Madison Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to timely complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS-an assessment tool) for 1 of 2 residents (Resident 53), reviewed for SCSA. This failure placed the residents at risk for delayed care planning, unmet care needs, and diminished quality of life. Findings included .Review of the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.20.1, dated October 2025, showed that an SCSA is a comprehensive assessment that must be completed when the Interdisciplinary Team determines a resident meets the significant change guidelines for a major decline or improvement in status that impacts more than one area of health status, and the condition is not expected to return to baseline within two weeks.Resident 53 was admitted to the facility on [DATE].Review of a quarterly MDS dated [DATE], coded Resident 53 with no pressure ulcer,…

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, interview and record review, the facility failed to ensure professional standards were met for 1 of 1 resident (Resident 76) sampled for intravenous (IV-into the vein) medication administration. The failure to have a physician's order for the IV flush (injecting a sterile solution to clear medications, prevent blood clots and verify the line is working) placed resident at risk for complications included blockage of line and adverse outcomes. Findings included . According to the facility policy titled Intravenous Therapy, dated 2025, the policy documented to utilize a 10 milliliter (ml) syringe of normal saline to inject and confirm patency of vascular access device per protocol. Resident 76 was admitted to the facility on [DATE] with diagnoses to include pyogenic arthritis (serious, painful bacterial infection of joint space). In an observation on 06/24/2026 at 4:06 PM, Staff N, Registered Nurse flushed Resident 76's central line (long flexible tube inserted into a large vein from the chest…

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, interview, and record review, the facility failed to ensure residents received proper assistive devices to maintain their hearing abilities for 1 of 2 residents (Resident 30) reviewed for hearing services. This failure placed the resident at risk for declined communication and decreased quality of life. Findings included .Review of the facility policy titled, Hearing and Vision Services, copyright date 2026, documented employees would assist the resident with the use of any devices or adaptive equipment needed to maintain hearing. Resident 30 was readmitted to the facility on [DATE]. In an interview and observation on 06/22/2026 at 8:34 AM, Resident 30 stated they could not hear when asked questions and they needed their hearing aids. It was observed the resident was not wearing hearing aids. In an observation on 06/22/2026 at 1:34 PM, Resident 30 was observed not wearing hearing aids. In an interview and observation on 06/23/2026 at 8:56 AM, Resident 30 stated they needed their hearing…

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 interview and record review, the facility failed to ensure dialysis communication documents were filled out after the resident had their dialysis appointments and returned to the facility for 1 of 1 resident (Resident 77) reviewed for dialysis. This failure placed Resident 77 at risk of inadequate or lack of assessment and documentation upon arrival back at the facility, undetected dialysis complications, and a decreased quality of life.Findings included .Review of the facility provided policy ''Hemodialysis,'' with an implementation date of 06/10/2026 documented the facility would assure that each resident received care and services for the provision of hemodialysis consistent with professional standards of practice. The ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments The nurse would monitor and document the status of the resident's access site upon return from the dialysis treatment Resident 77 was admitted to the facility on [DATE]…

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, interview and record review, the facility failed to ensure routine and emergency dental services were provided for 1 of 1 resident (Resident 56) reviewed for dental services. This failure had the potential to result in infection, pain and decreased quality of life. Findings included . Resident 56 admitted [DATE]. Review of the Nursing admission assessment dated [DATE] documented the resident had missing and broken teeth. A baseline care plan was initiated related to oral/dental problems. In an observation and interview on 06/23/2026 at 9:24 AM, Resident 56 stated their teeth were terrible. Resident 56 opened their mouth and pointed to their lower jaw with visible tooth fragments and missing teeth. Resident 56 said their teeth had been in bad shape for a long time and said they had been seen by someone here at the facility who told them they needed them all pulled. Resident 56 stated they had a prior dentist and was able to state the name and place of their community dental office. Resident…

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 interview and record review, the facility failed to ensure 3 of 5 residents reviewed for pre-admission screening and resident review (PASRR) received the required screening for mental health needs prior to admission for (Resident 1) and screenings were updated as required for (Residents 2 and 3). This failure placed the residents at risk of not receiving timely and necessary services to meet their mental health needs.Findings included.Review of a facility policy titled, Pre-admission Screening and Resident Review revised date 09/2025, documented any resident with a positive Level 1 screen must have a Level 2 evaluation conducted prior to admission.<RESIDENT 1>Resident 1 admitted to the facility on [DATE] with diagnosis of anxiety.Review of the PASSR level 1 screen, dated 09/26/2025, documented Resident 1 required a Level 2 evaluation for treatment of anxiety and depression.Review of a social services note, dated 09/29/2025, showed the state PASSR coordinator was contacted as resident required a level 2…

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 interview and record review, the facility failed to ensure the person designated to serve as the Director of Food and Nutrition Services (Staff S) had the required qualifications. This failure placed all residents at risk of receiving dietary services from staff without the required competencies and skills to carry out food and nutrition services.Findings included .In an interview on 07/16/2025 at 9:47 AM, Staff S, Dietary Manager (DM), stated they were not a certified DM. Staff S stated they were enrolled in the educational program to obtain their certification. Staff S stated the facility was using the certification of Staff T, Assistant DM, in place of their certification.In a review of the staff roster, undated, documented Staff S was the culinary director.\In a review of the facility assessment dated [DATE], documented Staff S as the certified dietary manager.In an interview on 07/21/2025 at 11:04 AM, Staff A, Administrator, stated Staff T was the dietary manager last year and thought the 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.

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in one of one facility kitchens, and one of one snack/nourishment refrigerators. The failure to ensure cleanliness of the kitchen, label opened food/beverage items, wash hands, and ensure dishwashing temperature were maintained at the proper temperature. These failures placed all residents at risk for their food to be contaminated, development of food borne illnesses, and consuming spoiled food.Findings included.<CLEANLINESS>On 07/17/2025 at 11:04 AM observed the dishwashing area to have a large hole (approximately 6 -8 inches) in the wall underneath the dishwashing basin. Observed a rusty gallon can (content unknown and not able to be determined), below pipes, underneath the dishwasher appeared to hold up one of the copper pipes. Observed a leak from underneath the handwashing station, which included a pool of discolored liquid directly underneath the sink drainpipe. Observed food debris and remnants and cracker wrappers on the floor 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.

Based on observation, interview and record review, the facility failed to have a system in place that ensured grievances were addressed and resolved in response to residents' verbal conveyance of concerns for 1 of 1 Resident Council groups and 1 of 1 sampled resident (Resident 27). The facility failed to track and investigate the concerns which led to residents repeatedly reporting the same care issues without resolution and placed them at risk of unidentified and unmet care needs, and diminished quality of life. Findings Included . Review of the undated facility policy titled Grievance Policy & Procedure, showed all grievance issues would be put into writing and brought to the Grievance Officer and would be addressed in an efficient manner. The administrator would contact the party initiating grievance to discuss and resolve any concerns. <RESIDENT COUNCIL> In an interview with Resident Council representatives on 07/16/2025 at 1:55PM: - * Resident 51 and Resident 47 stated the television (TV) noises, laughter and loud voices from staff at night was a continuous issue and 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 interview and record review, the facility failed to provide complete and updated Notification of Medicare Non-Coverage (NOMNC - a document informing Medicare beneficiaries that their covered services will be terminated and providing information on their appeal rights) for 4 of 4 sampled residents (Resident 4, 15, 25 and 55) reviewed for liability notice. This failure placed residents and/or their representatives at risk for not fully understanding their Medicare benefits and appeal rights and receiving inadequate information to make appeal decisions. Findings included .Review of the facility policy titled, Notice of Medicare non-coverage Letter (NOMNC), revised date 12/27/2024, showed the facility had to make sure the resident and/or representative understood the purpose and the contents of the notice, the appeal process and the associated time frames so they could make an informed decision on whether to appeal.Review of Center for Medicare and Medicaid Services (CMS) electronic web site (CMS.gov),…

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 interview and record review, the facility failed to issue a written notice of bed hold (holding or reserving a resident's bed while the resident was absent from the facility), provide a written notice to the resident and/or their representative and the ombudsman (independent and objective individual who investigates complaints against government agencies and other organizations) of a hospital transfer for 3 of 3 residents (Residents 14, 53 and 55) reviewed for hospitalization/discharge. These failures placed the residents at risk for lack of knowledge regarding their rights to a bed hold, monetary consequences, appeal rights, and available advocacy services, and possible unidentified or unmet care needs. Findings included .In a review of the facility policy titled Transfer or Discharge Notices, updated 07/13/2025, showed if a resident was transferred to the hospital a notice of transfer would be provided to the resident and representative as soon as practicable and a notice of facility bed hold and…

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, interview and record review the facility failed to ensure that 4 of 6 residents (Resident 3, 8, 29 and 30) reviewed for the Preadmission Screening and Resident Review (PASSR - a federally required screening of all individuals for Intellectual Disability (ID) or Related Condition and a Serious Mental Illness (SMI) prior to admission) process. The facility failed to refer the PASSRs for further review and failed to ensure any recommendations were incorporated into the plan of care. These failures placed residents at risk for unidentified mental health care needs, lack of mental health services and diminished quality of life.Findings included.Review of the facility policy titled, PASRR screening for Mental Disorder/Intellectual Disability, showed a positive Level I Screen (PASRR indicates that individual requires a PASRR Level ll Referral) necessitates an in-depth evaluation of the individual by the state-designated authority. PASRR Level ll which must be conducted prior to admission to a…

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 interview and record review, the facility failed to ensure ongoing communication and collaboration with the hemodialysis (medical procedure that uses a machine to filter and clean the blood when the kidneys are failing) center and consistently complete resident's pre and post dialysis assessments for 2 of 2 resident (Residents 4 and 28) reviewed for hemodialysis (HD) services. The failure of inconsistent communication and collaboration between the facility and the dialysis center about what occurred during HD and the inconsistent completion of the pre, and post dialysis assessments placed the residents at risk for unidentified medical complications and other potential/negative health outcomes.Findings included .In a review of the facility policy titled, Dialysis (Renal), Pre- and Post-Care revised 02/2025 showed the policy included ongoing communication and collaboration with the dialysis facility regarding dialysis care and service.<RESIDENT 4> Resident 4 initially admitted to the facility on [DATE]…

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 interview, observation, and record review, the facility failed to provide appetizing and palatable food to 3 of 7 residents (Residents 1, 27 and 49) reviewed for food temperature and palatability. This failure placed residents at risk for weight loss, inadequate nutrition, and a diminished quality of life.Findings included .<RESIDENT 27> During an interview on 07/15/2025 at 11:18 AM, Resident 27 reported that the food was not served hot. During an observation and interview on 07/17/2025 at 8:50 AM, Resident 27 had just received their breakfast tray. Resident reported the biscuits and gravy tasted “OK.” Resident 27 stated the food would taste better if it was hot, but it was only warm. There was no heated plate warmer under the resident’s plate. The edge and the bottom of the plate were cool to the touch. During an interview on 07/18/2025 at 12:50 PM, Resident 27 was observed finishing their lunch meal. Resident 27 reported the food was just lukewarm, so they did not eat all of it. There was half of the main entrée left on their plate. Review of the July 2025 Resident…

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 record review and interview, the facility failed to ensure funds were reimbursed to the resident and/or representative or the state Office of Financial Recovery (OFR) within 30 days of resident discharge or death for 1 of 4 (Resident 57) residents reviewed for trust accounts. This failure caused a delay in reconciling residents accounts within the 30 days requirement. Findings included .Resident 57 was admitted to the facility on [DATE]. According to the nursing progress note, the resident passed away on 04/08/2025. In a record review of the facility's trust transaction history dated 07/15/2025, it was documented that Resident 57 had a balance of $378.67.In an interview on 07/18/2025 at 7:54 AM, Staff C, Business Office Manager, stated that any balances from resident's trust account must be returned to the resident within 30 days after discharge. If a resident passed away, then they were to submit the balance amount to the OFR. Reviewed Resident 57's trust transaction history with Staff C and they…

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, interview, and record review the facility failed to develop and/or implement individualized comprehensive care plans for 1 of 2 residents (Resident 27) reviewed for catheter use and 1 of 2 residents (Resident 8) reviewed for dementia care. Failure to develop and implement care plans that were individualized and accurately reflected resident care needs placed residents at risk of unmet care needs and potential negative outcomes.Findings included.Review of an undated facility policy, titled, Comprehensive Person-Centered Care Planning, documented a comprehensive care plan would be developed to meet the residents medical and nursing needs and the IDT (interdisciplinary team) would review and/or revise the care plan after each assessment.<RESIDENT 8> Resident 8 was admitted to the facility on [DATE] with diagnoses to include unspecified dementia (memory impairment), anxiety disorder, and depression. Review of Resident 8’s Brief Interview for Mental Status (BIMS-an assessment to determine…

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 interview, and record review, the facility failed to ensure professional standards were met for 2 of 5 residents (Residents 3 and 30) reviewed for unnecessary medication review. The facility failed to recognize and ensure parameters were followed for blood pressure medication administration and bowel constipation protocol for the resident and failed to notify the medical provider when the resident's blood sugar levels were beyond the ordered parameters. These failures placed the residents at risk for adverse outcomes, medication errors, complications, and unmet needs. Findings included . Review of the undated facility policy titled Blood Sugar Parameters stated the facility was to notify the provider for any blood sugar levels below 70 or above 450. Review of the undated facility policy titled House Bowel Protocol stated that milk of magnesium (medication for constipation) was to be given to residents if they had no bowel movement in three days, to give a glycerin suppository (medication 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 observation, interview, and record review, the facility failed to ensure respiratory care and services were provided in accordance with physician's orders and accepted professional standards of practice for 2 of 2 residents (Resident 49 and 6) reviewed for respiratory care. The facility failed to ensure continuous positive airway pressure (CPAP, a form of non-invasive ventilation therapy used to facilitate breathing) orders were active and in place, to include the prescribed pressure settings, checking, refilling, and cleaning of the humidifier reservoir, and identifying what solution was to be used in the humidifier. Additionally, the facility failed to ensure oxygen (O2) was being administered per physician's orders. These failures placed residents at risk for ineffective breathing, decreased oxygen levels, respiratory infection and other respiratory complications.Findings included.Reviewed of an undated facility policy titled, CPAP Monitoring and Management, documented that CPAP machine settings and…

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, interview, and record review the facility failed to ensure staff were compliant with Infection Prevention and Control Guidelines and standards of practice for 1 of 4 residents (Resident 31) reviewed for transmission-based precautions (TBP), 1 of 4 residents (Resident 27) reviewed for bowel and bladder care, and 1 of 3 nurses (Staff F) reviewed for medication administration. The facility failed to ensure the staff were wearing appropriate personal protective equipment (PPE) in accordance with recommended national standards, failed to ensure staff were compliant with appropriate hand hygiene practices during perineal care (process of cleaning genitals and anal area), and failed to ensure there was a barrier in place during medication administration. These failures placed all residents and staff at risk of potential infection. Findings include . Review of the facility policy titled Enhanced Barrier Precautions (EBP), revised 02/2025, stated EBP was utilized to prevent the spread of potential…

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, interview and record review, the facility failed to honor the preferences of one of one resident (Resident 26) reviewed for Activities of Daily Living. Failure to provide staff to assist Resident 26 with recreational meal intake 7 days a week placed them at risk for decreased quality of life. Findings included . Resident 26 admitted to the facility on [DATE], with diagnoses to include a stroke affecting their ability to swallow and maintain adequate nutrition from oral intake. Review of current physician orders dated 04/19/2023, showed Resident 26 with an order for tube feeding (tube directly into the stomach) to meet 100% of their nutritional needs. Resident 26 had been assessed as being able to safely tolerate some oral intake daily with 1:1 (one to one staff to resident ratio) supervision related to their impaired swallowing. Review of the Speech Therapy Discharge Recommendations dated 06/21/2024 showed a recommendation to continue one recreational meal per day. Review of Resident 26's…

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, interview and record review, the facility failed ensure a homelike dining environment was provided during one of one dining observations. Failure to ensure licensed nurses refrained from administration of medications during resident meals placed residents at risk for diminished dignity and decreased quality of life. Findings included . Definition: Reasonable Person Concept: a standard used to determine whether an individual's actions or responses align with what a hypothetical reasonable person would do under similar circumstances. It defines the behavior expected of an ordinary, prudent, and rational individual. Resident 5 admitted to the facility on [DATE] with diagnoses to include dementia. Review of the Quarterly Minimum Data Set assessment dated [DATE] showed the resident could not complete the interview questions related to cognition. The staff assessment for cognition showed the resident had memory impairment and impaired decision making. Review of the facility policy titled…

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 interview and record review the facility failed to ensure resident grievances were filed and addressed for 1 of 1 resident (Resident 11) reviewed for grievances. The failure to address and resolve resident grievances placed residents at risk for diminished dignity, unresolved missing property and diminished quality of life. Findings included . Review of the facility's policy on 08/02/2024 titled, Grievances, showed a grievance report would be initiated for all concerns, the resident would be communicated with, and an attempt was made to resolve the grievance within 5 days. There would be follow up with the resident or representative about the grievance to ascertain satisfaction with the resolution of the reported concern. Resident 11 re-admitted to the facility on [DATE] and was alert and oriented. Review of the record showed the resident had a recent prior stay 03/21/2024 through 05/16/2024. In an interview on 07/31/2024 at 11:05 AM, Resident 11 stated they ended up back in the hospital and readmitted…

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 interview and record review, the facility failed to ensure the Resident Assessment Instrument (RAI - an assessment of a resident's needs, strengths, goals, and preferences, included thorough summaries of the Care Area Assessments, - a systematic process to interpret the triggered information from the Minimum Data Set assessment to assess the potential problem and determine if the area should be care planned), holistically analyzed the plan of care for 1 of 6 sampled residents (Resident 30) reviewed for comprehensive assessments. This failure placed the residents at risk of not having appropriate services provided based on their individualized needs. Findings included . Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2023, showed the RAI consists of three basic components: the Minimum Data Set (MDS - and assessment tool) assessment, the CAA process, and the RAI Utilization Guidelines (instructions for when and…

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, interview and record review, the facility failed to ensure care plan interventions were implemented for 1 of 3 sampled residents (Resident 13) reviewed for accidents. This failure placed residents at risk for injury, and decreased quality of life. Findings included . Resident 13 readmitted to the facility on [DATE] with diagnoses to include fall, high blood pressure, fracture of right upper leg. In an interview and observation on 07/31/2024 at 2:54 PM, Resident 13 stated they had fallen out of their bed around eight months ago. Resident 13 stated they had been asleep in their bed when they had moved the bed control and started to fall over to the right side and fell from their bed. During the observation a blue foam wedge was noted at the foot of Resident 13's bed. Review the incident report, dated 01/02/2024, showed that Resident 13 sustained a fall at 2:45 AM and was assisted back to bed after they refused to be sent to the hospital. The incident report showed Resident 13 voiced being…

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 interview and record review, the facility failed to revise comprehensive care plans for 2 of fourteen sampled residents (Residents 3 and 20), reviewed for care plan revisions. The failure to revise care plans for dental services and discharge planning placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . <RESIDENT 20> Resident 20 admitted to the facility on [DATE] with diagnoses to include above the knee amputation of the right leg, diabetes mellitus Type 2 (a condition where the body has a problem regulating blood sugar), and high blood pressure. In an interview on 07/31/2024 at 3:23 PM, Resident 20 stated they had planned to move to the Assisted Living Facility (ALF) next door. Resident 20 stated they had sold some property and were now not able to move to the assisted living. Resident 20 stated they were trying to contact someone at Home and Community Services (HCS) to work it all out. Review of Resident 20's care plan initiated 08/09/2022 and revised…

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, interview, and record review, the facility failed to ensure professional standards of practice were implemented for 2 of fourteen residents (Residents 21 and 26) reviewed. Failure to follow physician's orders for labs and medication parameters for Resident 21 and to follow Speech Language Pathologist (SLP) recommendations for Resident 26 placed the residents at risk for delay in treatment and potentially adverse outcomes. Findings included . <RESIDENT 26> Resident 26 admitted in 2023 and had diagnoses which included a stroke affecting their ability to swallow and maintain adequate nutrition from oral intake. Resident 26 had physician's order for a tube feeding (tube directly into the stomach) to meet 100% of their nutritional needs. Resident 26 had been assessed as being able to safely tolerate some oral intake daily with 1:1 (one to one staff to resident ratio) supervision related to their impaired swallowing. Review of the Speech Therapy Discharge Recommendations dated 06/21/2024 showed…

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, interview, and record review, the facility failed to provide assistance with activities of daily living for 2 of 2 sampled dependent residents (Residents 26 and 30) reviewed for activities of daily living (ADL's). Facility failure to provide residents, who were dependent on staff for assistance with hygiene including oral care and meal assistance placed residents at risk for diminished quality of life. <RESIDENT 30> Resident 30 admitted to the facility on [DATE] with diagnoses that included fracture of the right upper leg. Review of Resident 30's Minimum Data Set (MDS-an assessment tool) dated 06/18/2024 showed they required supervision or touching assistance with eating and partial/moderate assistance to complete their oral hygiene. In an interview on 07/31/2024 at 10:54 AM Resident 30's representative, Collateral Contact 1(CC 1), stated the resident spent most of their time in bed. CC 1 stated Resident 30 was assisted by staff with their meals, had their natural teeth (which were barely…

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, interview and record review, the facility failed to ensure residents received care and treatment in accordance with professional standards of practice and received the necessary care and services to attain or maintain their highest practicable level of well-being for 2 of 5 residents (Resident 21 and 30) reviewed. The facility failed to ensure Resident 21's alternating air mattress was set at the labeled setting and Resident 30 received routine repositioning. These failures placed the residents at increased risk of unmet care needs and potential skin breakdown. Findings included . Review of the facility policy titled Repositioning residents dated 08/2022 and revised 07/2024 showed it was the facility's policy to reposition residents for comfort and skin integrity. The policy identified repositioning was critical for a resident who was immobile or dependent upon staff for repositioning. The policy general guidelines included the following interventions: 1.A turning/repositioning program…

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 interview and record review, the facility failed to ensure annual Nurse Aide Certified (NAC) performance reviews were completed for 1 of 4 NAC's (Staff K) files reviewed who had been employed at the facility longer than one year. This failed practice had the potential to negatively affect the competency of these NACs and the quality of care provided to residents. Findings included . Staff K was hired on 07/06/2023. Review of Staff K's employee file showed there was no current employee evaluation done. There was no evidence the evaluator completed this evaluation nor if it was reviewed/discussed with Staff K. Review of the staff roster printed on 07/31/2024 on the first day of survey showed various hire dates for staff beginning on 06/12/1987 to 07/26/2024. In an interview on 08/06/2024 at 12:59 PM, Staff J, Staff Development Coordinator said they would be doing new performance evaluations, but everyone's start date was May 1st and they were all new employees. In an interview on 08/06/2024 at 2:48 PM, Staff B Director of Nursing Services said all staff completed new hire…

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 observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in 1 of 1 facility kitchens, 1 of 1 snack/nourishment refrigerators and 2 of 3 halls observed. The failure to monitor and document safe kitchen refrigerator temperatures, label opened food/beverage items, discard expired food items in the kitchen and unit refrigerators, ensure dishwashing temperature were maintained at the proper temperature, and cover desserts during meal delivery. These failures placed all residents at risk for their food to be contaminated, development of food borne illnesses, and consuming spoiled food. Findings included . <KITCHEN REFRIGERATOR> On 07/31/2024 at 8:54 AM during the initial kitchen tour, observed an undated sandwich in a bag on the first shelving unit, a thickened dairy beverage that was opened and undated, three trays of condiments, a pitcher of lemonade with a use by date of 07/29/2024, a pitcher of iced tea prepared 7/23/2024 with no use by date in the refrigerator. There was a stack of temperature…

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, interview and record review, the facility failed to ensure adherence to infection prevention and control practices. The facility failed to properly don (put on) and doff (take off) personal protective equipment (PPE) for 1 of 1 (Resident 23) reviewed for aerosol contact precautions related to Coronavirus Disease 2019 (COVID-19, an infectious disease-causing respiratory illness symptoms including cough, headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death) outbreak, and failed to cover clean linens during transport. The facility also failed to properly store oxygen (O2) tubing for 1 of 1 resident (Resident 3) reviewed for O2 therapy. These failures placed residents at risk for contracting infection and diminished quality of life. Findings included . In a review of the Facility Assessment, undated, showed the facility was prepared to manage the treatment of COVID-19 infection for their…

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 record review, and interview the facility failed to develop, implement and maintain an in-service training program to ensure 1 of 4 Nursing Assistant's (Staff K) reviewed for the required 12 hour of nurse aide training per year. The failure to ensure Nursing Assistants Certified (NACs) received 12 hours per year in-service training placed residents at risk for potential unmet care needs. Findings included . Review of the Facility Assessment, undated, showed the facility utilizes the following training topics during all staff in-services or department meetings at multiple times throughout the year: - Communication - effective communications for direct care staff with residents/family. Resident's rights and facility responsibilities - educate staff members on the rights of the resident and the responsibilities of a facility to properly care for its residents. - Abuse, neglect, and exploitation - educate staff on: (1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property; (2) Procedures for reporting incidents, of abuse, neglect,…

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.