Waunakee Valley Senior Living

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 a resident with CHF received necessary care and services in accordance with professional standards of practice. The resident was admitted with diagnoses including CHF, hypertension, obstructive sleep apnea, and respiratory failure, and the hospital discharge paperwork noted cardiomyopathy, atrial fibrillation, and heart failure with reduced ejection fraction. The discharge summary also documented a weight of 248 lbs and instructed staff to notify the physician if the resident’s weight increased or decreased by 3 lbs in one day or 3 lbs in one week. After admission, the resident was not weighed for the first 12 days at the facility. When a weight was finally obtained, it showed 260 lbs, which was documented by the dietitian as a +12 pound significant weight gain over 2 weeks. The record did not show physician notification at that time. The resident was later weighed at 261 lbs, reflecting a 13-pound gain from the earlier hospital weight, and again there was no evidence of physician notification. Additional weights were not documented for several days afterward, and there was no evidence that nursing staff monitored or assessed the resident for signs or symptoms of CHF exacerbation or edema during that period. The resident later had documented bilateral lower extremity edema, and subsequent notes described increasing edema, declining function, and verbal responses. The physician was updated and the resident was sent to the ER for evaluation and treatment of cardiac declines exacerbated by his muscular disorder. The resident was then admitted to the hospital with acute exacerbation of chronic heart failure with reduced ejection fraction, and hospital notes stated that the etiology was not entirely clear though diet and fluid indiscretion were possible because monitoring prior to admission was unclear. After discharge, the resident was again not weighed daily despite the hospital’s instructions to weigh before breakfast and not gain more than 3 lbs in one day or 5 lbs in a week. When the wife later requested the daily weights, staff found no orders for daily weights at that time, noted 2-3+ pitting edema with weeping around the ankles, and documented shortness of breath with repositioning and diminished lung sounds.

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 necessary respiratory care and services for a resident with congestive heart failure, hypertension, obstructive sleep apnea, and respiratory failure. The resident was cognitively intact with a BIMS score of 15 and was admitted with hospital discharge instructions stating to continue wearing home CPAP/BIPAP during sleepiness unless otherwise instructed. The physician’s admission orders included an auto BIPAP order, but the settings were left blank, and the record showed the resident was also ordered oxygen via nasal cannula at bedtime. Facility documentation showed the resident was recorded as wearing the BIPAP on most days early in the stay, but the same record also showed refusals on multiple dates. The facility tracked oxygen saturation daily for a limited period and then did not document it again until later in the stay. The resident’s treatment record directed staff to observe for signs of respiratory distress and notify the physician of new or worsening symptoms. On 10/13/25, the facility documented that the doctor was updated on recent declines in function, verbal responses, and increasing edema, and the resident was sent to the ER for evaluation and treatment of cardiac declines. The ER record stated the resident arrived with worsening hypoxia and ongoing hypercarbia and noted that the resident was on chronic BIPAP but did not appear to have been using it, which was identified as the most likely cause of the exacerbation. The resident later told the surveyor that the BIPAP was uncomfortable and that he had been using nasal cannula instead at night. Sleep clinic and DME records showed the resident had previously used the BIPAP consistently, then had markedly reduced use during the period before hospitalization. Surveyor interviews with nursing staff and the DON indicated staff expected BIPAP settings to be verified and physicians to be notified for repeated refusals, but the facility did not ensure the BIPAP settings were correct, did not ensure the device was being worn according to remote DME data, and did not contact the physician after repeated refusals.

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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection. The facility policy for the Infection Prevention and Control Program stated that the campus has a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases, including surveillance activities to identify, investigate, control, and prevent the spread of infection and reporting for the IPCP, with infections tracked per hall/unit and type of infection. During record review and interview, the facility's Infection Control Rates 2025/2026 form showed monthly totals for January, February, and March 2026, but the rates were not documented accurately and were not broken down by infection type. On 4/9/26, the DON stated the facility calculated monthly infection control rates only by including residents who had a facility-acquired infection and did not track residents admitted with an infection. The DON also stated the facility did not track infection control rates based on type of infection and could not determine rates for UTIs, wounds, respiratory infections, and other types from the form. The facility's LTC Respiratory Surveillance Line list for February 2026 included 3 residents positive for facility-acquired COVID, and the Infection Tracking - Antibiotic Surveillance Log for February 2026 included 4 residents with a facility-acquired infection, while the IC Rates form listed only 4 total residents for that month. Later that day, the facility provided an updated Infection Control Rate form showing 7 residents with a facility-acquired infection, indicating the original form was not accurate.

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 residents were clinically appropriate to self-administer medications for 1 of 1 sampled residents reviewed for self-administration. R10 was observed with 3 cups of medications left on the bedside table to take independently. R10 was admitted with diagnoses including chronic kidney disease, malnutrition, and heart disease, and the most recent MDS dated 3/27/26 showed a BIMS score of 15 out of 15, indicating cognitive intactness. The facility policy titled Guidelines for Self-Administration of Medications states that residents requesting to self-medicate or who have self-medication as part of their plan of care shall be assessed using the facility's self-administration assessment in the EHR, and the results are to be presented to the physician for evaluation and order. During interview, R10 stated staff leave medications on the table when they are sleeping so they can take them with breakfast. An LPN stated that R10 takes medications themselves and is independent with medications, but also stated there was no assessment for self-administration and no specific physician order for R10 to self-administer medications. The requested assessment was not provided, and the NHA also stated no assessment could be found and that R10's medications should not be left at bedside without an 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 did not ensure adequate supervision and safety to prevent accidents for one resident who was smoking. The resident was admitted with diagnoses including breast cancer, bone cancer, major depressive disorder, and bipolar disorder, and the most recent MDS dated 4/2/26 showed a BIMS score of 15 out of 15, indicating cognitive intactness. Although the resident’s care plan dated 7/9/25 stated that the resident currently used tobacco and included interventions related to smoking, the resident’s smoking status was not reflected in the MDS until 4/2/26, even though staff were aware the resident was smoking in July 2025. Surveyor interviews and observation showed that the resident reported smoking twice a day, going off premises to smoke, and keeping cigarettes and a lighter in the top drawer of the dresser. The surveyor observed a pack of cigarettes and a lighter in that drawer. When asked for a smoking assessment, the facility could not provide one. The NHA stated the facility was a non-smoking facility and did not have an assessment, later stating staff were aware the resident was going outside to smoke and that an MDS Coordinator had completed an assessment in July, but no documentation existed in the computer system and no notes were taken. The MDS Coordinator stated a care plan was added when staff learned the resident was smoking, but also stated there was no smoking assessment in the system and no documentation of the 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 provide necessary behavioral health services to a resident, identified as R11, who was admitted with a history of depression. Despite R11's significant life event of losing her husband, the facility did not offer appropriate psychological support or services related to her depression diagnosis. The resident's care plan included interventions such as encouraging social interaction and monitoring for signs of depression, but these were not effectively implemented or personalized to address her ongoing decline. R11's medical records indicated multiple instances of depression, with symptoms such as poor appetite, increased sleep, and expressions of wanting to die. Despite these clear signs of depression, the facility did not prescribe any medication specifically for depression, as the trazodone prescribed was intended for insomnia. The facility's staff, including CNAs and LPNs, observed R11's decline and reported it, but no significant actions were taken to address her mental health needs. Interviews with facility staff revealed a lack of follow-through on care plan interventions, such as referrals for psychiatric evaluation and counseling services. The Director of Social Services acknowledged informal contacts but did not pursue recommended grief services. The Nursing Home Administrator and Director of Nursing both recognized the deficiency in care planning and implementation, noting that R11's care plan should have been updated to reflect her ongoing depression and decline.

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 was free from significant medication errors, specifically concerning the administration of abiraterone, a medication used to treat prostate cancer. The resident, who was cognitively intact with a BIMS score of 14 out of 15, had specific instructions for the medication to be taken on an empty stomach with a full glass of water, and not to eat for at least two hours before and one hour after taking it. However, the medication was administered late on two occasions, which constituted significant medication errors. Interviews with facility staff, including LPNs and the Director of Nursing, revealed that there was an understanding that medications should be administered according to physician orders. Despite this, the medication was not given within the specified time frame, and the late administration was not reported to administrative staff as expected. The facility's policy on medication administration times was not adhered to, leading to the deficiency noted by the surveyors.

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 adhere to the Preadmission Screening and Resident Review (PASRR) process for a resident, identified as R48, who was admitted in April 2024. R48, who has diagnoses including bipolar disorder, major depressive disorder, PTSD, adjustment disorder, and other anxiety disorders, did not have a PASRR Level II completed as required. The facility follows the Wisconsin PASRR Quick Reference Guide, which mandates a Level I PASRR screen for all residents prior to admission and a Level II screen if the resident stays beyond a short-term exemption period. R48's PASRR Level I was completed with a 30-day exemption, but no Level II was conducted despite the extended stay. During an interview, the Director of Social Services (DSS C) acknowledged that a Level II PASRR should be completed if a resident stays longer than the anticipated 30 days. DSS C expressed uncertainty about whether a Level II PASRR was completed for R48, stating that if there was no copy available, it might have been missed. This oversight indicates a lapse in the facility's adherence to the PASRR process, as there was no documented evidence of a Level II PASRR for R48, despite the resident's extended stay and mental health diagnoses.

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 residents received treatment and care in accordance with professional standards of practice, specifically regarding the completion and oversight of nursing assessments. Two residents, identified as R52 and R305, were affected by this deficiency. Both residents had nursing assessments completed and signed by Licensed Practical Nurses (LPNs) without the required co-signature or notification of a Registered Nurse (RN). This practice is not in compliance with the Wisconsin Nurse Practice Act, which mandates that RNs utilize the nursing process, including assessment, planning, intervention, and evaluation, while LPNs are only permitted to assist with data collection. Resident R52, who was cognitively intact, had multiple progress notes documenting complete head-to-toe assessments conducted by LPNs over several days. These assessments were not co-signed by an RN, nor was there any record of RN notification. Similarly, Resident R305, a new admission with significant medical conditions, had progress notes indicating complete assessments by LPNs, including pain assessments, without RN co-signature or notification. Interviews with facility staff, including LPNs and the Director of Nursing (DON), revealed a lack of clarity and adherence to the proper protocol for nursing assessments. The Director of Nursing acknowledged that LPNs can perform observations but emphasized that head-to-toe assessments should be co-signed by an RN or discussed with an RN if new findings are present. Despite this expectation, the surveyor found several instances where this protocol was not followed, indicating a systemic issue in the facility's adherence to professional standards of practice for nursing assessments.

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 all drugs and biologicals were stored in accordance with currently accepted professional principles. During a three-day survey, one of three medication carts was observed to be left unattended, unlocked, and out of view of staff. Specifically, on January 21, 2025, at 9:18 AM, a surveyor observed a medication cart on A wing sitting in the hallway unlocked. At 9:19 AM, the surveyor noted that an LPN exited another room and approached the cart. Upon inquiry, the LPN admitted that the medication cart was not locked when they left it, despite the facility's policy requiring medication carts to be locked when not attended by authorized personnel. The Director of Nursing (DON) confirmed that the expectation was for nurses to lock their medication carts and take their keys with them when leaving the cart unattended. The DON acknowledged that the LPN's cart should have been locked when they left to enter another room. This incident highlights a failure to adhere to the facility's medication storage policy, which mandates that medication carts be locked when not attended by authorized personnel.

Penalty

Inspection fine: $16,055

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 adequate supervision and safety measures for a resident identified as at risk for wandering and elopement. The resident, who had a history of dementia, osteoarthritis, and other conditions, was equipped with a Wanderguard device attached to her walker. Despite this precaution, the resident managed to elope from the facility without triggering the alarm system. The facility was unaware of the resident's absence until contacted by local law enforcement, who found the resident four blocks away, having crossed a busy intersection. Interviews and record reviews revealed that the Wanderguard alarm system did not activate when the resident exited the building. Staff members, including the LPN on duty, reported that no alarms were heard, and the resident was last seen sitting in the hallway before her elopement. The head nurse and other staff members were unsure why the alarm system failed, and it was discovered that one of the dining room doors did not sound an alarm when opened. The facility's policy required staff to respond promptly to alarms and conduct headcounts, but these procedures were not effectively implemented in this instance. The resident's care plan and elopement risk assessments indicated that she was at risk for wandering and elopement, with specific interventions outlined to prevent such incidents. However, the failure of the Wanderguard system and the lack of immediate staff response to the resident's exit resulted in a serious oversight. The facility's inability to provide adequate supervision and ensure the functionality of safety devices led to a finding of immediate jeopardy, highlighting a significant deficiency in the facility's safety protocols.

Removal Plan

• Nursing Assessment completed for R4.
• Placed on 1:1 and then 15-minute checks.
• Notifications of MD and responsible party made.
• Wanderguard placed on wrist.
• Facility head count was completed all residents accounted for.
• Director of Plants Operation assessed Wanderguard system and all other campus egress doors all found functioning properly.
• Door monitor placed at the nurse station.
• Repair company was contacted to assess Wanderguard system and to install a keycode pad/mag lock for the employee entrance/exit door.
• All residents reviewed for elopement risk.
• Wandering and elopement care plans were reviewed by the DON.
• All elopement binders reviewed by DON.
• Elopement drill was conducted.
• Education initiated.
• Education including: Policy Review related to increasing exit seeking behaviors and what to do if resident found outside.
• Audit on Wanderguard function 5 times weekly.
• Audit 5 staff members what to do if resident is observed an increase in exit seeking behaviors 5 times weekly and then randomly thereafter.
• Elopement drills will be completed at least quarterly.
• DON will audit residents who are currently an elopement risk twice weekly to ensure appropriate interventions are in place.
• All audits submitted to the QAPI Committee for further review.

Penalty

Inspection fine: $16,055

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 Certified Nursing Assistant (CNA) staff received a performance review at least every 12 months, as required. This deficiency was identified for five CNAs who were selected for review. CNAs T, U, S, and R were all hired on March 1, 2023, and had not received an evaluation in the past 12 months, despite being due for one on or around March 1, 2024. Similarly, CNA H, hired on August 17, 2023, also had not received an evaluation within the required timeframe. The facility lacked a Policy and Procedure for conducting CNA performance evaluations. During an interview, the Assistant Divisional President (ADVP V) acknowledged that the facility does not conduct yearly evaluations for CNAs. Instead, the facility implements quarterly wage increases and Performance Improvement Plans (PIPs) when disciplinary actions are necessary. The surveyor referred ADVP V to the State Operations Manual, which mandates that facilities complete performance reviews of every nurse aide at least once every 12 months.

Penalty

Inspection fine: $16,055

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 residents received food at a palatable temperature, as evidenced by a test tray that was outside of the acceptable temperature range. According to the facility's Food Production Guidelines, hot food should be held at 135°F or above, and cold food should be held at 41°F or below. During an observation, the surveyor found that the meat and noodles on the test tray were at 123.8°F, the corn was at 125.8°F, and the milk was at 41.7°F. The meat was difficult to chew, and both the meat and noodles, as well as the corn, were cold, while the milk was warm. The Director of Food Services acknowledged that hot foods should be served hot and cold foods should be served cold, indicating an understanding of the concern regarding the temperatures of the food on the meal tray.

Penalty

Inspection fine: $16,055

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 pharmaceutical services that ensured the accurate administration of medications for a resident, identified as R3, who did not receive Acetaminophen, Aspirin, and Lacosamide as scheduled on ten separate days in August 2024. The facility's policy requires medications to be administered according to the prescriber's written orders and the established medication administration schedule. However, R3's Medication Administration Record (MAR) indicated that these medications were administered outside the designated time range of 6:00 AM to 10:00 AM on multiple occasions. The deficiency was further highlighted during interviews with LPN C, who admitted that R3 often refused morning medications, preferring to take them after breakfast. LPN C acknowledged that the medications were administered late, not just charted late, and failed to notify the provider to adjust the medication schedule. The Director of Nursing (DON B) and the Director of Health Services (DHS D) were made aware of the incorrect documentation and confirmed that the medications were indeed given late, contrary to the facility's expectations.

Penalty

Inspection fine: $16,80144 days payment denial

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 pressure ulcer care and prevent new ulcers from developing for two residents. Resident R4 was admitted without a pressure injury or catheter but returned from hospitalization with a Foley catheter. The facility did not implement interventions to prevent medical device-related pressure injuries, failed to complete weekly measurements and assessments, and did not perform treatments as ordered. As a result, R4 developed a full-thickness wound extending from the tip of the penis through the meatus and down to the shaft. Despite documentation of pressure from the Foley catheter causing redness, pain, and drainage, the facility did not conduct weekly assessments or measurements of the affected area. Resident R6 was admitted without a pressure injury but developed a stage 2 pressure ulcer on the coccyx. The facility did not implement interventions to prevent the development of pressure injuries upon admission, failed to notify the physician when the wound worsened, and did not ensure proper hand hygiene during wound care. The wound management notes indicated discrepancies in documentation, with two entries for the same time and date, and treatments were not signed out as completed on the Treatment Administration Record (TAR) until several days later. The facility's policies on wound care and catheter care were not followed, leading to the development and worsening of pressure injuries in both residents. The lack of timely assessments, documentation, and communication with healthcare providers contributed to the deficiencies observed by the surveyors. The facility's failure to adhere to professional standards of practice for pressure ulcer prevention and care resulted in immediate jeopardy for the residents involved.

Removal Plan

• The facility reviewed the care plan of resident to identify and complete follow up, if indicated for concerns related to the catheter device. The resident was sent to hospital for evaluation.
• The facility identified all residents currently admitted to identify any possible similar events related to abnormal findings for residents with catheters at risk for injury including but not limited to pressure ulcers.
• Facility conducted a sweep of all residents with an indwelling foley catheter to ensure interventions are in place to prevent PI development.
• Skin assessments have been completed on all residents with an indwelling catheter.
• The facility initiated proactive education with licensed nursing staff on catheter care and pressure ulcer prevention.
• Nursing staff will be educated to ensure correct positioning to prevent tubing from being taut or causing pressure on the urethra.
• Nursing staff will be educated on monitoring of skin integrity on residents with catheters during cares, paying special attention to skin impairment and will be completed with the change in condition policy. Any findings will be reported immediately.
• The facility initiated a skills check list for licensed nursing staff for catheter care.
• The facility audited all residents with catheters with or without wounds related to catheter use to ensure orders were appropriate and treatment plans were in place for care as well as prevention of pressure ulcers.
• Proactive education on the use of stat locks for catheters.
• Documentation is to include weekly measurements and assessments if a pressure ulcer is identified. These are to be signed out in the TAR as ordered.
• The facility initiated education with licensed nurses to ensure physician orders are transcribed correctly to the MAR/TAR.
• Licensed Nursing Staff were also educated on documenting and reporting changes of condition at the time of the observation to the physician as well as the resident's responsible party and hospice.
• The facility initiated reeducation with all Licensed Nursing Staff on identifying and reporting Changes of Condition when newly identified changes in health status are identified.
• The facility initiated reeducation with all Licensed Nursing Staff on completion of a comprehensive assessment on all skin events with a noted change in size, shape, and clinical presentation at the time of discovery.
• The Licensed Nursing staff was reeducated on completing a notification to the MD, RP, and or Guardian at the time of identification.
• The Licensed Nursing Staff were reeducated on catheter care including but not limited to pressure ulcer prevention and treatment.
• The Licensed Nursing staff were reeducated on transcribing orders to the MAR/TAR as ordered.
• The facility will review orders daily in the Morning Clinical Meeting to ensure that preventative orders are in place for catheters to decrease the risk for pressure.
• The facility will review Matrix EHR (electronic health record) daily during Morning Clinical Meeting to identify Changes of Condition and ensure notifications/consultations were completed. Follow up will be completed if indicated based on the outcome of the audit.
• The facility will complete random audits 3x weekly with Licensed Nurses to gauge understanding related to completion of Changes of Condition. Remedial education will be provided at the time of completion of audits if indicated.
• The facility will complete random audits 3x weekly on catheters to ensure care is provided per clinical standards. To include proper placement of leg strap/stat lock to prevent pressure. Remedial education will be provided at the time of completion of audits if indicated.
• The facility will complete random audits 3x weekly on pressure ulcers to ensure care is provided per clinical standards. Remedial education will be provided at the time of completion of audits if indicated.
• The facility will complete random audits 3x weekly on treatment records and weekly skin assessments to ensure care is provided per clinical standards. Remedial education will be provided at the time of completion of audits if indicated.
• The facility will audit residents with medical device pressure injuries 3x weekly to ensure weekly assessments are documented in the medical record including measurements.
• The results of the audits will be reported to the quality assurance and performance improvement (QAPI) committee and adjustments will be made to frequency of audits based on findings.

Penalty

Inspection fine: $16,80144 days payment denial

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 alleged violations involving abuse, neglect, exploitation, or mistreatment within the required timeframe for four of ten sampled residents. According to the State Operations Manual, such allegations must be reported immediately, but not later than 2 hours if they involve abuse or result in serious bodily injury, or not later than 24 hours if they do not involve abuse and do not result in serious bodily injury. The facility's policy, updated in 2024, aligns with these requirements, yet the facility did not adhere to them in several instances. One resident reported that a Certified Nursing Assistant (CNA) was rude and yelled at them, but this was not reported to the State Agency. Another resident was found with a black eye, an injury of unknown origin, which was also not reported. Additionally, a resident reported neglect when staff refused to assist with personal hygiene, stating that they were not obligated to do so. This incident was not reported to the State Agency either. Lastly, a resident claimed that personal items, including a white ski jacket and a pair of jeans, were stolen, but this allegation of misappropriation was not reported. The Nursing Home Administrator acknowledged during interviews with the surveyor that these allegations should have been reported to the State Agency. The facility's grievance log and progress notes documented these incidents, yet there was a failure to follow through with the required reporting procedures. This oversight indicates a significant lapse in adhering to regulatory requirements for reporting suspected abuse, neglect, or theft, as outlined in the facility's own procedural guidelines.

Penalty

Inspection fine: $16,80144 days payment denial

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 four residents. Resident 1 reported that a CNA was rude and yelled at them, but this allegation was not thoroughly investigated. The facility did not identify the allegation as potential abuse, did not interview other staff or residents, and did not suspend the suspected employee pending the outcome of the investigation. Additionally, there was a lack of complete documentation of the investigation. Resident 10 was found with a black eye, an injury of unknown origin, which was not thoroughly investigated. The facility failed to identify the injury as a potential abuse case, did not interview staff, did not update the physician or the resident's representative, and did not document a complete investigation. The lack of documentation in the resident's medical record further highlights the deficiency in handling this case. Resident 11 reported that staff refused to assist them with personal hygiene, which could be considered neglect. The facility did not thoroughly investigate this allegation, as they failed to interview other staff and residents, did not suspend the suspected employee, and did not document a complete investigation. Additionally, Resident 7 reported missing personal items, alleging misappropriation, but the facility did not investigate this concern thoroughly, as the NHA was unaware of the issue and no documentation of an investigation was provided.

Penalty

Inspection fine: $16,80144 days payment denial

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 necessary care and services in accordance with professional standards for a resident who experienced a change in condition. The resident, who had diagnoses including Metabolic Encephalopathy, Rhabdomyolysis, and congestive heart failure, reported not feeling well and had a gray emesis. Despite these symptoms, the nurse only took vital signs and did not perform a thorough assessment. The resident was later found deceased in his room with black liquid emesis present. The facility's policy on Notification of Change in Condition requires notifying the physician of significant changes in a resident's status. However, the nurse did not inform the physician of the resident's condition, nor did she conduct a follow-up assessment throughout the day. The nurse cited being overwhelmed with responsibilities as a reason for not following up. Interviews with staff, including the Director of Nursing and Nurse Practitioner, indicated that a more comprehensive assessment should have been conducted, including checking heart and bowel sounds. The Nursing Home Administrator was unable to provide a standard of practice for assessing changes in condition, and the facility lacked a specific policy on nurse assessments. The failure to conduct a focused assessment and notify the physician of the resident's change in condition contributed to the deficiency identified by the surveyors.