Montello Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure the effectiveness of psychotropic medication was assessed for 1 resident (R) (R25) of 5 sampled residents.R25 was prescribed trazodone (an antidepressant medication) for insomnia. The facility did not complete a sleep assessment for R25 to assess the effectiveness of the medication. In addition, R25 did not have a care plan for insomnia.Findings include:The facility's Sleep Disorders-Clinical Protocol, revised April 2018, indicates: .2. Nursing staff (especially night shift staff) will describe any sleep disturbance in detail; for example, patterns over time, associated behavior, daytime sleepiness, and factors that appear to improve or worsen the situation .Cause Identification: 1. The staff will consider various causes of sleep disturbance such as noise level, room temperature, lighting levels, bed comfort, roommate distractions, and staff intrusion .Treatment/Management: .2. The physician will order appropriate interventions to address…

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 implement their abuse policy and procedure for 1 (Certified Nursing Assistant (CNA)-R) of 8 staff reviewed for caregiver background checks. CNA-R was hired through a staffing agency and worked shifts at the facility starting on 7/9/25. The facility did not ensure the staffing agency completed an out-of-state background check for CNA-R who resided outside of Wisconsin within 3 years of hire. Findings include: The facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, indicates: .4. Conduct employee background checks and not knowingly employ or otherwise engage any individual who has: a. been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; b. had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents, or misappropriation of their property; or c. a disciplinary action in effect against his or her professional license by a state licensure body as 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interview and record review, the facility did not ensure a potential allegation of abuse was thoroughly investigated for 1 resident (R) (R5) of 1 sampled resident.On [DATE], staff discovered R5 in R5's room between the wall and the bed. Staffs' statements were inconsistent regarding R5's injuries. The facility did not investigate the discrepancy regarding the injuries. Findings include: From [DATE] to [DATE], Surveyor reviewed R5's medical record. R5 was admitted to facility on [DATE] and had diagnoses including anoxic brain damage, epilepsy, palliative care, asthma, hemiplegia, encephalopathy, and thrombocytosis. R5's Minimum Data Set (MDS) assessment, dated [DATE], indicated R5 was dependent for cares, transfers, and mobility. R5 had a legal Guardian. From [DATE] to [DATE], Surveyor reviewed a facility-reported incident that indicated R5 had a swollen right eye and face and abrasions on the right shoulder and arm on [DATE]. Administration was notified and started an investigation.…

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 Preadmission Screening and Resident Review (PASRR) requirements were met for 2 residents (R) (R2 and R25) of 4 sampled residents.R2 was admitted to the facility with a diagnosis of epilepsy. The facility did not include the diagnosis on R2's PASRR Level I Screen and did not submit a referral for a PASRR Level II Screen.R25 was admitted to the facility without a diagnosis of mental illness and was not on psychotropic medication. R25 was later prescribed medication for psychosis, anxiety, depression, insomnia, and conduct disorder. The facility did not complete a new PASRR Level I Screen or submit a referral for a PASRR Level II Screen.Findings include: The facility's Behavioral Assessment, Intervention and Monitoring Policy, revised February 2025, indicates: .2. Behavioral symptoms are identified using facility-approved behavioral screening tools and the comprehensive assessment. 3. The facility complies with regulatory requirements related…

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 nail care was provided for 2 residents (R) (R7 and R8) of 15 sampled residents.R7 and R8's fingernails were long, jagged, and contained dirt or chipped polish. R7 and R8 were not consistently provided nail care with activities of daily living (ADLs).Findings include:The facility's Care of Fingernails/Toenails policy, revised February 2018, indicates: The purpose of this procedure is to clean the nail bed, to keep nails trimmed, and to prevent infections .1. Nail care includes daily cleaning and regular trimming. 2. Proper nail care can aid in the prevention of skin problems around the nail bed .4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. 1.From 12/1/25 to 12/4/25, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, brain bleed, fractures of the right femur and second thoracic…

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 restorative care was provided for 1 resident (R) (R12) of 3 sampled residents. R12 had limited range of motion (ROM) and had a functional restorative program. Staff did not consistently provide restorative care for R12.Findings include:The facility's Restorative Nursing Services policy, revised July 2017, indicates: Residents will receive restorative nursing care as needed to help promote optimal safety and independence. 1. Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services. 2. Residents may be started on a restorative nursing program upon admission, during the course of stay, or when discharged from rehabilitative care. 3. Restorative goals and objectives are individualized and resident-centered and are outlined in the resident's plan of care .5. Restorative goals may include, but are not limited to, supporting and assisting 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 observation, staff and resident interview, and record review, the facility did not provide pharmacy services to ensure the accurate administration of medication for 2 residents (R) (R17 and R4) of 8 sampled residents.Staff did not administer a buprenorphine 10 microgram (mcg) per hour transdermal patch or a guaifenesin 600 mg extended release (ER) tablet to R17 in accordance with physician orders.Medications were left at the bedside for R4 to self-administer. R4's last self-administration of medication assessment indicated R4 could not safely and accurately self-administer medication. Findings include: The facility's Reordering, Changing, and Discontinuing Medication Orders policy, revised 7/1/24, indicates: .2. Reorder/Refill Orders: 2.1 Facilities are encouraged to reorder medications electronically or by fax whenever possible . The facility's Resident Self-Administration of Medications policy, revised 11/26/25, indicates: A resident may only self-administer medication after the facility's…

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 for adverse reactions to a high-risk medication was in place for 1 resident (R) (R19) of 4 sampled residents.R19 was prescribed cefdinir (an antibiotic) for prophylactic measures. R19 was not monitored for adverse reactions to the medication.Findings include:The facility's High Risk Medications policy, dated 2025, indicates: The facility recognizes that some medications are associated with greater risks of adverse consequences than other medications. These high-risk medications can include .antibiotics .6. The resident's plan of care shall alert staff to monitor for adverse consequences of any high-risk medications given.https://medlineplus.gov indicates cefdinir may cause side effects including vomiting, nausea, stomach pain, diarrhea, headache, vaginal itching, reddish-colored stools, rash, hives, swelling of the face, throat, tongue, lips or eyes, difficulty breathing or swallowing, watery or bloody stools, stomach cramps, or…

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 2 residents (R) (R8 and R13) of 2 sampled residents were assessed for safety and had care plans to guide assistance by Paid Feeding Assistants (PFAs).The facility did not assess if R8 and R13 were appropriate to be assisted by PFAs prior to using PFAs to assist R8 and R13 with dining. In addition, R8 and R13 did not have care plans that indicated they could be fed by PFAs.Findings include:The facility's undated Dining Assistant policy indicates: Dining Assistants will follow the requirements of federal regulations and the Wisconsin Feeding Assistant Program .I. The following individuals are able to provide feeding assistance: .C. Dining Assistants - 1) Who have successfully completed an approved training program, written quiz, and skills demonstration; 2) Who only physically assist feeding residents who have no complicated swallowing/feeding concerns, as determined by a Registered Nurse basic assessment who may consult with Interdisciplinary…

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 an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 1 resident (R) (R3) of 11 sampled residents.R3 had a Foley catheter but was not on enhanced barrier precautions (EBP). Staff provided high-contact care for R3 without wearing a gown. In addition, staff did not complete appropriate hand hygiene during the provision of care.Findings include: The facility's Enhanced Barrier Precautions policy, revised December 2024, indicates: Enhanced barrier precautions (EBP) are used to prevent the spread of multidrug-resistant organisms (MDROs) to residents .1. EBP refers to infection prevention and control interventions designed to reduce the transmission of MDROs during high-contact resident care activities. 2. EBP applies when: a. A resident is infected or colonized with a Centers for Disease Prevention and Control (CDC)-targeted MDRO, but does not have a wound or indwelling medical device, and does not have secretions or…

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 allegations of abuse were reported to the State Agency (SA) for 1 Resident (R) (R1) of 8 sampled residents.R1 was admitted to the facility for a 5-day respite stay and had a diagnosis of Alzheimer's disease. On the evening of 9/25/25, R1 became agitated when staff tried to help R1 get ready for bed. R1 attempted to leave the facility through multiple doors, however, staff held the doors shut and put hands on R1 to prevent R1 from leaving. A crisis report indicated staff held R1 in a chair. A police report indicated R1 stated that R1 had been attacked by numerous individuals. The facility did not report the allegations of abuse to the SA.Findings include:The facility's Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy indicates: If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to 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 allegations of abuse were thoroughly investigated for 1 Resident (R) (R1) of 8 sampled residents.R1 was admitted to the facility for a 5-day respite stay and had a diagnosis of Alzheimer's disease. On the evening of 9/25/25, R1 became agitated when staff tried to help R1 get ready for bed. R1 attempted to leave the facility through multiple doors, however, staff held the doors shut and put hands on R1 to prevent R1 from leaving. A crisis report indicated staff held R1 in a chair. A police report indicated R1 stated that R1 had been attacked by numerous individuals. The facility did not thoroughly investigate the incident by ensuring all staff involved were interviewed. The facility also did not obtain the police report or county crisis documentation which included allegations of abuse.Findings include: The facility's Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy, revised September 2022, indicates:…

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 failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 2 residents (R) (R1 and R2) of 2 sampled residents.On 7/14/25, R2 struck R1 in the face. The facility did not notify local law enforcement of the abuse.Findings include:The facility's Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy, revised 9/2022, indicates: .2. The Administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: .e. Law enforcement officials. (The facility's policy did not include examples of crimes that should be reported, including but not limited to assault and battery, and did not indicate that the facility consulted with local law enforcement to discuss what to report or not report.)On 8/1/25, Surveyor reviewed a facility-reported incident that indicated R2 slapped R1 across the face on 7/14/25 and the incident was witnessed by Med…

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 and staff interview, the facility did not provide a safe, functional, and sanitary environment for residents outside the facility. This practice had the potential to affect more than 4 of the 28 residents residing in the facility. On 6/12/25, the front of the facility appeared unkempt which included weeds, dirt and landscaping bark, an open dumpster that contained garbage, a laundry bin that contained items, a plastic chair that contained cardboard, and exposed wires from a missing doorbell. In addition, the front door was reported to be unlocked when it should have been locked. On 6/12/25 from 9:00 AM to 5:45 PM, Surveyor made observations of the front of the facility which faced the main parking lot and public roadway. Surveyor noted long weeds along the front of the facility, under residents' windows, along and under the fencing, and around trees. A dumpster in the front of the facility was open and contained garbage bags. There were three walls of privacy fence around the dumpster, however, the front did not have fence panels. The unfenced area faced 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 observation, staff and resident interview, and record review, the facility did not ensure 1 resident (R) (R2) of 3 sampled residents received the necessary care and services to prevent pressure injuries and/or promote healing. On 5/25/25, staff reported to Director of Nursing (DON)-B that R2's wound vac (negative pressure wound therapy) dressing was not adhered properly. DON-B did not assess the wound vac dressing or ensure R1's wound vac was functioning appropriately. Findings include: The facility's Negative Pressure Wound Therapy policy, revised 2/2014, indicates: The purpose of this procedure is to provide guidelines for establishing and maintaining negative pressure wound therapy .change dressing per physician orders and manufacturer guidelines .secondary layer of barrier adhesive .create a vacuum seal over the wound . The facility's Prevention of Pressure Injuries policy, revised 3/1/21, indicates: .For prevention measures associated with specific devices, consult current clinical practice…

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 provide adequate supervision and assistance to prevent accidents and did not ensure a fall was thoroughly investigated to determine a root cause for 1 resident (R) (R1) of 1 sampled resident. On 4/26/25, R1 fell out of bed and called 911 when staff did not respond to R1's calls for assistance. The facility did not complete a thorough investigation to determine the root cause of R1's fall. Findings include: The facility's Falls and Fall Risk, Managing policy, revised 3/2018, indicates: Based on previous evaluations and current data, staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling .According to the Minimum Data Set (MDS), a fall is defined as: Unintentionally coming to rest on the ground, floor, or other lower level but not as a result of an overwhelming external force .A fall without injury is…

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 1 resident (R) (R1) of 2 sampled residents was provided safe and accurate administration of drugs and biologicals. R1 was not administered a dose of an intravenous (IV) antibiotics on 5/25/25. Findings include: On 6/12/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including fibromyalgia, history of venous thrombosis embolism, Parkinson's disease, osteomyelitis of vertebra thoracic region, sciatica, and candidal stomatitis. R1's Minimum Data Set (MDS) assessment, dated 4/30/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 had intact cognition. R1 made R1's own medical decisions. R1 had an order for cefazolin reconstituted solution administer 6 grams in sodium chloride 0.9 % 320 milliliters (mls) intravenous (IV) to run continuously 24 hours once a day every morning for osteomylitis of vertebra, thoracic region. 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.

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) (R10) of 1 sampled resident had a medical record that contained complete and accurate information. Director of Nursing (DON)-B did not update R10's medical record when an observation and assessment was completed for R10. Findings include: The facility's Charting and Documentation policy, revised July 2017, indicates: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care .2. The following information is to be documented in the resident's medical record: a. Objective observations; .d. Changes in the resident's condition; .3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and…

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 maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 1 resident of (R) (R2) of 1 sampled resident. Registered Nurse (RN)-C did not complete proper hand hygiene during wound care for R2 and used soiled scissors to trim a clean dressing. Findings include: The facility's Handwashing/Hand Hygiene policy, revised 10/2023, indicates: .Hand hygiene is indicated .g. Immediately after glove removal .4. Single-use disposable gloves should be used .5. The use of gloves does not replace hand washing/hand hygiene . The facility's undated Wound Care policy indicates: .2. Wash and dry your hands thoroughly .4. Put on exam glove. Loosen tape and remove dressing .5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. 6. Put on gloves .21. Wipe reusable supplies with alcohol as indicated (i.e., .scissor blades, etc.) . On…

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 allegations of abuse were reported to the State Agency (SA) timely for 2 residents (R2 and R8) of 8 sampled residents. R2's medical record indicated R2 was sexually inappropriate and/or verbally and physically aggressive toward other residents on 1/10/25 and 1/29/25. In addition, R2 and R8 were involved in a verbal altercation on 2/8/25. The facility did not report the allegations of abuse to the SA. Findings include: The facility's Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy, revised September 2022, indicates: All reports of resident abuse .are reported to local, state and federal agencies as required by current regulations and thoroughly investigated by facility management. Findings of all investigations are documented and reported . The facility's Resident-to-Resident Altercations policy, revised September 2022, indicates: All altercations, including those that may represent resident-to-resident…

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 allegations of abuse were thoroughly investigated for 2 residents (R) (R2 and R8) of 8 sampled residents. Progress notes, dated 1/10/25 and 1/29/25, indicated R2's medical record indicated R2 was sexually inappropriate and/or verbally and physically aggressive toward other residents on 1/10/25 and 1/29/25. In addition, R2 and R8 were involved in a verbal altercation on 2/8/25. The facility did not thoroughly investigate the allegations of abuse. Findings include The facility's Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy, revised September 2022, indicates: All reports of resident abuse .are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported 6. Upon receiving an allegations of abuse .the Administrator is responsible for determining what actions (if any) are…

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 care plans were revised for 3 residents (R) (R4, R5 and R6 ) of 8 sampled residents. R4, R5 and R6 were assessed as high risk for falls. The facility did not ensure fall interventions were reviewed, revised, or added to R4, R5, and R6's falls care plans in a timely manner. Findings include: The facility's Falls and Fall Risk, Managing policy, revised March 2018, indicates: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling .5. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant . 1. On 4/2/25, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] and had diagnoses including chronic pain syndrome and unspecified dementia without…

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 ensure staff provided adequate supervision to prevent resident-to-resident altercations for 4 residents (R) (R1, R3, R4, and R5) of 5 sampled residents. On 7/20/24, R1 rolled R1's wheelchair into R2's foot. R2 said ouch and R1 raised R1's fists as if to hit R2. On 7/31/24, R1 was found in R3's room yelling at R3. R1 was placed on 15-minute checks. On 8/20/24, R1 was observed yelling at R4 in the hallway. R1 grabbed R4's shirt and hit R4's chest. R1 was placed on 1:1 supervision until a motion sensor and an audio monitor were in place. On 9/7/24, R1 became agitated and yelled at Med Tech (MT)-C. R5 approached R1 and said, Don't do that . R1 and R5 then hit each other. R1 was not provided 1:1 supervision at the time of the incident. Findings include: On 10/18/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including a fall with a fracture and dementia. R1's most recent Minimum Data Set…

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 an allegation of abuse was reported to the State Agency (SA) for 2 residents (R) (R1 and R5) of 5 sampled residents. On 9/7/24, R1 and R5 were involved in a physical altercation that involved hitting and slapping at each other. The resident-to-resident altercation was not reported to the SA. Findings include: The facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, with a revision date of April 2021, indicates: Residents have the right to be free from abuse .Objectives: 1. Protect residents from abuse, neglect .by anyone .If resident abuse .is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law .The Administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; .e. Law…

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 stored and prepared in a sanitary manner. This practice had the potential to affect all 30 residents residing in the facility. Cooling logs were not completed for leftover foods. A refrigerator that stored food for resident consumption contained dried food debris and a sticky substance on the interior shelves. Food holding temperatures were not monitored or documented. Food items for resident consumption were not labeled with open or expiration dates and/or were beyond the labeled discard date. Findings include: On 7/29/24 at 9:36 AM, Surveyor began an initial tour of the kitchen with the Dietary Manager (DM)-O who stated the facility follows the State and Federal Food Codes. Cooling Logs: The Food and Drug Administration (FDA) Food Code 2022 documents at 3-501.14 Cooling: (A) Cooked Time/Temperature Control for Safety Food shall be cooled: (1) Within 2 hours from 135º Fahrenheit (F) to 70°F; and (2) Within a total of 6 hours from 135ºF to 41°F or less. The facility's Food Temperature for…

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 help prevent the development and transmission of communicable disease and infection. This practice had the potential to affect all 30 residents residing in the facility. The facility did not maintain monthly and quarterly infection surveillance data. The facility did not implement enhanced barrier precautions (EBP) for 3 Residents (R) (R15, R14, and R11) with a history of multi-drug resistant organisms (MDROs). Findings include: Infection Surveillance: The facility's Infection Control Manual, dated 2019, outlines the facility's procedure for creating monthly and quarterly infection summary reports. On 7/30/24 at 8:56 AM, Surveyor reviewed the facility's infection control binder which did not contain documentation of monthly and quarterly infection surveillance. On 7/30/24 at 9:19 AM, Surveyor interviewed Director of Nursing (DON)-B who was also 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 staff interview and record review, the facility did not implement their abuse policy and complete timely and thorough background checks for 4 of 8 sampled staff. The facility did not obtain Integrative Background Information System (IBIS) or Department of Justice (DOJ) reports for Certified Nursing Assistant (CNA)-T. The facility did not obtain IBIS or DOJ reports for Dietary Aide (DA)-S. The facility obtained Physical Therapist (PT)-R's IBIS and DOJ reports after PT-R's hire date. The facility di not ensure a background check was completed within the last four years for CNA-U. In addition, the facility did not obtain IBIS or DOJ reports for CNA-U. Findings include: The facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, with a revision date of April 2021, indicates residents have the right to be free from abuse, neglect, misappropriation, and exploitation. The facility prevention program consists of a facility-wide commitment and resource allocation to support the following objectives .4. Conduct employee background checks and not…

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 3. On 7/30/24, Surveyor reviewed R15's medical record. R15 was admitted to the facility on [DATE] with diagnoses including cerebral hemorrhage (stroke), hemiplegia, and diabetes. R15's MDS assessment, dated 7/19/24, stated R15's BIMS score was 15 out of 15 which indicated R15 had intact cognition. On 7/30/24, Surveyor reviewed R26's medical record. R26 was admitted to the facility on [DATE] with diagnoses including neurocognitive disorder Lewy bodies and fracture of unspecified part of neck of left femur. R26's MDS assessment, dated 6/18/24, stated R26's BIMS score was 1 out of 15 which indicated R26 had severe cogitative impairment. R26 had a guardian for healthcare decisions. On 7/30/24 at 12:48 PM, Surveyor interviewed R15 who stated R15 was attacked by R26 on 7/20/24 and R15's Family Member ((FM)-L) was not notified. R15 stated R26 made fists and hit R15 in the chest. R15's medical record contained a nursing progress note, dated 7/22/24, that indicated: Two days ago, R26's wheelchair bumped into R15's…

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 5 Residents (R) (R19, R15, R4, R6, and R31) of 6 sampled residents who required assistance with activities of daily living (ADLs) were assisted per their plans of care. R19 was not assisted with meals as indicated in R19's plan of care. R15, R4, R6, and R31 did not consistently receive weekly scheduled showers. Findings include: The facility's Assistance with Meals policy, dated March 2022, states: Residents shall receive assistance with meals in a manner that meets the individual needs of each resident .Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example: a. not standing over residents while assisting them with meals. 1. On 7/31/24, Surveyor reviewed R19's medical record. R19 was admitted to the facility on [DATE] with diagnoses including dementia and failure to thrive. R19's Minimum Data Set (MDS) assessment, dated 6/16/24, indicated R19 required…

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 and staff and resident interview, the facility did not make a prompt effort to resolve a grievance for 1 Resident (R) (R15) of 1 sampled resident. In addition, the grievance was not contained in the facility's grievance file. During an interview on 7/30/24, R15 stated R15 called Family Member (FM)-L and asked FM-L to call the facility for assistance when staff didn't answer R15's call light. FM-L stated FM-L phoned the facility numerous times with no answer or ability to leave a message. R15 told staff the telephone wasn't answered and there was no way to leave a message. The facility did not follow-up with R15 and FM-L or resolve the grievance in a timely manner. Findings include: On 7/30/24, Surveyor reviewed R15's medical record. R15 was admitted to the facility on [DATE] with diagnoses including cerebral hemorrhage (stroke), hemiplegia (paralysis on one side of the body), and diabetes. R15's Minimum Data Set (MDS) assessment, dated 7/19/24, stated R15's Brief Interview for Mental Status…

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 and resident interview and record review, the facility did not ensure incidents involving potential abuse were reported to the Nursing Home Administrator (NHA) and the State Agency (SA) for 3 Residents (R) (R24, R15 and R26) of 5 sampled residents. On 4/2/24, staff discovered R24 had an injury of unknown origin. The facility did not report the injury of unknown origin to the NHA and the SA. On 7/20/24, R15 had a physical altercation with R26. The facility did not report the resident-to-resident altercation to the SA. Findings include: The facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, with revision date of April 2021, indicates: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation .Objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone .If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is…

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 a written notification of transfer, including the reason for the transfer, location of the transfer, appeal rights, and contact information for the State Long-Term Care Ombudsman was provided for 1 Resident (R) (R6) of 2 sampled residents reviewed for hospitalization. R6 was not provided a written transfer notice when R6 was transferred to the hospital on 5/12/24. Findings include: The facility's Transfer or Discharge, Facility-Initiated policy states: The transfer .is necessary for the resident's welfare and the resident's needs cannot be met in this facility .Transfer refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility when the resident expects to return to the original facility .The resident and representative are notified in writing of the following information: the effective date of the transfer .the specific location (such as the name of the new provider .to which 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) (R6) of 2 residents reviewed for hospitalization received written information of the duration of the bed hold policy, the reserve bed payment policy, and the right to return to the facility. R6 was transferred to the hospital on 5/12/24 and was not provided a bed hold notice. Findings include: The facility's Bed-Holds and Returns policy, revised October 2022, indicates: All residents/representatives are provided written information regarding the facility and state bed-hold policies which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided written notice about these policies .at the time of transfer (or, if the transfer was an emergency, within 24 hours) .The written bed-hold notice provided to the resident/representative explains in detail: the duration of the state bed-hold policy, if any, during which the resident…

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 Pre-admission Screen and Resident Review (PASRR) requirements were met for 1 Resident (R) (R22) of 5 sampled residents. R22's medical record indicated R22 had a history of mental illness (MI) or mental disorder (MD) diagnosis upon admission and was prescribed psychotropic medication. R22's PASRR Level I Screen was marked no for major mental disorder, yes for psychotropic medication, and no for history of intellectual disability (ID). The facility did not complete a PASRR Level II Screen when R22 remained in the facility for long-term care. Findings include: According to the State of Wisconsin Department of Health Services (DHS), PASRR is a federal requirement that all applicants to Medicaid-certified nursing facilities be assessed to determine whether they might have an intellectual/developmental disability (ID/DD) and/or mental illness (MI). This is called a Level I Screen. The purpose of a Level I Screen is to identify individuals whose…

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 develop a comprehensive plan of care following a smoking assessment for 1 Resident (R) (R25) of 15 sampled residents. R25's plan of care did not address R25's smoking assessment or include interventions specific to smoking at the facility. Findings include: The facility's undated Smoking Policy states: It is the policy of this facility to meet the needs and provide a safe environment for our residents that smoke. Smoking regulations will not be established to restrict the resident's smoking privileges. However, some restrictions will apply. The facility will have designated smoking areas. Smoking will be prohibited in any other area. If it becomes necessary to restrict an individual resident's smoking privileges because of safety and/or medical reasons, such information will be noted on the resident's care plan. Smoking policies will be reviewed with the resident and/or responsible party prior to or upon admission and as needed on an individual…

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 ensure 1 Resident (R) (R14) of 1 resident with an indwelling catheter received the appropriate care and services to prevent a urinary tract infection (UTI). During an observation on 7/29/24, staff did not keep R14's catheter drainage bag below the level of the bladder which prevented the flow of urine. Findings include: The facility's Catheter Care, Urinary policy, revised 4/2022, states: Maintaining Unobstructed Urine Flow: 3. Position the drainage bag lower than the bladder at all times to prevent urine from flowing back into the urinary bladder. From 7/29/24 to 7/31/24, Surveyor reviewed R14's medical record. R14 was admitted to the facility on [DATE] with diagnoses including quadriplegia C5-C7 complete, pressure injury sacral region stage 4, osteomyelitis, neurogenic bowel, diabetes mellitus type 2, extended spectrum beta lactamase (ESBL) resistance, urinary tract infections (UTIs), and neuromuscular dysfunction of the bladder. On…

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 ensure 1 Resident (R) (R20) of 3 sampled residents was offered fluid intake between meals. The facility did not provide fluids to R20 between meals. Findings include: The facility's Resident Hydration and Prevention of Dehydration policy states: .6. Nurse aides will provide and encourage intake of bedside, snack, and meal fluids on a daily and routine basis as part of daily care. From 7/29/24 to 7/31/24, Surveyor reviewed R20's medical record. R20 was admitted to the facility on [DATE] with diagnoses including aphasia (the loss or impairment of one's capacity to use or comprehend language), dysphagia (difficulty swallowing), neurocognitive disorder with Lewy body dementia, epilepsy, and Parkinson's disease. R20's Minimum Data Set (MDS) assessment, dated 5/31/24, stated R20's Brief Interview for Mental Status (BIMS) score was 00 out of 15 which indicated R20 was rarely/never understood and had severe cognitive impairment. R20 had an…

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 high-risk medications were monitored for 2 Residents (R) (R6 and R19) of 5 residents reviewed for unnecessary medications. The facility did not monitor R6 for side effects or adverse reactions of insulin and bumetanide. The facility did not monitor R19 for side effects or adverse reactions of apixaban and furosemide. Findings include: FDA.gov states drugs approved by the United States Food and Drug Administration (FDA) for sale in the United States must be safe and effective which means the benefits of the drug must be greater than the known risks .Side effects, also known as adverse reactions, are unwanted undesirable effects that are possibly related to a drug. Medline plus.gov states insulin is used to control blood sugar in people who have type 1 diabetes (a condition in which the body does not make insulin and cannot control the amount of sugar in the blood) or in people who have type 2 diabetes (a condition in which the blood sugar is too high because the body does not produce or use insulin normally) that…

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 assessment and rationale for psychotropic medications were completed for 3 Residents (R) (R1, R22, and R19) of 5 residents reviewed for unnecessary medications. R1 was prescribed lorazepam (an antianxiety medication) as needed (PRN) three times daily (TID) on 6/20/24. There was no rationale provided for continued use of the medication beyond 14 days. R22 was prescribed lorazepam 0.5 mg (milligrams) 1 tablet twice daily (BID) PRN on 2/7/24. There was no rationale provided for continued use of the medication beyond 14 days. R19 was prescribed lorazepam PRN TID on 6/20/24. There was no rationale provided for continued use of the medication beyond 14 days. Findings include: The facility's Psychotropic Medication Use Policy, dated July 2022, states: A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific 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.

Based on observation, staff interview, and record review, the facility did not ensure medications were stored appropriately for 1 Resident (R) (R4) of 6 residents observed during medication administration. On 7/31/24, Registered Nurse (RN)-N left two bottles of eye drops (fluorometholone and Sil-Optho) and a container of betamethasone valerate topical lotion that were prescribed to R4 and a scopolamine transdermal system 1 mg (milligram)/3 days patch that was not prescribed to R4 on R4's bedside table. Findings include: During an observation of medication administration on 7/31/24 at 6:59 AM, Surveyor observed a bottle of fluoromethalone 0.1 % ophthalmic suspension (a steroid medication used to treat eye inflammation) and a bottle of Sil-Optho eye lubricant (a silicone lubricant made for artificial eyes) labeled with R4's name on R4's bedside table. A scopolamine transdermal system (a medication to decrease secretions to prevent nausea and vomiting) 1 mg/3 days patch was also observed on R4's bedside table. On 7/31/24 at 6:59 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-G…

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 and staff, resident, and family interview, the facility did not ensure 1 Resident (R) (R15) of 12 sampled residents resided in a clean, comfortable, and home-like environment. This had the potential to affect multiple residents in the facility. During observations on 7/29/24 and 7/30/24, the 100 and 200 wings of the facility smelled of urine. During an interview on 7/30/24, R15 stated the facility smelled like an [NAME]. Findings include: Upon entering the facility on 7/29/24, Surveyors noted a urine odor. On 7/29/24, Surveyors noted a urine odor in the dining room during lunch service and in resident hallways and common areas. On 7/30/24, Surveyor noted a urine odor in resident hallways. The urine odor was strongest on the 100 wing. On 7/30/24 at 8:55 AM, Surveyor interviewed Housekeeper (HK)-K who verified the facility had a urine odor. HK-K stated the facility used to have air fresheners but did not have them any longer. HK-K indicated HK-K thought the caulk around the toilets contributed…

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 maintain an infection prevention and control program designed to provide a safe and sanitary environment and prevent the transmission of communicable disease and infection. This practice had the potential to affect all 29 residents residing in the facility. In addition, staff did not perform appropriate hand hygiene during incontinence care for 2 residents (R) (R9 and R6) of 2 residents. The facility did not appropriately monitor for infections and outbreaks. Staff did not perform appropriate hand hygiene during incontinence care for R9 and R6. Findings include: The facility's Surveillance for Infections policy, dated 9/2017, indicates: .5. Nursing staff will monitor residents for signs and symptoms that may suggest infection, according to current criteria and definitions of infections and will document and report suspected infections to the charge nurse as soon as possible. Data Collection and Recording 1. For residents 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility did not ensure medications were properly secured in a medication cart. This practice had the potential to affect multiple residents whose medications were stored in the cart. Surveyor observed R15 open a drawer of an unlocked medication cart in the lobby and remove two medication cards. Findings include: The facility's Security of Medication Cart policy, revised April 2007, indicates: .5. When the medication cart is not being used, it must be locked and parked at the nurses' station or inside the medication room. On 4/9/25, Surveyor reviewed R15's medical record. R15 was admitted to the facility on [DATE] with diagnoses including dementia. R15's Minimum Data Set (MDS) assessment, dated 1/24/24, contained a Brief Interview for Mental Status (BIMS) score of 0 out of 15 which indicated R15 had severe cognitive impairment. On 4/9/24 at 2:12 PM, Surveyor entered the lobby and observed a medication cart next to the nurses' station. Surveyor observed R15 lean from…

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 failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 2 residents (R) (R16 and R17) of 10 sampled residents. R16 stated in a resident council meeting that a staff kicked R16's foot off R16's chair on purpose and was rough with R16. The allegation of abuse was not reported to the State Agency (SA) or local law enforcement. R17 stated someone took money out of R17's purse. The allegation of misappropriation was not reported to the SA or local law enforcement. Findings include: The facility's Resident/Employee Abuse, Neglect, Mistreatment Policy and Procedure, dated 8/24/15, indicates: 1. Any alleged violation involving mistreatment, misappropriation of property, abuse, exploitation, neglect, or injuries of unknown source of a resident shall be immediately reported to the Administrator, the Clinical Manager or designee, the Division of Quality Assurance…

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 thoroughly investigate allegations of abuse and misappropriation for 2 residents (R) (R16 and R17) of 10 residents. R16 stated in a resident council meeting that staff kicked R16's foot of R16's chair on purpose and was rough with R16. The allegation of abuse was not thoroughly investigated. R17 stated someone took money out of R17's purse. The allegation of misappropriation was not thoroughly investigated. Findings include: The facility's Resident/Employee Abuse, Neglect, Mistreatment Policy and Procedure, dated 8/24/15, indicates: 4. The Administrator or designee shall thoroughly investigate all allegations and show evidence that they thoroughly investigated and must prevent further incidents while the investigation is in process. A thorough investigation includes but is not limited to: Interviewing alleged victims and witnesses, interviewing accused individuals, interviewing other residents to determine if they have ben abused or mistreated,…

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 ensure necessary care and services were provided to promote healing and/or prevent pressure injuries from worsening or developing for 1 resident (R) (R6) of 17 sampled residents. R6's medical record indicated R6 had open area(s) on the buttocks on 1/10/24 and 3/27/24. R6's medical record did not contain assessments or proof of monitoring for effectiveness of treatments. Findings include: The facility's Pressure Ulcers/Skin Breakdown-Clinical Protocol document, with a revision date of April 2018, indicates: .1. The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers .2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic (dead) tissue .d. Current treatments .4. The physician will assist the staff to identify the type (for…

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 and staff interview, the facility did not establish and maintain an infection control program designed to provide a safe and sanitary environment to help prevent the development and transmission of disease and infection for 1 Resident (R) (R1) of 3 residents observed during the provision of cares. Staff did not appropriately cleanse hands during the provision of cares for R1. Findings include: According to the Centers for Disease Control and Prevention (CDC) Hand Hygiene in Healthcare Settings Guidance: Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: * Immediately before touching a patient * Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices * Before moving from work on a soiled body site to a clean body site on the same patient * After touching a patient or the patient's immediate environment * After contact with blood, body fluids, or contaminated surfaces * Immediately after glove removal Healthcare facilities should: *…

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 safe food handling practices were implemented. This had the potential to affect all 28 residents residing in the facility. Food items for resident consumption were not labeled with open dates and/or expiration dates. A refrigerator with food for resident consumption contained missing daily temperature checks on the temperature log form. An air-handling unit and a condenser in the kitchen/kitchen walk-in cooler contained debris. Findings include: During an initial tour of the kitchen on 5/30/23 at 9:13 AM, Dietary Manager (DM)-C stated the facility follows the Wisconsin State Food Code as their standard of practice. 1. Date Marking Wisconsin (WI) Food Code 2022 documents at 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking .(A) Except when packaging food using a reduced oxygen packaging method as specified under § 3-502.12, and except as specified in (E), (F), and (H) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and held…

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 based on current standards of practice and designed to provide a safe environment to help prevent the development and transmission of communicable disease and infection. This practice had the potential to affect all 28 residents residing in the facility. The facility's Water Management Plan (WMP) was not based on current standards of practice and did not: -Include water management team members who were knowledgeable about Legionella and the facility's water system -Describe the building's water system using text and an accurate flow diagram of the system -Include an assessment of the facility's water system to identify all locations where Legionella could grow and spread -Identify where control measures should be applied based on where Legionella could grow and spread -Identify acceptable ranges of control limits (temperature ranges) and corrective action when 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 staff interview and record review, the facility did not ensure the Infection Preventionist (IP) completed specialized training in infection prevention and control. This had the potential to affect all 28 residents residing in the facility. The facility does not currently have an IP who completed specialized training in infection prevention and control. Findings include: CMS (Centers for Medicare and Medicaid Services) Ref: QSO-22-19-NH last revised date: June 29, 2022 contains the following information: In 2016, CMS overhauled the Requirements for Participation for Long-Term Care (LTC) facilities (i.e., nursing homes), which was implemented in three phases: Phase 3 - November 28, 2019 .Phase 3 .regulations which require nursing homes to have an Infection Preventionist (IP) who has specialized training onsite at least part-time to effectively oversee the facility's infection prevention and control program (IPCP). On 6/1/23 at 8:36 AM, Surveyor interviewed Director of Nursing (DON)-B who verified DON-B started employment with the facility in November 2022. DON-B stated 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 staff interview and record review, the facility did not ensure the development of a comprehensive person-centered care plan with measurable goals, timeframes, and interventions for 1 Resident (R) (R18) of 2 sampled residents. R18 was diagnosed with a right corneal eye ulcer and bacterial conjunctivitis. R18 was started on antibiotics. The facility did not develop a care plan to address R18's infection or antibiotic use including monitoring and possible side effects. Findings include: 1. From 5/31/23 through 6/1/23, Surveyor reviewed R18's medical record. Surveyor noted R18 was diagnosed with a right corneal eye ulcer and bacterial conjunctivitis (commonly known as pink eye, a common eye infection that causes inflammation of the tissues lining the eyelid (conjunctiva). Pink eye due to bacteria is highly contagious.) R18 was receiving moxifloxacin, tobramycin, and vancomycin (all antibiotic eye drops), and was placed on contact precautions (healthcare personnel caring for patients on contact precautions wear a gown and gloves for all interactions that may involve contact 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure influenza and pneumococcal vaccinations were reviewed, offered, and administered for 2 Residents (R) (R9 and R20) of 5 residents. The facility did not review R9's vaccination history or offer R9 the PCV20: 20-valent pneumococcal conjugate vaccine (Prevnar 20®). In addition, the facility did not offer R9 an annual influenza vaccine. The facility did not review R20's vaccination history or offer R20 the PPSV23: 23-valent pneumococcal polysaccharide vaccine (Pneumovax23®). Findings include: Abbreviations (www.cdc.gov): PCV13: 13-valent pneumococcal conjugate vaccine (Prevnar13®) PCV15: 15-valent pneumococcal conjugate vaccine (Vaxneuvance®) PCV20: 20-valent pneumococcal conjugate vaccine (Prevnar 20®) PPSV23: 23-valent pneumococcal polysaccharide vaccine (Pneumovax23®) The most recent Centers for Disease Control and Prevention (CDC) recommendations for pneumococcal vaccinations indicate: For adults 65 years or older who have only 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure a resident or resident's representative was provided education regarding the risks versus benefits of COVID-19 immunization and did not obtain consent or refusal for COVID-19 immunization for 3 Residents (R) (R9, R18 and R20) of 5 residents reviewed. R9's medical record did not contain documentation to indicate R9 or R9's representative was provided education regarding COVID-19 immunization and offered the opportunity to receive or decline COVID-19 immunization. R18's medical record did not contain documentation to indicate R18 or R18's representative was provided education regarding COVID-19 immunization and offered the opportunity to receive or decline COVID-19 immunization. R20's medical record did not contain documentation to indicate R20 or R20's representative was provided education regarding COVID-19 immunization and offered the opportunity to receive or decline COVID-19 immunization. Findings include: The Centers for Disease Control…

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.