Does MEADOWBROOK AT APPLETON have any serious inspection findings?

Yes, MEADOWBROOK AT APPLETON has 1 Immediate Jeopardy citation on record, which represent the most serious type of deficiency. The facility has 59 total deficiencies from recent inspections.

What are the staffing levels at MEADOWBROOK AT APPLETON?

MEADOWBROOK AT APPLETON has a three-star staffing rating from CMS with 1.04 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is MEADOWBROOK AT APPLETON located?

MEADOWBROOK AT APPLETON is located in APPLETON, WI. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does MEADOWBROOK AT APPLETON have?

MEADOWBROOK AT APPLETON has 104 certified beds.

Who owns MEADOWBROOK AT APPLETON?

MEADOWBROOK AT APPLETON is a for profit - corporation facility and is part of the SYNERGY SENIOR CARE chain.

What questions should families ask when visiting MEADOWBROOK AT APPLETON?

Families visiting MEADOWBROOK AT APPLETON should ask about staff retention and training programs, how serious violations have been addressed. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does MEADOWBROOK AT APPLETON compare to other nursing homes?

MEADOWBROOK AT APPLETON has a 1-star overall rating, which is below average compared to other nursing homes in WI. Families should carefully review inspection findings and consider alternatives.

MEADOWBROOK AT APPLETON

Name: MEADOWBROOK AT APPLETON
Address: 1335 S ONEIDA ST, APPLETON, WI, 54915, US
Telephone: (920) 731-6646
Rating: 1.0

1335 S ONEIDA ST, APPLETON, WI 54915 · (920) 731-6646

For profit - Corporation 104 Beds SYNERGY SENIOR CARE Data: November 2025 1 Immediate Jeopardy citation

Trust Grade

16/100

#295 of 321 in WI

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Last Inspection: July 2025

Inspected within the last 6 months. Data reflects current conditions.

Overview

Meadowbrook at Appleton has received a Trust Grade of F, indicating significant concerns about the facility's overall care and management. Ranked #295 out of 321 nursing homes in Wisconsin, they fall in the bottom half of all facilities in the state, and are the lowest-ranked option in Outagamie County. The facility is worsening, with issues increasing from 23 in 2024 to 24 in 2025, which raises concerns about the quality of care provided. Staffing has a moderate rating of 3 out of 5, but there is a high turnover rate of 60%, which is above the state average, suggesting instability among staff. Notably, there have been serious incidents, including a resident's death due to receiving the wrong diet and improper care leading to a worsening pressure injury, as well as inadequate food safety practices that could affect all residents. Overall, while there are some strengths in staffing coverage, the significant weaknesses and recent trends may be alarming for families considering this facility for their loved ones.

Trust Score: F
In Wisconsin: #295/321
Safety Record: High Risk
Inspections: Getting Worse
Staff Stability: 60% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: $15,642 in fines. Lower than most Wisconsin facilities. Relatively clean record.
Skilled Nurses: Each resident gets 62 minutes of Registered Nurse (RN) attention daily — more than 97% of Wisconsin nursing homes. RNs are the most trained staff who catch health problems before they become serious.
Violations: 59 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★★★☆☆

3.0

Staff Levels

★☆☆☆☆

1.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

↔

Stable

2024: 23 issues

2025: 24 issues

The Good

Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in fire safety.

The Bad

1-Star Overall Rating

Below Wisconsin average (3.0)

Significant quality concerns identified by CMS

Staff Turnover: 60%

14pts above Wisconsin avg (46%)

Frequent staff changes - ask about care continuity

Federal Fines: $15,642

Below median ($33,413)

Minor penalties assessed

Chain: SYNERGY SENIOR CARE

Part of a multi-facility chain

Ask about local staffing decisions and management

Staff turnover is elevated (60%)

12 points above Wisconsin average of 48%

The Ugly 59 deficiencies on record

1 life-threatening 1 actual harm

Jul 2025 12 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0553 (Tag F0553)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interview and record review, the facility did not ensure 3 residents (R) (R5, R7, and R6) of 16 sampled residents were given the right to participate in care planning.R5 was admitted to the facility in December of 2024. R5's medical record did not contain documentation of any care conferences.R7 was admitted to the facility in August of 2024. R7's medical record did not contain documentation of any care conferences.R6 was admitted to the facility in November of 2024. R6's medical record did not contain documentation of any care conferences.Findings include: The facility's Care Plan Conference policy, revised 2/2021, states the Interdisciplinary Team, in conjunction with the resident and/or the resident representative, will develop the plan of care based on the comprehensive assessment. The care plan conference is held to identify resident needs and establish obtainable goals .The facility must encourage residents and/or their representatives to participate in care planning including their attendance at the care planning conference. The facility must make efforts to schedule care planning meetings at the best time of day for residents and representatives .Document the care planning conference in the progress notes. Be sure to include at least the following information: summary of the meeting; list of attendees; and if the resident and/or their representative do not participate in the meeting, document the reason why 1.On 7/21/25, Surveyor reviewed R5's medical record. R5 was admitted to facility on 12/20/24. R5's medical record did not contain documentation of any care conferences. On 7/21/25 at 9:54 AM, Surveyor interviewed R5 who stated the facility does not communicate with R5 regarding discharge planning or R5's plan of care. R5 stated R5 has not had a care conference since R5 was admitted to the facility. On 7/23/25 at 11:28 AM, Surveyor interviewed Social Services Director (SSD)-M who stated R5 had a care conference upon admission, however, SSD-M was unable to find documentation of any care conferences. SSD-M indicated care conferences should be completed quarterly. 2. On 7/21/25, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE]. R7's medical record did not contain documentation of any care conferences. On 7/21/25 at 10:13 AM, Surveyor interviewed R7 who stated R7 had not had a care conference since R7 was admitted to the facility. On 7/23/25 at 11:28 AM, Surveyor interviewed SSD-M who stated R7 had a care conference upon admission, however, SSD-M was unable to find documentation of any care conferences. SSD-M indicated care conferences should be completed quarterly. 3. On 7/21/25, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE]. R6's medical record did not contain documentation of any care conferences. On 7/21/25 at 9:54 AM, Surveyor interviewed R6 who stated the facility does not communicate with R6 or R6’s Power of Attorney (POA). R6 indicated questions are asked about R6's treatment plan and discharge but no answers are received. R6 was not aware of any care conferences for R6. On 7/23/25 at 11:31 AM, Surveyor interviewed SSD-M who stated R6 had two care conferences, however, SSD-M was unable to find documentation of any care conferences. SSD-M indicated care conferences should be completed quarterly. On 7/23/25 at 1:17 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated care conferences should be completed on a quarterly basis.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interview and record review, the facility did not ensure 1 resident (R) (R28) of 17 sampled residents was offered the opportunity to create or obtain Power of Attorney for Healthcare (POAHC) paperwork.R28 was admitted to the facility on [DATE]. The facility did not obtain R28's POAHC document or offer R28 the chance to fill out a new document prior to 7/21/25. Findings include:The facility's Advanced Directive policy and procedure, dated October 2020, indicates: The resident has a right to accept or refuse medical or surgical treatment and to formulate an advance directive in accordance with state and federal law .Purpose: To help ensure a resident's right to formulate an advanced directive .2. The facility will inquire at the time of admission whether the resident has previously executed an advance directive. 3. If a resident has executed an advance directive, the facility must obtain a copy from the resident or the legal representative which is stored in the resident's medical record. Nursing notifies the physician of the resident's or the legal representative's wishes, obtains orders as appropriate, and enters the information in the electronic health record.On 7/21/25, Surveyor reviewed R28's medical record. R28 was admitted to the facility on [DATE]. R28's medical record did not contain POAHC documentation or a POAHC refusal document. On 7/21/25 at 10:15 AM, Surveyor interviewed R28 who stated R28's POAHC document was at home in a safe and R28's family had access to the document.On 7/21/25 at 1:50 PM, Surveyor interviewed Social Services Director (SSD)-M who stated R28 informed SSD-M that a copy of an advanced directive was in R28's safe at home and R28's family had access to the document. Surveyor reviewed a documented conversation with R28's family member that occurred on 5/12/25 and contained a request for a copy of the document. R28's medical record did not contain any further documented attempts to contact the family member to obtain R28's POAHC document. On 7/23/25 at 1:14 PM, Surveyor interviewed Director of Nursing (DON)-B who stated staff are expected to either obtain a copy of a resident's POAHC document or offer to create a new one.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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Based on observation and staff and resident interview, the facility did not provide a safe, clean, comfortable, and home-like environment for 1 resident (R) (R31) of 16 sampled residents.The facility did not ensure food debris, spills, dirt, and used medical supplies were removed from R31's floor or that R31's garbage was emptied in a timely manner. Findings include:On 7/21/25, Surveyor reviewed R31's medical record. R31 had diagnoses including pressure ulcer of sacral region stage 2, paraplegia, infection and inflammatory reaction due to indwelling urethral catheter, and pressure ulcer of right buttock stage 3. R31's Minimum Data Set (MDS) assessment, dated 6/26/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R31 had intact cognition. R31 was R31's own decision maker.On 7/21/25 at 9:15 AM, Surveyor observed R31 in bed. R31 expressed concerns with room cleanliness, specifically that the floor is dirty and the garbage is overflowing. R31 also indicated housekeeping was an issue. Surveyor observed clothing, linens, and various items stacked on R31's heating and cooling register. Surveyor noted R31's garbage was almost full and contained used personal protective equipment (PPE) and food. Surveyor also observed dirt, dust, food debris, a cotton swab used to clean wounds, and a lancet top on R31's floor. R31 indicated there is one housekeeper that does a good job but indicated no one had been in to clean R31's room or take out the garbage in a few days. R31 also indicated housekeeping does not clean on a regular basis. R31 stated R31 cannot physically do the tasks and relies on housekeeping to do them. On 7/21/25 at 1:09 PM, Surveyor observed R31 in bed and noted R31's floor was still dirty, the garbage was overflowing, and clothing, linens, and other items were still stacked on R31's heating and cooling register. Surveyor also noted the cotton swab and lancet top were still on the floor. R31 indicated no one cleaned R31's room or removed the garbage. R31 also indicated staff changed R31's socks earlier that morning and threw them on the floor next to the hamper. On 7/22/25 at 7:54 AM, Surveyor noted R31's room was in the same condition as the previous day. Surveyor observed an orange peel, a cotton swab, two lancet tops, dirt, and black debris on the floor and an overflowing garbage can that contained used PPE. R31 indicated no one cleaned R31's room, removed clothing and linens from the heating and cooling register, or took out the garbage. R31 indicated the housekeeper that does a good job would hopefully be in that day and clean R31's room. On 7/22/25 at 1:26 PM, Surveyor noted R31's room was still in the same condition as previously observed at 7:54 AM. Surveyor observed an orange peel, two lancet tops, dirt, and debris on R31's floor and an overflowing garbage can. Surveyor noted the cotton swab that was previously on the floor was in the garbage. R31 indicated R31 asked staff and was told someone would clean R31's room that day. On 7/22/25 at 1:28 PM, Surveyor interviewed Housekeeper (HSK)-F who indicated laundry and housekeeping staff do both jobs. HSK-F indicated one staff who usually works in laundry is on leave and HSK-F and another housekeeping staff were doing all of the housekeeping. HSK-F indicated there are usually two housekeepers per wing but currently there is only one per wing which is not enough. HSK-F indicated Maintenance Director (MD)-E is the laundry and housekeeping supervisor and is responsible for ensuring housekeeping and laundry tasks are completed per residents' requests and preferences. On 7/22/25 at 1:50 PM, Surveyor interviewed MD-E in R31's room. MD-E confirmed R31's floor contained dirt, debris, and black-colored stains and R31's garbage was overflowing. MD-E confirmed there were lancet tops on the floor and stacked laundry and linens on the the heating and cooling register. MD-E indicated resident rooms should be cleaned daily which includes removing the garbage and cleaning the floor. MD-E indicated one staff is on leave and the facility is attempting to hire. MD-E indicated one housekeeper comes in at 11:00 AM and only does floors. MD-E confirmed R31's room was not cleaned on 7/21/25 or 7/22/25.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not develop a comprehensive bowel and bladder care plan for 1 resident (R) (R7) of 16 sampled residents.R7 was admitted to the facility in August of 2024. Documentation indicated R7 was occasionally incontinent of bladder, typically during the night. R7's comprehensive care plan, updated on 5/16/25, did not include problems, goals, or interventions related to incontinence. Findings include: On 7/21/25, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including schizophrenia, dysphagia (difficulty swallowing), depression, and diabetes. R7's most recent Minimum Data Set (MDS) assessment, dated 5/16/25, had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R7 had moderate cognitive impairment. The MDS assessment also indicated R7 was occasionally incontinent of bladder and did not have a toileting program. R7 was R7's own decision maker. On 7/21/25, Surveyor reviewed R7's Certified Nursing Assistant (CNA) charting related to urinary incontinence over the last 30 days and noted R7 was incontinent on 4 out of 73 occurrences, all during the night shift. On 7/21/25 at 1:12 PM, Surveyor interviewed CNA-J who stated R7 was continent at all times and independent with toileting. CNA-J was not aware R7 was occasionally incontinent during the night shift. On 7/21/25 at 1:22 PM, Surveyor interviewed Director of Nursing (DON)-B who verified R7's comprehensive care plan did not include problems, goals, or interventions related to urinary incontinence. DON-B stated toileting/incontinence status should be included in a resident's comprehensive care plan.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for 1 resident (R) (R25) of 4 sampled residents.R25 fell on 5/2/25. An intervention was added to R25's care plan to ensure R25's bed was in the lowest position. The intervention was not consistently followed. Findings include:The facility's Fall Management Policy, revised October 2024, indicates: .9. The Interdisciplinary Team designee will discuss recommended significant changes to the care plan to minimize repeat falls with the resident and/or resident's representative. The care plan will be reviewed and/or revised as indicated .Kardexes (abbreviated care plans used by nursing staff) are updated as appropriate .On 7/21/25, Surveyor reviewed R25's medical record. R25 was admitted to the facility on [DATE] and had diagnoses including sequalae following cerebrovascular disease, dysphagia, hemiplegia, and hemiparesis. R25's Minimum Data Set (MDS) assessment, dated 5/15/25, had a Brief Interview for Mental Status (BIMS) score of 0 out of 15 which indicated R25 had severe cognitive impairment. R25 had an activated Power of Attorney for Healthcare (POAHC).A facility investigation indicated staff discovered R25 on the floor between R25's bed and window on 5/2/25 at 4:00 PM. R25 had a laceration on the top of the head and could not recall what R25 was attempting to do. The investigation indicated the fall occurred because R25 was exhibiting terminal restlessness. An intervention was added to have R25's bed in the lowest position. A care plan, initiated on 5/2/25, contained an intervention to ensure R25's bed was in the lowest position.On 7/22/25 at 7:44 AM, Surveyor observed R25 in bed and noted R25's bed was in the highest position.On 7/22/25 at 7:53 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-H who indicated R25 was not a fall risk and independently held the bed remote and adjusted the height of the bed. After reviewing R25's care plan, LPN-H verified R25's bed should be in the lowest position. LPN-H adjusted the height of R31's bed and removed the handheld control from R25. On 7/22/25 at 1:26 PM, Surveyor interviewed Director of Nursing (DON)-B who verified staff should follow a resident's care plan. On 7/22/25 at 2:23 PM, Surveyor observed R25 in bed and noted R25's bed was in a medium height position. On 7/22/25 at 2:23 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-I who verified R25's bed was not in the lowest position but should be. CNA-I then lowered R25's bed.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility did not provide the appropriate care and services for 2 residents (R) (R31 and R25) of 3 sampled residents with an indwelling catheter.R31 recently recovered from a urinary tract infection (UTI). On 7/21/25, R31's uncovered catheter bag was observed on the floor.R25 had a history of UTIs. On 7/22/25, R25's catheter bag was observed on the floor.Findings include: The facility's Catheter Care Policy, revised July 2025, indicates: …9. Ensure drainage bag is located below the level of the bladder to discourage backflow of urine . The Centers for Disease Control and Prevention (CDC) Guideline For Prevention of Catheter-Associated Urinary Tract Infection 2009 https://www.cdc.gov/infection-control/hcp/cauti/index.html, indicates: .III. Proper Techniques for Urinary Catheter Maintenance .B. Maintain unobstructed urine flow .2. Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor . 1. On 7/21/25, Surveyor reviewed R31's medical record. R31 had diagnoses including pressure ulcer of sacral region stage 2, paraplegia, infection and inflammatory reaction due to indwelling urethral catheter, neurogenic bladder, and pressure ulcer of right buttock stage 4. R31’s Minimum Data Set (MDS) assessment, dated 6/26/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R31 had intact cognition. R31 was R31's own decision maker. R31’s medical record indicated R31 was transferred to the emergency room (ER) on 6/22/25 due to cognitive change, weakness, and cloudy urine and diagnosed with a UTI. R31 received intravenous (IV) antibiotics in the ER, was prescribed oral antibiotics, and returned to the facility. On 7/21/25 at 9:15 AM, Surveyor observed R31 in bed and noted R31’s uncovered catheter bag was hung from the side of the bed and in contact with the floor. R31 indicated R31 recently had a UTI, was upset the catheter bag was on the floor, and stated, “That bag should not be on the floor like that.” R31 indicated the catheter bag is usually placed in a blue (dignity) bag. R31 indicated the dignity bag and keeping the catheter bag off the floor help with infection prevention. R31 indicated R31’s floor had not been cleaned in a few days and was dirty. On 7/21/25 at 9:22 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-G in R31's room. CNA-G indicated R31's catheter bag should not be on the floor. Surveyor observed CNA-G rehang the bag on the side of the bed and ensure it was off the floor. CNA-G did not place the bag inside a dignity bag. On 7/23/25 at 8:08 AM, Surveyor observed R31 in bed with the door open and noted R31’s catheter bag was hung facing the open door and hallway and was not in a dignity bag. On 7/23/25 at 9:13 AM, Surveyor observed R31 in bed with the door open and noted R31’s catheter bag was hung facing the door and hallway was not in a dignity bag. R31 indicated R31 was upset that the bag was hung on the side of the bed that faced the door and hallway and indicated R31 did not like bag hung on that side. R31 also indicated the catheter bag should be covered with a dignity bag. R31 indicated R31 would ask staff to move the bag and cover it with a dignity bag. On 7/23/25 at 9:24 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated residents with catheters should have a dignity bag and stated R31 had a dignity bag if R31 left the room. DON-B acknowledged a dignity bag should be used if a resident’s catheter bag is visible from the hallway and verified catheter bags should be hung below the bladder and should not be on the floor for infection prevention purposes. 2. On 7/21/25, Surveyor reviewed R25's medical record. R25 was admitted to the facility on [DATE] and had diagnoses including sequalae following cerebrovascular disease, UTI, dysphagia, hemiplegia, and hemiparesis. R25's MDS assessment, dated 5/15/25, had a BIMS score of 0 out of 15 which indicated R25 had severe cognitive impairment. R25 had an activated Power of Attorney for Healthcare (POAHC). On 7/22/25 at 10:51 AM, Surveyor observed R25 and noted R25's catheter bag was hung from the side of R25's bed. R25's bed was in the lowest position and the catheter bag was on the floor. On 7/22/25 at 10:52 AM, Surveyor interviewed CNA-I who verified R25's catheter bag was on the floor. CNA-I indicated when CNA-I put R25's bed in the lowest position, CNA-I did not notice that R25's catheter bag was on the floor. CNA-I verified catheter bags should not be on the floor. On 7/22/25 at 1:24 PM, Surveyor interviewed DON-B who stated staff should adjust catheter bags so they do not touch the floor.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility did not ensure 2 residents (R) (R35 and R4) of 2 sampled residents who were fed via enteral feeding (a way of sending nutrition right to the stomach or small intestine via tube) received care and services to avoid complications.On 7/21/25, Registered Nurse (RN)-C did not check for placement or residual prior to administering medication and enteral feeding to R35 .On 7/21/25 Licensed Practical Nurse (LPN)-H did not check placement or residual prior to administering medication to R4. Findings include: The facility's Enteral Feeding and Medication Administration Policy, dated March 2020, indicates: .Registered Nurse (RN)/Licensed Practical Nurse (LPN) will administer nutrition and medication through nasogastric, gastrostomy, or jejunostomy tube upon order of physician to provide nutrition and hydration for residents with compromised nutritional status or inability to consume oral intake .3. Check for proper placement prior to each feeding/medication administration (or every 4 hours for critically ill residents) by aspirating gastric contents or by auscultation while injecting 10 milliliter (ml) of air into tube. Notify physician if it appears tube has been displaced. 1. On 7/21/25, Surveyor reviewed R35's medical record. R35 was admitted to facility on 5/24/23 and had diagnoses including Parkinsonism, cerebral infarction, systemic inflammatory response, muscle wasting, atrophy, and neurocognitive disorder. R35's Minimum Data Set (MDS) assessment, dated 3/28/25, indicated R35 was dependent on staff for transfers, hygiene, dressing, feeding, and bathing. R35's tube feeding care plan, dated 8/30/23, contained an intervention to check for tube placement and gastric contents/residual volume per facility protocol and orders. On 7/21/25 at 11:54 AM, Surveyor observed RN-C administer an acidophilus capsule and Jevity 1.5 calorie 240 ml via percutaneous endoscopic gastrostomy (PEG) tube for R35. RN-C sanitized hands, donned a gown and gloves, opened R35's PEG tube port, and flushed the tube with 60 ml of water. RN-C then administered acidophilus with 30 ml water and flushed the tube with 60 ml of water. RN-C then administered 240 ml of Jevity 1.5 calorie and flushed with 60 ml of water. On 7/21/25 at 11:58 AM, Surveyor interviewed RN-C who indicated R35 did not have orders to check placement or residual. RN-C indicated RN-C often checks placement and residual if a resident is new and in rehab, however, R35 has had a PEG tube for a long time. On 7/23/25 at 11:32 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated it is a standard of practice to check placement and nurses should check for placement when administering medication or feeding via PEG tube. DON-B indicated one of the nurses approached DON-B yesterday and indicated they did not check placement when administering a medication via PEG tube. DON-B indicated DON-B educated all nurses on the facility's policy and put orders in the Medication Administration Record (MAR) for all residents with PEG tubes. 2. On 7/21/25, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] and had diagnoses including dysphagia with cerebral vascular accident, obesity, and type 2 diabetes. R4's MDS assessment, dated 6/2/25, had a BIMS score of 15 out of 15 which indicated R4 had intact cognition. The MDS assessment also indicated R4 received enteral feeding via gastronomy tube. A care plan, dated 5/9/25, indicated R4 required tube feeding post stroke related to tracheostomy, dysphagia, and swallowing issues. The care plan contained interventions to check for tube placement and gastric contents/residual volume per facility protocol. On 7/21/25 at 11:21 AM, Surveyor observed LPN-H administer R4 medication via gastrostomy tube. LPN-H washed hands, applied a gown and gloves, and crushed R4’s medication. LPN-H then added 90 cubic centimeters (ccs) of water and aspirated the medication into a syringe. LPN-H opened R4’s G-tube and administered the medications. Surveyor noted LPN-H did not check placement of the tube prior to administering the medication. Surveyor verified with LPN-H that tube placement should have checked prior to administering medication and that R4's MAR contained an order to check tube placement.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

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**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 effective pain management was provided for 1 resident (R) (R5) of 2 sampled residents.R5 had an order for a Fentanyl patch for pain to be changed every three days. During observations on 7/21/25 and 7/22/25, R5's Fentanyl patch was dated 7/17/25. R5 stated R5 felt achy and had difficulty sleeping. Findings include:The facility's Pain Management policy, revised 10/2024, states the facility will develop and implement a care plan for pain management. The goal of the pain management system is to effectively and consistently identify and treat pain .Staff should be proactive to address the resident's pain to aid in achieving relief. Evaluation of pain, implementation of interventions, and communicating with the care team regarding pain management strategies are important components of a successful pain management system .Nursing staff are to administer pain medications as ordered and observe for effectiveness. From 7/21/25 to 7/23/25, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had diagnoses including chronic deep vein thromboses (DVTs) (blood clots) of both legs, neuropathy, depression, anxiety, and chronic pain. R5's most recent Minimum Data Set (MDS) assessment, dated 5/29/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R5 had intact cognition. The MDS assessment also indicated R5 experienced pain almost constantly which frequently interfered with day-to-day activities and therapies. R5's comprehensive care plan, revised 5/29/25, indicated R5 experienced chronic pain related to bilateral DVTs of the lower extremities. The care plan contained interventions for repositioning, distraction, heat, and pain medications. On 7/21/25 at 1:24 PM, Surveyor interviewed R5 regarding pain management. R5 indicated R5 had a Fentanyl patch that was changed every three days. Surveyor noted the patch was dated 7/17/25. Per R5's physician order, the patch should have been changed on 7/20/25. R5 stated R5's pain was currently an 8 out of 10 and mostly in R5's legs due to the blood clots. On 7/22/25 at 7:59 AM, Surveyor observed R5's Fentanyl patch and noted it was still dated 7/17/25. R5 stated R5 had a tough time sleeping last night and was achy. R5 stated staff did not offer non-pharmacological interventions for pain but doubted they would be effective. R5's most recent comprehensive pain assessment, dated 7/10/25, stated R5 experienced pain almost constantly which affected R5's sleep and activities. On 7/22/25 at 8:51 AM, Surveyor entered R5's room with Director of Nursing (DON)-B who verified R5's Fentanyl patch was dated 7/17/25. DON-B verified R5's patch should have been changed on 7/20/25 but indicated the facility did not re-order the Fentanyl patch prior to using the last one on 7/17/25. On 7/22/25, Surveyor reviewed R5's Medication Administration Record (MAR) for 7/13/25 through 7/22/25 and noted R5's pain was typically between 5 and 7 out of 10. R5 took as needed (PRN) oxycodone every 6 hours during that time period. On 7/22/25, Surveyor reviewed a fax sent to R5's physician on 7/21/25 requesting a refill for R5's Fentanyl patch. On 7/23/25 at 8:01 AM, Surveyor noted R5's Fentanyl patch was dated 7/22/25. R5 indicated R5 felt much better and rated R5's pain at a 5 out of 10. On 7/23/25, Surveyor reviewed R5's MAR which indicated R5's Fentanyl patch was applied on 7/22/25 at 5:02 PM and R5's pain was rated at a 5 out of 10.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility did not ensure transmission-based precautions (TBP) were implemented for 1 resident (R) (R52) of 2 residents with a diagnosis of a transmittable infection.R52 had diagnoses of sepsis and pneumonia and was placed on droplet precautions. Staff did not don the appropriate personal protective equipment (PPE) when entering R52's room on 7/21/25 and 7/22/25. Findings include:The facility's Isolation Precautions policy, revised 3/2020, indicates: To establish transmission-based precautions for residents who are suspected or confirmed to have communicable diseases/infections that can be transmitted to others. Transmission- based precautions will be used when transmission cannot be reasonably prevented by standard precautions alone .Droplet precautions .prior to entering the isolation room, the following steps are required: Perform hand-hygiene and apply gloves and mask prior to entering the room, while providing direct resident care, remove gloves and wash hands after coming in contact with infectious material. Remove gloves and perform hand hygiene before leaving the room.On 7/21/25, Surveyor reviewed R52's medical record. R52 was admitted to the facility on [DATE] and had diagnoses including sepsis, pneumonia, and urinary tract infection (UTI) all due to E-coli, stage 1 pressure injury, chronic obstructive pulmonary disease (COPD), and paranoid schizophrenia. R52's admission Minimum Data Set (MDS) assessment, dated 7/16/25, had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 which indicated R52 had moderately impaired cognition. R52 had an activated decision maker for healthcare decisions. A care plan, dated 7/16/25, indicated R52 had pneumonia and contained the following interventions: Educate R52/family on precaution policies; Follow the facility's policy for implementation of any precautions related to active infection; Staff to follow standard precautions and transmission precautions when appropriate. On 7/21/25 at 9:15 AM, Surveyor observed R52 in R52's room and noted the door contained a sign that indicated R52 was on droplet precautions. Surveyor also observed a PPE cart outside R52's room. On 7/21/25 at 9:18 AM, Surveyor observed Certified Nursing Assistant (CNA)-G enter R52's room with an oxygen tank and close R52's door. CNA-G did not don PPE prior to entering the room. Surveyor also observed CNA-G in R52's room without a mask when CNA-G opened the door. Surveyor interviewed CNA-G who indicated unless CNA-G was doing cares, CNA-G did not need to wear a mask or PPE. CNA-G indicated CNA-G entered R52's room to give R52 oxygen and was not required to wear PPE because CNA-G was not in contact with bodily fluids. On 7/21/25 at 9:28 AM, Surveyor interviewed Director of Nursing (DON)-B who confirmed R52 was on droplet precautions and antibiotics for a UTI, pneumonia, and sepsis. DON-B indicated R52 would be removed from droplet precautions when R52's antibiotics were completed. On 7/22/25 at 7:42 AM, Surveyor observed housekeeping staff change R52's bed linens without wearing gloves or a mask. R52 was in the room at the time. On 7/23/25 at 9:24 AM, Surveyor interviewed DON-B who confirmed staff who enter R52's room should adhere to the facility's policy and procedure for TBP and verified staff should wear a mask when entering the room of a resident on droplet precautions. DON-B verified Surveyor's observations of staff in R52's room without proper PPE was not in accordance with the facility's policy and procedure.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0925 (Tag F0925)

Could have caused harm · This affected 1 resident

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**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 they completed regular pest control which affected 1 resident (R) (R30) of 17 sampled residents.R30 indicated there were fruit flies in R30's room and R30 had a bug bite on the right hand. The facility did not ensure they completed regular pest control.Findings include:On 7/21/25, Surveyor reviewed R30's medical record. R30 was admitted to the facility on [DATE] and had diagnoses including deep vein thrombosis/pulmonary embolism secondary to factor V Leiden mutation on Xarelto, chronic diastolic congestive heart failure, chronic obstructive pulmonary disease (COPD), and morbid obesity. R30's Minimum Data Set (MDS) assessment, dated 6/9/25, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R30 had intact cognition. A progress note, dated 7/21/25 at 9:24 AM, indicated the writer updated the Nurse Practitioner (NP) that R30 had a new bug bite on the right hand and had a previous bug bite that became infected. The area was slightly swollen, red, and itchy. The NP ordered hydrocortisone cream 1% three times daily (TID) as needed (PRN).On 7/22/25 at 11:15 AM, Surveyor interviewed R30 who indicated R30 did not get up much. R30 showed Surveyor R30's right hand and indicated R30 had a bug bite. R30 stated something bit R30 and it hurt so bad that R30 woke up and the bite swelled up right away. R30 indicated staff put cream on the bite and it looked better. R30 indicated R30 had been in the hospital due to a right hand infection and did not want to get another infection. R30 indicated the previous infection resulted from R30 wrapping a hospital band around R30's thumb. R30 thought a spider bit R30's hand. Surveyor checked R30's room for spiders and noted several fruit flies in the room. R30 indicated fruit flies are everywhere in the building. On 7/22/25 at 12:25 PM, Surveyor interviewed Maintenance Director (MD)-E who indicated the facility has routine pest care mostly for rodents and outside things. When Surveyor requested to see 6 months of pest control documentation, MD-E indicated MD-E does not keep records of when Company (CP)-K comes to the facility but thought CP-K had been there in May. MD-E indicated CP-K comes monthly to check traps, but MD-E did not have documentation. MD-E indicated CP-K changed hands multiple times and sometimes states they do not have an account for the facility. MD-E provided Surveyor with CP-K's number and indicated the facility had discussed using a different pest control companyOn 7/22/25 at 12:32, Surveyor contacted CP-K and spoke to Customer Service Agent (CSA)-L who indicated CP-K was last at the facility on 2/28/25. CSA-L indicated the facility contacted CP-K on 2/24/25 and CP-K provided services on 2/28/25. CSA-L indicated there was no active service for the facility and no one from CP-K checked traps or sprayed monthly.On 7/22/25 at 2:51 PM, Nursing Home Administrator (NHA)-A provided Surveyor with an invoice that indicated CP-K was last at the facility in February of 2025. NHA-A indicated CP-K told the facility there was an outstanding invoice so CP-K would not come to the facility to provide pest control. NHA-A confirmed the facility does not have a current contract for pest control and has not had pest control since February.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected multiple residents

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Based on observation and staff and resident interview, the facility did not ensure food was served at a safe and appetizing temperature for 5 residents (R) (R5, R6, R8, R12, and R30) of 16 sampled residents.During interviews on 7/21/25 and 7/22/25, R5, R6, R8, R12 and R30 indicated their food was not appetizing and was served at a temperature they did not prefer. A test tray obtained during meal service on 7/22/25 indicated the food was not served at a palatable temperature.Findings include:1.On 7/21/25, Surveyor reviewed R5's medical record. R5 had diagnoses including chronic deep vein thromboses (DVTs) of bilateral lower extremities, chronic obstructive pulmonary disease (COPD), neuropathy, edema, and anxiety. R5's Minimum Data Set (MDS) assessment, dated 5/29/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R5 had intact cognition. R5 was R5's own decision maker.On 7/21/2025 at 1:16 PM, Surveyor interviewed R5 who indicated food is delivered cold at every meal. R5 indicated R5 does not ask staff to reheat the food because staff are too busy during meals.On 7/22/25 at 9:26 AM, Surveyor interviewed R5 who indicated breakfast was served cold. R5 indicated R5 did not ask staff to reheat the meal because staff are too busy to reheat food to a temperature that is palatable for R5. 2. On 7/21/25, Surveyor reviewed R6's medical record. R6 had diagnoses including dementia, end stage renal disease (dialysis), COPD, and depression. R6's MDS assessment, dated 6/3/25, had a BIMS score of 10 out of 15 which indicated R6 had moderate cognitive impairment. R6 had an activated decision maker for healthcare decisions.On 7/21/25 at 9:16 AM, Surveyor interviewed R6 who indicated food is delivered cold all the time. R6 also indicated R6 uses butter but the butter does not melt and stays solid. 3. On 7/21/25, Surveyor reviewed R8's medical record. R8 had diagnoses including type 2 diabetes mellitus, chronic kidney disease stage 3, anxiety, and depression. R8's MDS assessment, dated 5/5/25, had a BIMS score of 15 out of 15 which indicated R8 had intact cognition. R8 was R8's own decision maker.On 7/21/25 at 11:08 AM, Surveyor interviewed R8 who indicated the food is not really great and stated R8 chooses to eat in R8's room. R8 indicated R8's room trays contain cold and lukewarm food which is not appetizing. R8 indicated even when the food is lukewarm it is not at a good temperature. R8 indicated R8 receives a meal tray timely because R8 is one of the first ones served. R8 indicated despite receiving room trays on time, the food is not served at an appetizing temperature. On 7/21/25 at 12:11 PM, Surveyor observed R8 receive a lunch tray. Surveyor interviewed R8 who indicated the vegetables were cold and the burger was warm. R8 indicated R8 was not going to eat cold vegetables. On 7/22/25 at 7:45 AM, Surveyor interviewed R8 who indicated yesterday's dinner was warm but not hot or appetizing. R8 stated if the meal is not at a desired temperature, R8 does not ask staff to reheat the meal because staff are too busy. R8 stated R8 will just not eat the cold items.4. On 7/21/25 Surveyor reviewed R12's medical record. R12 had diagnoses including type 2 diabetes mellitus, cellulitis, and pressure injury stage 4. R12's MDS assessment, dated 5/16/25, had a BIMS score of 15 out of 15 which indicated R12 had intact cognition. R12 was R12's own decision maker.On 7/21/25, at 11:44 AM, Surveyor interviewed R12 who indicated the food is not always hot and does not taste good at times due to the temperature. 5. On 7/21/25, Surveyor reviewed R30's medical record. R30 had diagnoses including osteomyelitis, dysphagia, post traumatic stress disorder (PTSD), and sprain of ligaments of cervical spine. R30's MDS assessment, dated 6/3/25, had a BIMS score of 14 out of 15 which indicated R30 had intact cognition. R30 was R30's own decision maker.On 7/21/25, at 11:15 AM, Surveyor interviewed R30 who indicated food for all meals arrives cold. R30 confirmed R30 receives meal trays and eats in R30's room.During a continuous observation that began at 10:25 AM on 7/22/25, Surveyor observed lunch service at the kitchen steam table. Surveyor noted the first room tray cart was full and one room tray was on top of the cart. Surveyor continued to observe lunch service and noted room trays for a second meal cart were placed in the cart. Surveyor requested a test tray as the last tray was served. Surveyor noted the tray cart was full and R8's tray was transported on top of the cart. The test tray was placed next to R8's tray on top of the cart. The cart left the kitchen to begin delivery to residents at 11:51 AM and Surveyor and Dietary Manager (DM)-D followed the cart to the unit. At 12:03 PM (halfway through the delivery of meal trays), DM-D removed the test tray from the top of the cart and temped the food. Surveyor observed DM-D obtain the following temperatures of food served to residents for lunch:~ The roast beef was 124 degrees Fahrenheit (F); The peas were 127 degrees F; The mashed potatoes were 123 degrees F.DM-D indicated kitchen staff received complaints from residents regarding food temperatures. DM-D indicated the facility has two meal service carts and had a third cart at one time. DM-D did not know if the plate warmer worked correctly or if the warmer was plugged in during meal service.On 7/22/25 at 12:07 PM, DM-D and Surveyor went to the kitchen and noted the plate warmer was not plugged in. When staff plugged in the plate warmer, Surveyor noted the light did not ignite. DM-D indicated the plate warmer was fixed a while ago and might need to be replaced. DM-D indicated the steam table was recently replaced due to resident complaints about cold food and indicated there were recent food temperature concerns from residents.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

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Jun 2025 9 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Pressure Ulcer Prevention (Tag F0686)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interview and record review, the facility did not provide the necessary care and services to prevent pressure injuries from developing and/or promote healing for 1 resident (R) (R13) of 2 sampled residents. R13 was admitted to the facility on [DATE] with a stage 4 pressure injury on the right hip and a wound vac (a device used to promote healing in wounds that are slow to close that includes a sealed dressing and a vacuum pump which helps remove fluid and bacteria, reduce swelling, and encourage new tissue growth). On 6/18/25, Wound Nurse Practitioner (WNP)-P indicated R13's wound vac dressing had been applied incorrectly which caused the skin around the wound to deteriorate and the wound to increase in size. Findings include: The facility's Pressure Ulcer Prevention and Treatment policy, revised August 2024, indicates the facility must ensure residents with pressure ulcers receive necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from forming. Treatments and interventions will be used based on current standards of practice and provider's orders. From 6/24/25 to 6/25/25, Surveyor reviewed R13's medical record. R13 was admitted to the facility on [DATE] and had diagnoses including stage 4 pressure injury, cellulitis, and paraplegia (paralysis of the lower half of the body). R13's most recent Minimum Data Set (MDS) assessment, dated 5/22/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R13 had intact cognition. R13 required the assistance of 1 to 2 staff for repositioning in bed. On 6/24/25, Surveyor reviewed a grievance, dated 6/18/25, that indicated R13 reported that R13's wound vac dressing was not being done correctly. The facility's investigation indicated Registered Nurse (RN)-K had completed R13's last dressing change on 6/16/25. Director of Nursing (DON)-B told R13 that RN-K and other nursing staff would be educated on proper placement of the wound vac dressing. R13's June 2025 Treatment Administration Record (TAR) indicated RN-K completed R13's right hip wound vac dressing change on 6/13/25 and 6/16/25. The order stated to remove the old vac dressing, apply skin prep to the peri-wound (skin surrounding the wound), window wound with vac drape, apply black sponge to wound bed and bridge to anterior upper thigh, apply top drape, and reconnect wound vac at 125 millimeters of mercury (mmHG) pressure. The order began on 5/30/25, was held on 6/18/25, and resumed on 6/26/25. Surveyor also noted R13 received intravenous (IV) ceftriaxone (an antibiotic) daily for a wound infection beginning on 5/20/25. R13's right hip weekly wound assessments indicated the following: ~ 5/28/25 - 4.6 centimeters (cm) x 8.9 cm x 2.2 cm, stage 4, heavy purulent (pus-filled) drainage ~ 6/4/25 - 6.3 cm x 9.2 cm x 2.5 cm, stage 4, heavy serosanguinous (blood-tinged) drainage ~ 6/11/25 - 6.7 cm x 9.5 cm x 1.8 cm, stage 4, moderate serosanguinous drainage; improving ~ 6/18/25 - 8.5 cm x 10 cm x 2.5 cm, stage 4, heavy serosanguinous drainage; worsening A wound note, dated 6/18/25 at 9:45 AM and written by WNP-P, indicated upon removal of the wound vac it was discovered that a drape was not placed to protect the skin during the last wound vac change which resulted in a secondary wound, skin erosion, and irritation. On 6/25/25 at 9:40 AM, Surveyor interviewed WNP-P who verified WNP-P observed R13's wound on 6/18/25 and noted the wound vac dressing was applied incorrectly when RN-K did not apply the base drape layer around the wound. WNP-P stated the purpose of the drape is to protect the skin around the wound from the drainage that is being pulled out of the wound via the vacuum as well as to help create an air-tight seal to ensure the vacuum is functioning to the best of its ability. WNP-P stated the skin around the wound was irritated and the wound was larger and had worsened from the previous week. WNP-P stated the wound vac could not be put back on and R13 needed a wet-to-dry dressing for a week so the skin around the wound could heal. WNP-P verified the incorrect application of the wound vac dressing contributed to the worsening of R13's pressure injury. WNP-P stated staff have WNP-P's phone number and are encouraged to call if there are any concerns with wounds or wound vacs. On 6/25/25 at 9:55 AM, Surveyor interviewed R13 who stated staff had issues with R13's wound vac in the past and verified R13 received IV antibiotics since admission for a right hip wound infection. R13 stated R13 spoke to RN-K the previous day (RN-K worked the AM shift on 6/24/25) and RN-K told R13 that RN-K had not received any recent education regarding wound vacs. R13 stated DON-B told R13 that the facility would be training all nursing staff on wound vacs and R13 now felt that DON-B was not sincere in addressing R13's concerns. R13 stated R13 felt the wound vac issues were delaying R13's discharge home which caused R13 to feel depressed. On 6/25/25 at 10:05 AM, the facility provided Surveyor with a correction plan related to the incorrect application of R13's wound vac dressing. The facility indicated the root cause was that the wound vac dressing was not completed accurately which caused skin irritation and was due to lack of education for the nurse who applied the dressing. The facility's plan stated all nursing staff would be educated on wound vac dressings by 6/24/25. Surveyor reviewed the signed education sheets and noted all nursing staff who worked the 6/24/25 PM shift, 6/24/25-6/25/25 night (NOC) shift, and the 6/25/25 AM shift had signed the staff education sheet. All other nursing staff were provided verbal education via telephone which did not include a demonstration of how to properly complete the wound vac dressing change. Surveyor also observed a 1:1 In-Service Record education form provided to RN-K, dated 6/18/25, regarding wound vacs. The education sheet was signed by DON-B and RN-K but did not contain signature dates. Surveyor noted R1 and R21 (who discharged on 6/23/25) also had active wound vac orders during that time. On 6/25/25 at 10:13 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-M who stated LPN-M was provided wound vac education on the evening of 6/24/25. On 6/25/25 at 10:15 AM, Surveyor interviewed RN-L who stated RN-L was provided wound vac education on the morning of 6/25/25 and did not receive education related to the incident prior to 6/25/25. On 6/25/25 at 10:21 AM, Surveyor interviewed RN-K who stated RN-K was not aware RN-K had completed R13's dressing incorrectly until R13 mentioned it on 6/24/25. RN-K verified RN-K was not provided education or follow-up until approximately 5:00 PM on 6/24/25 and did not sign the 1:1 In-Service Record form until approximately 5:30 PM on 6/24/25. On 6/25/25 at 11:13 AM, Surveyor interviewed DON-B who initially stated RN-K signed the 1:1 In-Service Form on 6/18/25 then indicated education was started on 6/18/25 but the form was not signed until 6/24/25. DON-B verified it was possible that some staff may have signed the staff education sheet on the evening of 6/24/25 or the morning of 6/25/25. DON-B stated the facility was planning a lunch and learn on 6/26/25 that would include a demonstration of the wound vac with the facility's wound care RN.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0551 (Tag F0551)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure Informed Consent for Medication forms were signed or verbal consent was obtained prior to administering psychotropic medication for 1 resident (R) (R6) of 1 sampled resident. R6 was administered psychotropic medication without written or verbal consent from R6's Power of Attorney for Healthcare (POAHC). Findings include: The facility's Psychotropic Management policy, revised July 2020, indicates: .1. Upon receipt of new orders for psychotropic medication, the licensed nurse will implement the following: .B. Complete the appropriate psychotropic medication consent form; Consents for psychoactive medications must be obtained by the physician if state regulation requires it. C. Education of the resident and/or the resident representative is conducted to communicate the risks and benefits of the medication. Per the facility's Psychotropic Management System flow chart step 3 .Nurse/physician completes informed consent and education with the resident or representative. From 6/24/25 to 6/25/25, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] and had diagnoses including encephalopathy, degeneration of nervous system due to alcohol, alcohol dependence with other alcohol-induced disorders, personal history of transient ischemic attack (TIA) and cerebral infarction (stroke), and anxiety disorder. R6's Minimum Data Set (MDS) assessment, dated 2/25/25, had a Brief Interview for Mental Status (BIMS) score of 4 out of 15 which indicated R6 had severely impaired cognition. R6 had an activated POAHC. R6's Medication Administration Record (MAR) indicated R6 was prescribed the following medications which require informed consent: Seroquel (started on 2/19/25); melatonin (started on 2/19/25); BuSpar (started on 2/19/25); citalopram (started on 3/1/25); and lorazepam (started on 2/28/25). Surveyor reviewed R6's Informed Consent for Medication forms and noted R6 had consents for Seroquel, melatonin, citalopram, and BuSpar which were signed on 2/21/25, however, the medications were started on 2/19/25. The consent forms did not indicate verbal consent was obtained prior to the start of the medications. R6's citalopram consent was signed on 3/7/25, however, the medication was started on 3/1/25. The consent form did not indicate verbal consent was obtained prior to the start of the medication. Surveyor verified R6 did not have an Informed Consent for Medication form for lorazepam when copies of R6's Informed Consent for Medication forms were provided to Surveyor. On 6/24/25 at 11:50 AM, Surveyor interviewed Director of Nursing (DON)-B who confirmed informed consent and Informed Consent for Medication forms should have been obtained prior to starting the medications.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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Based on staff interview and record review, the facility did not ensure a allegation of misappropriation was thoroughly investigated for 1 resident (R) (R3) of 1 sampled resident. On 5/16/25, R3 reported to the facility that R3 was a missing a blue jacket worth $75. The facility did not provide staff education on misappropriation of resident property or documenting residents' personal property upon admission despite the fact education was listed as an immediate and ongoing intervention in the facility's investigation. Findings include: The facility's Missing Resident Belongings policy, dated 3/2021, indicates: Synergy Senior Care seeks to ensure residents' belongings are protected from loss/theft. Every effort to ensure that missing items are located will be made .1. Missing belongings will be reported to all departments by residents, families, and nursing staff. 2. Staff should promptly fill out a concern form to identify missing item(s). The form should include follow-up and conclusion to be communicated to the resident or responsible party. 3. Social Services will assist the resident/family in searching the resident's room for the item .Nursing and housekeeping staff need to watch out for glasses. Nursing staff should check every pocket before sending items to laundry. Nursing and dietary staff should check napkins on plates. Housekeeping staff should check room trash for items which may have fallen into the waste basket. Laundry staff should check clothing tags to make sure laundry gets back into the correct closet. 4. Social Services will search for the item(s) in an appropriate area if any. 5. Social Services will notify administration, housekeeping, nursing, and other departments as appropriate of any missing item(s). An ongoing list will be kept in the Social Services area. 6. If there is an allegation or accusation of deliberate misappropriation (theft), the facility will immediately initiate an investigation in accordance with the facility abuse prevention policy (investigation, reporting, police report as required, etc.) On 6/25/25, Surveyor reviewed a facility-reported incident (FRI) that indicated R3 called the facility on 5/16/25 after R3 was discharged and indicated R3 was missing a blue jacket worth $75. The facility initiated an investigation on 5/16/25, notified the police, and filed a report with the State Agency (SA) after a search for the missing jacket was unsuccessful. Staff and resident interviews were completed for the allegation of misappropriation with no concerns noted. Staff interviews indicated staff had not seen R3 wear a blue jacket. The investigation indicated the facility could not substantiate misappropriation but would reimburse R3 for the jacket if R3 provided proof of the cost. The investigation indicated a personal inventory form was not completed upon R3's admission, therefore, the facility could not determine if R3's blue jacket was present upon admission. The investigation indicated the facility would educate staff on ensuring an inventory form is completed upon admission to ensure accuracy of personal items brought to the facility. On 6/25/25 at 1:00 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who verified the facility did not have proof of staff education regarding the allegation of misappropriation.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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Based on observation, staff and resident interview, and record review, the facility did not ensure staff provided activities of daily living (ADLs) in accordance with preferences for 1 resident (R) (R13) of 19 sampled residents. R13 was dependent on staff for oral care, pericare, and personal hygiene and filed a grievance on 5/26/25 regarding the provision of timely care. The grievance indicated the issue was resolved, however, staff continued to not provide care in a timely manner or at R13's preferred time of day. Findings include: The facility's Routine Resident Care policy, revised May 2020, indicates: Residents receive the necessary assistance to maintain good grooming and personal/oral hygiene .3. Daily personal hygiene minimally includes assisting or encouraging residents with washing their faces and hands, combing their hair each morning, and brushing their teeth and/or providing denture care .Incontinence care is provided timely according to each resident's needs .9. Residents' call lights are answered timely and residents' requests are addressed . From 6/24/25 to 6/25/25, Surveyor reviewed R13's medical record. R13 had diagnoses including pressure ulcer of right ankle unstageable, unspecified injury at T7-T10 level of thoracic spinal cord, paraplegia, pressure ulcer of right buttock stage 4, colostomy, and urostomy. R13's Minimum Data Set (MDS) assessment, dated 5/29/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R13 had intact cognition. A care plan, dated 5/19/25, indicated R13 had paraplegia related to a spinal cord injury and required assistance with ADLs and locomotion. On 6/24/25, Surveyor reviewed the facility's grievance file and noted a grievance filed by R13 on 5/26/25 regarding timely care. The grievance indicated R13 voiced concerns that R13 did not receive consistent morning cares. The grievance indicated the concern was resolved on 5/30/25, staff were educated, and R13 was updated and in agreement with staff follow-up. A summary of the investigation indicated Director of Nursing (DON)-B spoke with R13 and Certified Nursing Assistants (CNAs) scheduled on the days R13 reported concerns. The CNAs were educated on R13's daily care routine during a staff meeting. The summary of findings indicated there was miscommunication between the CNAs when one assumed another had completed cares. The grievance indicated R13 was aware staff were being educated and stated DON-B would follow-up with R13 on a regular basis. On 6/25/25 at 9:55 AM, Surveyor interviewed R13 who indicated R13 was washed up maybe fifty percent of the time and often did not receive assistance with cares until between 12:00 and 1:00 PM. R13 indicated most of the time PM shift staff provided ADLs for R13. R13 indicated R13 frequently asks for cares to be completed during the AM shift but staff say R13 has to wait and staff will come back, but never do. R13 indicated R13's grievance was not resolved because staff continue to not provide assistance with ADLs in the morning per R13's preference. R13's medical record to included documentation of oral cares and bathing/bed baths. Surveyor noted R13 received assistance with ADLs 26% of the time on the AM shift from 5/27/25 to 6/25/25 despite the fact R13 indicated R13 preferred to receive assistance with cares during the morning hours. On 6/25/25 at 12:02 PM, Surveyor interviewed DON-B who indicated DON-B followed-up with R13 and R13 indicated things were getting better. DON-B stated DON-B continues to follow-up with R13 who had not indicated that R13 still had concerns. On 6/25/25 at 12:10 PM, Surveyor interviewed R13 who indicated R13 had not seen DON-B since last week. R13 indicated the most recent times R13 spoke to DON-B were about wound care and not ADLs. R13 recalled that when the grievance was submitted, DON-B indicated staff education would occur. R13 indicated during the interview with Surveyor that R13 had not received oral care yet. R13 also indicated the only reason R13's Chux pad was changed that day was because R13 had wound care. R13 stated R13 had a colostomy and ostomy but still needed pericare, oral care, and a Chux pad change since R13 had wounds that seep and drain and had occasional drainage from the colostomy and ostomy. R13 stated R13 was made to just sit in that with a wet Chux. R13 indicated R13 was able to do oral care independently but needed assistance with set-up. R13 also stated R13 was not washed up in a timely manner and indicated R13 was paralyzed and unable to do certain things independently. R13 indicated R13 used the call light and repeatedly asked staff to provide cares which were not provided most of the time until the PM shift. R13 indicated R13 wakes up at 9:00 AM and informed staff and administrative staff several times that R13 prefers to be assisted with ADLs at approximately 10:00 AM which rarely happens.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility did not ensure the appropriate care and treatment was provided for a peripherally inserted central catheter (PICC) line for 1 resident (R) (R4) of 5 sampled residents. R4 had a PICC line. Staff did not complete a PICC line dressing change as ordered and in accordance with the facility's policy. Findings include: The facility's PICC/Central Vascular Access Device Dressing Change policy, revised 5/1/25, indicates: .To provide consistent guidance to licensed nursing staff in regards to changing PICC/Central access device (CVAD) dressings weekly or if soiled or not intact. Guidelines in this policy are to ensure that appropriate standards of care are followed to decrease the potential for infection .Catheter insertion site is a high-risk for bacteria to enter and could cause a catheter-related infection if not cared for and monitored correctly .2. Dressing changes to be done: a. Upon admission unless current dressing is clean, dry, and intact and dated less than 7 days from current date .b. Weekly. c. As needed (PRN) if the dressing has become loose, soiled or wet. On 6/24/25, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] and had diagnoses including sepsis, osteomyelitis of the left ankle and foot, and type 2 diabetes. R4's Minimum Data Set (MDS) assessment, dated 5/6/25, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R4 had intact cognition. R4's medical record contained the following PICC line orders: ~ Monitor dressing for intactness, moisture, and drainage every shift. Consider PRN dressing change (start date 4/30/25). ~ Change PICC dressing weekly. Use aseptic technique and PICC dressing kit. Scrub site for 10-15 seconds and let dry. Apply transparent dressing and anti-infective disk (not in kit) one time a day every Tuesday for weekly dressing change and as needed. Change if loose or soiled (start date 4/30/25). R4's Medication Administration Record (MAR) and Treatment Administration Record (TAR) contained orders for weekly PICC line dressing changes. Staff documented PICC line dressing changes on 5/5/25, 5/12/25, and 6/3/25 and a PRN PICC line dressing change on 5/27/25. On 6/24/25 at 9:24 AM, Surveyor interviewed Clinic Registered Nurse (RN)-Q who stated RN-Q saw R4 at (named clinic) on 5/21/25. RN-Q stated R4's PICC line dressing was dirty and peeling on 3 of the 4 corners. RN-Q changed R4's PICC line dressing and notified facility staff of the dressing change. On 6/24/25 at 3:21 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed R4's PICC line dressing was not changed by facility staff the week of 5/19/25 and was changed at the clinic on 5/21/25. DON-B confirmed R4's PICC line dressing was changed by facility staff on 5/12/25 and was due to be changed on 5/19/25 which did not occur. DON-B indicated PICC line dressing changes should be done weekly or as needed if the dressing is soiled.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility did not provide the necessary respiratory care and services for 1 resident (R) (R16) of 19 sampled residents. R16's bilevel positive airway presure (BiPAP) machine and equipment were not properly cleaned or cared for in accordance with the facility's policy. Findings include: The facility's CPAP-BiPAP Use policy, revised October 2020, indicates: .6. The continuous positive airway pressure (CPAP)/BiPAP mask, tubing, and humidifiers shall be cleansed weekly with soap and water and rinsed thoroughly unless otherwise specified by the physician or respiratory therapist. 7. If a humidifier is in use, the water will be discarded and replaced daily with fresh distilled water. From 6/24/25 to 6/25/25, Surveyor reviewed R16's medical record. R16 was admitted to the facility on [DATE] and had diagnoses including heart failure, asthma, obstructive sleep apnea, chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypercapnia, chronic respiratory failure with hypoxia, and anxiety. R16's Minimum Data Set (MDS) assessment, dated 2/2/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R16 had intact cognition. On 6/24/25 at 11:08 AM, Surveyor interviewed R16 and noted R16 used oxygen and had a BiPAP machine on the nightstand. When Surveyor asked if the BiPAP machine was cleaned regularly, R16 indicated Assistant Director of Nursing (ADON)-J washed and hung the mask and tubing last week. R16 indicated that was the first time since R16 was admitted that staff had cleaned the tubing, humidifier, and mask. Surveyor noted R16's medical record did not indicate a schedule for cleaning the BiPAP machine or humidifier tank. On 6/25/25 at 12:32 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed R16's medical record did not contain documentation of BiPAP or humidifier care.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0805 (Tag F0805)

Could have caused harm · This affected 1 resident

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Based on observation, staff interview, and record review, the facility did not ensure food was prepared in a form designed to meet the requirements of a mechanical soft diet for 1 resident (R) (R8) of 1 sampled resident. R8 had an order for a mechanical soft diet (smaller than bite-sized pieces/chopped). On 6/24/25, R8's lunch tray was delivered to the unit with regular texture roast beef. Findings include: www.iddsi.org Level 5 Minced & Moist Food for Adults (formerly known as mechanical soft diet) indicates minced and moist food texture consists of soft and moist but with no liquid leaking/dripping from the food. Biting is not required. Minimal chewing is required lumps of 4 millimeter (mm) in size which can be mashed with the tongue. Food can be easily mashed with a little pressure from a fork and should be able to be scooped onto a fork with no liquid dripping and no crumbles falling off the fork Level 5 Minced & Moist food may be used if you are not able to bite off pieces of food safely but have some basic chewing ability. Some people may be able to bite off a large piece of food but are not able to chew it into little pieces that are safe to swallow. Minced & Moist foods only need a small amount of chewing and for the tongue to collect the food into a ball and bring it to the back of the mouth for swallowing. It's important that Minced & Moist foods are not too sticky because this can cause the food to stick to the cheeks, teeth, roof of the mouth or in the throat. These foods are eaten using a spoon or fork. The facility's Diet Orders document, revised January 2021, indicates: Therapeutic diets are prescribed by the attending physician. Diet order terminology that is consistent with the list of available therapeutic diets in the diet manual facilitates serving meals that meet the nutritional and therapeutic needs of residents. Diets not available on the menu are developed by the Registered Dietitian .1. Therapeutic diets must be prescribed by the attending physician .2. Refer to the diet manual for standard diets for which menus are written. The diet standardization guide in the diet manual may assist in education with nurses, physicians, and other staff on available diets .Diet orders are communicated to the dietary department using the diet communication or physician orders diet form or by the diet type report if electronic orders are in use . On 6/24/25, Surveyor reviewed R8's medical record. R8 had a diagnosis of dysphagia oropharyngeal phase (a medical condition characterized by difficulty swallowing due to issues in the oropharynx which is the part of the throat. Common symptoms include difficulty transferring food from the mouth to the throat, choking, coughing during meals, and a sensation of food getting stuck). R8's Minimum Data Set (MDS) assessment, dated 5/21/25, indicated R8 ate meals independently and had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R8 had intact cognition. R8's medical record contained a physician's order for a mechanical soft diet. During a lunch observation at the kitchen steam table that began at 10:53 AM on 6/24/25, Surveyor observed [NAME] (CK)-H put regular texture roast beef in the blender to make the meat into a mechanical soft (minced and moist) texture. CK-H then put the mechanical soft roast beef in a steam table container for service. Surveyor observed CK-H plate R8's meal tray with a regular texture serving of roast beef and put the tray in a meal cart for delivery to the unit. Surveyor noted R8's meal ticket indicated at the top of the ticket highlighted in blue Mech/soft for R8's diet type. At 11:45 AM, Surveyor observed staff deliver the cart of resident room trays to the unit for staff to deliver to residents. On 6/24/25 at 11:50 AM, Surveyor observed R8's lunch tray with Dietary Manager (DM)-C who confirmed R8 was not provided a mechanical soft diet in accordance with R8's meal ticket. DM-C verified the roast beef on R8's lunch tray was regular texture roast beef and confirmed R8 should not have been served roast beef in that form.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

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**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 4 residents (R) (R7, R12, R15, and R17) of 19 sampled residents were provided safe administration of drugs and biologicals. On 6/24/25, Surveyor observed an albuterol inhaler and a vial of DuoNeb solution on R7's bedside table. Surveyor also observed a nebulizer on the nightstand that contained a full chamber of solution. R7 did not have a physician's order or self-administration of medication assessment that indicated R7 could self-administer medication. On 6/24/25, Surveyor observed a 1 ounce bottle of Afrin nasal spray on R12's nightstand. R12 did not have a physician's order for Afrin nasal spray or a self-administration of medication assessment that indicated R12 could self-administer medication or store medication at the bedside. On 6/24/25, Surveyor observed an albuterol inhaler on R15's bedside table. R15 did not have a physician's order or a self-administration of medication assessment indicated R15 could self-administer medication or store medication at the bedside. On 6/24/25, Surveyor observed 2 tubes of [NAME] Pain Relief, a 3 ounce bottle of miconazole 2% powder, a 16 ounce bottle of Dakin's solution, and a 1 ounce bottle of Adapt stoma powder on R17's nightstand. R17 did not have a physician's order or a self-administration of medication assessment that indicated R17 could self-administer medication or store medication at the bedside. Findings include: The facility's Self-Administration of Medication policy, revised May 2020, indicates: .3. The nurse will interview the resident to determine the resident's ability to identify, prepare, and self-administer medications. 4. Based on Interdisciplinary Team (IDT) review, a decision is made as to whether or not the resident is a candidate for self-administration. This will be recorded on the Medication Self-Administration Assessment .5. The nurse will obtain a physician's order for each resident self-administering medication. 1. From 6/24/25 to 6/25/25, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including respiratory failure, anxiety disorder, rhabdomyolysis, repeated falls, and weakness. R7's Minimum Data Set (MDS) assessment, dated 5/2/25, had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R7 had moderately impaired cognition. On 6/24/25 at 10:52 AM, Surveyor observed an albuterol inhaler and a vial of DuoNeb solution on R7's bedside table. Surveyor also observed a nebulizer on the nightstand that contained a full chamber of solution. R7 indicated R7 was unsure what medications R7 was prescribed. R7 confirmed R7 self-administered the inhaler for shortness of breath and indicated the DuoNeb vial was left for R7 to use in the nebulizer machine when R7 needed it. R7's medical record contained a self-administration of medication assessment, dated 4/26/25, that indicated R7 was not approved to self-administer medication. R7 had a physician's order to keep the albuterol inhaler at the bedside (dated 6/6/25). On 6/25/25 at 11:50 AM, Surveyor interviewed Director of Nursing (DON)-B who confirmed staff should have completed a new self-administration of medication assessment for R7 that indicated R7 could store the albuterol inhaler at the bedside in conjunction with the physician's order. DON-B also indicated staff should not leave medication for R7 to self-administer without a self-administration assessment and order. 2. From 6/24/25 to 6/25/25, Surveyor reviewed R12's medical record. R12 was admitted to the facility on [DATE] and had diagnoses including pneumonia, wedge compression fracture of 5th lumbar vertebra, hypothyroidism, atrial fibrillation, and abnormalities of gait and mobility. R12's MDS assessment, dated 5/5/25, had a BIMS score of 11 out of 15 which indicated R12 had moderately impaired cognition. On 6/24/25 at 11:00 AM, Surveyor observed a 1 ounce bottle of Afrin nasal spray on R12's nightstand. R12's medical record did not contain a physician's order for Afrin nasal spray or a physician's order or self-administration of medication assessment that indicated R12 could self-administer the nasal spray or keep the nasal spray at the bedside. On 6/25/25 at 11:50 AM, Surveyor interviewed DON-B who confirmed R12 did not have a physician's order for the use of Afrin nasal spray or a physician's order or self-administration of medication assessment that indicated R12 could self-administer the nasal spray. 3. From 6/24/25 to 6/25/25, Surveyor reviewed R15's medical record. R15 was admitted to the facility on [DATE] and had diagnoses including lymphedema, reduced mobility, weakness, and trigeminal neuralgia. R15's MDS assessment, dated 5/13/25, had a BIMS score of 12 out of 15 which indicated R15 had moderate cognitive impairment. On 6/24/25 at 11:04 AM, Surveyor observed an albuterol inhaler on R15's bedside table. R15's medical record did not contain a physician's order or self-administration of medication assessment that indicated R15 could self-administer the inhaler or store the inhaler at the bedside. On 6/25/25 at 11:50 AM, Surveyor interviewed DON-B who confirmed the albuterol inhaler should not have been at R15's bedside in accordance with a self-administration of medication assessment that indicated R15 was not able to self-administer medication or store medication at the bedside. 4. From 6/24/25 to 6/25/25, Surveyor reviewed R17's medical record. R17 was admitted to the facility on [DATE] and had diagnoses including traumatic spinal cord dysfunction, pressure ulcer-sacral region stage 2, muscle wasting and atrophy-multiple sites, metabolic encephalopathy, mononeuropathy of unspecified lower limb, weakness, and effusion of right hip. R17's MDS assessment, dated 5/1/25, had a BIMS score of 13 out of 15 which indicated R17 had intact cognition. On 6/24/25 at 11:34 AM, Surveyor observed 2 tubes of [NAME] pain relief, a 3 ounce bottle of miconazole 2% powder, a 16 ounce bottle of Dakin's solution, and a 1 ounce bottle of Adapt stoma powder on R17's nightstand. R17's medical record did not contain a physician's order or a self-administration of medication assessment that indicated R17 could self-administer the medications or store the medications at the bedside. On 6/25/25 at 11:50 AM, Surveyor interviewed DON-B who confirmed R17 did not have a physician's order or self-administration of medication assessment that indicated R17 could self-administer the medications or keep the medications at the bedside.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0921)

Could have caused harm · This affected multiple residents

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2. The 2022 Federal Food and Drug (FDA) Food Code documents at 5-501.113 Covering Receptacles: Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered: .(B) With tight-fitting lids or doors if kept outside the food establishment . On 6/24/25 at 7:33 AM, Surveyor conducted an environmental tour of the facility and noted a garbage dumpster in the rear parking lot was open on top and in the back. On 6/24/25 at 2:38 PM, Surveyor observed multiple pieces of discarded furniture near the dumpster in the rear parking lot and noted the top of the dumpster was still open. On 6/25/25 at 8:25 AM, Surveyor observed multiple pieces of discarded furniture near the dumpster in the rear parking lot and noted the top of the dumpster was still open. Surveyor observed Dietary Aide (DA)-D throw boxes in the recycling dumpster and walk back into the building without closing the lid of the dumpster that contained garbage. Based on observation, staff interview, and record review, the facility did not provide a safe, sanitary, and comfortable environment for residents, staff, and the public. This practice had the potential to affect more than 4 of the 44 residents residing in the facility. The facility's front entrance contained broken concrete outside the main entrance and lifted floor tile in the walkway between the main entrance front doors. On 6/24/25, a commercial dumpster that contained garbage was left open in the parking lot. Findings include: 1. On 6/24/25, Surveyor entered the facility and noted the cement in front of the main entrance was uneven, cracked, and heaving. When Surveyor entered the first door of the main entrance, Surveyor also noted the floor tile was lifted and cracked. On 6/24/25 at 3:56 PM, Surveyor again observed the flooring in the entrance way and noted it was lifted in the middle of the entrance way. On 6/25/25 at 12:58 PM, Surveyor measured the cracks at the front entrance. When facing the front door, the cement on the the left side of the entrance contained a crack that measured approximately 2.5 inches from the top piece of concrete to the next piece of concrete. The concrete also had an approximate 2.75 inch gap from the ground to top of the highest piece. The distance between the two pieces of concrete measured approximately 1.5 inches. At approximately the middle of the front entrance, Surveyor measured an approximate 5.5 inch gap/rise in the concrete from the ground. Several pieces of the concrete were cracked, missing, or flaking. To the right of the front entrance, Surveyor also measured an approximate 1 inch gap. On 6/25/25 at 1:00 PM, Surveyor measured an area on the left past the patio/sitting area outside the main entrance that contained a drop of approximately 4.5 inches on the right side of the raised concrete ramp going down to the sidewalk on the side of the building. On 6/25/25 at 1:05 PM, Surveyor and Maintenance-R toured the outside entrance and observed the concrete at the front entrance and the area in between the doors where the floor tile was lifted and cracked. Maintenance-R indicated repairs to concrete or flooring are completed by Maintenance-R as needed. Maintenance-R confirmed Maintenance-R completes smaller projects and indicated larger jobs need to be quoted and approved by management. Maintenance-R indicated the front concrete entrance way should be repaired along with the floor tiles in between the doors in the entrance way. Maintenance-R stated the facility has talked about replacing both but nothing was planned so far. On 6/25 at 1:12 PM, Surveyor and Director of Nursing (DON)-B toured the outside entrance and observed the concrete approach to the front door and the area in between the doors where the floor tile was lifted. DON-B indicated the facility had not had complaints or issues concerning the concrete or floor tile, however, the facility would look at it.

Mar 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Grievances (Tag F0585)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure a grievance was documented, thoroughly investigated, or resolved for 1 resident (R) (R4) of 9 sampled residents. R4's legal representative expressed concerns following R4's respite stay at the facility. The facility did not appropriately document, investigate, or thoroughly resolve the grievance. Findings include: The facility's Company Concerns Policy, dated October 2020, states it is the policy of the facility to provide a system whereby residents, and/or their significant others or representatives, can voice concerns about the quality of services received at the facility. The facility will designate a Concern Officer who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusion .The facility will maintain evidence demonstrating the results of all concerns for a period of no less than 3 years from the issuance of the grievance decision .6. All concerns receive immediate priority and must be investigated with efforts made toward resolution within 7 days .7. The resident will be provided with verbal follow up to their grievance .the resident may obtain a written decision upon request. On 3/24/25, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] for a respite stay. R4 had diagnoses including dementia and type 2 diabetes without complication. R4's Minimum Data Set (MDS) assessment, dated 12/20/24, had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated R4 had severe cognitive impairment. R4 had an activated Power of Attorney for Healthcare ((POAHC)-D) who was responsible for assisting R4 with healthcare decisions. R4 discharged from the facility on 12/30/24. On 3/24/25 at 9:24 AM, Surveyor interviewed POAHC-D who confirmed R4 had a respite stay at the facility from 12/14/24 to 12/30/24. POAHC-D stated POAHC-D expressed several concerns to Social Worker (SW)-C after R4 was discharged . POAHC-D stated the concerns included issues with hygiene, showers, blood sugar monitoring, and financial bills. POAHC-D stated SW-C told POAHC-D that the facility was still training new staff. POAHC-D stated POAHC-D did not receive follow-up for the concerns and the financial concerns were unresolved. On 3/24/25, Surveyor reviewed the facility's grievance log which did not contain a grievance from R4 or POAHC-D. On 3/24/25 at 12:07 PM, Surveyor interviewed SW-C who confirmed POAHC-D came to the facility approximately one week after R4 discharged and expressed concerns about R4 receiving showers and hygiene. POAHC-D also expressed concerns about financial statements. SW-C stated the financial concerns were resolved and SW-C relayed the care concerns to Director of Nursing (DON)-B. SW-C confirmed SW-C did not file a grievance or follow-up with POAHC-D. SW-C stated SW-C received a follow-up voicemail from POAHC-D which SW-C relayed to DON-B. SW-C stated DON-B would have followed-up. On 3/24/25 at 12:18 PM, Surveyor interviewed DON-B who stated DON-B thought POAHC-D was upset about some concerns but DON-B could not recall specifics. On 3/24/25 at 12:59 PM, Surveyor again interviewed DON-B who stated DON-B did not recall any concerns from POAHC-D. DON-B denied SW-C relayed any concerns regarding R4 to DON-B. DON-B indicated DON-B did not complete a grievance related to POAHC-D's concerns and did not follow-up with POAHC-D. On 3/24/25 at 1:27 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated NHA-A believed POAHC-D expressed concerns to SW-C which SW-C relayed to DON-B. NHA-A indicated the concerns were related to hygiene and the shower schedule. NHA-A confirmed there was not a grievance initiated for the concerns. NHA-A acknowledged a grievance should have been filed.

Jan 2025 2 deficiencies

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Menu Adequacy (Tag F0803)

Could have caused harm · This affected multiple residents

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Based on observation, staff and resident interview, and record review, the facility did not ensure nutritional needs were met for 5 residents (R) (R1, R4, R5, R8, and R9) of 5 residents. This practice had the potential to affect multiple other residents in the facility. R1, R4, R5, R8, and R9 were ordered carbohydrate-controlled diets. R1, R4, R5, R8, and R9's meal tickets did not contain diet modifications and the residents were served regular diet portions of dessert. In addition, dietary staff did not serve residents recommended portion sizes for all diet types. Finding include: The facility's Diet Orders policy, revised January 2021, indicates: Therapeutic diets are prescribed by the attending physician. Diet order terminology that is consistent with the list of available therapeutic diets in the diet Manual facilitates serving meals that meet the nutritional and therapeutic needs of the patients. Diets not available on the menu are developed by the Registered Dietitian .8. When physician orders for portion size changes are necessary, it is suggested that they be as specific as possible such as double meat or entrée or half portions of desserts. Refer to the diet Manual, Other Diet Information section for additional information on portion size changes .12. Diet orders are communicated to the dietary department using the Diet Communication or Physician Orders Diet/Tube Feeding forms or by the Diet Type Report . During a continuous kitchen observation that began at 7:15 AM on 1/21/25, Surveyor observed [NAME] (CK)-D begin breakfast service at the steam table. CK-D used one scoop to serve scrambled eggs and large cooking spoons to serve pureed scrambled eggs and toast. When Surveyor interviewed CK-D regarding how CK-D knew which scoop size to use, CK-D indicated the scoop size for the scrambled eggs was a #6 scoop which was an entrée scoop. Dietary Manager (DM)-C indicated at that time that large cooking spoons were used for pureed items which were served on divided plates. DM-C indicated dietary staff used a #6 scoop as an entrée scoop along with other ladles and scoops for side items and vegetables. DM-C indicated books provided by the facility's food vendor contained recipes for each meal, however, there was not an extended menu or form that indicated which scoops/serving sizes to use to ensure appropriate portions were served to residents. During a continuous kitchen observation that began at 7:15 AM on 1/21/25, Surveyor noted residents on all diet types were served the same portion of menu items. Surveyor requested and reviewed residents' meal tickets and noted R1, R4, R5, R8, and R9's meal tickets indicated they were on carb-controlled diets. There was no other information regarding R1, R4, R5, R8, and R9's diets on their meal tickets, including portion sizes or modifications. Surveyor interviewed DM-C who indicated dietary staff previously refused desserts for residents on carb-controlled diets but were informed they were not allowed to do so. DM-C indicated DM-C spoke with residents on therapeutic diets (including carb-controlled diets) and provided full dessert portions to residents who requested dessert for meals. DM-C indicated there were no other deviations to the diets. On 1/21/25, Surveyor reviewed R1's medical record. R1 had a diagnosis of type two diabetes mellitus. R1's Minimum Data Set (MDS) assessment, dated 11/24/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 was not cognitively impaired. On 1/21/25 at 11:23 AM, Surveyor interviewed R1 who indicated R1 received full dessert portions for all meals in which a dessert was offered. R1 confirmed R1 spoke with DM-C who asked if R1 wanted dessert for meals. R1 indicated R1 would like dessert. On 1/21/25 at 11:45 AM, Surveyor interviewed Registered Dietitian (RD)-E who indicated RD-E split weeks at several facilities. RD-E indicated diet cards which listed residents' diets were printed at each meal and used by dietary staff to serve residents the appropriate diets. RD-E indicated the appropriate scoop sizes to be used during meal service were contained on menus and recipe cards for the meals and also on residents' meal tickets. RD-E confirmed the following scoop sizes should have been used for the 1/21/25 breakfast meal: Scrambled eggs (regular and mechanical-soft texture) - #16 scoop; Pureed scrambled eggs - #12 scoop; Pureed toast - #20 scoop. RD-E confirmed the use of a #6 scoop for scrambled eggs and a large cooking spoon for pureed scrambled eggs and toast was not appropriate. RD-E indicated RD-E expects residents on carb-controlled diet to receive half-portions of dessert instead of full potions. RD-E confirmed dietary staff were not serving residents according to their diet orders and indicated retraining was needed.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0801 (Tag F0801)

Could have caused harm · This affected most or all residents

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Based on staff interview and record review, the facility did not designate a person to serve as the director of food and nutrition services who was a certified dietary manager, a certified food service manager, had a national certification for food service management and safety from a national certifying body, or who had an associate's or higher level degree in food service management or hospitality. This practice has the potential to affect all 46 residents residing in the facility. Dietary Manager (DM)-C did not complete an approved dietary manager or food service manager certification course or other related education. Findings include: During a continuous kitchen observation that began at 7:15 AM on 1/21/25, Surveyor interviewed DM-C who stated DM-C was hired as a Dietary Aide in 2021 and was promoted to Dietary Manager in April of 2024. DM-C did not indicate that DM-C had any experience or training prior to employment in the facility. DM-C indicated DM-C worked with Nursing Home Administrator (NHA)-A and Regional Dietitian (RD)-E to get certified, however, DM-C had to file for an extension because DM-C did not complete the course within the required time frame and had a mentor change during the course. DM-C stated RD-E was in the building twice monthly and available via email or phone. On 1/21/25 at 11:45 AM, Surveyor interviewed RD-E who confirmed RD-E worked between three facilities and was not onsite full-time weekly at any facility. On 1/21/25 at 1:45 PM, Surveyor interviewed NHA-A who indicated DM-C was enrolled in a course to become a certified food manager. NHA-A indicated NHA-A submitted an extension that day (1/21/25) because NHA-A had to adjust the time frame for completion of the course by DM-C.

Oct 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure neurological checks were completed per the facility's policy after a fall for 1 resident (R) (R1) of 1 sampled resident. Staff did not consistently complete neurological checks after R1 fell on 8/12/24 and 9/8/24. Findings include: The facility's Fall Management policy, revised July 2020, indicates: In the event a resident has a fall and it has been determined they hit their head, or it cannot be determined if they hit their head (i.e., the fall was unwitnessed or the patient cannot verbalize if they hit their head), the nurse initiates the following actions: .2. Neurological checks are completed and documented per instructions. Neurochecks should be completed per the facility's Neuro Check Assessment Form which indicates: Initial, every 15 minutes for 1 hour (4), every 30 minutes for 1 hour (2), every 1 hour for 4 hours (4), every 4 hours for 24 hours (6) and every shift until 72 hours (5). On 10/24/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including sepsis, diabetes type 2, and hypertension. R1's Minimum Data Set (MDS) assessment, 8/13/24, had a Brief Interview for Mental Status score 11 out of 15 which indicated R1 had moderate cognitive impairment. R1's medical record contained a risk for falls care plan (initiated on 8/8/24) and an actual fall with no injury care plan (initiated on 8/12/24). R1's medical record indicated R1 had unwitnessed falls on 8/12/24 and 9/8/24. Surveyor reviewed R1's neurological checks for the fall on 8/12/24 and noted staff missed 12 out of 22 neurochecks. Surveyor reviewed R1's neurological checks for the fall on 9/8/24 noted staff missed 2 out of 22 neurochecks. On 10/24/24 at 10:37 AM, Surveyor interviewed Director of Nursing (DON)-B who verified neurological checks were incomplete for R1's falls on 8/12/24 and 9/8/24. DON-B indicated DON-B expects staff to complete neurological checks per the facility's policy.

Jun 2024 1 deficiency

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

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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 40 residents residing in the facility. The facility did not have a system for monitoring cooked food temperatures or hot/cold holding temperatures. Staff did not practice safe food handling by donning hair and beard restraints while cooking and serving food. Findings include: Cooked and Hot/Cold Holding Temperatures: The facility's Food Temperature Record policy, with a revision date of February 2020, indicates: To ensure that foods and beverage are held and served at temperatures which comply with state and federal regulations. Each resident receives and the facility provides food that is palatable and at the proper temperature. Time and temperature control foods such as meat, poultry, fish, and eggs should be cooked to the minimum temperature specified below: Pork, beef, or veal - 145 degrees Fahrenheit (F) for 15 seconds Poultry - 165 degrees F for 15 seconds Fish - 145 degrees F for 15 seconds Ground meats - 155 degrees F for 15 seconds Shell eggs - 145 degrees F for 15 seconds and 155 degrees F if cooked and held for later service Foods not listed above must be cooked to a minimum of 135 degrees F and transferred to holding equipment .Hot foods must be held at a minimum of 135 degrees F .Cold foods must be held for service at a temperature of 41 degrees F or less .Holding temperatures must be recorded on the Food Temperature Record immediately prior to serving time and checked periodically as needed to maintain acceptable temperatures. The Federal Food and Drug Administration (FDA) Food Code 2022 documents at section 3-401.11 Raw Animal Foods: (A) Except as specified under (B) and in (C) and (D) of this section, raw animal foods such as eggs, fish, meat, poultry, and food containing these raw animal foods, shall be cooked to heat all parts of the food to a temperature and for a time that complies with one of the following methods based on the food that is being cooked .Internal Cooking Temperature Specifications for Raw Animal Foods .Raw eggs cooked for immediate service, fish, intact meat, except whole meat roasts and whole muscle intact beef steak at 145 degrees F for 15 seconds .Commercially raised game animals, rabbits at 155 degrees F for 17 seconds .Non-intact meats and raw eggs not for immediate service, wild game animals, poultry, stuffed fish, meat, pork, pasta, ratites, stuffing containing fish, meat, ratites and poultry at 165 degrees F for greater than 1 second . The FDA Food Code 2022 documents at section 3-403.11: (C) and (D) Food that is taken from a commercially processed, hermetically sealed container or intact package cooked to a temperature of 135 degrees F. The FDA Food Code 2022 documents at 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 6/12/24 at 8:13 AM, Surveyor observed [NAME] (CK)-D clean the steam table. Surveyor interviewed CK-D who indicated the breakfast meal was served and CK-D was no longer in the process of serving food. When Surveyor asked CK-D about food cooked temperatures and holding temperatures for the breakfast meal, CK-D obtained the food temperature log and indicated to Surveyor that temperatures for the breakfast meal were not documented. CK-D verified cooked temperatures and holding temperatures should be obtained and documented. The facility's Hot Holding Food Temperature Log, dated June 2024, indicates: The minimum hot holding temperature is 135 degrees F. If the food temperature is less than 135 degrees F, notify a manager or supervisor. If out of temperature for less than two hours, the food may be rapidly reheated to 165 degrees F (one time only). Surveyor noted the form was blank and did not contain hot holding temperatures for the month of June. The facility's Food Temperature Record, dated June 2024, did not contain any cooked food temperatures for the following days and meals: ~ 6/4/24 - dinner meal ~ 6/5/24 - dinner meal ~ 6/6/24 - lunch meal ~ 6/7/24 - breakfast and lunch meals ~ 6/8/24 - breakfast, lunch, and dinner meals ~ 6/9/24 - breakfast, lunch, and dinner meals ~ 6/10/24 - dinner meal ~ 6/11/24 - breakfast, lunch, and dinner meals ~ 6/12/24 - breakfast meal On 6/12/24 at 12:16 PM, Surveyor interviewed Dietary Manager (DM)-F who confirmed food temperatures should be obtained to ensure foods are thoroughly cooked. DM-F also confirmed food temperatures should be obtained for items in the steam table. DM-F confirmed staff did not obtain and document temperatures consistently . Hair and [NAME] Restraints: The facility's undated Hair Restraints policy indicates: Hair restraints are worn to keep hair away from food and to minimize touching or handling hair during food production. Hair is considered to be a foreign object and hair restraints help to avoid hair from falling into food .1. Hair restraints are worn by anyone in the kitchen .5. Hair restraints include: clean hats that cover all hair such as caps, chefs hats, hair coverings such as fine nets and surgical caps, beard or facial hair coverings. The FDA Food Code 2022 documents at 2-402.11: Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. On 6/12/24 at 8:13 AM, Surveyor observed Activity Director (AD)-C in the kitchen without a hair net. Surveyor observed AD-C leave the kitchen and then re-enter the kitchen without a hair net to obtain a cup. On 6/12/24 at 8:20 AM, Surveyor interviewed AD-C who confirmed AD-C was in the kitchen without a hair net and stated AD-C was just grabbing a cup. AD-C stated hair nets were not always available by the door where AD-C entered the kitchen. AD-C verified AD-C should wear a hair net when AD-C enters the kitchen. During a continuous kitchen observation beginning at 11:03 AM on 6/12/24, Surveyor observed CK-E gather items and season and prep foods for the dinner meal without a beard restraint. Surveyor noted CK-E had a full beard and mustache. Surveyor also observed CK-E stir food, open cans of food, and place the food in pots without a beard restraint. On 6/12/24 at 12:16 PM, Surveyor interviewed DM-F who stated staff should don a hair net prior to entering the kitchen. DM-F stated hair nets are available at the front and back entrances of the kitchen. DM-F stated CK-E is expected to wear a beard net and verified CK-E was not wearing one.

May 2024 19 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interview and record review, the facility did not ensure 1 resident (R) (R25) of 14 sampled residents was offered the opportunity to create or obtain Power of Attorney for Health Care (POAHC) paperwork. R25 was admitted to the facility on [DATE]. The facility did not obtain R25's POAHC document or offer R25 the chance to fill out a new document prior to 5/7/24. Findings include: The facility's Advanced Directive policy and procedure, dated October 2020, indicates: The resident has a right to accept or refuse medical or surgical treatment and to formulate an advance directive in accordance with state and federal law .Purpose: To help ensure a resident's right to formulate an advanced directive .Procedure: .2. The facility will inquire at the time of admission whether the resident has previously executed an advance directive. 3. If a resident has executed an advance directive, the facility must obtain a copy from the resident or the legal representative which is stored in the resident's medical record. Nursing notifies the physician of the resident's or the legal representative's wishes, obtains orders as appropriate, and enters the information in the electronic health record. On 5/6/24, Surveyor reviewed R25's medical record. R25 was admitted to the facility on [DATE]. R25's medical record did not contain POAHC documentation. On 5/7/24, Surveyor reviewed a POAHC refusal document, dated 4/12/24, that indicated R25 did not wish to complete paperwork at that time. On 5/7/24 at 10:15 AM, Surveyor interviewed R25 who stated Social Services Director (SSD)-D was just in R25's room and requested R25's POAHC document. R25 indicated R25 had a POAHC document from 2004 in R25's safe at home and did not wish to fill out another one. When Surveyor asked R25 to review the refusal document provided by the facility, R25 stated the document was filled out and signed on 5/7/24 approximately 10 minutes prior to the interview. On 5/7/24 at 10:40 AM, Surveyor interviewed Social Services Assistant (SSA)-C who stated SSA-C didn't have R25 sign the refusal document, however, SSA-C was asked to sign and date the document 4/12/24 by SSD-D after SSD-D obtained R25's signature on the document on 5/7/24. On 5/7/24 at 10:37 AM, Surveyor interviewed SSD-D who verified R25 signed the POAHC refusal document on 5/7/24.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not notify a Power of Attorney for Healthcare (POAHC) for when 1 resident (R) (R34) of 14 sampled residents experienced a change in condition. The facility did not notify R34's POAHC following a fall on 5/1/24. Findings include: The facility's Fall Management policy, dated July 2020, indicates when a fall occurs, it is the responsibility of the nurse to communicate the fall to the attending physician and the resident's representative, and document the notification on the Interdisciplinary Post Fall Review report. The nurse will discuss recommended interventions to reduce or prevent further falls with the resident and/or the resident representative. 1. From 5/6/24 to 5/8/24, Surveyor reviewed R34's medical record. R34 was admitted to the facility on [DATE] with diagnoses including Parkinsonism, muscle wasting and atrophy, unspecified severe protein-calorie malnutrition, and altered mental status. R34's Minimum Data Set (MDS) assessment, dated 4/20/24, indicated R34 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated R34 had severe cognitive impairment. A care plan, initiated on 9/21/23, indicated R34 was at high risk for falls related to confusion. R34 had an activated POAHC. On 5/6/24 at 2:03 PM, Surveyor interviewed POAHC-R who stated R34 had a recent fall and POAHC-R was not notified until POAHC-R visited R34 and was informed of the fall by R34. POAHC-R stated POAHC-R asked staff who verified R34 had a fall. On 5/7/24, Surveyor reviewed a fall incident report, dated 5/1/24, that stated R34 had an unwitnessed fall in R34's room. The fall report indicated R34's physician and Director of Nursing (DON)-B were notified. The fall report did not indicate POAHC-R was notified. On 5/8/24 at 1:20 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who confirmed POAHC-R was not notified of R34's fall on 5/1/24. NHA-A stated the nurse responsible for the notification confirmed to NHA-A that POAHC-R was not notified following the fall. NHA-A stated education was provided to the nurse. NHA-A confirmed NHA-A expects staff to update a resident's representative following a fall. NHA-A stated NHA-A called POAHC-R on 5/8/24 and notified POAHC-R of R34's fall.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. From 5/6/24 to 5/8/24, Surveyor reviewed R32's medical record. R32 was admitted to the facility on [DATE] with diagnoses including neoplasm of uncertain behavior of brain, moderate persistent asthma with (acute) exacerbation, acute respiratory failure with hypoxia, and acute on chronic diastolic (congestive) heart failure. R32's MDS assessment, dated 4/7/24, contained a BIMS score of 15 out of 15 which indicated R32 had intact cognition. R32 had an activated Power of Attorney for Healthcare (POAHC). R32's medical record indicated R32 was hospitalized on [DATE] with diagnoses of exacerbation of asthma, acute on chronic diastolic congestive heart failure, acute exacerbation of moderate persistent asthma, and acute hypoxic respiratory failure. A progress note, dated 3/10/24, indicated nursing staff called R32's POAHC to notify them of the transfer. R32 returned to the facility on 3/18/24. On 5/8/24 at 10:33 AM, Surveyor interviewed LPN-E and LPN-F. LPN-E indicated LPN-E verbally informs residents of the reason for the transfer and was not aware the facility has a transfer notice form. LPN-E and LPN-F indicated they were unaware a written transfer notice is required when a resident is transferred. On 5/8/24 at 1:20 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated the facility did not have documentation that a written transfer notice was provided to R32 or R32's POAHC. NHA-A stated a written transfer notice should have been provided. Based on staff interview and record review, the facility did not ensure 2 residents (R) (R145 and R32) of 2 residents reviewed for hospitalization received a transfer notice that included the date of the transfer, the reason for the transfer, the location of the transfer, and appeal rights. R145 was transferred to the hospital on 4/18/24 and was not provided with a written transfer notice. R32 was transferred to the hospital on 3/10/24. R32 and/or R32's legal representative were not provided with a written transfer notice. Findings include: The facility's Bedhold Notification policy, dated March 2021, includes a sample letter Notice of Transfer that states the reason for the resident's transfer and their right to appeal. 1. From 5/6/24 to 5/8/24, Surveyor reviewed R145's medical record. R145's latest admission to the facility was on 4/25/24. R145 had diagnoses including heart failure, morbid obesity with alveolar hypoventilation (a condition where the lungs do not get enough air which causes high levels of carbon dioxide in the blood and decreased oxygen), and obstructive sleep apnea. R145's Minimum Data Set (MDS) assessment, dated 1/6/24, contained a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R145 had intact cognition. R145's medical record indicated R145 fell on 4/18/24. After staff transferred R145 to bed, R145 was hard to arouse and no injuries were noted. R145 was sent to the hospital for evaluation and returned to the facility on 4/25/24. R145's medical record did not indicate a written transfer notice was provided to R145. On 5/8/24 at 10:33 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-E and LPN-F. LPN-E indicated LPN-E verbally informs residents of the reason for the transfer and was not aware the facility has a transfer notice form. LPN-E and LPN-F indicated they were unaware a written transfer notice is required when a resident is transferred. On 5/8/24 at 10:54 AM, Surveyor interviewed Director of Nursing (DON)-B who verified R145 did not receive a written transfer notice when R145 was transferred to the hospital on 4/18/24. DON-B indicated R145 should have received a written transfer notice.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. From 5/6/24 to 5/8/24, Surveyor reviewed R32's medical record. R32 was admitted to the facility on [DATE] with diagnoses including neoplasm of uncertain behavior of brain, moderate persistent asthma with (acute) exacerbation, acute respiratory failure with hypoxia, and acute on chronic diastolic (congestive) heart failure. R32's MDS assessment, dated 4/7/24, contained a BIMS score of 15 out of 15 which indicated R32 had intact cognition. R32 had an activated Power of Attorney for Healthcare (POAHC). R32's medical record indicated R32 was hospitalized on [DATE] with diagnoses of exacerbation of asthma, acute on chronic diastolic congestive heart failure, acute exacerbation of moderate persistent asthma, and acute hypoxic respiratory failure. R32 was readmitted to the facility on [DATE] following an acute hospital stay. On 5/8/24 at 1:20 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated the facility did not have documentation that a copy of the bed hold policy was provided or reviewed with R32 or R32's POAHC. NHA-A stated R32 should have received a copy of the facility's bed hold policy. Based on staff interview and record review, the facility did not ensure 2 residents (R) (R145 and R32) of 2 residents reviewed for hospitalization received notification of the facility's bed hold policy when they were transferred to the hospital. R145 was transferred to the hospital following a fall on 4/18/24. R145 was not provided written notice of the facility's bed hold policy. R32 was transferred to the hospital on 3/10/24. R32 was not provided written notice of the facility's bed hold policy. Findings include: The facility's Bedhold Notification policy, dated March 2021, states when a resident is transferred to the hospital, the facility will provide written notice to the resident and/or resident's representative regarding the resident's bed hold rights and the facility's bed hold policy. 1. From 5/6/24 to 5/8/24, Surveyor reviewed R145's medical record. R145's latest admission to the facility was on 4/25/24. R145 had diagnoses including heart failure, morbid obesity with alveolar hypoventilation (a condition where the lungs do not get enough air which causes high levels of carbon dioxide in the blood and decreased oxygen), and obstructive sleep apnea. R145's Minimum Data Set (MDS) assessment, dated 1/6/24, contained a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R145 had intact cognition. R145's medical record indicated R145 fell on 4/18/24. After staff transferred R145 to bed, R145 was hard to arouse and no injuries were noted. R145 was sent to the hospital for evaluation and returned to the facility on 4/25/24. R145's medical record did not indicate a copy of the facility's bed hold policy was provided to R145. On 5/8/24 at 10:33 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-E and LPN-F. LPN-E indicated LPN-E verbally informs residents or their representatives of the bed hold policy. When Surveyor asked LPN-E if LPN-E follows up with a written bed hold policy to ensure a signature, LPN-E indicated the Social Worker has the resident sign. LPN-F stated LPN-F was unsure of the facility's bed hold process. On 5/8/24 at 10:54 AM, Surveyor interviewed Director of Nursing (DON)-B who verified R145 did not receive a copy of the facility's bed hold policy when R145 was transferred to the hospital on 4/18/24. DON-B indicated R145 should have been given a copy of the bed hold policy.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0637 (Tag F0637)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure a comprehensive assessment was completed after a significant change in condition for 1 resident (R) (R8) of 14 sampled residents. R8 started Hospice services on 3/13/24. The facility did not complete comprehensive assessment for a significant change in condition. Findings include: The Centers for Medicare & Medicaid Service's (CMS's) Resident Assessment Instrument (RAI) Version 3.0 Manual, dated October 2023, indicates: OBRA-required comprehensive assessments include the completion of both the Minimum Data Set (MDS) and the Care Area Assessment (CAA) process, as well as care planning. Comprehensive assessments are completed upon admission, annually, and when a significant change in a resident's status has occurred or a significant correction to a prior comprehensive assessment is required . On 5/6/24, Surveyor reviewed R8's medical record. R8 was admitted to the facility on [DATE] with diagnoses including dementia, diabetes, and coronary heart disease. On 5/6/24 at 2:26 PM, Surveyor interviewed Power of Attorney for Healthcare (POAHC)-Q via telephone who stated R8 started Hospice services in March of 2024. Surveyor noted R8's medical record did not contain a comprehensive MDS assessment for a significant change of condition when R8 started Hospice services. On 5/8/24 at 10:15 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who verified that facility did not complete a significant change assessment for R8 but should have.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not develop a baseline care plan that included the minimum healthcare information necessary to properly care for 1 resident (R) (R149) of 14 sampled residents. R149's baseline care plan did not include information related to R149's dialysis, diet, and smoking status. Findings include: The facility's Baseline Care Plan (BCP) policy, revised February 2021, indicates: Each resident will have a baseline care plan developed within 48 hours of admission that addresses identified risk areas and the resident's initial individual needs .The BCP documents and communicates the resident's initial needs until the comprehensive care plan is finalized .Procedure: 1) The admitting nurse will perform an initial nursing assessment of the resident and gather specific information from the following sources: physician orders, diet, therapy, medications, activity limitations, treatments, and social services .4) The BCP includes the following key elements: Initial goals based on admission orders .dietary orders .6) A summary of the BCP will be provided to and discussed with the resident .The summary .should include .c) services, treatments and interventions to be administered by the facility . The facility's Safe Smoking/Tobacco Use policy, revised October 2020, indicates: The interdisciplinary team (IDT) determine if a resident may safely use tobacco products or e-cigarettes before the resident is permitted the privilege to do so .Safe Smoking/Tobacco Use Determination: An evaluation is conducted for all residents who use tobacco products or e-cigarettes in order to .observe the resident's ability to smoke/use tobacco in a safe manner. The resident's care plan reflects: That the resident smokes .the degree of supervision that is necessary, if the resident is to wear a protective smoking/vest/apron .Procedure: .3) A resident who smokes .is evaluated to determine whether the resident is safe or unsafe to use tobacco products or e-cigarettes using the following forms a) Upon admission or readmission, if the nursing admission data collection identifies that the resident uses tobacco .evaluation is completed .Residents who are determined to be unsafe while smoking are required to wear a protective smoking vest/apron and are supervised at all times while smoking . From 5/6/24 to 5/8/24, Surveyor reviewed R149's medical record. R149 was admitted to the facility on [DATE] with diagnoses including severe protein-calorie malnutrition, end stage renal disease, renal dialysis, nicotine dependence, and dysphagia (difficulty swallowing). R149's Minimum Data Set (MDS) assessment, dated 4/23/24, stated R149 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R149 had intact cognition. R149's medical record indicated the following: ~R149 was prescribed a low potassium diet with a mechanical soft texture and thin liquids. ~R149 had an order for dialysis on Tuesdays, Thursdays, and Saturdays. ~A smoking assessment indicated R149 required assistance to smoke. A baseline care plan, initiated 4/19/24, did not include information related to R149's dialysis, diet, and smoking status. On 5/8/24 at 10:04 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-F who indicated R149 could smoke independently. On 5/8/24 at 10:11 AM, Surveyor interviewed LPN-E who indicated R149 was an independent smoker. On 5/8/24 at 11:04 AM, Surveyor interviewed Director of Nursing (DON)-B who verified R149 did not have a care plan for smoking. DON-B confirmed a smoking assessment was completed and indicated R149 required assistance when smoking. DON-B indicated DON-B had not seen R149 smoke and did not think R149 smoked. DON-B indicated an intervention for assistance when smoking should have been included in R149's BCP. On 5/8/24 at 11:11 AM, Surveyor interviewed DON-B who verified R149's diet and dialysis were not included in R145's BCP but indicated both should have been included in R149's BCP.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure a comprehensive care plan was developed and implemented for 1 resident (R) (R8) of 14 sampled residents. R8 started Hospice services on 3/13/24. The facility did not develop a care plan to address R8's Hospice care. In addition, R8 did not have an order for Hospice prior to 5/8/24 Findings include: On 5/6/24, Surveyor reviewed R8's medical record. R8 was admitted to the facility on [DATE] with diagnoses including dementia, diabetes, and coronary heart disease. R8 began Hospice care on 3/13/24. On 5/6/24 at 2:26 PM, Surveyor interviewed Power of Attorney for Healthcare (POAHC)-Q via telephone who stated R8 started Hospice care in March of 2024. On 5/7/24, Surveyor reviewed R8's medical record and noted R8 did not have a care plan for Hospice or an order for Hospice care. On 5/8/24 at 10:19 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated staff should obtain a referral from the Hospice provider, obtain an order from the resident's physician, and implement a care plan when a resident starts Hospice care. DON-B verified R8 did not have an order or a comprehensive care plan for Hospice services. On 5/8/24 at 10:34 AM, Surveyor interviewed Regional Consultant (RC)-M who indicated R8 did not have a Hospice care plan prior to 5/8/24 when RC-M initiated a Hospice care plan for R8. On 5/8/24 at 10:51 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who provided Surveyor with a copy of R8's MD order for Hospice care. NHA-A verified the Hospice order was entered in R8's medical record on 5/8/24.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 5/7/24 and 5/8/24, Surveyor reviewed R4's medical record. R4 was readmitted to the facility on [DATE] following a hospitalization and had diagnoses including pressure injury of sacral region stage 4, quadriplegia unspecified, unspecified severe protein-calorie malnutrition, and osteomyelitis (bone infection) unspecified sites. R4's Quarterly Minimum Data Set (MDS) assessment, 4/14/24, contained a Brief Interview for Mental Status (BIMS) assessment that indicated R4 was rarely/never understood. R4's spouse was R4's legal guardian. A wound care treatment order on R4's medication administration record (MAR) indicated: Stage 4 pressure injury to coccyx: cleanse wound with Vashe cleanser. Ten minute soak. Apply Cavilon Advance to peri-wound. Place Prisma collagen to wound bed. Pack with Hydrofera Classic. Cover with bordered foam. Once daily every 2 days for stage 4 pressure wound and every 1 hour as needed (dated 4/18/24 at 2:45 PM). On 5/8/24 at 11:13 AM, Surveyor observed RN-H complete wound care for R4. RN-H stated RN-H would do the 10 minute soak, but the facility was out of Vanshe. When Surveyor asked how long the facility was out of Vanshe and if Vanshe was reordered, RN-H stated RN-H didn't know but indicated Vanshe was used when R4 was treated during wound rounds on 5/1/24. RN-H was unsure if Vanshe was used for three dressing changes between 5/1/24 and 5/8/24. On 5/8/24 at 1:20 PM, Surveyor interviewed DON-B who indicated RN-H would have ordered the wound care supplies. On 5/8/24 at 1:23 PM, Surveyor interviewed RN-H who provided Surveyor with an email of RN-H's request to DON-B on 4/26/24 to reorder Vashe. RN-H confirmed DON-B orders supplies. On 5/8/24 at 2:01 PM, Surveyor interviewed DON-B who indicated DON-B left two messages with the wound clinic but they didn't return the call. DON-B indicated DON-B should have continued to call the wound clinic to clarify the order. DON-B did not have documentation of the calls to the wound clinic. On 5/8/24 at 3:16 PM, Surveyor interviewed staff at Wound Care Clinic (WCC)-L who confirmed via encounter notes, a paper chart, and email that the wound clinic did not receive communication from DON-B or the facility related to R4's treatment from 4/26/24 to 5/8/24. Based on observation, staff interview, and record review, the facility did not ensure 2 residents (R) (R33 and R4) of 2 residents reviewed for pressure injuries received the necessary care and services to promote healing. R33 had an order to remove R33's wound vac on 3/13/24 and reapply the wound vac on 3/20/24. On 3/20/24, the order was changed to reapply the wound vac on 3/27/24. The facility did not reorder wound vac supplies in a timely manner and the wound vac was not reapplied until 4/10/24. R4 had a pressure injury on the coccyx and an order to cleanse the wound with Vanshe wound cleanser. During an observation of wound care on 5/8/24, staff did not use Vanshe cleanser during R4's dressing change and stated the facility was out of the cleanser. Findings include: The facility's Dressing Change policy, with a revision date of 3/2020, indicates staff should prevent wound contamination and promote healing and complete dressing changes per physician orders. 1. On 5/6/24, Surveyor reviewed R33's medical record. R33 had diagnoses including pressure ulcer of right buttock, stage 4 right ischial tuberosity, blister of left thigh, and lumbar spina bifida with hydrocephalus. R33's Minimum Data Set (MDS) assessment, dated 4/16/24, indicated R33 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R33 had intact cognition. R33 was R33's own decision maker. On 5/6/24 at 8:35 AM, Surveyor interviewed R33 who stated a wound vac previously applied to R33's right ischium was taken off on 3/13/24 and was to be reapplied on 3/20/24. On 3/20/24, an order indicated the wound vac should remain off for another week and be reapplied on 3/27/24. R33 stated the wound vac was not reapplied on 3/27/24 because the facility did not order wound vac supplies which caused R33's wound vac to remain off until 4/10/24. R33 indicated staff did not inform R33 the supplies were not ordered prior to 4/8/24. R33 stated R33 asked nursing staff and Registered Nurse (RN)-H when the wound vac would be reapplied and was told the supplies were ordered but had not been received. R33 stated nursing staff told R33 on 4/8/24 that the supplies would arrive the following day and the wound vac would be reapplied. R33 stated this concerned R33 because the wound vac remained off longer than intended. R33's medical record contained the following information regarding R33's wound vac: ~Wound vac removed from 3/13/24-3/20/24 to assist with peri-wound healing. Daily dressing changes ordered. ~Wound vac to remain off one more week to aide in peri-wound healing. Wound vac to be reapplied on 3/27/24. ~R33 was seen on 3/27/24 by Wound Clinic Advance Practice Nurse Practitioner (WCAPNP)-U. A note indicated the wound vac was on hold for one more week because the facility did not have wound vac supplies. -R33 was seen again on 4/8/24 and were still were no wound vac supplies. The supplies were then ordered and the wound vac was reapplied on 4/10/24. On 5/6/24 at 11:12 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-E who indicated the supplies needed to reapply R33's wound vac were not ordered timely. LPN-E indicated the supplies were received on 4/10/24 and the wound vac was reapplied. RN-E indicated the former Director of Nursing (DON) was responsible for ordering the supplies. On 5/6/24 at 1:03 PM, Surveyor interviewed DON-B and Nursing Home Administrator (NHA)-A regarding R33's wound vac. NHA-A indicated the original order for wound vac supplies should have been placed by the previous DON who was no longer employed by the facility. NHA-A indicated there was a miscommunication after the previous DON left employment as well as a lack of communication regarding follow up to ensure the supply order was placed. DON-B stated DON-B has a note on DON-B's calendar to review orders to ensure they are submitted every Friday.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not provide adequate monitoring post fall for 1 resident (R) (R34) of 2 residents reviewed for falls. The facility did not complete neurological checks per their policy after R34's unwitnessed falls on 9/21/23 and 10/21/23. Findings include: The facility's Fall Management policy, dated July 2020, indicates: In the event a resident has a fall and it is determined that they hit their head, or it cannot be determined if they hit their head, such as an unwitnessed fall, the nurse initiates neurological checks (an assessment used to monitor and detect possibility of head injury), and documents the checks. The facility's Neuro Check Assessment Form, copyright 2023, indicates nurses should complete neurochecks every 15 minutes for the first hour following the fall, then every 30 minutes for an hour, every hour for 4 hours, every 4 hours for 24 hours and then once per shift until 72 hours post fall. Neurochecks should include the resident's vital signs, level of consciousness, movement in all four extremities, hand grasps, speech, pupil reaction, and bilateral pupil size. From 5/6/24 to 5/8/24 Surveyor reviewed R34's medical record. R34 was admitted to the facility on [DATE] with diagnoses including Parkinsonism, muscle wasting and atrophy, unspecified severe protein-calorie malnutrition, and altered mental status. R34's Minimum Data Set (MDS) assessment, dated 4/20/24, indicated R34 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated R34 had severely impaired cognition. A care plan, initiated on 9/21/23, indicated R34 was at high risk for falls related to confusion. R34 had an activated Power of Attorney for Healthcare (POAHC). Surveyor reviewed R34's fall on 9/21/23. A Fall Incident Report indicated R34 was found on the floor next to R34's bed. R34 stated R34 was trying to catapult R34's self under the wheelchair. A Neurological Flow Sheet indicated an initial neurocheck was completed as well as every 15 minutes for the first hour and every 30 minutes for the next hour. No additional neurochecks were completed. Surveyor reviewed R34's fall on 10/21/23. A Fall Incident Report indicated R34 was found on the floor of R34's room in a sitting position with R34's back to the wall. R34 stated R34 hit R34's head. Neurochecks were completed for twenty four hours post-fall. No additional neurochecks were completed. On 5/8/24 at 11:22 AM, Surveyor interviewed Director of Nursing (DON)-B who stated DON-B expects staff to follow the facility's policy for completion of neurochecks which DON-B confirmed should be every 15 minutes for the first hour, every 30 minutes for the next hour, every hour for 4 hours, and then every shift for 72 hours. DON-B verified neurochecks were not appropriately completed following R34's falls on 9/21/23 and 10/21/23.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility did not ensure respiratory equipment was routinely cleaned for 2 residents (R) (R145 and R156) of 2 sampled residents. Staff did not clean R145 and R156's continuous positive airway pressure (CPAP) equipment and did not change R145 and R156's oxygen tubing per the facility's policy. Findings include: The facility's CPAP-BiPAP (Bilevel Positive Airway Pressure) Use policy, dated October 2020, indicates: Residents using CPAP/BiPAP will require a physician order to include approved order setting, duration of use, use of humidifier, if necessary, and a supporting diagnosis .6) The CPAP/BiPAP mask, tubing, and humidifiers shall be cleaned weekly with soap and water and rinsed thoroughly, unless otherwise specified by the physician or respiratory therapist. 7) If a humidifier is in use, the water will be discarded and replaced daily with fresh distilled water. The facility's Liquid Oxygen Use policy, dated October 2020, indicates: 3) Cleaning the unit: a) Wipe down outside of the unit with a clean damp cloth, b) Discard and replace the oxygen mask or cannula weekly and as necessary per facility policy. 1. From 5/6/24 to 5/8/24, Surveyor reviewed R145's medical record. R145's latest admission to the facility was on 4/25/24. R145 had diagnoses including heart failure, morbid obesity with alveolar hypoventilation (a condition where the lungs do not get enough air which causes high levels of carbon dioxide in the blood and decreased oxygen), and obstructive sleep apnea. R145's Minimum Data Set (MDS) assessment, dated 1/6/24, contained a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R145 had intact cognition. R145 had a physician order to change R145's oxygen tubing every week on Friday night (NOC). R145's medical record did not contain an order or care plan for CPAP cleaning. R145's Treatment Administration Record (TAR) also did not contain an order for CPAP cleaning. On 5/6/24 at 12:12 PM, Surveyor observed R145 use 3 liters per minute (LPM) of oxygen via nasal cannula. Surveyor noted R145's oxygen tubing did not indicate when the tubing was last changed. On 5/6/24 at 12:13 PM, Surveyor interviewed R145 who stated staff had not cleaned R145's CPAP equipment. On 5/8/24 at 10:17 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-E who indicated R145 had an order to change R145's oxygen tubing weekly which was completed by NOC shift staff. LPN-E indicated R145's CPAP equipment should be rinsed daily. LPN-E indicated LPN-E was unsure the last time R145's CPAP was cleaned. LPN-E confirmed R145's medical record did not contain an order to clean R145's CPAP or oxygen equipment. Per LPN-E, orders should have been entered for CPAP and oxygen cleaning. LPN-E also indicated staff should label oxygen tubing when the tubing is changed. On 5/8/24 at 10:19 AM, LPN-F indicated CPAP and oxygen tubing change orders should be listed on a resident's TAR. LPN-F verified R145's TAR did not contain orders. On 5/8/24 at 10:25 AM, LPN-F verified R145's green oxygen extender tubing was dated 3/10/24 and R145's clear oxygen tubing did not contain a date. 2. From 5/6/24 to 5/8/24, Surveyor reviewed R156's medical record. R156 was admitted to the facility on [DATE] and had diagnoses including heart failure, chronic obstructive pulmonary disease, dependence on supplemental oxygen, and chronic respiratory failure with hypoxia. R156's MDS assessment, dated 4/26/24, contained a BIMS score of 13 out of 15 which indicated R156 had intact cognition. R156 had an order to change R156's oxygen tubing every Friday NOC. R156's medical record and did not contain an order or care plan intervention to clean R156's CPAP equipment. On 5/6/24 at 10:35 AM, Surveyor interviewed R156 who indicated R156's CPAP equipment was not cleaned since R156 was admitted to the facility. R156 stated R156 cleaned R156's CPAP equipment weekly at home. R156 stated R156 noticed the CPAP reservoir was cloudy approximately two to three nights ago. Surveyor did not observe cloudiness in the reservoir. R156 also indicated R156's oxygen tubing was not changed since admission. Surveyor noted R156's oxygen tubing did not indicate when it was last changed. R156 received 1 LPM of oxygen via nasal cannula. On 5/8/24 at 10:27 AM, Surveyor interviewed LPN-E and LPN-F who verified R156's oxygen tubing was not dated. LPN-E indicated R156's oxygen tubing would have been changed if R156 notified staff that the tubing was not changed for three weeks. On 5/8/24 at 10:29 AM, LPN-E stated R156's medical record contained an order for CPAP cleaning, however, the order was placed on 5/6/24 and revised on 5/7/24. LPN-E indicated a CPAP cleaning order should have been entered and care planned upon admission. On 5/8/24 at 10:31 AM, Surveyor interviewed LPN-F who verified R156's TAR and care plan did not contain an order to change/clean R156's oxygen tubing. LPN-F indicated the order should have been entered upon admission. On 5/8/24 at 11:00 AM, Surveyor interviewed Director of Nursing (DON)-B who verified R145 and R156's medical records did not contain orders for CPAP or oxygen tubing cleaning/changes. DON-B indicated R156's medical record contained an order to rinse R156's CPAP equipment weekly, however, the order was entered on 5/6/24 and revised on 5/7/24. DON-B indicated scheduled cleanings should have been care planned upon admission. DON-B stated residents' oxygen tubing/extenders should be labeled with the date they were last changed. DON-B also indicated CPAP equipment should be cleaned weekly and oxygen tubing should be changed weekly.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure ongoing communication and collaboration with the dialysis center for 1 resident (R) (R17) of 2 resident reviewed for dialysis services. R17 received peritoneal dialysis daily at the facility and had an order for daily weights. R17's daily weight was not obtained on 8 out of 38 days. In addition, R17's physician orders were not clarified and the physician was not notified of weight increases above the specified parameters. Findings include: The facility's Peritoneal Dialysis policy dated March 2023, indicates: .15. Before, during and after receiving peritoneal dialysis, facility staff must, based on the physician's orders and professional standards of practice, do the following: a. Obtain vital signs, weights, assess the resident's stability, level of consciousness, and comfort or distress; b. Monitor for post-dialysis complications and symptoms such as, but not limited to dizziness, nausea, fatigue, or hypotension; . On 5/8/24, Surveyor reviewed R17's medical record. R17 was admitted to the facility on [DATE] with diagnoses including end-stage renal disease (ESRD) requiring daily peritoneal dialysis, diabetes mellitus, obesity, and congestive heart failure. R17's Quarterly Minimum Data Set (MDS) assessment, dated 4/12/24, contained a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R17 had intact cognition. R17 had an order from Dialysis Medical Doctor (DMD)-N, dated 10/13/23, to call the dialysis center or on-call dialysis nurse if R17's blood pressure is less than 90 and symptomatic (lightheaded, dizziness) or greater than 190 and symptomatic (headache, blurred vision, nausea/vomiting), pulse rate is less than 50 or greater than 110, temperature is greater than 100 degrees, dry weight is greater than 89 kg (kilograms), or weight is 5 pounds less than or greater than dry weight. R17 had an order from MD-O, dated 2/11/24, for daily weights and to obtain a dry weight after discontinuing dialysis (ESD 89 kg). The order indicated to call the clinic if R17's weight is more than 5 pounds below or above the estimated dry weight (EDW). Surveyor reviewed R17's weight documentation and noted R17's weight wasn't obtained on 8 (5/6/24, 5/4/24, 4/30/24, 4/27/24, 4/22/24, 4/14/24, 4/8/24, and 4/1/24) of 38 days. Surveyor reviewed R17's weight parameters as prescribed above and noted R17's dry weight was based on 89 kg which equaled 195.8 lbs. Surveyor noted R17's weights measured between 200 and 213.5 pounds between 3/31/24 and 5/7/24. R17's medical record did not indicate the physician or dialysis center was notified that R17's weight was above the specified parameters. A note written by Registered Dietitian (RD)-P, dated 4/12/24, indicated: R17's weight was 213.5 pounds on 4/12/24 and body mass index (BMI) was 33.9 (obesity). R17 had a significant weight change in 30 and 90 days: 3/12/24: 197 pounds (gain of 16.5 pounds, 8.4%); 1/12/24: 184.5 pounds (gain of 29 pounds, 15.7%). 10/11/23: 196 pounds (gain of 17.5 pounds, 8.9%) not significant. R17's Ideal body weight (IBW) was 132.5 pounds +/- 10%. On 5/8/24 at 12:01 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated R17 can connect and disconnect R17's peritoneal dialysis bags every morning and night. DON- B stated staff empty the bags and record the numbers from the peritoneal machine daily and send them to the dialysis clinic weekly. DON-B indicated R17 is weighed daily and that determines the bags and dialysis settings used for the day. When Surveyor asked about R17's missing weights and weight gains, DON-B found a message to a Nurse Practitioner (NP) regarding a 4.5 pound weight gain. DON-B indicated there was no other documented communication to the dialysis clinic. On 5/8/24 at 1:35 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-E who indicated nurses are trained in peritoneal dialysis and obtain daily weights. LPN-E stated sometimes R17 likes to stay in bed until lunch and will let staff know when R17 is ready. LPN-E indicated weights are written on a renal document. If the unit flow is over, staff contact the dialysis clinic. LPN-E stated the nurses were not sure what EDW meant and just discussed it. LPN-E stated LPN-E did not know the facility's dietitian and had no communication regarding weight gain. LPN-E indicated staff might have forgotten to document R17's missing weights. LPN-E indicated R17 wakes up late, weighs R17's self, and may forget to communicate R17's weight to staff. LPN-E verified R17's weight is required to determine the dialysis machine settings each night. On 5/8/24 at 2:06 PM, Surveyor interviewed DON-B who verified R17 had missing weights. DON-B stated DON-B will work on improving the dialysis program and obtain clarification on the MD order to use the EDW for daily weights. DON-B indicated DON-B called the dialysis clinic and confirmed there was no documented communication regarding R17's increased weight. The dialysis clinic recommended the facility develop a log to be kept by R17's dialysis machine so R17 can document R17's daily weights.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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Based on staff interview and record review, the facility did not ensure a physician order was transcribed for 1 resident (R) (R4) of 5 sampled residents. R4's hospital discharge paperwork, dated 4/4/24, contained an order for emergency administration of diazepam (an anxiolytic and sedative medication) during a seizure lasting longer than three minutes. The order was not transcribed in R4's medical record. Findings include: The facility's Physician Orders policy, with a revision date of March 2020, indicates: Physician orders are obtained to provide clear direction regarding the care of the resident .Orders given by a physician or state permitted health care professional must be accepted by a licensed nurse and documented in the resident's medical record .Transcribing a written/faxed order .Once the order is verified, the receiving licensed nurse documents the word noted next to the written order along with his or her signature with title and date .after noting an order, the receiving licensed nurse enters the order into the electronic medical record and ensures it is active in the electronic administration record . On 5/6/24, Surveyor reviewed R4's medical record. R4 had an activated Power of Attorney for Healthcare (POAHC) and diagnoses including quadriplegia and generalized idiopathic epilepsy and epileptic syndromes. R4's Minimum Data Set (MDS) assessment, dated 4/14/24, indicated R4 had a Brief Interview for Mental Status (BIMS) score of 0 out of 10 which indicated R4 had severe cognitive impairment. R4's medical record indicated R4 had a seizure lasting longer than three minutes on 3/31/24. R4 was sent to the emergency room (ER) and admitted due to an infection. R4's hospital discharge paperwork, dated 4/4/24, contained an order for diazepam 20 mg (milligram) rectal gel suppository to insert rectally as needed for seizures lasting longer than three minutes. The pharmacy delivered the order on 4/4/24 which was signed by nursing staff. The diazepam order was not transcribed in R4's medical record and was not contained on R4's medication administration record (MAR) or treatment administration record (TAR). On 5/6/24 at 1:25 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated R4 had an order for diazepam and confirmed the medication was delivered by the pharmacy. When Surveyor asked if the diazepam order was transcribed, DON-B reviewed R4's medical record and confirmed the order was not transcribed in R4's medical record which meant if R4 had a seizure lasting longer than three minutes, the medication would not be administered.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure medication regimens were reviewed monthly and pharmacy recommendations were reviewed and acted upon by a physician for 1 resident (R) (R32) of 5 sampled residents. A monthly medication regimen review (MRR) was not completed for R32 in September 2023, October 2023, November 2023, December 2023, January 2024, and March 2024. In addition, pharmacy recommendations for April 2024 were not acted upon or reviewed by R32's physician. Findings include: From 5/6/24 to 5/8/24, Surveyor reviewed R32's medical record. R32 was admitted to the facility on [DATE] with diagnoses including neoplasm of uncertain behavior of brain, moderate persistent asthma with (acute) exacerbation, acute respiratory failure with hypoxia, and acute on chronic diastolic (congestive) heart failure. R32's Minimum Data Set (MDS) assessment, dated 4/7/24, contained a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R32 had intact cognition. R32 had an activated Power of Attorney for Healthcare (POAHC). Surveyor reviewed R32's medications and noted on 4/11/24, R32 was prescribed 100 mg (milligrams) of doxycycline hyclate (an antibiotic) two times daily for three months for hidradenitis suppurativa (a condition that causes small, painful lumps to form under the skin). On 4/12/24, the order was changed to 100 mg doxycycline monohydrate two times daily for eighty eight days. A Pharmacy Consultant Report, dated 4/14/24, indicated R32 was prescribed doxycycline and Milk of Magnesia which may impact absorption and effectiveness. The pharmacy recommended the facility obtain an order to administer doxycycline at least two hours before or after Milk of Magnesia with plenty of water. It was also recommended that R32 remain upright for at least 10 minutes after doxycycline administration. On 5/8/24, the facility provided Surveyor an updated Pharmacy Consultation Report from 4/14/24 signed by Director of Nursing (DON)-B on 5/8/24. On the report, DON-B indicated R4 did not use Milk of Magnesia in the last 90 days and it would be discontinued. The report also indicated the additional recommendation would be added to R32's doxycycline order. On 5/8/24 at 1:40 PM, Surveyor interviewed DON-B who confirmed the only documentation for R32's monthly pharmacy MRR was the 4/14/24 recommendation report and a Consultation Report, dated 2/12/24-2/13/24, that listed residents, including R32, who were reviewed with no recommendations for February 2024. DON-B verified R32's 4/14/24 pharmacy recommendations were not acted on until 5/8/24 and did not provide evidence that the recommendations were reviewed by R32's physician.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility did not ensure 2 residents (R) (R15 and R4) of 2 residents were provided services to help prevent the transmission of infection. R15 had an order for droplet precautions pending further testing related to respiratory concerns. On 5/8/24, Surveyor observed Certified Nursing Assistant (CNA)-I assist R15's roommate (R4) with a room tray. CNA-I did not wear personal protective equipment (PPE) in the room. During an observation of wound care on 5/8/24, Registered Nurse (RN)-H reached beneath RN-H's gown to obtain a flashlight and scissors from RN-H's pocket. Without disinfecting the scissors, RN-H used the scissors to cut a dressing used to pack R4's wound. Findings include: The Centers for Disease Control and Prevention (CDC) guideline for PPE indicate: PPE, e.g., gloves, gowns, face masks, respirators, goggles and face shields, can be effective barriers to transmission of infections . The CDC guidelines at https://www.cdc.gov/infectioncontrol/guidelines indicate: Maintain separation between clean and soiled equipment to prevent cross contamination. Remove PPE before entering any non-clinical areas including restrooms, breakrooms, and administrative areas. PPE must remain in place and be worn correctly for the duration of work in potentially contaminated areas. PPE should not be adjusted during patient care. The facility's Dressing Changes policy, with a revision date of March 2020, indicates: To prevent wound contamination and promote healing . 1. On 5/8/24, Surveyor reviewed R15's medical record. R15 was admitted to the facility on [DATE] with a primary diagnosis of progressive neurological conditions. R15's Quarterly Minimum Data Set (MDS) assessment, dated 3/2/24, indicated R15 was rarely/never understood. R15 had a legal guardian. R15 had orders, dated 5/7/24, for isolation/droplet precautions, a chest X-ray, a viral panel if negative COVID-19 rapid test, and vital signs every shift for 3 days. On 5/8/24 at 8:15 AM, Surveyor observed CNA-I in R15 and R4's room. CNA-I sat between R15 and R4 and assisted R4 with breakfast. Surveyor observed an isolation cart outside the door and a droplet precautions sign that was not there on 5/7/24. From the doorway, Surveyor asked which resident was on precautions. CNA-I stated, No one. When Surveyor asked if PPE was required due to the PPE cart and sign outside the door, CNA-I replied, I am new, not sure. On 5/8/24 at 8:19 AM, Surveyor asked staff in the hallway about the PPE cart and droplet precautions sign outside R15 and R4's door. A CNA stated they learned in shift report that R15 was on isolation because R15 was tested for respiratory concerns. On 5/8/24 at 8:44 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-J regarding R15's precautions. LPN-J stated R4 was on precautions for chronic wounds, but R15 was not on precautions. LPN-J confirmed R15 was tested for respiratory concerns which included a viral respiratory panel and a chest X-ray and stated R15 had a negative rapid COVID-19 swab. When Surveyor asked about the policy for suspected respiratory concerns, LPN-J stated, You should wear mask and gloves and can gown as well. When Surveyor asked specifically about droplet precautions, LPN-J confirmed a gown, mask, and gloves should be worn when entering R15's room. On 5/8/24 at 8:50 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated R4 was on enhanced barrier precautions (EBP) related to R4's wound and stated R15 had a feeding tube. When Surveyor asked DON-B about the PPE cart and droplet precautions sign outside R15 and R4's room, DON-B indicated R15 was not coughing so there was no need for droplet precautions. On 5/8/24 at 10:08 AM, Surveyor interviewed DON-B regarding R15's physician-ordered droplet precautions as of 5/7/24 to which DON-B stated, Not aware of that. 2. From 5/7/24 to 5/8/24, Surveyor reviewed R4's medical record. R4 was readmitted to the facility on [DATE] following a hospitalization. R4 had diagnoses including pressure ulcer of sacral region stage 4, quadriplegia unspecified, unspecified severe protein-calorie malnutrition, and osteomyelitis (bone infection) unspecified sites. R4's Quarterly Minimum Data Set (MDS) assessment, dated 4/14/24, stated R4's Brief Interview for Mental Status (BIMS) assessment indicated R4 was rarely/never understood. R4 had a legal guardian. On 5/8/24 11:13 AM, Surveyor observed RN-H complete wound care for R4 with CNA-K's assistance. During the observation, Surveyor observed RN-H reach beneath RN-H's gown twice to retrieve a flashlight and scissors from RN-H's pocket. Surveyor noted RN-H did not disinfect the scissors prior to cutting a Hydrofera dressing that was placed inside R4's wound. After wound care was completed, CNA-K removed PPE except for CNA-K's face mask which CNA-K wore down the hallway and into another resident's room. RN-H removed PPE except RN-H's face mask on the far side of R4's room and walked across and out of the room. RN-H did not remove RN-H's face mask and replace it with a clean mask. On 5/8/24 at 11:30 AM Surveyor interviewed RN-H who indicated RN-H disinfected the scissors prior to placing them in RN-H's pocket. When Surveyor indicated the scissors were in contact with RN-H's pocket and should be disinfected prior to use, RN-H indicated RN-H could not find R4's scissors in the treatment bag during wound care which is why RN-H used RN-H's personal scissors.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure influenza B and pneumococcal vaccinations were reviewed, offered, and administered for 3 residents (R) (R8, R2, and R4) of 5 sampled residents. The facility did not review R8's vaccination history or offer R8 the PCV20 (Prevnar 20®) and influenza B vaccines. The facility did not review R2's vaccination history or offer R2 the Prevnar 20® and influenza B vaccines. The facility did not review R4's vaccination history or offer R4 the Prevnar 20® vaccine. Findings include: Abbreviations (www.cdc.gov): PCV13: 13-valent pneumococcal conjugate vaccine (Prevnar13®) 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 PPSV23, the CDC recommends: Give 1 dose of PCV15 or PCV20. The PCV20 dose should be administered at least 1 year after the most recent PPSV23 vaccination. Regardless of if PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. For those who have received PCV13 and 1 dose of PPSV23, the CDC recommends you give 1 dose of PCV20 at least 5 years after the last pneumococcal vaccine. For adults 65 years or older who have received PCV13, give 1 dose of PCV20 or PPSV23 at least 1 year after PCV13. Regardless of vaccine used, their vaccines are then complete. The facility's Pneumococcal Vaccine policy, dated September 2022, indicates: .1. All residents of our facility should receive the pneumococcal vaccine if they are [AGE] years of age or older; or younger than 65 years with underlying conditions that are associated with increased susceptibility to infection or increased risk for serious disease and its complications .3. Residents, staff, and volunteers may refuse vaccination. Vaccination refusal and reasons why (e.g., allergic, contraindicated, did not want vaccine, etc.) should be documented by the facility. The facility's Seasonal Influenza Vaccine policy, dated September of 2022, indicates: The CDC guidelines and recommendations are followed for the prevention and control of seasonal influenza. Influenza is a vaccine-preventable disease and high-risk target groups for vaccination include residents of nursing facilities .as well as those persons who can transmit influenza to those at high risk .2. Influenza vaccines shall be offered to all residents of the facility unless medically contraindicated. 3. The current CDC Influenza Vaccine Information Statement will be provided to the resident and/or legal representative to educate on the benefits and risks of receiving the influenza B vaccine. 1. R8 was admitted to the facility on [DATE]. R8 received a PPSV23 vaccine on 7/14/10. R8's medical record did not indicate R8 was offered or administered the PCV20 or influenza B vaccines. 2. R2 was admitted to the facility on [DATE]. R2 received a PPSV23 vaccine on 10/20/14 and refused a vaccine on 10/29/22. R2's medical record did not indicate R2 was offered or administered the PCV20 or influenza B vaccines. 3. R4 was admitted to the facility on [DATE]. R4 received a PPSV23 vaccine on 10/8/07 and a PCV13 vaccine on 11/25/15. R4's medical record did not indicate R4 was offered or administered the PCV20 vaccine. On 5/7/24 at 1:45 PM, Director of Nursing (DON)-B indicated the facility was not up to date with influenza B and pneumococcal vaccinations. DON-B indicated the facility was implementing their policies and will review vaccines annually. On 5/8/24 at 8:10 AM, Regional Consultant (RC)-M provided vaccination documents and indicated that facility did not have the required documents for R8, R2, and R4. RC-M stated the facility started a Process Improvement Plan (PIP) for resident vaccines and provided a copy to Surveyor which indicated: Opportunity for improvement you have identified: resident vaccines not up to date, missing consents/declinations/education for past vaccines, resident vaccine binder missing .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0887 (Tag F0887)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure medical records contained documentation related to COVID-19 immunization for 3 residents (R) (R19, R2, and R7) of 5 sampled residents. In addition, the facility did not implement a COVID-19 immunization program for staff. R19, R2, and R7's medical records did not include documentation that indicated the facility offered or administered COVID-19 immunizations. The facility did not have proof of a COVID-19 immunization program for staff. Findings include: The facility's COVID-19 Vaccination policy, effective January 2024, indicates: It is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complications from COVID-19 (SARS-CoV-2) by educating and offering our residents and staff the COVID-19 vaccine .COVID-19 vaccinations will be offered to residents when supplies are available, as per Centers for Disease Control and Prevention (CDC) and/or Food and Drug Administration (FDA) guidelines unless such immunization is medically contraindicated, the individual has already been immunized during this time period or refuses to receive the vaccine .15. The facility will educate and offer the COVID-19 vaccine to residents, resident representatives, and staff and maintain documentation of such. 16. The facility will maintain documentation related to staff COVID-19 vaccination and include at a minimum: a. Education to the staff regarding the risks, benefits, and potential side effects of the COVID-19 vaccine; b. The offering of the COVID-19 vaccine or information on obtaining the COVID-19 vaccine; c. The COVID-19 vaccination status of staff and related information as indicated by the NHSN (National Healthcare Safety Network.) . 1. R19 was admitted to the facility on [DATE]. R19's medical record did not indicate R19 was offered, declined, or administered a COVID-19 vaccine. 2. R2 was admitted to the facility on [DATE]. R2's medical record did not indicate R2 was offered, declined, or administered a COVID-19 vaccine. 3. R7 was admitted to the facility on [DATE]. R7's medical record did not indicate R7 was offered, declined, or administered a COVID-19 vaccine. On 5/7/24 at 8:36 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-E who indicated the facility did not provide staff information on COVID-19 or offered COVID-19 immunizations for staff. On 5/7/24 at 1:45 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated COVID-19 vaccine training for staff and residents was not in place yet. DON-B indicated the facility's policies will be reviewed annually moving forward. On 5/8/24 at 8:10 AM, Regional Consultant (RC)-M provided Surveyor with vaccination documents that indicated the facility did not have the required documents for R19, R2, and R7. RC-M indicated the facility started a Process Improvement Plan (PIP) for resident vaccines and provided Surveyor a copy which indicated: Opportunity for improvement you have identified: resident vaccines not up to date, missing consents/declinations/education for past vaccines, resident vaccine binder missing .

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0801 (Tag F0801)

Could have caused harm · This affected most or all residents

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Based on staff interview and record review, the facility did not ensure the individual designated as the food and nutritional services director met the minimum qualifications for the role. This had the potential to affect 47 of 48 residents residing in the facility. Dietary Manager (DM)-G did not complete an approved dietary manager or food service manager certification course or other related education. Findings include: On 5/6/24 at 8:40 AM, Surveyor interviewed DM-G who stated DM-G was hired as a Dietary Aide 3 years ago and was promoted to Dietary Manager a little over a month ago. DM-G did not indicate DM-G had any prior experience or training. DM-G stated DM-G was working with Nursing Home Administrator (NHA)-A and Regional Dietitian (RD)-P to get certified but was not enrolled and had not started a certification program. DM-G stated RD-P was in the building monthly and was available via email or phone. On 5/6/24 at 3:05 PM, Surveyor interviewed NHA-A who stated NHA-A was aware DM-G was not certified or enrolled in a certified training program. NHA-A stated RD-P and NHA-A have been working to get training set up for DM-G. On 5/7/24 at 1:38 PM, Surveyor conducted a follow-up interview with DM-G who stated DM-G spoke with RD-P and NHA-A and was enrolled in training to be a certified Dietary Manager as of 5/6/24.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

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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 47 of 48 residents residing in the facility. Staff did not monitor or document food cooling temperatures. The handwashing sink did not reach the required minimum temperature for proper hand hygiene. A can opener was not properly cleaned. Staff left visibly soiled oven mitts on top of condiment containers. Chemicals used for cleaning were stored by food containers and near food preparation areas. On two occasions, three resident room trays were delivered to the floor uncovered and on top of the food cart. Staff did not test or document parts per million (PPM) of the quaternary sanitizing solution per manufacturer's instructions. Seven food items were not dated when opened, not discarded when beyond the use-by/expiration date, and/or not stored appropriately. Findings include: The facility's Storage, Prepare, Distribute and Serve Food policy, dated April 2020, indicates the facility follows the Federal Food and Drug Administration (FDA) Food Code. 1. Cooling Temperatures The 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 57° Celsius (C) (135° Fahrenheit (F)) to 21° C (70° F); and (2) Within a total of 6 hours from 57° C (135° F) to 5° C (41° F) or less. (B) Time/temperature control for safety food shall be cooled within 4 hours to 5° C (41° F) or less. The FDA Food Code 2022 documents at section 3-501.15 Cooling Methods: (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under § 3-501.14 by using one or more of the following methods based on the type of food being cooled: (1) Placing the food in shallow pans; (2) Separating the food into smaller or thinner portions; (3) Using rapid cooling equipment; (4) Stirring the food in a container placed in an ice water bath; (5) Using containers that facilitate heat transfer; (6) Adding ice as an ingredient; or (7) Other effective methods. On 5/6/24 at 12:45 PM, Surveyor interviewed Dietary Aide (DA)-S who stated leftover food is placed in the refrigerator. DA-S was unsure how leftover food is cooled. On 5/7/24 at 1:38 PM, Surveyor interviewed Dietary Manager (DM)-G who stated staff place leftover food in smaller containers on the counter and put the containers in the cooler when the contents reach the appropriate temperature. DM-G confirmed the facility does not have a process to monitor cooling. 2. Handwashing Sink The FDA Food Code 2022 documents at section 5-202.12 Handwashing Sink, Installation (A): A handwashing sink shall be equipped to provide water at a temperature of at least 29.4 degrees C (85 degrees F) through a mixing valve or combination faucet. On 5/6/24 at 8:40 AM, Surveyor entered the kitchen for an initial tour. Upon entering the kitchen, Surveyor used the handwashing sink and noted the water was cool/room temperature after 20 seconds. On 5/6/24 at 11:33 AM, Surveyor again used the handwashing sink for 20 seconds and noted the water did not rise above room temperature. A sign posted near the sink indicated the water should reach at least 100 degrees for appropriate hand hygiene. On 5/7/24 at 1:38 PM, Surveyor interviewed DM-G who checked the water temperature in the handwashing sink. A thermometer indicated a temperature of 77 degrees after the hot water ran for 25 seconds. DM-G agreed the water temperature did not reach the recommended temperature. 3. Can Opener The FDA Food Code 2022 documents at 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils: (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. During an initial tour of the kitchen on 5/6/24 at 8:40 AM, Surveyor observed a can opener that contained dried debris and food residue on the blade. On 5/7/24 at 1:38 PM, Surveyor interviewed DM-G who indicated the can opener was wiped down and cleaned monthly by staff. DM-G verified the blade of the can opener contained debris and acknowledged it could contribute to cross contamination. 4. Soiled Oven Mitts The FDA Food Code documents at 4-803.11 Storage of Soiled Linens: Soiled linens shall be kept in clean, nonabsorbent receptacles or clean, washable laundry bags and stored and transported to prevent contamination of food, clean equipment, clean utensils, and single-service and single-use articles. During the initial kitchen tour and follow up visits to the kitchen on 5/6/24 and 5/7/24, Surveyor observed two oven mitts on top of condiment containers next to the ovens. The mitts were discolored and stained and contained what appeared to be food debris. Surveyor observed DA-S and DM-G use the mitts on several occasions to touch surfaces, including oven doors, pots, and pans, and then place the mitts on top of the condiment containers. On 5/7/24 at 1:38 PM, Surveyor interviewed DM-G who removed the oven mitts and acknowledged placing soiled oven mitts on top of food containers could lead to cross contamination. 5. Chemical Storage The facility's Chemical Use and Storage policy, dated April 2020, indicates consideration is given to the proper handling and storage of chemicals to minimize the risk of food contamination and injury .Chemicals are stored in a dry area away from food storage and preparation areas, food contact surfaces, and other chemicals that react with them. During an initial kitchen tour on 5/6/24 at 8:40 AM, Surveyor observed several cleaning chemicals and wire brushes stored on the bottom shelf of a rolling cart next to the ovens. The shelf contained wire cleaning brushes with dirt-like debris and products including a stainless steel cleaner, ZymeWorx (a bienzymatic floor cleaner), CitraWorx (an all-purpose cleaner), bleach, and [NAME] Gone (an adhesive remover). On 5/7/24 at 1:38 PM, Surveyor interviewed DM-G who showed Surveyor the chemical storage and cleaning supply closet. DM-G stated chemicals are usually stored in the closet, but more frequently used chemicals are kept on the cart for ease of use. DM-G acknowledged chemicals should be stored in the cleaning closet for safety. 6. Uncovered Transported Food The facility's Storage, Prepare, Distribute and Serve Food policy, dated April 2020, indicates it is the policy of the facility that all food/beverages must be covered when leaving the kitchen. On 5/6/24 at 11:33 AM, Surveyor observed room tray service and noted three trays on top of a room tray cart contained bowls of watermelon and strawberries that left the kitchen uncovered and were transported to residents' rooms. On 5/7/24 at 11:08 AM, Surveyor observed room tray service and noted two trays on top of a room tray cart had plates of cake that left the kitchen uncovered and were transported to residents' rooms. On 5/7/24 at 1:38 PM, Surveyor interviewed DM-G who acknowledged food items should be covered when they leave the kitchen. 7. Quaternary Sanitizing Solution TMA Quaternary Sanitizer directions for use indicate: Allow sanitized surfaces to adequately drain and air dry before contact with food, so that little or no residue remains. Do not rinse. For articles too large for immersing, apply a solution of 1-2.67 ounces per 4 gallons of water (150-400 ppm active) to sanitize hard, non-porous food contact surfaces with a brush, cloth, mop, sponge, auto scrubber, mechanical spray device, hand pump, coarse pump or trigger spray device. For spray applications, spray 6-8 inches from the surface .Surfaces must remain wet for at least 5 minutes. Allow sanitized surfaces to adequately drain and then air dry before contact with food, so that little or no residue remains. Do not rinse. Prepare a fresh solution daily or when visibly dirty. For mechanical application, used solution must not be reused for sanitizing applications but may be used for other purposes such as cleaning. During an initial kitchen tour on 5/6/24 at 8:40 AM, Surveyor interviewed DM-G who stated the facility does not have a process to ensure proper chemical sanitization is monitored for the 3-compartment sink and the sanitizing buckets. DM-G stated the facility does not use test strips to test ppm of the sanitizing solution. On 5/6/24 at 12:25 PM, Surveyor observed DA-T fill a sanitizing bucket. DA-T did not test the ppm of the sanitizing solution. Surveyor interviewed DA-T who stated DA-T did not receive education or training on chemical sanitization. DA-T stated DA-T fills sanitizing buckets with chemicals and water in a ratio that DA-T feels is appropriate. 8. Food Labeling/Storage The FDA 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) and (F) of this section, refrigerated, ready-to-eat, time/temperature control for food safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5º C (41º F) or less for a maximum of 7 days. The day of preparation shall be counted as day 1. The FDA Food Code 2022 documents at 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition (A): A food specified in 3-501.17 (A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17 (A), except time that the product is frozen; (2) Is in a container or package that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3-501.17 (A). During an initial kitchen tour on 5/6/24 at 8:40 AM, Surveyor and DM-G observed the following: -Three unlabeled, undated bulk packages of Cheerios -Banana cake dated 5/2/24 with a discard date of 5/5/24 -An open gallon of milk with an expiration date of 4/29/24. -An open and undated Thick n' Easy Apple Juice with label instructions to discard within 10 days of opening. -An open Thick n' Easy thickened lemon water, dated 3/28/24, with label instructions to discard within 10 days of opening. -An open Thick n' Easy Apple Juice, dated 3/15/24, with label instructions to discard within 10 days of opening. -Lemon juice on a shelf above the stove, dated 5/4 (and observed again on 5/7) with label instructions to refrigerate after opening. DM-G immediately discarded the items.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0882 (Tag F0882)

Could have caused harm · This affected most or all residents

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Based on staff interview and record review, the facility did not ensure a staff person designated as the Infection Preventionist (IP) completed specialized training in infection prevention and control. This practice had the potential to affect all 48 residents residing in the facility. Director of Nursing (DON)-B was the facility's designated IP. DON-B did not complete specialized training for infection prevention and control. Findings include: On 5/7/24 at 1:20 PM, Surveyor interviewed DON-B who was the facility's designated IP. When Surveyor asked if DON-B completed specialized infection prevention and control training as required by the Centers for Medicare & Medicaid Services (CMS), DON-B stated DON-B completed the Centers for Disease Control and Prevention (CDC) training modules but did not pass the certification test and could not retake the test until 2025. DON-B stated the facility hired an Assistant Director of Nursing (ADON) who would eventually become the IP, however, the ADON had not started the position yet. On 5/13/24 at 1:28 PM, Regional Consultant (RC)-M provided an email from DON-B, dated 5/13/24 at 1:15 PM, that indicated DON-B completed the CDC training modules and received a certificate for each module after completion but did not pass the final exam. DON-B stated DON-B did not realize there was a timeframe (30 days) to complete a second attempt and missed the deadline. DON-B stated DON-B was informed DON-B could not attempt to take the final test again until 2025.

Apr 2024 1 deficiency 1 IJ

CRITICAL (J) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Deficiency F0805 (Tag F0805)

Someone could have died · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure food was prepared and served in a form designed to meet individual needs for 1 resident (R) (R1) of 4 residents who had an order for a mechanically-altered diet. R1 was admitted to the facility on [DATE] following a hospitalization. R1's hospital discharge orders indicated R1 should receive a pureed diet, however, staff transcribed R1's diet order as mechanical soft with nectar-thickened liquids. On 3/13/24, R1 received the wrong meal tray and was served food that was not in accordance with R1's diet order. R1 aspirated, required hospitalization, and passed away on 3/23/24 from respiratory failure secondary to aspiration pneumonia. The facility's failure to prepare and serve food in a form to meet a resident's needs created a finding of Immediate Jeopardy that began on 3/13/24. The State Agency (SA) notified Nursing Home Administrator (NHA)-A of the Immediate Jeopardy on 4/2/24 at 3:34 PM. The Immediate Jeopardy was removed and corrected on 3/17/24. Findings include: As of October 2021, the Academy of Nutrition and Dietetics announced International Dysphagia Diet Standardization Initiative (IDDSI) is the only professionally recognized standard of care for texture modified diets in the Nutrition Care Manual of the Academy of Nutrition & Dietetics for the United States. The IDDSI framework identifies five levels for foods: 7. Regular, easy to chew; 6. Soft and bite-sized (most similar to mechanical soft); 5. Minced and moist; 4. Pureed; and 3. Liquidized. The facility's Consistency of Modified Foods policy, revised January 2021, indicates: Pureed foods are pudding-like or have a consistency similar to mashed potatoes with a homogenous consistency, without coarse textures . The facility's Physician Orders policy, revised March 2020, indicates: When receiving a written/faxed order .After noting an order, the receiving licensed nurse enters the order into the electronic medical record (EMR) and ensures it is active in the electronic administration record as appropriate. On 4/2/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including dementia, Down syndrome, anxiety, and dysphagia (difficulty swallowing). R1's Minimum Data Set (MDS) assessment, dated 3/14/24, contained a Brief Interview for Mental Status (BIMS) score of 99 which indicated R1 was cognitively impaired. R1's guardianship was active upon admission. On 4/2/24, Surveyor reviewed an investigation, dated 3/17/24. The investigation indicated R1 was given a regular diet instead of a pureed diet on 3/13/24 and had an episode of coughing and emesis (vomiting). R1 was hospitalized the following morning and diagnosed with aspiration pneumonia. The investigation indicated an incorrect diet was entered in R1's medical record upon admission. Surveyor noted R1's hospital discharge paperwork, dated 3/10/24, stated Dysphagia I Pureed diet, however, R1's medical record contained a diet order, dated 3/10/24, that stated Regular diet, mechanical soft texture, nectar thickened liquid consistency. R1's baseline care plan indicated R1 had a regular, mechanical soft diet with nectar-thickened liquids and ate in the dining room. A nursing progress note, dated 3/13/24, indicated: (Licensed Practical Nurse (LPN)-E) was informed by (Certified Nursing Assistant (CNA)-G) that (R1) was given the wrong tray in the dining room. (R1) coughed and vomited. (LPN-E) called the Nurse Practitioner (NP) who gave an order for a stat (immediate) chest X-ray one time only for suspected aspiration. On 4/2/24 at 9:40 AM, Surveyor interviewed NP-F who verified an on-call NP ordered an X-ray on 3/14/24 and instructed staff to send R1 to the hospital. NP-F reviewed R1's hospital record and stated R1 received intravenous (IV) antibiotics for aspiration pneumonia. NP-F confirmed R1 passed away at the hospital on 3/23/24 due to respiratory failure secondary to aspiration pneumonia. On 4/2/24 at 10:14 AM, Surveyor interviewed LPN-E who verified LPN-E took verbal report via telephone for R1's admission. LPN-E stated LPN-E was made aware of R1's pureed diet order and completed a dietary communication form that indicated R1 should receive a pureed diet. LPN-E stated on LPN-E's next shift on 3/13/24, CNA-G told LPN-E that R1 was coughing and spitting out R1's dinner. LPN-E immediately assessed R1 and notified the on-call NP. On 4/2/24 at 10:19 AM, Surveyor interviewed Dietary Manager (DM)-H who verified R1's dietary slip stated mechanical soft. DM-H stated R1 was served a bean and meat burrito, not cut up because the tortilla was soft enough, along with refried beans and banana crumble with no topping. On 4/2/24 at 11:10 AM, Surveyor interviewed Registered Nurse (RN)-D who verified RN-D entered a mechanical soft diet order in R1's medical record. RN-D could not recall where RN-D got the order and was unsure if a second check was completed for R1's admission orders. RN-D could not recall if RN-D placed R1's admission orders on the nursing station desk or in the basket designated for orders needing a second check. On 4/2/24 at 12:42 PM, Surveyor interviewed Chief Nursing Officer (CNO)-C who verified the facility was unable to confirm if a second check was completed for R1's admission orders, but confirmed all orders should be verified by a second licensed nurse. On 4/2/24, Surveyor reviewed a written and signed statement from [NAME] (CK)-I that indicated CK-I provided R1 with a dinner tray on 3/13/24. CK-I stated R1's dietary card stated mechanical soft and R1 was served a mechanical soft tray. On 4/2/24, Surveyor reviewed a written and signed statement from CNA-G, dated 3/17/24, that stated R1 was seen spitting up R1's food and coughing. CNA-G immediately notified LPN-E. CNA-G indicated R1 had not received a pureed diet since R1 was admitted to the facility. The failure to prepare and serve a diet which met R1's needs led to serious harm for R1 which created a finding of Immediate Jeopardy. The facility removed and corrected the jeopardy on 3/17/24 when it completed the following: 1. Reviewed residents' diet orders for accuracy. 2. Educated all nursing, dietary, and CNA staff. 3. Initiated daily audits to ensure diet accuracy.

Mar 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not provide treatment and care in accordance with professional standards of practice for 1 Resident (R) (R1) of 3 sampled residents. R1 received two different narcotic pain medications together multiple times between 1/13/24 and 1/22/24 which affected R1's mentation. Findings include: The facility's Pain Management policy, with a revision date of July 2020, indicates: .Guiding Principles .4. When medication is indicated, the goal should be to provide satisfactory pain relief by using the lowest possible dose of a medication with the fewest adverse effects . On 3/11/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including fracture of right humerus (bone in upper arm), wedge compression fracture of unspecified vertebra (bone in spine) and osteoarthritis (a type of painful joint disease that results from breakdown of joint cartilage and underlying bone). R1's Minimum Data Set (MDS) assessment, dated 3/4/24, contained a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R1 had little cognitive impairment. R1's medical record indicated R1 was responsible for R1's healthcare decisions. R1 was discharged to another skilled nursing facility on 3/5/24. R1's medical record contained the following physician orders: ~ Tylenol 8 Hour Arthritis Pain Oral Tablet Extended Release 650 mg (milligrams) (used for mild to moderate pain) Give 1 tablet by mouth three times a day for pain for 10 Days (Start Date 1/10/24 - End Date 1/20/24) ~ Hydrocodone-Acetaminophen (generic name for Vicodin) Oral Tablet 5-325 mg (narcotic medication used for moderate to severe pain) Give 1 tablet by mouth every 6 hours as needed (PRN) for pain (Start Date 1/7/24 - Discontinued 1/22/24) ~ Tramadol HCl (hydrochloride) Oral Tablet 50 mg (narcotic medication used for moderate to severe pain) Give 1 tablet by mouth every 4 hours as needed for pain (Start Date 1/7/24 - Discontinued 1/22/24) ~ Hydrocodone-Acetaminophen Oral Tablet 5-325 mg Give 1 tablet by mouth every 6 hours as needed for pain DO NOT GIVE WITHIN 4 HOURS OF TRAMADOL (Start Date 1/22/24) ~ Tramadol HCl Oral Tablet 50 mg Give 1 tablet by mouth every 4 hours as needed for pain DO NOT GIVE WITHIN 4 HOURS OF VICODIN (Start Date 1/22/24) On 3/11/24 at 10:26 AM, Surveyor interviewed Registered Nurse (RN)-C who indicated R1 usually did not complain of much pain. RN-C indicated R1 preferred to take just one of the two narcotic pain medications ordered by R1's physician. On 3/11/24 at 11:02 AM, Surveyor interviewed RN-D via phone. RN-D indicated R1 generally asked for PRN pain medication one in the morning and one at night. RN-D stated, One time, (R1) received both (PRN narcotic medications) which made (R1) a little loopy. On 3/11/24, Surveyor reviewed R1's Medication Administration Record (MAR) for January 2024 which indicated R1 was administered Vicodin and Tramadol together on the following dates and times: ~ 1/13/24 - Tramadol at 7:40 AM with Vicodin at 7:39 AM ~ 1/14/24 - Tramadol at 7:20 AM with Vicodin at 7:21 AM ~ 1/15/24 - Tramadol at 7:08 AM with Vicodin at 7:06 AM ~ 1/16/24 - Tramadol at 8:01 AM with Vicodin at 8:00 AM ~ 1/18/24 - Tramadol at 7:27 AM with Vicodin at 7:27 AM ~ 1/19/24 - Tramadol at 7:15 AM with Vicodin at 7:15 AM ~ 1/19/24 - Tramadol at 7:30 PM with Vicodin at 7:29 PM ~ 1/20/24 - Tramadol at 7:43 AM with Vicodin at 7:42 AM ~ 1/22/24 - Tramadol at 7:29 AM with Vicodin at 7:29 AM On 3/11/24, Surveyor reviewed R1's medical record which contained a Nurse Practitioner (NP) Visit Note, dated 1/22/24, that indicated: .Family reporting increased confusion .Will not give tramadol and vicodin within 4 hours of each other, as giving them together may be cause of increased confusion . On 3/11/24 at 1:39 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated R1's family expressed at a care conference that R1's mentation was varying. When asked if it was a standard of practice to give two narcotic medications at the same time, DON-B indicated DON-B preferred to err on the side of caution and advised the use of non-narcotic medications or non-pharmacological interventions for pain management first. DON-B verified it was not a standard of practice to administer two narcotic pain medications at the same time. DON-B indicated DON-B was unaware staff were administering two narcotic pain medications at the same time to R1.

Oct 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure adequate supervision to prevent accidents was provided for 1 Resident (R) (R2) of 10 sampled residents. The facility did not reassess R2 for elopement risk or revise R2's care plan after R2 left the faciity on 9/15/23. Findings include: The facility's Elopement policy, dated June 2023, indicates: It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible. All residents will be assessed for behaviors or conditions that put them at risk for wandering/elopement. All residents so identified will have these issues addressed in their individual care plan .All residents shall be reviewed for safety awareness impairment and elopement concerns upon admission, readmission, quarterly, and as needed . On 10/6/23, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses to include hemiplegia (paralysis/immobility on one side of the body) and hemiparesis (muscular weakness or partial paralysis restricted to one side of the body) following cerebral infarction (also known as a stroke) affecting the left non-dominant side. R2's Minimum Data Set (MDS) assessment, dated 7/20/23, contained a Brief Interview for Mental Status (BIMS) score of 7 out of 15 which indicated R2 had severely impaired cognition. R2 had a court-appointed Guardian who was responsible for R2's healthcare decisions. R2's medical record contained an Elopement Assessment, dated 4/28/23, that indicated R2 was not at risk for elopement. R2's progress notes contained the following information: ~A progress note, dated 9/15/23 at 1:37 AM, indicated: R2 was confused and thought R2 had R2's sibling's car keys and needed to return the car. R2 disconnected R2's tube feeding, walked down the hall to an exit door, and pushed the door until it opened when the alarm signaled. Staff promptly responded and found R2 walking less than 10 feet from the building looking for the car. Staff redirected R2 back inside. ~A progress note, dated 9/22/23 at 1:51 PM, indicated: The Interdisciplinary Team (IDT) met to review R2's recent exit out the smoking door on the patio. R2 was confused and stated R2 was looking for R2's sibling's car. The alarm sounded and staff responded appropriately. R2 was redirected into the building. R2's NP (Nurse Practitioner) and Guardian were updated. ~A progress note, dated 10/1/23 at 5:56 PM, indicated: R2 snuck out the smoking door with the smokers and stated R2 wanted to sit outside. R2 did not want to come back inside, but did so after sitting outside with staff. R2 wanted to sit outside again, but not in the courtyard. R2 was redirected back inside after staff offered a shower. ~A progress note, dated 10/5/23 at 2:50 PM, indicated: Staff observed R2 exit the smoking door in R2's wheelchair. R2 stated R2 was leaving to see R2's kids. Three staff went outside and Social Worker (SW)-C redirected R2 back inside. On 10/6/23, Surveyor reviewed R2's care plan which did not contain mention of elopement risk or interventions to keep R2 safe related to elopement attempts. On 10/6/23 at 12:20 PM, Surveyor interviewed R2 who stated R2 was happy with cares provided by staff and staff were nice to R2. R2 indicated R2 missed R2's family and military friends. R2 did not indicate a desire to leave the facility during the interview. On 10/6/23 at 12:56 PM, Surveyor interviewed SW-C who stated, This is the first week (R2's) actually been trying to leave. I was able to redirect (R2) in both times. SW-C indicated SW-C spoke with R2's Guardian and obtained permission for R2 to go on outings with military veteran friends to local VFW (Veterans of Foreign War) events at least once a month. When asked about the facility's process for assessing elopement risk, SW-C stated, I brought it up yesterday for a nurse to assess for wanderguard (device applied to a person's wrist or ankle which will alert staff if the person attempts to exit to an unsafe area). SW-C indicated SW-C offered R2 and R2's visitors the enclosed courtyard for safe outdoor time. On 10/6/23 at 1:28 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who verified the facility should have conducted an elopement assessment and updated R2's care plan after R2 left the faciity on 9/15/23 to look for a car.

Mar 2023 9 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0645 (Tag F0645)

Could have caused harm · This affected 1 resident

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**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 2 Residents (R) (R8 and R30) of 13 sampled residents. R8's Level I and Level II PASRR Screens were not completed timely. R30's Level I PASRR Screen was not completed timely. Findings include: The facility's Coordination-Pre-admission Screening and Resident Review (PASRR) policy, with a revision date of March 2021, contained the following information: Purpose .Evaluate individuals seeking admission to nursing facilities and current nursing facility residents to determine if they have a serious mental illness or intellectual disability .The PASRR screening consists of a two-stage identification and evaluation process and is conducted to ensure appropriate placement and treatment for those identified with Serious Mental Illness (SMI) and/or Mental Retardation (MR) .The facility will coordinate assessments with the pre-admission screening and resident review program under Medicaid in subpart C of this part to the extent practicable to avoid duplicative testing and effort . The State of Wisconsin Department of Health Services form F-22191 titled Preadmission Screen and Resident Review (PASRR) Level I Screen, dated 07/2017, contains the following information: Under these sections, nursing facilities must not admit any new resident who is suspected of having a serious mental illness or a developmental disability unless the State mental health authority/State developmental disability authority or designee has evaluated the person and determined if the person needs nursing facility placement and if the person needs specialized services .If a nursing facility admits a resident without completion of the appropriate screen(s), then the facility is in violation of the statutory requirement .If a Level II Screen is required, then the information on this (Level I) form is matched with information from the person's Level II Screen to ensure that the facility, the Department's designee/contractor and the Department has complied with all applicable federal statutes and regulations . 1. On 3/27/23, Surveyor reviewed R8's medical record. R8 was admitted to the facility on [DATE] with diagnoses to include depression for which R8 received medication. Surveyor noted R8's medical record did not contain a PASRR Level I form; however, R8's medical record contained a PASRR County Review, dated 1/24/23, that indicated a short-term exemption from the Level II process was allowed for 30 days. On 3/29/23 at 11:06 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who verified the PASRR County Review was the only PASSR documentation in R8's medical record. NHA-A stated Social Worker (SW)-D was conducting an audit and NHA-A was unsure if a PASRR Level II was sent to the State contractor. On 3/29/23, Surveyor reviewed PASRR documentation sent to the State contractor on 3/29/23. The documentation included R8's PASRR County Review, R8's hospital discharge summary (dated 10/25/22) and other pertinent documentation. The documentation did not include a PASRR Level I form. On 3/29/23 at 12:03 PM, Surveyor interviewed SW-D who verified the documents sent to the State contractor on 3/29/23 were as listed above and stated, We send the Level I, that paper (referred to PASRR County Review), and wait for them to send the Level II approval. On 3/29/23 at 12:46 PM, Surveyor interviewed NHA-A who stated the facility conducted an audit in January of 2023, noticed R8's PASRR Level I was missed on admission and obtained the PASRR County Review dated 1/24/23. NHA-A verified the PASRR Level I process should have been completed on or prior to R8's admission to the facility. NHA-A expressed understanding that a PASRR Level I form should have been sent to the State contractor on 3/29/23 in addition to documentation sent to request a Level II Screen. NHA-A verified the PASRR Level II process should have been followed when the facility realized R8 would be residing at the facility for longer than 30 days. NHA-A stated the facility started a Performance Improvement Plan (PIP) with the audit on 3/22/23. NHA-A verified the lack of R8's required PASRR documentation should have been caught with the audit conducted on 3/22/23. 2. On 3/27/23, Surveyor reviewed R30's medical record. R30 was admitted to the facility on [DATE] with diagnoses to include alcohol cirrhosis of the liver. R30's medical record contained a PASRR Level I form, dated 1/17/23, that indicated R30 was not suspected of having a serious mental illness or a developmental disability. On 3/29/23 at 12:50 PM, Surveyor interviewed NHA-A who verified R30's PASRR Level I form should have been completed on or prior to R30's admission to the facility.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure an accurate nutrition assessment was completed for 1 Resident (R) (R19) of 3 sampled residents reviewed for nutrition concerns. The facility did not complete an accurate nutrition assessment or update the physician when R19 had a significant weight loss of 18 pounds (6%) between 1/13/23 and 1/18/23. Findings include: The facility's Weight Management policy, with a revision date of 11/2021, contained the following information: Residents' nutritional status will be monitored on a regular basis to aid in the maintenance of acceptable parameters, such as body weight and protein levels .Significant weight variance is defined as: 5% in one month, 7.5% in three months, and 10% in six months .6. As residents are weighed, staff can compare current weight to previous weight. Residents with a weight variance are re-weighed within 48 hours .9. The Director of Nursing or designee will notify the attending physician of significant weight changes and document in the resident's progress notes. The attending physician will be notified of recommendations of the interdisciplinary team (IDT) and orders obtained, as indicated. 10. The assigned IDT member will communicate with the resident, resident's representative, and staff regarding interventions to be implemented. 11. The IDT will update the care plan and communicate interventions to staff, as indicated. From 3/27/23 through 3/29/23, Surveyor reviewed R19's medical record. R19 was admitted to the facility on [DATE] and had diagnoses to include diabetes, cerebrovascular disease, hypertension and a right leg pressure injury. R19's Minimum Data Set (MDS) assessment, dated 11/6/22, contained a Brief Interview for Mental Status (BIMS)score of 15 out of 15 which indicated R19 had intact cognition. R19's most recent MDS assessment, dated 2/6/23, documented a weight loss of 5% or more in the last month and indicated R19 was not on a physician prescribed weight loss program. A nutritional assessment, dated 11/2/22, indicated R19 had a significant weight loss this quarter and contained an intervention to continue to monitor weight trends. Surveyor reviewed R19's documented weights which were as follows: ~ 10/25/22 - 296 pounds ~ 1/13/23 - 296.1 pounds ~ 1/18/23 - 277 pounds ~ 2/17/23 - 278 pounds Surveyor noted R19's medical record did not contain any other evidence of weight monitoring. R19's next nutritional assessment, dated 2/2/23, contained the statement, Encourage resident to be weighed weekly as order states to accurately determine weight trends. On 3/29/23 at 12:01 PM, Surveyor interviewed Registered Dietitian (RD)-N who reviewed R19's medical record and verified R19's significant weight loss on 1/18/23. RD-N reviewed email notification and verified the facility did not notify RD-N of the weight loss. RD-N stated RD-N expected to be notified of the weight loss; however, RD-N also audited weights monthly. RD-N also reviewed R19's notes from February 2023. The notes indicated R19 had calf wounds that were not improving and it was important to follow both weight and wound goals comprehensively. On 3/29/23 at 1:02 PM, Surveyor interviewed Director of Nursing (DON)-B who stated weight loss was desirable for R19. DON-B also stated DON-B expected staff to notify a physician of any significant weight loss, including R19's weight loss on 1/18/23, and verified R19's medical record did not indicate R19's physician was updated.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interview and record review, the facility did not ensure consistent communication for 1 Resident (R) (R6) of 1 resident who received dialysis services. The facility did not provide R6 with a dialysis communication binder prior to routine dialysis appointments and did not have evidence of communication between the facility and the dialysis center on R6's dialysis days. Findings include: The facility's Hemodialysis policy, with a revision date of March 2023, contained the following information: Purpose: The facility will assure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. This will include: -The ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. -Ongoing assessment and oversight of the resident before, during and after dialysis treatments, including monitoring of the resident's condition during treatments, monitoring for complications, implementation of appropriate interventions, and using appropriate infection control practices. -Ongoing communication and collaboration with the dialysis facility regarding dialysis care services. From 3/27/23 to 3/29/23, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] with diagnoses to include end stage renal disease and diabetes with chronic kidney disease. R6 was dependent on dialysis and attended dialysis on Monday, Wednesday and Friday as ordered. R6's Minimum Data Set (MDS) assessment, dated 3/7/23, contained a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R6 had intact cognition. Surveyor noted R6's medical record did not contain dialysis communication documentation. On 3/29/23 at 8:14 AM, Surveyor interviewed R6 who stated the facility did not consistently obtain R6's vital signs pre and post dialysis. R6 verified R6 did not have a dialysis communication binder. On 3/28/23 at 2:47 PM, Surveyor interviewed Registered Nurse (RN)-L who stated RN-L had not seen a dialysis communication binder for R6. On 3/29/23 at 9:42 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-I who confirmed R6's vital signs and weights were not completed pre and post dialysis and verified a notebook for R6's vital signs and weights was started that morning. Surveyor noted the first and only page of the notebook was dated 3/29/23. On 3/29/23 at 9:56 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-M and RN-J who confirmed R6 did not have a dialysis communication binder and stated communication was completed by calling the dialysis center. LPN-M verified R6's pre and post vital signs were started that morning per Director of Nursing (DON)-B. RN-J stated R6 should have a communication binder. On 3/29/23 at 10:25 AM, Surveyor interviewed DON-B who confirmed R6 did not have a dialysis communication binder. DON-B stated DON-B expected staff to obtain R6's vital signs and weights pre and post dialysis and document them in a communication binder in order to relay information between the facility and the dialysis center. On 3/29/23 at 2:16 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who verified R6 should have a communication binder for dialysis.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review, the facility did not provide pharmacy services to ensure the accurate administration of medication for 3 Residents (R) (R4, R9, and R23) of 13 sampled residents. R4's medications were left at the bedside for R4 to self-administer. R4 did not have a physician's order to self-administer medication and was not assessed to determine if R4 could safely do so. R9's Humalog solution (Insulin Lispro) (fast-acting insulin used to control high blood sugar) pen was not marked with an open date. Per manufacturer's recommendations, Insulin Lispro is less effective 28 days after opening. R23's Refresh eye drops were not marked with an open date. In addition, staff were unsure of the facility's policy and were unable to determine when to discard the eye drops after opening. Findings include: The facility's Self-Administration of Medication policy, revised on 5/2020, contained the following information: Each resident has the right to self-administer medications if he or she can do so. The interdisciplinary team evaluates each resident who expresses a desire to self-administer medications to determine if the resident can safely self-administer medications. If the resident is determined to be capable, the facility provides the education and monitoring necessary to ensure safe administration. Guidelines: 5. The nurse will obtain a physician's order for each resident self-administering medication. Omnicare copyrighted 2021: Insulin Storage Recommendations graph: Insulin Lispro pen when opened, store at room temperature and discard in 28 days. Medication Storage Guidance states: Ophthalmic Products-Date when opened and discard unused portion after 28 days or in accordance with manufacturer's recommendations or facility policy. 1. From 3/28/23 to 3/29/23, Surveyor reviewed R4's medical record. R4 was admitted to the facility with diagnoses to include dysphagia, chronic heart failure, hypertension and depression. R4's Minimum Data Set (MDS) assessment, dated 3/7/2023, contained a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R4 had moderate cognitive impairment. On 3/28/23 at 7:50 AM, Surveyor observed R4 self-administer multiple medications from a small plastic cup left at the bedside by Licensed Practical Nurse (LPN)-G. R4 stated R4 self-administers medications while R4 eats. R4 stated, at times, nurses stay until R4 takes R4's medications and at other times nurses leave R4's medications at the bedside. R4 stated R4 did not complete a self-administration of medication assessment and did not have an order to self-administer medication. On 3/29/23, Surveyor reviewed R4's medical record. A self-administration assessment, dated 3/7/23, indicated R4 did not want to self-administer medication. Surveyor also noted R4's medical record did not contain a physician's order for self-administration. On 3/28/23 at 8:11 AM, Surveyor interviewed LPN-G who verified R4 did not have an order to self-administer medication. LPN-G stated R4 usually took the medications in LPN-G's presence and verified LPN-G should have supervised R4 until the medications were administered. On 3/29/23 at 1:37 PM, Surveyor interviewed Director of Nursing (DON)-B who stated medications should not be left at the bedside unless a resident has completed a self-administration of medication assessment and has a physician's order to self-administer. 2. On 3/29/23, Surveyor reviewed R9's medical record. R9 was admitted to the facility on [DATE] with diagnoses to include diabetes, morbid obesity and major depressive disorder. R9's MDS, dated [DATE], contained a BIMS score of 15 out of 15 which indicated R9 had intact cognition. On 3/28/23 at 7:37 AM, Surveyor observed LPN-G prepare R9's Lispro insulin pen and noted the pen was not dated when opened. Surveyor also noted the pharmacy packaging did not contain an open date. LPN-G confirmed the insulin pen was not dated and stated an open date should have been written on the pen. On 3/29/23 at 1:37 PM, Surveyor interviewed DON-B and ADON-C who verified insulin pens should be labeled with an open/first use date and discarded after the 28th day. 3. From 3/27/23 to 3/29/23, Surveyor reviewed R23's medical record. R23 was admitted to the facility on [DATE] with diagnoses to include retention of urine and benign prostatic hyperplasia (a condition in which the prostate gland is enlarged) with lower urinary tract symptoms. R23's MDS, dated [DATE], contained a BIMS score of 11 out of 15 which indicated R23 had moderate cognitive impairment. On 3/28/23 at 12:12 PM, Surveyor observed an open Refresh eye drop package containing 2 bottles of 0.5 fl oz (ounce) eye drops. One bottle was labeled with R23's name. Surveyor noted neither the bottle or package contained an open date. On 3/28/23 at 12:27 PM, Surveyor interviewed Registered Nurse (RN)-K and RN-L who both confirmed the eye drop packaging and bottle did not contain an open date. RN-K and RN-L were unsure what ophthalmic medication storage/discard policy the facility followed. On 3/29/23 at 1:37 PM, Surveyor interviewed DON-B and ADON-C regarding the facility's ophthalmic medication storage/discard policy. DON-B stated over-the-counter eye drops should be dated when opened in order to know when to discard the medication. DON-B and ADON-C both stated they were unsure what ophthalmic medication storage/discard the facility policy followed.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 3/29/23, Surveyor reviewed R188's medical record. R188 was admitted to the facility on [DATE] with a diagnosis of atherosclerotic heart disease. R188 had a physician's order for clopidogrel bisulfate oral tablet 75 mg by mouth daily. R188's medical record did not contain a care plan to address the use of clopidogrel bisulfate. R188's care plan also did not include monitoring for the effectiveness and potential side effects of the medication. On 3/29/23, Surveyor interviewed NHA-A regarding anticoagulant medication. NHA-A verified all residents on anticoagulant medication should have a care plan to monitor the effectiveness and potential side effects of the medication. Based on staff interview and record review, the facility did not ensure comprehensive resident-centered care plans were developed for 4 Residents (R) (R4, R24, R13, and R188) of 13 sampled residents. R4 had a physician's order for warfarin (an anti-coagulant medication used reduce the risk of stroke and blood clots). The facility did not develop a comprehensive care plan to monitor the effectiveness and potential side effects of the medication. R24 had physician orders for apixaban (an anti-coagulant medication used reduce the risk of stroke and blood clots), hydrocodone-acetaminophen (a high-risk opioid medication used to treat moderate to severe pain), and furosemide (a diuretic medication used to remove excess fluid from body tissues). The facility did not develop a comprehensive care plan to monitor the effectiveness and potential side effects of the medications. R13 had a physician's order for warfarin. The facility did not develop a comprehensive care plan to monitor the effectiveness and potential side effects of the medication. R188 had a physician's order for clopidogrel (an anti-coagulant medication used to reduce the risk of stroke and blood clots). The facility did not develop a comprehensive care plan to monitor the effectiveness and potential side effects of the medication. Findings include: 1. On 3/29/23, Surveyor reviewed R4's medical record. R4 was admitted to the facility with a diagnosis of chronic atrial fibrillation (an irregular often rapid heart beat that commonly causes poor blood flow). R4 had a physician's order for warfarin 2 milligrams (mg) by mouth daily. Surveyor noted R4's medical record did not contain a care plan to address the use of warfarin and monitor for the effectiveness and potential side effects of the medication. On 3/29/23 at 1:25 PM, Surveyor interviewed Director of Nursing (DON)-B regarding R4's use of warfarin. DON-B verified R4 did not have a care plan to address the use and potential side effects of the anti-coagulant medication. 2. On 3/29/23, Surveyor reviewed R24's medical record. R24 was admitted to the facility on [DATE] with diagnoses to include cardiomyopathy (disease of the heart muscle which makes it difficult for the heart to pump blood to other parts of the body). R24's medical record contained the following physician orders: ~ Apixaban Tablet 5 mg (milligrams) - Give 5 mg by mouth two times a day ~ Hydrocodone-Acetaminophen Tablet 5-325 MG - Give 1 tablet by mouth every 8 hours as needed for pain ~ Furosemide Tablet 40 mg Give 0.5 tablet by mouth one time a day .Give 20 mg daily Surveyor noted R24's care plan did not address R24's need for and use of apixaban, hydrocodone-acetaminophen and furosemide, including monitoring for side effects related to the medications. On 3/29/23 at 12:44 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who verified the high-risk medications should have been addressed on R24's care plan. 3. On 3/29/23, Surveyor reviewed R13's medical record. R13 was admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (COPD). R13's medical record contained a physician's order for Warfarin Sodium Oral Tablet 1 mg Give 1 mg by mouth one time a day. R13's care plan did not address R13's need for and use of warfarin, including monitoring for side effects related to the medication. On 3/28/23 at 1:39 PM, Surveyor interviewed NHA-A who stated facility's interdisciplinary team (IDT) should be care planning for high-risk medications. NHA-A verified R13's use of warfarin should have been addressed on R13's care plan.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

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Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This had the potential to affect all 40 residents residing in the facility. The facility did not monitor and document food cooling and holding temperatures. Staff did not test quaternary sanitizing solution per manufacturer's instructions. Findings include: During an initial tour of the kitchen on 3/27/23 at 8:50 AM, Dietary Manager (DM)-E stated the facility followed the Wisconsin Food Code. 1. Food Cooling Temperature Requirement The Wisconsin Food Code 2022 documents at section 3-501.14 Cooling. (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 57° Celsius (C) (135° Fahrenheit) (F) to 21° C (70° F); and (2) Within a total of 6 hours from 57° C (135° F) to 5° C (41° F) or less. (B) time/temperature control for safety food shall be cooled within 4 hours to 5° C (41° F) or less. The Wisconsin Food Code 2022 section 3-501.15 documents Cooling Methods. (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under §3-501.14 by using one or more of the following methods based on the type of food being cooled: (1) Placing the food in shallow pans; (2) Separating the food into smaller or thinner portions; (3) Using rapid cooling equipment; (4) Stirring the food in a container placed in an ice water bath; (5) Using containers that facilitate heat transfer; (6) Adding ice as an ingredient; or (7) Other effective methods. During an initial tour of the kitchen on 3/27/23 at 8:50 AM, Surveyor noted the cooler contained steam table containers sealed with plastic wrap and labeled with the food item and a date range. DM-E verified the first date documented on the plastic wrap was the date the food was made and put in the cooler. DM-E stated the date after the dash was the use by date. Surveyor observed the following items located in the cooler: One container labeled hardboiled eggs 3/27-4/1 One container labeled PB&J 3/27-3/30 One container labeled Ham and cheese 3/27-3/30 One container labeled French toast 3/27-3/30 One container labeled Puree carrots 3/26-3/29 DM-E verified the facility did not have cooling temperature documentation and did not monitor cooling temps. DM-E stated food items are left on the countertop to cool then sealed with plastic wrap, dated, and put in the cooler. On 3/27/23 at 11:20 AM, Surveyor interviewed [NAME] (CK)-F who verified the facility did obtain food cooling temperatures. CK-F stated if a meal service contained left over food, the left over food was put on the prep counter to cool, sealed with plastic wrap, labeled, and put in the cooler. CK-F verified temperatures were not obtained when the food was removed from the steam table or anytime prior to the food being placed in the cooler. CK-F confirmed the facility did not maintain food cooling temperature logs. On 3/28/23 at 9:30 AM, Surveyor and DM-E noted the cooler contained the following steam table containers labeled with the food item and date range and sealed with plastic wrap: One container labeled hardboiled eggs 3/27-4/1 One container labeled PB&J 3/27-3/30 One container labeled Ham and cheese 3/27-3/30 One container labeled French toast 3/27-3/30 One container labeled Puree carrots 3/26-3/29 One container labeled Egg salad sandwich 3/27-4/1 One container labeled Corn 3/27-3/30 One container labeled Egg salad 3/27-3/31 One container labeled French toast 3/27-3/30 One container labeled Chicken soup 3/27-4/8 DM-E verified the chicken soup container did not contain an appropriate use by date. DM-E verified staff are to label foods with a use by date of no longer than five days prior to placing them in the cooler. DM-E stated all food in the cooler would be thrown out just to be safe since the food was not cooled using food safety temperature cooling methods. 2. Hot/Cold Food Holding Temperature Requirement The Wisconsin Food Code 2022 documents at 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. In a January 2001 report, the National Advisory Committee on Microbiological Criteria for Foods (NACMCF) recommended that the minimum hot holding temperature specified in the Food Code: Be greater than the upper limit of the range of temperatures at which Clostridium perfringens (C. perfringens) and Bacillus cereus (B. Cereus) may grow; and Provide a margin of safety that accounts for variations in food matrices, variations in temperature throughout a food product, and the capability of hot holding equipment to consistently maintain product at a desired target temperature. C. perfringens has been reported to grow at temperatures up to 52° C (126° F). Growth at this upper limit requires anaerobic conditions and follows a lag phase of at least several hours. The literature shows that lag phase duration and generation times are shorter at incubation temperatures below 49° C (120° F) than at 52° C (125° F). Studies also suggest that temperatures that preclude the growth of C. perfringens also preclude the growth of B. cereus. The CDC (Centers for Disease Control and Prevention) estimates that approximately 250,000 foodborne illness cases can be attributed to C. perfringens and B. cereus each year in the United States. These spore-forming pathogens have been implicated in foodborne illness outbreaks associated with foods held at improper temperatures. This suggests that preventing the growth of these organisms in food by maintaining adequate hot holding temperatures is an important public health intervention. Taking into consideration the recommendations of NACMCF and the 2002 Conference for Food Protection meeting, the Food and Drug Administration (FDA) believes that maintaining food at a temperature of 57° C (135° F) or greater during hot holding is sufficient to prevent the growth of pathogens and is therefore an effective measure in the prevention of foodborne illness. During a continuous observation on 3/27/23 beginning at 11:10 AM, Surveyor reviewed the facility's Food Temperature Record which contained the following food temperatures for the 3/27/23 lunch meal: Regular meat: 176 degrees F Ground meat: 176 degrees F Pureed meat: 176 degrees F Vegetables: 180 degrees F Pureed Vegetables: 180 degrees F Starch: 186 degrees F Alternatives: 170 degrees F Dessert: room (temperature) Pureed Dessert: room (temperature) Milk/Juice/Coffee: undocumented temperature The Food Temperature Record indicated: All hot foods must be held at a minimum of 135 degrees F; The recommended temperature for food held on the serving line was 160 degrees F-180 degrees F; Cold foods should be maintained at or below 41 degrees F. CK-F stated the Food Temperature Record contained a temperature of room because the temperature of the food was measured at room temperature. CK-F stated all other recorded temperatures were taken after the food items were removed from the oven. CK-F confirmed there were no temperatures taken for milk, juice or coffee. Surveyor observed the prep counter and noted the counter contained an uncovered steam table container with what appeared to be rice. CK-F verified the contents of the container were rice casserole which contained rice and soup. CK-F stated the rice casserole was prepared and finished cooking just before Surveyor entered the kitchen at 11:10 AM. CK-F stated the casserole would be put in the oven at approximately 1:00 PM after lunch service was completed. CK-F verified the casserole would remain in the oven at a low temperature and would be served for dinner that evening. CK-F confirmed the facility's practice for cooking meals was to pre-cook meal items and hold them for service in the oven until right before meal service started. CK-F stated the temperature was obtained when the dish was removed from the oven prior to service. The temperature was recorded on the Food Temperature Record and no other food temperatures were obtained. Surveyor also observed staff prepare the steam table for lunch service. CK-F stated the food containers were placed in the steam table a little bit before Surveyor entered the kitchen at 11:10 AM. Surveyor asked CK-F to obtain temperatures on the items located in the steam table. CK-F obtained the following temperatures: Vegetables -140 degrees F Pureed Vegetables - 141 degrees F Tator tot casserole containing tator tots, cream soup, green beans, and ground beef - 120 degrees F Surveyor interviewed CK-F regarding the temperature of the tator tot casserole. CK-F stated the tator tot casserole would be put back in the oven and a temperature would be obtained when the tator tot casserole was at the right temperature. Surveyor observed CK-F put the casserole back in the oven, wait approximately 10 minutes, remove the casserole, and obtain a temperature of 170 degrees F. Surveyor noted CK-F did not document the temperature on the Food Temperature Record. On 3/28/23 at 11:28 AM, Surveyor observed CK-F load the steam table with food for hot holding prior to meal service. Surveyor noted food holding temperatures were not obtained prior to the meal service. At 12:19 PM, Surveyor noted all resident plates were served in the dining room and all room trays were being distributed. Surveyor requested food holding temperatures from the meal service. CK-F stated hot food holding temperatures were not obtained. Surveyor asked CK-F to obtain holding temperatures and noted the following temperatures obtained from steam table: Meatball - 161 degrees F Noodles - 152 degrees F Vegetables - 160 degrees F On 3/28/23 at 1:15 PM, Surveyor interviewed DM-E who indicated hot/cold food holding temperatures were not documented because foods for meal service were served right after they were removed from the oven where the cooking temperature was taken and documented on the Food Temperature Record. DM-E verified there was not a separate hot/cold food temperature record document. 3. Staff did not test quaternary sanitizing solution per manufacturer's instructions. TMA Quaternary sanitizer: Directions for use food contact sanitizing performance indicated: Allow sanitized surfaces to adequately drain and then air dry before contact with food, so that little or no residue remains. Do not rinse. For articles too large for immersing, apply a use solution of 1-2.67 oz (ounces) per 4 gallons of water (150-400 ppm (parts per million) active) to sanitize hard, non-porous food contact surfaces with a brush, cloth, mop, sponge, auto scrubber, mechanical spray device, hand pump, coarse pump or trigger spray device. For spray applications, spray 6-8 inches from surface. Do not breathe spray. Surfaces must remain wet for at least 5 minutes. Allow sanitized surfaces to adequately drain and then air dry before contact with food, so that little or no residue remains. Do not rinse. Prepare a fresh solution daily or when visibly dirty. For mechanical application, used solution must not be reused for sanitizing applications but may be used for other purposes such as cleaning. During an initial tour of the kitchen on 3/27/23 at 8:50 AM, Surveyor noted the three compartment sink contained one bucket of water. DM-E verified the bucket was prepared that morning and contained water and TMA Quaternary Solution. DM-E confirmed the facility did not test the sanitizing solution bucket per manufacturer's directions as the facility does not use the sanitizing solution to clean dishes only surfaces. DM-E confirmed the solution is put in buckets that are used to clean all food contact surfaces in the kitchen as well as the dining room and stated no other sanitizing solutions were used for that purpose. DM-E verified the facility did not have quaternary test strips and could not test the sanitizing solution per manufacturer's directions. DM-E stated DM-E had not seen quaternary test strips in the facility and did not know what quaternary test strips were. DM-E further stated the facility used wash cloths that turn colors to indicate the sanitizing solution is still good or needs to be replaced. On 3/28/23 at 9:30 AM, Surveyor interviewed DM-E who stated the wash cloths used to clean food contact surfaces and dining room tables were Sertun Sanitizer Washcloths. DM-E stated the wash cloths started off yellow in color and turned blue when the water and sanitizing solution needed to be replaced. Surveyor reviewed with DM-E the wash cloth instructions for use on the side of the product box that indicated the wash cloths were to be used with a water and quaternary sanitizing solution tested at 150-400 ppm active. DM-E verified DM-E did not know quaternary strips needed to be used to test the water and sanitizing solution buckets if used with the wash cloths. On 3/28/23 at 12:30 PM, DM-E brought quaternary test strips to Surveyor and asked Surveyor if the quaternary test strips were what the facility needed to use to test the sanitizing solution. DM-E stated DM-E found the strips in an office desk drawer and stated the facility would begin using the strips once DM-E learned how to use them. On 3/28/23 at 12:33 PM, Surveyor observed kitchen staff clean dining room tables with a bucket that contained sanitizing solution and a wash cloth.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. From 3/27/23 to 3/29/23, Surveyor reviewed R23's medical record. R23 was admitted to the facility on [DATE] with diagnoses to include retention of urine and benign prostatic hyperplasia (a condition in which the prostate gland is enlarged) with lower urinary tract symptoms. R23's Minimum Data Set (MDS) assessment, dated 2/6/23, contained a Brief Interview for Mental Status (BIMS) score of 11 which indicated R23 had moderate cognitive impairment. On 3/27/23 at 9:56 AM, Surveyor interviewed R23 regarding R23's indwelling urinary catheter. R23 stated R23 did not have a cover for R23's catheter drainage bag and R23's catheter caused UTIs in the past. Surveyor noted R23's uncovered catheter drainage bag touched the floor while hung from the middle of R23's wheelchair. On 3/28/23 at 9:56 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-H who confirmed R23's catheter bag dragged on the floor while hooked to the middle of R23's wheelchair. Per CNA-H, R23's catheter bag contained a cover at one time; however, the cover ripped and was likely thrown away. CNA-H stated CNA-H would ask for a cover; however, Surveyor did not observe a cover on R23's catheter drainage bag for the rest of the time Surveyor was at the facility that day. On 3/28/23 at 11:36 AM, Surveyor observed R23 request a catheter bag cover from laundry staff. A cover was not observed on R23's catheter drainage bag for the rest of the time Surveyor was at the facility that day. On 3/29/23 at 9:45 AM, Surveyor interviewed CNA-I who denied CNA-I saw a cover on R23's catheter drainage bag and had no knowledge of staff offering R23 a cover. On 3/29/23 at 9:50 AM, Surveyor noted R23's catheter drainage bag still did not contain a cover. R23 verified R23 had not received a cover thus far. On 3/29/23 at 10:06 AM, Surveyor interviewed Registered Nurse (RN)-J who stated residents with a catheter should have a cover for the drainage bag. RN-J then obtained a cover for R23. On 3/29/23 at 10:22 AM, Surveyor interviewed DON-B who verified R23's catheter bag should not touch the floor and should contain a cover to help prevent infections. Based on staff interview and record review, the facility did not establish and maintain an infection control program designed to help prevent the development and transmission of disease and infection. This had the potential to affect all 40 residents residing in the facility. The facility did not conduct continuous infection surveillance including tracking and trending of illnesses, potential infectious agents, and monitoring of staff signs and symptoms of infection or potential infection. The facility did not provide a cover for R23's catheter drainage bag which was observed dragging on the floor from 3/27/23 to 3/29/23. R23 had a history of urinary tract infections (UTIs) and was currently being treated with an antibiotic for a UTI. Findings include: 1. On 3/29/23, Surveyor reviewed the facility's infection control documentation for tracking staff illness. The facility provided Surveyor with staff surveillance for December of 2022. Surveyor noted the facility was in a COVID-19 outbreak during the month of December. Surveyor requested surveillance of staff illness not related to the COVID-19 outbreak; however, no documentation was provided. On 3/29/23, Surveyor interviewed Director of Nursing (who was also the facility's Infection Preventionist) (DON)-B who stated DON-B took over the infection prevention program in December of 2022; however, the previous DON oversaw the tracking of staff illness through February of 2023. DON-B stated the previous DON vacated the DON position in February of 2023 and DON-B was not aware staff surveillance was not occurring. On 3/29/23, Surveyor interviewed Nursing Home Administrator (NHA)-A who verified the facility only had documentation of staff illness surveillance for the month of December 2022 and could not provide Surveyor with further documentation.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0882 (Tag F0882)

Could have caused harm · This affected most or all residents

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Based on staff interview and record review, the facility did not have a qualified Infection Preventionist (IP) who completed specialized training in infection prevention and control. This had the potential to affect all 40 residents residing in the facility. Director of Nursing (DON)-B started as the facility's IP in December of 2022; however, DON-B did not complete specialized training for infection prevention and control. DON-B accepted the Director of Nursing role in February of 2023. Assistant Director of Nursing (ADON)-C started at the facility in March of 2023 and assisted with IP duties; however, ADON-C did not complete specialized training for 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 who has specialized training on-site at least part-time to effectively oversee the facility's infection prevention and control program (IPCP). On 3/28/23, Surveyor interviewed ADON-C who verified ADON-C started at the facility three weeks prior and did not complete infection prevention and control training. On 3/29/23, Surveyor interviewed DON-B who verified DON-B was the facility's designated full-time IP along with ADON-C. Surveyor asked DON-B if DON-B completed infection prevention and control courses as required by CMS. DON-B verified DON-B did not complete IP training. DON-B stated DON-B started the Centers for Disease Control and Prevention (CDC) infection prevention training, but did not finish the training. DON-B stated in December of 2022, DON-B started as the facility's IP and began the training; however, the facility experienced a COVID-19 outbreak and the training was put on hold. DON-B stated in February of 2023, the previous DON vacated the DON position and DON-B assumed the role. DON-B stated ADON-C was hired in March of 2023 and began to assist DON-B with infection prevention for the facility. On 3/29/23, Surveyor interviewed Nursing Home Administer (NHA)-A who verified the facility did not have a full-time qualified IP.

MINOR (C)

Minor Issue - procedural, no safety impact

Transfer Notice (Tag F0623)

Minor procedural issue · This affected most or all residents

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**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) (R23 and R27) of 2 residents reviewed for hospitalizations received the proper notice of transfer, reason for transfer, location of transfer, appeal rights, and contact information. R27 was transferred to the hospital on 1/2/23, 1/31/23, 2/16/23, and 3/21/23. A written notice of transfer was not provided to R27's representative for any of the transfers. R23 was not provided a written notice of transfer when R23 was transferred to the hospital on 2/2/23 and 2/15/23. Findings include: 1. On 3/29/23, Surveyor reviewed R27's medical record. R27 was admitted to the facility with diagnoses to include diabetes, non-pressure injuries to bilateral lower extremities, chronic obstructive pulmonary disease (COPD), acute kidney injury, fibromyalgia, and chronic pain syndrome with pain pump placement. R27's Minimum Data Set (MDS) assessment, dated 1/2/23, contained a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated R27 had moderate cognitive impairment. R27 had an activated Power of Attorney (POA) for medical decision making. R27's medical record indicated the following: R27 was transferred to the hospital on 1/2/23, 1/31/23, 2/16/23, and 3/21/23. R27's medical record did not include copies of transfer notices given to R27 and/or R27's representative. On 3/29/23 at 10:07 AM, Surveyor requested copies of the transfer notices given to R27's representative for R27's hospital transfers on 1/2/23, 1/31/23, 2/16/23, and 3/21/23. Nursing Home Administrator (NHA)-A stated a written transfer notice was not provided to R27 or R27's representative for any the transfers. NHA-A also stated the facility does not provide a written transfer notice to the resident/resident's representatives when a resident is transferred to the hospital. NHA-A indicated NHA-A did not have a full understanding of the difference between the bed hold documentation requirement and the notice of transfer documentation requirement. 2. From 3/27/23 to 3/29/23, Surveyor reviewed R23's medical record. R23 was admitted to the facility on [DATE] with diagnoses to include retention of urine and benign prostatic hyperplasia (a condition in which the prostate gland is enlarged) with lower urinary tract symptoms. R23's most recent MDS, dated [DATE], contained a BIMS score of 11 out of 15 which indicated R23 had moderate cognitive impairment. While reviewing R23's medical record, Surveyor was unable to locate a written notice of transfer for R23's hospital transfers on 2/2/23 and 2/15/23. On 3/29/23 at 9:06 AM, Surveyor interviewed NHA-A and requested a copy of the written notice of transfer for both of R23's hospital transfers. NHA-A was unable to provide the transfer notices and stated R23 only signed a bed hold policy for the hospitalizations. NHA-A verified a written notice of transfer was not provided to R23 for either hospital transfer.

Jan 2023 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility did not provide pharmacy services to ensure timely administration of medication for 3 Residents (R) (R1, R2 and R3) of 3 sampled residents. On 1/9/23, Surveyor reviewed R1, R2 and R3's medication administration records (MARs) for the time frame of 1/2/23 through 1/9/23 and noted a pattern of untimely medication administration for all 3 residents. In addition, during an observation of medication administration, R2's AM medications were administered late. Findings include: The facility's Medication Administration policy, dated May 2020, states: Resident medications are administered in an accurate, safe, timely and sanitary manner. Physician's Orders - Medications are administered in accordance with written orders of the attending physician. Procedure: 6. Administer medications within 60 minutes of the scheduled time. Unless otherwise specified by the physician, routine medications are administered according to the established medication administration schedule for the facility. For example, if the medication is ordered for 8:00 a.m., it must be given between 7:00 a.m. and 9:00 a.m. in order to be considered timely. 1. On 1/9/23, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses to include asthma, diabetes, fibromyalgia, pain, gastric esophageal reflux disease (GERD) (acid reflux), depression, high blood pressure, hypokalemia (low potassium), anemia (lack of red blood cells) and hyperlipidemia (high cholesterol). R1's most recent Minimum Data Set (MDS), dated [DATE], indicated R1 was cognitively intact. Surveyor reviewed R1's MAR which contained the following orders scheduled to be administered at 8:00 AM: ~Triamterene-Hydrochlorothiazide (used to treat high blood pressure) 37.5-25 milligrams (mg), give 1 tablet by mouth one time a day. ~Omeprazole Capsule Delayed Release (used to treat acid reflux), give 20 mg by mouth two times a day (BID) related to GERD, take 1 capsule by mouth twice daily before breakfast and supper. ~Potassium Chloride Extended Release (used to prevent/treat low potassium) 10 milliequivalents (mEq), give 1 tablet by mouth one time a day. ~ Duloxetine Delayed Release (used to treat depression/anxiety) 60 mg capsule, give 60 mg by mouth one time a day. ~Vitamin D2 (50000 international units (IU)), give 50000 IU by mouth one time a day every Monday. On 1/9/23, Surveyor reviewed R1's MAR from 1/2/23 through 1/9/23 and noted R1's scheduled 8:00 AM medications were administered as follows: On 1/7/23, R1's 8:00 AM medications were administered at 9:18 AM. R1's scheduled 8:00 AM medications were administered outside of the facility's time frame which was considered untimely per the facility's policy. R1's omeprazole was scheduled to be given BID, therefore, untimely administration of the 8:00 AM dose could affect the administration and efficacy of the next scheduled dose. 2. On 1/9/23, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses to include acute respiratory failure, urinary tract infection (UTI), chronic obstructive pulmonary disease (COPD), asthma, atrial fibrillation, GERD, anxiety disorder, depression, high cholesterol, anemia and edema (swelling). R2's most recent MDS, dated [DATE], indicated R2 was moderately cognitively impaired. Surveyor reviewed R2's MAR which contained the following medication orders scheduled to be administered at 6:00 AM and 2:00 PM, except cephalexin which was scheduled to be administered at 6:00 AM, 10:00 AM, 2:00 PM and 10:00 PM (started on 1/7/23 for 10 days). ~Vitamin C (used as a supplement), give 250 mg by mouth BID. ~Guaifenesin Extended Release (used to treat cough/congestion) 12-hour 600 mg, give 1 tablet BID. ~ Ferrous Sulfate Tablet (used as a supplement), give 325 mg by mouth BID. ~Cephalexin (used to treat infections) 500 mg, give 500 mg by mouth four times a day (QID). On 1/9/23, Surveyor reviewed R2's MAR from 1/2/23 through 1/9/23 and noted R2's scheduled 6:00 AM medications were administered as follows: On 1/2/23, R2's 6:00 AM medications were administered at 8:12 AM. On 1/3/23, R2's 6:00 AM medications were administered at 9:13 AM, except Vitamin C which was administered at 9:14 AM. On 1/4/23, R2's 6:00 AM medications were administered at 7:58 AM, except guaifenesin which was administered at 7:59 AM. On 1/5/23, R2's 6:00 AM medications were administered at 7:45 AM. On 1/6/23, R2's 6:00 AM medications were administered at 9:03 AM. On 1/7/23, R2's 6:00 AM medications were administered at 9:51 AM. On 1/8/23, R2's 6:00 AM medications were administered at 7:33 AM. On 1/9/23, R2's 6:00 AM medications were administered at 9:46 AM. R2's scheduled 6:00 AM medications were administered outside of the facility's time frame which was considered untimely per the facility's policy. The untimely administration of medication scheduled BID and QID could affect the administration and efficacy of the next scheduled dose(s). On 1/9/23, Surveyor reviewed R2's MAR which included the following medications scheduled to be administered once daily at 8:00 AM or 8:00 PM. Medications that were ordered BID were scheduled to be administered at 8:00 AM and 8:00 PM. ~Tramadol (used to treat pain) Oral Tablet 50 mg, give 25 mg by mouth BID. ~Oxybutynin Chloride (used to treat bladder spasms) Tablet 5 mg, give 1 tablet by mouth BID. ~Duloxetine (used to treat anxiety) Delayed Release Capsule 60 mg, give 60 mg daily. ~Solifenacin (used to treat bladder-neck obstruction) 5 mg tablet, give 5 mg by mouth daily. ~Trelegy Ellipta (used to treat/prevent shortness of breath (SOB)/wheezing) 100-62.5-25{28 EA}, give 1 puff inhale orally daily . ~Quetiapine (used to treat depression) fumarate 25 mg tablet, give 1 tablet by mouth at bedtime. ~MiraLax (used for constipation) Powder 17 gm (grams)/scoop, give 1 scoop by mouth daily . ~Lorazepam (used to treat anxiety) Tablet 0.5 mg, give 1 tablet by mouth BID. ~Omeprazole (used to treat acid reflux) Tablet Delayed Release 20 mg, give 20 mg by mouth BID. ~Diltiazem (used to treat high blood pressure) 24-hour Extended-Release capsule 120 mg, give 1 capsule by mouth in the morning. ~Furosemide (used to treat swelling) 20 mg tablet, given 20 mg by mouth in the morning. ~Atorvastatin (used to treat high cholesterol) 20 mg tablet, give 20 mg by mouth at bedtime. ~Metoprolol (used to treat abnormal heart rhythm) Extended Release 100 mg tablet, give 100 mg by mouth in the morning. ~Amiodarone (used to treat abnormal heart rhythm) 200 mg tablet, give 200 mg by mouth in the morning. On 1/9/23, Surveyor reviewed R2's MAR from 1/2/23 through 1/9/23 and noted R2's scheduled 8:00 AM medications were administered as follow: On 1/4/23, R2's 8:00 AM medications were administered between 9:08 AM and 9:13 AM. On 1/6/23, R2's 8:00 AM medications were administered at 9:03 AM. On 1/9/23, R2's 8:00 AM medications were administered between 9:46 AM and 9:50 AM. R2's scheduled 8:00 AM medications were administered outside of the facility's time frame which was considered untimely per the facility's policy. The untimely administration of medications scheduled BID could affect the administration and efficacy of the next scheduled dose. 3. On 1/9/23, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and had diagnoses to include osteomyelitis (bone infection), allergic rhinitis (hay fever), Vitamin D deficiency, high blood pressure and epilepsy. R3's most recent MDS, dated [DATE], indicated R3 was cognitively intact. Surveyor reviewed R3's MAR which included the following medications scheduled to be administered at 8:00 AM: ~Lovenox (to prevent blood clots) Solution 80 mg/0.8 milliliter (ml), inject 80 mg subcutaneously every 12 hours. ~Lisinopril (used for high blood pressure) tablet 20 mg, give 1 tablet via percutaneous endoscopic gastrostomy (PEG) (feeding tube through abdominal wall) one time a day. ~Clonazepam (used to prevent/treat seizures) tablet 0.5 mg, give 0.25 mg by mouth three times a day (TID). ~Keppra (used to treat seizures) tablet 1000 mg, give 2000 mg by mouth BID. ~ Doxycycline (used to treat infections) tablet 100 mg, give 1 tablet orally BID. On 1/9/23, Surveyor reviewed R3's MAR from 1/2/23 through 1/9/23 and noted R3's scheduled 8:00 AM medications were administered as follows: On 1/5/23, R3's 8:00 AM medications were administered between 10:06 AM and 10:11 AM. On 1/6/23, R3's 8:00 AM medications were administered between 10:32 AM and 11:00 AM. On 1/7/23, R3's 8:00 AM medications were administered between 9:11 AM and 9:18 AM. R3's scheduled 8:00 AM medications were administered outside of the facility's time frame which was considered untimely per the facility's policy. The untimely administration of medications scheduled BID and TID could affect the administration and efficacy of the next scheduled dose(s). On 1/9/23 at 9:50 AM, Surveyor interviewed Registered Nurse (RN)-E. Per RN-E, medications were usually late since Unit 2 nurses had to observe the dining room during the breakfast meal and Unit 1 nurses had to observe the dining room during the lunch meal. RN-E stated RN-E supervised the dining room that morning for an hour during the breakfast meal. RN-E stated RN-E was an hour behind on RN-E's AM medication pass and had seven residents who had yet to receive AM medications. Surveyor then observed RN-E walk toward R2's room with a cup of medication and a Trelegy inhaler. RN-E verified the medications and inhaler were R2's AM medications. On 1/9/23 at 9:53 AM, Surveyor reviewed R2's MAR and noted R2 had medications scheduled to be administered at 6:00 AM, 7:00 AM and 8:00 AM. RN-E confirmed R2's scheduled 6:00 AM, 7:00 AM and 8:00 AM medications were given late. On 1/9/23 at 10:00 AM, Surveyor interviewed R2 regarding medication administration. R2 confirmed medications were frequently administered late. On 1/9/23 at 11:15 AM, Surveyor interviewed Director of Nursing (DON)-B regarding medication administration. DON-B stated the facility had a 4-hour time frame for AM medication administration; however, DON-B was unable to provide a medication administration policy with the 4-hour time frame. DON-B verified if a medication was scheduled for a certain time, the expectation was to administer the medication either one hour before or one hour after. DON-B verified a medication was considered late if it was administered outside of the time frame. DON-B stated DON-B expected staff to follow the facility's medication administration policy and administer medications timely.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility did not ensure it was free of a medication error rate of 5% or greater. During medication administration observations, 5 errors occurred during 36 opportunities which resulted in an 13.89% medication error rate that affected 3 Residents (R) (R4, R5 and R6) of 4 residents observed during medication pass. R4 had a physician order for pantoprazole (used to treat stomach and esophagus problems) which was recommended to be taken on an empty stomach. During an observation of medication administration, Licensed Practical Nurse (LPN)-C administered pantoprazole to R4 after R4 had eaten breakfast. Additionally, R4 had a physician order for Vitamin C. LPN-C also did not administer R4's Vitamin C. R5 had physician's order for folic acid (Vitamin B-9) with an ordered dose of 1 mg (milligram) (1 mg = 1000 mcg (micrograms)). During an observation of medication administration, LPN-C administered 800 mcg of folic acid to R5. R6 had a physician order for carbidopa-levodopa (used to treat Parkinson's symptoms) scheduled to be administered at 7:00 AM. During an observation of medication administration, LPN-C administered R6's carbidopa-levodopa at 9:41 AM. Additionally, R6 had physician order for omeprazole (used to treat stomach problems) which was recommended to be taken on an empty stomach. LPN-C administered omeprazole to R6 after R6 ate breakfast. Findings include: The facility's Medication Administration policy, with a revision date of May 2020, stated, Resident medications are administered in an accurate, safe, timely and sanitary manner .Medications are administered in accordance with written orders of the attending physician .Administer medications within 60 minutes of the scheduled time . 1. On 1/9/23, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] with diagnoses to include gastritis (inflammation of the protective lining of the stomach), gastroesophageal reflux disease (GERD) (a chronic digestive disease where the liquid content of the stomach refluxes into the esophagus) and Wernicke's encephalopathy (a degenerative brain disorder caused a the lack of thiamine (Vitamin B1) often as result of alcohol abuse and/or eating disorders). On 1/9/23 at 9:12 AM, Surveyor observed LPN-C prepare and administer medication for R4 which included one 40 mg tablet of pantoprazole. LPN-C indicated Vitamin C was also ordered for R4; however, LPN-C was unable to administer Vitamin C because the facility's supply had been out for a few days. On 1/9/23, Surveyor reviewed R4's medical record which contained the following orders: ~ Pantoprazole Sodium Tablet .Give 40 mg by mouth one time a day for reflux. ~ Ascorbic Acid (Vitamin C) Tablet 250 mg .Give 1 tablet by mouth one time a day for supplement. On 1/9/23 at 9:42 AM, Surveyor interviewed LPN-C who indicated the facility's supply of Vitamin C supply was out a few days and stated, I let the [staff person] that orders supplements know. LPN-C stated staff in the Business Office ordered stock supplements. On 1/9/23 at 12:44 PM, Surveyor interviewed LPN-C who verified medications like pantoprazole should be given on an empty stomach and stated, Usually before breakfast. LPN-C further stated, Tricky to get everyone before breakfast. On 1/9/23, Surveyor reviewed R4's Medication Administration Record (MAR) which indicated R1 had not received a dose of Vitamin C since 1/3/23. On 1/9/23 at 1:09 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated DON-B was unaware the facility's stock of Vitamin C was out until that day (1/9/23). DON-B verified medications like pantoprazole should be given on an empty stomach and verified it was not the facility's standard of practice to administer pantoprazole on a full stomach. 2. On 1/9/23, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] with diagnoses to include folate deficiency anemia (a decrease in red blood cells due to a lack of folate which is a type of B vitamin also called folic acid). On 1/9/23 at 9:23 AM, Surveyor observed LPN-C prepare and administer medication for R5 which included one 800 mcg tablet of folic acid. On 1/9/23, Surveyor reviewed R'5 medical record which contained the following order: ~ Folic Acid Tablet .Give 1 mg by mouth one time a day for supplement. On 1/9/23 at 12:44 PM, Surveyor interviewed LPN-C regarding R5's folic acid. LPN-C stated, Wrong dose in the cart. One mg dose comes from pharmacy so gave 800 mcg (from facility stock) and documented that a partial dose was administered. On 1/23/22, Surveyor reviewed R5's medical record which contained the following nursing note: ~On 1/9/23: .Administration Note .Folic Acid Tablet 1 mg .only 800 mcg tab available. On 1/9/23 at 1:06 PM, Surveyor interviewed DON-B who verified the administration of 800 mcg of folic acid when 1000 mcg was ordered was considered a medication error. DON-B stated a medication supply that was going to run out should be re-ordered from the pharmacy a week ahead of time. 3. On 1/9/23, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] with diagnoses to include Parkinson's disease (a progressive nervous system disorder that affects movement), GERD and diaphragmatic hernia (a birth defect in which there is an abnormal opening in the diaphragm which allows abdominal organs to move into the chest). On 1/9/23 at 9:41 AM, Surveyor observed LPN-C prepare and administer medication for R6 which included two tablets of carbidopa-levodopa 25/100 mg and one tablet of omeprazole 20 mg. On 1/9/23, Surveyor reviewed R6's medical record which contained the following orders: ~ Carbidopa-Levodopa Tablet 25-100 mg .Give 2 tablets by mouth four times a day for Parkinson's disease. ~ Omeprazole Tablet .Give 20 mg by mouth one time a day for GERD. On 1/9/23, Surveyor reviewed R6's MAR which indicated R6's carbidopa-levodopa was scheduled to be given at 7:00 AM, 11:00 AM, 3:00 PM and 7:00 PM. On 1/9/23 at 12:44 PM, Surveyor interviewed LPN-C regarding R6's carbidopa-levodopa. LPN-C stated, I gave it late because I didn't get to (R6) early this morning. LPN-C further stated, This morning, I passed by (R6's) room and (R6) was sleeping. I wasn't going to wake (R6) for it (carbidopa-levodopa administration). When questioned when R6's next carbidopa-levodopa dose was, LPN-C stated, Eleven (11:00 AM). I gave that one late also. LPN-C stated R6's 11:00 AM dose of carbidopa-levodopa was given at 12:11 PM. LPN-C indicated medications were to be given within one hour before or after the time the dose was scheduled. Additionally, LPN-C verified medications like omeprazole should be given on an empty stomach and stated, Usually before breakfast. LPN-C further stated, Tricky to get everyone before breakfast. On 1/9/23 at 1:06 PM, Surveyor interviewed DON-B who stated, They (nurses) have an hour on each side of scheduled time (to administer medications). DON-B verified if R6 received a 7:00 AM dose of carbidopa-levodopa at 9:41 AM it was considered a medication error. Additionally, DON-B verified medications like omeprazole should be given on an empty stomach and verified it was not the facility's standard of practice to administer omeprazole on a full stomach.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"What changes have you made since the serious inspection findings?"
"Why is there high staff turnover? How do you retain staff?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• Licensed and certified facility. Meets minimum state requirements.

Concerns

• Multiple safety concerns identified: 1 life-threatening violation(s), 1 harm violation(s). Review inspection reports carefully.
• 59 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
• $15,642 in fines. Above average for Wisconsin. Some compliance problems on record.
• Grade F (16/100). Below average facility with significant concerns.

Bottom line: Trust Score of 16/100 indicates significant concerns. Thoroughly evaluate alternatives.

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About This Facility

What is Meadowbrook At Appleton's CMS Rating?

CMS assigns MEADOWBROOK AT APPLETON an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Wisconsin, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Meadowbrook At Appleton Staffed?

CMS rates MEADOWBROOK AT APPLETON's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 60%, which is 14 percentage points above the Wisconsin average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.

What Have Inspectors Found at Meadowbrook At Appleton?

State health inspectors documented 59 deficiencies at MEADOWBROOK AT APPLETON during 2023 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, 56 with potential for harm, and 1 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.

Who Owns and Operates Meadowbrook At Appleton?

MEADOWBROOK AT APPLETON is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by SYNERGY SENIOR CARE, a chain that manages multiple nursing homes. With 104 certified beds and approximately 46 residents (about 44% occupancy), it is a mid-sized facility located in APPLETON, Wisconsin.

How Does Meadowbrook At Appleton Compare to Other Wisconsin Nursing Homes?

Compared to the 100 nursing homes in Wisconsin, MEADOWBROOK AT APPLETON's overall rating (1 stars) is below the state average of 3.0, staff turnover (60%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting Meadowbrook At Appleton?

Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the facility's high staff turnover rate.

Is Meadowbrook At Appleton Safe?

Based on CMS inspection data, MEADOWBROOK AT APPLETON has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Wisconsin. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at Meadowbrook At Appleton Stick Around?

Staff turnover at MEADOWBROOK AT APPLETON is high. At 60%, the facility is 14 percentage points above the Wisconsin average of 46%. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?

Was Meadowbrook At Appleton Ever Fined?

MEADOWBROOK AT APPLETON has been fined $15,642 across 1 penalty action. This is below the Wisconsin average of $33,235. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.

Is Meadowbrook At Appleton on Any Federal Watch List?

MEADOWBROOK AT APPLETON is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 104
Avg. Residents: 46
Occupancy: 44.5%
Ownership: For profit - Corporation
Chain: SYNERGY SENIOR CARE
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
High Turnover: -5
1 Immediate Jeopardy citation: -12
1 Actual Harm citation: -5
59 Deficiencies: -10
Fines ($15,642): -2
Final Score: 16/100

Nearby Alternatives

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Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 525264