Ingleside Manor

F-F609

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 13 525331 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525331 B. Wing 03/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ingleside Manor 407 N Eighth St Mount Horeb, WI 53572

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42440

Residents Affected - Few Based on record review, interview, and facility policy review, the facility failed to administer medications as scheduled for 1 of 12 Residents (Resident R3) reviewed for medication administration.

Resident R3's medications were documented as not being administered and/or documented as being administered late.

Findings include:

Review of the facility's Administering Medications policy, dated April 2019, revealed Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions and Medications are administered in accordance with prescriber orders, including any required time frame. In addition, Medications are administered within one hour of their prescribed time, unless otherwise specified.

Review of Resident R3's Face Sheet tab in the electronic medical record (EMR) revealed she was admitted to the facility on [DATE REDACTED]. Resident R3 had diagnoses which included pulmonary hypertension, hypertension, and localized edema.

Review of Resident R3's quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date of 02/18/25, located in the EMR RAI [Resident Assessment Instrument] tab, revealed Resident R3 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition.

Review of Resident R3's Medication Administration Record (MAR) located in the Reports tab of the EMR for the dates of 12/18/24 to 12/20/24 revealed the following orders:

-hydralazine (vasodilator used to treat high blood pressure) 50 milligrams (mg) three times daily at 8:00 AM, 12:00 PM, and 4:00 PM

-fexofenadine (antihistamine for allergies) 180mg daily at 8:00 AM

-folic acid 1mg daily at 8:00 PM

-liothyronine (thyroid medication) 25 micrograms (mcg) daily at 8:00 AM

-losartan (blood pressure medication) 100mg daily at 8:00 AM

-torsemide (diuretic) 10mg two tabs daily at 8:00 AM

Review of Resident R3's Medications Administration History report provided by the facility for the dates of 12/18/24 to 12/20/24 revealed:

On 12/18/24 the 4:00 PM dose of hydralazine was documented as Not administered: Drug item unavailable.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 13 525331 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525331 B. Wing 03/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ingleside Manor 407 N Eighth St Mount Horeb, WI 53572

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 On 12/19/24 the 8:00 AM doses of fexofenadine and liothyronine were signed off as charted late at 1:24 PM;

the 8:00 AM and 12:00 PM doses of hydralazine were charted late at 1:25 PM, and the 4:00 PM dose was Level of Harm - Minimal harm or signed off as late administration other on 12/19/24. The 8:00 AM doses of folic acid, losartan, and torsemide potential for actual harm were signed off as administered late at 9:15 AM. On 12/20/24, the liothyronine and torsemide were documented as not administered: drug/item unavailable. Residents Affected - Few

Review of Resident R3's Medication Administration Record (MAR), located in the Reports tab of the EMR, for the dates of 03/10/25 to 03/12/25, revealed the following orders:

-carvedilol (blood pressure medication) 3.125mg twice a day at 8:00 AM and 4:00 PM

-cephalexin (antibiotic) 500mg four times at 8:00 AM and 12:00 PM (course completed after noon dose 03/10/25)

-fexofenadine 180mg daily at 8:00 AM

-liothyronine 25mcg daily at 8:00 AM

-torsemide 10mg two tabs daily at 8:00 AM

Review of Resident R3's Medications Administration History report provided by the facility for the dates of 03/10/25 to 03/12/25 revealed all 8:00 AM medications on 03/10/25 were signed off at 10:38 AM with the note late administration: administered late.

The noon dose of cephalexin on 03/10/25 was given at 1:07 PM.

All 8:00 AM medications on 03/11/25 were charted as late between 12:37 PM and 12:38 PM.

During an interview on 03/12/25 at 2:15 PM, Resident R3 reported getting medications late or occasionally having medications not available. Resident R3 recalled concerns with medications on 12/18/24 and 12/19/24, and stated she received her 8:00 AM medications around 12:30 PM. Resident R3 stated she received 8:00 AM medications well after 9:00 AM on 03/10/25 and 03/11/25. Resident R3 reported occasionally having chest pain and having to ask for nitroglycerin when her blood pressure medications were not given on time, by 9:00 AM.

During an interview on 03/14/25 at 2:15 PM, the Director of Nursing (DON), who was covering the floor, reported the expectation that medications are administered from an hour before until an hour after the scheduled time. The DON confirmed the late medication administrations.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 13 525331 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525331 B. Wing 03/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ingleside Manor 407 N Eighth St Mount Horeb, WI 53572

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42440 potential for actual harm Based on observation, interview and record review, the facility did not ensure a medication error rate of 5% Residents Affected - Few or less. During the medication administration task, Surveyors observed 18 errors out of 28 medication opportunities, resulting in an error rate of 64.28% This affected 3 out of 4 Residents (R) observed for medication administration (Resident R10, Resident R11 & Resident R12).

Resident R10, Resident R11 and Resident R12 received their 8:00 AM medications more than an hour past their scheduled administration time.

Evidenced by:

Review of the facility's Administering Medications policy, dated April 2019, revealed Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions and Medications are administered in accordance with prescriber orders, including any required time frame. In addition, Medications are administered within one hour of their prescribed time, unless otherwise specified.

Example 1:

Review of Resident R10's Face Sheet tab of the EMR revealed she was admitted to the facility on [DATE REDACTED] and had diagnoses including end stage renal disease, dependence on renal dialysis, type 2 diabetes mellitus, hypothyroidism and hypertension (high blood pressure).

Review of Resident R10's MAR for March 2025 revealed orders:

- Aspirin 81mg (milligram) chew tablet once a day 8:00 AM

- B complex tablet once a day at 8:00AM

- Carvedilol 3.125mg tablet once a day sun, mon, wed, fri take 6.25mg on non-dialysis days Hold if systolic BP (blood pressure) is less than or equal to 120 or HR (heart rate) less than 60bpm (beats per minute) 8:00AM

- Loratadine 10mg tablet once a day 8:00AM

- Nifedipine 30mg extended release once a day on Sun, Mon, wed, fri on non-dialysis days in AM 8:00AM.

- Omeprazole 20mg once a day 8:00 AM

- Sertraline 25mg tablet once a day 8:00 AM

- Sevelamer carbonate 800mg three times a day 8:00AM, 12:00PM, and 4:00PM.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 13 525331 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525331 B. Wing 03/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ingleside Manor 407 N Eighth St Mount Horeb, WI 53572

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 - Systane eye drops 0.4-0.3% (percent) once a day every other day place 2-3 drops into both eyes 8:00 AM

Level of Harm - Minimal harm or - Vitamin D3 25mg (1000 unit) once a day 8:00AM potential for actual harm - Levothyroxine 100mcg (micrograms) once a day 8:00 AM Residents Affected - Few

On 03/12/25, Registered Nurse (RN) 3 started preparing medications for Resident R10 at 8:50 AM and administered them at 9:09 AM to Resident R10. RN3 reported it was her second day at the facility, and she was behind on the medication pass when residents started lining up at the medication cart and talking. When asked how many more residents she had to administer 8:00 AM medication to, RN counted and responded, seven.

(Of note: Resident R10's medications were given at 9:09 AM, which is greater than an hour from the scheduled administration time)

Example 2

Review of Resident R11's Face Sheet tab of the EMR revealed she was admitted to the facility on [DATE REDACTED] and had diagnoses which included diabetes and myopathy (muscle weakness and pain).

Review of Resident R11's quarterly MDS with an ARD of 01/06/25, located in the EMR RAI tab, revealed a BIMS score of 13 out of 15 which indicated intact cognition.

Review of Resident R11's MAR for March 2025 revealed orders:

-Humalog insulin (a short acting insulin) 30 units with breakfast at 8:00 AM

-Lantus insulin (a long acting insulin) 44 units twice daily at 8:00 AM and 8:00 PM

-lidocaine adhesive patch 5%, apply to low back for pain at 8:00 AM and remove at 8:00 PM

During an observation on 03/12/25 at 9:47 AM, Certified Nurse Aide/Medication Aide (CNA) 1 administered Lantus 44 units, Humalog 30 units, and a lidocaine patch to Resident R11 in her room. No breakfast tray was observed.

(Of note: Resident R11's medications were given at 9:47 AM, which is greater than an hour from the scheduled administration time.)

During an interview on 03/12/25 at 9:49 AM, Resident R11 reported she had finished her breakfast, and she often received her morning medications around the current time.

Example 3

Review of Resident R12's Face Sheet tab of the EMR revealed she was admitted to the facility on [DATE REDACTED] and had diagnoses including heart failure, pulmonary hypertension, anxiety, and hypertension (high blood pressure).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 13 525331 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525331 B. Wing 03/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ingleside Manor 407 N Eighth St Mount Horeb, WI 53572

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Review of Resident R12's annual MDS with an ARD of 01/07/25, located in the EMR RAI tab, revealed a BIMS score of 11 of 15 which indicated moderately impaired cognition. Level of Harm - Minimal harm or potential for actual harm Review of Resident R12's MAR for March 2025 revealed orders:

Residents Affected - Few -bupropion HCl (antidepressant) 150mg daily at 8:00 AM

-furosemide (diuretic) 20mg daily at 8:00 AM

-lorazepam (anti-anxiety) 0.5mg twice a day at 8:00 AM and 8:00 PM

-metoprolol tartrate (blood pressure medication) 25mg twice a day at 8:00 AM and 8:00 PM

-vitamin B6 25mg 2 tabs daily at 8:00 AM

-vitamin D3 2000 units daily at 8:00 AM

During an observation on 03/12/25 at 10:10 AM, CNA1 administered Resident R12's 8:00 AM medications except for

the lorazepam and bupropion, which the resident refused.

(Of note: Resident R12's medications were given at 10:10 AM, which is greater than an hour from the scheduled administration time)

During an interview on 03/12/25 at 10:15 AM, CNA1 stated medications were to be administered from an hour before to an hour after the scheduled time. CNA1 reported she started late and was pulled to do other things.

During an interview on 03/12/25 at 10:20 AM. Resident R12 stated she did not want to talk.

During an interview on 03/14/25 at 12:10 PM, RN4 stated sometimes they did not have medications and had to keep on the out-of-town pharmacy to get the medications. The facility's contingency supply did not include some necessary medications and not all agency staff have access to it. RN4 reported there were times things like falls with frequent neurological checks or lab draws came up which made it difficult to administer all medications timely. RN4 focused on insulins and other time-sensitive medications if she was running behind.

During an interview on 03/14/25 at 2:15 PM, the Director of Nursing (DON), who was covering the floor, reported the expectation that medications are administered from an hour before until an hour after the scheduled time. The DON confirmed the late medication administrations.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 13 525331

F-F610

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 13 525331 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525331 B. Wing 03/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ingleside Manor 407 N Eighth St Mount Horeb, WI 53572

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42440 potential for actual harm Based on interviews, record review, and facility policy review, the facility failed to interview all staff who may Residents Affected - Few have had knowledge of a resident-to-resident abuse allegation involving 2 of 12 sampled Residents (Resident R1 & Resident R2).

Facility did not thoroughly investigate a resident-to-resident abuse allegation involving Resident R1 and Resident R2.

Findings include:

Review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating revised September 2022 revealed, All allegations are thoroughly investigated. The administrator initiates investigations . The individual conducting the investigation as a minimum: . interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; . documents the investigation completely and thoroughly.

Review of the Face Sheet tab, located in the electronic medical record (EMR), revealed Resident R1 was admitted to

the facility on [DATE REDACTED]. Resident R1 had diagnoses including metabolic encephalopathy (condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body.)

Review of the Face Sheet tab, located in the EMR, revealed Resident R2 was admitted to the facility on [DATE REDACTED]. Resident R2 had diagnoses including dementia and anxiety.

Review of a State of Wisconsin Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report submitted to the Department of Health Services on 12/20/24 at 5:22 PM and supplied by the facility revealed Resident R1 reported being backhanded in the face by another resident, Resident R2. The report stated the event occurred on 12/19/24 around 7:30 PM and was discovered on 12/20/24. The report stated there were no known witnesses, a head-to-toe skin assessment revealed no injuries, and the resident did not report feeling unsafe. Investigation is ongoing.

The facility investigative file provided by the Assistant Administrator revealed the facility's former Admissions Director received an email on 12/20/24 from Resident R1's family member (FM)1 of an incident on 12/19/24, initially believed by FM1 to have been between a staff member and Resident R1. The file stated when the Assistant Administrator interviewed Resident R1, Resident R1 reported Resident R2 yelled at her, Your children are [NAME] along with other comments Resident R1 could not recall as Resident R1 tried to exit her room in her wheelchair. When Resident R1 told Resident R2 to get away from her, Resident R2 backhanded Resident R1 in the mouth. Resident R2 then rammed her wheelchair into Resident R1's wheelchair as Resident R1 moved away from Resident R2. Resident R1 recalled the events occurring between 7:00 PM and 8:00 PM on 12/19/24 and reported she notified the Registered Nurse (RN) on duty who spoke to Resident R2. When the Assistant Administrator interviewed Resident R2, Resident R2 could not recall any incident with Resident R1. The Social Services Director (SSD) completed a Brief Interview of Mental Status (BIMS) on each resident on 12/20/24. Resident R1 scored 10 out of 15, which indicated moderately impaired cognition, and Resident R2 scored two out of 15, which indicated severely impaired cognition.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 13 525331 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525331 B. Wing 03/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ingleside Manor 407 N Eighth St Mount Horeb, WI 53572

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Further review of the facility investigative file revealed the facility conducted interviews with staff asking if

they had witnessed any resident being physically abusive toward another resident and if they knew who to Level of Harm - Minimal harm or notify if they witnessed or suspected abuse. None of the seven certified nurse aides (CNAs) or three RNs potential for actual harm included in these interviews were on duty on the shift when the abuse allegation occurred.

Residents Affected - Few The facility investigative file contained an email the Assistant Administrator sent to the former Administrator

on 12/20/24 at 5:33 PM regarding interviews she conducted with Certified Nurse Aide (CNA) 3 and CNA5 on 12/20/24. During the interviews, CNA3 stated he had not witnessed the incident but had heard CNA5 talking about it and heard that CNA4 saw the incident. CNA5 stated Resident R2 had swung at her and CNA4 the evening before. CNA5 did not witness Resident R2 swing at Resident R1. The email stated, [CNA4] is an agency staff member. Her phone number is . if you would like to reach out.

During an interview on 03/11/25 at 9:15 AM, Resident R2 smiled and reported everyone at the facility was nice, and

she had never hit anyone, nor had anyone ever hit her.

During an interview on 03/11/25 at 12:25 PM, Resident R1 reported Resident R2 had rammed into the back of my wheelchair with her wheelchair. Resident R1 could not recall if Resident R2 touched her but did recall telling the nurse what had happened. Resident R1 felt the nurse addressed it because she [Resident R2] hasn't bothered me since.

During an interview on 03/11/25 at 2:57 PM, FM1 stated she spoke to Resident R1 each night. FM1 recalled on 12/19/24, Resident R1 told FM1 that a woman tried to get past her to use the phone and had backhanded her. Resident R1 told FM1 she had told the staff. FM1 tried to call the facility but no one answered, and so she sent an email.

During an interview on 03/12/25 at 10:40 AM, the Assistant Administrator reported she had interviewed Resident R1 and Resident R2 as well as CNA3 and CNA5. The Assistant Administrator stated the former Administrator interviewed

the other staff and residents. The Assistant Administrator was unable to verify if CNA4 had been contacted.

During an interview on 03/12/25 at 4:10 PM, CNA4 reported she had not witnessed Resident R2 hit Resident R1. CNA4 recalled that on 12/19/24 the two residents had a verbal altercation and had been separated. Resident R1 later reported to CNA4 that Resident R2 had bopped her in the mouth, and CNA4 reported it immediately to the nurse [RN6]. CNA4 recalled Resident R1 did not seem injured. CNA4 stated Resident R2 had a history of wandering and being combative with staff who tried to redirect her. CNA4 stated no one from the facility had reached out to her regarding the incident.

During an interview on 03/13/25 at 2:51 PM, CNA3 stated Resident R2 went from really happy to really upset quickly for no known reason, but he did not believe Resident R2 had ever hit another resident prior to 12/19/24. CNA3 stated

he did not witness Resident R2 hit Resident R1, but Resident R1 reported to him that Resident R2 hit her in the face. CNA3 stated he went right to

the nurse to report the allegation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 13 525331 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525331 B. Wing 03/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ingleside Manor 407 N Eighth St Mount Horeb, WI 53572

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 During an interview on 03/14/25 at 8:30 AM, the Assistant Administrator stated at the time of the allegation,

she was primarily overseeing the non-nursing facility part of the building while the former Administrator Level of Harm - Minimal harm or oversaw the nursing facility, so she was not really involved in the investigation outside of assisting with the potential for actual harm two resident and two staff interviews. She could not verify that any further staff interviews were conducted outside of the two she completed. The Assistant Administrator confirmed the investigation was not thorough. Residents Affected - Few The Assistant Administrator stated she would have reached out to everyone on the schedule that shift as well as previous shifts, to find out more about what may have escalated any behaviors.

Cross-reference to