Geneva Lake Manor

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

Surveyors identified that the facility failed to provide necessary treatment and services to prevent and promote healing of pressure injuries for two residents. One resident, who had severe protein-calorie malnutrition, traumatic brain injury, dementia, and was receiving hospice care, had physician orders for Prevalon boots to be worn at all times while in bed due to bilateral heel pressure injuries. However, observations revealed the resident was in bed without the boots, and staff were unaware of the order. The care plan and care card did not reflect the order for Prevalon boots, and the boots were not initially found in the resident's room. Only after inquiry did staff locate and apply the boots, and the Director of Nursing acknowledged the care plan needed updating to include this intervention. Another resident, with vascular dementia, cerebral atherosclerosis, and an unstageable pressure injury on the coccyx, had a physician order to be laid down after all meals. Despite this, the resident was repeatedly observed in a broda chair in common areas after meals, contrary to the order. The wound was noted to be improving, but the facility leadership acknowledged the concern when it was brought to their attention. These findings demonstrate that the facility did not ensure physician orders related to pressure injury prevention and care were consistently implemented for residents at 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

A deficiency occurred when a resident with multiple complex medical conditions, including Parkinson's Disease, Type 1 and Type 2 Diabetes Mellitus, neurogenic bladder, and bilateral nephrostomy tubes, did not receive nephrostomy care in accordance with physician orders and professional standards. The resident's care plan required nephrostomy tube care every shift, and physician orders specified cleansing the insertion site with 1/4 strength Dakins solution, covering with calcium alginate, and then with 4x4 border gauze, ensuring no adhesive was on the tubing. Additionally, the orders required the use of securement devices for the nephrostomy tubes, to be replaced as needed if soiled or losing adherence. During observation, it was found that both nephrostomy sites were covered with a large ABD pad adhered with tape, rather than the ordered dressing materials. Furthermore, the right nephrostomy tube did not have a securement device in place, contrary to the physician's order. The LPN providing care had to obtain and apply the securement device during the observation. The DON confirmed that the nephrostomy tubes should always have securement devices and should not be covered by ABD pads. No additional information was provided by the facility regarding these concerns.

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 a resident requiring dialysis received care and services consistent with professional standards of practice, specifically regarding communication and monitoring before and after dialysis treatments. The facility's policy required staff to communicate with the dialysis center before and after each treatment using a designated communication form and to coordinate care plans, including any special considerations and emergency contacts. However, for one resident with a complex medical history—including end stage renal disease on hemodialysis, congestive heart failure, COPD, diabetes with complications, and a history of unresponsive episodes primarily after dialysis—these procedures were not followed. The resident had recently been hospitalized for chest pain and shortness of breath, during which multiple unresponsive episodes occurred, mostly during hemodialysis. Hospital records indicated that these episodes were likely functional neurologic syndrome and recommended close monitoring, with instructions not to send the resident to the hospital unless new symptoms arose. Despite this, the facility did not document the resident's history of unresponsive episodes or the need for additional monitoring after dialysis. On one occasion, after returning from dialysis, the resident complained of a headache, had difficulty speaking, and exhibited abnormal vital signs, but there was no documentation of a post-dialysis assessment or evidence that staff were aware of the resident's specific risks. Review of facility records showed that the dialysis communication form for the relevant date was not completed upon the resident's return, and there was no evidence that staff contacted the dialysis center to obtain a report as required by policy. Nursing staff interviewed were not aware of any special monitoring needs for the resident, and documentation of vital signs lacked time stamps. The lack of communication and failure to follow established procedures resulted in the resident not receiving dialysis care and monitoring consistent with professional standards.

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 prescribed medications were administered to residents in a timely manner, as required by facility policy and physician orders. For one resident with type 2 diabetes, obesity, and COPD, multiple weekly doses of Ozempic injections were not administered because the medication was not available on several scheduled dates across three months. Medication Administration Records (MARs) documented the absence of the medication, and the Director of Nursing (DON) attributed the issue to nurses not ordering medications on time, though no further explanation was provided for the missed doses. Another resident with Parkinson's Disease, type 1 and type 2 diabetes, and an amputation experienced delays in receiving morning medications, including insulin and Parkinson's medications. On the day of surveyor observation, the resident reported only receiving an early morning dose and was still waiting for the remainder of the scheduled medications after breakfast. The delay was due in part to the LPN needing to retrieve medication cart keys after being temporarily absent from the facility. The LPN confirmed that the resident's medications, including insulin, had not been administered on time and had not performed a blood sugar check prior to breakfast. Review of the MAR and physician orders confirmed that several medications were either marked as given on time despite being administered late or were documented as not available. The DON acknowledged awareness of the late administration and high blood sugar reading but could not explain discrepancies in MAR documentation. No additional information was provided regarding the reasons for the late or missed medication administration.

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 a resident with diagnoses including Parkinson's Disease, Type 1 and Type 2 Diabetes Mellitus, and an acquired absence of the right leg below the knee did not receive prescribed insulin medications according to physician orders and facility policy. The resident, who had intact cognition and required insulin therapy, did not receive the scheduled 8 AM dose of Insulin glargine until after 11 AM. Additionally, the resident's Lispro insulin, which was ordered to be administered 15-20 minutes before meals, was not given as directed, and the 8 AM dose was held without a physician order. The resident also did not have a blood glucose check or receive insulin prior to breakfast as required. The sequence of events began when the resident, who typically got up around 5:30 AM, was not out of bed until around 9 AM for reasons that were unclear. The LPN responsible for medication administration had to leave the facility for approximately 15 minutes, and the Director of Nursing (DON) was unable to cover the medication cart due to other responsibilities. As a result, the resident's morning medications, including insulin, were significantly delayed. When the LPN returned, the resident's blood glucose was found to be 300, and the LPN administered the long-acting insulin and made decisions regarding the short-acting insulin without timely physician consultation or adherence to the special instructions for administration relative to meals. Documentation reviewed by the surveyor confirmed that the insulin doses were either late, held without a physician order, or not administered according to the specified timing in the orders. The facility's medication administration policy required medications to be given within one hour of the prescribed time and for any deviations to be documented and communicated appropriately. The DON was unable to explain why the Lispro was marked as held and then given at noon, or why the special instructions for timing with meals were not followed. No additional information was provided to clarify the rationale for these actions.

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 was identified when an LPN failed to perform required hand hygiene during the provision of wound care to a resident with severe cognitive impairment and total dependence for activities of daily living. The resident, who was on hospice care for dementia and had a stage 3 pressure injury, was observed during a wound treatment procedure. The facility's hand hygiene policy requires hand hygiene before and after resident contact, after glove removal, and before performing aseptic tasks. However, the LPN did not perform hand hygiene after cleaning up an incontinence episode, after removing gloves, or before proceeding with wound care and dressing changes. During the observed procedure, the LPN washed hands and donned gloves before touching the resident, but subsequently failed to perform hand hygiene at multiple required points, including after removing soiled gloves and before handling the wound and dressing supplies. The LPN continued to change gloves and handle both the wound and the resident's environment without performing hand hygiene as outlined in the facility's policy. The deficiency was confirmed through observation, interview, and record review.

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 treatment and care in accordance with professional standards of practice and the Wisconsin Nurse Practice Act for a resident who experienced a significant change in condition. The resident, who had a history of diabetes mellitus, Parkinson's disease, and severe cognitive impairment, became increasingly lethargic, refused food, had a small emesis, and had not had a bowel movement for three days. Despite these changes, there was no documentation of a nursing assessment, including vital signs, at the time of the change in condition. Additionally, there was no documentation of the emesis, administration or results of medication for constipation, or the administration and results of a COVID-19 test, even though these were referenced in a nurse practitioner's note. Laboratory work was ordered and collected, and results showed a critically elevated white blood cell count, which was reported to the facility late in the evening. However, there was no evidence that facility nursing staff acknowledged receipt of these results, notified the nurse practitioner or physician, or monitored the resident for further decline. Interviews with staff revealed a lack of communication between shifts regarding the resident's change in condition and pending laboratory results. Staff on subsequent shifts were unaware of the resident's status or the need for close monitoring, and no vital signs or assessments were documented after the initial change in condition. On the following day, the resident was found to be in severe distress, with altered mental status and respiratory difficulty, and was transferred to the hospital by EMS. Hospital records confirmed diagnoses of septic shock due to a urinary tract infection, acute hypoxic respiratory failure, and cardiogenic shock. There was no documentation in the facility's records prior to transfer explaining the circumstances leading to the emergency call or the resident's deteriorating condition. The lack of assessment, monitoring, documentation, and communication among staff directly contributed to the failure to provide care according to professional standards and the resident's comprehensive assessment.

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 implement its abuse prevention policy and procedure regarding timely employee background checks for one of eight employees reviewed. Specifically, a dietary aide who was also working as an activity aide did not have an updated background check completed within the required four-year interval. The employee was initially hired with all required background check documentation completed at that time, but no subsequent background check was performed by the four-year deadline as mandated by facility policy. This lapse was identified during a review of personnel files requested by the surveyor. The Director of Nursing acknowledged the oversight when informed, and the Human Resources representative confirmed that background checks are their responsibility. The deficiency was confirmed when the Nursing Home Administrator provided background check forms for the employee that were only completed on the day of the survey, rather than within the required timeframe.

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 nursing staff, specifically a certified nursing assistant (CNA) and a medication technician (MT), possessed the appropriate competencies and skills to assure resident safety and respond to resident needs. The CNA assessed vital signs for a resident experiencing a change of condition without documented proof of competency to collect vitals and without a comprehensive assessment being performed by a registered nurse (RN) or monitoring by a licensed practical nurse (LPN). According to facility policy and job descriptions, CNAs are required to report changes in resident condition to a nurse, and only nurses or trained med techs are permitted to take vital signs in certain situations. Interviews with staff and review of records confirmed that the CNA took vital signs during a change of condition, and there was no evidence of a licensed nurse assessment or documentation of the vital signs in the resident's medical record. Additionally, the MT responsible for blood draws did not have evidence of certification to perform blood draws as required by state regulations. The facility relied on the MT to perform all blood draws, as the contracted laboratory did not provide this service. When requested, the facility was unable to provide documentation of the MT's certification for blood draws, only that the MT had requested transcripts of a completed course. This lack of documentation meant the facility could not demonstrate that the MT was qualified to perform this task. Furthermore, the MT did not complete the required four hours of pharmacy-related in-service education for each of the past three calendar years, as mandated by state guidelines. Review of the MT's education records showed insufficient hours in 2022, 2023, and 2024, with no education provided in 2022 and less than the required hours in subsequent years. The MT did meet the requirement for hours worked, but the deficiency in required education and lack of certification documentation for blood draws affected the facility's ability to ensure safe and competent care for approximately 25 residents in the affected zones.

Penalty

Inspection fine: $113,919

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 care consistent with professional standards of practice to prevent the development and worsening of pressure injuries for six residents who either had pressure injuries or were at risk. Multiple residents did not receive comprehensive skin assessments upon admission, and subsequent wound documentation was often inaccurate, incomplete, or missing. For example, one resident was admitted with multiple wounds, but the initial skin assessment was not completed, and subsequent documentation lacked measurements, staging, and descriptions. Wounds were not assessed weekly as required, and there were significant gaps in documentation, with some wounds not being documented for weeks at a time. In several cases, wounds progressed in severity, including deep tissue injuries advancing to unstageable or Stage 4 pressure injuries, and new wounds developed during the residents' stays. Interventions to prevent pressure injuries, such as the use of pressure-relieving mattresses, heel boots, and regular repositioning, were inconsistently implemented or not documented as being in place. Observations revealed that some residents' heels were left on mattresses without proper offloading, and prescribed support surfaces were not always functioning (e.g., an unplugged air mattress). In one case, a resident with limited mobility and a prescribed immobilizer brace did not have evidence of regular skin checks under the device, increasing the risk for device-related pressure injuries. Additionally, care plans and interventions were not always updated or followed, and there was conflicting or unclear documentation regarding wound locations and status. Nutritional interventions recommended by the Registered Dietician (RD) to support wound healing were not implemented in a timely manner, with some recommendations not being followed for over two months. The RD's recommendations for wound healing supplements were documented repeatedly without action, and the RD reported a lack of confidence that their recommendations would be implemented. Overall, the facility did not adhere to its own policies and procedures for pressure injury prevention and management, including timely assessments, accurate documentation, implementation of preventive interventions, and prompt follow-through on interdisciplinary recommendations.

Penalty

Inspection fine: $113,919

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 was identified when a resident with bilateral nephrostomy tubes experienced repeated complications, resulting in six transfers to the emergency department within a 120-day period. The resident, who is cognitively intact and has multiple comorbidities including neuromuscular bladder dysfunction and diabetic nephropathy, required specialized care for nephrostomy tubes. The care plan included interventions such as the use of an abdominal binder, regular assessment and documentation of drainage, monitoring for infection, and catheter care. However, the care plan also contained outdated interventions that were not relevant to the resident's current needs, such as references to a Foley catheter and voiding trials. Despite the care plan, the resident experienced multiple incidents of nephrostomy tube dislodgement, malfunction, and infection. Documentation revealed that tubes were frequently pulled out during transfers, particularly with the use of a Hoyer lift, and that staff sometimes improvised solutions, such as attaching a Foley catheter to the nephrostomy tube. The resident also developed infections requiring hospitalization and intravenous antibiotics. Interviews with staff and the resident indicated inconsistent use of the abdominal binder, with the resident discontinuing its use due to a rash, and staff not being fully aware of this change. Training for staff on nephrostomy tube care and safe transfer techniques was limited to verbal discussions and occasional meetings, with no formal competency assessment documented in the facility assessment. Surveyor interviews further revealed that staff had only minimal training on nephrostomy tube care, and that interventions to prevent tube dislodgement were not consistently implemented or updated based on the resident's feedback and clinical needs. The facility's failure to ensure staff competency, update care plans appropriately, and consistently implement interventions led to repeated medical interventions and hospitalizations for the resident.

Penalty

Inspection fine: $113,919

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 a charge nurse was designated for each shift, as required to meet the needs of all residents. Over a 30-day review period, nursing staff schedules did not indicate who was assigned as charge nurse for each tour of duty. When questioned, the nursing scheduler stated that during the day, the DON or Assistant DON were present, and on the PM shift, the Nurse Educator was usually in the building, with an on-call person listed at the bottom of the schedule for contact by phone. However, there was no clear designation of a charge nurse physically present in the building for each shift on the schedules. The facility did not provide further explanation for the lack of a designated charge nurse for each shift.

Penalty

Inspection fine: $113,919

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 comprehensive infection prevention and control program, as evidenced by incomplete surveillance data, lack of infection rate calculations, and deficiencies in the water management plan. Outbreak summaries and line lists for COVID-19 and other infections were inconsistent, with mismatched numbers of affected residents and staff, and incorrect outbreak conclusion dates. The infection preventionist acknowledged not calculating monthly infection rates, and the Quality Assessment and Assurance (QAA) committee was only provided with line lists, making it difficult to identify infection trends. The water management plan lacked a detailed description and diagram of the water system, did not include all required team members, and failed to identify control measures and monitoring processes. Water temperature logs showed readings below CDC recommendations, and there was no clear policy for corrective action when temperatures were not met. Multiple residents under Enhanced Barrier Precautions (EBP) due to wounds or indwelling devices did not receive appropriate infection control measures during care. Staff, including registered nurses and certified nursing assistants, were observed performing wound care and incontinence care without donning required personal protective equipment (PPE) such as gowns, despite signage indicating EBP status. Staff also brought treatment carts into resident rooms during wound care, contrary to best practices. Interviews with staff revealed a lack of understanding or adherence to EBP protocols, with some staff unaware of the need for PPE or the reasons for EBP status. The facility's policies and procedures for infection surveillance, EBP, and water management were not fully implemented or followed. The infection preventionist was not consistently involved in the water management team, and documentation for water system control measures was incomplete. Logs for cleaning and sanitizing equipment and fixtures were not always filled out, and the facility's water temperature policy conflicted with CDC guidelines. These deficiencies affected the facility's ability to prevent, identify, report, and control infections and communicable diseases, and to maintain a sanitary environment for all residents.

Penalty

Inspection fine: $113,919

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 implement its antibiotic stewardship program as required, potentially affecting all 53 residents. Review of infection surveillance logs revealed that antibiotics were administered to residents without documentation of appropriate use, specifically lacking evidence that the McGeer criteria were reviewed prior to starting antibiotics. The Assistant Director of Nursing (ADON) acknowledged that while the facility aimed to use the McGeer criteria for each resident on antibiotics, this had not been consistently done. Infection surveillance logs for several months showed multiple residents receiving antibiotics without the required documentation of McGeer criteria review. Specific examples included residents diagnosed with urinary tract infections who were started on antibiotics without a completed McGeer criteria review documented in their records. In one case, a resident was prescribed Macrobid following a urine culture, and in another, a resident was switched to ciprofloxacin based on physician orders, but in both cases, there was no evidence that the McGeer criteria had been reviewed prior to antibiotic initiation. The surveyor confirmed with facility leadership that there was no documentation in the medical records to support that the standard of practice for antibiotic stewardship was followed before antibiotics were administered.

Penalty

Inspection fine: $113,919

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 each resident’s drug regimen was free from unnecessary medications, as evidenced by the lack of follow-up on pharmacy consultant recommendations for five residents. For each of these residents, the pharmacy consultant provided monthly medication regimen reviews with specific recommendations, such as discontinuing unused PRN medications, monitoring for drug interactions, and updating medication administration instructions. However, the facility did not obtain or document physician responses to these recommendations, nor did they include the pharmacy reports and responses in the residents’ permanent medical records as required by policy. For example, one resident with dementia, anxiety, and depression had recommendations to discontinue an unused PRN medication and to reevaluate the use of multiple medications known to prolong the QT interval. Another resident receiving an inhaled corticosteroid was recommended to have their order updated to include mouth rinsing instructions to reduce the risk of thrush, but there was no evidence of physician review or order update. Additional residents had recommendations related to discontinuing unused medications, monitoring lab work for those on antiplatelets, and ensuring appropriate monitoring for anticoagulant and antidepressant medications, none of which were documented as addressed by the facility. Interviews with the DON and Administrator confirmed that there was a breakdown in the system for communicating pharmacy recommendations to physicians, and that pharmacy reports were not consistently available in the medical records. In several cases, pharmacy recommendations had to be downloaded and printed upon request, indicating they were not integrated into the residents’ records. The facility was unable to provide evidence that pharmacy recommendations were reviewed or acted upon by physicians, resulting in noncompliance with both facility policy and regulatory requirements for medication regimen review.

Penalty

Inspection fine: $113,919

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

Dietary staff failed to adhere to facility policy and professional standards regarding food safety and hygiene during breakfast service. A dietary aide was observed serving food and taking food temperatures in the common dining room without wearing a hair net, despite facility policy requiring hair restraints to prevent hair from contacting food. The aide acknowledged she was supposed to wear a hair net at all times while serving food but was not wearing one when observed, stating she had just returned from the restroom and was caught off guard. The aide was later seen wearing a hair net during the same meal service. Additionally, food temperatures were not obtained or documented prior to or during the breakfast service, as required by facility policy. The temperature log for the morning in question had no entries at the time residents were eating, and only one temperature was recorded after the surveyor prompted the aide. The cook confirmed that food temperatures are expected to be taken and documented before and during meal service, and that additional entries should have been present for the breakfast period. These lapses in food safety practices had the potential to affect all residents receiving meals in the common dining room.

Penalty

Inspection fine: $113,919

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 a resident was transferred to a different room upon return from the hospital without being provided prior written notice or an explanation for the room change. The facility failed to take the resident's preferences into account or offer a choice of available rooms, and there was no documentation that the resident or their representative received information about the reason for the transfer. The facility's own policy requires orientation to the transfer, information about the new room and roommate, and written documentation of the process, none of which were followed in this case. The resident, who was cognitively intact and able to make decisions, was readmitted to the facility with a history of MRSA, hemiplegia, Parkinsonism, diabetes with nephropathy, and neuromuscular bladder dysfunction. Upon return, the resident was placed in a new room due to the MRSA diagnosis, but was not given notice or an opportunity to view or choose the new room. The resident expressed confusion and concern about the move, noting that personal belongings and decorations were not promptly transferred and that there was uncertainty about the duration of the room assignment. Interviews with facility staff revealed a lack of clear communication and documentation regarding the room change. Staff members were unsure about the process for organizing the resident's new room and could not provide evidence that the resident had been informed in advance or that their preferences were considered. There was also no documented follow-up on how the resident was adjusting to the new environment, further indicating noncompliance with facility policy and regulatory requirements.

Penalty

Inspection fine: $113,919

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

Staff did not follow a resident's documented preference to be woken up at 6:30 AM, as outlined in the care plan and posted reminders. Despite clear instructions in the care plan, including signs in the resident's room and at the nurses' station, the resident was not consistently assisted to get up at the requested time after returning from a hospital stay. Observations by the surveyor on multiple mornings found the resident still in bed or receiving morning care well after the preferred wake time. Interviews with the resident confirmed that their request to be up by 6:30 AM had not been honored since their recent readmission, impacting their ability to maintain independence and meet personal needs. The resident, who is cognitively intact and has a history of insomnia, expressed that being up in their power wheelchair by the requested time is essential for independence, including access to food, water, and medications. Staff interviews revealed inconsistent documentation of refusals and a lack of adherence to the resident's stated preferences. The Director of Nursing acknowledged the issue, noting that refusals should be documented but were not. The deficiency centers on the facility's failure to promote and facilitate the resident's right to self-determination regarding their sleep schedule.

Penalty

Inspection fine: $113,919

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 a resident was free from the use of physical restraints that were not required to treat a medical symptom and did not document ongoing re-evaluation of the need for such restraints. Specifically, a resident with multiple diagnoses, including hemiplegia, Parkinsonism, and diabetic nephropathy, was found to have an abdominal binder in place that restricted freedom of movement and could not be easily removed by the resident. The medical record lacked a physician's order, signed consent, documentation of the binder as the least restrictive alternative, scheduled times for use, and ongoing evaluation of the need for the binder. The resident's Minimum Data Set (MDS) indicated no use of physical restraints, and there was no evidence in the Medication Administration Record (MAR) or Treatment Administration Record (TAR) of monitoring the restraint. Interviews with facility staff revealed that the abdominal binder was implemented to prevent dislodgement of nephrostomy tubes during transfers, but there was no assessment or consideration of the binder as a restraint. The resident reported discontinuing use of the binder due to a rash, and staff were unaware of this change. The care plan referenced the binder for tube placement but did not document the rationale, duration, or alternative interventions. The facility did not provide evidence of a comprehensive assessment or care plan for the use of the abdominal binder as a restraint.

Penalty

Inspection fine: $113,919

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 complete a Pre-Admission Screening and Resident Review (PASARR) Level I assessment for a resident upon admission. The facility's policy requires that all new admissions and readmissions be screened for mental disorders, intellectual disabilities, or related disorders through the PASARR process, regardless of payer source. The resident in question was admitted with documented diagnoses of bipolar disorder, depression, anxiety, and PTSD, as noted in both the facility and hospital records. Despite these diagnoses, there was no evidence that a Level I PASARR was completed at the time of admission. The Medicaid Pending Manager (MPM) confirmed during an interview that she is responsible for reviewing new admissions and completing the Level I PASARR, but acknowledged that the assessment for this resident was not completed until the day of the survey. The delay was attributed to the MPM's workload across multiple facilities, resulting in the oversight. The Level I PASARR was only completed and submitted on the day of the survey, and a Level II PASARR was requested but not yet completed. Facility leadership was made aware of the deficiency during the surveyor's visit.

Penalty

Inspection fine: $113,919

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 a resident with a history of swallowing difficulties and multiple diagnoses, including neuropathy, dementia, and GERD, experienced a choking episode while eating breakfast. The resident had previously shown signs of coughing and choking during meals and was on a mechanically altered diet. Despite these documented concerns, after the choking incident, nursing staff did not immediately notify the physician or update the resident's plan of care to address the swallowing issue. There was also no immediate referral to the dietician or speech therapy to reassess the resident's dietary needs or supervision requirements. The medical record review revealed that the resident's choking episode was not promptly communicated to the interdisciplinary team, including the dietician and speech therapist. The resident continued to receive meals with larger food items, such as sausage, that were not pre-cut, contrary to previous recommendations. The lack of timely assessment and intervention following the choking incident meant that the resident's risk for further choking was not adequately addressed. Staff interviews confirmed that key team members were not made aware of the incident, and there was a delay in obtaining orders for further evaluation, such as a swallow study and speech therapy assessment. The deficiency was further evidenced by the absence of documentation regarding follow-up actions after the choking event, including the lack of immediate changes to the resident's diet or supervision level. The facility did not ensure that the resident received the necessary care and services to prevent further accidents related to swallowing difficulties. This lapse in care created a situation where the resident remained at risk for additional choking episodes without appropriate safeguards in place.

Penalty

Inspection fine: $113,919

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 a resident, who previously had an indwelling urinary catheter, did not receive a comprehensive bladder assessment or an updated care plan after the catheter was removed. The facility's policy requires a thorough assessment and the development of a toileting program to restore continence, but this was not completed for the resident. The care plan continued to reference the indwelling catheter even after its removal, and no new interventions or toileting plans were implemented to address the resident's urinary incontinence. The resident, who was cognitively intact and had multiple medical diagnoses including fractures, diabetes, congestive heart failure, and morbid obesity, was observed to be lying in bed with a soiled incontinence brief and an odor of urine. The resident reported not being changed since the previous night and expressed a desire for a bedside commode to avoid urinating in the brief. Staff interviews confirmed that while hourly documentation of voiding and incontinence care was completed, no nurse or nurse manager reviewed this information to establish a toileting program such as prompted voiding. Further interviews revealed that the resident was aware of the need to urinate and could communicate this to staff, but was not offered appropriate toileting options such as a bedside commode or a properly positioned bed pan. The lack of a comprehensive assessment and individualized toileting plan following catheter removal led to the resident continuing to experience unmanaged urinary incontinence.

Penalty

Inspection fine: $113,919

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 medical conditions, including a left femur fracture, hemiparesis, polyneuropathy, and cerebrovascular disease, experienced a significant weight loss of 9.2% over a two-month period. The resident was dependent on staff for all activities of daily living and was initially assessed as low nutritional risk, but later developed a stage 3 pressure injury and was identified as high nutritional risk due to wounds. The resident's weight was not consistently monitored, with a missing weight record for one month, and the facility failed to implement recommended interventions from the Registered Dietician (RD), such as providing a liquid protein supplement and conducting weekly weights after the significant weight loss was identified. The RD made several recommendations over the course of the resident's stay, including offering a house supplement daily, obtaining recent and weekly weights, and providing additional protein to support wound healing. Despite these recommendations, documentation shows that the facility did not timely initiate or follow through with the RD's interventions. The care plan included monitoring and recording weight, notifying the healthcare provider and family of significant weight changes, and providing supplements as ordered, but these actions were not consistently carried out. Interviews with staff revealed a lack of clarity regarding facility procedures for obtaining weights and a delay in responding to dietary recommendations. The newly appointed RD confirmed that recommendations should be implemented within 24 hours and noted that the previous RD had reported issues with the facility not responding to or following up on recommendations. The survey team found that the facility did not adequately address the resident's nutritional needs, as evidenced by the unaddressed weight loss and lack of timely intervention.

Penalty

Inspection fine: $113,919

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 a resident requiring dialysis received care and services consistent with professional standards, specifically regarding communication with the dialysis center before and after treatments. The facility's policy requires staff to communicate with the dialysis center using a designated communication form for each dialysis visit. However, for a resident with diagnoses including dementia, pleural effusion, end stage renal disease, and dependence on renal dialysis, only two dialysis communication forms were found in the medical record for January and February, despite multiple scheduled dialysis sessions during that period. Interviews with staff revealed that the process involves sending an orange folder with the resident containing pertinent information to the dialysis center, which is supposed to return the completed form after each treatment. Despite this process, several communication forms were missing for multiple dialysis dates, and the issue persisted even after the facility administration had discussed the problem with the dialysis center. No additional documentation was provided to account for the missing forms.

Penalty

Inspection fine: $113,919

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 diagnoses including Parkinsonism, MRSA, hemiplegia, type 2 diabetes with nephropathy, and neuromuscular bladder dysfunction did not receive three scheduled doses of Amantadine HCl 100mg, a medication ordered once daily for Parkinsonism. The medication administration record (MAR) documented these missed doses as 'drug/item unavailable' over several days, despite a physician order in place. On one of the days, the medication was signed out as given, but the surrounding missed doses and documentation raised questions about its actual administration. The resident was cognitively intact, able to communicate, and reported to the surveyor that improper medication or dosing occurred at least three times a week, requiring vigilance during medication administration. Interviews with facility staff revealed that the Amantadine HCl had been delivered and placed in an overflow area, but nurses did not check there, resulting in the missed administrations. The medication was not available in the contingency supply, and staff were unclear about the process for locating and administering the medication. There was no further explanation provided as to why the facility failed to ensure the resident was free from this significant medication error, as required by facility policy and physician orders.

Penalty

Inspection fine: $113,919

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 nurse staffing data, including the date, resident census, and total actual hours worked by RNs, LPNs, and CNAs, was posted daily in a visible location. Over a review of 30 days, there were no nurse staff postings available, and the facility had no record of such postings being completed or maintained for the past 18 months. When the surveyor requested to see the postings, none were found in the reception area or other visible locations accessible to residents and visitors. Interviews with facility staff revealed that the nurse staffing information was being posted inside the nurse stations, which required entry through a closed door and was not accessible to the public. The information posted was the nursing staff schedule, not the required staffing data, and it lacked pertinent details. Staff acknowledged that this method did not meet the requirements for visibility or content, and the deficiency had the potential to affect all 53 residents currently residing in the facility.

Penalty

Inspection fine: $16,801

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 appropriate treatment and care for two residents experiencing a medical change in condition, as per the standards of practice consistent with the Wisconsin Nurse Practice Act. One resident, who had a history of aphasia, hemiplegia, gastrostomy, diabetes, and severe sepsis with septic shock, developed a high fever, erratic pulse, and oxygen saturations, and had rapid gargled breathing. Despite these symptoms, there was no evidence of communication with a medical provider for consultation and treatment. The resident experienced cardiac arrest and passed away in the facility. The lack of medical intervention for the resident's high temperature, gargled breathing, high blood sugar, and erratic vital signs created a finding of immediate jeopardy. Another resident, who had a diagnosis of vascular dementia and a urinary tract infection, experienced blood in their urine after completing an antibiotic course. There was no assessment or notification to a medical provider about the resident's change in condition until several days later. The resident was eventually taken to the hospital by their family and diagnosed with a urinary tract infection and sepsis. The facility's delay in assessing the resident and consulting with a medical provider contributed to the resident's deteriorating condition. The facility's policy required prompt notification of changes in a resident's condition to the attending physician and the resident's representative. However, in both cases, there was a lack of thorough assessment, documentation, and communication with medical providers regarding the residents' changes in condition. This failure to adhere to the facility's policy and the standards of practice for registered nurses resulted in significant deficiencies in the care provided to the residents.

Removal Plan

• All nurses were provided education related to recognition of physiological changes of condition as well as reporting of such changes of condition.
• Education provided includes interventions, notifications and documentation. The education includes review of facility policy and procedure as it relates to condition changes, response to those changes and appropriate notifications to provider.
• Establish a standard for vital signs parameters so that nursing staff call 911 if they are unable to reach a medical provider.
• The Stop and Watch Early Warning Tool Interact tool has been implemented. The tool is available electronically within the EHR and copies have been made and placed in all nursing assistant and ancillary staff work stations.
• All direct care staff will be educated on the Stop and Watch Early Warning tool as well as reporting any resident change of condition to a nurse.
• Mandatory education is to include agency staff.
• Post tests given following education to ensure competency in both notification and treatment responses as well as when to use the Stop and Watch tool.
• The Change of Condition policy has been reviewed by the DON and with the Medical Director. Modifications include the addition of: Examples of change of condition, Use of Interact tools-Stop and Watch, VS will be taken immediately or as soon as possible with a change of condition. Once VS and immediate assessment is completed, MD will be notified. VS will be taken a minimum of every 4 hours and more frequently as indicated by the change in condition or MD order.
• All changes of condition will be listed on the 24-hour report board.
• The DON and ADON will review progress notes and 24-hour report board for any changes of condition to ensure all resident condition changes have been identified and action taken in response to resident condition changes.
• Audits will continue and results will be brought to the quality improvement committee for review.

Penalty

Inspection fine: $16,801

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 address and resolve grievances for four residents, as observed through interviews and record reviews. One resident, who was receiving dialysis, had multiple complaints about medication administration and staffing issues that were communicated by the dialysis center to the facility. Despite these communications, no grievances were recorded or investigated by the facility. The resident's dialysis social worker confirmed that the resident was alert and oriented, and the facility's grievance log showed no entries for this resident. Another resident's Power of Attorney filed a grievance regarding medication administration, which was not thoroughly investigated. The social worker only interviewed the nurse on duty and did not review the medication administration record or interview other witnesses. The social worker assumed there was no issue because the resident was sleeping peacefully, despite the POA's concerns about restlessness and medication administration. A grievance was also filed on behalf of a resident by hospice staff, reporting neglect when the resident was found soiled and wet. The facility did not thoroughly investigate this grievance, as no other residents were interviewed, and staff education was not adequately documented. Additionally, another resident expressed concerns about long call light response times and inadequate care, but the investigation lacked documentation of staff interviews or a resolution plan to prevent recurrence. The facility's failure to properly document and investigate these grievances indicates a significant deficiency in their grievance handling process.

Penalty

Inspection fine: $16,801

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 report several allegations of abuse, neglect, and injuries of unknown origin to the Nursing Home Administrator (NHA) and the State Agency within the required time frames. Resident 12 had an allegation of neglect on August 28, 2024, which was not reported to the NHA until September 6, 2024, when a grievance was filed. The allegation was never reported to the State Agency. Resident 12, who was enrolled in hospice services, was found by hospice staff with urine and feces on them and experienced a fainting episode. The registered nurse involved did not recall reporting the concern to anyone, and the assistant nursing home administrator admitted that it did not occur to them to submit a report to the State Agency. Resident 9 was observed with bruising to the left side of their face on August 17, 2024, which was not reported to the NHA, State Agency, or police within the required two-hour window. The resident was cognitively impaired and had a history of cerebral infarction and other conditions. The injury was only reported after the resident returned from the hospital, and the NHA began an investigation. The Director of Nursing acknowledged the delay in reporting and had no additional information to provide. Resident 10 expressed a grievance about long call light response times, which resulted in an incontinent episode. The grievance was not reported to the State Agency as neglect. The social worker involved directed the concern to the appropriate department, but the Director of Nursing did not recall the concern. Additionally, Resident 5 had a bruise of unknown origin on their wrist, which was not reported to the State Agency. The Licensed Practical Nurse who documented the bruise did not report it to anyone, assuming the progress note would suffice. The Director of Nursing was unaware of the bruise until the surveyor's visit.

Penalty

Inspection fine: $16,801

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 allow a resident's representative to exercise their rights as delegated by an activated power of attorney (POA). The resident, who was deemed incapacitated by a physician and a psychologist, was admitted to the facility without the presence of their designated POA, FM-Z. Despite the activation of the POA, the resident signed all admission consents and contracts, which should have been signed by FM-Z. The facility's policy required that the decisions of a resident representative be treated as the decisions of the resident, but this was not adhered to in this case. The resident had a history of multiple medical conditions, including a wedge compression fracture, lung cancer, malnutrition, Parkinsonism, congestive heart failure, atrial fibrillation, emphysema, and peripheral vascular disease. Despite being assessed as incapacitated, the resident was involved in signing various admission documents, including consents for treatment and advanced directives, without the involvement of the activated POA. The facility's failure to involve the POA in the admission process and decision-making was a significant oversight. Throughout the resident's stay, there were multiple instances where the facility did not adequately involve the POA in decision-making processes, including care conferences and discharge planning. The resident expressed a desire to revoke the POA, citing concerns about the POA's intentions, but the facility did not take appropriate steps to address the situation or ensure a new decision-maker was appointed. The facility's inaction in involving the POA and addressing the resident's concerns about their decision-making rights led to a deficiency in the care provided.

Penalty

Inspection fine: $16,801

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 all alleged violations involving abuse, neglect, exploitation, or mistreatment were thoroughly investigated for a resident who had an injury of unknown origin. The facility's policy on investigating allegations requires that all allegations be thoroughly investigated, with the administrator initiating the investigation and ensuring that the resident and their representative are informed of the progress. However, in this case, the facility did not initiate an investigation into the resident's bruise of unknown origin until it was brought to their attention by a surveyor. The resident involved was admitted with diagnoses including encephalopathy, vascular dementia, and general anxiety disorder, and was on hospice care. The resident's medical record indicated a bruise on the left wrist of unknown cause, documented by an LPN. Despite the facility's policy, the investigation was only initiated after the surveyor raised concerns during a meeting with facility staff, indicating a lapse in the facility's adherence to its own procedures for handling such incidents.

Penalty

Inspection fine: $16,801

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 for two residents, R16 and R7, within 48 hours of their admission, as required by their policy. R16 was admitted with multiple diagnoses, including metabolic encephalopathy, vascular dementia, and severe sepsis, and required significant assistance with daily activities. Despite these needs, a baseline care plan was not initiated until four days after admission. The Director of Nursing (DON) acknowledged the oversight, attributing it to a transition period and the absence of an admissions nurse, but confirmed that a care plan should have been in place upon admission. For R7, a baseline care plan was initiated on the third day after admission, but it lacked individualized, person-centered interventions. R7 had complex medical conditions, including a wedge compression fracture, lung cancer, and Parkinsonism, necessitating specific care approaches. The care plan initially documented generic interventions without selecting the appropriate care level based on R7's needs. It was only revised three days post-admission to include personalized care strategies. The Assistant Nursing Home Administrator (ANHA) admitted to not reviewing the care plan closely and agreed that it lacked personalization until revised. The surveyor's findings highlighted the facility's failure to adhere to its policy of creating a baseline care plan within 48 hours of admission, which is crucial for meeting residents' immediate health and safety needs. The lack of timely and individualized care plans for R16 and R7 indicates a gap in the facility's admission process and care planning, as acknowledged by the facility's staff during interviews with the surveyor.

Penalty

Inspection fine: $16,801

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 a proper discharge plan for a resident, leading to an unsafe transition to home care. The resident, who was incapacitated and had no appointed decision maker, was discharged without home health services or medications. The facility's policy required an individualized post-discharge plan, but this was not effectively implemented for the resident. The resident had a history of multiple medical conditions, including a wedge compression fracture, cancer, and Parkinsonism, and was deemed incapacitated by medical professionals. Despite this, the resident revoked the existing Power of Attorney (POA), leaving them without a designated decision maker. The facility did not adequately address this change in the resident's decision-making capacity, resulting in a lack of coordination for necessary post-discharge services. Interviews and documentation revealed that the facility did not conduct a discharge meeting with the resident's family members, and there was no evidence of a safe discharge plan. The resident was discharged without the necessary support, as home health services could not be initiated due to the absence of a responsible party to sign the admission paperwork. Additionally, the resident did not have access to medications upon discharge, further compromising their safety and well-being.

Penalty

Inspection fine: $16,801

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 medically related social services to ensure the highest practicable physical, mental, and psychosocial well-being for a resident, identified as R7, during the discharge process. R7 was admitted with multiple diagnoses, including a wedge compression fracture, lung cancer, and Parkinsonism, and had an activated Power of Attorney (POA) upon admission. However, the facility did not include the POA in the admission process, nor did they assist R7 in obtaining a decision-maker or guardian after R7 revoked the POA. Additionally, the facility did not assist R7 in applying for Medicaid after a change in payor sources from Medicare, and failed to ensure a safe discharge plan. R7's admission process was flawed as the facility did not involve the activated POA, FM-Z, in the admission paperwork, which was signed solely by R7. Despite being deemed incapacitated by medical professionals, R7 expressed a desire to revoke the POA, citing concerns about FM-Z's intentions and actions. The facility's social worker, SW-I, was involved in discussions with R7 and external parties, including the Ombudsman and Adult Protective Services (APS), but there was confusion and lack of clarity regarding R7's rights and the facility's responsibilities. The facility did not effectively coordinate with the POA or ensure that R7's financial and legal needs were addressed, particularly concerning Medicaid application and discharge planning. The discharge process was further complicated by family dynamics and conflicting interests. R7's family members, including FM-Z and FM-AA, had differing opinions on R7's care and living arrangements, leading to disputes over R7's discharge to home versus an assisted living facility. The facility's failure to secure a clear decision-maker or guardian for R7, coupled with inadequate communication and coordination with family members, resulted in an unsafe discharge plan. Despite recommendations from therapy and medical professionals that R7 was not safe to discharge home, the facility proceeded with the discharge without ensuring all necessary supports and services were in place.

Penalty

Inspection fine: $16,801

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 thoroughly investigate medication administration errors involving two residents, R6 and R2. R6 was mistakenly administered 40 milliequivalents of potassium, which was not prescribed for them. The error occurred due to an incorrect entry in the electronic medication administration record (E-Mar) intended for another resident. Although appropriate notifications and monitoring were documented after the error, there was no documentation of the possible cause of the error or interventions to prevent its recurrence. The Director of Nurses (DON) and other facility leaders were unable to provide additional information regarding the investigation of this error. R2, who has multiple diagnoses including type 2 diabetes, end-stage renal disease, and dementia, experienced a medication error when their medications were crushed instead of being administered whole, as required for optimal effectiveness. Despite a progress note indicating that the dialysis center had communicated concerns about R2's medication administration, the facility did not conduct an investigation into the error. The Director of Nursing confirmed that administering crushed medications when whole medications are required constitutes a medication error, yet no investigation was completed following the incident.

Penalty

Inspection fine: $16,801

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 a resident, identified as R17, was free from significant medication errors. R17 did not receive several prescribed medications from September 2024 through November 2024 because the medications were not available. The medications that were not administered included Trulicity for diabetes, losartan hydrochlorothiazide for blood pressure, allopurinol for gout, latanoprost for glaucoma, sertraline for depression, Toprol XL for blood pressure, pantoprazole for GERD, and fluticasone for asthma. This deficiency was identified through interviews and record reviews conducted by the surveyor. R17 was admitted to the facility with diagnoses including cellulitis of the abdominal wall, morbid obesity, type 2 diabetes, and COPD. The resident was cognitively intact and independent with eating, bed mobility, and transfers with a walker. During an interview, R17 reported frequently not receiving all prescribed medications and was informed by staff that the medications were unavailable. The Director of Nursing acknowledged the issue, stating that the facility had changed its medication refill process and was providing ongoing education to staff, including agency staff, but did not provide additional information on why the medications were not consistently available to R17.