CEDARBURG HEALTH SERVICES
For profit - Corporation
50 Beds
NORTH SHORE HEALTHCARE
Data: November 2025
Trust Grade
60/100
#141 of 321 in WI
Last Inspection: January 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Cedarburg Health Services has a Trust Grade of C+, indicating it is slightly above average but not outstanding. It ranks #141 out of 321 nursing homes in Wisconsin, placing it in the top half of facilities statewide, and #2 out of 4 in Ozaukee County, suggesting only one nearby option is better. Unfortunately, the facility's trend is worsening, with issues increasing from 5 in 2024 to 6 in 2025. Staffing is rated average with a turnover rate of 48%, which is consistent with the state average, but it has concerning RN coverage, being less than 83% of similar facilities. While there are no fines on record, indicating no recent compliance issues, there are specific concerns such as staff failing to properly sanitize food preparation areas, leading to potential health risks for residents, and not consistently providing adequate hydration for some residents, which could impact their health.
- Trust Score
- C+
- In Wisconsin
- #141/321
- Safety Record
- Low Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 48% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Wisconsin facilities.
- Skilled Nurses ○ Average
- Each resident gets 41 minutes of Registered Nurse (RN) attention daily — about average for Wisconsin. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 29 deficiencies on record. Higher than average. Multiple issues found across inspections.
60/100
Top 43%
No red flags
5 → 6 violations
★★★☆☆
3.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2024: 5 issues
2025: 6 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
3-Star Overall Rating
Near Wisconsin average (3.0)
Meets federal standards, typical of most facilities
Staff Turnover: 48%
Near Wisconsin avg (46%)
Higher turnover may affect care consistency
Chain: NORTH SHORE HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 29 deficiencies on record
Jan 2025
6 deficiencies
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure a physician was notified of blood sugar levels that were...
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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 physician was notified of blood sugar levels that were outside the ordered parameters for 1 resident (R) (R20) of 15 sampled residents.
R20 had a diagnosis of diabetes and a physician's order that instructed staff to notify the physician if R20's blood sugar level was over 400 (milligrams/deciliter (mg/dL)). On 12/19/24, 12/23/24, and 1/3/25, R20's blood sugar level was over 400 mg/dL. R20's physician was not notified.
Findings include:
The facility's Change in Condition of the Resident policy, dated 9/20/22, indicates: Notifications that do not require immediate consultation with a physician may be made via phone, fax, or method preferred by the physician being contacted. The Center shall develop a method to track faxes sent to ensure timely response.
On 1/22/25, Surveyor reviewed R20's medical record. R20 was admitted to the facility on [DATE] and had a diagnosis of diabetes. R20's Minimum Data Set (MDS) assessment, dated 11/8/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R20 had intact cognition.
R20's care plan indicated R20 had insulin-dependent diabetes.
R20 had a physician order that indicated: Accucheck two times a day for diabetes. Call (physician) if (blood glucose) less than 60 or greater than 400. Before breakfast and before dinner checks.
R20's medical record indicated the following:
~ On 12/19/24, R20 had a blood sugar level of 410.
~ On 12/23/24, R20 had a blood sugar level of 422.
~ On 1/3/25, R20 had a blood sugar level of 421.
R20's medical record did not indicate the physician was notified in accordance with R20's order.
On 1/22/25 at 2:10 PM, Surveyor interviewed [NAME] President of Success (VPS)-E who indicated the facility could not locate physician notifications for R20's blood sugar levels. VPS-E confirmed staff should have notified R20's physician and documented that R20's physician was notified.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility did not ensure adequate supervision during meals for 2 re...
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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 adequate supervision during meals for 2 residents (R) (R24 and R10) of 8 sampled residents observed during mealtime.
R24 had a diagnosis of dysphagia (difficulty swallowing). R24's care plan indicated R24 required full assistance with eating and should be cued to take one sip at a time and slow down. On 1/21/25, R24 was observed eating lunch in the dining room without staff assistance. In addition, staff removed R24 from the dining room after R24 coughed, drooled, and appeared to be in distress during the meal.
R10's care plan indicated R10 had difficulty swallowing and contained interventions to remind R10 to swallow after each bite and take a drink after every 2-3 bites. On 1/21/25, R10 was observed eating lunch in the dining room without staff assistance.
Findings include:
During the survey, the facility indicated they do not have a policy related to dining assistance.
1. From 1/21/25 to 1/23/25, Surveyor reviewed R24's medical record. R24 was admitted to the facility on [DATE] and had diagnoses including Parkinson's disease, dementia, dysphagia, traumatic subdural hemorrhage, traumatic brain injury, and impaired vision. R24's most recent Minimum Data Set (MDS) assessment, dated 12/29/24, indicated R24 had moderate cognitive impairment.
R24 had an activities of daily living (ADL) self-care deficit related to Parkinson's disease, weakness, unsteady gait, and impaired vision care plan. The care plan contained the following interventions: One assist with feeding for all meals; Feed slowly; Double swallow; Drinks in-between bites; Make sure R24 is sitting upright in wheelchair.
R24's nutrition care plan indicated R24 was at risk for nutritional status changes related to Parkinson's disease, dementia, diabetes, inconsistent intake, and texture modified diet. The care plan contained the following interventions: Full assist with eating; Have R24 in the dining room and feed R24; Cue to take 1 sip at a time and to slow down; Cut up meats; Use handled cup.
R24's medical record indicated R24 was discharged from speech therapy on 9/11/24 because R24 reached the maximum potential with skilled services. Speech therapy discharge recommendations included supervision and assistance at meal time for swallow safety.
On 1/21/25 at 12:18 PM, Surveyor observed Licensed Practical Nurse (LPN)-H enter the dining room and sit alone at a table apart from the residents. Surveyor observed LPN-H work on a laptop during lunch service.
On 1/21/25 at 12:22 PM, Surveyor observed R24 eat lunch in the dining room and noted there were no staff seated at the table with R24. Surveyor observed R24 feed R24's self and drink liquids without staff at the table to assist. Surveyor observed R24 cough after eating a bite of food and then cough and drool after taking a drink. LPN-H checked on R24 and then sat back down at a table alone and continued to work on R24's laptop.
On 1/21/25 at 12:24 PM, Surveyor observed R24 continue to eat and drink without staff assistance. Surveyor observed R24 take a drink and then cough, drool, and lean forward in R24's wheelchair. R24 appeared to be in distress. LPN-H continued to work on LPN-H's laptop and did not react to R24. Nursing Home Administrator (NHA)-A (who was assisting with meal trays in the dining room) checked on R24 and removed R24 from the dining room.
On 1/21/25 at 12:27 PM, Surveyor interviewed LPN-H who confirmed LPN-H supervised residents during the lunch meal. LPN-H confirmed R24 was at risk for aspiration and required monitoring during meals. LPN-H indicated it was not required for staff to sit at the table with R24. LPN-H indicated if LPN-H was in the same room as R24 it was considered adequate supervision.
2. From 1/21/25 to 1/23/25, Surveyor reviewed R10's medical record. R10 was admitted to the facility on [DATE] and had diagnoses including dementia, dysphagia following unspecified cerebrovascular disease, aphasia following cerebral infarction, and cerebral vascular accident with residual right sided hemiplegia. R10's most recent MDS assessment, dated 12/24/24, indicated R10 had moderate cognitive impairment.
R10's care plan (dated 12/16/24) indicated R10 required assistance/potential to restore function for eating related to difficulty swallowing. The care plan contained the following interventions: Cue/remind R10 to swallow after each bite; Take small bites; Take a drink after every 2-3 bites; Tell R10 to cough loud when clearing throat.
On 1/21/25 at 12:22 PM, Surveyor observed R10 eat lunch in the dining room and noted there were no staff seated at the table with R10. Surveyor observed R10 feed R10's self and drink liquids without a staff seated at the table to assist.
On 1/21/25 at 12:38 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated DON-B expects two staff to circulate in the dining room to monitor residents during meals. DON-B indicated staff are not expected to sit at the table with residents who require assistance during meals.
On 1/21/25 at 12:50 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-F who indicated CNA-F is sometimes assigned to monitor residents during meal time in the dining room. CNA-F indicated staff circulate around to assist all residents during meal time. CNA-F confirmed staff do not sit at a table with residents to assist with meals.
On 1/21/25 at 1:03 PM, Surveyor interviewed NHA-A who indicated NHA-A expects staff to sit next to residents who require assistance with meals. NHA-A indicated the seated staff should monitor residents for aspiration and provide feeding assistance.
On 1/22/25 at 1:43 PM, Surveyor interviewed Speech Therapist (ST)-G who reviewed R24 and R10's care plans. ST-G indicated a staff should be seated next to R24 and R10 during meals to supervise, set up, and cue R24 and R10.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility did not ensure the accurate administration of medication ...
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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 accurate administration of medication for 3 residents (R) (R13, R18, and R19) of 15 sampled residents.
R13's physician order for fluticasone (a nasal spray) indicated not to keep fluticasone at the bedside. On 1/21/25, fluticasone was observed at R13's bedside.
R18's medication administration record (MAR) did not accurately reflect the time polyethylene glycol (an osmotic laxative) was administered on 1/22/25.
Staff administered hydralazine (a vasodilator medication used to lower blood pressure) to R19 on 1/22/25 prior to obtaining R19's blood pressure in accordance with the physician's order. In addition, R19's MAR did not accurately reflect the time polyethylene glycol was administered on 1/22/25.
Findings include:
The facility's Medication Administration Self-Administration by Resident policy, dated 1/2023, indicates: Residents who desire to self-administer medication are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe and the medications are appropriate and safe for self-administration.
The facility's Medication Administration General Guidelines policy, dated 1/23, indicates: The individual who administered the medication records the administration on the resident's medication administration record (MAR) immediately following the medication being given .Obtain and record any vital signs as necessary prior to medication administration .
1. From 1/21/25 to 1/23/25, Surveyor reviewed R13's medical record. R13 was admitted to the facility on [DATE] and had a diagnosis of allergic rhinitis. R13's Minimum Data Set (MDS) assessment, 1/21/25, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R13 had intact cognition.
On 1/21/25 at 11:01 AM, Surveyor interviewed R13 in R13's room and observed a bottle of fluticasone nasal spray on R13's bedside table.
R13's medical record contained the following:
~ R13 was prescribed Flonase Allergy Relief Nasal Suspension 50 micrograms/actuation (mcg/act) (Fluticasone Propionate); 1 spray in both nostrils every morning and at bedtime for allergic rhinitis. The order indicated: May not keep at bedside, nursing to store in med cart.
~ A self-administration of medication assessment, dated 12/18/23, indicated R13 was aware of the use and administration times for fluticasone but had over-used nasal sprays in the past. The assessment indicated R13 was not safe to self-administer fluticasone and fluticasone should not be kept at the bedside.
~ A self-administration of medication assessment, dated 12/4/24, indicated R13 preferred that staff administer medications.
On 1/22/25 at 10:21 AM, Surveyor interviewed Registered Nurse (RN)-D who worked regularly with R13. When Surveyor informed RN-D that R13 had fluticasone at the bedside, RN-D indicated R13 was able to keep fluticasone at the bedside. When RN-D reviewed R13's order for fluticasone, RN-D confirmed the order indicated fluticasone should not be kept at R13's bedside. RN-D indicated RN-D would remove fluticasone from R13's room.
On 1/22/25 at 10:50 AM, Surveyor interviewed Director of Nursing (DON)-B who confirmed if R13's order states not to leave fluticasone at the bedside, staff should not leave fluticasone at R13's bedside. DON-B indicated if staff set medications at R13's bedside, R13 sometimes takes the medications and staff have difficulty getting the medications back.
2. From 1/21/25 to 1/23/25, Surveyor reviewed R18's medical record. R18 was admitted to the facility on [DATE] and had diagnoses including dementia, cancer, and diabetes mellitus. R18's most recent MDS assessment, dated 1/23/25, indicated R18 had moderate cognitive impairment.
On 1/22/25 at 8:54 AM, Surveyor observed RN-D prepare and administer medication to R18. Surveyor did not observe RN-D administer polyethylene glycol.
Following the observation, Surveyor reviewed R18's MAR and noted RN-D documented that RN-D administered polyethylene glycol to R18 at 9:24 AM.
On 1/22/25 at 11:24 AM, Surveyor Interviewed RN-D who confirmed RN-D did not administer polyethylene glycol to R18 at the time it was documented in the MAR. RN-D indicated R18 preferred to take polyethylene glycol early in the day, therefore, RN-D had administered polyethylene glycol earlier.
On 1/22/25 at 3:46 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated staff should document medication administration at the time the medication is administered.
3. From 1/21/25 to 1/23/25, Surveyor reviewed R19's medical record. R19 was admitted to the facility on [DATE] and had diagnoses including stroke with hemiplegia and seizure disorder. R19's most recent MDS assessment, dated 12/30/24, indicated R19 had moderate cognitive impairment.
On 1/22/25 at 9:02 AM, Surveyor observed RN-D prepare and administer medication to R19, including one hydralazine HCL 10 mg tablet. Surveyor did not observe RN-D obtain R19's blood pressure prior to administering hydralazine. In addition, Surveyor did not observe RN-D administer polyethylene glycol to R19.
Following the observation, Surveyor reviewed R19's MAR and noted R19's hydralazine HCL order contained instructions to hold the medication if R19's systolic blood pressure was less than 110. Surveyor also noted R19's MAR indicated RN-D administered polyethylene glycol at the same time R19's other AM medications were administered (9:23 AM).
On 1/22/25 at 11:25 AM, Surveyor interviewed RN-D who verified RN-D did not obtain R19's blood pressure prior to administering hydralazine. RN-D also verified RN-D documented that RN-D administered polyethylene glycol to R19 at 9:23 AM, but had not yet administered the medication. RN-D indicated R19 preferred to take polyethylene glycol later in the day.
On 1/22/25 at 3:29 PM, RN-D informed Surveyor that RN-D had just administered R19's polyethylene glycol. Surveyor noted R19's MAR still indicated R19 was administered polyethylene glycol at 9:23 AM.
On 1/22/25 at 3:46 PM, Surveyor interviewed NHA-A who indicated staff should document medication administration at the time the medication is administered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility did not ensure it was free a medication error rate of 5% ...
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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 it was free a medication error rate of 5% or greater. During medication administration observations, 3 errors occurred during 30 opportunities which resulted in a 10% medication error rate that affected 1 resident (R) (R19) of 5 residents observed during medication administration.
During medication administration observations for R19 on 1/22/25, staff did not administer Biofreeze menthol topical analgesic (a pain relieving treatment), cholecalciferol (a vitamin supplement), or levetiracetam (a seizure medication) as ordered.
Findings include:
1. From 1/21/25 to 1/23/25, Surveyor reviewed R19's medical record. R19 was admitted to the facility on [DATE] and had diagnoses including stroke with hemiplegia, hypertension, and seizure disorder. R19's most recent Minimum Data Set (MDS) assessment, dated 12/30/24, indicated R19 had moderate cognitive impairment.
On 1/22/25 at 9:02 AM, Surveyor observed Registered Nurse (RN)-D prepare and administer 13 medications to R19. RN-D stated RN-D was administering Biofreeze but applied Diclofenac 1% topical cream to R19's legs.
Surveyor reviewed R19's medication administration record (MAR) and noted R19 did not have an order for Diclofenac 1% topical cream. R19 had an order for Biofreeze 4% menthol external gel to be applied three times a day to the left hip. RN-D documented on R19's MAR that Biofreeze was administered during the medication pass. Surveyor also noted that RN-D documented that cholecalciferol 25 micrograms (mcg) 1 tablet was administered, however, Surveyor did not observe RN-D administer cholecalciferol. In addition, Surveyor noted R19 had an order for levetiracetam twice daily but did not observe RN-D administer levetiracetam during the medication pass.
On 1/22/25 at 11:25 AM, Surveyor interviewed RN-D who confirmed RN-D did not administer levetiracetam at the scheduled time of 7:30 AM because the medication was not available. RN-D could not recall if cholecalciferol was administered.
On 1/22/25 at 3:46 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated staff should document a medication as administered when the medication is administered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, and record review, the facility did not ensure all drugs or biologicals were discarded when expired in 1 of 2 medication rooms in the facility.
On 1/21/25, expir...
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Based on observation, staff interview, and record review, the facility did not ensure all drugs or biologicals were discarded when expired in 1 of 2 medication rooms in the facility.
On 1/21/25, expired stock medications were observed in a cabinet and refrigerator in the 400 unit medication room.
Findings include:
The facility's Disposal of Medications, Syringes and Needles policy, dated 2007, indicates: .5. Dispose of discontinued medications within 90 days of the date the medication was discontinued .7. Outdated medications .shall be destroyed according to the above policy .
On 1/21/25 at 11:06 AM, Surveyor and Director of Nursing (DON)-B observed medications stored in the medication room on the 400 unit and noted the following expired medications in the floor stock medication cabinet:
~ An unopened bottle of diphenhydramine HCL 25 milligram (mg) tablets with an expiration date of 10/2024
~ An open bottle of diphenhydramine HCL 25 mg tablets with an expiration date of 6/2024
~ An unopened bottle of loratadine 10 mg tablets with an expiration date of 10/2024
Surveyor and DON-B observed the following expired medications in the medication refrigerator:
~ An open box of acetaminophen 650 mg suppositories with an expiration date of 12/2024
~ A COVID-19 vaccine with an expiration date of 5/4/24
Following the observations, DON-B confirmed the above medications were expired and should have been discarded.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control prog...
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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 maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 2 residents (R) (R9 and R15) of 4 sampled residents.
R9 and R15 had symptoms of an upper respiratory infection and were not placed on precautions in a timely manner.
Findings include:
The facility's Transmission Based (Isolation) Precautions policy, revised 9/24/24, indicates: 1. Facility staff will apply transmission based precautions, in addition to standard precautions, to residents who are known or suspected to be infected or colonized with certain infectious agents requiring additional controls to prevent transmission. 2. The facility will use standard approaches, as defined by the Centers for Disease Control and Prevention (CDC) for transmission based precautions; airborne, contact, and droplet precautions. 9. Initiation of Transmission Based Precautions (Isolation Precautions): a. Nursing staff may place residents with suspected or confirmed infectious diarrhea, influenza, or symptoms consistent with a communicable disease on transmission based precautions/isolation empirically while awaiting confirmation .11. Droplet Precautions: a. Intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions (i.e., respiratory droplets that are generated by a resident who is coughing, sneezing, or talking.)
The CDC indicates at https://www.cdc.gov/long-term-care-facilities/hcp/respiratory-virus-toolkit/index.html Viral Respiratory Pathogens Toolkit for Nursing Homes, dated 1/8/25: Healthcare personnel (HCP) who enter the room of a resident with signs or symptoms of an unknown respiratory viral infection that is consistent with SARS-CoV-2 infection should adhere to standard precautions and use a NIOSH-approved® particulate respirator with N95® filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). This personal protective equipment (PPE) can be adjusted once the cause of the infection is identified. Test anyone with respiratory illness signs or symptoms. Selection of diagnostic tests will depend on the suspected cause of the infection (e.g., which respiratory viruses are circulating in the community or the facility, recent contact with someone confirmed to have a specific respiratory infection) and if the results will inform clinical management (e.g., treatment, duration of isolation). At a minimum, testing should include SARS-CoV-2 and influenza viruses with consideration for other causes (e.g., RSV).
1. From 1/21/25 to 1/23/25, Surveyor reviewed R9's medical record. R9 was admitted to the facility on [DATE] and had diagnoses including multiple sclerosis and depression. R9's Minimum Data Set (MDS) assessment, dated 12/16/24, had a Brief Interview for Mental status (BIMS) score of 15 out of 15 which indicated R9 had intact cognition. R9's medical record indicated R9 had an Activated Power of Attorney for Healthcare (POAHC).
A progress note, dated 1/19/25 at 7:09 PM, indicated R9 complained of a headache, nasal congestion, and sore throat. R9's temperature was 99.7 degrees. Tylenol was administered. R9's COVID-19 test was negative.
A progress note, dated 1/20/25 at 11:58 AM, indicated R9 complained of a sore throat and headache over the weekend and tested negative for COVID-19 on 1/18/25. R9 was tested again for COVID-19 on 1/20/25 and was negative. R9 did not have a sore throat, fatigue, or headache. Tylenol was administered for pain.
A progress note, dated 1/21/25 at 3:35 AM, indicated R9 was weak, febrile, and congested. Tylenol was administered.
On 1/21/25 at 10:28 AM, Surveyor interviewed R9 and noted there was not a contact or droplet precaution sign on R9's door or a personal protective equipment (PPE) cart inside or outside R9's room.
A progress note, dated 1/21/25 at 7:23 PM, indicated R9's face was flushed and R9 complained of achy muscles and chills. R9's lungs contained crackles. R9 was sent to the emergency room (ER).
A progress note, dated 1/21/25 at 11:17 PM, indicated R9 was diagnosed with influenza A and returned from the ER with a precaution sign and PPE in place.
A progress note, dated 1/22/25 at 2:38 AM, indicated R9 had chills, body aches, wheezing, and complained of weakness. R9 returned from the ER and indicated R9 wanted to sleep. Droplet isolation precautions were initiated.
A progress note, dated 1/22/25 at 1:21 PM, indicated R9 was tired and slept most of the AM shift. R9 denied a headache, cough, or congestion. Tamiflu was ordered.
On 1/23/25 at 9:58 AM. Surveyor interviewed Infection Preventionist (IP)-C who indicated R9 was tested for COVID-19 twice due to complaints of nasal congestion, sore throat, fever, and headache and both tests were negative. IP-C indicated R9 was assessed on 1/20/25 and did not have any respiratory symptoms. IP-C indicated IP-C was notified by nursing staff on 1/21/25 that R9 complained of a sore throat, congestion, fever, and a headache and was placed on droplet precautions. The physician was updated on 1/21/25 at 8:09 AM and ordered R9 be evaluated in the ER where R9 was diagnosed with influenza A. IP-C verified R9 was symptomatic of upper respiratory symptoms starting on 1/19/25 and was not put on droplet precautions until 1/21/25 at 11:37 PM.
2. From 1/21/25 to 1/23/25, Surveyor reviewed R15's medical record. R15 was admitted to the facility on [DATE], received Hospice services, and had diagnoses including malignant neoplasm of endometrium and encounter for palliative care. R15's MDS assessment, dated 12/20/24, had a BIMS score of 13 out of 15 which indicated R15 had intact cognition.
On 1/21/25 at 9:37 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated one resident was on isolation precautions for COVID-19. NHA-A indicated the resident had just tested negative but would remain on isolation precautions for the full 10 days.
On 1/21/25 at 11:20 AM, Surveyor interviewed R15 who was in bed. R15 indicated R15 did not feel well, had a sore throat and cough, and was congested. R15 indicated R15's symptoms started a couple of days prior. Surveyor did not observe a precautions sign or PPE cart near R15's door.
R15's medical record indicated R15 was administered guaifenesin (Robitussen) oral tablet 200 milligrams (mg) for allergies, cough and congestion on 1/17/25 at 2:02 PM and 1/20/25 at 3:05 PM.
On 1/22/25 at 10:20 AM, Surveyor interviewed Registered Nurse (RN)-D who confirmed R15 was congested and RN-D placed oxygen on R15 that morning. RN-D indicated RN-D thought Director of Nursing (DON)-B contacted the physician that morning regarding R15. RN-D confirmed R15 was not on precautions.
On 1/22/25 at 10:36 AM, Surveyor interviewed IP-C who was not aware that R15 had illness symptoms. IP-C indicated if R15 had illness symptoms, R15 should be on precautions.
On 1/22/25 at 10:44 AM, Surveyor interviewed DON-B who confirmed nurses can put a resident on precautions if they have illness symptoms. DON-B indicated DON-B did not contact R15's physician and was not aware that R15 had illness symptoms. DON-B indicated DON-B would expect R15 to be on precautions, however, R15 was on Hospice and Hospice directed R15's care. DON-B confirmed staff should put precautions in place for residents at symptom onset while figuring out what testing should be completed.
On 1/23/25, Surveyor noted R9 (in the previous example) had tested positive for Influenza A.
Oct 2024
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
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff and resident interview, the facility did not ensure 2 residents (R) (R13 and R9) of 14 sampled re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff and resident interview, the facility did not ensure 2 residents (R) (R13 and R9) of 14 sampled residents had hot water in their bathrooms.
During observations on 10/4/24, R13 and R9's bathroom sinks did not have hot water.
Findings include:
1. On 10/4/24, Surveyor reviewed R13's medical record. R13 was admitted to the facility on [DATE] with diagnoses including congestive heart failure and diabetes mellitus. R13's Minimum Data Set (MDS) assessment, dated 8/24/24, stated R13's Brief Interview for Mental Status (BIMS) score was 14 out of 15 which indicated R13 had intact cognition. R13's MDS assessment also indicated R13 required staff set up/supervision for oral hygiene and toileting and moderate assistance for bathing. R13's medical record indicated R13 was responsible for R13's healthcare decisions.
On 10/4/24 at 9:21 AM, Surveyor entered R13's bathroom and tested the hot water. Surveyor noted there was no hot water in the sink. R13 was not in R13's room at the time.
On 10/4/24 at 2:44 PM, Surveyor interviewed R13 who indicated R13 had not had hot water since June. R13 indicated it would be nice to have hot water and stated staff brought a basin of hot water from down the hall. R13 indicated the lack of hot water made R13 feel crummy and made R13 not like R13's room. R13 also indicated R13 was frustrated and wanted to wash R13's hands with soap and warm water and brush R13's teeth without waiting so long.
2. On 10/4/24, Surveyor reviewed R9's medical record. R9 was admitted to the facility on [DATE] with diagnoses including dementia, anxiety, and depression. R9's MDS assessment, dated 9/29/24, stated R9's BIMS score was 11 out of 15 which indicated R9 had moderate cognitive impairment. R9's MDS assessment also indicated R9 was dependent on staff for personal hygiene, toileting, and bathing. R9's medical record indicated R9's Power of Attorney for Healthcare (POAHC) was responsible for R9's healthcare decisions.
On 10/4/24 at 9:25 AM, Surveyor entered R9's bathroom and tested the hot water. Surveyor noted there was no hot water in the sink. R9 was not in R9's room at the time.
On 10/4/24 at 1:44 PM, Surveyor interviewed R9 who indicated R9 was upset because there was no hot water in R9's bathroom sink.
On 10/4/24 at 2:39 PM, Surveyor again interviewed R9 regarding the lack of hot water. R9 indicated staff brought hot water in a basin from another room which slowed down R9's activities of daily living (ADL) cares. R9 also indicated R9 would like hot water in R9's sink.
On 10/4/24 at 10:08 AM, Surveyor interviewed Maintenance Manager (MM)-C who confirmed the facility had an underground leak in February and excavated multiple times to fix the water pipes which were ultimately unredeemable. Per MM-C, the facility completed a project to install hot water. The facility recently discovered issues with water pipes under the therapy gym and there was no way to bypass the pipes which led to a whole building water shut down in August. Per MM-C, temporary water lines were installed overhead in order to run water to units. MM-C confirmed 3 rooms did not have hot water, including R13 and R9's rooms and one unoccupied room. MM-C indicated the first project approval took a month and the facility needed another approval to fix the pipes and ensure all rooms had hot water.
On 10/4/24 at 3:37 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who confirmed R13 and R9's rooms did not have hot water. NHA-A indicated the facility tried to transition residents out of the rooms and were working on fixing the water pipes.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident representative interview and record review, the facility did not ensure a grievance was thoroughly r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident representative interview and record review, the facility did not ensure a grievance was thoroughly resolved for 1 resident (R) (R3) of 14 sampled residents.
Resident Representative (RR)-H filed a grievance on behalf of R3 on 8/8/24 that indicated R3 experienced a delayed call light response time and was not attended to in a timely manner. The facility did not resolve the grievance in a timely manner.
Findings include:
The facility's Grievance Policy, with a revision date of 7/2022, indicates: When a complaint/grievance report is initiated: .The Department Head that is assigned the concern form is responsible for investigating the issue and following up to provide a resolution to the issue within 72 hours of being assigned the grievance.
The facility's Call lights: Accessibility and Timely Response policy, with a revision date of 8/8/24, indicates: .10. All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified. 11. Process for responding to call lights: a. Turn off the signal light in the resident's room. b. Identify yourself and call the resident by name. c. Listen to the resident's request and respond accordingly. Inform the resident if you cannot meet the need and assure him/her that you will notify the appropriate personnel. d. Inform the appropriate personnel of the resident's need. e. Do not promise something you cannot deliver. f. If assistance is needed with a procedure, summons help by using the call light. Stay with the resident until help arrives.
On 10/4/24, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] with diagnoses including dementia and overactive bladder. R3 received Hospice services and had an activated Power of Attorney for Healthcare (POAHC) who was noted as the first contact in R3's medical record. RR-H was noted as the second contact.
R3's care plan contained the following interventions: Toileting assistance with 2 staff; Transfer with sit-to-stand lift; Provide assistance with toileting; Remind and assist as needed with toileting at routine times such as upon arising in AM, before/after meals, activities, therapy and at bedtime.
On 10/4/24, Surveyor reviewed a grievance, dated 8/8/24, that contained a concern from RR-H that R3's call light was on for a period of time and was not answered in a timely manner. Nursing Home Administrator (NHA)-A was the individual designated to take action on the concern. The date to be resolved was 8/10/24. Actions to be taken included: NHA-A to do call light audits for three weeks; Continuous education for nursing staff on the call light policy. The grievance contained call light response time education that indicated the following: Objective: 1) Answer call lights in a timely manner. 2) Call lights are to be accessible to residents at all times. 3) All staff members can assist with call lights. A document titled Call Light Response Times was included with the education and indicated: Ensuring the imperativeness of answering call lights in a timely manner is paramount in any healthcare setting to guarantee patient safety, satisfaction, and overall well-being. Prompt response to call lights is a critical component of patient care, reflecting the attentiveness and responsiveness of the healthcare staff. It helps in addressing immediate needs, reducing anxiety, and preventing potential complications, such as falls or unmanaged pain. Staff signatures accompanied the document.
Surveyor reviewed another grievance form, dated 9/9/24, that was initiated by a former resident's family member and contained multiple concerns, including call light response time. The resolution portion of the grievance indicated NHA-A conducted audits for 3 weeks. Staff education was not part of the grievance.
On 10/4/24 at 9:05 AM, Surveyor interviewed R3's POAHC (POAHC-I) who indicated on the evening of 9/25/24 and 9/26/24, nursing staff responded to R3's call light and said R3 had to wait to use the bathroom because supper was on the way. POAHC-I indicated staff turned off R3's call light and did not return to assist R3 to the bathroom.
Surveyor reviewed the staff signatures of those who were educated on answering call lights for R3's 8/8/24 grievance. Surveyor compared the signatures to the staff who worked on 9/25/24 and 9/26/24. Surveyor noted Certified Nursing Assistant (CNA)-D, CNA-E, CNA-F, and CNA-G were assigned to R3's wing on 9/25/24 or 9/26/24; however, only CNA-D was listed on the staff signatures sheets as having received call light response time education.
On 10/4/24 at 10:30 AM, Surveyor interviewed RR-H who was visiting R3 in R3's room. RR-H indicated RR-H visited daily in the morning through lunch except for Sundays and POAHC-I visited in the afternoon through supper. RR-H indicated R3 sometimes went 5 hours without being assisted to the bathroom by staff. RR-H indicated in the morning when R3 has to use the bathroom, staff say Hospice will take R3. RR-H indicated Hospice staff come to the facility some mornings. RR-H indicated when RR-H lets staff know that R3 has to use the bathroom, staff don't assist R3 and say Hospice will be there soon. RR-H indicated nursing staff enter R3's room when R3's call light is on, turn off the call light, say they will be back when they find another person to assist, but then don't come back. RR-H indicated some staff use the sit-to-stand lift with two staff and some say they do not need two staff and use the lift alone. RR-H also said some staff come in and turn off the call light, do not say anything at all, and leave the room. RR-H indicated R3's skin has been raw due to R3 being left in urine and stool. RR-H indicated staff do not typically assist R3 before meals to the bathroom and some say they will help R3 after lunch but lunch varies and can last from 12:30 PM to 2:00 PM. RR-H verified CNAs pass room trays. RR-H indicated Hospice staff assisted R3 to the bathroom that morning at 10:00 AM.
On 10/4/24 at 11:00 AM, Surveyor interviewed CNA-D who confirmed the majority of residents eat in their rooms and CNAs deliver room trays. CNA-D indicated call lights are answered unless staff are in the middle of passing trays because CNAs need to be careful to not cross-contaminate.
On 10/4/24 at 12:08 PM, Surveyor noted staff had not started to pass meal trays. Surveyor interviewed RR-H who was still visiting R3 in R3's room. RR-H indicated R3 had not been toileted before the lunch meal as of that time.
On 10/4/24 at 12:20 PM, Surveyor noted meal trays were being served on R3's wing.
On 10/4/24 at 12:53 PM, Surveyor interviewed NHA-A who confirmed of the 4 CNAs assigned to R3's wing on 9/25/24 and 9/26/24, only one CNA was listed on the staff signature sheet as having received call light education. NHA-A indicated the training format was a read and sign related to call light accessibility and timely response.
On 10/4/24 at 2:05 PM, Surveyor interviewed POAHC-I who was visiting R3 in R3's room. POAHC-I indicated on 9/25/24, R3's call light was activated at 4:30 PM. Staff entered R3's room, turned off the call light, and said they would help R3 after supper. Supper arrived at 6:00 PM and POAHC-I asked staff if they could assist R3 to the bathroom but was told R3 had to wait. POAHC-I indicated staff assisted R3 at 7:45 PM.
On 10/4/24 at 3:04 PM, Surveyor interviewed Hospice Staff (HS)-J who indicated HS-J visited R3 on Monday, Wednesday, and Friday mornings at 9:30 AM. HS-J indicated sometimes R3 had not been assisted up or to the bathroom yet when HS-J arrived .
Apr 2024
3 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
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
Based on staff interview and record review, the facility did not ensure thorough background checks were completed for 2 of 8 sampled staff.
The facility did not ensure a Department of Justice (DOJ) le...
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Based on staff interview and record review, the facility did not ensure thorough background checks were completed for 2 of 8 sampled staff.
The facility did not ensure a Department of Justice (DOJ) letter and State of Wisconsin Department of Health Services (DHS) Governmental Findings Report (GFR) (formerly known as the Integrated Background Information System (IBIS) letter) were obtained for Certified Nursing Assistant (CNA)-C and CNA-E prior to hire.
Findings include:
The Wisconsin Background Check and Misconduct Investigation Program Manual by the Department of Health Services, revised January 2024, indicates: An entity is required to complete caregiver background checks on caregivers. At a minimum, a complete caregiver background check completed for a caregiver consists of the following three documents:
1. A completed DHS F-82064 (Background Information Disclosure) form.
2. A response from the DOJ, either
~A 'no record found' response or
~A criminal record transcript; and
3. A GFR from DHS that reports the person's status, including administrative finding or licensing restrictions.
The facility's Abuse, Neglect, and Exploitation policy, reviewed/revised on 7/15/22, indicates: The components of the facility's abuse prohibition plan are discussed herein: I. A. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference, and credentials checks shall be conducted on potential employees .Background checks .will be completed consistent with applicable state laws and regulation.
On 4/4/24, Surveyor selected a sample of eight staff to review for background checks, including CNA-C and CNA-E.
Surveyor noted CNA-C was hired on 10/24/23, however, CNA-C's DOJ letter and GFR were not obtained until 11/20/23.
Surveyor noted CNA-E was hired on 10/2/23, however, CNA-E's DOJ letter and GFR were not obtained until 1/17/24.
On 4/4/24 at 2:03 PM, Surveyor interviewed [NAME] President of Success (VPS)-D who indicated an audit was done on 11/20/23 by the Human Resources (HR) Support Center that indicated CNA-C did not have a background check and CNA-C's DOJ letter and GFR (IBIS letter) were obtained on 11/20/23. VPS-D provided Surveyor with a copy of the facility's Performance Improvement Plan (PIP) to implement audits of background checks starting on 11/21/23. The action item: Ensure each new employee has a background check completed prior to first day on the job was reviewed by HR Support Center staff to ensure the facility was in compliance as of 12/20/23. VPS-D verified CNA-E was hired on 10/2/23 and did not have a DOJ letter or GFR completed until 1/17/24. VPS-D confirmed background screening should have been completed prior to hire.
On 4/4/24 at 2:45 PM, Surveyor interviewed Scheduler (SC)-E who indicated SC-E was unsure why CNA-E's background check was not completed prior to hire because SC-E did not start as the Scheduler/HR assistant until 2/24/24. SC-E was also unsure if a new PIP was completed after CNA-E's background check was not completed 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
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 1...
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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 allegation of abuse was thoroughly investigated for 1 resident (R) (R2) of 1 sampled resident.
R2 reported care and treatment concerns. The facility did not thoroughly investigate the allegation of abuse.
Findings include:
The facility's Abuse Neglect and Exploitation policy, reviewed/revised on 7/15/22, indicates: V. Investigation of Alleged Abuse, Neglect and Exploitation .B. Written procedures for investigations include .4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations(s) .6. Providing complete and thorough documentation of the investigation .VII. Reporting/Response .B. The Administrator will follow up with government agencies to report the results of the investigation when final within 5 working days of the incident, as required by State Agencies.
On 4/4/24, Surveyor reviewed R2's medical record. R2's diagnoses included paroxysmal atrial fibrillation (irregular heartbeat), malignant neoplasm of ampulla of [NAME] (cancerous tumor of the duct formed by the union of the common bile duct and pancreatic duct within the wall of the small intestine), status post decompression and fusion of cervical vertebras 1 and 2, and polyneuropathies. R2's Minimum Data Set (MDS) assessment, dated 12/14/23, contained a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R2 had intact cognition. R2 was responsible for R2's health care decisions.
On 4/4/24, Surveyor reviewed a facility-reported incident (FRI) that involved an allegation of abuse related to R2.
The investigation indicated on 12/10/23 at approximately 9:30 AM, CNA-C provided morning care for R2. R2 reported to R2's daughter that CNA-C was too rough and stated the incident was painful, uncomfortable, and caused R2 to cry. R2's daughter reported the allegation of abuse to a nurse on the PM shift. CNA-C was suspended pending the results of the investigation. The police were notified and conducted an onsite visit which included an interview with R2. The police investigation indicated a crime was not committed.
Surveyor noted the investigation did not include a 5-day report submitted to the State Agency (SA), an interview with R2 and other residents cared for by CNA-C, an interview with CNA-C and other staff, and documentation that R2's physician was notified. Surveyor also noted R2's activities of daily living (ADLs) and pain care plans were not reviewed or revised following the incident.
On 4/4/24 at 11:48 AM, Surveyor interviewed [NAME] President of Success (VPS)-D who indicated VPS-D spoke with Nursing Home Administrator (NHA)-A and verified NHA-A did not know where the interviews with R2, other residents, and staff were located. VPS-D did not provide the above-mentioned interviews and agreed the interviews should have been included in the investigation.
On 4/4/24 at 1:30 PM, Surveyor interviewed VPS-D who verified that although the investigation summary indicated R2's provider was notified, VPS-D could not provide documentation that R2's provider was notified.
On 4/4/24 at 1:34 PM, Surveyor interviewed VPS-D and Director of Nursing (DON)-B who verified they could not locate the 5-day investigation in the Misconduct Incident Reporting (MIR) system (used by facilities to report incidents to the SA). VPS-D also verified R2's ADL and pain care plans were not updated following the incident and did not contain an intervention(s) that informed staff how to move R2 during toileting to prevent or decrease pain. VPS-D stated R2's plan of care should have been updated.
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
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected multiple residents
**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 fluids were provided on a con...
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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 fluids were provided on a consistent basis for 4 residents (R) (R3, R4, R5, and R6) of 4 sampled residents.
R3, R4, R5 and R6 did not receive fresh drinking water on a consistent basis or in accordance with their nutritional assessment.
Findings include:
The facility's Hydration policy, with a review date of 7/26/22, indicates each resident should be offered sufficient fluids, to include water and other liquids, based on resident preferences and needs, to maintain proper hydration and health. This includes ensuring fluids are available and within reach.
1. R3 was admitted to the facility on [DATE] with diagnoses including morbid obesity with alveolar hypoventilation, type 2 diabetes mellitus with diabetic neuropathy, chronic diastolic (congestive) heart failure, irritable bowel syndrome without diarrhea, and gastroesophageal reflux disease without esophagitis. R3's Minimum Data Set (MDS) assessment, dated 1/30/24, contained a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R3 had intact cognition. R3's care plan contained an intervention for staff to encourage and assist R3 as needed to consume foods and/or supplements and fluids offered.
On 4/4/24 at 11:53 AM, Surveyor interviewed R3 who stated at times staff are either too busy to fill R3's water cup or take R3's water cup and don't bring it back. Surveyor observed and touched the outside of R3's water cup and noted the water was at what appeared to be room temperature. R3 was unsure when the cup was provided.
On 4/4/24, Surveyor reviewed R3's medical record including a Nutritional Assessment, dated 1/24/24, that indicated R3 received a controlled carbohydrate (CCHO) cardiac diet with thin liquids. The Nutritional Assessment indicated R3 had a recommended estimated total daily fluid intake between 1960-2287 ccs (cubic centimeters). Documentation for March of 2024 indicated R3 received [PHONE NUMBER] ccs of fluid per day. The documentation contained 40 incomplete entries and 26 entries that indicated R3 refused fluids.
2. R4 was admitted to the facility on [DATE] with diagnoses including traumatic subarachnoid hemorrhage without loss of consciousness, depression, and anxiety. R4's MDS assessment, dated 3/7/24, contained a BIMS score of 11 out of 15 which indicated R4 had moderate cognitive impairment.
On 4/4/24 at 10:44 AM, Surveyor interviewed R4 who stated R4 wanted water every night but ice and water were rare. Surveyor observed an empty water cup on R4's bedside table.
On 4/4/24, Surveyor reviewed R4's medical record including a Nutritional Assessment, dated 3/6/24, that indicated R4 received a regular diet and had a recommended estimated total daily fluid intake between 2695-3144 ccs. Documentation for March of 2024 indicated R4 received [PHONE NUMBER] ccs of fluid per day and contained 45 incomplete entries.
3. R5 was readmitted to the facility on [DATE] with diagnoses including chronic diastolic (congestive) heart failure, and a history of urinary (tract) infections. R5's MDS assessment, dated 3/29/24, contained a BIMS score of 10 out of 15 which indicated R5 had moderate cognitive impairment.
On 4/4/24 at 12:00 PM, Surveyor interview R5 who stated staff do not always have time to pass water. R5 indicated several residents expressed water concerns to administration and stated there are some evenings when R5 is dying of thirst.
On 4/4/24, Surveyor reviewed R5's medical record including a Nutritional Assessment, dated 3/27/24, that indicated R5 received a regular diet and had a recommended estimated total daily fluid intake between 1886-2113 ccs. Documentation for March of 2024 indicated R5 received between [PHONE NUMBER] ccs of fluid per day and contained 26 incomplete entries.
4. R6 was admitted to the facility on [DATE] with diagnoses including cerebral palsy, unspecified. R6's MDS assessment, dated 3/10/24, contained a BIMS score of 14 out of 15 which indicated R6 had intact cognition.
On 4/4/24 at 12:10 PM, Surveyor interviewed R6 who indicated R6's ability to receive water on a regular basis depended on the staff and how busy they were. Surveyor observed an almost empty water cup next to R6 who indicated the water was from the previous evening.
On 4/4/24, Surveyor reviewed R6's medical record which included a Nutritional Assessment, dated 3/6/24, that indicated R6 received a regular diet and had a recommended estimated total daily fluid intake between 2045-2250 ccs. Documentation for March of 2024 indicated R6 received between 0-1200 ccs of fluid per day and contained 29 incomplete entries.
On 4/4/24 at 11:47 AM, Surveyor interviewed Medication Technician (MT)-H who stated staff should pass water every few hours and during medication pass. MT-H stated MT-H felt there were times when water was not passed as it should be.
On 4/4/24 at 12:57 PM, Surveyor interviewed Director of Nursing (DON)-B who stated DON-B expects Certified Nursing Assistants (CNAs) to pass water every shift and as requested by residents. DON-B stated DON-B was not aware residents had concerns with receiving water.
Nov 2023
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
**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 2 Residents (R) (R17 and R36)...
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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 2 Residents (R) (R17 and R36) of 2 sampled residents had a self-administration of medication assessment, or a physician's order to self-administer medication and keep medication at the bedside.
R17 kept a nasal spray and multivitamins on R17's bedside table and stated R17 self-administered both medications. R17 did not have a physician's order to self-administer medication or a self-administration of medication assessment that indicated R17 could safely and accurately self-administer medication.
R36 kept a bottle of iron on R36's bedside table and stated R36 self-administered the medication. R36 did not have a physician's order to self-administer medication or a self-administration of medication assessment that indicated R36 could safely and accurately self-administer medication.
Findings include:
The facility's Medication Administration Self-Administration by Resident policy, revised January 2023, indicated: Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe and the medications are appropriate and safe for self-administration.
1. R17 was admitted to the facility on [DATE] with diagnosis including history of diabetes, coronary artery disease, and hypertension. R17's Minimum Data Set (MDS) assessment, dated 10/21/23, contained a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R17 was not cognitively impaired. R17 did not have an activated Power of Attorney for Healthcare (POAHC).
On 11/27/23 at 11:40 AM, Surveyor observed a bottle of multivitamins and fluticasone nasal spray on R17's bedside table. R17 stated R17 used the nasal spray independently twice daily and took one multivitamin daily.
On 11/27/23, Surveyor reviewed R17's medical record which did not contain a physician's order to self-administer medication or a self-administration of medication assessment. R17's Treatment Administration Record (TAR) indicated R17's nasal spray was administered twice daily by staff.
On 11/28/23 at 10:20 AM, Surveyor notified Director of Nursing (DON)-B that R17 had medication at the bedside.
On 11/28/23 at 11:51 AM, Surveyor interviewed DON-B who verified R17 did not have a physician's order to self-administer medication and stated the facility will implement a process improvement for better tracking.
2. R36 was admitted to the facility on [DATE] with diagnosis including history of care following a joint replacement, hypertension, and asthma. R36's MDS assessment, dated 10/30/23, contained a BIMS score of 12 out of 15 which indicated R36 had moderate cognitive impairment. R36 did not have an activated POAHC.
On 11/27/23 at 11:43 AM, Surveyor observed a bottle of iron on R36's bedside table. R36 stated R36 took 2 iron tablets daily.
On 11/27/23, Surveyor reviewed R36's medical record which did not contain a physician's order to self-administer medication or a self-administration of medication assessment for iron.
On 11/28/23 at 10:20 AM, Surveyor notified DON-B that R36 had medication at the bedside.
On 11/28/23 at 11:51 AM, Surveyor interviewed DON-B who verified R36 did not have a physician's order to self-administer medication and stated the facility will implement a process improvement for better tracking.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interview, and record review, the facility did not ensure the medical record contained advanced dire...
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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 the medical record contained advanced directives for 1 Resident (R) (R25) of 17 sampled residents.
R25 was admitted to the facility on [DATE]. R25's medical record did not contain advanced directives, including a Power of Attorney for Healthcare (POAHC) document.
Findings include:
On 11/27/23, Surveyor reviewed R25's medical record. R25 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease with dyskinesia (uncontrolled, involuntary muscle movement), dementia, encounter for palliative care, and senile degeneration of the brain. R25's Minimum Data Set (MDS) assessment, dated 9/1/23, contained a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R25 was not cognitively impaired. Surveyor noted R25's medical record did not contain advanced directives, including a POAHC document.
On 11/28/23 at 12:40 PM, Surveyor interviewed R25 who verified R25 did not currently have a POAHC document. When Surveyor asked if the facility asked if R25 would like to complete advanced directive documents, R25 stated R25 was asked a lot of questions on admission and could not remember. When Surveyor asked if R25 was recently asked about advanced directive documents, R25 stated R25 was not recently asked, but would like to complete them.
On 11/28/23 at 1:15 PM, Surveyor interviewed Director of Nursing (DON)-B who verified R25 did not have advanced directive documents, including a POAHC document, on file and directed Surveyor to speak with Social Worker (SW)-F.
On 11/28/23 at 1:20 PM, Surveyor interviewed SW-F who stated SW-F was not sure who speaks to residents about advanced directives. SW-F stated if SW-F was aware R25 wanted to complete an advanced directive, SW-F would assist R25.
On 11/28/23 at 1:24 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated NHA-A expects advanced directive documents to be addressed by the first care conference. NHA-A verified R25's advanced directive documents were missed and stated SW-F did not realize advanced directives were within SW-F's scope of duty.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**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 a safe environment that was f...
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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 a safe environment that was free of accident hazards for 1 Resident (R) (R17) of 17 sampled residents.
R17 had a space heater in R17's room which was not in accordance with the facility's policy.
Findings include:
The facility's Space Heater Policy, with a review date of 5/25/23, included the following: .Portable space heating devices are prohibited in this facility .
On 11/27/23, Surveyor reviewed R17's medical record. R17 was admitted to the facility on [DATE] with diagnoses including history of diabetes, coronary artery disease, and hypertension. R17's Minimum Data Set (MDS) assessment, dated 10/21/23, contained a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R17 was not cognitively impaired. R17 did not have an activated Power of Attorney for Healthcare (POAHC).
On 11/27/23 at 11:40 AM, Surveyor interviewed R17 who indicated R17's room was cold. R17 stated R17 was unsure if the facility was going to do anything about it because R17 reported the concern a few weeks ago. R17 could not recall who R17 reported the concern to. R17 stated staff gave R17 extra blankets and pointed to a stack of blankets on R17's chair. R17 stated R17's room wasn't currently cold, though, and pointed to a white, approximately three foot long and one foot high, space heater.
On 11/28/23 at 10:00 AM, Surveyor observed the same space heater in R17's room.
On 11/28/23 at 10:20 AM, Surveyor notified Director of Nursing (DON)-B of R17's space heater and room temperature concern.
On 11/28/23 at 11:51 AM, Surveyor interviewed DON-B who stated the space heater was removed from R17's room. DON-B stated R17's family was notified and asked to pick up the space heater.
On 11/29/23 at 8:33 AM, Surveyor interviewed Maintenance Staff (MS)-G who stated MS-G wasn't aware R17's room was cold. MS-G stated during the first few months of cold weather, an increase in work orders are submitted and MS-G works with each resident on the specific concerns. MS-G verified the space heater was removed form R17's room and stated the facility's policy does not allow the use of space heaters.
On 11/29/23 at 11:12 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who verified space heaters are not allowed in the facility.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**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) (R3) of 1 sampled 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) (R3) of 1 sampled resident received catheter care in accordance with their prescribed plan of care.
R3 had physician's orders to irrigate R3's Foley catheter with 60 mL (milliliters) of sterile saline 3 times per week (Monday, Wednesday, and Friday) at HS (bedtime) and PRN (as needed), and for catheter care every shift. The orders were not consistently followed.
Findings include:
From 11/27/23 through 11/29/23, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease stage 3, schizoaffective disorder bipolar type, unspecified dementia, cognitive communication deficit, and neuromuscular dysfunction of bladder. R3's Minimum Data Set (MDS) assessment, dated 10/9/23, contained a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated R3 had moderate cognitive impairment. The MDS also indicated R3 was dependent on staff for toileting.
R3 had a physician's order, dated 7/3/23, to irrigate R3's Foley catheter with 60 mL of sterile saline 3 times per week (Monday, Wednesday, and Friday) at HS and PRN, and a physician's order, dated 7/2/23, for catheter care every shift. R3's care plan contained the following interventions: Indwelling catheter care every shift and as needed; Ensure peri area and tubing is cleaned every shift; Irrigate catheter as ordered.
On 11/28/23, Surveyor reviewed R3's Treatment Administration Record (TAR) from 9/1/23 through 11/29/23. R3's TAR contained missing documentation for 7 of 38 opportunities to irrigate R3's catheter and 14 of 114 opportunities to provide catheter care.
On 11/29/23 at 11:41 AM, Surveyor interviewed R3 who stated R3 thought staff provided catheter care once per day, but was unsure how often staff irrigated R3's catheter.
On 11/29/23 at 12:20 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated DON-B expects all documentation to be completed regarding catheter care and irrigation. DON-B stated DON-B was unsure if the missed documentation meant the care wasn't provided or if staff provided the care but did not document the care was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure ongoing communication with a dialysis facility for 1 Res...
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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 with a dialysis facility for 1 Resident (R) (R193) of 1 resident who received dialysis care and services.
R193 received dialysis three times per week. The facility did not ensure ongoing communication occurred between the nursing facility and the dialysis facility prior to and following R193's dialysis appointments.
Findings include:
The facility's Care of Hemodialysis policy, with a revision date of 9/10/23, 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. That will include: Ongoing communication and collaboration with dialysis facility regarding care and services.
Compliance Guidelines: 2. The facility will coordinate and collaborate with the dialysis facility to ensure that: d. There is ongoing communication and collaboration for the development and implementation of the dialysis care plan by nursing home and dialysis staff. 4. The licensed nurse will communicate to the dialysis facility by utilizing the Pre-dialysis communication UDA, that will include, but not limit itself to: Timely medication administration by the nursing home and/or dialysis facility; Physician/treatment orders, laboratory values, and vital signs; .
From 11/27/23 through 11/29/23, Surveyor reviewed R193's medical record. R193 was admitted to the facility on [DATE] with diagnoses including end stage renal disease, dependence on renal dialysis, and Alzheimer's disease. R193's medical record indicated R193 attended dialysis on Mondays, Wednesdays, and Fridays.
On 11/28/23, Surveyor reviewed R193's dialysis communication sheets from 9/11/23 through 11/27/23 (with the exception of 10/20/23 through 10/23/23 and 11/8/23 through 11/21/23 when R193 was hospitalized ). Surveyor noted 7 communications sheets were dated, but not completed by the facility or dialysis center, and 6 communication sheets were missing for a total of 13 incomplete or missing communication sheets for 26 dialysis sessions.
On 11/28/23 at 2:26 PM, Surveyor interviewed Director of Nursing (DON)-B regarding R193's dialysis communication sheets. DON-B stated DON-B expects staff to complete the dialysis communications sheets. DON-B stated if the communication sheets are not returned to the facility, staff should call the dialysis center to get their documentation.
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
Based on staff interview and record review, the facility did not thoroughly investigate a medication error for 1 Resident (R) (R38) of 1 resident reviewed.
On 11/9/23, R38 had a seizure and was admin...
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Based on staff interview and record review, the facility did not thoroughly investigate a medication error for 1 Resident (R) (R38) of 1 resident reviewed.
On 11/9/23, R38 had a seizure and was administered Narcan (an opioid antagonist medication used to reverse an opioid overdose) in error.
Findings include:
The facility's Medication Administration General Guidelines policy, dated 1/23, indicated: Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record (MAR). Compare the medication and dosage schedule on the resident's MAR with the medication label. If the label and MAR are different, and the container is not flagged indicating a change in direction, or if there is any other reason to question the dosage or directions, the prescriber's orders are checked for the correct dosage schedule .Verify medication is correct three times before administering the medication:
a. When pulling medication package from med cart
b. When dose is prepared
c. Before dose is administered
On 11/27/23, the facility provided Surveyor with an investigation related to a medication that was administered in error to R38 on 11/9/23. The investigation indicated R38 had a witnessed seizure and was administered Narcan by Licensed Practical Nurse (LPN)-E who thought Narcan was an anti-seizure medication. R38 had a physician's order for scheduled Keppra (an anti-seizure medication), but did not have a prescribed PRN (as needed) anti-seizure medication.
On 11/29/23 at 10:36 AM, Surveyor interviewed LPN-E who indicated LPN-E was surprised R38 had a seizure. LPN-E stated LPN-E removed Narcan from the medication cart, and thought Narcan was a rescue anti-seizure medication for R38. LPN-E stated LPN-E administered Narcan to R38 before LPN-E realized the error. LPN-E notified R38's physician and R38's representative. LPN-E stated LPN-E received education related to medication administration following the medication error.
The facility's investigation did not include other resident or staff interviews and did not include education for other licensed nursing staff aside from LPN-E. In addition, R38's plan of care was not updated or revised to include interventions to prevent a future medication administration error.
On 11/29/23 at 11:15 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who verified the facility's investigation did not include other resident and staff interviews, education for other licensed staff, or interventions to prevent a future medication administration error.
Nov 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
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff an resident interview, and record review, the facility did not ensure an injury of unknown origin was reported to...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff an resident interview, and record review, the facility did not ensure an injury of unknown origin was reported to the State Agency (SA) for 1 Resident (R) (R2) of 6 sampled residents.
R2 had an injury of unknown origin which was discovered on 8/30/23. The facility did not report the injury to the SA.
Findings include:
The facility's Abuse, Neglect and Exploitation policy, with a review date of 7/15/22, indicated: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .Employee Training .C. Training topics will include: .4. Reporting process for abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown source .Identification of Abuse, Neglect and Exploitation .B. Possible indicators of abuse include, but are not limited to: .3. Physical injury of a resident, of unknown source .Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, State Agency, Adult Protective Services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury .
On 11/7/23, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses to include unspecified dementia without behavioral disturbance and rheumatoid arthritis (a chronic progressive disease causing inflammation in the joints and resulting in painful deformity and immobility). R2's Minimum Data Set (MDS) assessment, dated 10/9/23, indicated R2's Brief Interview for Mental Status (BIMS) score was 10 out of 15 which indicated R2 had moderate cognitive impairment. R2 had a court-appointed guardian who was responsible for R2's healthcare decisions.
A nursing progress note indicated R2 had a witnessed fall on 8/29/23, but did not complain of right arm pain until 8/30/23. A nursing note, dated 8/30/23, indicated: Results of humerus (long bone of upper arm) and forearm X-rays received. Review reveals the following: subacute to chronic mildly displaced supracondylar fracture of distal humerus. Mild callus formation compatible with partial healing .Spoke with (physician) from (mobile X-ray company) who advised to notify (R2's) provider in (morning) as this is likely a healing fracture from greater than 6 weeks ago.
On 11/7/23 at 12:01 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated a staff assessment of R2 after the witnessed fall on 8/29/23 revealed no indication of injury. DON-B indicated R2 complained of pain during therapy on 8/30/23 which is why an X-ray was obtained. DON-B verified the X-ray indicated R2 had a healing fracture of the right humerus estimated to be greater than six weeks old. DON-B indicated R2 had no known falls or incidents likely to cause injury since January 2023. When asked if R2's right humerus fracture was considered an injury of unknown origin, DON-B stated, It could be, but physicians are also saying it's old.
On 11/7/23, Surveyor reviewed a soft file document with a dated timeline from 8/29/23 through 10/16/23 that indicated: (R2) has had no falls since January this year. (R2) propels self in (R2's) wheelchair throughout the facility and at times gets very close to walls and door jams. Pain levels reviewed .9/1/23 Spoke with (physician) . Requested bone density (test). Order received to schedule test .9/15/23 Bone density test completed. Indicative of osteopenia (bones are weaker than normal but not so far gone that they break easily, which is the hallmark of osteoporosis) .
On 11/7/23, Surveyor reviewed R2's X-ray report, dated 8/30/23, which indicated: 1. Subacute to chronic mildly displaced supracondylar fracture of distal humerus. Mild callus formation compatible with partial healing. 2. Mild osteopenia .
On 11/7/23, Surveyor reviewed R2's bone density study, dated 9/15/23, which indicated: Left forearm (bone mineral density) is 0.737 g/cm2 (grams per centimeter squared) (T-score: -1.7) .Osteopenia is defined as a T-score between -1.0 and greater than -2.5. Osteoporosis is defined as a T-score of -2.5 or below .
On 11/7/23 at 12:33 PM, Surveyor interviewed R2 who indicated staff were nice and no one had hurt R2. R2 could not recall the fall on 8/29/23.
On 11/7/23 at 12:58 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated NHA-A was not employed by facility at the time of R2's fall on 8/29/23. NHA-A verified R2's right humerus X-ray revealed an injury of unknown origin and stated the injury should have been reported to the SA.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interview, and record review, the facility did not ensure an injury of unknown origin was thoroughly...
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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 an injury of unknown origin was thoroughly investigated for 1 Resident (R) (R2) of 6 sampled residents.
R2 had an injury of unknown origin which was discovered on 8/30/23. The facility did not thoroughly investigate the injury to rule out possible abuse.
Findings include:
The facility's Abuse, Neglect and Exploitation policy, with a review date of 7/15/22, indicated: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .Identification of Abuse, Neglect and Exploitation .B. Possible indicators of abuse include, but are not limited to: .3. Physical injury of a resident, of unknown source .An immediate investigation is warranted when allegation or suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: .4. Identifying and interviewing all involved persons, including alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation(s) .
On 11/7/23, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses to include unspecified dementia without behavioral disturbance and rheumatoid arthritis (a chronic progressive disease causing inflammation in the joints and resulting in painful deformity and immobility). R2's Minimum Data Set (MDS) assessment, dated 10/9/23, indicated R2's Brief Interview for Mental Status (BIMS) score was 10 out of 15 which indicated R2 had moderate cognitive impairment. R2 had a court-appointed guardian who was responsible for R2's healthcare decisions.
A nursing progress note indicated R2 had a witnessed fall on 8/29/23, but did not complain of right arm pain until 8/30/23. A nursing note, dated 8/30/23, indicated: Results of humerus (long bone of upper arm) and forearm X-rays received. Review reveals the following: subacute to chronic mildly displaced supracondylar fracture of distal humerus. Mild callus formation compatible with partial healing .Spoke with (physician) from (mobile X-ray company) who advised to notify (R2's) provider in (morning) as this is likely a healing fracture from greater than 6 weeks ago.
On 11/7/23 at 12:01 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated a staff assessment of R2 after the witnessed fall on 8/29/23 revealed no indication of injury. DON-B indicated R2 complained of pain during therapy on 8/30/23 which is why an X-ray was obtained. DON-B verified the X-ray indicated a healing fracture of R2's right humerus estimated to be greater than six weeks old. DON-B indicated R2 had no known falls or incidents likely to cause injury since January 2023. When asked if R2's right humerus fracture was considered an injury of unknown origin, DON-B stated, It could be, but physicians are also saying it's old. In addition, DON-B stated I did not investigate the humerus specifically and indicated the fall likely irritated R2's right arm because R2 fell on the right side.
On 11/7/23, Surveyor reviewed a soft file document with a timeline from 8/29/23 through 10/16/23 that indicated: (R2) has had no falls since January this year. (R2) propels self in (R2's) wheelchair throughout the facility and at times gets very close to walls and door jams. Pain levels reviewed .9/1/23 Spoke with (physician) .Requested bone density (test). Order received to schedule test .9/15/23 Bone density test completed. Indicative of osteopenia (bones are weaker than normal, but not so far gone that they break easily, which is the hallmark of osteoporosis) .
On 11/7/23, Surveyor reviewed R2's X-ray report, dated 8/30/23, which indicated: 1. Subacute to chronic mildly displaced supracondylar fracture of distal humerus. Mild callus formation compatible with partial healing. 2. Mild osteopenia .
On 11/7/23, Surveyor reviewed R2's bone density study, dated 9/15/23, which indicated: Left forearm (bone mineral density) is 0.737 g/cm2 (grams per centimeter squared) (T-score: -1.7) .Osteopenia is defined as a T-score between -1.0 and greater than -2.5. Osteoporosis is defined as a T-score of -2.5 or below .
On 11/7/23 at 12:33 PM, Surveyor interviewed R2 who indicated staff were nice and no one had hurt R2. R2 could not recall the fall on 8/29/23.
On 11/7/23 at 12:58 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated NHA-A was not employed by facility at the time of R2's fall on 8/29/23. NHA-A verified R2's right humerus X-ray revealed an injury of unknown origin and stated the injury should have been investigated.
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
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility did not self-report to the State agency within 2 hours after an allegation o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility did not self-report to the State agency within 2 hours after an allegation of abuse for 1 (R1) of 2 Residents reviewed for allegations of abuse. The facility was aware of R1's allegation of abuse on 11/4/22, however, did not self-report to the State agency until 11/7/22.
Findings include:
Surveyor reviewed the facility's Compliance with Reporting Allegations of Abuse/Neglect/Exploitation policy and procedure reviewed/revised 8/16/22 and implemented 9/1/22 and notes the following applicable:
It is the policy of the facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of Resident property are reported immediately to the Administrator and/or designee of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed timeframes.
Procedure for Response and Reporting Allegations of Abuse/Neglect/Exploitation:
When suspicion of abuse/neglect/exploitation or reports of abuse/neglect/exploitation occur, the following procedure will be initiated:
1. The Licensed Nurse will:
a. Respond to the needs of the Resident and protect him/her from further incident
b. Remove the accused employee from Resident care areas.
c. Notify the Administrator or designee.
d. Notify the attending physician, Resident's family/legal representative, and Medical Director.
e. Monitor and document the Resident's condition, including response to medical treatment or nursing interventions.
f. Document actions taken in the medical record.
g. Complete an incident report is indicated.
h. Revise the Resident's care plan if the Resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse.
2. The Administrator or designee will:
a. Notify the appropriate agencies immediately: as soon as possible, but no later than 24 hours after discovery of the incident. In the case of serious bodily injury, no later than 2 hours after discovery of the incident. In the case of serious bodily injury, no later than 2 hours after discovery or forming the suspicion.
b. Obtain statements from direct care staff.
c. Administratively suspend the accused employee pending completion of the investigation.
d. Follow up with appropriate agencies, during business hours, to confirm the report was received.
e. Report to the state nurse aide registry or nursing board any knowledge of any actions which would indicate an employee is unfit for service.
f. Within 5 working days of the incident, report sufficient information to describe the results of the investigation, and indicate any corrective actions taken, if the allegation was verified.
R1 was admitted to the facility on [DATE] with diagnoses Diffuse Traumatic Brain Injury, Traumatic Subarchnoid Hemorrhage, Chronic Respiratory Failure, Dysphagia, Depression, Bipolar Disorder, Major Depressive Disorder, and Anxiety Disorder. R1 discharged from the facility on 11/11/22. R1 had a legal guardian while residing at the facility.
Surveyor reviewed R1's Quarterly Minimum Data Set (MDS) dated [DATE] and notes that R1's Brief Interview for Mental Status (BIMS) score is 8, indicating R1 demonstrates moderately impaired skills for daily decision making. R1's MDS documents that R1 demonstrated physical, verbal, and other behaviors 1-3 days of the assessment period. R1's MDS also documents that R1 required extensive assistance for bed mobility, transfers, dressing, toileting, and hygiene. R1 had range of motion impairment on one side of lower extremity.
Surveyor reviewed R1's comprehensive care plan with revisions.
On 12/3/21 it was initiated that R1 has behavior concerns as manifested by: confabulations, and saying things that may not be true.
On 11/4/22 R1's care plan was revised to include copying/parroting peers and false allegations of abuse. Surveyor notes 11/4/22 is the date when R1 originally reported an allegation of abuse.
On 11/8/22, R1's care plan was updated with the intervention of buddy system for all cares. Surveyor notes this is one day after R1's allegation of abuse was self-reported to the State Agency.
Surveyor reviewed the self-report documentation including staff statements that was provided by the facility.
On 11/4/22, Occupational Therapist Assistant (OTA-C) provided a written statement that documents the following: (R1) stated on 11/4/22 at 8:00 AM. Approached R1 in room, upon arrival R1 was upset when OTA-C asked why, (R1) stated '(expletive) hit me in the face. I wouldn't make that up'. When asked where, (R1) stated, 'right side of cheek with fist'. Alerted and reported to management immediately and quoting what (R1) said.
On 11/9/22 at 10:36 AM, Surveyor interviewed OTA-C in regards to the above statement. OTA-C confirmed the statement was accurate. OTA-C stated this was the first time R1 had said something like this to OTA-C. OTA-C stated R1 was upset and anxious when R1 reported the allegation of abuse to OTA-C. OTA-C confirmed that OTA-C informed the Traumatic Brain Injury Director (TBI-D) immediately.
Further written documentation of the self-report indicates that Assistant Director of Traumatic Brain Injury (TBI-E) notified TBI-D on 11/4/22 at 10:30 AM, that family was upset as R1 had informed family that R1 had been slapped in the face yesterday on PM shift. The statement also includes that family had been called the previous evening by the nurse requesting family try and calm down and redirect R1 as R1 was being behavioral on their shift.
On 11/9/22 at 10:57 AM, Surveyor interviewed TBI-E in regards to the above written statement. TBI-E confirmed that TBI-E had been informed by family on 11/4/22 that a 'large .man had hit R1'. TBI-E stated that there is no one matching that description that works on the TBI unit, but there is someone that matches that description that works elsewhere in the facility. TBI-E confirmed TBI-E informed TBI-D of the allegation. TBI-E reported to Surveyor that this was the first time R1 had made an allegation of abuse that TBI-E was aware of.
On 11/4/22, an agency certified nursing assistant (CNA) reported that R1 was behavioral all night. The CNA indicated that she did not witness any physical interaction between R1 and staff except another CNA had to move R1's chair backwards at one point.
The following statement was documented in regards to TBI-D addressing the allegation of abuse by R1. TBI-D was called to (R1's) room on 11/4/22 at 8:30 AM by OTA-C. OTA-C reported that (R1) had stated (R1) was hit in the face. TBI-D went to R1's room immediately. (R1) stated, 'that .(expletive) slapped me'. (R1) pointed to (R1's) right side of face. (R1) pointed two times that the right hand was used to hit. TBI-D asked if it was a slap or a hit. (R1) stated a punch. (R1) also indicated a fist had been used to punch.
On 11/9/23 at 10:03 AM, Surveyor interviewed TBI-D. TBI-D confirmed that OTA-C had reported (R1's) allegation of abuse on 11/4/22 to TBI-D who interviewed (R1) and stated that at that time, (R1)kept changing his story, description, and timeline. TBI-D had discussed (R1's) allegation of abuse with previous Administrator on 11/4/22 who indicated he had been giving an inservice on abuse at the nurse's station and R1 was present and most likely overheard the conservation. TBI-D stated TBI-D did not obtain staff statements on 11/4/22. TBI-D stated that it is up to the Administrator and Director of Nursing (DON-B) to report allegations of abuse or neglect. TBI-D stated the former Administrator did not feel the need to report to the State agency on 11/4/22.
Surveyor notes that on 11/6/22 it is documented that R1's legal guardian voiced concerns about abuse. R1's nursing progress notes document that R1 had a bump on the right cheek which is now a purple color with some redness. On 11/7/22, R1's legal guardian and R1 met with the former Administrator and TBI-D. On 11/7/22, R1 is sent out to the emergency room to evaluate for possible underlying issues causing blue/purple area to right cheek.
Surveyor notes that it is at this point an initial self-report dated 11/7/22 was submitted to the State agency. Surveyor notes the Misconduct Incident Report was submitted within five working days.
On 11/9/22 at 1:15 PM, Surveyor interviewed DON-B in regards to R1's allegation of abuse. DON-B stated DON-B did not know (R1's) allegation of abuse had been originally reported on 11/4/22. DON-B stated if (R1's) allegation of abuse was made on 11/4/22 it should have been self-reported right away. DON-B confirmed that if a Resident has on the care plan a history of making false accusations, any allegation of abuse or neglect should still be reported. DON-B stated DON-B thought the former Administrator was guiding TBI-D. DON-B understands and agrees that (R1's) allegation of abuse on 11/4/22 should have been self-reported right away. On 11/9/22, Surveyor met with DON-B and Administrator(NHA-A) and went over the concern of R1's allegation of abuse on 11/4/22 not be submitted to the State agency within 2 hours of an allegation of abuse. Both DON-B and NHA understand the concern and provided no further information at this time.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure all alleged violations were thoroughly investigated for 1 of 2...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure all alleged violations were thoroughly investigated for 1 of 2 allegations of abuse reviewed involving Resident (R1).
* R1 expressed an allegation of abuse on 11/4/22 and staff statements were not obtained until 11/7/22 as well as no other Residents were interviewed to determine if they had any concerns of abuse or neglect. In addition, the facility did not report this allegation to the local law enforcement agency.
Findings include:
Surveyor reviewed the facility's Abuse, Neglect and Exploitation policy and procedure implemented 3/2018 and reviewed/revised 7/15/22 and notes the following
Policy:
It is the policy of this facility to provide protections for the health, welfare and rights of each Resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of Resident property.
V. Investigation of Alleged Abuse, Neglect and Exploitation
A. An immediate investigation is warranted when allegation or suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.
B. Written procedures for investigations include:
1. Identifying staff responsible for the investigation.
2. Exercising caution in handling evidence that could be used in a criminal investigation.
3. Investigating different types of alleged violations.
4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witness, and others who might have knowledge of the allegation.
5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause.
6. Providing complete and thorough documentation of the investigation.
R1 was admitted to the facility on [DATE] with diagnoses Diffuse Traumatic Brain Injury, Traumatic Subarchnoid Hemorrhage, Chronic Respiratory Failure, Dysphagia, Depression, Bipolar Disorder, Major Depressive Disorder, and Anxiety Disorder. R1 discharged from the facility on 11/11/22. R1 had a legal guardian while residing at the facility.
Surveyor reviewed R1's Quarterly Minimum Data Set (MDS) dated [DATE] and notes that R1's Brief Interview for Mental Status (BIMS) score is 8, indicating R1 demonstrates moderately impaired skills for daily decision making. R1's MDS documents that R1 demonstrated physical, verbal, and other behaviors 1-3 days of the assessment period. R1's MDS also documents that R1 required extensive assistance for bed mobility, transfers, dressing, toileting, and hygiene. R1 had range of motion impairment on one side of lower extremity.
Surveyor reviewed R1's comprehensive care plan with revisions.
On 12/3/21 it was initiated that R1 has behavior concerns as manifested by: confabulations, and saying things that may not be true.
On 11/4/22 R1's care plan was revised to include copying/parroting peers and false allegations of abuse. Surveyor notes 11/4/22 is the date when R1 originally reported an allegation of abuse.
On 11/8/22, R1's care plan was updated with the intervention of buddy system for all cares. Surveyor notes this is one day after R1's allegation of abuse was self-reported to the State Agency.
Surveyor reviewed the self-report documentation including staff statements that was provided by the facility.
It is noted that on 11/4/22, R1 expressed an allegation of abuse which was not thoroughly investigated. Staff statements were not obtained on 11/4/22. Other Resident statements on the unit were not obtained in regards to concerns of abuse or neglect. The facility did not report to the local law enforcement agency.
On 11/4/22, Occupational Therapist Assistant (OTA-C) provided a written statement that documents the following: (R1) stated on 11/4/22 at 8:00 AM. Approached (R1) in room, upon arrival (R1) was upset when OTA-C asked why, (R1) stated '(expletive) hit me in the face. I wouldn't make that up'. When asked where, (R1) stated, 'right side of cheek with fist'. Alerted and reported to management immediately and quoting what (R1) said.
On 11/9/22 at 10:36 AM, Surveyor interviewed OTA-C in regards to the above statement. OTA-C confirmed the statement was accurate. OTA-C stated this was the first time R1 had said something like this to OTA-C. OTA-C stated R1 was upset and anxious when R1 reported the allegation of abuse to OTA-C. OTA-C confirmed that OTA-C informed the Traumatic Brain Injury Director (TBI-D) immediately.
Further written documentation of the self-report indicates that Assistant Director of Traumatic Brain Injury (TBI-E) notified TBI-D on 11/4/22 at 10:30 AM, that family was upset as R1 had informed family that R1 had been slapped in the face yesterday on PM shift. The statement also includes that family had been called the previous evening by the nurse requesting family try and calm down and redirect R1 as R1 was being behavioral on their shift.
On 11/9/22 at 10:57 AM, Surveyor interviewed TBI-E in regards to the above written statement. TBI-E confirmed that TBI-E had been informed by family on 11/4/22 that a 'large .man had hit R1'. TBI-E stated there is no one matching that description that works on the TBI unit, but there is someone that matches that description that works elsewhere in the facility. TBI-E confirmed TBI-E informed TBI-D of the allegation. TBI-E reported to Surveyor that this was the first time (R1) had made an allegation of abuse that TBI-E was aware of.
Surveyor notes that the facility did not obtain a statement from this employee to rule out possible abuse.
On 11/4/22, an agency certified nursing assistant (CNA) reported that (R1) was behavioral all night on 11/3/22. The CNA indicated that she did not witness any physical interaction between (R1) and staff except another CNA had to move R1's chair backwards at one point.
The following statement was documented in regards to TBI-D addressing the allegation of abuse by R1. TBI-D was called to (R1's) room on 11/4/22 at 8:30 AM by OTA-C. OTA-C reported that (R1) had stated (R1) was hit in the face. TBI-D went to R1's room immediately. (R1) stated, 'that .(expletive) slapped me'. (R1) pointed to (R1's) right side of face. (R1) pointed two times that the right hand was used to hit. TBI-D asked if it was a slap or a hit. (R1) stated a punch. (R1) also indicated a fist had been used to punch.
On 11/9/23 at 10:03 AM, Surveyor interviewed TBI-D. TBI-D confirmed that OTA-C had reported (R1's) allegation of abuse on 11/4/22 to TBI-D who interviewed (R1) and stated that at that time, (R1) kept changing his story, description, and timeline. TBI-D had discussed (R1's) allegation of abuse with previous Administrator on 11/4/22 who indicated he had been giving an inservice on abuse at the nurse's station and (R1) was present and most likely overheard the conservation. TBI-D stated TBI-D did not obtain staff statements on 11/4/22. TBI-D stated that it is up to the Administrator and Director of Nursing(DON-B) to report allegations of abuse or neglect. TBI-D stated the former Administrator did not feel the need to report to the State Agency on 11/4/22.
Surveyor notes that on 11/6/22 it is documented that R1's legal guardian voiced concerns about abuse. R1's nursing progress notes document that R1 had a bump on the right cheek which is now a purple color with some redness. On 11/7/22, R1's legal guardian and R1 met with the former Administrator and TBI-D. On 11/7/22, R1 is sent out to the emergency room to evaluate for possible underlying issues causing blue/purple area to right cheek.
Surveyor notes that it is at this point that an initial self-report dated 11/7/22 was submitted to the State agency. Surveyor notes the Misconduct Incident Report was submitted within five working days. However, Surveyor notes that no other Resident statements are obtained to rule out concerns of abuse/neglect with them in order to rule out a pattern. The facility did not report to the local law enforcement agency.
On 11/9/22 at 1:15 PM, Surveyor interviewed DON-B in regards to R1's allegation of abuse. DON-B agreed that other Residents should have been interviewed in regards to possible concerns of abuse or neglect.
On 11/9/22, Surveyor met with DON-B and Administrator(NHA-A) and went over the concern of R1's allegation of abuse and that a thorough investigation was not completed to include other Resident statements of possible abuse or neglect and the local law enforcement agency was not notified. Both DON-B and NHA understand the concern and provided no further information at this time.
Aug 2022
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0551
(Tag F0551)
Could have caused harm · This affected 1 resident
Based on staff interviews and record review, the facility did not ensure a Resident's (R) guardian and/or proposed guardian exercised rights within limits set by state statutes for 2 (R7 and R298) of ...
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Based on staff interviews and record review, the facility did not ensure a Resident's (R) guardian and/or proposed guardian exercised rights within limits set by state statutes for 2 (R7 and R298) of 4 sampled residents with guardians or proposed guardians.
The facility allowed a person named as R7's proposed guardian on guardian petitioning paperwork to act as R7's guardian without obtaining court's hearing determination on competency, guardianship, and protective placement.
The facility admitted R298 to the facility without ensuring court transferred R298's protective placement from previous facility.
Findings include:
1. Wisconsin (WI) State Statute (ss) Chapter 54.10(3)(a) documents A court may appoint a guardian of the person or a guardian of the estate, or both, for an individual based on a finding that the individual is incompetent . (e) In appointing a guardian under this subsection, the court shall authorize the guardian to exercise only those powers under ss. 54.18, 54.20, and 54.25 (2) (d) that are necessary to provide for the individual's personal needs and property management and to exercise the powers in a manner that is appropriate to the individual and that constitutes the least restrictive form of intervention.
From 8/22/22 through 8/24/22, Surveyor reviewed R7's medical record which documented the court was petitioned on 3/2/22 for R7's guardianship and protective placement. A hearing was scheduled for 3/17/22 to determine R7's need for guardianship and protective placement. Surveyor noted court determination of competence, guardianship, and protective placement were not in R7's medical record. R7's profile documented the proposed guardian listed on guardianship petition as R7's guardian and responsible party. Surveyor noted facility documents, including consents, requiring signatures were signed by proposed guardian.
On 8/23/22 at 10:16 AM, Surveyor interviewed Traumatic Brain Injury (TBI) unit Program Director (PD)-D regarding R7. PD-D confirmed no determination from hearing, including an order for guardianship and protective placement, were in R7's medical record and proposed guardian was acting as R7's decision maker at time of investigation. PD-D explained the usual practice would be for facility Social Worker (SW) to follow-up with court and obtain determination documents but SW role at facility was vacant since 6/16/22. PD-D indicated SW-F, who generally worked for non-TBI unit completed some SW tasks for TBI unit residents since previous SW's departure and PD-D completed other tasks, but former SW, SW-F and PD-D missed following up on R7's court determination.
2. WI ss chapter 55.15 documents non-emergency transfer of protectively placed wards requires written consent of the ward's guardian in addition to 10 days written notice prior to transfer to the court that ordered protective placement.
From 8/22/22 through 8/24/22, Surveyor reviewed R298's medical record which documented R298 had a court ordered guardian and was protectively placed at a different facility on 4/14/22. R298 transferred to current facility on 7/27/22. Surveyor was not able to locate documentation of protective placement being transferred to facility.
On 8/22/22 at 12:26 PM, Surveyor interviewed PD-D regarding R298's protective placement. PD-D verified the facility did not have a court protective placement transfer order. PD-D explained the TBI unit SW stopped employment at facility on 6/16/22. PD-D explained SW-F and PD-D attempted to cover responsibilities of vacant position, but R298's protective placement transfer was not obtained.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
Based on staff interviews and record review, the facility did not ensure a Resident (R) requiring a Preadmission Screen and Resident Review (PASRR) level 2 screen had county approval or were completed...
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Based on staff interviews and record review, the facility did not ensure a Resident (R) requiring a Preadmission Screen and Resident Review (PASRR) level 2 screen had county approval or were completed as required for 2 (R1 and R298) of 13 sampled residents.
The facility did not identify R1's situational depression, which was treated with an anti-depressant medication, as a mental illness based on Diagnostic and Statistical Manual of Mental Disorders (DSM) 5 during the PASRR level 1 screen; therefore, the facility did not complete a PASRR level 2 to determine if Skilled Nursing Facility (SNF) placement was appropriate and if R1 required specialized services to treat R1's depression.
The facility identified R298's DSM 5 qualifying diagnosis as a mental illness and identified R298 may qualify for a 30 day hospital exemption for PASRR level 2 completion but did not obtain the required county approval for 30 day exemption.
Findings include:
1. From 8/22/22 through 8/24/22, Surveyor reviewed R1's medical record which documented R1's PASRR level 1 screen, dated 5/5/22, did not identify R1 as suspected of a serious mental illness or developmental disability. The medication portion of PASRR level 1 screen identified R1 was prescribed Zoloft (an antidepressant medication) to treat situational depression. R1 was still prescribed Zoloft at the time of investigation
On 8/23/22 at 9:50 AM, Surveyor interviewed Social Worker (SW)-F regarding R1's PASRR level 1 screen. SW-F verified situation depression was a qualifying DSM 5 diagnosis to suspected a serious mental illness and a PASRR level 2 screen should have been completed.
2. On 8/22/22, Surveyor reviewed R298's medical record and noted no PASRR screens were available. R298 and a diagnosis of adjustment disorder with depressed mood and was prescribed Zoloft as treatment.
On 8/22/22 at 12:26 PM, Surveyor interviewed Traumatic Brain Injury (TBI) unit Program Director (PD)-D regarding R298's PASRR screen. PD-D explained TBI unit had its own SW until 6/16/22 and a new SW began on 8/22/22. PD-D reviewed R298's medical record and verified PASRR screen was not in R298's medical record. At 2:52 PM, PD-D provided Surveyor with copy of R298's PASRR level 1 screen, dated 7/27/22, which documented R298 was suspected of a serious mental illness and qualified for a 30 day exemption review. PD-D explained R298's PASRR was completed and located in SW-F's office at the time of record review. PD-D verified the facility did not have county approval for R298's 30 day exemption.
On 8/23/22 at 9:54 AM, Surveyor interviewed SW-F regarding 30 day exemptions. SW-F explained SW-F had a practice of maintaining PASRR level 1 screens which qualified for 30 day exemptions in office to ensure tracking and sending in PASRR level 2 screens timely for residents who remained in facility more than 30 days. SW-F explained SW-F was not aware county approval was required for 30 day exemptions prior to Surveyor investigation.
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
Based on staff interviews and record review, the facility did not ensure care plans were developed to ensure Resident (R) safety for 2 (R5 and R40) of 13 sampled residents.
The facility did not develo...
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Based on staff interviews and record review, the facility did not ensure care plans were developed to ensure Resident (R) safety for 2 (R5 and R40) of 13 sampled residents.
The facility did not develop a care plan to address R5's moderate risk of wandering or actual attempts to elope.
The facility did not develop a care plan to monitor for dangerous side effects of high risk medication for R40's use of anticoagulant (blood thinner) medication.
Findings include:
1. From 8/22/22 through 8/24/22, Surveyor reviewed R5's medical record which documented R5's three wandering risk assessments dated between admission and investigation assessed R5 at moderate risk of wandering. The most recent assessment was completed 8/22/22. Surveyor noted R5 did not have a care plan addressing wandering or elopement and interventions to implement when R5 fixated on leaving the facility. R5 swore at Legal Guardian (LG) on 8/8/22 when R5 expressed a desire to leave facility and LG informed R5 that R5 needed to remain at facility. Further nursing notes on 8/8/22 documented R5 as preoccupied with talk of leaving facility. On 8/13/22, R5 attempted to leave facility. Surveyor noted R5 was not reassessed for wandering risk after attempt to leave.
Surveyor observed R5 resided on a secure unit for persons with Traumatic Brain Injuries (TBI) where exit doors required a code to disable door alarm which sounded when doors were opened without code.
On 8/23/22 at 11:30 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-E regarding R5's elopements. LPN-E verified working consistently in TBI unit and confirmed being familiar with R5. LPN-E revealed LPN-E was R5's nurse on the date R5 attempted to leave the building. LPN-E recalled that R5 attempted to leave twice during the same shift. LPN-E's opinion was R5 thought a delivery was coming and wanted to go out to meet the delivery and not necessarily trying to to exit the building to leave the facility. LPN-E explained R5's elopement attempts were address through redirection and then a one on one caregiver until management team could discuss R5's situation. LPN-E identified R5 as confused and explained staff monitored R5's location routinely to help ensure R5 was not taking other people's belongings. LPN-E recalled reviewing R5's elopement situations at standup (a staff meeting). LPN-E expressed a belief that R5's wandering and elopement decreased as R5's sleep pattern improved. LPN-E verified not creating a care plan to address R5's wandering and indicated management, such as Assistant Director of Nursing (ADON)-G would create care plans.
On 8/23/22 at 11:44 AM, Surveyor interviewed ADON-G regarding R5's care plan. ADON-G indicated R5 had a general behavior care plan. At the time of interview, ADON-G accessed R5's care plan and verified R5's behavior care plan did not identify R5 was at risk for wandering or elopement. ADON-G expressed that wandering or elopement care plans typically were not created for residents on the secure TBI unit because the doors sounded an audible alarm when opened without the code to disarm alarm. ADON-B identified that staff would likely respond to wandering and elopement by using interventions on R5's behavior care plan, such as providing music on headphones.
2. From 8/22/22 through 8/24/22, Surveyor reviewed R40's medical record which documented R40's prescription for rivaroxaban (anticoagulant, commonly called a blood thinner) taken daily. Surveyor noted R40 did not have a care plan to ensure monitoring for potential negative side effects associated with anticoagulant use.
On 8/24/22 at 10:00 AM, Surveyor interviewed Director of Nursing (DON)-B regarding R40's anticoagulant use. DON-B verified a prescription was in place for R40 to take an anticoagulant daily. DON-B accessed R40's medical record at the time of interview and confirmed there was no care plan to address monitoring for potential negative side effects. DON-B indicated anticoagulant side effect monitoring would include monitoring for signs of bleeding, such as excessive bruising or bleeding that wouldn't stop.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility did not ensure 2 Residents (R) (R28 and R40) of 5 residen...
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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 2 Residents (R) (R28 and R40) of 5 residents reviewed for pressure injuries received appropriate care and services to promote healing.
1. R28 saw a wound physician and the facility did not transcribe R28's wound physician orders into R28's electronic health record. This led to R28 receiving the incorrect wound care treatment on numerous occasions.
2. R40 saw a wound physician and the facility did not transcribe R40's wound physician orders into R40's electronic health record. This led to R40 receiving the incorrect wound care treatment on numerous occasions.
Findings include:
The Facility policy titled Pressure and Non-Pressure Injuries, dated 8/2/21, indicated: Initiate treatment per order.
1. 8/22/22 through 8/24/22, Surveyor reviewed R28's medical record. R28 was admitted on [DATE] and had related diagnoses that include end stage renal disease (a medical condition in which a person's kidney cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), cirrhosis of liver (chronic liver damage from a variety of causes leading to scarring and liver failure), muscle weakness, pressure ulcer of sacral region state 4, hypertensive chronic kidney disease (high blood pressure caused by the narrowing of your arteries that carry blood to your kidneys), dependence on renal dialysis, and thrombocytopenia (a low number of platelets in the blood). Surveyor observed R28's Treatment Administration Record (TAR) for August and July:
~R28's TAR indicated R28's wound care treatments as of 8/22/22 was: coccyx cleanse wound with wound wash, pat dry, skin prep peri wounds, apply medi honey to wound bed f/b (follow by) calcium alginate, cover with border foam 3 times a week and PRN (as needed). One time a day on Tue, Thu, and Sun for coccyx dated 8/21/22. R28's TAR indicated R28's wound care treatment as of 8/22/22 was: Left foot great toe, plantar aspect, skin prep qd (every day) dated 8/21/22.
~R28's TAR indicated R28's wound care treatments from 8/6/22 through 8/21/22 was: Cleanse wounds x 2 with wound wash, pat dry, skin prep peri wounds, apply medi honey to sacrum base of OA (open area) f/b (follow by) foam bandage. Apply calcium alginate to coccyx pressure OA (open area), followed by a gauze bandage and secure with tape. Change daily and PRN (as needed) if soiled or dislodged.
~R28's TAR indicated R28's wound care treatments from 7/30/22 through 8/4/22 was: Sacrum MASD (moisture associated skin damage) cleanse area apply skin prep and cover with hydrocolloid thin cut to size f/b (followed by) film being used for wound vac on coccyx pressure wound. Change TUE/THUR/SAT and PRN (as needed) one time a day for wound care.
On 8/22/22, Surveyor observed R28's medical record contained scanned in documents from R28's wound physician.
~R28's document titled Wound Evaluation and Management Summary, dated 8/19/2022, indicated R28's sacrum dressing treatment plan was Primary Dressing Leptospermum honey apply three time per week and as needed, Secondary Dressing Derma foam with adhesive. R28's unstageable DTI (Deep Tissue Injury) of left first toe treatment plan was Primary Dressing Leptospermum honey once daily, Secondary Dressing Gauze Island w/ (with) bdr (boarder) apply once daily. R28's coccyx wound was resolved on 8/19/22.
~R28's document titled Wound Evaluation and Management Summary, dated 8/4/22, indicated R28's sacrum dressing treatment plan was Primary dressing leptospermum honey three times per week and as needed, secondary dressing derma foam with adhesive three time per week and as needed. R28's coccyx dressing treatment plan was primary dressing alginate calcium daily, secondary dressing gauze island w/ (with) bdr (border).
~R28's document titled Wound Evaluation and Management Summary, dated 7/28/22, indicated R28's sacrum dressing treatment plan was Primary dressing leptospermum honey three times per week and as needed, secondary dressing Derma foam with adhesive, may then place wound vac on adjacent wound three times per week and as needed.
On 8/24/22 at 7:17 AM, Surveyor observed ADON-G complete R28's dressing change to sacrum and left great toe. ADON-G completed R28's dressing changes as ordered on the TAR and not as MD-P ordered on the wound evaluation and management summary. Surveyor observed wound to sacrum and left great toe. Surveyor observed R28's skin to be intact to coccyx area.
2. 8/22/22 through 8/24/22 Surveyor reviewed R40's medical record. R40 was admitted on [DATE] and had related diagnoses that include acute on chronic combined systolic and diastolic heart failure (systolic congestive heart failure, the ventricles cannot produce enough pressure in the contraction phase to push blood into circulation, diastolic congestive heart failure, the ventricles cannot relax, expand, or fill with enough blood), diabetes type two, unsteadiness on feet, muscle weakness, pressure injury to left heel stage 3, chronic atrial fibrillation (abnormal heart rate), and chronic kidney disease stage 3. Surveyor observed R40's TAR for August and July:
~R40's TAR indicated R40's wound care treatments as of 8/22/22 was: Left heel cleanse with wound wash, pat dry, apply medi honey f/b (followed by) bordered gauze qd (every day) and prn (as needed) dated 8/9/22.
~R40's TAR indicated R40's wound care treatment from 7/30/22 through 8/9/22 was: Left heel cleanse with wound wash, pat dry, apply calcium alginate with silver (Ag) f/b (followed by) bordered gauze qd (every day) and prn (as needed) one time a day for wound care.
~R40's TAR indicated R40's wound care treatment from 7/22/22 through 7/25/22 was: Left heel cleanse with wound wash, apply calcium alginate with silver followed by gauze island with border q (every) day and PRN (as needed) one time a day for wound care.
On 8/22/22, Surveyor observed R40's medical record contained scanned in documents from R40's wound physician.
~R40's document titled Wound Evaluation and Management Summary, dated 8/19/22, indicated R40's left heel dressing treatment plan was Primary Dressing Leptospermum honey and alginate calcium w/ (with) silver once daily, Secondary Dressing Gauze Island w/ (with) bdr (border) once daily.
~R40's document titled Wound Evaluation and Management Summary, dated 8/4/22, indicated R40's left heel dressing treatment plan was Primary Dressing Leptospermum honey and alginate calcium w/ (with) silver once daily, Secondary Dressing Gauze Island w/ (with) bdr (border) once daily.
~R40's document titled Wound Evaluation and Management Summary, dated 7/28/22, indicated R40's left heel dressing treatment plan was Primary Dressing Leptospermum honey and alginate calcium w/ (with) silver once daily, Secondary Dressing Gauze Island w/ (with) bdr (border) once daily.
~R40's document titled Wound Evaluation and Management Summary, dated 7/21/22, indicated R40's left heel dressing treatment plan was Primary Dressing Leptospermum honey and alginate calcium w/ (with) silver once daily, Secondary Dressing Gauze Island w/ (with) bdr (border) once daily.
On 8/24/22 at 7:42 AM, Surveyor observed ADON-G complete R40's dressing change to left heel. ADON-G completed R40's dressing change as ordered on the TAR and not as MD-P ordered on the wound evaluation and management summary.
On 8/23/22 at 2:20 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-G regarding R28 and R40's wound treatments observed on the TAR and R28 and R40's dressing treatment plan observed on Wound Evaluation and Management Summary. ADON-G shared that when the Wound Evaluation and Management Summaries were received ADON-G will review them and transcribe the orders into the electronic medical records. Surveyor presented ADON-G with R28's and R40's TAR and R28's and R40's Wound Evaluation and Management Summary. ADON-G verified R28's and R40's orders observed in the TAR did not match the orders observed on the Wound Evaluation and Management Summary. ADON-G stated they had issues with the wound clinic physician because when the physician was rounding the verbalizations were different orders then what was documented on the wound evaluation and management summary. ADON-G reported to Surveyor that the MD-P recently stated that R28's coccyx wound was healed but ADON-G indicated this is incorrect and that R28's sacrum wound is healed not the coccyx. ADON-G continued to discuss they would attempt to follow up with the wound care physician and ADON-G stated at the end of the day the residents need orders, and I will put orders in.
On 8/23/22 at 3:27 PM, Surveyor interviewed R28 and R40's Wound Medical Doctor (MD)-P regarding R28 and R40's current wound care treatment orders. MD-P verified they expected the facility to follow the orders MD-P put in the Wound Evaluation and Management Summary. Surveyor read the most recent orders on the wound Evaluation and Management Summary, dated 8/19/22 to MD-P who confirmed the identified orders were expected to be completed.
On 8/23/22 at 3:39 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A regarding R28 and R40's current wound treatment orders. NHA-A verified they expected the Wound Evaluation and Management Summary dressing treatment plan orders to be followed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure ongoing communication with the dialysis facility was consisten...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure ongoing communication with the dialysis facility was consistent with professional standards of practice and monitoring fistula and post dialysis weight were consistently completed for 1 Resident (R28) of 1 resident receiving dialysis care and services.
R28 dialysis communication sheet were not consistently filled in and R28's fistula monitoring and post dialysis weights were not consistently completed.
Findings include:
Facility policy titled Hemodialysis, dated 4/13/2021, read as follows: 13. Document the post-dialysis (dry weight) obtained by the dialysis center in the Dialysis Communication UDA after each dialysis treatment
8/22/22 through 8/24/22, Surveyor reviewed R28's medical record. R28 was admitted on [DATE] and had related diagnoses that included end stage renal disease, hypertensive chronic kidney disease, and dependence on renal dialysis. R28 had physician orders for:
~Enter post dialysis weight from dialysis communication form, dated 4/2/2021.
~Fistula: Located Left Arm Thrill and Bruit present? (Y/N) every shift for Dialysis access site evaluation assess site every shift for Thrill and Bruit if not present notify MD, dated 6/26/2020.
8/22/22 through 8/24/22, Surveyor reviewed R28's Treatment Administration Record (TAR). Surveyor observed missing documentation on R28's TAR for Enter post dialysis weight from dialysis communication form on the following dates: 5/2/22, 5/16/22, 5/18/22, 5/27/22, 5/30/22, 6/20/22, 6/27/22, 6/29/22, 7/1/22, 7/6/22, 7/8/22, 7/15/22, 7/18/22, 7/22/22, 8/5/22, 8/8/22, 8/10/22, 8/15/22, 8/17/22 and 8/22/22. Surveyor observed missing documentation on R28's TAR for Fistula: Located Left Arm Thrill and Bruit present? (Y/N) every shift for Dialysis access site evaluation assess site every shift for Thrill and Bruit if not present notify MD on the following dates: 5/2/22, 5/3/22, 5/8/22 for two shifts, 5/12/22, 5/16/22, 5/18/22, 5/26/22, 5/27/22, 5/29/22, 5/30/22, 5/31/22, 6/18/22, 6/20/22, 6/29/22, 7/1/22, 7/8/22, 7/18/22, 7/22/22 for two shifts, 8/5/22, 8/15/22, 8/18/22, 8/20/22 for two shifts and 8/22/22.
8/22/22 through 8/24/22, Surveyor reviewed R28's hemodialysis communication forms. On the following dates Surveyor observed hemodialysis communication forms not consistently completed:
~8/22/22: no post treatment weight.
~8/17/22: no post treatment weight.
~8/15/22: facility did not complete portion of the form.
~8/8/22: no communication form observed.
~8/5/22: no post treatment weight.
~7/18/22: facility did not complete portion of the form.
~6/29/22: dialysis did not complete portion of the form.
~6/27/22: no communication form observed.
~6/24/22: facility did not complete portion of the form.
On 8/23/22 at 2:20 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-G regarding R28's TAR regarding post dialysis weights and monitoring Fistula. ADON-G verified expects staff to document on the TAR and further discussed if not documented, not done. ADON-G verifed R28's TAR had missing documentation.
On 8/24/22 at 8:31 AM, Surveyor interviewed Director of Nursing (DON)-B regarding R28's TAR regarding post dialysis weights and monitoring Fistula. DON-B discussed expects staff to document on the TAR. DON-B verbalized expects staff to checking the fistula and filling in the post dialysis weights as order. Surveyor asked about R28's dialysis communication forms and DON-B discussed expects staff to fill in the communications form and especially the top two sections with vital signs and vascular access. DON-B further discussed if dialysis does not fill in there portion of the communication form expect staff to follow up with dialysis. DON-B verified R28's dialysis communication forms had missing information.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
**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...
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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 it was free of a medication error rate of 5% or greater. During medication administration observations, 2 errors occurred during 25 opportunities which resulted in an 8% medication error rate affecting 2 Residents (R) (R17 and R46) of 12 residents observed during medication pass.
R17 had a physician order for acetaminophen (used to treat mild to moderate pain) in a dose of two 325 mg (milligram) tablets. During the observation of R17's medication administration on 8/22/22, R17 received two 500 mg tablets of acetaminophen.
R46 had a physician order for Humulin 70/30 insulin (used to treat high blood sugars for both long-acting and short-acting durations) 60 units (unit of measure). During the observation of R46's medication administration on 8/22/22, R46 would have received 58 units of Humulin 70/30 insulin had the Surveyor not intervened.
Findings include:
Facility provided policy titled Medication Administration dated June 2017 stated, To safely and accurately administer physician-ordered medication to each resident . 5. Remember the six (6) Rs (Rights) of correct medication administration: a. Right Resident . b. Right Drug . c. Right Dose . d. Right Dosage Form . e. Right Time . f. Right Route . 18. When administering insulin, ask another nurse to double-check the dose with you before injecting into the resident . 28 . Medication error must be reported immediately to the nursing supervisor as well as the physician and resident/resident representative. A Medication Error report must be completed and submitted for review to the Quality Assessment and Assurance Committee and the facility's Medical Director. Vital signs will be monitored for at least 24 hours following the error .
Humulin 70/30 KwikPen Instructions for Use with a June 2020 revision date stated, . Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. Step 8: To prime your Pen, turn the Dose Knob to select 2 units. Step 9: Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Step 10: Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the Needle. If you do not see insulin, repeat priming steps 8 to 10, no more than 4 times. If you still do not see insulin, change the Needle and repeat priming steps 8 to 10 .
1. On 8/22/22, Surveyor reviewed R17's medical record. R17 was admitted to the facility on [DATE] with diagnoses to include diverticulosis (a condition that causes small pockets to form in the lining of the intestines) and pain of right hip and thigh (upper leg).
On 8/22/22 at 4:09 PM, Surveyor observed Licensed Practical Nurse (LPN)-C prepare and administer medications for R17 which included two acetaminophen 500 mg tablets.
On 8/22/22, Surveyor reviewed R17's Medication Administration Record (MAR) which contained a physician order stating, Tylenol Tablet 325 mg (Acetaminophen) Give 2 tablets by mouth two times a day for Pain.
On 8/22/22 at 4:32 PM, Surveyor interviewed LPN-C. LPN-C verified the acetaminophen administered to R17 was two 500 mg tablets. Surveyor discussed with LPN-C the physician order for two 325 mg tablets of acetaminophen. LPN-C verified a medication error had occurred. When questioned what next steps LPN-C should take, LPN-C stated, I don't know. Ask the DON (Director of Nursing). I've never made a med (medication) error before.
On 8/22/22 at 4:33 PM, Surveyor interviewed DON-B who indicated medication errors were to be reported and the physician notified. DON-B stated, There is a med error sheet we fill out. DON-B verified the wrong dose of acetaminophen was considered a medication error.
2. On 8/22/22, Surveyor reviewed R46's medical record. R46 was admitted to the facility on [DATE] with diagnoses to include fracture (broken bone) right tibial spine (located at the end of a lower leg long bone within the knee) and diabetes mellitus (a disease in which blood sugar levels are too high).
On 8/22/22 at 4:19 PM, Surveyor observed LPN-C prepare medications for R46 which included 60 units of Humulin 70/30 insulin in a KwikPen dispenser. LPN-C attached a new needle cap to the KwikPen and dialed the pen to 60 units. Prior to administration, Surveyor stopped LPN-C and questioned if there was anything LPN-C would need to do with the KwikPen prior to actually administering insulin to R46. LPN-C indicated LPN-C would need to remove the air from the syringe of the KwikPen. Surveyor requested LPN-C perform that step. Surveyor observed LPN-C dial the KwikPen and press the plunger button enough times for air observed in the syringe to be visibly removed, but not enough for the attached needle cap to be filled with insulin. Surveyor questioned LPN-C if there was anything else PLN-C would need to do prior to actually administering insulin to R46. LPN-C indicated there were no more steps required prior to administration. Surveyor explained to LPN-C the need to prime the needle cap with 2 units of insulin prior to dialing the KwikPen to R46's ordered dose of 60 units as per manufacturer's recommendations. Surveyor explained to LPN-C, if this priming step was not done, R46 would only receive 58 units of insulin. LPN-C primed the needle as instructed by Surveyor then dialed the KwikPen to 60 units and administered the dose to R46. LPN-C indicated priming of the new needle cap was new information to LPN-C and stated, I never did that step before.
On 8/22/22, Surveyor reviewed R46's MAR which contained a physician order stating, Humulin 70/30 KwikPen Suspension Pen-injector (70-30) 100 UNIT/ML (units per milliliter) (Insulin NPH Isophane (long-acting insulin) & Regular (short-acting insulin)) Inject 60 units subcutaneously in the evening for DM (Diabetes Mellitus).
On 8/23/22 at 9:03 AM, Surveyor interviewed DON-B who, following the discussion of Surveyor observations of KwikPen use as stated above, verified the medication error would have occurred if R46 had received 58 units of insulin from use of an unprimed KwikPen needle cap.
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
Based on observation, staff interviews, and record review, the facility did not ensure food was stored, prepared, and served under sanitary conditions. Those practices had the potential to affect all ...
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Based on observation, staff interviews, and record review, the facility did not ensure food was stored, prepared, and served under sanitary conditions. Those practices had the potential to affect all 43 residents.
Dietary Manager (DM)-H did not test sanitizing solution according to test strip manufacturer directions. The sanitizing solution did not dispense in water resulting in water rinse instead of sanitization of the food preparation sink. The facility did not maintain documentation of sanitizing solution testing.
Dietary [NAME] (DC)-I did not wash hands after touching soiled items and prior to continuing with food preparation.
Staff left scoops with handles in full contact with food in bulk food containers.
Staff did not remove 25 expired containers of beverages from the refrigerator and 2 expired containers of lemon juice from dry storage to prevent use.
Staff did not invert or cover seven bowls and seven frying pans to protect from splash and dust accumulation.
Findings include:
On 8/22/22 at 9:38 AM, Surveyor interviewed DM-H who indicated the facility utilized ServSafe as its standard of practice. ServSafe is based on the Food and Drug Administration (FDA) Food Code.
Sanitizing Solution
Sanitizing solution test strip manufacturer insert directions document the solution must be between 65 and 75 degrees Fahrenheit (F) for testing.
On 8/22/22, during an initial kitchen tour beginning at 9:38 AM, Surveyor observed the three compartment sink set up for use and red sanitizing solution containers available in the kitchen. Surveyor requested sanitizing solution testing documentation. DM-H indicated the current (August 2022) testing log had coffee spilled on it and was unavailable for viewing since DM-H needed to transfer information to a new form. The previous month of sanitizer testing documentation was requested. Facility did not provide any documentation of sanitizing solution testing.
On 8/24/22 at 11:04 AM, Surveyor observed DC-I prepare a red sanitizing solution container in the utility closet to sanitize the food production sink DC-I rinsed soiled utensils into. DC-I did not test the sanitizing solution prior to wiping out the sink. DC-I wiped out the sink, placed strainer in the sink, and dumped cooked broccoli into the strainer. Surveyor was socially distanced from DC-I and not able to observe whether or not water from the cooked broccoli pot backed up in the sink or drained as quickly as poured.
On 8/24/22 at 11:52 AM, Surveyor requested DM-H demonstrate sanitizer solution testing in a red sanitizer solution container utilized for the food production sink by DC-I at 11:04 AM. Surveyor observed DM-H did not take the temperature of the water prior to testing. A test strip dropped in the solution by DM-H did not change color (no Parts Per Million (PPM) means no solution in plain water). At that time, Surveyor inquired about the temperature of the sanitizing solution at the time of testing. DM-H was not aware of the temperature requirements. Surveyor reviewed the sanitizing solution test paper manufacturer insert for directions which documented 65 to 75 degrees F was required for testing. DM-H indicated it was not the practice of kitchen staff to monitor the sanitizing solution temperature prior to testing. DM-H proceeded to dump the red sanitizing solution bucket of water and check the dispenser in the utility closet. DM-H explained the knob to fill the container with sanitizing solution was set to water, not sanitizing solution. DM-H proceeded to fill the red sanitizing solution container from the sanitizing solution dispenser at the three compartment sink location. DM-H did not test the temperature of the water prior to testing the sanitizing solution. Surveyor requested DM-H obtain the sanitizing solution temperature. DM-H placed the thermometer in the sanitizing solution and verbalized the sanitizing solution was over 80 degrees F.
Hand Hygiene
FDA Food Code 2017 documents at 2-301.14 FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES
On 8/24/22 at 11:04 AM, Surveyor was continuously observing lunch meal preparation. DC-I dropped a steam table divider on the floor, picked the steam table divider up with a gloved hand, tossed the steam table divider in the wash compartment of the three compartment sink, and without removing gloves or washing hands picked up a pitcher and began operating the hot water dispenser on the beverage machine. DC-I continued to prepare a potato mix, touched the interior handle of the kitchen exit door, and without washing hands or changing gloves, returned to clean up spill around the potato mix. DC-I then changed gloves without washing hands between the glove change, and continued to constitute pureed bread mix. After the puree bread was finished, DC-I removed gloves and washed hands.
On 8/24/22 at 12:01 PM, DM-H verified hands should be washed after touching soiled items and with glove changes when changing tasks.
Bulk Container Scoops
FDA Food Code 2017 documents at 3-304.12 During pauses in FOOD preparation or dispensing, FOOD preparation and dispensing UTENSILS shall be stored: (A) Except as specified under ¶ (B) of this section, in the FOOD with their handles above the top of the FOOD and the container; (B) In FOOD that is not TIME/TEMPERATURE CONTROL FOR SAFETY FOOD with their handles above the top of the FOOD within
containers or EQUIPMENT that can be closed, such as bins of sugar, flour, or cinnamon;
On 8/22/22, during an initial kitchen tour beginning at 9:38 AM, Surveyor observed and DM-H verified a bulk flour container and a bulk powdered sugar container both had scoops in bulk food with the scoop handles in full contact with food. DM-H verified scoop handles should not be in contact with food when stored in bulk food containers.
Expired Goods
On 8/22/22, during an initial kitchen tour beginning at 9:38 AM, Surveyor observed and DM-H verified the walk-in refrigerator contained nine honey thickened dairy drink beverage containers which expired 12/22/21, ten honey thickened dairy drink beverage containers which expired 6/18/22, four nectar thickened dairy drink beverage containers which expired 7/7/22, and two nectar thickened dairy drink beverage containers which expired 3/10/22. DM-H explained the expired beverages were discovered in the freezer approximately one month prior to the observation when the facility was locating and removing beverages affected by a product recall. DM-H confirmed staff should have discarded the products after thawing or even upon removal from the freezer. Surveyor entered the dry storage and observed two 32 ounce containers of lemon juice with use by dates of 5/19/22. DM-H verified the products were expired and explained the products were retained for cleaning use. DM-H confirmed the facility had a separate storage area for cleaning products, marked the containers not for consumption and moved the containers to an appropriate area.
Dish Storage
FDA Food Code 2017 documents at 4-903.11 (B) Clean EQUIPMENT and UTENSILS shall be stored as specified under ¶ (A) of this section and shall be stored: (1) In a self-draining position that allows air drying; and (2) Covered or inverted.
On 8/22/22, during an initial kitchen tour beginning at 9:38 AM, Surveyor observed and DM-I verified clean dish storage shelving located between cooking equipment and the three compartment sink held seven food preparation bowls which were not covered or inverted and seven frying pans which were not covered or inverted. DM-I confirmed the clean dishes should be covered or inverted when stored.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not establish and maintain an infection surveillance program designed to ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not establish and maintain an infection surveillance program designed to help prevent the development and transmission of disease and infection which had the potential to affect all 43 Residents (R) in the facility. Additionally, based on observation, record review and interview, the facility did not ensure implementation of infection control standards designed to prevent the transmission of disease and infection which had the potential to affect the 9 residents residing on the 300 unit of the facility.
The facility did not include a Return to Work (RTW) date for Certified Nursing Assistant (CNA)-K, who had respiratory illness symptoms, on the Respiratory Surveillance Line List and tested positive for Covid-19 (a mild to severe respiratory illness that is caused by a coronavirus) so as to ensure CNA-K did not return to the facility while contagious.
The facility did not include Licensed Practical Nurse (LPN)-L, who called off work on 8/1/22 due to Pinkeye (a contagious bacterial infection of one or both eyes), on a Surveillance Line List as to ensure LPN-L did not return to the facility while contagious.
The facility did not include CNA-M, who called all work 6/25/22 due to reported Strep Throat (a contagious bacterial infection of the throat), on a Surveillance Line List as to ensure CNA-M did not return to the facility while contagious.
Registered Nurse (RN)-O did not sanitize RN-O's eye protection after administering medication to R41, who resided on the 300 unit and was on droplet/contact precautions for Covid-19.
Findings include:
1. On 8/23/22, Surveyor reviewed facility provided Respiratory Surveillance Line Lists which included staff and residents who either exhibited signs and symptoms of Covid-19 and/or tested positive for Covid-19. Respiratory Surveillance Line Lists did not include other respiratory illnesses such as Pinkeye or Step Throat. Facility did not provide any other Surveillance Line Lists for employee illnesses.
Facility provided Respiratory Surveillance Line List for August 2022 included CNA-K illness onset date of 8/10/22 with listed symptoms of body aches, chills, stomach ache and throat sore. Respiratory Surveillance Line List indicated CNA-K had a negative Covid-19 test on 8/8/22 and a positive Covid-19 test on 8/10/22 C-19. Respiratory Surveillance Line List indicated CNA-K's symptoms resolved on 8/20/22 but did not include CNA-K's RTW date.
On 8/23/22 at 12:08 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated facility's scheduler kept employee call off slips. DON-B indicated if reason for employee call off was illness related, DON-B made follow-up calls to the employee to track symptoms. DON-B indicated facility did not maintain a surveillance line list to track trends of employee illnesses. DON-B indicated facility only started a line list at times of a possible new outbreak.
On 8/23/22, Surveyor reviewed facility provided Employee Call In/Absence Report (ECAR) slips for June, July and August 2022 which included the following:
ECAR slip for CNA-K indicated CNA-K called off work on 8/9/22 and stated, Reason for calling in: Body aches, chills, stomach ache, throat sore (Covid (-) (negative) 8.8.22) and 8/10/22 Came in to retest due to previous test being (-). Tested (+) (for Covid-19). There was no RTW date listed.
ECAR slip for LPN-L indicated LPN-L called off work on 8/1/22 and stated, Reason for calling in: Pink Eye and Directed to see MD (medical doctor) for ABT (antibiotic). May return 24 hours /p (after) ABT. Already started. There was no RTW date listed.
ECAR slip for CNA-M indicated CNA-M call off work on 6/25/22 and stated, Reason for calling in: 'Strep throat'. No other follow-up information was listed including no RTW date.
On 8/23/22 at 12:36 PM, Surveyor interviewed [NAME] President of Success (VPS)-N who indicated facility would be implementing a new line list to track trends of all employee illnesses and included section to document RTW date. VPS-N stated, They (facility) should have been doing this (tracking all employee illnesses). VPS-N verified Pinkeye and Strep Throat employee illnesses should have been included in surveillance process.
On 8/23/22 at 1:13 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated DON-B did not include employee RTW dates on Surveillance Lists and stated, I just write date of resolution based on 10-day isolation requirement. DON-B indicated CNA-K returned to work on 8/22/22. DON-B indicated LPN-L returned to work on 8/2/22 and stated, [LPN-L] was already on an antibiotic at time of call-in and returned to work 8/2/22 because that was 24 hours (of being on antibiotic). Regarding CNA-M, DON-B stated, I don't even remember [CNA-M]. Don't know if [CNA-M] was actually positive (for strep throat).
On 8/23/22 at 2:18 PM, Surveyor reviewed facility provided Timecard Punch Details which indicated: CNA-K's returned to work post-illness on 8/22/22; LPN-L's last day of work prior to illness was 7/31/22 and LPN-L returned to work post-illness on 8/2/22; and CNA-M did not work at facility any shift from 6/20/22 through 6/30/22.
2. On 8/22/22, Surveyor reviewed R41's medical record. R41 was admitted to the facility on [DATE]. R41's medical record indicated R41 tested positive for Covid-19 on 8/16/22 when R41 experienced symptoms of fever, headache, body chills, sinus pain and cough. R41 was placed on droplet/contact precautions on 8/16/22.
On 8/22/22 at 11:36 AM, Surveyor observed RN-O administer medication to R41 who resided on the 300 wing. Surveyor observed when RN-O exited R41's room, RN-O removed all RN-O's Personal Protective Equipment (PPE), including removal of RN-O's eye protection which RN-O set on top of isolation cart while RN-O removed RN-O's N-95 mask, performed hand hygiene and applied a surgical mask. After performing hand hygiene and without sanitizing eye protection, RN-O re-applied same eye protection worn in R41's room to continue medication administration tasks to other residents on 300 unit of facility. Surveyor observed RN-O touch and adjust eye protection while talking with Surveyor.
On 8/23/22 at 1:54 PM, Surveyor interviewed Infection Preventionist (IP)-J and discussed above observation of RN-O not sanitizing of eye protection after caring for R41. IP-J indicated IP-J had educated all employees on sanitization process of eye protection and verified RN-O should have sanitized RN-O's eye protection after exiting R41's room and prior to interacting with other residents or staff.
On 8/23/22, Surveyor reviewed facility provided resident Covid-19 vaccination rate of 83.3 % (percent) and staff Covid-19 vaccination rate of 73 %.
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
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most Wisconsin facilities.
Concerns
- • 29 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Mixed indicators with Trust Score of 60/100. Visit in person and ask pointed questions.
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About This Facility
What is Cedarburg Health Services's CMS Rating?
CMS assigns CEDARBURG HEALTH SERVICES an overall rating of 3 out of 5 stars, which is considered average nationally. Within Wisconsin, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Cedarburg Health Services Staffed?
CMS rates CEDARBURG HEALTH SERVICES's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 48%, compared to the Wisconsin average of 46%. RN turnover specifically is 82%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Cedarburg Health Services?
State health inspectors documented 29 deficiencies at CEDARBURG HEALTH SERVICES during 2022 to 2025. These included: 29 with potential for harm.
Who Owns and Operates Cedarburg Health Services?
CEDARBURG HEALTH SERVICES 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 NORTH SHORE HEALTHCARE, a chain that manages multiple nursing homes. With 50 certified beds and approximately 43 residents (about 86% occupancy), it is a smaller facility located in CEDARBURG, Wisconsin.
How Does Cedarburg Health Services Compare to Other Wisconsin Nursing Homes?
Compared to the 100 nursing homes in Wisconsin, CEDARBURG HEALTH SERVICES's overall rating (3 stars) matches the state average, staff turnover (48%) is near the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting Cedarburg Health Services?
Based on this facility's data, families visiting should ask: "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?" "Can I speak with family members of current residents about their experience?"
Is Cedarburg Health Services Safe?
Based on CMS inspection data, CEDARBURG HEALTH SERVICES has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #1 of 100 nursing homes in Wisconsin. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Cedarburg Health Services Stick Around?
CEDARBURG HEALTH SERVICES has a staff turnover rate of 48%, which is about average for Wisconsin nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Cedarburg Health Services Ever Fined?
CEDARBURG HEALTH SERVICES has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Cedarburg Health Services on Any Federal Watch List?
CEDARBURG HEALTH SERVICES 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.