Madison Post Acute

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide a homelike environment for 3 of 3 resident care areas (100 hall (to include room [ROOM NUMBER] and 402), 200 hall and 300 hall) and 2 of 2 residents rooms (Resident 20 and 33) reviewed for environment. The facility failed to ensure the carpet in the hallways were clean and maintained, walls repaired, privacy curtains laundered, and comfortable sound levels were maintained for the residents. The facility's failure to provide maintenance and housekeeping services and management of noise level placed residents at risk for diminished rest and quality of life. Findings included . <NOISE> In a continuous observation on 10/11/2023 from 1:29 PM to 2:03 PM, Resident 33 called out 28 times Help Me, which could be heard down the 200 hall. In a continuous observation on 10/11/2023 from 2:13 PM to 3:45 PM, there was frequent loud banging into the walls heard from the kitchen. In observations on 10/12/2023 at 11:44 AM and 2:31 PM, there was loud banging noise…

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 facility failed to implement their abuse/neglect policy and procedure, thoroughly investigate falls, allegations of potential abuse and/or neglect to identify the root cause and all contributing factors related to an allegation for 11 of 12 investigations (3, 93, 22, 25, 94, 24, 91, 11, 10, 33, and 19) reviewed. Failure to thoroughly investigate allegations of abuse and/or neglect placed residents at risk for additional abuse/neglect. Findings included . Review of the facility policy titled, Abuse/neglect Incident Policy and Procedure, undated, revealed the facility was to identify, correct and intervene in situations in which abuse, neglect was more likely to occur. All incidents will be thoroughly investigated upon discovery of the incident. If a staff to resident incident is suspected, the staff is removed from the area or facility. The hotline is to be notified within 2 hours. The staff were directed to seek to determine by analyzing facts,…

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 (CAA's), an assessment of a specific resident care or medical issue, to holistically analyze the plan of care for 5 of 9 residents (10, 11, 20, 19 and 34) reviewed for comprehensive assessments. This failure placed the residents at risk of not having appropriate services provided based on the resident's individualized needs and placed all other residents at risk of their needs and preferences not met. Findings included . Review of the facility's policy, Care Area Assessments, revised November 2019, showed CCA's are used to help analyze data obtained from the [NAME] Data Set (MDS - an assessment tool) and to develop individualized care plans. Triggered care areas are evaluated by the interdisciplinary team to determine the underlying causes, potential consequences, 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.

Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5 percent (%). Ten During observation of 27 opportunities for error, 10 medication errors were identified for 2 of 4 residents (Resident 8 and 16) observed during 27 medication administration opportunities that resulted in a medication error rate of 37.03%. This failure placed residents at risk for side effects, unmanaged pain, altered medication effectiveness and the possibility to receive medications outside of the scheduled time it was to be given. Findings included . During a medication administration observation on 10/13/2023 at 9:36 AM, Staff F, Registered Nurse (RN), prepared Resident 8's scheduled 8:00 AM medications. Medications prepared and given to Resident 8 included: - Pantoprazole (Acid reflux/indigestion), - Metolazone (diuretic), - Nicotine patch (smoking cessation), and - Methadone (pain medication) Review of Resident 8's October 2023 Medication Administration Record (MAR), showed Resident 8 was to receive those four scheduled medications at 8:00 AM.…

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 the Infection Prevention and Control Program (IPCP), specifically hand hygiene and donning/doffing personal protective equipment, was followed during wound care for 2 of 2 residents (Resident 20 and 8) and standard infection control measures were followed for 3 of 10 staff (Staff K, F, and L) observed for standard infection control practices. These failures placed residents at risk for exposure to infections and a decreased quality of life. Findings included . <WOUND CARE> RESIDENT 20 In a wound care observation on 10/13/2023 from 11:45 to 12:10 PM, Staff B, Registered Nurse (RN)/Director of Nursing Services, performed wound care to Resident 20. Staff B placed a barrier on the over bed table and set up the dressing supplies necessary for the wound care. While the resident was repositioning in bed, the TV remote fell near the barrier and dressing supplies. With gloved hands, Staff B moved the TV remote and opened the clean dressing…

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 advanced notice when Medicare coverage ended. The facility did not issue a Notification of Medicare Non-Coverage (NOMNOC) at least two calendar days before coverage for Medicare services ended, as required, for 1 of 3 residents (Resident 40) reviewed for required liability notices. This failure prevented the resident from exercising the right to appeal and dispute the termination of Medicare covered care. Findings included . Review of the Centers for Medicare & Medicaid Services (CMS) form titled, Instructions for the Notice of Medicare Non-coverage (NOMNC), on 10/13/2023, showed the Medicare provider or health plan must give an advanced, completed copy of the NOMNC to beneficiaries/enrollees receiving skilled nursing, home health, comprehensive outpatient rehabilitation facility, and hospice services, not later than two calendar days before the termination of services. Resident 40 admitted to the facility on [DATE] with diagnosis to include…

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 comprehensively assess, monitor, and review the need for bed and wheelchair alarms for 2 of 2 residents (Resident 37 and 19) reviewed for restraints. This failure placed the residents at risk for injury and decreased quality of life. Findings included . Review of facility Policy titled, Use of Alarms in Fall Prevention/Wander guard, dated 12/05/2018, showed: - Alarm Usage: LN's (Licensed Nurses) will assess resident for fall risk at time admission. If at risk, LNs will determine need for alarms and indicate on plan of care type of alarm, times, and location of alarm. - Responsibilities to alarms: Placement & functions: It is the responsibility of the caregiver, NAC (Nursing Assistant Certified) or LN, to place alarm and assure it is in good working order at all times indicated in care plan. - It is the responsibility of team charge nurse to observe and check for proper placement of alarms on all his/her residents needing alarms. -…

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 implement their Abuse Prohibition policy by not ensuring reference checks were conducted prior to hire for 3 of 5 employees (Staff X, AA, and BB) reviewed for reference checks. These failures placed residents at risk for abuse, neglect, unmet care needs, mistreatment by staff and a diminished quality of life. Findings included . Review of the facility policy titled, Abuse/Neglect Policy and Procedure, undated, showed no resident would be subjected to abuse, mistreatment .The procedure showed prior to hiring, staff would be screened, and professional references would be verified by the facility representative and documented. Staff X was hired on 11/10/2022 as a Nursing Assistant Certified (NAC). Review of Staff X's employee file showed there were no professional or personal reference checks completed. Staff AA was hired on 05/03/2023 as a NAC. Review of Staff AA's employee file showed there were no professional reference checks completed. Staff BB was hired on 09/14/2004 as a Registered Nurse. Review of Staff BB's employee…

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 report allegations of potential abuse for 1 of 2 residents (Resident 11) reviewed for abuse and neglect. This failure to report to the required state agency resulted in lack of timely investigations and placed all residents at risk of being victims of unidentified and uninvestigated abuse and/or neglect. Findings included . A review of the facility policy titled, Abuse/Neglect Policy and Procedure, undated, showed staff were directed to report to the hotline suspected abuse/neglect/exploitation and misappropriation, immediately or within two hours. Resident 11 admitted on [DATE] with diagnoses to include stroke with left side hemiparesis (weakness) and hemiplegia (partial or nearly complete paralysis), and depression. In an interview on 10/09/2023 at 10:23 AM, Resident 11 stated they had an issue with Staff AA, Nursing Assistant Certified (NAC) when they laughed and were physical with them. When asked what that meant, Resident 11 said Everyone knows…

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 accurately assess 3 of 6 sampled residents (Residents 33, 8, and 31) reviewed for Minimum Data Set (MDS - an assessment tool). The failure to ensure accurate assessments regarding health conditions including their fall history, skin pressure ulcers (PU's), and physician documented diagnoses place residents at risk for unidentified and/or unmet care needs and a diminished quality of life. Findings included . <RESIDENT 33> Resident 33 was admitted to the facility on [DATE] with diagnosis of anoxic (lack of oxygen) brain damage that caused severe impairments in cognition and physical functional movements. Review of Resident 33's most recent MDS assessment, dated 07/03/2023, indicated the resident had no falls since admission or since their prior assessment. Review of Resident 33's medical records and the facility incident reporting logs showed the resident had falls in the facility on 08/03/2023, 08/10/223, 08/25/2023, 08/28/2023, and 09/25/2023. In 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 observation, interview and record review, the facility failed to refer 2 of 5 sampled residents (Resident 10 and 31) reviewed for Pre-admission Screening and Resident Review (PASRR - a federally required screening of all individuals who has both an Intellectual Disability (ID) or Related Condition (RC) and a serious mental illness (SMI) prior to admission to a Medicaid-certified nursing facility or a significant change of condition) for a Level II (an evaluation to determine whether the resident requires specialized rehabilitation services) evaluation after Resident 10 exhibited hallucinations, delusions and possible serious mental disorder diagnosis. This failure increased residents' risk for experiencing fear, anxiety and having unmet behavioral health care needs. Findings included . <RESIDENT 10> Review of Resident 10's record indicated the resident admitted on [DATE] with diagnoses including bipolar disorder (a serious mental illness characterized by extreme mood swings), dementia without behavioral…

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 make a referral for the Pre-admission Screening and Resident Review (PASRR - a federally required screening of all individual's wo are being referred to a Medicaid-certified nursing facility) for a Level II (an evaluation to helps determine resident placement and the need for specialized services needed prior to admitting to a facility) evaluation for 1 of 5 sampled residents (Resident 34). This failure placed the resident at risk for unidentified mental health care needs, lack of mental health services and a diminished quality of life. Findings included . Resident 34 admitted to the facility on [DATE] with diagnosis that included dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems). Review of Resident 34's PASRR Level I (a screening to determine if a resident may have a SMI/ID related condition and if positive a Level II PASRR is required), dated 05/23/2023, showed a serious…

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 develop and implement comprehensive care plans for 1 of 6 sampled residents (Resident 34) reviewed for comprehensive care plans. The failure to develop and implement a Pre-admission Screening and Resident Review (a screening assessment for possible serious mental health disorders or intellectual disabilities) Level II (an in-depth evaluation to determine whether the resident requires specialized rehabilitation services) care plan placed residents at risk for unmet care needs, and a diminished quality of life. Findings included . Resident 34 admitted to the facility on [DATE] with diagnoses that included fracture of the right leg (broken right leg), hypertension (high blood pressure, and unspecified dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems). Review of the PASSR, dated 05/23/2023, showed Resident 34 showed signs of a serious mental illness, had a primary diagnosis 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 interview and record review, the facility failed to review and revise care plans for 3 of 6 sampled residents (Resident 20, 10, and 35) reviewed for care planning. These failures placed the residents at risk for lack of consistent interventions, unmet care needs, adverse health effects, and a diminished quality of life. Findings included . Review of the facility's, Care plan policy and procedure, revised 08/08/2019, showed the care plan was to include the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. <RESIDENT 20> Resident 20 admitted on [DATE] with diagnoses which included antibiotic resistant infection to their right hip prosthesis, breast cancer, neuropathy (nerve disease that impairs sensation and movement), chronic pain syndrome, high blood pressure, and chronic anemia. The resident had not pressure ulcers. Review of the progress note, dated 08/29/2022, showed there was an incident regarding new skin…

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 2 of 2 sampled residents (Resident 10 and 34) reviewed for activities, received an ongoing program of activities to meet the individual residents' interests and needs. This failure placed the residents at risk for a decreased quality of life. Findings included . <RESIDENT 10> Resident 10 was admitted to the facility on [DATE] with diagnoses to include depression, dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems), anxiety, and chronic obstructive pulmonary disease (COPD - causes airway blockage and difficulty breathing). Review of Resident 10's admission Minimum Data Set (MDS - an assessment tool) assessment, dated 09/29/2023 showed that the resident required extensive assist of one or two staff with their Activities of Daily Living (ADL - dressing, transfers, bed mobility, walking/locomotion, bathing personal hygiene, toileting and eating). 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 interview and record review, the facility failed to provide proper treatment to maintain vision for 1 of 1 resident (Resident 19) reviewed for vision. This failure placed the resident at risk for frustration, decline in the ability to see, and diminished quality of life. Findings included . Resident 19 admitted to the facility on [DATE] and most recently admitted on [DATE] with diagnoses that included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), diabetes mellitus type 2 (medical condition in which the body doesn't use insulin properly), fracture of the right femur (broken right leg). Review of Resident 19's Minimum Data Set (MDS - an assessment tool), dated 06/07/2023, showed the resident had adequate vision. Review of Resident 19's care plan, dated 08/08/2023, had no problem, goal, or intervention identified for their vision. In an interview on 10/10/2023 at 9:17 AM, Resident 19…

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 thoroughly assess and document pressure ulcers (PU's) weekly, maintain clear and accurate PU documentation, and develop and implement an individualized care plan for 1 of 2 sampled residents (Resident 20) reviewed for PU's. This failure placed residents at risk for deterioration of their PU's and a diminished quality of life. Findings included . Review of the facility policy titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol, revised April 2018, showed the nursing staff and practitioner will assess and document an individual's significant risk factors for developing PU, for example, immobility, recent weight loss, and a history of PU's. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue. b. Pain assessment. c. Resident's mobility status. d. Current treatments, including support…

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 safety and mobility interventions were developed, implemented, and consistently provided as directed in the care plan for three of four residents (Resident 19 and 34) reviewed for falls. This failure placed the residents at risk for avoidable falls with injury and diminished quality of life. Findings included . Review of a facility policy titled, Falls and FaII Risk, Managing, dated March 2018, showed that staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The facility policy showed position-change alarms would not be used as the primary or sole intervention to prevent falls, rather to identify patterns and routines of a resident.<RESIDENT 19> Resident 19 admitted to the facility on [DATE] and most recently admitted on [DATE] with diagnoses included Parkinson's disease (a brain disorder that causes…

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 1 of 1 residents (Resident 34) who was incontinent of bladder received appropriate treatment and services to restore continence to the extent possible. This failure placed residents at increased risk of urinary tract infections and decreased quality of life. Findings included . Resident 34 admitted to the facility on [DATE] with diagnoses that included fracture of the right leg (broken right leg), high blood pressure, and unspecified dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems). Review of Resident 34's Minimum Data Set (MDS - an assessment tool) assessment, dated 06/07/2023, showed that they were frequently incontinent and not on a toileting program. In a review of the Care Area Assessment (CAA - an assessment of a specific care or medical issue), dated 06/08/2023, showed Resident 34's incontinence would be addressed in the care plan. There 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 observation, interview and record review, the facility failed to ensure enteral nutrition (the delivery of nutrients through a feeding tube directly into the stomach or small intestine) was administered in accordance with professional standards of practice for 1 of 1 sampled resident (Resident 32) reviewed for enteral nutrition. The facility failed to ensure orders were processed and transcribed accurately which placed the resident at risk for inadequate nutrition, hydration, and weight loss. Findings included . Review of a facility policy titled, Enteral Nutrition, dated 2001 and revised November 2018, showed complete orders for enteral nutrition should include: the enteral nutrition product, the delivery site (tip placement); the specific enteral access device (nasogastric, gastric, jejunostomy tube, etc.), the administration method (continuous, bolus, intermittent); the volume and rate of the administration, and the volume/rate goals and recommendations for advancement toward these; and instructions…

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 followed according to professional standards of practice for 2 of 3 residents (Residents 8 and 19) reviewed for respiratory care. The failure to transcribe and/or follow physician's orders for respiratory care and routinely change oxygen tubing placed the residents at risk of unmet care needs, respiratory infections, and related complications. Findings included . <RESIDENT 8> Resident 8 was admitted to the facility on [DATE], with diagnoses to include heart failure, atrial fibrillation (a fast irregular heart rate), and chronic obstructive pulmonary disease (COPD - group of diseases that cause airflow blockage and breathing problems). Review of Resident 8's admission Minimum Data Set (MDS - an assessment tool) assessment, dated 10/03/2023, showed no documentation the resident used oxygen. Review of Resident 8's care plan, initiated on 09/25/2023, showed the resident was oxygen dependent and had 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 observation, interview, and record review, the facility failed to ensure appropriate treatment and services were provided to 2 of 2 residents (Resident 10 and 34) reviewed for dementia care. Failure to implement resident-specific interventions to address the resident's hallucinations (where someone sees, hears, smells, tastes or feels things that don't exist outside their mind) and delusions (unshakeable belief in something that isn't true, or likely to happen), placed the residents at risk for having unidentified and/or unmet care needs, avoidable decline, and diminished quality of life. <RESIDENT 10> Resident 10 admitted on [DATE] with dementia without behavioral disturbance, anxiety, mood disturbance, depression, and bipolar disorder (a serious mental illness characterized by extreme mood swings). Review of the admission Minimum Data Set (MDS - an assessment tool) assessment, dated 09/29/2023, showed the resident experienced hallucinations (the perception of the presence of something that is not…

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 adequate indications for use, failed to ensure target behaviors were individualized and monitored, failed to complete necessary assessments, and failed to address pharmacist recommendations related to psychotropic medication use for 2 of 5 residents (Resident 10 and 31) reviewed for unnecessary medications. These failures placed residents at risk for a decreased quality of life, medication side effects, and did not promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being. Findings included . Review of a facility policy titled, Psychotropic Medication Monitoring, dated 11/27/2006, showed before starting psychoactive medications to address the problem on the care plan and social services would write management approaches and target behaviors. If unable to manage behaviors with management approaches, contact the physician. Ask for a mental health order, and if medication was ordered do not…

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 dental services were provided for 1 of 2 Medicaid sampled residents (Resident 11) reviewed for dental services. Failure to follow up on dental referrals and timely assistance with appointment scheduling extended the time residents had to wear ill-fitting dentures. These failures placed residents at risk for difficulty chewing and a decreased self-image and diminished quality of life. Findings included . Review of Resident 11's 09/13/203 Quarterly Minimum Data Set (MDS - an assessment tool), an assessment tool, showed the resident was cognitively intact, required physical assistance with hygiene including oral care. The resident was edentulous (had no natural teeth) and did not have loosely fitting dentures. Review of the activities of daily living (ADL) care plan, dated 09/20/2023, Resident 11 had upper and lower dentures and needed assistance with oral care. Staff were directed to remove and clean dentures at bedtime. The care plan indicated the resident used a denture adhesive daily. During an interview 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.