Meadowbrook at Appleton

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not ensure 2 residents (R) (R35 and R4) of 2 sampled residents who were fed via enteral feeding (a way of sending nutrition right to the stomach or small intestine via tube) received care and services to avoid complications.On 7/21/25, Registered Nurse (RN)-C did not check for placement or residual prior to administering medication and enteral feeding to R35 .On 7/21/25 Licensed Practical Nurse (LPN)-H did not check placement or residual prior to administering medication to R4. Findings include: The facility's Enteral Feeding and Medication Administration Policy, dated March 2020, indicates: .Registered Nurse (RN)/Licensed Practical Nurse (LPN) will administer nutrition and medication through nasogastric, gastrostomy, or jejunostomy tube upon order of physician to provide nutrition and hydration for residents with compromised nutritional status or inability to consume oral intake .3. Check for proper placement prior to each…

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, staff and resident interview, and record review, the facility did not ensure effective pain management was provided for 1 resident (R) (R5) of 2 sampled residents.R5 had an order for a Fentanyl patch for pain to be changed every three days. During observations on 7/21/25 and 7/22/25, R5's Fentanyl patch was dated 7/17/25. R5 stated R5 felt achy and had difficulty sleeping. Findings include:The facility's Pain Management policy, revised 10/2024, states the facility will develop and implement a care plan for pain management. The goal of the pain management system is to effectively and consistently identify and treat pain .Staff should be proactive to address the resident's pain to aid in achieving relief. Evaluation of pain, implementation of interventions, and communicating with the care team regarding pain management strategies are important components of a successful pain management system .Nursing staff are to administer pain medications as ordered and observe for effectiveness. From…

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, staff interview, and record review, the facility did not ensure transmission-based precautions (TBP) were implemented for 1 resident (R) (R52) of 2 residents with a diagnosis of a transmittable infection.R52 had diagnoses of sepsis and pneumonia and was placed on droplet precautions. Staff did not don the appropriate personal protective equipment (PPE) when entering R52's room on 7/21/25 and 7/22/25. Findings include:The facility's Isolation Precautions policy, revised 3/2020, indicates: To establish transmission-based precautions for residents who are suspected or confirmed to have communicable diseases/infections that can be transmitted to others. Transmission- based precautions will be used when transmission cannot be reasonably prevented by standard precautions alone .Droplet precautions .prior to entering the isolation room, the following steps are required: Perform hand-hygiene and apply gloves and mask prior to entering the room, while providing direct resident care, remove gloves…

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, staff and resident interview, and record review, the facility did not ensure they completed regular pest control which affected 1 resident (R) (R30) of 17 sampled residents.R30 indicated there were fruit flies in R30's room and R30 had a bug bite on the right hand. The facility did not ensure they completed regular pest control.Findings include:On 7/21/25, Surveyor reviewed R30's medical record. R30 was admitted to the facility on [DATE] and had diagnoses including deep vein thrombosis/pulmonary embolism secondary to factor V Leiden mutation on Xarelto, chronic diastolic congestive heart failure, chronic obstructive pulmonary disease (COPD), and morbid obesity. R30's Minimum Data Set (MDS) assessment, dated 6/9/25, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R30 had intact cognition. A progress note, dated 7/21/25 at 9:24 AM, indicated the writer updated the Nurse Practitioner (NP) that R30 had a new bug bite on the right hand and had a previous bug…

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, staff and resident interview, and record review, the facility did not ensure 4 residents (R) (R7, R12, R15, and R17) of 19 sampled residents were provided safe administration of drugs and biologicals. On 6/24/25, Surveyor observed an albuterol inhaler and a vial of DuoNeb solution on R7's bedside table. Surveyor also observed a nebulizer on the nightstand that contained a full chamber of solution. R7 did not have a physician's order or self-administration of medication assessment that indicated R7 could self-administer medication. On 6/24/25, Surveyor observed a 1 ounce bottle of Afrin nasal spray on R12's nightstand. R12 did not have a physician's order for Afrin nasal spray or a self-administration of medication assessment that indicated R12 could self-administer medication or store medication at the bedside. On 6/24/25, Surveyor observed an albuterol inhaler on R15's bedside table. R15 did not have a physician's order or a self-administration of medication assessment indicated R15 could…

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.

2. The 2022 Federal Food and Drug (FDA) Food Code documents at 5-501.113 Covering Receptacles: Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered: .(B) With tight-fitting lids or doors if kept outside the food establishment . On 6/24/25 at 7:33 AM, Surveyor conducted an environmental tour of the facility and noted a garbage dumpster in the rear parking lot was open on top and in the back. On 6/24/25 at 2:38 PM, Surveyor observed multiple pieces of discarded furniture near the dumpster in the rear parking lot and noted the top of the dumpster was still open. On 6/25/25 at 8:25 AM, Surveyor observed multiple pieces of discarded furniture near the dumpster in the rear parking lot and noted the top of the dumpster was still open. Surveyor observed Dietary Aide (DA)-D throw boxes in the recycling dumpster and walk back into the building without closing the lid of the dumpster that contained garbage. Based on observation, staff interview, and record review, the facility did not provide a safe, sanitary, and comfortable environment 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 staff interview and record review, the facility did not ensure Informed Consent for Medication forms were signed or verbal consent was obtained prior to administering psychotropic medication for 1 resident (R) (R6) of 1 sampled resident. R6 was administered psychotropic medication without written or verbal consent from R6's Power of Attorney for Healthcare (POAHC). Findings include: The facility's Psychotropic Management policy, revised July 2020, indicates: .1. Upon receipt of new orders for psychotropic medication, the licensed nurse will implement the following: .B. Complete the appropriate psychotropic medication consent form; Consents for psychoactive medications must be obtained by the physician if state regulation requires it. C. Education of the resident and/or the resident representative is conducted to communicate the risks and benefits of the medication. Per the facility's Psychotropic Management System flow chart step 3 .Nurse/physician completes informed consent and education with 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 staff interview and record review, the facility did not ensure a allegation of misappropriation was thoroughly investigated for 1 resident (R) (R3) of 1 sampled resident. On 5/16/25, R3 reported to the facility that R3 was a missing a blue jacket worth $75. The facility did not provide staff education on misappropriation of resident property or documenting residents' personal property upon admission despite the fact education was listed as an immediate and ongoing intervention in the facility's investigation. Findings include: The facility's Missing Resident Belongings policy, dated 3/2021, indicates: Synergy Senior Care seeks to ensure residents' belongings are protected from loss/theft. Every effort to ensure that missing items are located will be made .1. Missing belongings will be reported to all departments by residents, families, and nursing staff. 2. Staff should promptly fill out a concern form to identify missing item(s). The form should include follow-up and conclusion to be communicated to the resident or responsible party. 3. Social Services will assist 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, staff and resident interview, and record review, the facility did not ensure staff provided activities of daily living (ADLs) in accordance with preferences for 1 resident (R) (R13) of 19 sampled residents. R13 was dependent on staff for oral care, pericare, and personal hygiene and filed a grievance on 5/26/25 regarding the provision of timely care. The grievance indicated the issue was resolved, however, staff continued to not provide care in a timely manner or at R13's preferred time of day. Findings include: The facility's Routine Resident Care policy, revised May 2020, indicates: Residents receive the necessary assistance to maintain good grooming and personal/oral hygiene .3. Daily personal hygiene minimally includes assisting or encouraging residents with washing their faces and hands, combing their hair each morning, and brushing their teeth and/or providing denture care .Incontinence care is provided timely according to each resident's needs .9. Residents' call lights are answered timely and residents' requests are addressed . From 6/24/25 to 6/25/25,…

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, staff interview, and record review, the facility did not ensure the appropriate care and treatment was provided for a peripherally inserted central catheter (PICC) line for 1 resident (R) (R4) of 5 sampled residents. R4 had a PICC line. Staff did not complete a PICC line dressing change as ordered and in accordance with the facility's policy. Findings include: The facility's PICC/Central Vascular Access Device Dressing Change policy, revised 5/1/25, indicates: .To provide consistent guidance to licensed nursing staff in regards to changing PICC/Central access device (CVAD) dressings weekly or if soiled or not intact. Guidelines in this policy are to ensure that appropriate standards of care are followed to decrease the potential for infection .Catheter insertion site is a high-risk for bacteria to enter and could cause a catheter-related infection if not cared for and monitored correctly .2. Dressing changes to be done: a. Upon admission unless current dressing is clean, dry, and intact 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, staff interview, and record review, the facility did not provide the necessary respiratory care and services for 1 resident (R) (R16) of 19 sampled residents. R16's bilevel positive airway presure (BiPAP) machine and equipment were not properly cleaned or cared for in accordance with the facility's policy. Findings include: The facility's CPAP-BiPAP Use policy, revised October 2020, indicates: .6. The continuous positive airway pressure (CPAP)/BiPAP mask, tubing, and humidifiers shall be cleansed weekly with soap and water and rinsed thoroughly unless otherwise specified by the physician or respiratory therapist. 7. If a humidifier is in use, the water will be discarded and replaced daily with fresh distilled water. From 6/24/25 to 6/25/25, Surveyor reviewed R16's medical record. R16 was admitted to the facility on [DATE] and had diagnoses including heart failure, asthma, obstructive sleep apnea, chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypercapnia,…

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, staff interview, and record review, the facility did not ensure food was prepared in a form designed to meet the requirements of a mechanical soft diet for 1 resident (R) (R8) of 1 sampled resident. R8 had an order for a mechanical soft diet (smaller than bite-sized pieces/chopped). On 6/24/25, R8's lunch tray was delivered to the unit with regular texture roast beef. Findings include: www.iddsi.org Level 5 Minced & Moist Food for Adults (formerly known as mechanical soft diet) indicates minced and moist food texture consists of soft and moist but with no liquid leaking/dripping from the food. Biting is not required. Minimal chewing is required lumps of 4 millimeter (mm) in size which can be mashed with the tongue. Food can be easily mashed with a little pressure from a fork and should be able to be scooped onto a fork with no liquid dripping and no crumbles falling off the fork Level 5 Minced & Moist food may be used if you are not able to bite off pieces of food safely but have some basic chewing ability. Some people may be able to bite off a large piece 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 staff interview and record review, the facility did not ensure a grievance was documented, thoroughly investigated, or resolved for 1 resident (R) (R4) of 9 sampled residents. R4's legal representative expressed concerns following R4's respite stay at the facility. The facility did not appropriately document, investigate, or thoroughly resolve the grievance. Findings include: The facility's Company Concerns Policy, dated October 2020, states it is the policy of the facility to provide a system whereby residents, and/or their significant others or representatives, can voice concerns about the quality of services received at the facility. The facility will designate a Concern Officer who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusion .The facility will maintain evidence demonstrating the results of all concerns for a period of no less than 3 years from the issuance of the grievance decision .6. All concerns receive immediate priority 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 staff interview and record review, the facility did not designate a person to serve as the director of food and nutrition services who was a certified dietary manager, a certified food service manager, had a national certification for food service management and safety from a national certifying body, or who had an associate's or higher level degree in food service management or hospitality. This practice has the potential to affect all 46 residents residing in the facility. Dietary Manager (DM)-C did not complete an approved dietary manager or food service manager certification course or other related education. Findings include: During a continuous kitchen observation that began at 7:15 AM on 1/21/25, Surveyor interviewed DM-C who stated DM-C was hired as a Dietary Aide in 2021 and was promoted to Dietary Manager in April of 2024. DM-C did not indicate that DM-C had any experience or training prior to employment in the facility. DM-C indicated DM-C worked with Nursing Home Administrator (NHA)-A and Regional Dietitian (RD)-E to get certified, however, DM-C had to file 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.

Based on observation, staff and resident interview, and record review, the facility did not ensure nutritional needs were met for 5 residents (R) (R1, R4, R5, R8, and R9) of 5 residents. This practice had the potential to affect multiple other residents in the facility. R1, R4, R5, R8, and R9 were ordered carbohydrate-controlled diets. R1, R4, R5, R8, and R9's meal tickets did not contain diet modifications and the residents were served regular diet portions of dessert. In addition, dietary staff did not serve residents recommended portion sizes for all diet types. Finding include: The facility's Diet Orders policy, revised January 2021, indicates: Therapeutic diets are prescribed by the attending physician. Diet order terminology that is consistent with the list of available therapeutic diets in the diet Manual facilitates serving meals that meet the nutritional and therapeutic needs of the patients. Diets not available on the menu are developed by the Registered Dietitian .8. When physician orders for portion size changes are necessary, it is suggested that they be as specific as…

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 staff interview and record review, the facility did not ensure neurological checks were completed per the facility's policy after a fall for 1 resident (R) (R1) of 1 sampled resident. Staff did not consistently complete neurological checks after R1 fell on 8/12/24 and 9/8/24. Findings include: The facility's Fall Management policy, revised July 2020, indicates: In the event a resident has a fall and it has been determined they hit their head, or it cannot be determined if they hit their head (i.e., the fall was unwitnessed or the patient cannot verbalize if they hit their head), the nurse initiates the following actions: .2. Neurological checks are completed and documented per instructions. Neurochecks should be completed per the facility's Neuro Check Assessment Form which indicates: Initial, every 15 minutes for 1 hour (4), every 30 minutes for 1 hour (2), every 1 hour for 4 hours (4), every 4 hours for 24 hours (6) and every shift until 72 hours (5). On 10/24/24, Surveyor reviewed R1's medical…

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, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 40 residents residing in the facility. The facility did not have a system for monitoring cooked food temperatures or hot/cold holding temperatures. Staff did not practice safe food handling by donning hair and beard restraints while cooking and serving food. Findings include: Cooked and Hot/Cold Holding Temperatures: The facility's Food Temperature Record policy, with a revision date of February 2020, indicates: To ensure that foods and beverage are held and served at temperatures which comply with state and federal regulations. Each resident receives and the facility provides food that is palatable and at the proper temperature. Time and temperature control foods such as meat, poultry, fish, and eggs should be cooked to the minimum temperature specified below: Pork, beef, or veal - 145 degrees Fahrenheit (F) for 15 seconds Poultry - 165 degrees F for 15 seconds Fish - 145 degrees F for 15 seconds…

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 staff interview and record review, the facility did not ensure the individual designated as the food and nutritional services director met the minimum qualifications for the role. This had the potential to affect 47 of 48 residents residing in the facility. Dietary Manager (DM)-G did not complete an approved dietary manager or food service manager certification course or other related education. Findings include: On 5/6/24 at 8:40 AM, Surveyor interviewed DM-G who stated DM-G was hired as a Dietary Aide 3 years ago and was promoted to Dietary Manager a little over a month ago. DM-G did not indicate DM-G had any prior experience or training. DM-G stated DM-G was working with Nursing Home Administrator (NHA)-A and Regional Dietitian (RD)-P to get certified but was not enrolled and had not started a certification program. DM-G stated RD-P was in the building monthly and was available via email or phone. On 5/6/24 at 3:05 PM, Surveyor interviewed NHA-A who stated NHA-A was aware DM-G was not certified or enrolled in a certified training program. NHA-A stated RD-P and NHA-A have…

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, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect 47 of 48 residents residing in the facility. Staff did not monitor or document food cooling temperatures. The handwashing sink did not reach the required minimum temperature for proper hand hygiene. A can opener was not properly cleaned. Staff left visibly soiled oven mitts on top of condiment containers. Chemicals used for cleaning were stored by food containers and near food preparation areas. On two occasions, three resident room trays were delivered to the floor uncovered and on top of the food cart. Staff did not test or document parts per million (PPM) of the quaternary sanitizing solution per manufacturer's instructions. Seven food items were not dated when opened, not discarded when beyond the use-by/expiration date, and/or not stored appropriately. Findings include: The facility's Storage, Prepare, Distribute and Serve Food policy, dated April 2020, indicates the facility follows the Federal Food…

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 staff interview and record review, the facility did not ensure a staff person designated as the Infection Preventionist (IP) completed specialized training in infection prevention and control. This practice had the potential to affect all 48 residents residing in the facility. Director of Nursing (DON)-B was the facility's designated IP. DON-B did not complete specialized training for infection prevention and control. Findings include: On 5/7/24 at 1:20 PM, Surveyor interviewed DON-B who was the facility's designated IP. When Surveyor asked if DON-B completed specialized infection prevention and control training as required by the Centers for Medicare & Medicaid Services (CMS), DON-B stated DON-B completed the Centers for Disease Control and Prevention (CDC) training modules but did not pass the certification test and could not retake the test until 2025. DON-B stated the facility hired an Assistant Director of Nursing (ADON) who would eventually become the IP, however, the ADON had not started the position yet. On 5/13/24 at 1:28 PM, Regional Consultant (RC)-M provided 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 staff and resident interview and record review, the facility did not ensure 1 resident (R) (R25) of 14 sampled residents was offered the opportunity to create or obtain Power of Attorney for Health Care (POAHC) paperwork. R25 was admitted to the facility on [DATE]. The facility did not obtain R25's POAHC document or offer R25 the chance to fill out a new document prior to 5/7/24. Findings include: The facility's Advanced Directive policy and procedure, dated October 2020, indicates: The resident has a right to accept or refuse medical or surgical treatment and to formulate an advance directive in accordance with state and federal law .Purpose: To help ensure a resident's right to formulate an advanced directive .Procedure: .2. The facility will inquire at the time of admission whether the resident has previously executed an advance directive. 3. If a resident has executed an advance directive, the facility must obtain a copy from the resident or the legal representative which is stored in the resident'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 staff interview and record review, the facility did not notify a Power of Attorney for Healthcare (POAHC) for when 1 resident (R) (R34) of 14 sampled residents experienced a change in condition. The facility did not notify R34's POAHC following a fall on 5/1/24. Findings include: The facility's Fall Management policy, dated July 2020, indicates when a fall occurs, it is the responsibility of the nurse to communicate the fall to the attending physician and the resident's representative, and document the notification on the Interdisciplinary Post Fall Review report. The nurse will discuss recommended interventions to reduce or prevent further falls with the resident and/or the resident representative. 1. From 5/6/24 to 5/8/24, Surveyor reviewed R34's medical record. R34 was admitted to the facility on [DATE] with diagnoses including Parkinsonism, muscle wasting and atrophy, unspecified severe protein-calorie malnutrition, and altered mental status. R34's Minimum Data Set (MDS) assessment, dated 4/20/24,…

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 staff interview and record review, the facility did not ensure 2 residents (R) (R145 and R32) of 2 residents reviewed for hospitalization received a transfer notice that included the date of the transfer, the reason for the transfer, the location of the transfer, and appeal rights. R145 was transferred to the hospital on 4/18/24 and was not provided with a written transfer notice. R32 was transferred to the hospital on 3/10/24. R32 and/or R32's legal representative were not provided with a written transfer notice. Findings include: The facility's Bedhold Notification policy, dated March 2021, includes a sample letter Notice of Transfer that states the reason for the resident's transfer and their right to appeal. 1. From 5/6/24 to 5/8/24, Surveyor reviewed R145's medical record. R145's latest admission to the facility was on 4/25/24. R145 had diagnoses including heart failure, morbid obesity with alveolar hypoventilation (a condition where the lungs do not get enough air which causes high levels 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 staff interview and record review, the facility did not ensure 2 residents (R) (R145 and R32) of 2 residents reviewed for hospitalization received notification of the facility's bed hold policy when they were transferred to the hospital. R145 was transferred to the hospital following a fall on 4/18/24. R145 was not provided written notice of the facility's bed hold policy. R32 was transferred to the hospital on 3/10/24. R32 was not provided written notice of the facility's bed hold policy. Findings include: The facility's Bedhold Notification policy, dated March 2021, states when a resident is transferred to the hospital, the facility will provide written notice to the resident and/or resident's representative regarding the resident's bed hold rights and the facility's bed hold policy. 1. From 5/6/24 to 5/8/24, Surveyor reviewed R145's medical record. R145's latest admission to the facility was on 4/25/24. R145 had diagnoses including heart failure, morbid obesity with alveolar hypoventilation (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 staff interview and record review, the facility did not ensure a comprehensive assessment was completed after a significant change in condition for 1 resident (R) (R8) of 14 sampled residents. R8 started Hospice services on 3/13/24. The facility did not complete comprehensive assessment for a significant change in condition. Findings include: The Centers for Medicare & Medicaid Service's (CMS's) Resident Assessment Instrument (RAI) Version 3.0 Manual, dated October 2023, indicates: OBRA-required comprehensive assessments include the completion of both the Minimum Data Set (MDS) and the Care Area Assessment (CAA) process, as well as care planning. Comprehensive assessments are completed upon admission, annually, and when a significant change in a resident's status has occurred or a significant correction to a prior comprehensive assessment is required . On 5/6/24, Surveyor reviewed R8's medical record. R8 was admitted to the facility on [DATE] with diagnoses including dementia, diabetes, and coronary…

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 staff interview and record review, the facility did not develop a baseline care plan that included the minimum healthcare information necessary to properly care for 1 resident (R) (R149) of 14 sampled residents. R149's baseline care plan did not include information related to R149's dialysis, diet, and smoking status. Findings include: The facility's Baseline Care Plan (BCP) policy, revised February 2021, indicates: Each resident will have a baseline care plan developed within 48 hours of admission that addresses identified risk areas and the resident's initial individual needs .The BCP documents and communicates the resident's initial needs until the comprehensive care plan is finalized .Procedure: 1) The admitting nurse will perform an initial nursing assessment of the resident and gather specific information from the following sources: physician orders, diet, therapy, medications, activity limitations, treatments, and social services .4) The BCP includes the following key elements: Initial goals…

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 staff interview and record review, the facility did not ensure a comprehensive care plan was developed and implemented for 1 resident (R) (R8) of 14 sampled residents. R8 started Hospice services on 3/13/24. The facility did not develop a care plan to address R8's Hospice care. In addition, R8 did not have an order for Hospice prior to 5/8/24 Findings include: On 5/6/24, Surveyor reviewed R8's medical record. R8 was admitted to the facility on [DATE] with diagnoses including dementia, diabetes, and coronary heart disease. R8 began Hospice care on 3/13/24. On 5/6/24 at 2:26 PM, Surveyor interviewed Power of Attorney for Healthcare (POAHC)-Q via telephone who stated R8 started Hospice care in March of 2024. On 5/7/24, Surveyor reviewed R8's medical record and noted R8 did not have a care plan for Hospice or an order for Hospice care. On 5/8/24 at 10:19 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated staff should obtain a referral from the Hospice provider, obtain an order from 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 observation, staff interview, and record review, the facility did not ensure 2 residents (R) (R33 and R4) of 2 residents reviewed for pressure injuries received the necessary care and services to promote healing. R33 had an order to remove R33's wound vac on 3/13/24 and reapply the wound vac on 3/20/24. On 3/20/24, the order was changed to reapply the wound vac on 3/27/24. The facility did not reorder wound vac supplies in a timely manner and the wound vac was not reapplied until 4/10/24. R4 had a pressure injury on the coccyx and an order to cleanse the wound with Vanshe wound cleanser. During an observation of wound care on 5/8/24, staff did not use Vanshe cleanser during R4's dressing change and stated the facility was out of the cleanser. Findings include: The facility's Dressing Change policy, with a revision date of 3/2020, indicates staff should prevent wound contamination and promote healing and complete dressing changes per physician orders. 1. On 5/6/24, Surveyor reviewed R33's medical record.…

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 staff interview and record review, the facility did not provide adequate monitoring post fall for 1 resident (R) (R34) of 2 residents reviewed for falls. The facility did not complete neurological checks per their policy after R34's unwitnessed falls on 9/21/23 and 10/21/23. Findings include: The facility's Fall Management policy, dated July 2020, indicates: In the event a resident has a fall and it is determined that they hit their head, or it cannot be determined if they hit their head, such as an unwitnessed fall, the nurse initiates neurological checks (an assessment used to monitor and detect possibility of head injury), and documents the checks. The facility's Neuro Check Assessment Form, copyright 2023, indicates nurses should complete neurochecks every 15 minutes for the first hour following the fall, then every 30 minutes for an hour, every hour for 4 hours, every 4 hours for 24 hours and then once per shift until 72 hours post fall. Neurochecks should include the resident's vital signs, level…

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, record review, and staff interview, the facility did not ensure respiratory equipment was routinely cleaned for 2 residents (R) (R145 and R156) of 2 sampled residents. Staff did not clean R145 and R156's continuous positive airway pressure (CPAP) equipment and did not change R145 and R156's oxygen tubing per the facility's policy. Findings include: The facility's CPAP-BiPAP (Bilevel Positive Airway Pressure) Use policy, dated October 2020, indicates: Residents using CPAP/BiPAP will require a physician order to include approved order setting, duration of use, use of humidifier, if necessary, and a supporting diagnosis .6) The CPAP/BiPAP mask, tubing, and humidifiers shall be cleaned weekly with soap and water and rinsed thoroughly, unless otherwise specified by the physician or respiratory therapist. 7) If a humidifier is in use, the water will be discarded and replaced daily with fresh distilled water. The facility's Liquid Oxygen Use policy, dated October 2020, indicates: 3) Cleaning 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 staff interview and record review, the facility did not ensure ongoing communication and collaboration with the dialysis center for 1 resident (R) (R17) of 2 resident reviewed for dialysis services. R17 received peritoneal dialysis daily at the facility and had an order for daily weights. R17's daily weight was not obtained on 8 out of 38 days. In addition, R17's physician orders were not clarified and the physician was not notified of weight increases above the specified parameters. Findings include: The facility's Peritoneal Dialysis policy dated March 2023, indicates: .15. Before, during and after receiving peritoneal dialysis, facility staff must, based on the physician's orders and professional standards of practice, do the following: a. Obtain vital signs, weights, assess the resident's stability, level of consciousness, and comfort or distress; b. Monitor for post-dialysis complications and symptoms such as, but not limited to dizziness, nausea, fatigue, or hypotension; . On 5/8/24, Surveyor…

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 staff interview and record review, the facility did not ensure a physician order was transcribed for 1 resident (R) (R4) of 5 sampled residents. R4's hospital discharge paperwork, dated 4/4/24, contained an order for emergency administration of diazepam (an anxiolytic and sedative medication) during a seizure lasting longer than three minutes. The order was not transcribed in R4's medical record. Findings include: The facility's Physician Orders policy, with a revision date of March 2020, indicates: Physician orders are obtained to provide clear direction regarding the care of the resident .Orders given by a physician or state permitted health care professional must be accepted by a licensed nurse and documented in the resident's medical record .Transcribing a written/faxed order .Once the order is verified, the receiving licensed nurse documents the word noted next to the written order along with his or her signature with title and date .after noting an order, the receiving licensed nurse enters the order into the electronic medical record and ensures it is active in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure medication regimens were reviewed monthly and pharmacy recommendations were reviewed and acted upon by a physician for 1 resident (R) (R32) of 5 sampled residents. A monthly medication regimen review (MRR) was not completed for R32 in September 2023, October 2023, November 2023, December 2023, January 2024, and March 2024. In addition, pharmacy recommendations for April 2024 were not acted upon or reviewed by R32's physician. Findings include: From 5/6/24 to 5/8/24, Surveyor reviewed R32's medical record. R32 was admitted to the facility on [DATE] with diagnoses including neoplasm of uncertain behavior of brain, moderate persistent asthma with (acute) exacerbation, acute respiratory failure with hypoxia, and acute on chronic diastolic (congestive) heart failure. R32's Minimum Data Set (MDS) assessment, dated 4/7/24, contained a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R32 had intact cognition. R32 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, staff interview, and record review, the facility did not ensure 2 residents (R) (R15 and R4) of 2 residents were provided services to help prevent the transmission of infection. R15 had an order for droplet precautions pending further testing related to respiratory concerns. On 5/8/24, Surveyor observed Certified Nursing Assistant (CNA)-I assist R15's roommate (R4) with a room tray. CNA-I did not wear personal protective equipment (PPE) in the room. During an observation of wound care on 5/8/24, Registered Nurse (RN)-H reached beneath RN-H's gown to obtain a flashlight and scissors from RN-H's pocket. Without disinfecting the scissors, RN-H used the scissors to cut a dressing used to pack R4's wound. Findings include: The Centers for Disease Control and Prevention (CDC) guideline for PPE indicate: PPE, e.g., gloves, gowns, face masks, respirators, goggles and face shields, can be effective barriers to transmission of infections . The CDC guidelines at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure influenza B and pneumococcal vaccinations were reviewed, offered, and administered for 3 residents (R) (R8, R2, and R4) of 5 sampled residents. The facility did not review R8's vaccination history or offer R8 the PCV20 (Prevnar 20®) and influenza B vaccines. The facility did not review R2's vaccination history or offer R2 the Prevnar 20® and influenza B vaccines. The facility did not review R4's vaccination history or offer R4 the Prevnar 20® vaccine. Findings include: Abbreviations (www.cdc.gov): PCV13: 13-valent pneumococcal conjugate vaccine (Prevnar13®) PCV20: 20-valent pneumococcal conjugate vaccine (Prevnar 20®) PPSV23: 23-valent pneumococcal polysaccharide vaccine (Pneumovax23®) The most recent Centers for Disease Control and Prevention (CDC) recommendations for pneumococcal vaccinations indicate: For adults 65 years or older who have only received PPSV23, the CDC recommends: Give 1 dose of PCV15 or PCV20. The PCV20 dose should be…

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 staff interview and record review, the facility did not ensure medical records contained documentation related to COVID-19 immunization for 3 residents (R) (R19, R2, and R7) of 5 sampled residents. In addition, the facility did not implement a COVID-19 immunization program for staff. R19, R2, and R7's medical records did not include documentation that indicated the facility offered or administered COVID-19 immunizations. The facility did not have proof of a COVID-19 immunization program for staff. Findings include: The facility's COVID-19 Vaccination policy, effective January 2024, indicates: It is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complications from COVID-19 (SARS-CoV-2) by educating and offering our residents and staff the COVID-19 vaccine .COVID-19 vaccinations will be offered to residents when supplies are available, as per Centers for Disease Control and Prevention (CDC) and/or Food and Drug Administration (FDA) guidelines unless such…

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 staff interview and record review, the facility did not provide treatment and care in accordance with professional standards of practice for 1 Resident (R) (R1) of 3 sampled residents. R1 received two different narcotic pain medications together multiple times between 1/13/24 and 1/22/24 which affected R1's mentation. Findings include: The facility's Pain Management policy, with a revision date of July 2020, indicates: .Guiding Principles .4. When medication is indicated, the goal should be to provide satisfactory pain relief by using the lowest possible dose of a medication with the fewest adverse effects . On 3/11/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including fracture of right humerus (bone in upper arm), wedge compression fracture of unspecified vertebra (bone in spine) and osteoarthritis (a type of painful joint disease that results from breakdown of joint cartilage and underlying bone). R1's Minimum Data Set (MDS) assessment, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure adequate supervision to prevent accidents was provided for 1 Resident (R) (R2) of 10 sampled residents. The facility did not reassess R2 for elopement risk or revise R2's care plan after R2 left the faciity on 9/15/23. Findings include: The facility's Elopement policy, dated June 2023, indicates: It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible. All residents will be assessed for behaviors or conditions that put them at risk for wandering/elopement. All residents so identified will have these issues addressed in their individual care plan .All residents shall be reviewed for safety awareness impairment and elopement concerns upon admission, readmission, quarterly, and as needed . On 10/6/23, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses to include hemiplegia (paralysis/immobility on one side of the body) 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, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This had the potential to affect all 40 residents residing in the facility. The facility did not monitor and document food cooling and holding temperatures. Staff did not test quaternary sanitizing solution per manufacturer's instructions. Findings include: During an initial tour of the kitchen on 3/27/23 at 8:50 AM, Dietary Manager (DM)-E stated the facility followed the Wisconsin Food Code. 1. Food Cooling Temperature Requirement The Wisconsin Food Code 2022 documents at section 3-501.14 Cooling. (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 57° Celsius (C) (135° Fahrenheit) (F) to 21° C (70° F); and (2) Within a total of 6 hours from 57° C (135° F) to 5° C (41° F) or less. (B) time/temperature control for safety food shall be cooled within 4 hours to 5° C (41° F) or less. The Wisconsin Food Code 2022 section 3-501.15 documents Cooling Methods. (A) Cooling shall be accomplished in accordance with 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 staff interview and record review, the facility did not establish and maintain an infection control program designed to help prevent the development and transmission of disease and infection. This had the potential to affect all 40 residents residing in the facility. The facility did not conduct continuous infection surveillance including tracking and trending of illnesses, potential infectious agents, and monitoring of staff signs and symptoms of infection or potential infection. The facility did not provide a cover for R23's catheter drainage bag which was observed dragging on the floor from 3/27/23 to 3/29/23. R23 had a history of urinary tract infections (UTIs) and was currently being treated with an antibiotic for a UTI. Findings include: 1. On 3/29/23, Surveyor reviewed the facility's infection control documentation for tracking staff illness. The facility provided Surveyor with staff surveillance for December of 2022. Surveyor noted the facility was in a COVID-19 outbreak during the month of…

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

Based on staff interview and record review, the facility did not have a qualified Infection Preventionist (IP) who completed specialized training in infection prevention and control. This had the potential to affect all 40 residents residing in the facility. Director of Nursing (DON)-B started as the facility's IP in December of 2022; however, DON-B did not complete specialized training for infection prevention and control. DON-B accepted the Director of Nursing role in February of 2023. Assistant Director of Nursing (ADON)-C started at the facility in March of 2023 and assisted with IP duties; however, ADON-C did not complete specialized training for infection prevention and control. Findings include: CMS (Centers for Medicare and Medicaid Services) Ref: QSO-22-19-NH last revised date: June 29, 2022 contains the following information: In 2016, CMS overhauled the Requirements for Participation for Long-Term Care (LTC) facilities (i.e., nursing homes), which was implemented in three phases: Phase 3 - November 28, 2019 .Phase 3 .regulations which require nursing homes to have 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 2. On 3/29/23, Surveyor reviewed R24's medical record. R24 was admitted to the facility on [DATE] with diagnoses to include cardiomyopathy (disease of the heart muscle which makes it difficult for the heart to pump blood to other parts of the body). R24's medical record contained the following physician orders: ~ Apixaban Tablet 5 mg (milligrams) - Give 5 mg by mouth two times a day ~ Hydrocodone-Acetaminophen Tablet 5-325 MG - Give 1 tablet by mouth every 8 hours as needed for pain ~ Furosemide Tablet 40 mg Give 0.5 tablet by mouth one time a day .Give 20 mg daily Surveyor noted R24's care plan did not address R24's need for and use of apixaban, hydrocodone-acetaminophen and furosemide, including monitoring for side effects related to the medications. On 3/29/23 at 12:44 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who verified the high-risk medications should have been addressed on R24's care plan. 3. On 3/29/23, Surveyor reviewed R13's medical record. R13 was admitted to the facility on [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure Pre-admission Screen and Resident Review (PASRR) requirements were met for 2 Residents (R) (R8 and R30) of 13 sampled residents. R8's Level I and Level II PASRR Screens were not completed timely. R30's Level I PASRR Screen was not completed timely. Findings include: The facility's Coordination-Pre-admission Screening and Resident Review (PASRR) policy, with a revision date of March 2021, contained the following information: Purpose .Evaluate individuals seeking admission to nursing facilities and current nursing facility residents to determine if they have a serious mental illness or intellectual disability .The PASRR screening consists of a two-stage identification and evaluation process and is conducted to ensure appropriate placement and treatment for those identified with Serious Mental Illness (SMI) and/or Mental Retardation (MR) .The facility will coordinate assessments with the pre-admission screening and resident review program under…

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 staff interview and record review, the facility did not ensure an accurate nutrition assessment was completed for 1 Resident (R) (R19) of 3 sampled residents reviewed for nutrition concerns. The facility did not complete an accurate nutrition assessment or update the physician when R19 had a significant weight loss of 18 pounds (6%) between 1/13/23 and 1/18/23. Findings include: The facility's Weight Management policy, with a revision date of 11/2021, contained the following information: Residents' nutritional status will be monitored on a regular basis to aid in the maintenance of acceptable parameters, such as body weight and protein levels .Significant weight variance is defined as: 5% in one month, 7.5% in three months, and 10% in six months .6. As residents are weighed, staff can compare current weight to previous weight. Residents with a weight variance are re-weighed within 48 hours .9. The Director of Nursing or designee will notify the attending physician of significant weight changes 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 staff and resident interview and record review, the facility did not ensure consistent communication for 1 Resident (R) (R6) of 1 resident who received dialysis services. The facility did not provide R6 with a dialysis communication binder prior to routine dialysis appointments and did not have evidence of communication between the facility and the dialysis center on R6's dialysis days. Findings include: The facility's Hemodialysis policy, with a revision date of March 2023, contained the following information: Purpose: The facility will assure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. This will include: -The ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. -Ongoing assessment and oversight of the resident before, during and after dialysis treatments, including monitoring of the resident's condition during…

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, staff interview and record review, the facility did not provide pharmacy services to ensure the accurate administration of medication for 3 Residents (R) (R4, R9, and R23) of 13 sampled residents. R4's medications were left at the bedside for R4 to self-administer. R4 did not have a physician's order to self-administer medication and was not assessed to determine if R4 could safely do so. R9's Humalog solution (Insulin Lispro) (fast-acting insulin used to control high blood sugar) pen was not marked with an open date. Per manufacturer's recommendations, Insulin Lispro is less effective 28 days after opening. R23's Refresh eye drops were not marked with an open date. In addition, staff were unsure of the facility's policy and were unable to determine when to discard the eye drops after opening. Findings include: The facility's Self-Administration of Medication policy, revised on 5/2020, contained the following information: Each resident has the right to self-administer medications if he or…

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