Dove Healthcare - Superior

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility did not ensure that an alleged abuse of R1 was reported to the State Agency (SA).The facility did not report the alleged abuse of Licensed Practical Nurse (LPN) D hitting R1 on the buttocks to the SA.Findings include:The facility's policy titled, Resident Abuse, Neglect, Misappropriation of Property, and Exploitation Prevention Program revised October 2025 states in part, .7. Reporting and Response: The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment. are reported per Federal and State laws. Reporting allegations immediately: a. But no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse .R1 was admitted to the facility on [DATE]. Diagnoses included vascular dementia, major depressive disorder, anxiety disorder, and pain.Most recent Minimum Data Set (MDS) assessment, completed on 1/20/26, indicated that R1 required assist with ambulation, no behaviors…

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 interview and record review, the facility did not ensure a thorough investigation was conducted when receiving a report of alleged physical abuse.The facility did not thoroughly investigate to rule out abuse of a Resident (R1). No interviews were conducted with other residents to ensure there had been no further incidents of abuse, a thorough physical exam/skin assessment or a psycho-social exam were not conducted. The acting administrator was not notified of the incident. Findings include:The facility's policy titled, Resident Abuse, Neglect, Misappropriation of Property, and Exploitation Prevention Program revised October 2025 states in part, .5. Investigation- A thorough investigation is an investigation that adequately addresses the circumstances of the allegation. The facility will promptly and thoroughly investigate reports of abuse that includes mistreatment. Designated facility personnel will begin the investigation immediately and will collect information that corroborates or disproves 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 and interview, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. This affected 1 out of 3 residents (R) reviewed. (R4) Certified Nurse Assistant (CNA) E did not doff contaminated gloves after emptying urine from catheter into graduate before continuing R4's cares. Findings include: The facility policy, titled Enhanced Barrier Precautions, revised January 2025, states:.4. High contact resident acre activities include:e. Changing linens.f. Changing briefs or assisting with toileting.g. Device care or use. Urinary catheters.Surveyor reviewed R4's record, which indicated R4 is on enhanced barrier precautions (EBP) for history of extended-spectrum beta-lactamase (ESBL) in the urine and R4 has a suprapubic catheter. On 08/26/25 at 3:15 PM, Surveyor followed CNA E into R4's room. Surveyor observed CNA E don Personal Protective Equipment (PPE) before entering R4's room. CNA E pushed R4 into 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 observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. This had the potential to affect all 62 residents in the facility. -The facility did not have a water management program to reduce the risk of growth and spread of Legionella and other opportunistic waterborne pathogens. -Facility surveillance does not provide adequate evidence of tracking and monitoring infections. -Residents with known infections were not placed on precautions or placed on incorrect precautions. -Bins for discarding personal protective equipment (PPE) were placed in the hallways. Soiled PPE was hanging outside of the bins and exposed. -Clean linens were not covered during transport. Clean linens were stored in shower rooms inside shower stall and on shower bench. -Staff did not sanitize mechanical lifts between 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 interview and record review, the facility did not provide written notice of transfer to the resident or their representative and did not send a copy of the notice of transfer to the hospital to a representative of the Office of the State Long-Term Care Ombudsman for 6 of 6 residents (R) reviewed for hospitalization. (R58, R68, R10, R25, R57, and R41) Findings include: Example 1 R58 was admitted to the facility on [DATE]. R58 had a Brief Interview for Mental Status (BIMS) score of 08/15, indicating R58 had moderate cognitive impairment. The record identified R58 had a legal guardian who was responsible for R58's medical decision-making. The record showed R58 was hospitalized on [DATE] and on 02/04/25 after falls at the facility. On 03/10/25 at 1:39 PM, Surveyor interviewed R58's legal guardian who reported the facility did call before transferring R58 to the hospital, but the guardian did not remember receiving anything in writing. Surveyor reviewed R58's medical record and was not able to find a written…

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 interview and record review the facility did not provide written notice of bed-hold policy to the resident or their representative for 5 of 6 residents (R) reviewed for hospitalization. (R58, R68, R25, R57, and R41) Findings include: Example 1 R58 was admitted to the facility on [DATE]. R58 had a Brief Interview for Mental Status (BIMS) score of 08/15, indicating R58 had moderate cognitive impairment. The record identified R58 had a legal guardian who was responsible for R58's medical decision-making. The record showed R58 was hospitalized on [DATE] and on 02/04/25 after falls at the facility. On 03/10/25 at 1:39 PM, Surveyor interviewed R58's legal guardian who reported the facility did call before transferring R58 to the hospital, but the guardian did not remember receiving anything in writing about a bed-hold policy. Surveyor reviewed R58's medical record and was not able to find a written bed-hold notice for the hospitalizations. Surveyor requested copies of the written bed-hold notice for the two…

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, interview and record review, the facility did not ensure the resident's environment remains as free of accident hazards as possible. The facility did not ensure staff followed transfer precautions and supervision when needed to prevent accidents which had the potential to affect 21 out 62 residents. -Surveyor observed Certified Nurse Assistant (CNA) U bathe R57 in bath house without a call system in place for emergencies during bath/shower cares. -R41 was at risk for falls. Facility did not implement new interventions put into place post falls. -Staff ambulated R41 without gait belt in place during ambulation transfer process. -R58 had a history of frequent falls with major injury and the facility failed to ensure adequate supervision and implementation of interventions to prevent further falls. Findings include: Example 1 Facility policy titled, Fall Prevention Program, dated reviewed on [DATE], states in part: .#6. When any resident experiences a fall, the facility will: a. Assess 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, interview and record review, the facility did not ensure that sufficient nursing staff was provided for the third floor to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident (R). This has the potential to affect all 14 residents residing on the third floor. Residents on the third floor have had multiple falls with injuries. A resident (R19) had an unwitnessed fall and no staff responded to calls for help until Surveyor intervened. R9 who is frequently incontinent of urine did not receive assistance with repositioning or toileting for 4 1/2 hours. Findings include: Facility Assessment, dated 02/03/25, stated in part: .Information About Our Staffing Patterns section stated Average Nurse Aide/Resident Ratio (Direct Care Staff) Average about 1 Nurse Aide to 10 Residents . Surveyor reviewed the daily staffing postings and nursing schedules for the past month. The schedule showed one nurse and one Certified Nursing Assistant (CNA) scheduled…

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 interview and record review, the facility did not ensure medication reviews were completed for 5 out of 5 residents (R) reviewed (R65, R17, R53, R41, and R61) for unnecessary medications. Medication reviews were not completed at least monthly by a licensed pharmacist and documentation of review was not maintained in the resident's medical records. Findings include: The facility policy titled, Consultant Pharmacist Reports IIIA1: Medication Regimen Review revised December 2019, states in part, .B. The consultant pharmacist the medication regimen of each resident at least monthly . H. At least monthly, the consultant pharmacist reports any irregularities to the attending physician, medical director and the director of nursing, at a minimum . The policy titled, Consultant Pharmacist Reports IIIA2: Documentation and Communication of the consultant Pharmacist Recommendations revised December 2019, states in part, .A. A record of the consult pharmacist's observations and recommendations is made available in…

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, interview and record review, the facility did not ensure that snack/nourishment refrigerators on the first floor and third floor were maintained with the proper temperatures and food items are dated and labeled to prevent the potential for food-borne illness. This has the potential to effect all residents on the first floor and third floor. Findings include: According to the US Food and Drug Administration (FDA) Food Code 2022: Annex 3-123 .Date marking is the mechanism by which the Food Code requires active managerial control of the temperature and time combinations for cold holding. Industry must implement a system of identifying the date or day by which the food must be consumed, sold, or discarded. Date marking requirements apply to containers of processed food that have been opened and to food prepared by a food establishment, in both cases if held for more than 24 hours, and while the food is under the control of the food establishment . According to the US FDA Food Code 2022: Annex 3-164 to 165: .A permanent temperature measuring device is required in…

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 interview and record review, the facility did not provide reasonable accommodation of resident needs and preferences for 1 of 16 sampled residents (R7). -R7 was not provided a wheelchair to allow her to get out of bed while residing in the facility. Findings include: The facility's policy titled, Resident Rights, reads in part .To ensure that all residents have a right to a dignified existence, self-determination and communication with and access to persons and services and outside of the facility. 3. The facility will provide care to the resident in a manner and environment that promotes the maintenance or enhancement of his/her quality of life. 5. Equal access to quality care will be provided to each resident regardless of diagnosis, severity of condition, or payment source. R7 was admitted to the facility on [DATE]. Diagnoses include left sided paralysis, stage 1 pressure ulcer to back, buttock and hip, bi-polar disorder, and anxiety. Minimum Data Set (MDS) assessment completed on 01/25/25 included…

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 interview and record review, the facility did not promote and facilitate resident self-determination through support of resident choice for 1 of 16 sampled residents (R10). R10 reported her dissatisfaction with male caregivers providing personal care assistance after the facility identified R10's preference for female caregivers only. Findings: The facility policy titled, Resident Rights, reads in part .To ensure that all residents have a right to a dignified existence, self-determination and communication with and access to persons and services inside and outside of the facility. 1. The facility will protect and promote the right of each resident . 3. The facility will provide care to the resident in a manner and environment that promotes the maintenance or enhancement of his/her quality of life . 10. The facility will assist residents in exercising rights in regards to autonomy and choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care . R10 was…

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, interview and record review, the facility did not develop and implement a comprehensive person-centered care plan addressing medical and nursing needs. This occurred for 1 of 16 residents reviewed (R25). -R25 did not have a care plan identifying interventions for controlling and preventing the spread of infection related to Extended Spectrum Beta Lactamase (ESBL) resistance. Findings: The facility's policy titled Comprehensive Care Plan, read in part . 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. f. Resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated. 6. The comprehensive care plan will include measurable objectives and timeframes to [NAME] the resident's needs and identified in the resident's comprehensive assessment. According…

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 record review, observation and interview, the facility did not ensure a resident who required substantial assistance for repositioning and toileting received timely assistance for 1 of 4 residents (R) reviewed for Activities of Daily Living (ADLs) (R9). R9 who is frequently incontinent of urine did not receive assistance with repositioning or toileting for 4 1/2 hours. Findings include: R9 was admitted to the facility on [DATE] with the following diagnoses in part, chronic kidney disease, vascular dementia, unspecified urinary incontinence, leg pain, and osteoarthritis. R9's Minimum Data Set (MDS) assessment, dated 01/06/25, identified R9 was unable to complete a Brief Interview for Mental Status assessment due to severe cognitive impairment. The MDS assessment further identified R9 had no behaviors of rejection of cares and required substantial or maximal assistance for all mobility and toileting. The MDS assessment also indicated R9 was frequently incontinent of urine and always incontinent of bowel.…

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, interview and record review, the facility failed to ensure residents received care and treatment in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 16 residents (R) reviewed for quality of care (R58). R58 had a witnessed fall and was transferred from floor to bed by Certified Nursing Assistant (CNA) before a Registered Nurse assessed the resident for injuries. Findings include: R58 was admitted to the facility on [DATE] with the following diagnoses in part, unspecified dementia with psychotic disturbance, Alzheimer's disease, age-related physical debility, osteoporosis, unspecified visual disturbance, weakness, and abnormalities of gait and mobility. R58 had a fall risk assessment score of 20 on 02/20/25 which indicated R58 was high risk for falls. R58 had two recent falls resulting in a left humerus fracture and and a left femoral neck fracture. On 03/13/25 at 6:41 AM, Surveyor observed the ambulance team arrive on 3rd floor 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, interview and record review, the facility failed to provide care consistent with standards of practice, to prevent pressure injuries (PI) for 1 of 5 residents (R) reviewed for pressure injuries (R36). -R36 was at risk for development of pressure injuries and was not repositioned to reduce pressure for greater than 4 hours. Findings include: According to the National Pressure Injury Advisory Panel (NPIAP) 2019, page 115, . Repositioning and mobilizing individuals is an important component in the prevention of pressure injuries. The underlying cause and formation of pressure injuries is multifaceted; however, by definition, pressure injuries cannot form without loading, or pressure, on tissue. Extended periods of lying or sitting on a particular part of the body and failure to redistribute the pressure on the body surface can result in sustained deformation of soft tissues and, ultimately, in tissue damage . According to Wound Care Education Institute (WCEI) 2018, for immobile or bed bound…

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 observations, interviews and record review, the facility did not ensure residents with limited mobility received services to maintain or prevent further reduction in mobility for 1 of 1 resident (R) R23. R23's walking program was not developed to maintain or prevent reduction in mobility. Facility staff were not providing assist of 1 with front wheel walker and gait belt walking program. This is evidenced by: The facility policy, titled Restorative Nursing Program- Superior, dated April 2007 states: Maintenance Restorative Program Definition: This program is designed for those residents who through assessment require interventions with the goal to maintain present functioning. Due to the resident's physical or cognitive condition the assessment is that the resident will not progress and may be expected to decline. Example: The resident ambulates well but cognitively is unable to safely ambulate alone. If the Certified Nursing Assistant (CNA) or other nursing staff will be carrying out the interventions,…

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, interview and record review, the facility did not ensure residents with indwelling foley catheters received care and treatment consistent with professional standards of practice to prevent complications or urinary tract infections (UTI) from the catheter for 1 of 1 resident (R) R25 reviewed for catheter. -Urology recommended foley be removed when R25's strength increased; facility removed foley the following day. -No monitoring after removal of foley catheter. Findings include: The facility policy titled, Indwelling Catheter Use & Removal, reads in part .It is the policy of this facility to ensure that indwelling urinary catheters that are inserted or remain in place are justified or removed according to regulations and current standards of practice .Monitoring for excessive post void residual, after removing a catheter that was inserted for obstruction or overflow incontinence .Verify practitioner's order .Assess for first voiding post-catheter removal .Document procedure . R25 was…

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 observations, record review and staff interviews, the facility did not ensure 1 of 1 resident (R) reviewed who required oxygen and respiratory care was provided such services consistent with professional standards of practice, the resident's comprehensive person-centered care plan, and physician orders (R2). -On 03/11/25, Certified Nurse Assistant (CNA) S did not connect portable oxygen tank to R2 when CNA S placed R2 in dining room for breakfast. -Facility did not attempt a weaning schedule R2 off of oxygen as able. Findings include: Facility policy titled, Oxygen Administration Policy, dated reviewed on December 2024 states in part: .Policy Explanation and Compliance Guidelines: #1. Oxygen is administered under orders of a physician, except in the case of an emergency. #3. Staff shall document the initial and ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy. #4. The resident's care plan shall identify the interventions for oxygen therapy, based upon…

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, interview and record review, the facility did not provide pharmaceutical services, including procedures that ensured the accurate acquiring, dispensing, administering, storage, and disposal of all drugs and biologicals. The facility did not ensure controlled medications were disposed of timely and per appropriate standard of practice or agency policy for 1 out of 1 resident (R) 60. Findings include: The Statute DHS 132.65 Pharmaceutical Services refers to the handling of medication in Wisconsin facilities, including hospitals and nursing homes. It states in part, .(c) Destruction of medications. 1. 'Time limit.' Unless otherwise ordered by a physician, a resident's medication not returned to the pharmacy for credit shall be destroyed within 72 hours of a physician's order discontinuing its use, the resident's discharge, the resident's death or passage of its expiration date. The facility policy titled Medication Destruction, dated [DATE], states in part, All unused, contaminated, or expired…

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 observations, interview and record review, the facility did not ensure drugs and biologicals were stored in accordance with currently accepted professional practice. This had the potential to affect 6 out of 6 residents (R) (R2, R34, R36, R40, R62, R69) for proper storage. 7 new unopened insulin pens, 1 unopened injectable solution, 1 unopened vaccine, and 1 unopened oral suspension that are temperature sensitive were found in an out of temperature range refrigerator on second floor. On second floor refrigerator, temperature logs are incomplete for 4 out of the 5 last months. Findings include: The facility policy, titled Medication Storage, dated 8/7/2015 states: a. All medication requiring refrigeration are stored in refrigerators located in the pharmacy and at each medication room. b. Temperature are maintained within 36-46 degrees F. Charts are kept on each refrigerator and temperature levels are recorded daily by the charge nurse or other designee. The Wisconsin Pharmacy Chapter 6 titled, Pharmacy Licenses and Equipment states: (e) Refrigerator means a place in which…

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 interview and record review, the facility did not have documentation included in the resident's medical record that the resident either received or did not receive the pneumococcal and/or the influenza vaccination for 2 of 5 residents (R) reviewed for immunizations (R41 and R53). -R41's record does not include evidence resident was offered pneumococcal vaccination. -R53's record does not include evidence resident was offered influenza or pneumococcal vaccination. Findings include: The facility's policy titled Pneumococcal Vaccine Series, read in part .2. Each resident will be offered a pneumococcal immunization unless it is contraindicated, or the resident has already been immunized. 4. The resident/representative retains the right to refuse the immunization. The facility will document in the clinical record the reason for the refusal or the medical contraindication of the immunization. The facility policy titled Influenza Exposure Control, read in part .2. The current season's influenza vaccine will 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.

Based on interview and record review, the facility did not report an incident of a resident-to-resident altercation, when a resident (R) R5 grabbed wrist of R4, resulting in R4 being transferred to emergency room for x-rays and acquiring bruising to wrist, to the State Survey Agency or police department, immediately upon learning of the incident and did not submit the 5-day completed investigation within 5 days as required. The facility practice had the potential to affect 1 of 4 residents (R) reviewed for abuse (R4). This is evidenced by: The facility policy titled, Resident Abuse, Neglect, Misappropriation of Property, and Exploitation Prevention Program last reviewed October 2024, states in part under section 7. Reporting/Response, To whom to report - To the Administrator, State survey agency, local law enforcement. An Adult Protective Services; and when to report, Immediately but not later than two hours after forming the suspicion and if no seriously bodily injury report not later than 24 hours . Report results of all investigations of alleged violations within 5 working days…

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 interview and record review, the facility did not conduct an investigation of a resident-to-resident altercation that occurred on 10/05/24, wherein resident (R) R5 grabbed wrist of R4, resulting in R4 being transferred to emergency room for x-rays. Immediately upon learning of the incident, the facility did not conduct an investigation, staff and residents were not interviewed, interventions and monitoring were not put into place to prevent reoccurrence until 10/09/24. The facility practice had the potential to affect 1 of 4 residents (R) reviewed for abuse (R4). This is evidenced by: The facility policy titled, Resident Abuse, Neglect, Misappropriation of Property, and Exploitation Prevention Program last reviewed October 2024, states in part under section 7. Reporting/Response, Dove healthcare must report alleged violations related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source and misappropriation of resident property and report the results of all investigations to the state survey agency, and other proper officials such as 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, interview and record review, the facility did not ensure the preparation of food in a clean and sanitary environment with the potential to affect all 71 residents in the facility. Staff did not consistently monitor or document cooked food temperatures. Staff did not consistently date or label food items when opened. Staff did not consistently test or document parts per million (PPM) of the quaternary sanitizing solution. Staff did not consistently document refrigerator temperatures. Staff observed touching ready to eat food with contaminated gloves. Findings: Monitor/document food temperatures: The 2022 FDA Food Code documents at section 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding .Time/Temperature Control for Safety Food shall be maintained: (1) At 57° Celsius (C) (135°Fahrenheit (F)) or above, except that roast cooked to a temperature and for a time specified in 3-401.11 (B) or reheated as specified in 3-403.11 (E) may be held at a temperature of 54°C (130°F) or above; (2) At 5°C (41°F) or less. On 10/08/24 at 11:24 AM, Surveyor…

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, interview and record review, the facility did not ensure each resident received adequate supervision for 1 resident (R) R10, reviewed for wandering and elopement potential. Findings: The facility policy titled, Elopement and Wandering Residents, last reviewed March 2024, states in part: Policy: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk . Policy Explanation and Compliance Guidelines: 1. The facility is equipped with door locks/alarms to help avoid elopements. R10 was admitted to the facility on [DATE] with a Brief Interview of Mental Status score of 14, indicating R10's cognition was intact. R10 had diagnoses of alcohol dependence, bipolar, dementia, and senile degeneration of the brain. R10 was the only resident noted on the 1st floor as 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 observation, interview and record review, the facility did not ensure that 2 of 3 residents (R) (R2, R7), reviewed for respiratory care were provided care consistent with professional standards of practice. R2 and R7 require oxygen and have a physician's orders to change oxygen tubing weekly. These were not changed as ordered. This is evidenced by: Example 1 R2 was admitted to the facility with diagnoses that include emphysema, chronic respiratory failure with hypoxia, and chronic obstructive pulmonary disease. R2 utilizes continuous oxygen. On 10/08/24 and 10/09/24, Surveyor observed R2's oxygen tubing which was dated 9/26/24. R3's physician orders state in part, Oxygen: Change oxygen tubing weekly. Example 2 R7 was admitted to the facility with diagnoses that include hypertension, rhinitis, dysphagia and a history of pneumonia. emphysema, chronic respiratory failure with hypoxia, and chronic obstructive pulmonary disease. R7 utilizes oxygen as needed. On 10/08/24 and 10/09/24, Surveyor observed R7's oxygen tubing which was dated 9/14/24. R7's physician orders state in…

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 interview, the facility failed to provide food that is palatable. 3 of 11 sampled residents expressed concerns about the palatibility of their food. R3, R8, and R9 reported issues to surveyors with the quality of their food. This is evidenced by: On 10/08/23 at 12:35 PM, Surveyor sampled a test tray for palatability, The pumpkin bar that was served was approximately 1/8-1/4 inch thick; it was very dry and difficult to cut with a fork. The bar tasted dry, hard and bland. Surveyor observed R8 a short time later; she was speaking to another resident about the pumpkin bar. R8 stated, It's hard as a rock. A short time later she said to the other resident, Be careful you don't break a tooth. On 10/08/24 at 12:36 PM, during dining observation on 2nd floor, R3 wheeled up to Surveyor in a wheelchair and said, The breakfast here is either warm or rotten. On 10/08/24 at 2:40 PM, Surveyor spoke with Dietary Manager (DM) F about the above observations. Surveyor asked if DM F ever performs test trays to ensure the food is palatable, DM F stated No. On 10/09/24 at 11:30…

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 interview and record review, the facility did not complete a thorough investigation of a reportable incident for 1 of 1 resident (R2). The facility was unable to provide a clear and concise timeline of events. The facility completed limited staff interviews, resulting in a conflicting timeline of the incident. Findings: The facility's abuse policy states, in part, Investigation: All investigations will be thorough, well documented, and immediate to determine if mistreatment occurred and, if so, to what extent. A thorough investigation may include: -Identifying staff responsible for the investigation. -Interviewing alleged victims and witnesses. -Interviewing accused individual allegedly responsible for mistreatment or suspected of causing an injury of unknown source. -Interviewing staff who worked on the same shift as the accused to determine if they ever witnessed any mistreatment by the accused. -Interviewing staff who worked previous shifts to determine if they were aware of an injury or accident. On 03/18/24, the facility submitted an Alleged Nursing Home 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.

Based on observation and interview, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development of communicable diseases and infections for 2 of 2 residents (R) (R1, R10) observed during transfers and 1 of 1 resident, (R1) observed during incontinence cares. *Staff did not perform proper hand hygiene during incontinence cares for R1 or after incontinence care before touching R1's bedding, pillow, and remote control. *Staff did not sanitize EZ stand after transferring R10 from chair to bed. *Staff did not sanitize Hoyer lift after transferring R1 from chair to bed. Findings include: Example 1 On 03/05/24 at 8:30 a.m., Surveyor observed Certified Nursing Assistant (CNA) J and CNA K transfer R10 with an EZ stand from R10's wheelchair to R10's bed. CNA J and CNA K washed their hands and donned gloves. R10 was then lifted with the lift to a standing position with the remote control and then wheeled over to the bed. CNA J lowered the lift so R10 could sit on the bed, the strap…

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 record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This deficient practice has the potential to affect 78 of the 78 residents residing in the facility at the time of the survey. The facility did not have a clear water management process or plan in effect to prevent transmission of Legionella infection. Certified Nursing Assistant (CNA) T picked up R74's nasal oxygen tubing from the floor and placed the contaminated tubing in R74's nose. Meal tray delivery was observed in which staff did not wash or sanitize their hands from one resident to the next. Insulin administration was observed in which staff did not sanitize or glove prior to administration of the medication. Findings include: Example 1 Surveyor reviewed the facility policy titled, Water Management Program, with 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not obtain written consent, explaining medication risks and benefits, options, and alternatives when psychotropic medications were initiated and every 15 months thereafter. The facility practices affected 4 of 5 residents reviewed for unnecessary medications (R35, R21, R51, R39). This is evidenced by: Surveyor requested and reviewed the facility policy titled Use of Psychotropic Medication with date implemented 11/04/2023. The policy in part reads: ~Residents and/or representatives shall be educated on the risks and benefits of psychotropic drug use . ~The written, informed consent of any patient shall first be obtained . ~Informed consent means written consent voluntarily signed by a patient who is competent and who understands the terms of the consent or by the patient's legal guardian . ~The time period for which the consent is effective, which shall be no longer than 15 months from the time the consent is given . Example 1 Surveyor reviewed R35's record…

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 interviews and record review, the facility did not involve residents and/or their representatives in the care planning process when changes were made during the Minimum Data Set (MDS) assessment periods. The facility practice affected 4 of 19 sampled and supplemental residents (R35, R21, R51 and R5). This is evidenced by: Surveyor requested and reviewed the facility policy titled Care Planning-Resident Participation with date implemented 08/02/23. The policy in part reads: ~The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals for care. ~The facility will discuss the plan of care with the resident and/or representatives at regularly scheduled care plan conferences and allow them to see the care plan, initially at routine intervals, and after significant changes. Example 1 Surveyor reviewed R35's MDS assessments and noted they were completed as follows: 03/17/23 Annual assessment 06/16/23 Quarterly assessment 07/17/23 Significant Change in 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.

Based on observation, record review and interview, the facility did not distribute fluids in a manner to prevent contamination. The facility practice has the potential to affect 11 of 25 sampled and supplemental residents who are served meals in their rooms on the second floor (R38, R70, R12, R40, R53, R21, R68, R60, R57, R55 and R30). This is evidenced by: Surveyor requested and received the facility policy titled Food Safety Requirements with a date implemented 9/01/23. The policy in part states: ~Food Distribution means the process involved in getting food to the residents. ~Food safety practices shell be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with deliver of food to the resident. ~Foods and beverages shall be distributed and served in a manner to prevent contamination . Example #1: Surveyor observed lunch service on 01/21/24 and breakfast service on 01/22/24 on the second floor. Surveyor observed staff to pour beverages and transport them to residents on their meal tray to their rooms…

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 observations and interviews, the facility did not ensure each resident is treated with a dignified existence by providing privacy while Resident (R31) was toileting and appropriate clothing was worn when R36 was in dining room. This occurred for 2 of 20 sampled and supplemental residents (R) R31 and R36. Findings include: Example 1 R31 was admitted to the facility on [DATE], and has diagnoses that include polyosteoarthritis, congestive heart failure, scoliosis and age related osteoporosis. On 01/23/24 at 10:35 am, Surveyor was walking down the hallway and walked past R31's room. The door was open. Surveyor observed from the hallway R31 sitting on the toilet with the bathroom door open. Anyone walking past R31's room would have been able to see R31 sitting on the toilet in the bathroom with R31's pants down around ankles. Surveyor stood across the hall. About 4 minutes later, Surveyor observed Licensed Practical Nurse (LPN) G walk past R31's room. LPN G did not stop to provide privacy for R31. 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 record review and interview, the facility did not conduct a Preadmission Screening and Resident Review (PASARR) for 2 of 3 residents reviewed (R12 and R15) within 30 days of admission to ensure individuals with a serious mental disorder received care and services in the most integrated setting possible. This is evidenced by: The facility policy, entitled Resident Assessment - Coordination with PASARR Program, with a date implemented of 09/01/23, reads in part The Level II resident review must be completed within 40 calendar days of admission. Example 1 Surveyor reviewed R12's record and noted R12 was admitted on [DATE] with diagnoses that included anxiety disorder, vascular dementia, bipolar disorder, and major depressive order. R12's orders include: 11/04/23: divalproex sodium 2 tablets once a day for major depression 11/05/23: fluoxetine 40 mg once a day for major depression Surveyor reviewed R12's record and could not locate a Level 1 PASARR. On 01/22/24 at 1:11 p.m., Surveyor interviewed Social…

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 interview and record review, the facility did not ensure 1 of 18 sampled residents (R3) has a comprehensive individualized care plan for peripheral catheter, multiple drug resistant organisms (MDRO), or transmission based precautions (TBP) to meet the needs of the resident. This is evidenced by: R3 was admitted to the facility on [DATE] and has diagnoses that include spina bifida, post-surgical malabsorption, ileus, neurogenic bowel, resistance to vancomycin, neurogenic bladder, sepsis due to unspecified organism, sepsis due to enterococcus, sepsis due to other specified staphylococcus, calculus of kidney, and terminal atrophy of kidney. R3 has a peripherally inserted central catheter (PICC) line in right chest for intravenous (IV) fluid access and lab draws. R3's physician orders state, change PICC dressing every Thursday in the afternoon, with order active on 08/10/23 and Heparin Sodium Lock Flush Intravenous Solution 100 UNIT/ML Use 5 ml intravenously in the morning every Monday, Wednesday, Friday…

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 record review and interview, the facility did not review and revise the comprehensive care plan, for 1 of 18 sampled residents (R), R432, for increased pain/pain management or changes in activities of daily living (ADLs) for fractures of right and left humerus. Findings include: R432 was admitted to the facility on [DATE] (original admission) and readmitted to the facility on [DATE] following hospitalization with diagnoses including but not limited to unspecified fracture of humerus left arm, unspecified fracture of shaft of right arm, multiple myeloma without having achieved remission, Parkinson's disease, and dementia. Minimum Data Set (MDS) assessment dated [DATE] discharge-return anticipated indicates Brief Interview for Mental Status (BIMS) score is 0 out of 15, which indicates severe cognitive impairment. R432 required substantial/maximum assistance with eating, dependent with transfers, personal hygiene, and dressing. R432 sustained a fall on 01/02/24 with pain in right arm. On 01/04/24, x-ray 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 observation, interview and record review, the facility failed to provide care, consistent with standards of practice, to prevent pressure injury, prevent infection, and prevent new pressure injuries from forming for 1 of 1 resident (R) reviewed for pressure injuries. (R36) -R36 was not repositioned or offered repositioning per care plan. -Facility failed to provide adequate cushion for wheelchair for resident with stage 3 pressure injury. -Facility failed to provide appropriate hand hygiene, glove changes, order of treatment, sanitizing table and lying down barrier for work area during wound care. Findings include: Repositioning: According to the National Pressure Injury Advisory Panel (NPIAP) 2019, page 115, . Repositioning and mobilizing individuals is an important component in the prevention of pressure injuries. The underlying cause and formation of pressure injuries is multifaceted; however, by definition, pressure injuries cannot form without loading, or pressure, on tissue. Extended periods 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.

Based on interview, the facility failed to employ a full time dietary manager with the appropriate certifications. This has the potential to affect all 79 residents of the facility. Findings include: On 01/02/24 at 1:55 p.m., Surveyor interviewed Dietary Manager (DM) D and asked how often the dietician is in the facility. DM D stated DM D saw the dietician twice in two months. DM D stated DM D communicates with the dietician via email. Surveyor asked DM D if DM D was certified or enrolled in a course. DM D stated DM D was working on it. On 01/03/24 at 11:00 a.m., Surveyor interviewed Nursing Home Administrator (NHA) A and asked if DM D was certified or enrolled in a course. NHA A stated DM D was not certified but the facility would be enrolling DM D in a dietary manager course, but have not enrolled DM D as of this point. Surveyor asked NHA A how long DM D has been in the position of dietary manager. NHA A stated DM D has been the dietary manager since 10/27/23. NHA A stated a certified individual was supposed to start working at the facility on 01/08/23 but then did not take 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 and interview, the facility did not ensure each resident receives food prepared by methods that conserve nutritive value, flavor and appearance, and the food is palatable, attractive for 10 of 10 residents (R4, R6, R7, R8, R9, R10, R11, R12, R13, R14), and 1 of 1 test trays. Evidenced by: On 01/02/24 at 10:20 a.m., Surveyor interviewed R4 and asked about the food at the facility. R4 stated the food was awful. Tasted bland, and it was not always hot enough. On 01/02/24 at 10:42 a.m., Surveyor interviewed R6 and asked about the food at the facility. R6 stated R6 does not like the food. R6 stated the food is tasteless and if you mention you like something, they give it to you day after day. R6 stated the food is cold. On 01/02/24 at 11:05 a.m., Surveyor interviewed R7 and asked about the food at the facility. R7 stated the food is horrible and it has no flavor. R7 said, The presentation is poor. It looks like someone had the runs. On 01/02/24 at 11:35 a.m., Surveyor interviewed R8 and asked about the food at the facility. R8 stated the food is not good. R8 stated…

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 interview and record review, the facility did not ensure no more than 14 hours between a substantial evening meal and breakfast the following day and when over 14 hours did not ensure a nourishing snack were served at bedtime to 11 of 11 residents (R) (R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, and R14). This is evidenced by: On 01/02/24, Surveyor reviewed the facility mealtime hours. Breakfast is at 7:30 a.m., lunch is at 12:00 p.m., and dinner is at 5:00 p.m. On 01/02/24 at 5:00 p.m., Surveyor observed dining service for the dinner meal. On third floor the dinner cart was delivered to the floor at 5:12 p.m. and all dinner trays were delivered to the residents by 5:25 p.m. On second floor the dinner cart was delivered to the floor at 5:26 p.m., and all dinner trays were delivered to the residents by 5:37 p.m. On first floor the dinner cart was delivered to the floor at 5:42 p.m. and all dinner trays from the first cart were delivered to the residents by 5:49 p.m. The second dinner cart was delivered to the first floor at 5:53 p.m., and all dinner trays were delivered 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 observations and interviews, the facility did not provide a sanitary and comfortable environment for residents who had dirty bathrooms, dirty floors, overflowing garbage for 13 of 55 residents (R) (R9, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, and R10). This is evidenced by: On 01/02/23 between 11:50 a.m. and 12:30 p.m., Surveyor toured facility third floor. R9's room *Urine in toilet *Dried feces on toilet bowl *Brown and dried stain on floor next to the toilet *Bathroom sink filled with mouth wash bottle, emesis basin, and wash basin *Dried sticky substance on floor next to bed R16's room *Feces on toilet bowl *Feces on toilet riser *Garbage in room wastebasket full *Floor in resident room dried dirty shoe prints on floor R17's room *Resident room floor dirty with crumbs, floor filmy *Resident room wastebasket full R18's room *Dried feces on toilet R19's room *Dried dark spill on floor in front of recliner chair *Resident wastebasket not emptied Room of R20 and R21 (Shared bathroom) *Debris on floor, dirty: Not swept *Floor not mopped *Light not working in…

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 interview and record review, the facility did not ensure all incidents involving potential abuse were thoroughly investigated for unexplained bruising for 1 of 3 residents, (R) reviewed (R27). This is evidenced by: The facility's Abuse, Neglect, and Exploitation Policy dated 10/01/23, revised 10/13/23 states: Policy: It is the policy of this facility to provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations;…

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 record review and interview, the facility did not immediately consult with the resident's physician when the resident had a significant change for 1 of 1 resident (R) 8 reviewed for MD notification. R8 eloped from the facility; the physician was not consulted about this event. Findings include: The facility policy, entitled Notification of Changes, dated 10/02/22, states in part The facility must inform the resident, consult with the resident's physician and/or notify the family member or legal representative when there is a change requiring such notification. R8 was admitted to the facility on [DATE] with diagnoses that include but not limited to spastic hemiplegia affects right dominate side, diabetes, mild cognitive impairment, depression, other seizures, and epileptic syndrome with complex partial seizures. R8's Minimum Data Set (MDS) assessment indicated that R8 scored a 08 out of 15 for the Brief Interview for Mental Status (BIMS) which indicates R8's cognition is moderately impaired. On 09/09/23…

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 record review and interview, the facility did not review and revise the comprehensive care plan for 1 of 8 sampled residents (R), R8. R8's care plan was not updated after an elopement on 09/09/23. Findings include: The facility policy, entitled Elopements and Wandering Residents, dated 09/01/22, states in part: .The resident and family/authorized representative will be included in the plan of care . R8 was admitted to the facility on [DATE] and had diagnoses that include spastic hemiplegia affects right dominate side, diabetes, mild cognitive impairment, depression, other seizures, and epileptic syndrome with complex partial seizures. R8's Minimum Data Set (MDS) assessment indicated that R8 scored 08 out of 15 for the Brief Interview for Mental Status (BIMS) which indicates R8's cognition is moderately impaired. On 09/09/23 at about 11:30 AM, a family member of another resident stated to the 1st floor nurse that they saw a person in a wheelchair with their foot bandaged, wheeling themselves northbound…

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 interviews and record review, the facility did not ensure allegations of abuse were reported in accordance with state law for 1 of 3 residents (R) (R5). The facility did not report alleged violation of abuse to law enforcement when R5 slapped R2 across the face. Findings: Facility policy entitled Abuse prevention/vulnerable adult plan - Wisconsin, revised 02/02/23, states in part: Abuse is the willful infliction of injury .with resulting physical harm, pain, or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm pain, or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, intended to inflict injury, psychosocial harm, harassment, humiliate, threaten, or frighten a resident. The designated person will notify the designated agency, local law enforcement, . as soon as possible after reviewing the investigation. Administration or other designated staff will report the results…

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 interview and record review, the facility failed to develop a comprehensive care plan to include new developed interventions for 2 residents (R) (R2 and R5) of 3, whose care plans were reviewed, R2 and R5's care plans were not updated to reflect additional interventions put into place to prevent resident to resident altercations. This is evidenced by: On 08/22/23, Surveyor reviewed a facility reported incident investigation that identified R2 yelling at another resident, when R5 approached R2 and slapped R2 in the face. Staff intervened and separated residents and placed on 15-minute checks for three hours and then moved to one-hour checks for the remaining 24 hours. Social services coordinated efforts with R2 and R5 to reduce the amount of time spent together in proximity. Care Plan was not updated to indicate new interventions. On 08/22/23 at 1:30 pm, Surveyor interviewed Certified Nursing Assistant (CNA) H regarding the resident to resident altercation. CNA H stated awareness of the incident but is not aware of new interventions made to the care plans. On 08/22/23 at…

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.