Barron Care And Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice that would meet each resident's physical, mental, and psychosocial needs.-The facility did not obtain and enter orders for 1 of 1 resident reviewed (R51).-The facility did not update provider related to new skin impairment for 1 of 1 resident reviewed (R10).-The facility did not implement interventions to assess skin under immobilizer to prevent skin breakdown for 1 of 1 resident reviewed (R26). Findings include: Facility Policy titled, Provision of Physician Ordered Services, implemented in 2025, reads in part: The purpose of this policy is to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality.Qualified nursing personnel will submit timely requests for physician ordered services (laboratory, radiology, consultations) to the appropriate…

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 did not provide care consistent with professional standards to prevent development of a pressure injury (PI) for one of one resident (R) reviewed for pressure injuries (R34).The facility did not provide, document, or evaluate interventions to prevent the development of multiple pressure injuries and/or promote healing of R34's pressure injuries.Facility did not have orders or documentation to perform daily skin assessments to assess R34's skin of R34's left foot, which had a post-operative shoe due to amputaion of left great toe. The facility's lack of skin assessments of R34's left foot lead to development of a stage 2 pressure injury on toip of R34's left foot because facility did not observe that there was no cushion between the skin on R34's left foot and the post-operative shoe.Wrong Hoyer sling used on R34, which caused stage 2 sacral ulcer. No new interventions provided to promote healing.This is evidenced by:The facility's policy titled,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure residents (R) with intermittent catheterization received care and treatment consistent with professional standards of practice to prevent complications or urinary tract infections (UTI) for 1 of 1 resident (R)(R4) reviewed.R4 completed self-catheterization without facility assessment and indication of need. R4 developed a UTI on 12/02/25 and 12/31/25.This is evidenced by:Facility policy titled, Catheterization of a Male, with a date of 2025, states in part: Policy: Urinary catheterization will be performed in accordance with current standards of practice to minimize risk for bacterial contamination or urethral trauma.Centers for Disease Control and Prevention (CDC) states that current standards of practice to prevent UTI and complications, intermittent catheterizations should be completed with clinical indications at regular intervals of 4-6 times daily and consider using a portable ultrasound device to assess urine volume in patients undergoing…

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, interviews and record review, the facility did not ensure pain management interventions were provided for 1 out of 2 residents (R) reviewed for pain management.The facility did not assess and provide non-pharmacologic interventions to R6 as ordered for pain management.This is evidenced by:The facility policy titled, Pain Assessment & Scale dated 4/12/2001, reads in part. 3. Consider alternative pain relief measures such as: distraction, massage, cold or warm packs, repositioning, or backrub.R6 was admitted to the facility on [DATE]. Diagnoses include fracture of upper end of left humerus. R6's Minimum Data Set (MDS) assessment completed on 12/4/25 indicated R6 scored 14/15 during Brief Interview for Mental Status (BIMS), indicating intact cognition. R6's care plan updated 12/16/25 indicated resident has acute pain related to humerus fracture, chronic pain related to kyphosis and history of spinal fractures. Goal, pain will be managed at a level of comfort. Interventions include, offer…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review, the facility did not ensure that a resident (R) who requires dialysis receives such service, consistent with professional standards of practice for 1 of 1 sampled resident (R3) reviewed for dialysis.The facility failed to provide ongoing assessment of R3's condition and monitoring for complications before and after dialysis treatments.Findings include:R3 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, stage 4 (severe) and dependence on renal dialysis.R3 is transported to hemodialysis off site on Mondays, Wednesdays, and Fridays. R3's orders as of 10/21/25, indicate to take a full set of vitals and weight post dialysis treatment one time a day every Monday Wednesday, and Friday. Post vital signs were not taking on 11/28/25 and on 12/1/25 after R3's hemodialysis. R3's care plan states R3 requires dialysis related to renal failure with a goal to have no signs and symptoms of complications from dialysis. Interventions state…

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

Based on observation, interview and record review, the facility did not ensure a medication error rate of less than 5% for 2 of 3 residents observed (R21, R22).-Facility had a medication error rate of 11.54%.-R21 received the wrong dose for two medications (artificial tears and Citalopram).-R22 received the wrong medication. R22 received Calcium with Vitamin D 500mg tab and the physician order was for Calcium Carbonate 1250 (500 Ca) and to give 2 tablets by mouth one time a day.Findings include:Facility policy titled, Medication Administration, last revised 11/25, states in part: Medications are administered to residents by qualified personnel in compliance with federal and state laws and standards of professional practice.to ensure the safe, appropriate, and accurate administration and handling of medications in a dignified manner.Licensed Nurses will . observe the seven rights of proper medication administration.right drug.right dose. On 01/06/26 at 7:22 AM, Surveyor observed Licensed Practical Nurse (LPN) F administer medications to R21. LPN F administered 1 drop of artificial…

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 did not notify the resident/representative in writing of the reason for the transfer/discharge for 5 of 6 residents reviewed who were discharged (R10, R14, R25, R8, R15). This is evidenced by: The facility's policy titled Resident [NAME] of Rights documented, in part: 14. Transfer and Discharge .Before a facility transfers or discharges a resident, the facility must notify the resident and, if known, a family member or legal representative of the resident, of the transfer or discharge and the reasons, proposed date and location of transfer; record the reasons in the resident's clinical records; and include in the notice . Example 1 R10 was admitted to the facility on [DATE]. R10's medical record documented diagnoses in part, dementia with behavioral disturbance, Alzheimer's, Parkinson's, UTI, sepsis, infectious gastroenteritis, dysphagia, and CVA. R10 was transferred to the emergency department on 04/26/24 for right lower quadrant pain and was admitted 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 that written bed hold notice required for facility-initiated transfers was given to the residents or resident representatives for 5 of 6 residents reviewed for hospitalization (R10, R14, R25, R8, R15) This is evidence by: The facility's policy titled Bed Hold & Return to Facility with revised date of 05/03/24 documented, in part: It is the policy of this facility that residents who are transferred to the hospital or go on a therapeutic leave are provided with written information about the State's bed hold duration and payment amount before the transfer. Example 1 R10 was admitted to the facility on [DATE]. R10's medical record documented diagnoses in part, dementia with behavioral disturbance, Alzheimer's, Parkinson's, UTI, sepsis, infectious gastroenteritis, dysphagia, and CVA. R10 was transferred to the emergency department on 04/26/24 for right lower quadrant pain and was admitted to the hospital. Surveyor requested a copy of the bed hold…

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 did not ensure residents (R) were treated with respect and dignity and cared for in a manner to enhance their quality of life. Facility staff used clothing protector to wipe resident's face while assisting to eat. This affected 3 of 3 residents observed. (R13, R18, and R17) This is evidenced by: Example 1 Facility's policy titled Resident [NAME] of Rights documented in part: Quality of Life, 19. Dignity, The facility must promote and care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. R13's medical record documented current diagnoses including in part, Alzheimer's disease, major depressive disorder, dysphagia following cerebrovascular disease, CKD stage 3A, dementia, and mild protein-calorie malnutrition. R13's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented R13 having severe impaired cognition and dependent on staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and staff interview, the facility did not ensure 1 resident (R) (R18) of 15 sampled residents was reasonably accommodated with access to a call light. R18 was observed in R18's room without access to a call light or means to notify staff if assistance was needed. Findings include: R18 was admitted to the facility on [DATE] with diagnoses including in part, vascular dementia, hemiplegia and hemiparesis cerebral infarction, dysphagia, osteomyelitis left elbow, pressure ulcer stage 3 left elbow, type 2 diabetes mellitus, heart failure, and benign prostatic hyperplasia with lower urinary tract infections. R18's Minimum Data Set (MDS) assessment, dated 09/13/24, identified R18 had a Brief Interview for Mental Status (BIMS) score of 08. This indicated R18 had moderate cognitive impairment. The MDS assessment also identified R18 required total dependent assistance of two people for bed mobility, taking on and off footwear, rolling left to right, sit to lying, chair to bed,…

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 did not develop and initiate a comprehensive care plan with targeted interventions for a resident to maintain baseline Activities of Daily living (ADL)s. This occurred for 2 of 15 residents (R) reviewed for care planning, (R17 and R14) Findings include: Example 1 R17 was admitted to the facility on [DATE] with diagnoses including in part, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, dysphagia, atherosclerotic heart disease, essential hypertension, and osteoarthritis of left knee. R17's Minimum Data Set (MDS) assessment, dated 08/17/24, identified that R17 had a Brief Interview for Mental Status (BIMS) score of 12. This indicated R17 had moderate cognitive impairment. The MDS assessment also identified R17 required total dependent assistance of two people for bed mobility, taking on and off footwear, rolling left to right, sit to lying, chair to bed, toileting, and for transfers. On 10/07/24 at 9:08 AM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not review and revise comprehensive care plans for falls, incontinence, and activities of daily living for 2 of 15 residents (R)14 and R17). This is evidenced by: Example 1 R14 was admitted to the facility on [DATE]. R14's medical record documented diagnoses in part: fracture part of neck of right femur, dislocation of internal right hip prosthesis, muscle weakness, chronic lymphocytic leukemia of b-cell type not having achieved remission, peripheral venous insufficiency, dementia mild with behavioral disturbance, pain, repeated falls, dizziness and giddiness, and anxiety. The Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 07. This indicated R14 had severe cognitive impairment. The MDS documented R14 had impairment to one side of the lower extremities. R14 is dependent for transfers, toileting hygiene, showering, oral care, lower body dressing, bed mobility to roll side to side and sit to lying partial 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 observation, interview and record review, the facility did not ensure 1 of 10 residents (R14) who are unable to carry out activities of daily living receive the necessary services for toileting and to maintain good personal hygiene. This is evidenced by: R14 was admitted to the facility on [DATE]. R14's medical record documented diagnoses in part: fracture part of neck of right femur, dislocation of internal right hip prosthesis, muscle weakness, chronic lymphocytic leukemia of b-cell type not having achieved remission, peripheral venous insufficiency, dementia mild with behavioral disturbance, pain, repeated falls, dizziness and giddiness, and anxiety. The Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 07. This indicated R14 had severe cognitive impairment. R14 had inattention and disorganized thinking. The MDS documented R14 had impairment to one side of the lower extremities. R14 is dependent for transfers, toileting hygiene, showering, oral care,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure residents with limited range of motion receive appropriate treatment and services to maintain or increase range of motion. This occurred for 1 of 2 residents (R) R17, who were reviewed for range of motion services. R8 has a left arm and left leg weakness following a stroke effecting non-dominant side. The resident's range of motion program was never started. This is evidenced by: R17 was admitted to the facility on [DATE] with diagnoses including in part, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, dysphagia, atherosclerotic heart disease, essential hypertension, and osteoarthritis of left knee. R17's Minimum Data Set (MDS) assessment, dated 02/02/24, identified that R17 had a Brief Interview for Mental Status (BIMS) score of 12. This indicated R17 had moderate cognitive impairment. The MDS assessment also identified R17 required substantial/maximal assistance with bed mobility, rolling…

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, record review and interview, the facility did not ensure drugs and biologicals used in the facility are labeled in accordance with current accepted professional principles for 1 of 2 insulin pen medications reviewed during medication administration observation. This had the potential for harm to affect resident (R)2. This is evidenced by: Current Wisconsin State pharmacy labeling requirements effective December 2020 state all prescription medications must include in part: .patient name, date of birth , name and strength of medication, dosage, route . R2 was admitted to facility on 04/30/20 with a pertinent diagnosis of diabetes mellitus II. R2 has a prescription order for Admelog SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 140 - 179 = 4; 180 - 219 = 6; 220 - 259 = 8; 260 - 299 = 10; 300 - 339 = 12; 340 - 379 = 14; 380 - 399 = 15 greater than 399 call MD, subcutaneously two times a day for Diabetes my interchange lispro and aspart Hold if resident ref meal BS Parameters below 60 or above 400 call MD On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Staff did not perform hand hygiene with glove changes during morning cares and catheter cares for 2 of 4 residents (R). (R2 and for R29) Findings include: Facility policy and procedure entitled, Hand Hygiene, dated 02/02/24, states in part, .The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves . Example 1 R2 was admitted to the facility on [DATE] with diagnoses including, in part, type 2 diabetes, renal failure and neurogenic bladder. On 10/07/24 at 11:48 AM, Surveyor observed a sign on the outside of R2's room that stated enhanced barrier precautions (EBP). Record review identified R2 was on EBP due to an indwelling Foley…

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

Based on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This had the potential to affect all 34 residents in the building. The facility's Water Management Plan (WMP) was not based on current standards of practice and did not: - Describe the building's water system using a flow diagram of the system to include an assessment of the facility's water system to identify all locations where Legionella could grow and spread. - Identify where control measures should be applied to prevent Legionella growth. - Include a process to confirm the WMP was being implemented and was effective. The facility failed to perform proper hand hygiene when providing care for Resident (R) 8 and R32. This was evidenced by: Example 1: The facility policy entitled, Care & Rehab Barron: Legionella Water Management Plan (WMP), states: .Potential risk areas for Legionella to grow at Care…

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

Based on observation and interview, the facility did not prepare, store or distribute food under sanitary conditions. This can potentially affect 11 of 33 residents (R) (R19, R29, R5, R9, R12, R26, R18, R28, R3, R16, R6) who ate all meals in their rooms. Staff were distributing food and drinks to rooms without covering them, potentially exposing residents to contaminated food. Findings include: The facility Policy, entitled Food Service - Preparing and Cooking Foods, dated 04/16/20, states, A. Hot foods: . c. keep foods covered to retain heat and to keep contaminants from falling into food B. Cold Foods: . c. protect cold foods form contaminants with covers or food shields . On 10/23/23 at 12:05 PM, Surveyor observed that all desserts in rolling metal containers used to transport food to the residents' rooms were uncovered, and all other foods were covered on the trays. Surveyor observed that there is no barrier preventing exposure to other residents' foods when the cart door is open and when food is being delivered to any one individual resident. On 10/23/23 at 12:05 PM, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not develop and implement a comprehensive resident-centered care plan for 3 of 12 sampled residents (R28, R19 and R136). The facility did not develop a care plan for precautions or monitoring related to use of anticoagulation medication, or for immobility related to an amputation for R28. The facility did not develop a comprehensive resident-centered care plan for R19 who has a foley catheter. The facility did not develop a care plan for R136 who was on an antipsychotic medication. Evidenced by: The facility policy titled, Care Plan Process revised 04/30//2020, states in part, It is the policy of Care and Rehab- Barron to develop an initial baseline care plan addressing the major area of risk with 48 hours of admission. Within seven days of the completion of initial MDS or within twenty-one days after admit, the complete comprehensive care plan will be finished . Example R28 was admitted on [DATE] with diagnoses that include right below the knee amputation,…

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 interview, the facility did not review and revise the comprehensive care plans for 1 of 12 sampled residents (R), R8. R8's care plan was not updated to identify the resident was experiencing severe weight loss. This is evidenced by: The facility policy, entitled Care Plan Process, dated May 5, 2010, stated: With every new MD order that changes the way a resident receives care or an incident that needs different interventions, or/and the onset of illness a temporary care plan will be put into place or the nurse must revise the care plan . If the problem will be longer than 21 days, add the problem to the main care plan in the chart and on the care plan in the resident room for the nurse aid. R8 was admitted to the facility on [DATE] and has diagnoses that include unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R8's minimum data set (MDS) assessment, dated 08/19/23, indicated that R8 had 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 observations, interviews and record review, the facility did not ensure that residents who are fed by enteral means received the appropriate treatment to prevent complications of enteral feeding in 2 of 2 residents (R32, R136) observed for cares with a gastric tube (g-tube). Surveyors observed enteral feedings to R32 and R136 and confirmation of placement was not checked prior to the administration. Findings include: The American Association of Critical Care Nurses, April 2016, Initial and Ongoing Verification of Feeding Tube Placement in Adults advises, .Checking Tube Location at Regular Intervals After Feedings Are Started, Unfortunately, feeding tubes can become dislocated during use. For this reason, it is necessary to monitor tube location at regular intervals while the tube is being used for feedings or medication administration. Observing for change in external tube length .Reviewing routine chest and abdominal radiography reports .Observing for changes in volume of feeding tube aspirates…

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 did not ensure that psychotropic drugs are not given unless the medication is necessary to treat a specific condition as diagnosed or specific behaviors in the clinical record. The facility did not implement targeted behavioral monitoring, assessment or implement alternate interventions, prior to initiating or increasing the dosage and frequency of a psychotropic medication for 1 of 8 residents (R) 29. This is evidenced by: The facility policy entitled Behavior Observation and Monitoring revised 11/17/16, states: Resident's identified with targeted behavior will be monitored on a daily basis, will be recording identifying target behaviors, interventions, outcomes of interventions, and frequency of behaviors exhibited. R29 was admitted to the facility on [DATE] and has a diagnosis of Alzheimer's disease. R29's admission Minimum Data Set (MDS), dated [DATE], and most recent quarterly MDS, dated [DATE], noted R29 received antipsychotic medication daily, and had no…

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 did not ensure residents were free from medication errors for 2 of 2 sampled residents (R32 and R136) getting medications through a G-tube. Findings include: Facility policy titled, Medication Administration via Enteral Tubes, revised 07/09/21, stated in part, .Medication Review: .4. Each medication will be administered separately to avoid risks for physical and chemical incompatibilities, tube obstruction, and altered therapeutic response; however, if provider has approved, medications may be crushed and comingled (given together) . Example R32 was admitted on [DATE] with diagnoses of cerebral palsy, functional intestinal disorder, epilepsy, disorders of bone density, gastrostomy (g-tube is a tube inserted through the belly that brings nutrition directly to the stomach). On 10/24/23 at 9:30 AM, Surveyor observed tube feeding care with R32 by Licensed Practical Nurse (LPN) C. After proper hand hygiene and glove use, LPN C gathered supplies needed…

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 did not ensure each resident (R) is offered a pneumococcal immunization for 1 resident (R29) of 5 residents reviewed for immunizations. R29's medical record did not contain documentation of R29 being screened and offered pneumococcal vaccine. Findings include: The facility policy, entitled: Nursing Home Guidelines for Pneumococcal Vaccination (PCV13 and PPSV23) of Residents, revised 09/26/23, states: .will offer the pneumococcal pneumonia vaccination (PPV) to all residents who meet immunization criteria and who cannot provide documentation of previous vaccination. Those who are unsure or do not know their vaccination status will be offered the vaccine. R29 was admitted to the facility on [DATE] and has a diagnosis of Alzheimer's disease, chronic bronchitis (an inflammation of the airways that carry air to your lungs), immunodeficiency due to conditions classified elsewhere (deficiency of immune response or a disorder characterized by deficient immune response).…

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 did not ensure each resident (R) is offered a Covid-19 Immunization for 1 resident (R29) of 5 residents reviewed for immunizations. R29's medical record did not contain documentation of R29 being screened and offered Covid-19 Immunization. The facility policy, entitled: Covid 19, revised 09/26/23, states: .all residents will be offered Covid 19 vaccine. Vaccinations will be required per CMS guidelines. R29 was admitted to the facility on [DATE] and has a diagnosis of Alzheimer's disease, chronic bronchitis (an inflammation of the airways that carry air to your lungs), immunodeficiency due to conditions classified elsewhere (deficiency of immune response or a disorder characterized by deficient immune response). Review of R29's medical record did not document an assessment upon admission for eligibility to receive Covid-19 vaccination and was not offered the vaccine. On 10/24/23 at 2:00 PM, Surveyor interviewed Director of Nursing (DON) B, who stated R29 was 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.