Autumn Lake Healthcare At Madison

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, review of clinical records, review of photographs, and review of facility policy for 1 sampled resident (Resident #43) reviewed for discharge and 2 additional previously discharged residents (Resident #48 and Resident #89) the facility failed to ensure protected personal information remained secured and private. The findings include:Interview with Person #6 (Resident #43's family member) on 8/18/2025 at 11:31 AM identified that upon Resident #43's discharge on [DATE], he/she was sent home with a bag of prescriptions medications for Resident #48 and Resident #89. The medications were given to Person #6 by Registered Nurse (RN) #1. Person #6 stated that he/she had just returned the incorrect prescriptions to the Administrator. Person #6 indicated that although none of the incorrect other resident medications had been taken by Resident #43, he/she was very upset that the wrong medications were sent home at discharge and that he/she had taken pictures of the medications to report to the State…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility policy, and staff interviews for 2 of 2 sampled residents (Resident #83, and #89) reviewed for blood glucose testing, the facility failed to clean and disinfect a Glucometer (glucose testing) device per the manufacturer's instructions for use. The findings include:Interview with RN #3 (Infection Prevention Nurse) on 8/15/2025 at 11:58 AM identified that glucometers are to be cleaned between every use and as needed with the Super Sani Disinfectant with the purple top lid. 1. Resident #83's diagnoses included type 2 diabetes, hypertension, and osteoarthritis.The Nursing admission assessment dated [DATE] identified Resident #83 had a Brief Interview of Mental Status (BIMS) score of 15 indicating intact cognition, required maximal assistance with his/her personal hygiene, and required extensive assistance with walking in his/her room.A physician's order dated 8/1/2025 directed to obtain a blood glucose level by fingerstick and to administer lispro…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policies and interviews for two of three sampled residents (Residents #1 and #2) who were reviewed for a resident-to-resident altercation, Resident #1 had the right to be free from physical abuse by Resident #2. The findings include: Resident #1's diagnoses included Alzheimer's Disease, transient ischemic attack, and generalized muscle weakness. The Resident Care Plan dated 1/4/24 identified Resident #1 had difficulty communicating, impaired cognitive function and wandered into other residents' rooms. Interventions directed to anticipate and meet needs, administer medications as ordered, discuss changes with family regarding resident's abilities and needs, redirection techniques, and provide activities that interested and engaged the resident. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily life, exhibited wandering behaviors, occasionally rejected care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for end of life, the facility failed ensure the responsible party was notified timely when a change in skin integrity was identified. The findings include: Resident #1 was admitted with diagnosis that include schizoaffective disorder, generalized muscle weakness and senile degeneration of the brain. The Resident Care Plan (RCP) dated 9/22/2023 identified Resident #1 was at risk for skin breakdown due to inadequate oral intake, fragile skin, incontinence, and limited mobility. Interventions directed to float heels while in bed, low loss mattress, and to evaluate for skin problems. A quarterly MDS assessment dated [DATE] identified Resident #1 was severely cognitively impaired, required extensive assistance for bed mobility, was non-ambulatory, was at risk for pressure ulcers and had one (1) Stage III pressure ulcer. Clinical record review identified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for end-of-life care, the facility ensure a complete and accurate record to include records prior to facility ownership, to include documentation of ADL care, documentation of hospice services and documentation of an assessment of death. The findings include: Resident #1 was admitted with diagnosis that include schizoaffective disorder, generalized muscle weakness and senile degeneration of the brain. The Resident Care Plan (RCP) dated [DATE] identified Resident #1 was at risk for skin breakdown due to inadequate oral intake, fragile skin, incontinence, and limited mobility. Interventions directed to float heels while in bed, low loss mattress, and to evaluate for skin problems. A quarterly MDS assessment dated [DATE] identified Resident #1 was severely cognitively impaired, required extensive assistance for bed mobility, was non-ambulatory, was at risk for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, facility documentation, resident council minutes, facility policy, review of facility staffing hours, and interviews, the facility failed to adequately staff Nurse Aides (NA) throughout the facility resulting in resident care needs not being met. The findings include: 1. Resident #21 's diagnoses included dementia, heart disease, and communication deficit. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #21 was moderately cognitively impaired and required supervision with transfers and extensive assistance with dressing and personal hygiene. The Resident Care Plan dated 9/1/22 identified Resident #21 required assistance with Activities of Daily Living. Interventions included providing staff assistance with personal hygiene. Observation on 11/6/23 at 3:10 PM, identified Resident #21 at the nursing station, with dark debris under 9/10 fingernails that were long, as well as long facial hair. Review of NA flow sheets (amount of care required) from 11/1/23 through…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, facility policy, facility documentation, and interviews for 2 of 2 resident units, for Resident #'s 28, 51, 61, 278, and 428, who were reviewed for receiving a nourishing snack when mealtimes exceeded 14 hours, the facility failed to provide adequate snacks. The findings include: Intermittent interviews on 10/31/23 between 10:30 AM and 2:00 PM and 11/2/23 between 12:00 PM and 2:00 PM with Resident's #28, 51, 61, 278, and 428 identified that the residents were receiving a small snack in the evening only upon request. The resident's reported examples of the snacks brought when requested were a cookie, cookie bar, apple sauce, or juice and they did not feel that this was an adequate and substantive snack. Interview and review of facility documentation with Dietary Supervisor #2 on 10/31/23 at 10:45 AM during the initial kitchen tour identified that meals were served at 7:30 AM, 11:30 AM, and 4:30 PM and that snacks were given in the evening hours and consist of small items. A 15-hour gap was noted between the dinner service at 4:30 PM and breakfast service at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, facility documentation, facility policy, and interviews, the facility failed to follow infection control practices on 1 of 2 units to provide a clean environment for Resident #53, and for the Infection Control Program, failed to ensure all required infection control policies and procedures were present in the Infection Control Manuals. The findings include: 1. Resident #53's diagnoses included Alzheimer's disease, cognitive communication deficit, and inflammatory polyarthropathy (arthritis affecting 5 or more joints). The quarterly Minimum Data Set assessment dated [DATE] identified Resident #53 was severely cognitively impaired and required the assistance of 1 staff with bed mobility and transfers. The Resident Care Plan dated 11/2/23 identified Resident #53 was at risk for decreased ability to perform activities of daily living (ADLs) in bathing, grooming, personal hygiene, and dressing related to recent illness, fall, hospitalization resulting in fatigue, activity intolerance, confusion.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility Resident Council meeting documentation, interviews, and facility policy, the facility failed to adequately respond to resident grievances. The findings include: 1. Review of Resident Council minutes dated 9/21/23 identified the following concerns: A. The supper meal was arriving too early, at approximately 4:10 PM, and residents were not receiving their alternative meal choices. Review of the Resident Council minutes identified that cooks were made aware of the concern. B. Residents remained in bed until lunch due to the lack of staff, resident beds are not made or changed after residents get up, and staff can be heard discussing concerns regarding staffing issues at the facility. C. The 3:00 PM to 11:00 PM staff were heard loudly discussing residents' personal information in the hallways, using inappropriate language, and nurses were heard yelling down the hall instead of going to directly to speak with staff. 2. Review of the Resident Council minutes dated 10/19/23 identified the following: A. Residents were informed by the Dietary Department of a new…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews for 2 of 2 nursing units reviewed for the environment, the facility failed to ensure equipment and furniture was maintained in a clean, comfortable home-like manner. The findings included: During the initial facility tour, observation 10/31/23 at 10:30 AM, on the Tuxis Unit identified trash on the floors in the hallways and in resident's rooms #224, #226, #227, and #228. In room [ROOM NUMBER], Resident #51, surveyor observed a medicine cup on the floor with a white powder that had fallen out of the cup. The white powder was noted to be all over the floor and on the side of the bedside table. Used medical gloves rolled into balls were seen in the flower boxes on both the [NAME] and Tuxis units. Observation on 11/7/23 at 10:00 AM with the Director of Maintenance, in room [ROOM NUMBER] of the [NAME] Unit, identified a piece of wood molding under the window seat that was broken off, exposing a very sharp, rough edge of the wood. Observation of all resident rooms on the Tuxis unit…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility documentation, facility policy, and interviews for 5 of 35 residents (Resident #21, #27, #46, #53 and #69) reviewed for Activities of Daily Living (ADLs), the facility failed to ensure personal hygiene care and services was provided to dependent residents. The findings include: 1. Resident #21 's diagnoses included dementia, heart disease, and communication deficit. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #21 was moderately cognitively impaired and required supervision with transfers and extensive assistance with dressing and personal hygiene. The Resident Care Plan dated 9/1/22 identified Resident #21 required assistance with Activities of Daily Living. Interventions included providing staff assistance with personal hygiene. Observation on 11/6/23 at 3:10 PM, identified Resident #21 at the nursing station, with dark debris under 9/10 fingernails that were long, as well as long facial hair was noted. Review of NA…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility policy, and interviews for 1 of 2 units for Resident #2, #51, #57 and #279 reviewed for oxygen therapy, the facility failed to appropriately label oxygen tubing. The findings include: 1. Resident # 4's diagnoses included anoxic brain damage, hypertension, and anxiety. The annual Minimum Data Set assessment dated [DATE] identified Resident #4 was moderately cognitively impaired and required assistance of 2 staff for bed mobility, transfers, and personal hygiene. The Resident Care Plan dated [DATE] identified Resident #4 was at risk for respiratory complications related to recent hospitalization for upper respiratory infection. Interventions included observing respiratory rate, signs/symptoms of dyspnea (shortness of breath), use of accessory muscles, indicating respiratory distress, and report any signs of respiratory distress to the physician. A physician's order dated [DATE] directed oxygen administration via nasal canula at 2-3 liters per minute to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of personnel files for 2 of 3 Nurse Aides (NA #10 and NA #11), facility policy and interviews, the facility failed to complete annual performance appraisals. The findings include: NA #10's last performance appraisal in NA #10's personnel file was not dated by NA #10 or the next level manager. NA #11's last performance appraisal in NA #11's personnel file was dated 1/23/18 (5 years ago). Interview and facility documentation review with the Administrator on 11/8/23 at 4:04 PM identified she was aware that NA #11's performance appraisals had not been done since 2018 and indicated being aware they should be completed annually. She stated they were not completed due to not having consistent staff, reporting that they had not had payroll, scheduling, or Human Resource staff, and that the Director of Nursing (DNS), had changed numerous times. She indicated the current DNS was trying to catch up on tasks that were not completed by previous staff. The Administrator indicated that the DNS was responsible for completing nursing performance appraisals until all facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for one of five residents (Resident #62) reviewed for unnecessary medication, and for the only sampled resident (Resident #527) reviewed for physical restraint, the facility failed to ensure that behavior monitoring was completed on a resident receiving psychotropic medications. The findings include: 1. Resident #62's diagnoses included dementia with agitation, anxiety and paranoid personality disorder. An admission physician's order dated 3/10/23 directed to administer Risperidone (an antipsychotic medication) 0.25 milligrams (mg), one tablet by mouth once daily for agitation. Review of APRN #2 orders dated 8/29/23 directed Risperdal 0.25 mg, be given, one tablet by mouth, every evening at 9:00 PM for extreme fear and agitation. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #62 was severely cognitively impaired and required the assistance of 1 staff with bed mobility and 2 staff for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the clinical record review, facility policy and interviews for 1 sampled resident (Resident #61) reviewed for dentition, the facility failed to provide dental services. The findings include: Resident #6 was admitted to the facility on [DATE] with diagnosis that included end stage renal disease, right above knee amputation, and coronary artery disease. A Resident Care Plan dated 2/25/22 identified Resident #61 was at risk for oral health or dental care problems as evidence by tooth decay. Interventions included to obtain dental consultation as ordered, assess for oral lesions, inflammation, bleeding and signs and symptoms of pain during care and to report to MD as indicated. An oral health evaluation completed on 2/25/22 at 1:47 PM by Register Nurse (RN) #1 indicated a dental consult as ordered. Resident #61 had an oral health evaluation done on 2/26/23 at 4:51 PM by RN #4 which indicated a dental consult as ordered. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #61 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, facility documentation, facility policy and interviews, the facility failed to ensure safe water temperatures for 1 of 2 units in resident areas. The findings include: Observation on 10/31/23 at 10:46 AM identified the bathroom sink water temperature for Resident #19 and Residents #43 was 125.6 degrees Fahrenheit. Observations on 10/31/23 at 11:20 AM with the Director of Maintenance identified the following: For Resident #19 and Resident's #43, the Director of Maintenance identified the bathroom sink temperature to be 123.4 degrees Fahrenheit (F), and 125.1 degrees F was measured by the surveyor. For Resident #29 and Resident's #41, the Director of Maintenance identified the bathroom sink water temperature to be 122.6 degrees F, and 124.5 degrees F was measured by the surveyor. For Resident #52 and Resident's #62, the Director of Maintenance identified the bathroom sink temperature to be 125.3 degrees F, and 127.0 degrees F was measured by the surveyor. For Resident #327, the Director of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on facility documentation, facility policy, and interviews, the facility failed to ensure Nurse Aide (NA) #1 and NA #10 completed 12 hours of in-service education annually, and failed to provide evidence that all NAs were provided the mandatory 12 hours of in-service training. The findings include: NA #1 completed 5.78 hours of online training, plus an in-person facility training on Personal Protective Equipment (PPE) and hand washing on 12/10/22 (did not specify length) and an in-person training on Abuse, Neglect and Exploitation on 2/10/23 (did not specify length). The training failed to reflect NA #1 received any dementia care training. NA #10 did not complete any of the online training, but did complete an in-person facility training on PPE and hand washing on 12/10/22 (did not specify length) and an in-person training on Abuse, Neglect, and Exploitation on 2/10/23 (did not specify length). The training failed to reflect NA #10 received any training on dementia care. Interview with RN #5 on 11/8/23 at 3:58 PM identified she provided all of their education and in-service…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, facility policy, and interviews for 1 of 1 sampled resident (Resident #477) reviewed for dignity, the facility failed to ensure a urinary privacy bag was utilized. The findings include: Resident #477's diagnosis included fracture of the left femur, benign prostatic hyperplasia with lower urinary tract symptoms, and dementia. A Nursing admission assessment dated [DATE] identified Resident #477 was moderately cognitively impaired, required limited assistance of 1 for bed mobility, extensive assistance of 1 for personal hygiene, bathing, toileting, dressing, and transfers. The Nursing admission Assessment further identified Resident #477 had a suprapubic catheter in place. The Resident Care Plan dated 11/4/23 identified Resident #477 required an indwelling suprapubic catheter. Interventions included to provide privacy and comfort and to keep the catheter off the floor. Observation on 11/7/23 at 12:00 PM identified Resident #477 was sitting in a wheelchair in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility policy, and interviews for 3 of 4 residents, (Resident #21, 428, and 527), reviewed for advance directive, the facility failed to ensure Resident #21's current preference for code status was present in the clinical (paper and electronic) health record to appropriately direct staff in the event of a medical emergency and failed to ensure Resident #428 and 527 had an advance directive code status present in the clinical record. The findings include: 1. Resident #21's diagnoses included heart failure, dementia, and anemia. Review of Face Sheet documentation in the clinical record identified Person #3 was the resident representative for Resident #21. The Resident Care Plan (RCP) dated [DATE] identified Resident #21 had an established advanced directive of full code. Interventions included activating resident's advanced directive as indicated, informing resident/healthcare decision maker of any change in status or care needs, provide resident/healthcare decision maker…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy and interviews for 1 of 3 sampled residents (Resident #47) reviewed for nutrition, the facility failed to ensure the resident representative was notified of a significant weight loss. The findings include: Resident #47's diagnosis included dementia, myocardial infarction, and hypertension. Review of a face sheet document in the clinical record identified that Resident #47 was not responsible for him/herself and maintained a resident representative. An admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #47 was severely cognitively impaired and required set up assistance with eating. The MDS also identified Resident #47 had not had a significant weight loss/gain. Review of Resident #47's weight summary identified the following: on 7/1/23 Resident #47 weighed 139.1 pounds (lbs), on 8/1/23 Resident #47 weighed 133.7 lbs which was a 5.4 lb/7.6 percent (%) weight loss. A physician order dated 8/9/23 directed to weigh…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility documentation, and interviews for the only sampled resident (Resident #527) who was reviewed for a physical restraint, the facility failed to ensure the resident's right to be free from a physical restraint. The findings include: Resident #527's was admitted with diagnoses that included Down Syndrome, Alzheimer's Disease, and diabetes mellitus. The admission Nursing assessment dated [DATE] identified Resident #527 was admitted due to psychiatric/behavior/mental health issues and for therapy following a fall. Additionally, Resident #527 had agitation/restlessness and was hyperactive. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #527 had long and short term memory problems and required extensive assistance of 2 staff for bed mobility, transfers, and extensive assistance of 1 staff with toileting. The Resident Care Plan dated 10/25/23 identified Resident #527 had behaviors, was resistive to care, removed clothing in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for the only sampled resident (Resident #527) who was reviewed for a physical restraint, the facility failed to report the allegation of mistreatment to the state agency in a timely manner. The findings include: Resident #527's was admitted with diagnoses that included Down Syndrome, Alzheimer's Disease, and diabetes mellitus. The admission Nursing assessment dated [DATE] identified that Resident #527 was admitted due to psychiatric/behavior/mental health issues and for therapy following a fall. Additionally, Resident #527 had agitation/restlessness and was hyperactive. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #527 had long and short term memory problems and required extensive assistance of 2 staff for bed mobility, transfers, and extensive assistance of 1 staff with toileting. The Resident Care Plan dated 10/25/23 identified Resident #527 had a behavioral problem, was resistive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, observation, facility documentation, facility policy, and interviews for 3 of 3 residents (Resident #6, #68 and #527) reviewed for falls, and for 1 of 6 residents reviewed for pressure ulcers, (Resident #9), the facility failed to update the resident care plan and failed to implement interventions to the resident's care plan. The findings include: 1. Resident #6 's diagnoses included muscle weakness, Alzheimer's disease, and seizures. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6 with moderate cognitive impairment for decision making and poor long and short-term memory. Additionally, Resident #6 was dependent on staff for rolling side to side in bed, for lower body dressing, and transfers to and from bed. The Resident Care Plan dated 9/3/23 identified Resident #6 as a fall risk. Interventions included the use of floor mats for safety and encouraging Resident #6 to use the call bell for assistance. A. The Reportable Event dated 10/14/23…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and observation for the only sampled resident (Resident #23) reviewed for foot care, the facility failed to provide podiatry services. The findings include: Resident #23's was admitted on [DATE] with diagnoses that included chronic kidney disease, total hip arthroplasty, and gout. The admission Minimum Data Set assessment dated [DATE] identified Resident #23 was cognitively intact and required extensive assistance with bed mobility, toilet use, and personal hygiene. The Resident Care Plan dated 8/25/23 identified Resident #23 was at risk for alterations in comfort. Interventions included assisting resident to a position of comfort. A physician's order dated 8/25/23 directed to consult podiatry as needed. A physician's progress note dated 9/7/23 identified Resident #23's right great toe was swollen. No referral to podiatry was noted in the medical record. Observations and interview on 11/7/23 at 11:27 AM, with Person #2, identified that the toenails of Resident #23 were long…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical records, facility documentation, facility policy, and interviews for 3 of 5 sampled residents (Residents #6, 68, & 527) reviewed for falls, the facility failed to ensure care plan interventions were implemented, failed to provide adequate supervision to prevent a fall, and failed to conduct a risk assessment following falls. The findings include: 1. Resident #6 's diagnoses included muscle weakness, Alzheimer's disease, and seizures. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6 with moderate cognitive impairment for decision making and poor long and short term memory. Additionally, Resident #6 was dependent on staff for rolling side to side in bed, for lower body dressing, and transfers to and from bed. The Resident Care Plan dated 9/3/23 identified Resident #6 as a fall risk. Interventions included the use of floor mats for safety and encouraging Resident #6 to use the call bell for assistance. A. The Reportable Event dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of the clinical record, facility documentation, facility policy, and interviews for two (2) of three (3) staff members (NA #1 and #2) reviewed for abuse training, the facility failed to ensure direct care staff completed the annual abuse prohibition training. The findings include: Review of the Vital Learn facility educational training and tracking document identified the following: 1. NA #1 last completed her abuse prohibition training on 9/6/22 (21 days overdue). 2. NA #2 last completed his abuse prohibition training on 4/6/22 (174 days overdue). Interview with the nurse educator on 9/27/23 at 2:00 PM identified she has not completed any abuse prohibition in-services and was unable to provide any documentation of completed in-services. Interview with the Administrator on 9/27/23 at 3:00 PM identified the facility changed their electronic training platform from Vital Learn to Healthdrive around November/December 2022. She identified NA #1 and NA #2 have not completed any courses in Healthdrive. She identified abuse training should be completed annually. Review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #2) reviewed for care plans the facility failed to create a care plan and interventions for a resident with identified behavioral concerns. The findings include: Resident #2 was admitted to the facility with diagnoses that included heart failure and cellulitis. The care plan dated 7/15/23 identified Resident #2 was at risk for falls due to cognitive loss with interventions that included to arrange the resident's environment to enhance vision and maximize independence. A Psychiatric evaluation dated 7/18/23 identified Resident #2's diagnoses included adjustment disorder, depressive episodes and anxiety with confusion and a memory impairment. The evaluation further identified Resident #2 had a chronic psychiatric illness and was stable on his/her current regimen. The admission MDS dated [DATE] identified Resident #2 had no impairments in cognition, no delusions or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, and staff interviews for 5 of 7 residents (Resident #34, Resident #43, Resident #47, Resident #51 and Resident #54) reviewed for activities of daily living, the facilty failed to ensure timely incontinent care, bathing and failed to offer out of bed assistance to residents. The findings included: 1. Resident #34's diagnoses included cerebral infarction due to thrombosis of precerebral artery, schizophrenia, major depressive disorder and dysphagia. The quarterly Minimum Data Set, dated [DATE] identified Resident #34 had a moderate cognitive impairment and was dependent with extensive assistance of two-person physical support for transfers. A Resident Care Plan identified Resident #34 required assistance/was dependent for care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfers, locomotion, and toileting related to limited mobility. Interventions included to utilize a bed rail as an enabler, provide resident with total assist of two for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of clinical records, facilty documentation and staff interviews for 5 of 24 sampled residents (Resident #34, Resident #43, Resident #47, Resident #51, and Resident #54) reviewed for timeliness of personal care and meal consumption documentation (Resident #51), the facilty failed to ensure adequate staffing to provide personal care and record meal consumption documentation. The findings included: 1. Resident #34's diagnoses included cerebral infarction due to thrombosis of precerebral artery, schizophrenia, major depressive disorder and dysphagia. The quarterly Minimum Data Set, dated [DATE] identified Resident #34 had a moderate cognitive impairment and was dependent with extensive assistance of two-person physical support for transfers. A Resident Care Plan identified Resident #34 required assistance/was dependent for care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfers, locomotion, and toileting related to limited mobility. Interventions included…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility documentation, review of facility policy and interviews for 1 of 2 sampled residents (Resident #119) reviewed for advanced directives, the facility failed to ensure advanced directives were in place to reflect the resident's choice to not have cardiopulmonary resuscitation (CPR) performed. The findings include: Resident #119's was admitted to the facility on [DATE] with diagnoses that included chronic pain, rheumatoid arthritis, spinal stenosis and cervical disc degeneration. The nursing admission assessment dated [DATE] at 12:36 PM identified Resident #119 was alert and oriented to time, person, place and situation but lacked documentation regarding advanced directives/code status. A physician's undated admission History and Physical identified Resident #119 as a Full Code (perform CPR). A Resident Care Plan dated [DATE] identified a problem with requiring assistance with activities of daily living. Interventions included to utilize bed rails as an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record and staff interviews for 1 of 5 residents (Resident #15) reviewed for medication administration, the facility failed to ensure resident identification was verified prior to administering medications. The findings included: Resident #15's diagnoses that included dementia, with behavioral disturbance, depression, and a long-term degenerative disorder of the central nervous system. A quarterly Minimum Data Set, dated [DATE] identified Resident #15 had a moderate cognitive impairment. Physician's order dated 7/1/21 directed to administer Aspirin 81 mg by mouth daily, Calcium 600 plus D Tablet-600-400 mg-Unit 1 tab by mouth daily, Cymbalta 60 mg by mouth daily, Gabapentin 300 mg by mouth daily, Metoprolol Tartrate 12.5 mg by mouth two times daily, Sennosides-Docusate Sodium 7.6-50 mg 2 tablets by mouth two times daily, Zyrtec 10 mg by mouth daily, and Miralax 17 gm by mouth daily. Observation of medication administration with Licensed Practical Nurse (LPN) #2 on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility documentation, review of facility policy and interviews for 1 of 2 sampled residents (Resident #67) reviewed for position/mobility, the facility failed to apply splints per physician orders. The findings include: Resident #67 diagnoses included hydrocephalus, acute respiratory failure requiring tracheostomy, intracranial injury with loss of consciousness, traumatic brain injury and seizures. An Occupational Therapy discharge recommendation dated 4/1/21 directed for Resident #67 to don bilateral elbow splints during AM care and doff during PM care. Physician's order dated 5/18/21 directed for Resident #67 to wear bilateral elbow splints during the day, check skin pre/post application. A Resident Care Plan dated 6/11/21 identified Resident #67 was dependent for care in bathing, grooming, personal hygiene, dressing, bed mobility, transfers, locomotion, and toileting related to impaired mobility due to intracranial injury. Interventions included to don…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, and staff interviews for 1 of 3 sampled residents (Resident #51) reviewed for nutrition, the facility failed to ensure weights were obtained per physicians order, failed to consistently document meal intake and failed to report a significant weight loss to the Dietician timely. The findings included: Resident #51's diagnosis included dementia, adult failure to thrive, dysphagia, gastro-esophageal reflux disease, and anxiety. An Advanced Practice Registered Nurse (APRN) progress note dated 2/8/21 identified Resident #51 reported loose stools and a lack of appetite at baseline. a. A nutrition assessment completed by the Dietician and dated 2/23/21 identified Resident #51 had a stable weight of 92.4 pounds, declined a house supplement, a family member provided an Ensure supplement and Resident #51 drank 8 ounces per day. Additionally, the nutritional assessment noted that meals alone did not meet Resident #51's nutritional needs and supplements were needed to meet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility's documentation, review of facility's policy and interviews for 1 resident (Resident #67) reviewed for respiratory care, the facility failed to change oxygen tubing per physician orders. The findings include: Resident #67's diagnoses included hydrocephalus, acute respiratory failure requiring tracheostomy, intracranial injury with loss of consciousness, traumatic brain injury and seizures. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #67 had a problem with short/long term memory and required total assistance of 2 for bed mobility. Additionally, the MDS identified Resident #67 required total assistance with 1 for dressing, eating, toilet use, personal hygiene and utilized oxygen. A Resident Care Plan dated 9/14/20 and currently in effect identified Resident #67 was at risk for respiratory complications related to having a tracheostomy. Interventions included to keep the head of bed at 30 degrees, monitor and report oxygen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, review of the facility policy, review of the clinical record and staff interviews for 1 of 5 residents (Resident #7) reviewed for medication administration, the facility failed to sanitize the glucometer machine per facility's policy and manufacturer's recommendations. The findings included: Observation and interview with Licensed Practical Nurse (LPN) #3 on 7/12/21 at 11:20 AM identified she utilized a Clorox Healthcare Bleach Germicidal and Disinfectant cloth to wipe down the Evencare G2 glucometer before entering Resident #7's room to complete his/her blood glucose test. LPN #3 wiped the glucometer using a Clorox Healthcare Bleach Germicidal and Disinfectant wipe by making contact to all areas of the glucometer with the wipe, disposing of the wipe and then placing the machine on a clean tissue located on top of the medication cart. LPN #3 identified that 30 seconds would be needed to complete disinfection of the glucometer and that 30 seconds had elapsed from the time of her wiping the glucometer and the time it took the glucometer to air dry. Observation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.