WI Veterans Hm Ainsworth Hall

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect more than 4 of the 105 residents residing in the facility. Food items for resident consumption were not appropriately labeled and/or were beyond the discard date. Equipment in the main kitchen and unit 2 kitchenette was not in clean condition and/or covered. Findings include: On 3/17/25 at 9:20 AM, Surveyor interviewed Dietary Manager (DM)-K who stated the facility follows the Federal Food Code. Food Labeling/Storage: The 2022 FDA Food Code documents at 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking: .(B) Except as specified in (E)-(G) of this section, refrigerated, ready-to-eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection. This practice had the potential to affect more than 4 of the 105 residents residing in the facility. During two care observations, staff did not adhere to enhanced barrier precautions (EBP) for R8. Hand hygiene was not offered or completed for multiple residents prior to or after dining. Findings include: The facility's Transmission-Based Precautions (TBP) policy, dated 4/11/24, states: Enhanced Barrier Precautions (EBP): For members with novel or targeted multidrug-resistant organism (MDRO) infections, indwelling medical devices and wounds, including as part of a public health containment response. This type of precaution falls between standard and contact precautions and requires gown and glove use for certain members during specific high-contact member care activities that have been found to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, and record review, the facility did not provide a safe, clean, comfortable, and home-like environment for 1 resident (R) (R97) of 26 sampled residents. The third floor day room, dining room, and hallway contained several missing and broken floor tiles. Staff indicated the missing and broken floor tiles were a potential safety hazard. R97 indicated the tiles were unsightly and should be fixed. Findings include: The facility's admission Agreement document, dated 2/2025, indicates: Rights of Nursing Home Members: The Home must protect and promote the rights of each Member, including each of the following rights: .I. Right to a dignified existence, self-determination .II. Right to be treated with respect and dignity and to be cared for in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing the Member's individuality. The facility did not provide a policy related to a home-like environment or safety of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure 1 resident (R) (R22) of 2 residents reviewed for hospitalization received a transfer notice that included the date of the transfer, the reason for the transfer, the location of the transfer, and appeal rights. R22 was transferred to the hospital on 9/23/24 and 11/28/24. R22 was not provided with a written transfer notice on 9/23/24 or 11/28/24. In addition, the Ombudsman was not notified of R22's 9/23/24 hospital transfer. Findings include: The facility's Notice of Transfer policy, revised 1/31/23, indicates: .The Notice of Transfer document must include the following: date/time of the transfer, destination of the transfer, reason for the transfer, who was notified of the transfer, transfer appeal rights, and the facility's bed hold policy. The notice shall be issued to members/representatives at the time of any emergent transfer and prior to any planned/non-emergent transfer or admission to another health care facility. Following the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure 1 resident (R) (R22) of 2 sampled residents received written information of the duration of the facility's bed hold policy, the reserve bed payment policy, and the right to return to the facility. R22 was transferred to the hospital on 9/23/24 and 11/28/24. Neither R22 or R22's Guardian were provided with a written bed hold notice for either transfer. Findings include: The facility's Notice of Transfer policy, revised 1/31/23, indicates: .The Notice of Transfer document must include the following: date/time of the transfer, destination of the transfer, reason for the transfer, who was notified of the transfer, appeal rights, and the facility's bed hold policy. The notice shall be issued to members/representatives at the time of any emergent transfer and prior to any planned/non-emergent transfer or admission to another health care facility. Following the transfer, a written notice shall be issued to the notified representative within a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview and record review, the facility did not ensure Minimum Data Set (MDS) assessments were coded correctly for 3 residents (R) (R30, R49, and R1) of 26 sampled residents. R30's MDS assessment, dated 2/26/25, contained diagnoses of long term (current) use of anticoagulant medication and long term (current) use of aspirin; however, R30 was not prescribed anticoagulant medication or aspirin. The MDS assessment also indicated R30 received hypnotic medication; however, R30 was not prescribed hypnotic medication. In addition, MDS assessments, dated 6/5/24, 6/21/23, 4/13/23, and 4/20/22, indicated R30 did not have a Preadmission Screening and Resident Review (PASRR) Level II Screen; however, a PASRR Level II Screen was completed and indicated R30 had a mental illness. R49's MDS assessment, dated 3/5/25, contained a diagnosis of long term (current) use of anticoagulant medication and indicated R49 received anticoagulant medication and insulin; however, R49 was not prescribed anticoagulant medication or insulin. R1's MDS assessment, dated 2/12/25, indicated R1 received…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview and record review, the facility did not ensure Preadmission Screening and Resident Review (PASRR) requirements were met for 1 resident (R) (R16) of 7 sampled residents. R16 had a mental illness (MI) diagnosis. R16's PASRR Level I Screen stated No to MI. R16 did not have a PASRR Level II Screen. Findings include: The facility's Preadmission Screening and Resident Review (PASRR) policy, dated 11/8/24, indicates: A Level I Screen is required for all applicants being admitted to the facility to assess for mental illness or intellectual disability. It is used to determine if the individual requires specialized services. Level I Screens that indicate mental illness or intellectual disability require additional assessment to confirm the intellectual disability or mental illness, this is a Level II Screen .Members admitting to the facility from another nursing facility will require a new Level I Screen effective January 2025 to associate the level screening with a new level of care request. The discharging facility is expected to provide the admitted facility with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview and record review, the facility did not ensure a comprehensive care plan to meet psychosocial needs was developed and implemented for 1 resident (R) (R30) of 26 sampled residents. R30 was identified as having a serious mental illness of post-traumatic stress disorder (PTSD). R30 did not have a a care plan or interventions in place to address the diagnoses. Findings include: From 3/17/25 to 3/19/25, Surveyor reviewed R30's medical record. R30 had a Preadmission Screening and Resident Review (PASRR) Level I Screen, dated 10/8/15, that indicated R30 had a serious mental illness. A Behavioral Consulting Services (BCS) determination, dated 10/8/15, indicated R30 had a serious mental illness but was appropriate for nursing home placement without specialized services. Surveyor reviewed a life events checklist (LEC-5 extended) assessment completed by Social Worker (SW)-G on 4/15/22 that indicated R30 witnessed a natural disaster, fire or explosion and sudden accidental death and suffered a transportation accident and life-threatening illness or injury. R30 described…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for 2 residents (R) (R22 and R31) of 2 sampled residents. R22 and R31 were known smokers. Staff did not follow R22 and R31's assessments and care plans for safe smoking. Findings include: The Facility's Tobacco Use policy, dated 2/25/25, indicates: .Members who use tobacco must be able to do so independently. It shall be addressed in the member's plan of care. Supervised and assisted smoking is prohibited .6. After assessment and all observations, if no safety concerns were noted, the care team discusses the member's smoking. The team collaborates with the member to develop or revise a safety plan addressing their choice to use tobacco. 6.1 The plan must include an intervention identifying the member as a tobacco user and any items needed for safe, independent smoking (e.g., smoking apron) . The Facility's Member Smoking and Tobacco Use…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure monitoring interventions for adverse reactions to antipsychotic medication were in place for 1 resident (R) (R104) of 6 sampled residents. R104 was prescribed quetiapine (an antipsychotic medication) 50 milligrams (mg) once daily with a start date of 11/22/24. The facility did not ensure an Abnormal Involuntary Movement Scale (AIMS) assessment was completed when R104 started the medication. Findings include: The facility's Tardive Dyskinesia Monitoring policy, revised 7/24/24, indicates: Members taking antipsychotic, tricyclic antidepressants, and/or metoclopramide shall be screened: on admission or new order, every 6 months, at discontinuation, and monthly every 3 months following discontinuation. On 3/18/25, Surveyor reviewed R104's medical record. R104 was admitted to the facility on [DATE] and had diagnoses including major depressive disorder, anxiety disorder, Parkinson's disease with dyskinesia (involuntary movements), unspecified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview and record review, the facility did not ensure kitchen equipment was monitored appropriately to ensure food safety. This practice had the potential to affect all 164 residents residing in the facility. Mechanical warewashing wash, sanitization, and internal surface temperature logs were not consistently completed. Cooking and cooling temperature logs for food cooked in the oven were not consistently completed. Logs that documented parts per million (PPM) of the sanitizing solution in sanitizer buckets and sanitization levels in the 3 compartment sink were not consistently completed. Findings include: On 1/29/24 at 8:40 AM, Surveyor began an initial kitchen tour with Dietary Administrator (DA)-F and Food Service Manager (FSM)-H. DA-F indicated the facility followed the US Food and Drug Administration (FDA) Food Code. The FDA Food Code 2022 at 3-402.12 Records, Creation and Retention indicates: Records must be maintained to verify that the critical limits required for food safety are being met. Records provide a check for both the operator and the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, and record review, the facility did not ensure food was prepared and served in a sanitary manner. This practice had the potential to affect all 151 residents. The Warewashing machine (dishwasher) sanitizing rinse did not meet the required minimum temperature of 180 degrees Fahrenheit (F) during observation and per monitoring logs in November and December of 2022. In addition, the internal surface temperature monitoring device did not meet the required 160 degrees F during observation. The kitchen floor was visibly soiled and not cleanable in multiple areas. Findings include: On 12/5/22 at 9:08 AM, Dietary Manager (DM)-D indicated the facility used the Food and Drug Administration (FDA) Food Code as its standard of practice. Dishwashing Machine FDA Food Code 2017 documented at 4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures. (A) Except as specified in ¶ (B) of this section, in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than 90oC…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, and record review, the facility did not maintain appropriate infection control procedures to ensure residents' clothing, pillows and linens were protected from contamination in the facility's laundry area. This practice had the potential to affect all 151 residents. The floor in the facility's kitchen kettle room was in disrepair and contained numerous divots and areas of missing flooring. The kettle room was located above the facility's clean storage and laundry labeling area. The laundry area contained a plastic bin that collected approximately 37 gallons of liquid per day that drained from the kitchen floor through a membrane in the ceiling that contained hoses and funnels. The plastic bin was located in an area that contained residents' clothing, labeling equipment, spare pillows and linens. Findings include: On 12/5/22 beginning at 10:47 AM, Surveyor toured the laundry area with Laundry Supervisor (LS)-L. When entering the clean storage and laundry labeling area, Surveyor smelled a foul odor and observed a large plastic laundry container…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, and record review, the facility did not ensure a safe and sanitary environment for staff. Kitchen floor disrepair caused tripping or injury to at least 4 (Dietary [NAME] (DC)-H, Dietary Aide (DA)-F, Dietary Supervisor (DS)-E, and DC-I) dietary staff and had the potential to be unsafe for 48 dining services staff. DC-H and former DA-F submitted injury reports related to the unsafe state of the kitchen floor. DS-E and DC-I both verbalized tripping on the unsafe kitchen floor. Findings include: On 12/5/22, during an initial tour of the kitchen beginning at 9:08 AM, Surveyor observed and Dietary Manager (DM)-D verified the kitchen floor was in a state of disrepair. Surveyor observed food residue in areas of the floor that were no longer smooth. Surveyor stepped over divots in the floor where food residue and other debris settled. Floor leading into a walk-in cooler and blast chiller had layers pulled away with powdery material visible, white mesh material visible, and black unknown material visible in areas where the blue top coat was worn away.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.