transferred to the hospital. During this time, the resident was also receiving medications known to interact with warfarin and potentially increase INR, including vancomycin for C. difficile infection and prednisone for cough. There was no documentation that staff notified the ACC of the initiation of prednisone or that monitoring was increased in response to these additional medications. Nursing staff reported that they did not obtain any INRs for the resident and that there were no active INR orders in the electronic record while the resident was present. Ultimately, an RN found the resident with a large amount of blood in the stool and on an incontinent pad, with additional blood expelled from the rectum when the resident was repositioned and transferred to a stretcher. The resident was sent to the emergency room and was found to have a critical INR of 9.3, requiring administration of vitamin K and Kcentra to reverse the anticoagulation and prevent further bleeding.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, particularly related to critical medications such as antirejection agents, anticonvulsants, and anticoagulants. One resident with a history of kidney and pancreatic transplants (R5) did not receive prescribed antirejection medications Mycophenolate Mofetil and Tacrolimus for extended periods. The MAR showed Mycophenolate Mofetil was not given or held for 37 days, and Tacrolimus was not given or held for several days. Progress notes documented that Mycophenolate Mofetil was not in the facility, required prior authorization, and was on hold per the nurse practitioner, with repeated entries that it was ordered but not available. For Tacrolimus, notes indicated it was ordered, held per the nurse practitioner, or ordered but not yet delivered. There was no medication error report found for the missed Tacrolimus doses. The pharmacy’s business assistant reported that the facility first requested refills for R5’s antirejection medications on a specific date and that the pharmacy repeatedly sent forms requesting transplant-related information and clarification on payment responsibility. The pharmacy documented multiple attempts over several days to obtain the needed information from the facility, with no response, leading the pharmacy to place the medication request on hold (“profiled”) until the facility reinitiated contact about a month later. The medications were eventually dispensed only after the DON agreed the facility would cover the cost pending insurance information. Interviews with the pharmacist and pharmacy staff emphasized that the facility commonly failed to respond in a timely manner to pharmacy requests. The DON later stated that staff should have notified the provider immediately about the interruption of antirejection medications, acknowledged awareness of the resident’s concern about not receiving these medications, and initially attributed the problem to the pharmacy not sending medications. The DON could not produce documentation showing that the requested pharmacy form had been completed prior to late March. R5 and a family member reported that the resident repeatedly asked the facility to refill antirejection medications and became anxious, afraid, and depressed when the medications were not provided for over a month. R5 stated that the transplant physician had instructed that antirejection medications were lifelong and should not be missed, and described daily feelings of anxiety, fear, and depression due to the prolonged lack of medication. The family member reported not being contacted for weeks and observed that the resident had become increasingly anxious, depressed, withdrawn, and preferred to stay in the room, feeling like a nuisance to staff. Facility staff, including the ADON, acknowledged that the resident and spouse were upset and concerned about transplant rejection and that the lack of antirejection medications could be contributing to the resident’s seclusion. Another resident (R3) with a history including end-stage renal disease, kidney transplant, and seizure prophylaxis was ordered Lacosamide 100 mg twice daily as an anticonvulsant. The MAR showed that Lacosamide was not given or held for four consecutive days. Progress notes documented that the medication was not available, ordered but not received, pending delivery, and that pharmacy had been called for a refill with an e-script request sent to the provider. The DON stated not knowing the resident was on an anticonvulsant and agreed the seizure medication should not have been missed, while also stating a belief that the missed doses did not contribute to the resident’s subsequent hospitalization. The nurse practitioner reported being unaware that the anticonvulsant had been missed for four days and stated that anticonvulsant medications should not be stopped abruptly. A third resident (R2) with chronic atrial fibrillation and other cardiac conditions was discharged from the hospital with instructions to take warfarin 2.5 mg orally once daily and to have repeat INR monitoring. The hospital discharge summary noted that the resident’s INR had been supratherapeutic on admission, warfarin had been held, and the INR had decreased prior to discharge, with specific follow-up INR dates recommended. At the facility, however, the medication orders documented that the resident was to receive warfarin 5 mg (two 2.5 mg tablets) on Mondays and Fridays and 2.5 mg on the remaining days, which did not match the hospital discharge instructions for a consistent 2.5 mg daily dose. A fourth resident (R9) experienced a warfarin dosing error when the facility failed to discontinue a previous warfarin order, resulting in the resident receiving a double dose. The report notes that R5’s case was cited at severity level 3 (actual harm) due to psychosocial harm manifested by ongoing anxiety, fear, and depression related to the prolonged lack of antirejection medications. The other residents’ cases (R2, R3, and R9) were cited at severity level 2 for potential for more than minimal harm. Across these examples, the facility did not follow its own medication ordering and receipt policy, did not ensure timely communication and follow-through with the pharmacy, did not consistently notify the provider of prolonged medication unavailability, and did not adhere to hospital discharge orders for warfarin dosing, resulting in significant medication errors and missed critical therapies.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to protect a resident from verbal abuse by another resident and to investigate and document a resident-to-resident altercation associated with a fall. Facility policy states that residents have the right to be free from abuse, including verbal abuse, and that suspected abuse incidents must be documented and reported to the Administrator within specified time frames, with an immediate investigation and written findings. The policy copy provided to the surveyor contained blanks where required reporting time frames should have been specified. The State Operations Manual Appendix PP requires facilities to treat resident-to-resident altercations as potential abuse, investigate all incidents, assess residents for injuries, develop care plans to prevent recurrence, and report incidents. One resident (R11), admitted with diagnoses including alcohol abuse with intoxication, atrial fibrillation, COPD, and sepsis, had an MDS showing clear speech, moderate cognitive impairment (BIMS 12/15), and no documented behaviors. R11’s care plan, initiated in February and last revised in March, contained no behavior or resident-to-resident altercation interventions. Another resident (R12), admitted with age-related cognitive decline, bladder cancer, type 2 diabetes, prosthetic heart valve, and chronic kidney disease, had an MDS showing clear speech, moderate cognitive impairment (BIMS 8/15), and no documented behaviors, but the care plan identified potential for physical aggression related to poor impulse control and directed staff to analyze triggers and intervene early when the resident became agitated. On the date of the incident, staff reported that R11 was heard yelling at R12 in the dining room, telling him to “shut up” and threatening that if he did not shut up, R11 would help him shut up. During this time, R12 experienced a fall in the dining room that was not witnessed. Multiple staff interviews confirmed awareness of the yelling and altercation but revealed a lack of documentation and formal investigation. A CNA reported hearing R11 yell threatening statements at R12 and stated that R12 fell while R11 was yelling, but there was no documentation in either resident’s medical record about the altercation. The LPN on duty stated that everyone heard the residents yelling, that she was told about the fall, and that staff discussed hearing them yell at each other, but she did not recall the exact words and was unaware of any care-planned interventions to monitor or separate the residents. The Social Services Director acknowledged hearing about the incident, stated that R12 can be loud and repetitive and that R11 gets irritated and yells at him to shut up, and confirmed that the fall was documented on the same date as the yelling. The DON recalled being aware that the residents were yelling and that R12 fell that day, but there was no contemporaneous investigation of the verbal altercation as potential abuse. The Administrator stated that he only completes written investigations if an incident is reportable, did not conduct a formal investigation of the yelling incident, had no documentation of what was said, and acknowledged that staff heard the altercation in the dining room. Review of the fall report showed no mention of the yelling or altercation, and there was no evidence of an abuse investigation or care plan revisions related to the resident-to-resident verbal abuse. Title: Failure to Protect Resident From Verbal Abuse and Investigate Resident-to-Resident Altercation ShortSummary: Two moderately cognitively impaired residents with multiple comorbidities, including alcohol abuse, COPD, age-related cognitive decline, and cancer, were involved in a dining room incident where one resident loudly yelled at and threatened the other to “shut up,” during which the threatened resident experienced an unwitnessed fall. Staff, including a CNA, an LPN, the SSD, the DON, and the NHA, acknowledged awareness of the yelling and the fall, but there was no documentation in either resident’s record of the altercation, no formal abuse investigation, and no behavior or separation interventions care planned for the resident making threats, despite facility policies requiring prompt reporting, documentation, and investigation of suspected abuse and federal guidance treating resident-to-resident altercations as potential abuse.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to thoroughly investigate an allegation of verbal abuse between two residents and to implement protective interventions. On 3/29/26, staff became aware of an altercation in the dining room in which one resident (R11) yelled at another resident (R12), telling R12 to shut up and stating that if R12 did not shut up, R11 would help shut R12 up. A CNA reported hearing this exchange, and the DON recalled being informed that the residents were yelling at each other in the dining room, although she was unsure of the exact date. The facility’s own policies define verbal abuse as the use of oral, written, or gestured language that includes disparaging or derogatory terms and require prompt reporting and investigation of suspected abuse, including completion of documentation forms, witness statements, and notification of the Administrator and other entities. Despite these requirements, there was no formal investigation initiated at the time of the incident between R11 and R12. The NHA acknowledged that there was no formal investigation and stated that he only completes paper documentation if an incident is considered reportable, and that he does not always document situations he looks into if everyone appears fine. He also stated that he would report resident-to-resident physical altercations, and verbal altercations only if emotional or mental distress is noted, and confirmed there was no documentation of what was actually said during the altercation. Review of the medical records and care plans for both residents showed no documentation of the altercation and no indication that an abuse investigation had been conducted. Interviews with staff further confirmed the lack of appropriate follow-through. The CNA who heard the incident described R11 yelling at R12 to shut up or R11 would help shut R12 up. The SSD reported being aware that R11 had yelled at R12 to shut up and stated she would not be surprised if R11 had made the threatening statement reported by the CNA. The DON stated that in cases of resident-to-resident altercations, the facility’s practice is to separate the residents and notify the NHA, who would conduct the investigation, but in this case no such documented investigation occurred. There were also no care plan interventions implemented to protect R11 from further verbal abuse by R12 or to address the ongoing pattern of R11 becoming irritated and yelling at R12, despite the facility being aware of these interactions and the requirement under federal guidance to investigate resident-to-resident altercations as potential abuse and to develop care plans to prevent recurrence.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A resident with multiple complex medical conditions, including kidney and pancreatic transplant status, immunodeficiency due to drugs, type 1 diabetes with complications, dementia, Charcot joints, left foot drop, and osteoporosis, was identified as being at risk for falls and requiring substantial/maximal assistance with transfers, dressing, and toileting. The resident’s MDS showed intact cognition, and the ADL care plan documented transfer assistance as “weight bearing assistance,” without specifying use of a Hoyer lift. The fall care plan included interventions such as Dycem in the wheelchair and transfer to bed for naps, and PT notes from January through mid-April documented that the resident required a Hoyer lift with two staff for transfers. A PT communication sheet also indicated the resident was dependent on two staff with a Hoyer mechanical lift. Despite these PT directives, staff continued to transfer the resident using a mechanical sit-to-stand lift and later with a two-person stand-pivot transfer, which conflicted with PT’s determination that the resident was not appropriate for sit-to-stand and could not safely bear weight on the lower extremities. The resident reported to the surveyor that they had previously been transferred with a sit-to-stand lift and then by two staff performing a stand-pivot transfer, and that this caused fear and led them to often refuse to get out of bed. During observation, the surveyor saw two slings in the resident’s room, one for a sit-to-stand lift that was reportedly no longer in use and one for a Hoyer lift, while a CNA stated the resident currently transferred with heavy assist of two, sometimes stand-pivot, and had previously used a sit-to-stand lift. Interviews with the ADON, PT staff, PTA, and DON revealed that therapy staff consistently considered the resident to be a Hoyer-lift transfer only and that the resident had “always” been a Hoyer lift case. The ADON acknowledged uncertainty about when PT assessed and discontinued the sit-to-stand and recognized that PT transfer status changes were not being promptly incorporated into the care plan or CNA Kardex. The DON confirmed that the resident was supposed to be transferred only with a Hoyer lift and that the care plan still reflected “weight bearing assistance” rather than Hoyer use. An audit of transfer statuses provided to the surveyor did not identify this resident as affected, and the resident’s care plan and transfer status discrepancies were not captured in the facility’s audit process, resulting in staff not having accurate written guidance on the required Hoyer lift transfers.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to maintain acceptable nutritional status for a resident receiving enteral nutrition and to follow physician orders for daily weights. The resident was admitted with multiple significant diagnoses, including CHF, acute kidney failure, dysphagia, and hemiplegia, and received nutrition via tube feeding. Admission orders from the discharging clinic directed that the resident be weighed daily at 5 a.m., but after an initial weight of 115.2 lbs on admission, no weights were documented from the following day through several weeks. When a weight was finally recorded on 3/6, it showed a loss of 11 lbs (9.55%) from admission, and there was no weight documented the next day despite ongoing orders for daily weights. The resident’s care plan identified nutritional risk related to CHF, CAD, dysphagia, need for tube feeding, and underweight BMI, with interventions to monitor intake, weight, skin, labs, diet tolerance, and hydration, and to notify the MD of significant weight changes. The care plan was later revised to include daily weights and to address a triggered 10% weight loss in 30 days. Despite this, there were additional gaps in daily weight documentation on specific dates, with no recorded refusals. Subsequent weights showed continued decline, including a weight of 92.0 lbs on 3/16, indicating a 20.14% loss from admission. Nursing progress notes also documented that the resident turned off the tube feeding, and the DON later stated the resident frequently stopped tube feedings and resisted water flushes, though CNA charting did not document diarrhea as described by the DON. The facility’s own Enteral Nutrition policy required that a dietician assess residents receiving enteral feedings and, if not available prior to the first feeding, that the on-call dietician be contacted to review admission information and determine initial orders. However, the resident did not receive a registered dietician assessment until 3/13, seven days after the significant weight loss was identified. The only documented dietician note was dated 3/13 and referenced recent weight loss and an underweight BMI. The DON acknowledged that daily weights were not started with admission despite the physician’s order and stated that the facility initially followed admission orders and involved the dietician only after the resident began losing weight, which conflicted with the written policy requiring dietician assessment at admission for residents on enteral feedings.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide safe, appropriate IV therapy and PICC line care in accordance with physician orders, the resident’s care plan, and professional standards of practice for one resident. The resident was re-admitted with a PICC line and multiple serious diagnoses, including end stage renal disease, abdominal pelvic abscess on chronic IV daptomycin therapy, dependence on dialysis, history of sepsis, and other complex conditions. The care plan and physician orders required regular IV antibiotic administration, routine PICC line flushing, dressing changes, monitoring of the PICC site, and measurement of arm circumference and external catheter length. These orders were intended to support ongoing treatment of the resident’s chronic pelvic abscess and to maintain PICC line patency and integrity. Record review showed that from early February through early April, normal saline flushes ordered every 8 hours were not consistently administered and were often documented as not given, held, or left blank on the MAR, indicating they were not performed as ordered. Required PICC-related assessments and care were also missed or undocumented: arm circumference above the insertion site was not documented or completed on specified dates, external catheter length was not documented or completed on a required date, and PICC needless connector changes were not documented or completed on two ordered dates. IV daptomycin doses ordered for administration after dialysis on specific Mondays, Wednesdays, and Fridays were not administered on multiple ordered days. Additionally, although the MAR showed that PICC dressing changes were documented as completed on three separate dates in March, a photograph dated later in March showed the PICC dressing still bearing a date and initials from mid-March, indicating the dressing had not been changed every 7 days as ordered. Further, hospital documentation from early April stated that the resident, known for a non-operable chronic pelvic abscess on chronic antibiotics and frequent admissions for sepsis, was brought to the ER minimally responsive, and that the PICC line had been accidentally removed at the nursing home sometime in the prior 24 hours. The EMT report from that day did not indicate a PICC line in place during transport. Interviews with nursing staff revealed confusion and inconsistency regarding who was responsible for PICC care. One LPN stated that dialysis usually completed all PICC care and reported not doing anything with the PICC line, despite the LPN’s initials appearing on the MAR for PICC flushes, external catheter length measurements, and dressing changes, with some entries marked as not administered. The LPN could not explain why their initials appeared on the MAR. An RN reported that the PICC functioned well and believed, but was not certain, that the PICC was in place before transfer. The DON stated there were no progress notes indicating accidental PICC removal or malfunction and was unaware of the missed PICC care tasks and discrepancies between MAR documentation and the dated dressing shown in the photograph. The DON confirmed that staff were expected to complete all provider orders as written and to notify leadership and the provider if orders could not be followed. The combination of missed IV flushes, missed or undocumented PICC assessments and connector changes, missed IV antibiotic doses, inaccurate or conflicting MAR documentation, and lack of clear recognition or reporting of PICC line issues prior to hospital transfer constituted the failure to ensure the resident received IV therapy and PICC care consistent with physician orders, the care plan, and professional standards of practice.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide dialysis care and monitoring consistent with professional standards, the resident’s care plan, and physician orders for a resident with end-stage renal disease and a left forearm fistula. The facility’s own policy on care of residents with ESRD requires staff education on ESRD management, daily/shift assessments, recognition of complications, and care of shunts and fistulas, and states that the comprehensive care plan will reflect dialysis-related needs. The resident’s care plan and physician orders specified dialysis three times weekly, monitoring of the left forearm fistula for thrill and bruit, not drawing blood or taking blood pressure in the graft arm, daily weights with pre- and post-dialysis weights on dialysis days, and vital signs on Monday, Wednesday, and Friday with notification of the provider for abnormalities. Record review showed that these ordered assessments and monitoring were not carried out or documented. The surveyor could not find documentation in the MAR, TAR, progress notes, or other records that the resident’s left forearm fistula was assessed as ordered, including monitoring for thrill and bruit or site concerns. The surveyor also could not find evidence that pre- and post-dialysis weights were obtained every Monday, Wednesday, and Friday as required; only a few scattered weight entries over several weeks were present, rather than consistent dialysis-day pre/post weights. Additionally, vital signs were not assessed and documented every Monday, Wednesday, and Friday pre and post dialysis as ordered for management of dialysis treatments and hypertension medications. The surveyor identified specific instances of abnormal blood pressure readings (186/105 mmHg and 197/96 mmHg) without documentation that the on-call provider was notified or that any interventions were implemented. Interviews with staff further demonstrated inconsistent understanding and implementation of the required dialysis-related assessments. An LPN stated that they did not do anything with the resident’s fistula, believing it to be outside their scope of practice, while an RN and the DON described expectations that staff assess the fistula, perform head-to-to-toe assessments, obtain vitals and weights, and document findings on a Dialysis Communication Form. When the surveyor requested these forms for the review period, only a limited number were produced, and the DON acknowledged that staff were not accurately monitoring the resident’s care pre and post dialysis treatments as ordered.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure a medication error rate of 5% or less, as evidenced by 1 error out of 10 observed medication opportunities, resulting in a 10% error rate. A resident with low back pain, difficulty walking, spondylopathy of the lumbosacral region, and pain in the left shoulder and left knee had an order for Voltaren 1% gel to be applied to the left knee twice daily, not to exceed 4 g per application, 16 g per joint per day, or 32 g total per day. The resident had moderate cognitive impairment, was forgetful at times, but could make needs known and had clear, understandable speech. During a medication pass, a CMA prepared the Voltaren gel by squirting two lines of gel into a plastic medication cup without using any measuring device or dosing card, then applied part of the gel to the resident’s left knee and the remainder to the resident’s back, despite the order specifying use for the left knee. In subsequent interviews, the CMA stated that he did not know how many grams he was administering, believed the order did not specify how much to apply, and reported he had been taught to put one squirt in the cup for each area, applying only a thin layer. He also stated he did not think the medication cup could be used to measure the dose and that no one at the facility had instructed him otherwise, and he had never seen the Voltaren dosing card. The DON stated that nurses should verify the correct medication with the MAR before administration and that topical medications were generally applied as a thin layer, and she was unsure how staff ensured correct dosages for topical medications. When asked specifically about Voltaren gel, the DON stated she did not think there was anything different about its administration and was not aware of the dosing card or printed dosing instructions on the Voltaren box. Later review of the stock Voltaren revealed the dosing card inside the carton, which the DON stated she had never seen.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to treat two residents with respect and dignity and to promote their quality of life by not properly managing audio and visual surveillance in their shared room. One resident with moderate cognitive impairment, who had a guardian appointed to assist with decision making, was admitted to a room already containing a video monitoring camera placed by the roommate’s activated POA. The camera was located on top of the roommate’s closet, pointed toward the corner of the roommate’s side of the room, and had audio capability. The facility did not have access to the surveillance, but the roommate’s POA could observe both video and audio, allowing them to hear conversations occurring anywhere in the room, including those involving the cognitively impaired resident. Surveyor review of records found no evidence that the cognitively impaired resident or the resident’s guardian had been informed of or consented to the presence of the camera, and no documentation that this was discussed at a care conference, despite the NHA’s statement that Social Services had done so. The guardian confirmed she was not aware of the camera and was not comfortable with it being in the resident’s room. Additionally, there was no consent in the roommate’s record for the camera, despite an email chain months earlier indicating the need for such consent from the roommate’s POA. Neither resident’s care plan included any information or interventions related to the video surveillance in their room.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to revise a resident’s care plan to reflect current fall risk interventions following multiple falls. The resident was admitted after hospitalization for increased confusion and falls at home, had a BIMS score indicating moderately impaired cognition, and had an activated POA for decision-making. Initial assessments documented no elopement risk and a low fall risk, and the care plan identified increased risk for falls related to deconditioning, ataxia, recent fall, muscle weakness, and noncompliance with transfer assistance, with interventions such as keeping the call light within reach and therapy evaluation and treatment. Despite this, the resident experienced several falls, including a fall with major injury resulting in a fractured pelvis and subsequent falls in the room. After each fall, new fall interventions were documented on eINTERACT forms and in progress notes, such as placing a “Call for Help” sign and removing the walker when the resident was in bed with the wheelchair at bedside, but these interventions were not incorporated into the resident’s care plan. Surveyor observations confirmed the presence of the “Call for Help” sign and the walker’s placement in the room, and staff interviews showed varying understandings of the resident’s fall interventions, including toileting after meals, use of a floor mat, and keeping the bed in the lowest position. The DON confirmed that fall interventions documented after each fall had not been added to the care plan and that nurses were responsible for updating the care plan after completing eINTERACT forms. The surveyor determined that the facility did not revise the resident’s care plan to reflect current interventions to reduce fall risk.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide pressure injury (PI) prevention and treatment consistent with professional standards of practice for one resident, resulting in the development and deterioration of a left heel PI. The resident was admitted after hospitalization for sepsis with multi-organ failure and had multiple comorbidities, including type 2 diabetes mellitus, chronic kidney disease stage 3, unspecified dementia, hypertension, and heart failure. The initial care plan identified the resident as at increased risk for pressure ulcer development and included interventions such as a pressure-reducing mattress, administering treatments as ordered, and using barrier creams with each incontinent episode. A comprehensive MDS indicated the resident was at risk for pressure ulcer development, but the surveyor could not obtain documentation of the assessment tool or score used to determine this risk. Subsequently, the resident developed skin integrity issues, including a Stage 3 pressure wound on the right medial buttock that was later resolved. Later, an SBAR form documented a new wound to the heel, described as an open area measuring 8 cm by 5 cm, with a bandage applied and pressure boots placed while in bed. The wound was actually on the left heel, but it was incorrectly documented as the right heel. At that time, there was no comprehensive wound assessment completed that described wound characteristics beyond basic measurements. A treatment order was entered on the TAR for the left heel to cleanse with normal saline, pat dry, apply foam dressing, and secure with Kerlix once daily at bedtime, with daily assessment of drainage, appearance, and surrounding skin. The surveyor could not find evidence of a comprehensive wound assessment for the left heel until a later date. When the wound care physician evaluated the resident, the left heel blister had ruptured and was an open wound with nonviable tissue and necrosis, and debridement was performed. The physician ordered a new treatment plan including Betadine and dressing changes twice daily and as needed, but the TAR was not updated and nursing continued the prior once-daily treatment without Betadine until a later date. The care plan was not updated to reflect the new left heel surgical wound or to include weekly treatment documentation and monitoring until well after the wound had developed. Facility nurses did not complete comprehensive wound assessments upon discovery of the new PI or between weekly physician visits, and the NHA stated the facility does not do comprehensive assessments, relying instead on SBAR forms, of which only one was completed for the new heel PI. Over time, the left heel wound progressed. Subsequent wound care notes documented changes in wound size and treatment modifications, including discontinuation of Betadine and initiation of Hydrofera Blue and other dressings. The resident was hospitalized and later returned with a Stage 4 pressure wound of the left heel, with specific measurements and new treatment orders including Hydrofera Blue, collagen powder, and hypochlorous acid solution. An additional hospital order directed topical Tobramycin Sulfate Injection solution to the left heel twice daily. Later, the resident was again sent to the ER for chills and rigors, with the wound gently packed and the physician noting the resident appeared septic with tachypnea and tachycardia. Hospital records documented sepsis secondary to streptococcus dysgalactiae bacteremia and left calcaneal osteomyelitis, with diagnoses including an open wound and Stage 4 PI of the left heel. The surveyor concluded that the facility failed to implement aggressive interventions to prevent PI development, failed to ensure treatment orders were transcribed and completed as ordered, and failed to complete comprehensive assessments upon discovery and during the course of the left heel PI, leading to an avoidable PI that deteriorated to Stage IV with osteomyelitis requiring hospitalization and IV antibiotics. Interviews with facility leadership confirmed these failures. The DON acknowledged that wound care orders from the wound care physician were not followed, the care plan was not updated, and that the expectation was for nurses to complete and document ordered wound treatments and update the care plan for changes and new interventions. The DON also stated that comprehensive wound assessments were performed by the wound care physician, which explained the lack of comprehensive wound assessment documentation by facility nurses. The NHA, when asked why comprehensive assessments were not completed with the development of the new heel PI and changes in treatment, stated that the facility does not do comprehensive assessments and instead uses SBAR forms for changes in residents, despite only one SBAR being completed for the new heel PI. These documented inactions and omissions formed the basis of the deficiency and the finding of immediate jeopardy.

Removal Plan

• Facility initiated education for all licensed nursing staff (RNs and LPNs) including: prompt identification and reporting of new pressure injuries; completion of comprehensive assessments upon discovery of a new pressure injury; completion of daily diabetic foot checks; accurate transcription, initiation, and completion of physician ordered treatments; implementation of aggressive pressure injury prevention and treatment interventions per standards of practice; education on notification of physician/NP of all new pressure injuries as well as any significant changes to pressure injuries.
• Licensed nursing staff completed competency validation related to pressure injury staging and documentation, treatment application per physician orders, and heel offloading, repositioning, skin protection, and preventive interventions.
• Facility conducted skin assessments and Braden scale assessments of all residents in the facility.
• Facility conducted TAR audits of residents to ensure wound treatments were completed as ordered.
• Facility reviewed resident wound treatment orders to ensure they were accurate and appropriate.
• Facility conducted wound round audits on all residents with wounds/pressure injuries.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure that a registered nurse (RN) was on duty for at least eight consecutive hours a day, seven days a week, as required. Review of the PBJ Staffing Data Report for Quarter 4 of 2025 (July 1–September 30) showed four days within the quarter with no RN hours reported: 08/15/2025, 09/08/2025, 09/09/2025, and 09/14/2025. Further review of the facility’s staff schedules and nurse postings for the last 92 days of that quarter confirmed that on 08/15/2025 (Friday), 09/08/2025 (Monday), and 09/09/2025 (Tuesday), there was no RN scheduled for eight consecutive hours. The facility was unable to provide documentation to support that an RN worked at least eight consecutive hours on those three dates. During interviews on 01/14/2026, the Nursing Home Administrator and Assistant Nursing Home Administrator explained that the receptionist posts the daily staffing sheet in the morning after updating the census, and that the facility does not manually update the public posting to reflect subsequent staffing changes, relying instead on the internal schedule, which is not publicly posted. Later that day, the Assistant Nursing Home Administrator provided documentation supporting RN coverage for 09/14/2025 and stated that corporate RNs had been rotating to provide the required eight hours of RN coverage between 08/15/2025 and 09/14/2025. However, no additional records or documentation could be produced to verify RN coverage for 08/15/2025, 09/08/2025, and 09/09/2025, resulting in a finding that the facility did not ensure RN coverage for at least eight consecutive hours on those dates for all 47 residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not develop and implement policies and procedures to prevent abuse, neglect, exploitation, and misappropriation of resident property through required employee background screening. Record review and staff interviews showed that multiple sampled employees did not have complete background checks, including the Background Information Disclosure (BID), DOJ criminal background record, and State of Wisconsin Caregiver Background Check Government Findings Report. Of the 17 sampled staff, 16 did not have a full background check reviewed. Several staff members, including CNA O, CNA P, CNA Q, LPN R, SW F, DM E, and AD I, did not have DOJ criminal background records or Government Findings Reports within 60 days of hire or as required. CNA W, hired in 2020, did not have a current BID, DOJ criminal background record, or Government Findings Report within the last 4 years. CNA G had lived in Florida from 2017 to 2023, but no background check was completed for Florida. Other sampled staff, including CNA HH, CNA II, DA JJ, BO KK, RN LL, and LPN K, did not have a BID, and their DOJ criminal background records and Government Findings Reports were completed only after the surveyor entered the facility. Surveyor review showed that some reports were obtained only after repeated requests during the survey, and several were dated the same day the surveyor was in the facility. During interview, the NHA and DON stated they used third-party vendors for background checks and were not aware that Wisconsin DOJ criminal background checks and caregiver background checks were required upon hire. The NHA also stated that the facility was working on implementing the BID form at time of hire and acknowledged that the background checks for the sampled staff were not completed timely.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not ensure safe storage and labeling of foods in accordance with professional standards for food service safety for 47 of 47 residents. In the kitchen dry storage area, surveyors observed an opened package of yellow cake mix sitting on top of a box on a shelf without a date opened or use by date, as well as three opened and partially used bags of dry cereal that were not labeled with a date opened or use by date. The facility policy, Food Receiving and Storage, states that dry foods stored in bins will be removed from original packaging, labeled, and dated with a use by date. In the resident common area refrigerator, surveyors observed a half sandwich covered with clear film wrap without a use by date, a large plastic red container of pasta meal with no identification of ownership, date opened, or use by date, an opened bottle of Miracle Whip salad dressing and a tub of Land O' Lakes butter with no use by date, and a solidified yellow substance in a storage drawer and along the bottom of the refrigerator from an unknown source. The refrigerator temperature was observed at 50 degrees, and the door was slightly ajar because a large box of pudding was stored inside. On a later observation, a partially eaten pizza in a cardboard box and an unmarked disposable cup containing an unknown liquid were also found in the same refrigerator without identification of ownership or use by date. The Dietary Manager stated that opened foods in dry storage should be transferred into a labeled container with a use by date, and that foods in resident refrigerators should be labeled with a resident's name and date opened or delivered.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not ensure all garbage and refuse was properly contained inside dumpsters to prevent the harborage and feeding of pests. On 01/11/2026 at 9:27 AM, the surveyor observed several bags of garbage on the ground next to dumpsters located outside and near the kitchen back door. When asked about the facility policy for garbage disposal, the Dietary Manager stated that none of the bags observed on the ground came from the kitchen and that the bags were left there by other staff, namely nursing, and that this happened every day. The Dietary Manager also stated that administration had been made aware on several occasions that this was happening.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not provide an infection prevention and control program that maintained a safe, sanitary, and comfortable environment or helped prevent the development and transmission of communicable diseases and infections. Surveyors observed multiple infection control failures affecting residents and staff, including lack of sanitizing of a mechanical lift after use, residents not being offered hand hygiene before meals, PPE not being worn in isolation rooms, no Enhanced Barrier Precautions (EBP) for a resident with an indwelling catheter, no droplet precautions for a resident with COVID-19, improper hand hygiene during care, dirty linens placed on the floor, and a urinary catheter lying on the floor. One resident was admitted with an indwelling urinary catheter and was observed without EBP signage or PPE outside the room. Another resident with an indwelling urinary catheter was on EBP, but the catheter bag was observed touching the floor and later lying directly on the floor under the bed. During transfer care, a CNA handled the catheter bag and provided direct care without wearing a gown, despite the resident being on EBP. The DON stated catheter bags should not touch the ground and agreed gowns were expected for direct patient care such as transfers for a resident on EBP. Surveyors also observed an LPN leaving an EBP room with a Hoyer lift and placing it in the hall without cleaning it. In rooms with droplet precautions for COVID-positive residents, a maintenance director entered wearing only a facemask. Another resident who had just tested positive for COVID had no isolation signage present near the room, and staff stated the signage and PPE were being prepared after the positive result was identified. Additional observations showed a CNA failing to change gloves and perform hand hygiene after incontinence care before touching clean items, and another CNA discarding a contaminated washcloth on the floor and continuing care without hand hygiene. Residents were brought to meals without hand hygiene being offered, and dietary staff confirmed hand hygiene was not routinely offered before meals.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure abuse training was provided at hire and annually for 9 of 9 staff reviewed. Staff members identified in the record review included CNA W, CNA GG, CNA HH, CNA G, CNA II, Dietary Aide JJ, Business Office KK, RN LL, and LPN K. The report states that these staff members had no documented abuse, neglect, exploitation, and misappropriation training available to the surveyor upon hire, and for some staff, no annual training was documented as well. During the survey, the Nursing Home Administrator was asked to provide proof of abuse, neglect, exploitation, and misappropriation training for the listed staff. The administrator provided two large binders of in-services but could not readily produce evidence of the requested training. The administrator stated the facility did not have a system to track education for staff and was working on getting one. The facility policy required staff training and orientation on abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior, and the facility assessment listed abuse, neglect, exploitation, and dementia care as training topics.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide required bed-hold notices and transfer/discharge notices to residents or their representatives in connection with hospital transfers. Record review and interviews showed that five residents did not receive proper notification of the facility’s bed-hold policy, including information on reserve payment, and did not receive notice before transfer or discharge indicating the specific reason for the transfer/discharge. One cognitively intact resident (R43), who scored 15/15 on the BIMS, was transferred to the hospital on 1/5/26 with a summary sent, but the social worker reported there was no bed-hold notice for this transfer. Another resident (R8), with moderate cognitive impairment (BIMS 9/15), was admitted to the hospital for hip pain related to an injury of unknown origin, and there was no bed-hold notice provided to the resident or representative for that transfer. Additional residents were similarly affected. One resident (R7) was transferred to the hospital for change in condition on two separate occasions and did not receive a notice of bed-hold indicating reserve payment or a notice before transfer/discharge stating the specific reason for the transfer/discharge. Two cognitively intact residents (R2 and R14), each scoring 15/15 on BIMS, had bed-hold forms signed by care managers from managed care organizations indicating they wished to reserve their rooms; however, R2’s bed-hold notice did not include the daily rate for reservation, and R14 did not receive a bed-hold notice for a subsequent hospital transfer. During the survey, the social worker responsible for transfers was unavailable due to illness, and the assistant nursing home administrator reported not being aware of the transfer/discharge process and needed to consult the nursing home administrator, but no follow-up was provided by survey exit.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not maintain a system to account for the disposition of all controlled drugs in sufficient detail to allow accurate reconciliation for 25 residents reviewed for controlled substance reconciliation. During review of the narcotic count reconciliation records for January 2026, the facility’s documentation was incomplete because it did not show oncoming and outgoing nursing staff reconciling controlled substances at each shift change, as required by the facility policy stating that nursing staff must count controlled drugs at the end of each shift and document any discrepancies. On 01/12/2026, the surveyor observed two locked narcotic carts in the hallways outside the nurses’ station, each containing a locked box with controlled substances, including individually packaged narcotics for residents. Review of the narcotic count sheets found missing oncoming and outgoing nurse/CMA signatures on both carts, including multiple missing signatures for halls 100 and 200 and extensive missing signatures for halls 300 and 400, where signatures were absent for every shift change from January 1st through January 6th and additional shifts on January 9th and January 10th. DON C and DON J both stated that two nurses are expected to count controlled substances at each shift change and sign the narcotic count record, and DON J stated discrepancies are to be reported immediately and investigated.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to protect a resident from misappropriation of personal property and to follow its abuse and misappropriation investigation and reporting policies. On 01/07/26, the facility was made aware that a resident (R29) was missing multiple personal items, including a cell phone, cell phone charger, wallet containing $80.00, tennis shoes, two grabbers, and a wicker/wooden box with household items such as keys. The facility’s own policies stated that residents have the right to be free from misappropriation of property and that all reports of misappropriation must be promptly reported to local, state, and federal agencies and thoroughly investigated. Despite this, the facility did not protect the resident from misappropriation, did not report the allegation to the State Agency, and did not begin an investigation until 01/09/26. When the surveyor reviewed a complaint submitted to the State Agency by the resident’s family member on 01/08/26, the family member confirmed the list of missing items and stated she had filed two grievances with the facility and also reported the incident to law enforcement. Review of the facility’s grievance log for the prior three months showed only one grievance for this resident, dated 10/06/25, unrelated to missing property, and the facility did not provide its grievance policy when requested. Over several days, the surveyor repeatedly requested the facility’s internal investigation of the missing property; the facility did not provide any investigation documentation until 01/13/26, at which time only a single Grievance/Complaint form dated 01/07/26 was produced. That form showed the grievance was assigned on 01/09/26 and documented that staff searched the resident’s room and laundry and were waiting for the daughter to call back to make a plan to replace items. The facility was unable to locate the missing property and did not provide any additional information indicating that required interviews or a thorough investigation had been conducted.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to conduct timely and thorough investigations into allegations of abuse and misappropriation of resident property for two residents. For one resident, the facility was notified that personal property, including $80 in cash, was missing. Although the grievance was reportedly filed by the family member, the facility did not begin its investigation until two days after being made aware of the missing items. The only documented investigative action was a grievance/complaint form indicating that staff searched the resident’s room and laundry, waited a couple of days, rechecked laundry, and then contacted the resident’s daughter about replacing the items. No documentation was provided to show that staff or other residents were interviewed, and the facility was unable to locate the missing property. The surveyor requested the facility’s internal investigation multiple times over several days and was only provided the single grievance form, with no additional investigative documentation. For the second resident, the deficiency centers on the facility’s incomplete investigation into a pelvic fracture of unknown origin. This resident had a history of falls and multiple fall-related care plan interventions, and had moderate cognitive impairment as evidenced by a BIMS score of 9/15. On the morning in question, the resident began to complain of pain but initially denied falling. A progress note, lacking date, time, and author, documented that the resident complained of left hip pain, denied any falls during the night, was given acetaminophen, and that an x-ray was ordered. Due to weather-related delays with mobile x-ray, the resident was sent to the ER, where imaging revealed a markedly comminuted fracture of the left acetabulum and a nondisplaced fracture of the left inferior pubic ramus, with associated hemorrhage. The facility’s investigation into the resident’s injury did not meet its own policy requirements for a thorough abuse or injury-of-unknown-source investigation. The investigation worksheet identified two staff members, an LPN and a CNA, as involved or potential witnesses, and only these two staff were interviewed. The LPN reported finding the resident partially off the bed and assisting the resident back to bed without signs of pain, and the CNA reported responding to the resident’s calls during the night, noting restlessness but no complaints and that the resident was asleep when the Foley catheter was emptied. The worksheet documented that no interview was conducted with the resident by facility staff, that a complete physical and emotional assessment identifying areas of injury was not completed, and that there were no new interventions or clear conclusions about how or why the incident occurred. It also noted that documentation in the resident record was not complete and left sections regarding root cause, care plan revisions, and other corrective actions unanswered. The nursing home administrator confirmed that the paperwork submitted to the state constituted the entirety of the 5-day investigation and that no additional investigation was performed. Across both examples, the facility’s actions did not align with its written policies on abuse prevention and abuse investigation and reporting, which require prompt reporting, thorough investigation, and interviews with the resident, the reporter, witnesses, and staff on all shifts who had contact with the resident during the relevant period. In the case of the missing property, the facility did not document interviews or a comprehensive inquiry into the alleged misappropriation. In the case of the pelvic fracture, the facility did not complete a full assessment, did not interview the resident, did not identify a root cause, and did not fully document the incident in the medical record, resulting in an incomplete investigation of a serious injury of unknown source and failure to rule out abuse as required by policy.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to follow physician orders and provide wound care and monitoring according to professional standards for two residents. One resident with chronic osteomyelitis, bilateral foot ulcers with necrosis of bone, toe amputations, diabetes, and sepsis was admitted with active treatment orders on the TAR for nightly and as-needed dressing changes to bilateral lower extremities, including monitoring for infection, documenting drainage, and documenting pain scores. The resident’s initial care plan did not address wounds or wound care interventions. Surveyor review of the TAR showed no documentation of daily assessments or dressing changes from 1/5/26 to 1/10/26, despite the active orders. When observed, the resident’s foot dressings were loosely wrapped, and the resident reported having wounds on both feet and not believing dressing changes had been done since admission. An LPN stated the dressing changes were done as needed and would be documented in the TAR, but the TAR lacked entries for the specified dates. The DON confirmed that the TAR orders required daily dressing changes and that documentation only showed dressing changes on 1/11 and 1/12/26, indicating the dressings were not changed on 1/5 through 1/10/26. The second resident, with hypertension, chronic kidney disease, and cognitive decline, experienced a fall from a recliner and was found on the floor, incontinent but alert and oriented, with vital signs stable except for low blood pressure. The nurse documented that the NP was notified and instructed staff to push fluids and assess blood pressure every hour to determine if hospital transfer was needed, and to hold all blood pressure medications until blood pressure reached proper levels. The MAR showed antihypertensive medications were held on the day of the incident, and all medications were administered as ordered on the following two days, including the morning of 12/23/25. However, surveyor review could not locate documentation of blood pressure readings after the initial incident, nor documentation that medications were held as ordered beyond what appeared on the MAR. The DON stated she was unable to find documentation that nursing staff followed the NP’s orders to monitor blood pressure until it reached acceptable levels or that medications were held as directed.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision and assistive devices for two residents. One resident with anxiety, depression, dementia, and severe cognitive impairment (BIMS 5/15) had been assessed as an elopement risk and care planned to wear a wanderguard on the left wrist, with orders and TAR documentation indicating staff were to check the device’s placement, function, and the skin around it every shift. The elopement assessment, care plan, and elopement binder all identified this resident as an elopement risk with a wanderguard in place. However, during surveyor observations and interviews on the same day, the resident was repeatedly observed without a wanderguard on the left wrist, left ankle, body, or wheelchair. Despite this, nursing documentation reflected that the wanderguard was being checked, and staff interviews showed uncertainty about whether the resident had a wanderguard on, with one CNA reporting that when taking the resident outside to smoke, no alarm had ever sounded. The second example concerns a resident with moderately impaired cognition (BIMS 5) who required substantial/maximal assistance for toilet transfers and had a care plan specifying a two‑person transfer with a gait belt. A surveyor observed this resident sitting on the toilet under the supervision of a CNA, with no gait belt in place. The CNA then performed incontinence care and transferred the resident independently to a wheelchair without using a gait belt. When questioned, the CNA stated that they had not been using a gait belt for this resident’s transfers and, after checking the care plan, stated that it did not indicate the need for a gait belt, despite the documented care plan approach requiring one.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to obtain written consents that explained the risks, benefits, options, and alternatives before initiating psychotropic medications for 2 of 5 residents reviewed for unnecessary medications, R26 and R50. R26 was admitted with diagnoses including dementia, psychotic disturbance, mood disturbance, and anxiety, and had an activated POA. R26’s physician orders included quetiapine, sertraline, and lorazepam, and the care plan for antipsychotic and antidepressant use stated that the resident/family/caregivers would be educated about risks, benefits, side effects, and toxic symptoms. R50 was admitted with a history of traumatic brain injury, moderate dementia with psychotic disturbance, generalized anxiety, and major depressive disorder, and also had an activated POA. R50’s physician orders included haloperidol, quetiapine, mirtazapine, and escitalopram, and the care plan for antipsychotic and antidepressant use likewise stated that the resident/family/caregivers would be educated about risks, benefits, side effects, and toxic symptoms. On review of the records, the surveyor was unable to locate signed consents for either resident before the psychotropic medications were started, and the DON stated the facility could not find signed consents prior to 01/08/26 and did not have a policy regarding psychotropic medications.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not determine whether self-administration of medications was clinically appropriate for one resident, who had diagnoses including COPD, chronic kidney disease stage 3, and shoulder pain. The resident was alert and oriented to person, place, and time, but the medical record did not contain documentation from the interdisciplinary team or the physician showing that the resident, or a family representative, had been determined safe to self-administer medications or had demonstrated self-administration. There was also no physician order for self-administration, and the care plan did not include interventions for self-administration by the resident or administration by a family member. During observation, an LPN administered medications while the resident’s wife stated she had already given the resident the Ellipta inhaler that morning and sometimes applied Voltaren 1% gel to the resident’s shoulder. The wife said she did this daily and had told the doctor, pharmacist, and head nurse. The resident’s wife showed the surveyor an Ellipta inhaler and a partially used tube of Voltaren gel stored in a bag inside the resident’s closet, which was not locked. Review of the MAR showed both medications were scheduled and initialed by nurses, with no indication they were to be self-administered. The DON stated that self-administration required a physician order, a return demonstration, and the medications to be kept in a locked container in the room.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that two residents were accurately monitored for targeted behaviors related to psychotropic medication use. R26 was admitted with diagnoses including dementia, psychotic disturbance, mood disturbance, and anxiety, and had an activated POA. R26 had physician orders for quetiapine 25 mg three times daily, sertraline 100 mg daily for depression, and a lorazepam 0.5 mg PRN order for anxiety that was initiated and discontinued on the same day. Monitoring for targeted behaviors related to the antipsychotic, antidepressant, and anti-anxiety medications was not established until 01/12/26, when the surveyor requested supporting documentation. R50 was admitted with an activated POA and had physician orders for mirtazapine 30 mg at bedtime for antidepressant use and escitalopram 10 mg daily for depression. Monitoring for targeted behaviors related to the antidepressant medications was also not put into place until 01/12/26, when the surveyor requested supporting documentation. On 01/14/2026, the DON stated the facility was unable to locate targeted behavior monitoring prior to 01/12/26 and said the facility did not have a policy regarding psychotropic medications.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to timely report a reasonable suspicion of a crime to law enforcement and failed to report an allegation of misappropriation to the state agency for one resident, R29. On 01/07/26, the facility was made aware that R29 was missing personal property, including a men's watch, cell phone and charger, two grabbers, black/white tennis shoes, an octagon wooden box with keys, and a wallet containing $80 cash. The facility did not report the missing property to the State Agency and did not report the allegation of misappropriation to law enforcement or the Ombudsman. The facility did not begin its investigation until 01/09/26. On 01/07/26, the Nursing Home Administrator received a formal grievance from the resident's family member regarding the missing items. The grievance was assigned to the Assistant Nursing Home Administrator on 01/09/26 with a resolution date of 01/14/26. On 01/13/26, the investigation documentation stated that IDT members searched the room and laundry for the missing items, checked again after letting laundry go for a couple of days, and were still unable to locate the items. The documentation also stated that the daughter was called to discuss replacing the items and that the resolution was waiting for the daughter to call back.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not ensure that two residents received necessary care and services upon admission. For one resident, admission orders included wound care for the lower spine and sacrum, but the electronic health record showed the sacrum treatment was entered on 01/07/26 and not started until 01/09/26, and the lower spine treatment was entered on 01/11/26 and not started until 01/12/26. The resident stated the bandages were not changed during the first few days after admission. The MAR also showed scheduled sacrum treatments on 01/07/26 and 01/08/26 with no administration or documentation recorded, and the first spine treatment was not completed until later than scheduled. For the second resident, admission orders required the resident's cochlear implants to be placed in every morning and removed at bedtime, but the MAR showed no administration or monitoring since admission. A family member stated the resident was very hard of hearing without the implants and rarely had them in during visits. Surveyor observations showed the resident did not have the cochlear implants in on multiple occasions, and the implants were found in a plastic container on the nightstand. An LPN stated the task was completed by CNAs but the nurse remained responsible for follow-up, and the DON stated physician orders are expected to be entered upon admission and followed.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not ensure a second PASRR was completed for one resident who had a PASARR I indicating suspected serious mental illness and a hospital discharge exemption with a 30-day maximum. The resident was admitted for short-term rehab and had pertinent diagnoses including depression, with medications including fluoxetine and Depakote. The PASARR I showed the provider agreed the resident was suspected of having a serious mental illness, and the resident exceeded the 30-day exemption period without a PASARR II being completed. During interview, the DON stated the resident was intended to stay only 30 days or less for therapy and acknowledged that the PASARR II was overdue.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident, R65, who was reviewed in a sample of 16 residents. R65 was admitted with diagnoses including COPD, chronic kidney disease stage 3, and pain in an unspecified shoulder. The record showed that R65 did not have a baseline care plan in place within 48 hours of admission to include the minimum healthcare information needed to properly care for him, including the ability to self-administer medications. On 01/12/2026, the resident’s record review showed a care plan dated 01/11/2026 with focus areas for advanced directives and anticoagulant/antiplatelet therapy, but no other baseline care plan focus, goals, or interventions were developed and implemented within 48 hours of admission. The record did not include baseline instructions for therapies, physician orders, nutrition orders, initial goals, social services, or assistance with mobility or ADLs. During interview, the DON stated a baseline care plan must be developed and implemented within 48 to 72 hours of admission and is based on the admission assessment, but the DON could not provide a baseline care plan for R65.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not develop and implement a person-centered care plan for each resident consistent with resident rights and the resident’s highest practicable physical, mental, or psychosocial needs for 2 of 15 residents reviewed. One resident was admitted with diagnoses including depression, anxiety, chronic pain, chronic kidney disease, reduced mobility, vitamin D deficiency, and adult failure to thrive, and had a BIMS score of 15/15 indicating intact cognition. The resident’s care plan addressed resistance to care and refusals of weights, but there was no nutritional care plan related to weight loss, no physician orders for weight monitoring, and no documented notification to the provider or dietitian after significant weight loss was identified. The resident’s weight decreased from 261.8 lbs to 236 lbs, a 9.85% loss, and from 258 lbs to 236 lbs, an 8.53% loss, with no follow-up documented for either loss. Another resident had ESRD and a dialysis graft to the left arm, and the care plan included dialysis-related interventions such as checking and changing the dressing, monitoring the site, and monitoring vital signs. However, the care plan did not include the possible complications of using the left arm for blood pressure measurements, labs, or other procedures because of the graft. Survey review of blood pressure records showed that on several occasions blood pressures were completed on the left arm since admission. The DON stated this instruction should have been present in the care plan or Kardex for nursing staff.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not ensure that two residents who were unable to carry out activities of daily living received the necessary assistance to maintain good nutrition. Facility policy stated residents should receive the correct diet, prompt meal service, and appropriate feeding assistance, and care plans were to address identified problem areas and functional decline. One resident with a history of strokes had a care plan for set up assistance with eating, but told the surveyor that staff brought the meal tray, placed it on the table, and left while the resident remained lying flat in bed and could not reach the food independently. The resident also stated staff had not attempted to get the resident up in a wheelchair since admission, which would have helped with eating meals. A second resident with a BIMS score of 0/15 and severe cognitive impairment had a care plan calling for eating assistance with supervision, oversight, and verbal cues/encouragement. The resident’s family member reported staff would bring the meal tray in and leave it. Surveyors observed the resident’s lunch tray sitting covered on the over-bed table while no staff were present, and later observed the breakfast tray still in the room and uneaten with the bedroom door closed and no staff present. A CNA stated staff could access the resident care plan and Kardex in the computer system to see what care each resident needed.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide weekend activities for residents, despite an activity calendar posted in the hallway showing scheduled events, including a card game at 2:00 PM. On 01/11/26 at 2:00 PM, the surveyor observed that no activities were taking place at the scheduled time. Residents interviewed stated there were no activities on weekends and that they had to make their own activities because the Activity Director only worked weekdays. One resident stated the calendar listed weekend activities, but those activities had not occurred since admission to the facility. During interviews, the Activity Director stated weekend activities had not been provided because the facility was short-staffed and did not have anyone to work weekends, and some activities had been cancelled due to COVID in the building. In a resident council meeting, residents voiced that it would be nice to have weekend activities and stated they were told activities were supposed to be covered by aides, but weekend activities had not been happening. An LPN stated there was supposed to be an activity between 10:00 AM and 2:00 PM on weekend days and that the manager on duty or hospitality aide was responsible, while a CNA was unsure whether weekend activities were provided. The DON stated there was no activity policy/procedure to provide, but expected activities to be available every day and was unaware they were not being completed on weekends.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Appropriate care was not provided for residents with bowel and bladder needs, including catheter care and toileting. R60, who was admitted with diagnoses including malnutrition, syncope and collapse, age related osteoporosis, and atrial fibrillation, had an indwelling urinary catheter with orders for Foley catheter care every shift and as needed. During observation, R60’s catheter drainage bag was hooked to the bed frame while the resident was being rolled in bed, and the catheter tubing was pulled tightly as the resident was repositioned. The catheter tubing was not secured to the resident in any way during the observation, and the CNA later returned with an adhesive device to secure it. The DON stated the expectation was that catheter tubing be secured and the bag should not be hooked to the bed when a resident is being rolled or repositioned. R35, who had a BIMS score of 5/15 indicating severe cognitive impairment, had physician orders and care plan interventions for bladder and bowel incontinence, toileting around the clock, and incontinence care after every episode. R35 also had a history of an actual fall with no injury and was receiving furosemide and preventative treatment to the peri area related to previous moisture-associated skin injury. Surveyor observations showed R35 was moved from the room to the nurse’s station area, taken to the dining room for breakfast, and later placed near the nurse’s station, but was not toileted for 5 hours and 55 minutes before incontinence care was provided. Staff interviews indicated rounds were generally every 2 to 3 hours, and the DON stated around-the-clock toileting meant rounding at all times of day, including night shift.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not ensure a resident maintained acceptable parameters of nutritional status when it failed to notify the provider or registered dietician of significant weight loss. The resident was admitted with diagnoses including depression, anxiety, chronic pain, vitamin D deficiency, reduced mobility, chronic kidney disease, and adult failure to thrive, and had intact cognition with a BIMS score of 15/15. The resident’s care plan addressed resistance to care and refusals of weights, but survey review found no nutritional care plan related to weight loss and no physician orders for weight monitoring. Survey review showed the resident weighed 261.8 lbs on 06/16/2025 and 236 lbs on 11/13/2025, a 9.85% loss, and weighed 258 lbs on 08/10/2025 and 236 lbs on 11/13/2025, an 8.53% loss. The facility policy required any weight change of 5% or more to be retaken the next day for confirmation and, if verified, nursing was to immediately notify the dietician in writing. The record showed the provider or registered dietician was not notified of either weight loss. During interview, the DON in training stated the resident refusing weights was care planned, but there was no nutritional care plan or follow-up with a provider or dietician.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Provide safe, appropriate dialysis care/services for a resident who requires such services was not met for R27. R27 was admitted to the facility and had a BIMS score of 0/15, indicating severe cognitive impairment. R27’s care plan addressed dialysis related to ESRD, including a dialysis graft to the left arm with interventions to check and change the dressing, monitor the site, and monitor vital signs, but it did not include instructions about the complications of using the left arm for blood pressure, labs, or other care related to the fistula or graft. During the survey, R27’s family member stated that a staff member had recently taken the resident’s blood pressure on the left arm and that blood pressure should not be taken there because of the fistula. An LPN stated there were standing orders for residents on dialysis not to perform blood pressures on an arm with a graft or fistula, and the DON stated blood pressure should never be taken on the arm with a graft or fistula and that an alternate location should be used. The DON also stated this was a standing order that should be in place for every resident with a graft or fistula.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not ensure a medication error rate of 5% or less during observed medication administration, with an 8% error rate identified for 2 of 4 residents reviewed. One resident, who had diagnoses including COPD, chronic kidney disease stage 3, and shoulder pain, was ordered methylprednisolone 4 mg to be given in the morning before breakfast, but the medication was observed being administered after the resident had already eaten breakfast. The resident’s MAR listed the routine administration time as 6:00 AM, and the nurse signed the dose as given at that time even though the surveyor observed it being administered at 9:34 AM after breakfast was completed. Another resident, who had diagnoses including morbid obesity, type 2 diabetes mellitus with hyperglycemia, long-term insulin use, and hemiplegia and hemiparesis following subarachnoid hemorrhage, was observed receiving Novolog insulin based on a blood glucose reading of 332. The physician’s sliding scale order required 12 units for that blood glucose range, but the nurse administered only 9 units. The resident later stated that one nurse gave 9 units and another nurse returned to give 3 more units, but there was no documentation of any additional insulin administration in the chart or MAR. The record also showed a documented blood glucose of 217 earlier that morning with 6 units of Novolog signed as administered, and a later nursing entry documented the 332 reading.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not ensure residents were free from significant medication errors, as multiple residents did not receive ordered medications within the required time frames and some medications were administered far outside the prescribed schedule. The facility policy titled, Administering Medications, stated medications must be administered in accordance with the orders and within one hour of the prescribed time unless otherwise specified. Survey findings showed that medications were frequently given late, and in some cases doses were clustered together or administered at times that did not match the orders. R58, who had diagnoses including allergic bronchopulmonary aspergillosis, acute and chronic respiratory failure with hypoxia, COPD with acute lower respiratory infection, emphysema, and bronchiectasis, was ordered Ipratropium-Albuterol nebulizer treatments every 4 hours with associated respiratory assessments. Record review showed multiple treatments were given hours late, including one ordered for 7:00 AM and administered at 11:53 AM, another ordered for 7:00 AM and administered at 10:56 AM, and another ordered for 7:00 AM and administered at 2:50 PM. On one day, the 11:00 AM and 3:00 PM treatments were both administered at 2:50 PM. On another day, the 11:00 AM and 3:00 PM treatments were both administered at 7:06 PM. During observation, an LPN entered with the nebulizer medication and did not perform the associated respiratory assessment before administering it. R58 stated treatments were not received on time, sometimes were skipped, and sometimes two were given at the next time. R61, who had diagnoses including type 2 diabetes mellitus with hyperglycemia and hypothyroidism, had multiple medications ordered for morning, evening, and bedtime administration, including insulin, metformin, carvedilol, spironolactone, furosemide, levothyroxine, and Eliquis. Record review showed several doses were administered many hours late, including morning medications given in the afternoon, evening medications given after midnight, and insulin doses ordered for the morning but administered in the afternoon. R61 told surveyors that blood sugar had not been checked and insulin had not been given after breakfast, and that levothyroxine was being given with other morning medications instead of before breakfast. On one observation, an LPN stated she would check the blood sugar later because she had family matters and other residents to attend to, and the blood glucose was not obtained until later. R10 and R55 also reported and demonstrated repeated late medication administration. During a resident council interview, R10 stated she had not received morning medications that should have been given at breakfast, including a blood pressure pill, Eliquis, and vitamin D, and R55 stated bedtime medications were sometimes given in the middle of the night after staff woke her. Record review confirmed that R10’s morning medications were not given at the scheduled 6:00 AM time on multiple dates, including doses given at 11:22 AM and 1:35 PM. R55’s medication audit showed several medications were administered 5 to 7 hours after scheduled times, including morning metoprolol and Miralax given at 11:51 AM, evening metoprolol given at 11:59 PM, levothyroxine scheduled for 4:00 AM and given at 11:46 PM, and evening metoprolol, Seroquel, and melatonin given at 11:13 PM.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not ensure that all drugs for resident self-administration were stored in a locked compartment in the resident room for one resident who was reviewed for safe medication administration. The resident had diagnoses including COPD, chronic kidney disease stage 3, and pain in an unspecified shoulder, was alert and oriented to person, place, and time, and did not have a BIMS score available. The resident’s wife stated she gave the resident an Ellipta inhaler every morning and sometimes applied Voltaren 1% gel to the resident’s shoulder for pain relief, and she said she had spoken with the doctor and pharmacist about it. During observation, the resident’s wife removed the inhaler from a closet in the resident’s room and returned it there after speaking with the LPN. The closet door was not locked, and the resident and wife stated it was never locked. The wife also showed the surveyor the Ellipta inhaler in a bag in the closet and a partially used tube of prescription Voltaren 1% gel. The LPN stated she was not aware the medications were stored in the closet and said medications kept in a resident room should be in a locked box. Record review showed the resident’s care plan had no interventions for safe and secure storage of personal medications in the room.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Accurate documentation was not maintained in accordance with accepted professional standards for one resident who had physician orders for nebulizer assessments and a low air loss mattress. The resident reported that nurses were not performing respiratory assessments before or after nebulizer treatments and stated they had not seen a stethoscope since being admitted. During observation, a surveyor saw an LPN administer a nebulizer treatment without performing a respiratory assessment, instead opening the cannula, pouring in the medication, handing the nebulizer to the resident, and turning the machine on, with no pre-treatment assessment documented or observed. The resident also had an order for a low air loss mattress with instructions to check its function every shift, but surveyors observed the mattress still rolled up in plastic on the resident’s floor and not on the bed. The MAR documented that the mattress had been checked and was in working order on night shift, despite the mattress not being in place. Interviews with nursing staff and the DON showed that nurses were expected to complete pre- and post-nebulizer assessments, including lung sounds and vital signs, and to check the mattress function each shift, but the observed care and documentation did not match those expectations.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain documentation of screening, education, offering, and/or declination of influenza and pneumococcal vaccinations for 2 residents, R44 and R65, out of 5 residents reviewed for immunizations in a sample of 17 residents. The facility policies for Influenza Vaccine and Pneumococcal Vaccine state that residents are to be offered these vaccines, provided information and education on benefits and potential side effects, and that acceptance or refusal is to be documented in the medical record. On 1/12/2026, record review found no documentation in either resident’s chart of screening for influenza or pneumococcal vaccination status, education, consent, or declination since admission. R44 was admitted with diagnoses of diabetes mellitus, malnutrition, and COPD, and had a BIMS score of 13/15, indicating cognitive intactness. R65 was admitted with COPD, was alert and oriented x 3, and made his own medical decisions. On 1/13/2026, R65 told the surveyor he had been offered vaccinations on admission but had already received all vaccinations during a physician visit before admission; however, there was no documentation in the medical record to confirm this. The DON stated that newly admitted residents are reviewed for prior vaccination status, offered immunizations, and that consent or refusal should be signed and documented, but during the interview the DON could not locate consents, declinations, or documentation of assessments or education for either resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not maintain documentation of screening, education, offering, and/or declination of the COVID-19 vaccine for 2 residents, R44 and R65, out of 5 residents reviewed for COVID immunization in a sample of 17 residents. The facility also did not develop and implement policies and procedures regarding the COVID-19 vaccine immunization. The facility policy titled COVID-19 Policy, revised 05/11/2023, stated that it is recommended that everyone remain up to date with all recommended COVID-19 vaccine doses, but it did not include a COVID vaccination protocol for screening, education, or offering residents the vaccine. R44 was admitted with diagnoses including diabetes mellitus, malnutrition, and COPD, and had a BIMS score of 13/15, indicating cognitive intactness. R65 was admitted with COPD, had no BIMS score available, and was alert and oriented x 3 and made his own medical decisions. Surveyors observed signage indicating a positive COVID-19 outbreak in the facility, and record review showed no documentation in either resident’s medical record of assessment of COVID vaccination status, education on risks and benefits, consent, or declination since admission. R44 tested positive for COVID 10 days after admission, and at the time of admission there were 10 residents who were positive or had COVID-like symptoms and later tested positive within the prior 14 days. At the time of R65’s admission, 16 residents either tested positive or had COVID-like symptoms and later tested positive within the prior 14 days. The DON stated that admissions are offered immunizations upon admission or shortly after, that vaccination status is reviewed, education is provided, consent or declination is signed, and documentation is maintained, but the DON could not locate consents, declinations, or documentation of assessments or education for R44 or R65.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not ensure that 2 of 5 CNAs, CNA W and CNA G, received the required minimum of 12 hours of in-service training each year. Record review showed CNA W had a date of hire of 10/01/20 and CNA G had a date of hire of 07/02/24, and the facility did not provide 12 hours of in-service training for either CNA. The deficiency was identified through record review and interviews with facility leadership. During the survey, the NHA was asked for the continuing education hours for CNA W and CNA G, but stated the facility did not have a system to track continuing education hours. When asked how the facility calculates CNA continuing education hours each year for reporting, the NHA stated the facility was working on getting a system, such as Relias, so the hours could be tracked. The cited requirement also states in-service training must include dementia management training and resident abuse prevention training.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that daily nurse staffing information was accurately posted and updated, including the total number of hours and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift, potentially affecting all 47 residents in the facility. On entrance to the facility, the surveyor observed that the Direct Care Report posted in the lobby was dated several weeks earlier and reflected a census of 47, indicating it was not current. Subsequent review of staff schedules and staff postings from early December through mid-January showed that schedules had multiple marked changes on specific dates, but the corresponding daily staff postings did not reflect accurate staffing numbers for several of those days. During an interview, the Nursing Home Administrator and Assistant Nursing Home Administrator explained that the receptionist posts the daily staffing information in the morning after updating the census, and that the daily posting is not manually updated when staffing changes occur, with changes only reflected on the internal daily schedules rather than on the publicly posted staffing information. No specific residents, medical histories, or clinical conditions were described in the report beyond the total facility census of 47 residents who could be affected by the inaccurate staffing postings.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when the facility failed to consult with a physician and follow hospital discharge instructions regarding wound care for a resident admitted after hospitalization for sepsis related to necrotizing fasciitis and Fournier's gangrene. The resident, who had moderately impaired cognition, was discharged from the hospital with orders for a wound VAC (vacuum assisted closure) and vancomycin solution irrigation to be applied to a large right groin wound. Upon admission, these orders were not properly communicated or implemented by facility staff. Facility records and staff interviews revealed that the wound VAC and vancomycin solution were not available or administered as ordered. The admitting nurse, who was from an agency, did not ensure the wound care orders were entered or followed. Other nursing staff were unaware of the specific wound care requirements until several days after admission, and the vancomycin solution was never ordered. The wound VAC was not ordered until staff discovered documentation in the resident's room, and it was delivered two days after admission. During this period, the resident did not receive the prescribed wound care, and documentation of wound care was missing for several shifts. When the wound VAC was finally to be applied, staff discovered the resident's wound was contaminated with stool, and the resident was experiencing significant pain. The physician determined that the wound VAC had not been applied as intended and that the wound was at risk due to contamination. The resident was subsequently sent to the emergency room for wound care. Interviews with staff and review of records confirmed that the facility did not consult with a physician when unable to obtain the necessary wound care supplies and did not follow the hospital's discharge instructions for wound management.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when the facility failed to develop and implement a baseline care plan for wound care within 48 hours of admission for a resident who was admitted following hospitalization for sepsis related to necrotizing fasciitis and Fournier's gangrene of the right groin. The resident had a history of multiple debridements, extensive antibiotic therapy, and required a Foley catheter to maintain wound cleanliness. Upon discharge from the hospital, the resident had specific wound care orders, including the initiation of a wound VAC and vancomycin irrigation, as well as ongoing antibiotic therapy. Despite these complex medical needs and clear physician orders for wound care, the facility's care plan for the resident only included documentation for a Foley catheter and advanced directives, with no baseline care plan addressing wound care. This omission was confirmed during an interview with an LPN, who acknowledged that a baseline care plan for wound care had not been developed for the resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A resident was admitted to the facility following hospitalization for sepsis related to necrotizing fasciitis and Fournier's gangrene of the right groin, with a significant wound requiring specialized care. Upon admission, the resident had physician orders for wound care, including the use of a wound VAC and vancomycin solution irrigation, as well as a Foley catheter to maintain cleanliness. However, the facility failed to implement a baseline care plan addressing the resident's wounds, and the wound care orders were not accurately or promptly entered into the treatment administration record (TAR). The only wound care documented was a single wet-to-dry dressing change, and there was no evidence that the vancomycin solution was ordered or administered as prescribed. The facility did not ensure the timely provision of a wound VAC, which was specifically ordered to prevent contamination of the wound with stool due to its location and severity. The wound VAC was not ordered until several days after admission, and it did not arrive until the morning the resident was sent back to the hospital. During this period, the resident's wound was left exposed and ultimately became contaminated with stool, as documented by both a physician assistant and a physician who assessed the resident. The lack of appropriate wound care and delay in obtaining the wound VAC resulted in the resident experiencing significant pain and required transfer back to the hospital for further treatment. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's wound care needs and orders. The admitting nurse was from an agency and could not be interviewed, while other nursing staff were unaware of the specific wound care orders until documentation was found in the resident's room. The facility's documentation and assessment of the wound were also inaccurate, misclassifying the wound type and failing to measure it upon admission. No additional evidence was provided to support that the resident received the ordered care during the period in question.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to designate a registered nurse (RN) to serve as the Director of Nursing (DON) on a full-time basis, as required by federal regulations. Instead, the DON position was filled by an LPN, and there was a period when the facility had no DON at all. This was confirmed through interviews with the Assistant Nursing Home Administrator and the Assistant Director of Nursing, both of whom stated that after the previous DON, who was an RN, resigned, there was a gap before the LPN was hired as DON. During this time, the ADON, also an LPN, was the only nursing leadership present. The surveyor reviewed multiple complaint investigations and the facility's grievance log during the period when the LPN was serving as DON. Several complaint investigations resulted in citations related to pharmacy services, food procurement, catheter care, bedhold, notice of transfer, Ombudsman notification, CPR, intravenous fluids, medication errors, and quality assurance activities. The grievance log showed a notable number of grievances filed during the months when the LPN was acting as DON, indicating ongoing concerns during this period.