Rolling Hills Rehab Ctr

F-F640 regulation. NHA A stated they will transmit them all from now on.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 33 525430 Department of Health & Human Services Printed: 09/08/2025 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 525430 B. Wing 02/20/2025

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

Rolling Hills Rehab Ctr 14400 Cty Hwy B Sparta, WI 54656

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 0688 Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44863

Residents Affected - Some Based on observation, interview and record review, the facility did not ensure residents received appropriate treatment and services to maintain range of motion (ROM). This had the potential to affect four residents (R) reviewed for mobility (Resident R25, Resident R26, Resident R30, and Resident R31).

-Resident R25 was not provided restorative services at least three times per week as identified in her care plan.

-Resident R26's care plan did not identify the frequency and duration of restorative services needed.

-Resident R30 was not provided restorative services daily as identified in her care plan.

-Resident R31 was not provided restorative services five times per week as identified in her care plan.

This is evidenced by:

Per Appendix PP of the State Operations Manual (SOM), regulation

F-F688 reads in part . The facility must develop resident care policies in collaboration with the medical director, director of nurses, and as appropriate, physical/occupational therapy consultant. This includes policies on restorative/rehabilitative treatments/services, based on professional standards of practice. The care plan must identify the type of treatments, frequency, and duration, as well as the measurable objectives and resident goals.

Example 1

Resident R25 admitted to facility on 05/13/24, with a diagnosis including arthritis. Minimum Data Set (MDS) assessment confirmed Resident R25 scored 15/15 during Brief Interview for Mental Status (BIMS), indicating intact cognition.

Resident R25's MDS assessment completed on 01/24/25 indicated the following changes in functional abilities related to transfers, since admission:

-Sit to stand, partial assistance increased to substantial assistance.

-Chair to bed, partial assistance increased to substantial assistance.

-Toilet transfer, partial assistance increased to substantial assistance.

Resident R25's Restorative Aide Program documentation indicated restorative goal to decrease joint pain, risk of falls, and decline in transfers and mobility. GOAL: Participate in restorative services at least three times per week to maintain strength and promote safe transfers and mobility.

Resident R25's Restorative Aide Program documentation indicated Resident R25 participated in restorative program as follows:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 33 525430 Department of Health & Human Services Printed: 09/08/2025 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 525430 B. Wing 02/20/2025

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

Rolling Hills Rehab Ctr 14400 Cty Hwy B Sparta, WI 54656

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 0688 -12/2024, 6 of 31 days.

Level of Harm - Minimal harm or -01/2025, 5 of 31 days. potential for actual harm -02/20/25, 5 of 20 days. Residents Affected - Some

During the survey period of 02/17/25-02/20/2025, Surveyor did not observe Resident R25 participating in restorative services.

On 02/19/25 at 1:46 PM, Surveyor interviewed Resident R25. Resident R25 stated she participates in a restorative program to help strengthen her muscles. Resident R25 reported she is supposed to receive exercises with Restorative Aide (RA) L, three times per week, but sometimes she doesn't come at all.

Example 2

Resident R26 was admitted to the facility on [DATE REDACTED] and diagnoses included muscular dystrophy. MDS assessment confirmed Resident R26 scored 15/15 during BIMS, indicating intact cognition.

Resident R26's MDS assessment completed on 01/22/25 indicated Resident R25 is dependent on staff for all transfers.

Resident R26's Restorative Aide Program documentation indicated restorative goal to prevent decline, contractures, and falls. GOAL: Participate in exercises and transfers to maintain ability to safely transfer and ambulate with staff assist. (Surveyor noted Resident R26's restorative care plan did not include a frequency or duration).

Resident R26's Restorative Aide Program documentation indicated Resident R26 participated in restorative program as follows:

-10/2024, 13 of 31 days.

-11/2024, 8 of 30 days.

-12/2024, 4 of 31 days.

-01/2025, 7 of 31 days.

-02/2025, 3 of 20 days.

During the survey period of 02/17/25-02/20/2025, Surveyor did not observe Resident R26 participating in restorative services.

On 02/17/25 at 10:40 AM, Surveyor interviewed Resident R26. Resident R26 stated he had not received his exercise program last week. Resident R26 reported he usually receives exercise program once weekly, but stated twice weekly would be better for him to maintain his abilities. Resident R26 stated he reported this to a nurse sometime this winter but had not received any updates related to frequency of his weekly exercises.

Example 3

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 33 525430 Department of Health & Human Services Printed: 09/08/2025 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 525430 B. Wing 02/20/2025

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

Rolling Hills Rehab Ctr 14400 Cty Hwy B Sparta, WI 54656

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 0688 Resident R30 was admitted to the facility on [DATE REDACTED]. Diagnoses included osteoarthritis, pain, and history of blood clot

in limb. MDS assessment confirmed Resident R30 scored 15/15 during BIMS, indicating intact cognition. Level of Harm - Minimal harm or potential for actual harm Resident R30's MDS assessment, completed on 11/06/2024, indicated Resident R30 requires substantial assistance from staff with all transfers. Residents Affected - Some Resident R30's Restorative Aide Program documentation indicated restorative goal to reduce decline in functional transfers and contracture risk. GOAL: Participate in daily exercises to maintain safe transfer ability.

Resident R30's Restorative Aide Program documentation indicated the following:

-10/2024, 5 of 31 days.

-11/2024, 7 of 30 days.

-12/2024, 9 of 31 days.

-01/2025, 7 of 31 days.

-02/2025, 3 of 20 days.

During the survey period of 02/17/2025-02/20/2025, Surveyor did not observe Resident R30 participating in restorative services.

On 02/19/25 at 2:04 PM, Surveyor interviewed Resident R30 regarding his restorative services. Resident R30 responded, No, not too much. Not even once a week. I want to be able to transfer and stand.

Example 4

Resident R31 was admitted to the facility on [DATE REDACTED]. Diagnoses included Parkinson's disease and pain caused by compression fractures in back. MDS assessment confirmed Resident R31 scored 13/15 during BIMS, indicating intact cognition.

MDS assessment completed on 12/18/24 indicated Resident R31 is dependent on staff for all transfers. Review of previous MDS assessment, completed on 09/18/24, confirmed Resident R31 declined in toileting transfers from substantial assistance to dependent on staff.

Resident R31's Restorative Aide Program documentation included goal to reduce decline in range of motion, strength, and mobility. GOAL: Participate in restorative services five times per week to maintain strength and mobility as evidenced by ability to ambulate 50 feet with walker and staff assistance.

Resident R31's Restorative Aide documentation included the following:

-11/2024, 12 of 30 days.

-12/2024, 10 of 31 days.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 33 525430 Department of Health & Human Services Printed: 09/08/2025 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 525430 B. Wing 02/20/2025

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

Rolling Hills Rehab Ctr 14400 Cty Hwy B Sparta, WI 54656

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 0688 -01/2025, 5 of 31 days.

Level of Harm - Minimal harm or -02/2025, 4 of 20 days. potential for actual harm

During the survey period of 02/17/2025-02/20/2025, Surveyor did not observe Resident R31 participating in restorative Residents Affected - Some services.

On 02/18/25 at 1:00 PM, Surveyor interviewed Physical Therapy Assistant (PTA) O. PTA O reported Certified Nursing Assistant (CNA) tasks and restorative program exercises are separate. CNAs do not complete restorative program exercises; the facility has RA L complete restorative program exercises. The facility has a Restorative Aide Program binder, kept in the therapy department, to document how often services were provided to each resident.

PTA O stated RA L's schedule recently changed to part-time schedule. PTA O reported if RA L cannot complete the restorative programs for all the residents, therapy staff try to complete what RA L could not. PTA O confirmed DON B is the 'head' of the restorative program.

On 02/18/25 at 1:10 PM, Surveyor interviewed Director of Nursing (DON) B. DON B confirmed she oversees

the facility's restorative program. DON B confirmed RA L's schedule was changed to part-time and not available full-time, and the facility was working on a plan to have more than one restorative aide to ensure a full-time schedule for restorative services. DON B confirmed if RA L is not able to complete the services, therapy staff assist with ensuring restorative services are completed.

DON B stated the facility would like to offer residents restorative services daily, so the frequency is set as daily in the hopes the resident will participate in services 3-5 days per week. DON B stated the purpose of

the restorative program is to maintain or prevent loss of a resident's current functioning. DON B stated each resident's restorative program is reviewed monthly when she changes out the documentation in the Restorative Aide Program binder, and the nurses document in the resident's record.

Surveyor requested the facility's policy related to restorative services. Director of Nursing (DON) B reported

the facility did not have a Restorative Services Policy.

Surveyor reviewed records for Resident R25, Resident R26, Resident R30, and Resident R31. Surveyor was unable to find nursing documentation related to restorative services.

On 02/20/25 at 7:04 AM, Surveyor interviewed RA L. RA L confirmed she works every Thursday and Friday and every other weekend. RA L reported there are approximately 13 residents participating in the restorative program, and she tries to get to all residents but sometimes it is difficult due to resident schedules, activities, mealtimes, or resident declination to participate. RA L stated it can be difficult to complete the restorative program as she gets pulled to work on the floor as a CNA a lot. RA L reported on average she works as a CNA about one day per week. RA L confirmed if she is unable to complete restorative exercises with a resident, therapy staff attempt to complete those services with the resident. RA L stated she reports to therapy staff which residents did not receive the services, by writing it on a whiteboard in the therapy department and documenting in the Restorative Aide Program binder.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 33 525430 Department of Health & Human Services Printed: 09/08/2025 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 525430 B. Wing 02/20/2025

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

Rolling Hills Rehab Ctr 14400 Cty Hwy B Sparta, WI 54656

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 0688 On 02/20/25 at 8:58 AM, Surveyor interviewed Certified Occupational Therapy Assistant (COTA) Q. COTA Q stated therapy staff are responsible for evaluating a resident's level of skill and the nursing department is Level of Harm - Minimal harm or responsible for putting the evaluations into place and into the plan of care. COTA Q explained CNAs are potential for actual harm responsible for completing the functional restorative program tasks, to help residents benefit from participating in independence in daily tasks. The RA is responsible for the Functional Aide Program, which is Residents Affected - Some the restorative exercises recommended by therapy staff. COTA Q stated, If a frequency is not identified, ideally residents would receive restorative services daily, so let's see if we can get to them at least 3 days per week.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 33 525430 Department of Health & Human Services Printed: 09/08/2025 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 525430 B. Wing 02/20/2025

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

Rolling Hills Rehab Ctr 14400 Cty Hwy B Sparta, WI 54656

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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49353

Residents Affected - Few Based on observation, interview and record review, the facility did not ensure resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 2 of 15 residents (Resident R13, Resident R35) reviewed.

Resident R13 was left unattended while connected to mechanical lift equipment.

Resident R35 did not have increased supervision to prevent resident to resident altercations after incidents on 06/22/24, 09/16/24, 01/10/25, and 01/28/25.

This is evidenced by:

Example 1

The Food and Drug Administration (FDA) Safety Information guidance provided in Kwikpoints Patient Lifts Safety Guide, states in part: Do not leave patient unattended while in lift. Never keep patient suspended in sling for more than a few minutes.

Resident R13 was admitted to the facility on [DATE REDACTED] with pertinent diagnoses of spastic quadriplegic cerebral palsy and muscle weakness of extremities.

Resident R13's most recent Minimum Data Set (MDS) assessment dated [DATE REDACTED] indicated that Resident R13 has moderate cognitive impairment that requires cues and supervision and is dependent with assist for chair to bed transfers.

On 02/18/25 at 12:45 PM, Surveyor observed Resident R13 in his room, seated in broda chair, with mechanical lift sling positioned under him and attached to mechanical lift. Surveyor looked inside room and did not see a staff member present.

On 02/18/25 at 12:51 PM, Surveyor observed Certified Nursing Assistant (CNA) C walking from around the corner of dining area from another resident hallway and enter Resident R13's room. Surveyor observed CNA C check Resident R13's sling attachment to mechanical lift by tugging slightly on sling strap. CNA C then walked to doorway, looked in both directions in hallway, and then returned to resident still suspended in sling attached to mechanical lift.

On 02/18/25 at 12:53 PM, Surveyor observed another CNA enter Resident R13's room to assist CNA C with transfer of Resident R13.

On 02/18/25 at 1:00 PM, Surveyor interviewed CNA C regarding observation. Surveyor asked CNA C why Resident R13 was left unattended in his room while attached to the mechanical lift. CNA C stated she was waiting for her partner to assist with Resident R13's transfer because he is a two person assist. Surveyor asked CNA C if this was

a common practice for residents to be left unattended while connected to lift equipment. CNA C stated no.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 33 525430 Department of Health & Human Services Printed: 09/08/2025 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 525430 B. Wing 02/20/2025

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

Rolling Hills Rehab Ctr 14400 Cty Hwy B Sparta, WI 54656

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 0689 On 02/19/25 at 12:41 PM, Surveyor interviewed Director of Nursing (DON) B regarding observation and mechanical lift safety. Surveyor asked DON B if it would be an acceptable practice for staff to leave residents Level of Harm - Minimal harm or unattended while connected to lift equipment. DON B stated that other than an emergent situation, staff potential for actual harm would be expected to stay with a resident while lift equipment is being used. Surveyor informed DON B of

observation of Resident R13 being left unattended for 6 minutes while attached to the lift machine. DON B stated Residents Affected - Few disappointment and concern that this action could have resulted in harm from entrapment.

48793

Example 2

On 02/17/25, Surveyor reviewed Resident R35's medical record. Resident R35 was admitted on [DATE REDACTED], with dementia unspecified with behavioral disturbances, cataracts, hypertensive heart disease, and insomnia. Resident R35's Minimum Data Set (MDS) assessment, dated 11/06/24, had a Brief Interview for Mental Status (BIMS) score of 00 which indicated Resident R35 had severe impaired cognition and could not complete the BIMS test.

Surveyor reviewed Resident R35's care plan for Alzheimer's disease major neurocognitive disorder due to medical condition with behavior disturbance:

-On 11/16/22: Nurse to report any behavioral issues. Has wander management bracelet.

-On 02/15/23: After wife visits monitor more closely for wandering or behaviors.

-On 02/15/23: If attempt to swing fist may need to leave alone and reapproach later or get alternate staff.

-On 02/21/24: Report to nurse if noting any behavioral issues or hitting peers.

-On 06/25/24: Night shift to look in on him on rounds x 3. Keep door alarm on so as to alert staff to exiting room.

On 1:1 visits as needed.

-On 11/16/24: If pacing or restless, trying to go into peer's room offer to take toilet in his room. Redirect away from peers' rooms.

-On 01/04/25: Turn on chime on outside door when he goes to bed, to alert staff when Resident R35 exit seeks.

-On 01/28/25: If in peers' room or noting to be touching peers, redirect Resident R35.

Surveyor reviewed Resident R35's nursing progress notes that indicated,

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 33 525430 Department of Health & Human Services Printed: 09/08/2025 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 525430 B. Wing 02/20/2025

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

Rolling Hills Rehab Ctr 14400 Cty Hwy B Sparta, WI 54656

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 0689 . -On 06/22/2024 at 4:09 PM, Note: [Resident R35] was sitting at the dining table eating and suddenly he yelled at resident across the table who was eating his meal and then kicked the table and was swearing. We were Level of Harm - Minimal harm or going to remove him from the area but then he continued to eat, and we stayed nearby. When he appeared potential for actual harm not to be eating, we offered that he could go watch tv if he wanted to. He got up and started pacing the hallway. After residents were done eating one resident stayed in his chair by the dining room table to watch Residents Affected - Few tv and [Resident R35] came up behind him and hit the back of the chair hard. This frightened the resident in the chair, and he got up with his walker and went to his room .

Surveyor did not find documentation that staff implemented any new interventions to increase supervision or provide 1:1 for Resident R35 after the resident altercation on 6/22/24.

Nurse progress note indicated,

-On 07/26/24: Resident R35 was grabbing, pushing, and swinging. Attempted to put hands around writers' neck while trying to provide cares.

Surveyor did not find documentation that staff implemented any new interventions to increase supervision for

the other residents on the unit, when Resident R35 exhibited increased aggressive behaviours on 7/26/24.

Nurse progress note indicated,

. On 09/16/24 at 9:30 PM, Note: [Resident R35] spent first part of our shift outside. He did not eat much of his supper

this evening. Given cold fluids as it was warm outside. Brought him in to get ready for bed but he has been very resistive to cares again his shift. I only now was able to get him to take his medications. Will attempt to change him again when he has had his meds in him for 30 minutes or so. CNA informed me that, [Resident R35] walked by another resident and apparently swung as to hit him but did not. It is very difficult to address his cares even with two staff. Will continue to monitor behaviors and chart .

Surveyor did not find documentation that staff updated any new interventions to increase supervision or provide 1:1 for Resident R35 to protect other residents on the unit when Resident R35 was observed swinging at another resident on 9/16/24.

Nurse progress note indicated,

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 33 525430 Department of Health & Human Services Printed: 09/08/2025 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 525430 B. Wing 02/20/2025

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

Rolling Hills Rehab Ctr 14400 Cty Hwy B Sparta, WI 54656

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 0689 .On 01/10/2025 at 5:16 PM, PRN MED GIVEN: hydrOXYzine HCl 25MG Tablet (1 tablet / 25mg) given for agitation tried to throw chair in dining room. 6:44PM PRN MED RESULT: at 6:44 PM, Improved but still Level of Harm - Minimal harm or present. At 9:00 PM BEHAVIOR: abusive behavior wandering behaviors Pushing /Grabbing Behavior potential for actual harm occurred. Note: We were trying to direct [Resident R35] over to his food at the table. He did not want to come to the table but was trying to take plates from the dietetic worker instead. As we attempted to guide him to his table, Residents Affected - Few he became agitated and attempted to pick up a chair as if he was going to throw it. It was eased back to floor, and we directed [Resident R35] back to tv area. There are three other residents at his table and two staff trying to feed residents and another resident that was not being too cooperative with eating. It seemed too much activity for [Resident R35] at the time and he got very agitated and angry. I then gave him his prn atarax which had little effect tonight. About 7:30 he grabbed another resident by the wrist and staff intervened before he could hurt the resident. He was angry because this resident grabbed his blanket he was holding and so he turned around quickly and grabbed her, and staff were standing there when he grabbed her. I turned down lights early this evening to slow things down because residents seemed quite wound up tonight. Will continue to monitor him closely around other residents .

Surveyor did not find documentation that staff updated any new interventions or increased supervision for Resident R35 when he was exhibiting increased unsafe behaviors towards staff and residents on 1/10/25.

Nurse progress note indicated,

.On 01/28/2025 at 4:38 PM, Late Entry for: 01/27/2025. DATE OF INCIDENT: 01/27/2025, TIME OF INCIDENT: 17:12, INJURY: no apparent injury There was an altercation during supper time. Resident was grabbing at [Resident R36] walker during supper, [Resident R36] tried to stop him by talking loudly. [Resident R35] grabbed [Resident R36]. [Resident R36] stated if he grabs him again, he was going to, punch him. Staff had intervened. At 4:39PM, Today there was no further altercations between [Resident R35] and [Resident R36], they were kept apart from each other. At 10:13 PM, [Resident R35] was aggressive and combative at the beginning of the shift. Resident was found in another resident's room and will not follow redirection from the CNA. Instead, he swung his hand on the CNA hitting the CNA on the chest .

Surveyor did not find any new intervention or increased supervision for Resident R35 or 1:1 after Resident R35 grabbed Resident R36's walker and grabbed Resident R36.

Interviews:

On 02/19/25 at 10:25 AM, Surveyor interviewed Resident R36 and asked Resident R36 if there have been any resident-to-resident altercations that have occurred on the unit. Resident R36 stated, Yes, with [Resident R35]! Who has not had an altercation with [Resident R35]. One time [Resident R35] came at me in the dining room, but I put him in his place. I yelled to tell him not to ever touch me again or I'd punch him. Surveyor asked Resident R36 to explain the incident in

the dining room with Resident R35. Resident R36 indicated that Resident R35 came at Resident R36 and grabbed Resident R36's walker and then swung at Resident R36, hitting Resident R36 and grabbing Resident R36's wrist.

On 02/19/25 at 10:30 AM, Surveyor interviewed CNA F and asked how CNA F supervises difficult residents that may wander into others' rooms or become aggressive. CNA F indicated that CNA F tries to monitor residents such as Resident R35 from becoming angry and wandering but sometimes CNA F is in rooms taking care of other residents and can't always monitor.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 33 525430 Department of Health & Human Services Printed: 09/08/2025 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 525430 B. Wing 02/20/2025

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

Rolling Hills Rehab Ctr 14400 Cty Hwy B Sparta, WI 54656

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 0689 On 02/19/25 at 11:27 AM, Surveyor interviewed Licensed Practical Nurse (LPN) G and asked LPN G what is LPN G's process when there is an altercation between a resident to resident or if there is an incident that Level of Harm - Minimal harm or happens with a resident that may need extra supervision. LPN G indicated LPN G will intervene if LPN G potential for actual harm observes the resident-to-resident altercation. LPN G would try to redirect Resident R35 or any other resident who is aggressive and acting out. Surveyor asked LPN G if LPN G does any kind of extra supervision for Resident R35's Residents Affected - Few outbursts. LPN G indicated that LPN G will try to observe from afar while in the common area. Surveyor asked LPN G how LPN G intervenes if Resident R35 is from afar in the common area and Resident R35 is about to swing at another resident. LPN G indicated that LPN G tries to make sure Resident R35 is within close proximity but that is not always feasible when LPN G has to go into other rooms to pass medications.

On 02/20/25 at 8:02 AM, Surveyor interviewed Director of Nursing (DON) B and asked what interventions for increased supervsion are in place for Resident R35 due to his aggressive behaviors towards staff and residents.

DON B indicated that sometimes staff will keep a close eye on Resident R35 in the common area and kind of perform

a 1:1. Surveyor asked DON B to explain what 1:1 means. DON B indicated that 1:1 means there is an actual staff member designated to 1:1 with Resident R35 and staff do not let Resident R35 out of sight. Surveyor asked DON B if 1:1 was utilized on 06/22/24, 09/16/24, 01/10/25, and 01/28/25. DON B indicated that DON B was unsure, but that DON B doubts it since some of these events occurred. Surveyor indicated to DON B that through review of documentation that Surveyor could not find that Resident R35 was 1:1. DON B indicated that Resident R35 was probably not 1:1 as we do not have enough staff to be 1:1 at this time. DON B acknowledged that increased supervision was not provided for Resident R35 to prevent incidents with other residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 33 525430 Department of Health & Human Services Printed: 09/08/2025 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 525430 B. Wing 02/20/2025

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

Rolling Hills Rehab Ctr 14400 Cty Hwy B Sparta, WI 54656

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** 51095 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 4 errors out of 35 medication opportunities, resulting in an error rate of 11.4%. This affected 2 out of 4 residents (R) observed for medication administration sample. (Resident R11 and Resident R39)

Resident R11 received two insulin injections by using injectable pens that were not primed before administration.

Resident R39's insulin was not primed prior to administration of insulin.

Findings include:

Manufacturer's instructions for Basaglar Kwikpen (insulin glargine) states in part, .Priming your pen: Priming means removing the air from the Needle and Cartridge that may collect during normal use. It is important to prime your Pen before each injection so that it will work correctly. If you do not prime before each injection, you may get too much or too little insulin.

Step 6: To prime your Pen, turn the Dose Knob to select 2 units.

Step 7: Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at

the top.

Step 8: 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 the priming steps, but not more than 4 times. If you still do not see insulin, change the Needle and repeat the priming steps .

The facility procedure document entitled Insulin Injection, procedure reviewed date 2/25, states, in part,

9. If using an insulin pen, cleanse hub, apply needle, then prime pen with 2 units (dial 2 units\, hold pen upright, flick to bring air bubbles to top, push button all the way until dose returns to zero- you should see drop of insulin at needle tip\, if not change needle and repeat) Turn dial until desired dose.

Example 1

Resident R11 was admitted to the facility on [DATE REDACTED] with a diagnosis including type 2 diabetes mellitus. Resident R11 orders include, Insulin Aspart 100 unit/ML solution, Dose 12 units subcutaneously twice per day AM and noon and (Basaglar Kwik-pen) Insulin Glargine 100units/ml, Dose 18 units subcutaneously daily in the AM.

Resident R11 received two insulin injections via injectable pens that were not primed by Licensed Practical Nurse (LPN) J before administration of insulin dose.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 33 525430 Department of Health & Human Services Printed: 09/08/2025 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 525430 B. Wing 02/20/2025

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

Rolling Hills Rehab Ctr 14400 Cty Hwy B Sparta, WI 54656

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 On 2/18/25 at 7:32 AM, Surveyor observed LPN J remove 2 insulin pens from the med drawer. LPN J dialed

the Glargin pen (Basaglar 100units/ml) to 18units and the Aspart pen to 12 units without priming the pens Level of Harm - Minimal harm or first. Surveyor asked if the insulin pens needed to be primed. LPN J stated these insulin pens did not need to potential for actual harm be primed. Surveyor observed LPN J administer the insulins subcutaneously into Resident R11'S abdomen.

Residents Affected - Few On 2/18/25 at approximately 8:30 AM, Surveyor interviewed Director of Nursing (DON) B on the type of education and training that has been provided to nursing staff. DON B reported there had been a training on how to use an insulin pen in Dec. 2022. DON B reported her expectation would be that nursing staff prime

the insulin pen prior to injecting a resident with insulin. DON B reported awareness of LPN J not understanding the need to prime insulin pens prior to injecting insulin.

48793

Example 2

On 02/18/25 at 8:00 AM, Surveyor observed LPN G administer a Humalog insulin pen into Resident R39's abdomen. Surveyor did not observe an open date or expiration date label on the used Humalog pen. Surveyor did not observe LPN G prime the Humalog insulin pen with 2 units before prepping 6 units into the insulin pen.

On 02/18/25 at 8:05 AM, Surveyor interviewed LPN G and asked what LPN G's process is for priming and administering insulin. LPN G indicated that LPN G forgot to prime and should have primed the Humalog insulin pen with 2 units and discard the 2 units first before prepping the 6 units for Resident R39's Humalog insulin.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 33 525430 Department of Health & Human Services Printed: 09/08/2025 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 525430 B. Wing 02/20/2025

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

Rolling Hills Rehab Ctr 14400 Cty Hwy B Sparta, WI 54656

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 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 51095 Residents Affected - Few Based on observation, interview and record review, the facility did not ensure drugs and biologics were stored in accordance with current accepted professional practice. This had the potential to affect 2 out of 2 residents (R) for proper labeling. (Resident R29 and Resident R39)

This is evidenced by:

According to the Food and Drug Administration (FDA), insulin pens should be discarded 28 days after opening the pen to ensure effectiveness of the medication.

According to the American Diabetes Association, insulin products contained in vials or cartridges supplied by

the manufacturers (opened or unopened) may be left unrefrigerated at a temperature between 59 and 86 degrees F for up to 28 days and continue to work. After 28 days the insulin should be discarded.

On 3/29/21, Resident R29 was admitted to the facility with a diagnosis including type 2 diabetes mellitus. Resident R29's orders included Tresiba FlexTouch/ Insulin Deglu[DATE REDACTED]u/ml Solution Pen-injector Dose 45 unit subcutaneous twice per day.

On 2/19/25 at 10:25 AM, during a tour of medication storage, with Registered Nurse (RN) K, Surveyor observed Resident R29's insulin pen, Tresiba FlexTouch 100u/ml exp 8/31/26, pharmacy label reads, 45 units SQ BID, opened, not refrigerated, and not labeled with an opened date, in the drawer of the medication cart.

Surveyor interviewed RN K, who reports she forgot to date it when it was originally opened. RN verbalized understanding that insulin pens should be labeled with an opened-on date when they are taken out of the refrigerator and used within 28 days.

48793

Example 2

On 02/18/25 at 8:00 AM, Surveyor observed Licensed Practical Nurse (LPN) G administer a Humalog insulin pen into Resident R39's abdomen. Surveyor did not observe an open date or expiration date label on the used Humalog pen.

On 02/18/25 at 8:05 AM, Surveyor interviewed LPN G and asked what LPN G's process is for administering insulin without an open date. LPN G stated, That is a good question. I guess I would figure out when the pen was opened before giving to [Resident R39]. Surveyor asked LPN G was it the correct process to still give the Humalog insulin without an open date to Resident R39. LPN G indicated that LPN G probably should have discarded

the Humalog insulin and got another one, but LPN G did not.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 33 525430 Department of Health & Human Services Printed: 09/08/2025 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 525430 B. Wing 02/20/2025

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

Rolling Hills Rehab Ctr 14400 Cty Hwy B Sparta, WI 54656

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 46693 potential for actual harm Based on observation, interview and record review, the facility did not maintain an infection prevention and Residents Affected - Many control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections that has the ability to affect all 50 residents (R).

-Facility staff failed to transport linens in a manner to prevent the spread of infection.

-Facility staff did not properly doff personal protective equipment (PPE) for a resident on enhanced barrier precautions (EBP).

-Facility staff demonstrated poor hand hygiene during medication administration.

-Facility staff did not prep skin prior to administering a subcutaneous injection of insulin.

This is evidenced by:

Example 1

Federal Regulation S483.80(e) Linens state, Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

On 02/17/25 at 10:02 AM, Surveyor observed Nursing Support Aide (NSA) N passing clean linens in the hallway without the clean linen cart being covered. Surveyor asked NSA N if it is normal practice to pass out personal clean linen without them being covered. NSA N stated, Yes. I have not seen the carts covered in a long time.

On 02/18/25 at 11:00 AM, Surveyor observed NSA N again passing out clean personal linens on a cart in the hallway without a cover.

On 02/18/25 at 1:19 PM, Surveyor interviewed Nursing Home Administrator (NHA) A who stated the towels and bedding linens are sent out and covered all the time. Personal linens are done on each wing on PM and night shifts. They are then put on the carts and in the morning, the aides deliver them to the residents' rooms. NHA agreed that all clean linens should be covered, and NHA A will ensure personal linens are covered as well. NHA added that it probably slipped by us when we changed from sending out all linens to be cleaned, to the facility doing the personal clothing in house.

On 02/18/25 at 1:59 PM, Surveyor interviewed Infection Control (IC) P nurse. IC P brought Surveyor to the laundry area and stated the clean linen carts are supposed to be covered. IC P retrieved a cover and placed

it on the cart.

49353

Example 2

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 33 525430 Department of Health & Human Services Printed: 09/08/2025 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 525430 B. Wing 02/20/2025

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

Rolling Hills Rehab Ctr 14400 Cty Hwy B Sparta, WI 54656

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 0880 Facility policy titled, Enhanced Barrier Precautions (EBP), with a reviewed date of 10/23/24, stated in part:

Level of Harm - Minimal harm or Policy statement: Rolling Hills Rehabilitation Center will utilize EBP to expand the use of PPE to resident potential for actual harm care activities that have high potential for contaminating staff's hand and clothes with blood or bodily fluids .

Residents Affected - Many 3. Gown and gloves must be put on before entering room and taken off at room exit .

4. Position a trash can inside the resident room and near the exit for discarding PPE after removal (garbage and PPE removal bins in cupboard outside room), prior to exit of the room .

The Centers for Disease Control and Prevention (CDC) guidelines for removal of PPE with EBP precautions states in part:

Facilities should remember to have an appropriate disposal container available in the resident room to allow for removal of PPE inside the room.

On 02/18/25 at 7:00 AM, Surveyor observed an Enhanced Barrier Precaution (EBP) sign on Resident R2's door. The EBP sign indicated the use of personal protective equipment (PPE) of a gown and gloves be used when providing direct care for the resident. The PPE was stored just outside of Resident R2's room behind closed doors. Underneath the PPE storage area was a separate compartment with a sign that stated 'Garbage.'

On 02/18/25 at 9:02 AM, Surveyor observed Certified Nursing Assistant (CNA) C don a gown, gloves, and goggles and enter Resident R2's room to assist Resident R2 with toileting.

On 02/18/25 at 9:10 AM, Surveyor observed CNA C exit Resident R2's room wearing the gown, gloves and goggles. Surveyor observed CNA C open the garbage compartment outside of Resident R2's room, remove and dispose of all

the PPE she was wearing in garbage, and close garbage compartment door. Surveyor then observed CNA C complete hand hygiene.

On 02/18/25 at 9:12 AM, Surveyor interviewed CNA C. Surveyor asked CNA C if it is common practice to remove PPE outside of resident room. CNA C stated yes because that is where the garbage is located.

On 02/19/25 at 12:41 PM, Surveyor interviewed Director of Nursing (DON) B regarding EBP. Surveyor asked DON B what the expectation is for staff to don/doff PPE with EBP. DON B stated that staff are expected to don PPE before entering a resident's room and remove PPE just outside of resident's room. Surveyor asked DON B if this expectation met the facility's and current CDC guidelines. DON B stated that she felt this was acceptable as it is just outside of the room. Surveyor asked DON B if just outside the resident room was the same as the facility's policy of before exiting the resident's room. DON B then reluctantly stated that it did not. Surveyor asked DON B if this practice had the potential to transmit infection by staff touching equipment outside of room while wearing the contaminated PPE after providing direct care. DON B stated yes, she could see how that could be a potential concern.

51095

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 33 525430 Department of Health & Human Services Printed: 09/08/2025 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 525430 B. Wing 02/20/2025

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

Rolling Hills Rehab Ctr 14400 Cty Hwy B Sparta, WI 54656

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 0880 Example 3

Level of Harm - Minimal harm or The facility policy document titled: Hand Hygiene and Gloving, reviewed on 10/23/24, states in part, .All staff potential for actual harm are required to wash their hands promptly and thoroughly between resident contacts and after contact with blood, body fluid, mucous membranes, secretions, excretions and equipment or articles contaminated by Residents Affected - Many them. Gloves are also used for the above resident contacts and handwashing must follow both application and removal of gloves.

The facility procedure document titled Insulin Injection, procedure reviewed date 2/25, states, in part, C. Injection of Insulin .

1. Take insulin alcohol pad to resident. Wash hands, put on gloves.

2. Cleanse injection site with alcohol pad. Allow to dry before injecting.

On 2/18/25 at 7:28 AM, during medication administration pass, Surveyor observed Licensed Practical Nurse (LPN) J apply gloves without using hand hygiene prior to gloving. LPN J obtained a finger stick blood sample for Resident R27. After performing the test, LPN J removed her gloves, did not sanitize or wash her hands and proceeded to move medication cart to the next resident's door.

On 2/18/25 at 7:32 AM, Surveyor observed LPN J put on gloves, without hand hygiene prior, and obtain a finger stick blood sample for Resident R11. LPN J then removed her gloves, did not sanitize or wash her hands, removed 2 insulin pens from the medication drawer and administer the insulins subcutaneously into Resident R11's abdomen. LPN J did not use an alcohol pad to cleanse injection site prior to injecting.

On 2/18/25 at 7:34 AM, Surveyor interviewed LPN J about hand hygiene practices, and she reported hand hygiene should be performed before and after gloving. LPN J stated, I did not do it, you make me nervous. Surveyor also asked if she used an alcohol wipe on the injection site prior to injecting insulin. LPN stated she did not wipe Resident R11's injection site with alcohol prior to administering insulin. I usually do, I just forgot.

On 2/18/25 at approximately 8:30 AM, Surveyor interviewed DON B. DON B reported her expectation would be that staff follow infection control procedures. DON B reported she is aware that LPN J did not follow appropriate infection control practices.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 33 525430