Northwoods Lodge

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure residents were appropriate for the use of mobility bars, for 1 or 3 residents (Resident 103) reviewed for physical restraint, and to ensure prior to use of mobility bars that residents were evaluated for risk of entrapment and informed consent was obtained for 3 of 3 residents (Residents 103, 8 & 33) reviewed for physical restraint. This failure placed residents at risk for not knowing risks of mobility bars, accidents/harm/entrapment related to mobility bars, and a diminished quality of life. Findings included . Review of the document titled, Proper Use of Side Rails, dated December 2016, showed the facility was to assess for risk of entrapment, to add the assistive device to the resident's care plan, and was to obtain consent. The document also specified that side rails were only allowed if they were used to treat a medical symptom and assist with mobility or transfer of the resident. 1) Resident 103 was admitted to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review the facility failed to store, prepare and serve food to residents in accordance with professional standards for 1 of 1 kitchen and 2 of 2 unit refrigerators/freezers reviewed for food service safety. The failure to maintain documented refrigerator, freezer and dishwasher temperatures, prevent contamination of uncovered foods during transportation, to throw out expired foods and maintain sanitary conditions placed residents at risk of foodborne illness (caused by the ingestion of contaminated food or beverages), unsanitary conditions, and diminished quality of life. Findings included . <Food storage temperature logs> Review of the food storage temperature logs documented the following missing entry dates: Walk in refrigerator: 11/03/2024 AM shift 01/02/2025 PM shift Walk in Freezer: 11/03/2024 AM shift 01/02/2025 PM shift Kitchen refrigerator: 11/03/2024 AM shift 01/02/2025 PM shift Kitchen Freezer: 11/03/2024 AM shift 01/02/2025 PM shift Pantry…

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 transmission based precautions (TBPs, extra precautions to prevent spread of infection) were implemented consistently and as indicated for 3 of 3 sampled residents (Residents 105, 40,33) reviewed for aerosol generating procedures (AGPs, procedures that generate aerosols that could be infectious), 2 of 3 sampled residents (Residents 17 &33) reviewed for enhanced barrier precautions (EBPs, infection control precaution of wearing gown and gloves during high contact activities during resident care) and 1 of 2 sampled residents (Resident 38) reviewed for contact precautions (infection control precaution of wearing gown and gloves before room entry and while in room) observation. Additionally, the facility failed to ensure the Legionella Water Management Programs (LWMP) was updated to current industry standards, and that sharps containers were replaced when full. These failures placed residents at risk of cross-contamination, infection,…

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 antibiotic stewardship program had an accurate and complete antibiotic line listing, with symptoms and McGeers Criteria (tool for infection surveillance and antibiotic stewardship, provided criteria to show if antibiotics were indicated) reviewed, and providers were updated on residents that did not meet criteria for antibiotic usage, for 3 of 3 residents (Resident 30, 354, & 355) reviewed for antibiotic line listing. This failure placed residents at risk of developing multi-drug resistant organisms, unidentified care needs, and a diminished quality of life. Findings included . During an interview on 01/08/2025 at 8:14 AM, Staff A, Administrator/Director of Nursing Services (DNS)/Infection Preventionist (IP), when asked to describe the antibiotic stewardship program, said they looked to see if the antibiotic use was appropriate/indicated, reviewed cultures as they resulted, and made sure the treatment/antibiotic was susceptible to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure residents and/or their representatives were offered the opportunity to participate in care conferences for 5 for 6 sampled residents (Resident 21, 156, 154, 40 & 25) reviewed for right to participate in planning care. This failure placed residents at risk of a diminished quality of life when not allowed to be involved in their long-term care needs. Findings included . 1) Resident 21 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS, an assessment tool), dated 12/09/2024, documented Resident 21 was cognitively intact. On 01/07/2025 at 2:45 PM, Resident 21 said they had not had a care conference or any meeting to discuss their care while at the facility. The Electronic Health Record (EHR) documented Resident 21 had no care conference since being admitted . On 01/13/2025 at 10:01 AM, Staff A, Administrator, said no formal care conference was completed with Resident 21. Staff A said a care conference should have been…

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 choices regarding bathing type were honored for 1 of 4 sampled residents (Resident 103) reviewed for choices. The facility's failure to accommodate resident preferences related to type of bathing placed residents at risk for feelings of un-cleanliness, powerlessness, diminished self-worth, and a decreased quality of life. Findings included . Resident 103 was admitted to the facility on [DATE]. The Entry Minimum Data Set, an assessment tool, dated 01/05/2025, documented Resident 103 was cognitively intact, and required assistance with bathing and transfer. On 01/08/2025 at 9:25 AM, Resident 103 said they were told they could not have a shower and were told they could only receive a bed bath. Resident 103 stated, I want a shower. On 01/10/2025 at 6:23 AM, Resident 103 said they received a bed bath yesterday and was told they could not have a shower due to mobility. The Electronic Health Record documented Resident 103 was scheduled to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to provide a written transfer/discharge notice to the resident and/or their representative for 2 of 2 sampled residents (Residents 30 & 40), reviewed for hospitalization. This failure placed the resident and/or their representative at risk for not having an opportunity to make informed decisions about transfers/discharges. Findings included . 1) Resident 30 was admitted to the facility on [DATE]. The 5-Day Minimum Data Set (MDS, an assessment tool), dated 11/19/2024, documented Resident 30 was cognitively intact. Resident 30's Electronic Health Record (EHR) showed Resident 30 was transferred to the hospital on [DATE] and returned to the facility on [DATE]. Resident 30's EHR did not show documentation that Resident 30 was offered and/or provided a transfer/discharge notice. On 01/10/2025 at 1:29 PM, Staff E, Admissions Coordinator, said the transfer notice should have been sent with the resident at the time of transfer to the hospital. Staff E said she…

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 written bed hold notices at the time of transfer to the hospital for 2 of 2 sampled residents (40 and 30) reviewed for hospitalization. This failure placed the residents at risk for lack of knowledge regarding their right to hold their bed while in the hospital. Findings included . 1) Resident 40 was admitted to the facility on [DATE]. The 5-day Minimum Data Set (MDS, an assessment tool) dated 12/16/2024, documented Resident 40 was moderately cognitively impaired. A review of the Electronic Health Record (EHR) showed Resident 40 was transferred to the hospital on [DATE] and returned to the facility on [DATE]. Resident 40's EHR did not show documentation that Resident 40 was offered and/or provided a bed hold notice at the time of transfer. On 01/09/2025 at 3:40 PM, Staff G, Resident Care Manager, said the bed hold policy was addressed when a resident was admitted to the facility and not when they are transferred to the hospital. On 01/09/2025…

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 a baseline care plan, within 48 hours of admission, that included instruction needed to properly care for 1 of 11 residents (Resident 105) reviewed for new admission. This failure placed residents at risk for unidentified and unmet needs, and other negative health outcomes. Findings included . Resident 105 admitted to the facility on [DATE] with orders for oral suctioning, which is an aerosol generating procedure (AGP/a procedure that creates respiratory particles that are small and light enough to remain suspended in air for long periods of time and that can travel past six feet from source and through surgical masks). Review of the baseline care plan showed it was not identified the resident required suctioning or AGP precautions. On 01/13/2025 at 11:01 AM, Staff D Resident Care Manager (RCM), said Resident 105's need for suctioning and AGP precautions should have been addressed on the baseline care plan. Resident 105 admitted…

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 implement person-centered comprehensive care plans that identified resident specific care needs and interventions for 1 of 4 residents (Resident 13) reviewed for activities of daily living. The failure to identify residents' self-care deficits, and develop and implement interventions to meet their needs, placed residents at risk for feelings of helplessness, frustration, decreased intake/weight loss and a diminished quality of life. Findings included . Resident 13 admitted to the facility on [DATE]. The admission MDS, dated [DATE], showed Resident 13 had decreased function to the upper extremities (includes the arms, wrists, and hands), needed limited to moderate assistance with ADLs, and was moderately cognitively impaired. On 01/08/2025 at 9:36 AM, Resident 13 was observed with a breakfast tray that had an unopened protein drink and a packet of cocoa. When asked about how breakfast was, Resident 13 said they couldn't…

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 re-assess and revise the care plan for 1 of 7 residents (Resident 23) reviewed for care planning. This failure placed residents at risk for skin impairment related to immobility, for delay in care services, and for a diminished quality of life. Findings included . Resident 23 admitted to the facility on [DATE] with diagnoses of fractures of the left shoulder and hip and type 2 diabetes with neuropathy (nerve damage, usually to the legs and feet). The admission Minimum Data Set, an assessment tool, dated 12/09/2024, showed Resident 23 was moderately cognitively impaired and needed extensive assistance with activities of daily living. <Skin impairment risk and Mobility> Review of the care plan, dated 12/04/2024, showed Resident 23 had risk for skin impairment related to surgical incision, left shoulder sling, and immobility. Interventions included: Float bilateral heels when in bed. Arm sling to support left proximal humerus (shoulder),…

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 services provided met professional standards of practice for 4 of 35 sampled residents (Residents 105, 33, 304 & 49) reviewed. The failure of nursing staff to follow and/or clarify incomplete physicians' orders, to accurately document the medication dose that was administered, and to notify the provider of trendable medication refusals, placed residents at risk for medication errors, adverse side effects, unmet care needs and other potential negative outcomes. Findings included . 1) Resident 105 admitted to the facility on [DATE]. Review of the 12/26/2024 hospital transfer paperwork showed the residents transfer diagnoses were identified as: severe hypoglycemia (low blood sugar); fecal impaction (severe constipation at the end of gastrointestinal tract) with overflow diarrhea and clostridium difficile (a bacterium that causes an infection of the colon) carrier. On 12/31/2024, an order was obtained to give polyethylene glycol (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 that pharmacological and non-pharmacological interventions were implemented for 2 of 7 residents (Residents 45 and 8) reviewed for bowel managment. This failure placed the residents at risk for discomfort, constipation, and a decreased quality of life. Findings included . The Bowel Disorders-Clinical Protocol policy, revised September 2017, stated, the physician will identify and order pertinent cause-specific and symptomatic interventions 1) Resident 45 admitted to the facility on [DATE] with a diagnosis of wedge compression fracture (occurs when the front of a bone in the spine collapses, giving it a wedge shape) requiring pain medication. The admission Minimum Data Set (MDS), an assessment tool, dated 12/19/2024, showed Resident 45 was cognitively intact and needed limited to moderate assistance with activities of daily living. On 01/08/2025 at 10:35 AM, Resident 45 said they had a pain contract for chronic (long term) pain management.…

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 precautions were followed prior to administering enteral (tube feeding) nutrition for 1 of 1 resident (Resident 105 ) reviewed for enteral nutrition. The failure to validate enteral tube placement and to check gastric residuals (food, liquid, or material from a previous feeding left in the stomach at the start of the next feeding) placed residents at risk for increased abdominal distention, reflux (stomach acid coming up from the stomach into the esophagus), aspiration, respiratory compromise and other potential adverse outcomes. Findings included . Review of the facility's Enteral Feedings - Safety Precautions policy, revised May 2014, showed licensed staff were directed to: check enteral tube placement prior to each feeding and administration of medication; check gastric residual every 6-8 hours after a resident's target feeding volume and rate have been established; and document all assessments, findings, 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 obtain physician orders for continuous positive airway pressure (CPAP) machine settings and oxygen orders for use including label/date, oxygen tubing/supplies and nasal cannula (NC, flexible tubing that sits inside the nose and delivers oxygen) for 2 of 5 sampled residents (Resident 21 & 40) reviewed for respiratory care. This failure placed the residents at risk for unmet care needs, respiratory infections, and a diminished quality of life. Findings included . 1) Resident 21 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS, an assessment tool), dated 12/09/2024, documented Resident 21 was cognitively intact. On 01/08/2025 at 9:34 AM, Resident 103 was observed wearing a NC. The oxygen concentrator was set at 2.5 liters per minute. The oxygen tubing had no date or labeling. Review of the Electronic Health Record (EHR) provided no physician's order for the use of oxygen, no setting and no cleaning 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 that 1 of 3 sampled residents (Resident 30) received foods that accommodated the residents' preferences and allergies. This failure placed residents at risk for meal dissatisfaction, allergic reaction, and a diminished quality of life. Findings included . Resident 30 was admitted to the facility on [DATE]. The 5-Day Minimum Data Set (MDS, dated [DATE]) documented Resident 30 was cognitively intact. On 01/07/2025 at 10:35 AM, Resident 30 said the food did not taste good and there was no taste to the food. Resident 30 said the dietitian would visit them, take their food preferences and then nothing would happen. Resident 30 said the dietitian had visited them at least three times since their admission and they were still getting items on the meal tray they should not have. Resident 30 said they did not like beef and had requested a substitution, but they continued to receive beef with meals. Resident 30 said she was diabetic 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 interview and record review, the facility failed to thoroughly investigate allegations of abuse, neglect, and accident hazards for 4 of 5 residents (1, 2, 3, & 4) reviewed for abuse, neglect and accidents. The failure to thoroughly investigate an allegation of staff to resident mistreatment, identify the alleged perpetrator (AP), and implement interventions to ensure the alleged victims (AV) and other residents' safety, placed residents at risk for continued abuse/neglect, psychosocial harm, accident risk, and decreased quality of life. Findings included . <Resident 1> Resident 1 was admitted to the facility on [DATE] with diagnoses of major depressive disorder, bipolar disorder (mental illness that can cause unusual shifts in mood, energy, activity levels, and concentration), and heart failure. The quarterly Minimum Data Set (MDS), dated [DATE], documented Resident 1 has severe cognitive impairment. Resident 1 required partial to moderate assistance from staff with activities of daily living (ADLs).…

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 Intravenous (IV) access devices were assessed and monitored in accordance with professional standards of practice for 3 of 3 residents (Residents 40, 206 and 46) reviewed for IV therapy. The facility failed to provide Peripherally Inserted Central Catheter (PICC/ a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart) care, maintenance and monitoring to include changing needleless injection caps, flushes, dressing changes, monitoring the external length to verify the line had not migrated, and monitoring insertion site for signs and symptoms of infection. These failures placed residents at risk for loss of vascular access, infection, and other potential negative outcomes. Findings included . Review of the facility's undated Central Venous Access Device (CVAD) Dressing Change policy showed staff must measure the upper arm circumference and external length of PICCs as part…

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 a baseline care plan (CP), within 48 hours of admission, that provided the minimum healthcare information necessary to meet the immediate care needs for 2 of 15 residents (Residents 206 & 102) reviewed for care planning. This failure placed the residents at risk for medical complications and unmet care needs. Findings included . 1) Resident 102 admitted to the facility on [DATE]. Review of the 12/31/2023 admission Minimum Data Set (MDS, an assessment tool), showed the resident was cognitively intact, had a diagnoses of heart and lung disease with acute respiratory failure and obstructive sleep apnea, and required non-invasive mechanical ventilation utilizing a continuous positive airway pressure machine (CPAP). Review of Resident 102's physician's orders, dated 12/27/2023, documented for a suction machine to be placed at the at the resident's bedside, for use of a CPAP machine when napping and at bedtime, fuerosemide (a diuretic medication)…

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 services provided met professional standards of practice for 3 of 21 sampled residents (Residents 34, 102 and 40) reviewed. The failure to follow, obtain, and/or clarify incomplete physicians' orders when indicated, and to only sign for those tasks completed, placed residents at risk for medication errors and unmet care needs. Findings included . 1) Resident 34 admitted to the facility on [DATE]. Review of their current physician orders showed a 12/14/2023 order for tamsulosin daily for benign prostatic hyperplasia (BPH/enlarged prostate), hold the medication for a systolic blood pressure (SBP) less than 110 or a pulse (P) less than 60. Review of Resident 34's November and December 2023 and January 2024 Medication Administration Records (MARs), showed facility nurses administered the resident's tamsulosin with a SBP less than 110, instead of holding the medication as ordered on the following occasions: November 2023: 11/04/2023…

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 1 of 1 resident (Resident 102) reviewed for respiratory care and services, was provided such care, in accordance with professional standards of practice. The failure to obtain the prescribed pressure settings for resident's continuous positive airway pressure (CPAP/an external device that provides a fixed pressure to keep breathing airways open while you sleep) machine, precluded staff from validating the CPAP was correctly programmed and the resident received the amount of positive airway pressure they had been assessed to require. This failure placed residents at risk for ineffective assisted ventilation and unmet respiratory needs. Findings included . Review of the facility's CPAP/BiPAP Support policy, revised March 2015, showed prior to application of a resident's CPAP, staff were to review the physician's order to determine the prescribed positive end-expiratory pressure (PEEP) for the machine. Nursing staff would then explain the…

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

Based on observation and interview, the facility failed to ensure drugs and biologicals were labeled and dated in accordance with accepted professional standards of practice, and that expired medications were discarded for 2 of 2 (South cart and [NAME] cart) medication carts observed. These failures placed residents at risk to receive expired medications and negative health outcomes. Findings included . <West Medication Cart> Observation of the [NAME] medication cart on 01/12/2024 at 7:17 AM, with Staff D, Assistant Director of Nursing (ADON), revealed the following expired and/or undated medications: 1) A bottle of magnesium gluconate (supplement) 27 milligram (mg) with a use by date of 12/31/2023. 2) Resident 30's fluticasone propionate diskus (a steroid), was opened and undated. Review of the fluticasone propionate diskus package insert showed the medication should be discarded six weeks after the foil pouch is opened or when the counter reads zero, whichever comes first. Staff D, ADON, was present and confirmed Resident 30's fluticasone propionate diskus was opened and undated.…

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 assess, monitor and implement interventions to mitigate worsening of a non-pressure skin issue for 1 of 4 sampled residents (Resident 1) reviewed for quality of care related to skin and wound management. This failure placed residents at risk for unidentified wound decline, infection, and diminished quality of life. Findings included . Review of the facility's wound care policy, revised October 2010, showed when a wound was inspected it was to be assessed for wound bed color, size and drainage and this information documented in the resident's medical record. Resident 1 was admitted to the facility on [DATE] with diagnosis including a contusion (bruise) to the resident's left knee. The admission Minimum Data Set (MDS), an assessment tool, dated 06/30/2023, documented the resident was cognitively intact. The admission skin assessment, dated 06/27/2023, documented the resident had purple discoloration and swelling to the left knee and the bruising went…

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.