Beaver Dam Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not develop, current up-to-date policies and procedures to ensure that each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized, this affects 1 of 5 residents (R8) reviewed for immunizations. The facilities Pneumococcal Vaccine (Series) dated 3/1/19 does not have the current up-to-date standard of practice involving an adults age. R8 has consent given for pneumococcal vaccine, the facility does not have documentation that the vaccine was offered or administered. This is evidenced by: Example 1The facilities Pneumococcal Vaccine (Series) dated 3/1/19, documents in part: .7. A series of vaccines will be offered to immunocompetent *adults > (greater than or equal to) 65, depending on current vaccination status and practitioner recommendation. The current Standard of Practice from the CDC (Center for Disease Control and Prevention) dated 10/24 is: Pneumococcal Vaccine…

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

Based on interview and record review, the facility did not ensure that each resident is offered a COVID-19 immunization, unless the immunization is medically contraindicated or the resident has already been immunized, this affects 1 of 5 residents (R8) reviewed for immunizations. R8 has consent given for COVID-19 vaccine, the facility does not have documentation that the vaccine was offered or administered. This is evidenced by: The facilities Infection Prevention and Control Program Policy and Procedure dated 10/1/25, documents in part: .10. COVID-19 Immunization: a. Residents and staff will be offered the COVID-19 vaccine when vaccine supplies are available to the facility. R8's Immunization Consent or Declination marks yes for COVID-19 vaccine, with verbal consent documented as obtained by POA (Power of Attorney) 11/4/25. R8's medical record does not reflect that she received a COVID-19 vaccine nor that she refused it at the time of injection. On 5/14/26 at 4:50 PM, Surveyor interviewed ADON/IP C (Assistant Director of Nursing/Infection Preventionist). Surveyor asked ADON/IP C if…

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 that all residents are clinically appropriate to self-administer medications for 1 of 1 resident (R1) reviewed for self-administration of medications.Nursing staff reported to Surveyor that R1 has a backpack full of medications. R1 does not have a completed self-administration of medication assessment.Evidenced by:The facility policy, Self-Administration of Medications, dated 10/24, states, in part;.In order to maintain the residents' high level of independence, residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer.If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility 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.

Based on interview and record review, the facility did not ensure CNAs (Certified Nursing Assistants) received the required 12 hours of annual in-service training for 5 of 5 CNAs reviewed for in-service training.This had the potential to affect all residents who reside in the facility.CNA P, CNA/MA DD (Certified Nursing Assistant / Medication Assistant), CNA EE, CNA FF, and CNA GG did not have documentation of 12 hours of annual in-service training.Findings include:The facilty's Required Training, Certification and Continuing Education of Nurse Aides policy, dated 10/1/22, states, in part: . 5. The facility will provide at least 12 hours of in-service training annually, based on the employment date, not calendar year. a. Documentation of in-services will be forwarded to the HR (Human Resources) Director and maintained in the employee's personnel file.Surveyors randomly selected 5 CNAs to review their 12 hours of in-service training and requested the documentation from the facility CNA P has a hire date of 2/8/2023. CNA P's education record, dated Year 2025, indicates 10 hours 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 observation, interview, and record review the facility failed to maintain an effective pest control program so that the facility is free of pests, such as bed bugs for 4 of 4 residents reviewed (R14, R6, R15, R25). R6 indicated she has observed bed bugs in her room this week. Staff indicated they have seen bed bugs in R14's and R25's rooms within the last two weeks and captured one in a closed container to show NHA A (Nursing Home Administrator). Staff indicated they saw a bed bug in R15's room last night/this morning. Director of Maintenance K indicated he was not following manufacturer's guidelines for use of the facility's chemical treatment and does not know when the product was purchased or when it expires. NHA A indicated he was unaware the products were donated to the facility and not purchased. NHA A indicated he is unsure when the product expires or when it was opened. Evidenced by: Pest Control Invoice, dated 11/10/25, includes: Bed bug K9 inspection . Pest Control Invoice, dated 11/11/25,…

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 interview and record review the facility failed to have evidence that all alleged violations are thoroughly investigated for 2 of 6 resident-to-resident altercations involving 4 Residents (R9, R10, R2, and R8). Resident to Resident altercation between R9 and R10 was not thoroughly investigated. Resident to resident altercation between R2 and R8 was not thoroughly investigated. Findings include: Review of the undated policy titled, Abuse/Neglect/Exploitation, specified it is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Review of the facility's undated policy titled, Abuse/Neglect/Exploitation, revealed, The Administrator should will [sic] follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when…

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 that a resident who needs respiratory care is provided such care consistent with professional standards of practice for 2 of 2 residents (R3 and R1) reviewed for oxygen. R3 had Physician Notes with orders for oxygen therapy. These orders were not in R3's MAR/TAR (Medication Administration Record/Treatment Administration Record). Staff were unsure how many liters of oxygen R3 was supposed to be on. R1 did not have orders for bipap (bilevel positive airway pressure, non-invasive ventilation therapy used to assist with breathing.) and oxygen. Evidenced by: The facility's Oxygen Administration policy, undated, states, in part: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the residents' goals and preferences. 1. Oxygen is administered under orders of a physician, except in the case of an emergency. In such case, oxygen is administered…

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

Based on interview and record review, the facility did not ensure that MAs (Medication Assistants) had 4 hours of medication based in-service training per year for 1 of 1 MA reviewed for in-service training.CNA/MA DD (Certified Nursing Assistant/Medication Assistant) did not have documentation of 4 hours of medication based in-service. Evidenced by:CNA/MA DD has a hire date of 3/20/06. CNA/MA DD's education record dated Year 2025 indicates 1 hour of completed inservice (0.5 hours in Quality Assurance and Performance Improvement and 0.5 hours in Compliance and Ethics. The record shows no medication based in-service. A Medication Administration Education for Nursing Staff form, dated 11/6/25, signed by CNA/MA DD, does not include documentation of credited in-service hours.On 2/18/26 at 2:32 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and asked about in-service training for MAs. NHA A stated that MAs needed an additional 4 hours of education that is medication related. Surveyor asked if CNA/MA DD was provided with the additional 4 hours of education. NHA A stated there…

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 received the necessary care and services in accordance with professional standards of practice to meet each resident's physical needs for 3 of 3 sampled residents (R1, R3 & R2). R1 and R3 did not receive all scheduled wound care treatments as ordered. Facility did not update physician on missed wound care treatments. Facility did not provide residents with risks and benefits due to missing treatments. R2 did not have daily assessments while receiving antibiotic therapy. Evidenced by: The facility policy entitled, Wound Management, dated 2019, states, in part: . To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Policy Explanation and Compliance Guidelines: 1.Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency…

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 provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 3 residents (R2) reviewed for medications.R2 did not have the correct order for his Gabapentin (medication to treat nerve pain).This is evidenced by:The facility's policy Preventing and Detecting Adverse Consequences and Medication Errors, dated 10/25/14, includes: When a resident receives a new medication, the medication order is evaluated for the following: 1) The dose, rout of administration, duration, and monitoring are in agreement with the current clinical practice, clinical guidelines, and/or manufacturer's specifications for use.R2 admitted to the facility on [DATE] with a diagnosis of polyneuropathy (damage or disease affecting peripheral nerves).R2's hospital discharge paperwork, dated 10/9/25, includes an order for Gabapentin 100 mg capsule…

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 all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse to the appropriate agencies for 2 of 2 abuse allegations involving Residents (R3 and R6). CNA F (Certified Nursing Assistant) reported an abuse allegation involving CNA I and R3 that occurred on 3/20/25 to NHA A (Nursing Home Administrator). R6 reported multiple incidents of CNA I mocking her accent to NHA A. These incidents were not treated as abuse and were not reported to the state agency. Evidenced by: Facility policy entitled Abuse/Neglect/Exploitation, undated, states, in part: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility did not ensure that a resident who is fed by enteral means receives the appropriate treatment and services for 1 of 1 resident (R5) reviewed for gastrostomy tube (G/T, or G-Tube) care. R5 had a G-Tube placed 11/8/24 and currently does not use it. R5 does not receive the appropriate care and treatment as ordered to G-Tube to maintain the patency. Evidenced by: The facility policy entitled, Enteral Nutrition, dated January 2025, states, in part: . Policy Statement: Adequate nutritional support through enteral feeding will be provided to residents as ordered. Policy Interpretation and Implementation: . 6. If the resident has a feeding tube placed prior to admission or returning to the facility, the Physician and the interdisciplinary team will review the rationale for the placement of the feeding tube, the resident's current clinical and nutritional status, and the treatment goals and wishes of the resident . 13. Staff caring for residents with feeding…

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 pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 3 residents (R6) reviewed for pain. R6 was admitted to the facility with rhabdomyolysis (a condition where muscle tissue breaks down, causing sever muscle pain, tenderness, and muscle cramps). The facility failed to obtain R6's pain medication, and failed to offer R6 any non-pharmacological interventions to treat her pain, resulting in R6 having continued pain. Evidenced by: The facility policy titled Pain Management, dated 10/1/22, states in part, The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents goals and preferences . Recognition: . Facility staff will observe for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not store and prepare food in accordance with professional standards for food service safety. This has the potential to affect all 68 residents. Surveyor observed food that had been removed from original containers and not labeled with a use by date. Surveyor observed food that was uncovered and not labeled in the main refrigerator. Surveyor observed opened food without use by dates and expired food in circulation in the facility's kitchenette. Surveyor observed the microwave in the facility's kitchenette to have several multi-colored dried-on splatters on the inside. Evidenced by: Facility policy titled Food Receiving and Storage with a revision date of 1/2025 states in part . 7. Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date) .8. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date) .14. Food items and snacks kept on the nursing units must 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.

Based on interview and record review, the facility does not have a system for preventing, identifying, reporting, investigating, and controlling infections and communicable disease for all residents. This has the potential to affect the census of 68 residents. The facility's staff surveillance line lists do not include signs and symptoms (s/sx) of illness or specific symptoms, s/sx onset date, date of last s/sx, return-to-work dates, or area last worked. The facility's resident surveillance line lists do not include s/sx or specific s/sx, type of infection, and type of precautions with start and end dates. This is evidenced by: The facility policy titled, Infection Prevention and Control Program, dated 11/17, states, in part: . Policy: It is a policy of this facility to establish and 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. Policy Explanation and Control Program: . 3. Surveillance: a. A system of surveillance is…

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

Based on interview and record review, the facility did not develop, implement, and maintain an effective emergency training program for all facility and contracted staff consistent with their expected roles and based on the facility assessment. This has the potential to affect the total census of 68 residents and 3 of 3 units. 15 different facility staff were interviewed on 3 of 3 units, who did not know where to locate emergency outlets during a power outage. Staff had not received training on electric power outages or emergency outlet use. Evidenced by: Facility policy titled Power Outage, undated, includes: it is the policy of the facility to protect our residents, staff, and others who may be in our facility from harm during emergency events. To accomplish this we have developed procedures for specific hazards which build on the cross cutting strategies in our continuity of operations plan . Our facility is prepared to safely manage resident care through effective and efficient nursing home operations during the loss of power in this facility. To mitigate the impact of a power…

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 Example 6: R10 admitted the facility on 5/11/23. His most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 2/12/25, indicates R10's cognition is intact with a BIMS (Brief Interview for Mental Status) score of 15 out of 15. R16 admitted to the facility on [DATE]. His most recent MDS with ARD of 11/19/24 indicates R16's cognition is intact with a BIMS score of 15 out of 15. R47 admitted to the facility on [DATE]. His most recent MDS with ARD of 1/15/25 indicates R47's cognition is moderately impaired with a BIMS score of 12 out of 15. R36 admitted to the facility on [DATE]. Her most recent MDS with ARD of 11/18/24 indicates R36's cognition is moderately impaired with a BIMS score of 12 out of 15. R7 admitted to the facility on [DATE]. His most recent MDS with ARD of 12/2/24 indicates R7's cognition is intact with a BIMS score of 15 out of 15. On 2/25/25 at 10:03 AM, during Resident Council Task, R47, R36, R16, R10, and R7 indicated they have concerns with the cleanliness of the facility. R47,…

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 that the residents environment remained as free of accidents and hazards as possible for 2 of 2 sampled residents (R33& R10) and 8 supplemental residents (R47, R36, R16, R38, R59, R4, R13, R60) and 1 of 1 sampled resident (R263) reviewed for oxygen therapy. Surveyor observed a motorized wheelchair being charged in the main dining room with other residents present during meal time. Surveyor observed R263's portable oxygen tank to be on the floor below clothing that was hanging above it. Evidenced by: Facility policy, entitled Electric Wheelchair Policy dated 3/8/20 states in part . Due to the potential for fire or explosion, all electric wheelchairs will be recharged in an area which is not used by the residents for sleeping and which has no oxygen in the vicinity . Example 1: On 2/24/25 at 11:34 AM, Surveyor observed CNA F (Certified Nursing Assistant) plug in R35's electric wheelchair in the main dining room while residents were…

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 drugs and biologicals are labeled in accordance with currently accepted professional standards for 4 of 4 residents who had undated open insulin vials (R41, R48, R63, and R31) and did not ensure 2 medication carts were not left unlocked or with unlocked medications on top of the cart This is evidenced by: The facility policy, Storage of Medications, dated 10/25/14, states in part as follows: When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration (Note: the best stickers to affix contain both a date opened and expiration notation line). The expiration date of the vial or container will be 30 days unless the manufacturer recommends another date or regulations/guidelines require different dating. Example 1: R41's Physician Orders indicate the following:…

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 is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized for 4 of 5 residents (R26, R10, R25, and R9) reviewed for immunizations. R26, R10, R25, and R9 were not offered pneumococcal vaccines. The facility does not have a declination or consent for the pneumococcal vaccine for any of the 4 residents. Evidenced by: The facility policy, titled Infection Prevention and Control Program, dated November 2017, states, in part: . Policy: It is a policy of this facility to establish and 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. Policy Explanation and Compliance Guidelines: . 7. Influenza and Pneumococcal Immunization: . b. Residents will be offered the pneumococcal vaccines recommended by the CDC…

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 that all residents are clinically appropriate to self-administer medications for 1 of 1 Residents (R9) reviewed for self administration. R9 was observed to have her medications left at bedside. This is evidenced by: The facility policy entitled, Self-Administration, undated, states, in part: . Policy: In order to maintain the residents' high level of independence, residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer. Procedures: A. If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive (including orientation to time), physical, and visual ability to carry out this responsibility during the care planning process . C. For those residents…

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 a comprehensive person-centered care plan included a sleep assessment and sleep tracking for 1 of 5 residents (R25) reviewed for unnecessary medications and failed to ensure a comprehensive person-centered care plan included how to care for a tube feeding for 1 of 1 residents (R9) reviewed for tube feeding. R25 is receiving Melatonin for sleep and did not have a sleep assessment or sleep tracking completed. R25's care plan does not indicate Melatonin use. R9 is receiving nourishment through a feeding tube and R9's care plan does not indicate how to care for the tube. This is evidenced by: Surveyor requested facility policy for sleep assessments and document was not provided. Example 1 R25 was admitted to the facility on [DATE] with diagnoses that include, in part: atherosclerosis (the build-up of fats, cholesterol, and other substances in and on the artery walls); morbid (severe) obesity; major depressive disorder, unspecified (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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each resident. This has the potential to affect 1 of 2 sampled residents (R264) reviewed for activities. Surveyor observed R264 sitting in recliner in front of the television in R264's room for long periods of time. R264 is legally blind and R264's Preference Evaluation lists it is very important for R264 to keep up with the news and listen to music R264 likes, and somewhat important for R264 to be around animals. Facility has no documentation to show activities were offered to R264. R264's care plan does not list R264's interests. Evidenced by: The facility policy entitled, Activity, dated 11/17, states, in part: . Policy: It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences of 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.

Based on interview and record review, the facility did not ensure each resident was provided care and services in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for 1 of 1 sampled residents (R43). R43 reported that she had an unwitnessed fall where she hit her head. Facility staff observed a bruise to R43's face, but did not initiate neuro checks or continue monitoring. Evidenced by: Facility policy, titled Falls Management Process, undated, includes: Obtain neurological checks per policy for any unwitnessed fall or any fall with evidence of injury to head. R43's Fall Investigation, dated 2/3/25, includes: On 2/3/25 . staff found a bruise on R43's forehead and hand and does not recall how it happened. Summary of critical information obtained during investigation: R43 was found with a bruise on her forehead and hand, though the cause of the injury is unclear. She has a bims (brief interview of mental status) score of 3, indicating significant cognitive impairment, that remains mostly independent with daily…

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 that residents with an indwelling catheter received the appropriate care and services to prevent a urinary tract infection (UTI) for 2 of 2 residents (R26 and R63) reviewed for catheters as catheter bags were observed to be uncovered and resting on the floor. Surveyor observed R63's and R26's indwelling catheter bags to be resting in direct contact with the floor. This is evidenced by: The Centers of Disease Control and the Healthcare Infection Control Practices Advisory Committee - Guidelines for Prevention of Catheter-Associated Urinary Tract Infections 2009. III. Proper Techniques for Urinary Catheter Maintenance B. Maintain unobstructed urine flow. 1. Keep the catheter and collecting tube free from kinking. 2. Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. 1. R63 admitted to the facility on [DATE] with the following diagnoses: Type 2 Diabetes Mellitus, polyneuropathy, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure the provision of pharmaceutical services (including procedures that assure that accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 1 sampled resident (R9) reviewed for timing of medications. R9's levothyroxine was left at bedside and R9 self-administered the medication. Levothyroxine is scheduled for 6 AM and R9 took the medication at 11:17 AM. Evidenced by: The facility policy entitled, Medication Administration, dated 2002, states, in part: . Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and are only by persons legally authorized to do so . The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. Procedures: . 4. Five Rights- Right Resident, Right Drug, Right Dose, Right Route, and Right Time,…

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 they followed their antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for 1 of 5 (R26) sampled residents and 1 of 1 (R57) supplemental resident reviewed for antibiotic stewardship. R57 was on an antibiotic for a urinary tract infection. Facility did not have documentation of Culture and Susceptibility (C&S). Facility unable to determine if R57 met criteria to be treated with antibiotics. R26 was on an antibiotic for a urinary tract infection without an appropriate indication in December 2024 and January 2025. Facility did not have documentation of urinalysis (UA) and C&S. Facility unable to determine either time if R26 met criteria to be treated with antibiotics. Evidenced by: The facility policy entitled, Antibiotic Stewardship Program, dated 3/1/19, states, in part: . Policy: It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility'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 and resident interview and record review, the facility did not ensure accurate administration of medication for 1 resident (R) (R2) of 5 sampled residents. R2 did not receive 2 doses of a scheduled intravenous antibiotic. In addition, multiple medication orders were transcribed incorrectly and R2 did not receive the medications as ordered. Findings include: The facility's Medication Administration policy, dated 10/25/14, indicates: Medications are administered as prescribed .2) Medications are administered in accordance with written orders of the prescriber. 3) If a dose seems excessive considering the resident's age and condition .the nurse calls the provider pharmacy for clarification prior to the administration of the medication or if necessary, contacts the prescriber for clarification .Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule .6) .If consecutive doses of a vital medication are withheld,…

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

Based on record review and staff and vendor interview, the Bedrock Corporation governing body did not ensure adequate funds were made available to provide for the safe and efficient management of the facility. The failure to maintain current payment status with service providers and vendors has the potential to affect all 54 residents in the facility. The Bedrock corporate governing body failed to maintain current payment status with several service providers and vendors which resulted in vendors refusing to provide services or providing discontinuation notices until payment is received, the governing body has not paid State bed tax or federal Civil Money Penalties (CMPs), the facility pharmacy provider was abruptly terminated after a past due notice was issued, including potential of disruption of service. The failure of the Bedrock governing body to maintain current contract payments has resulted in loss of service and notice of disruption of service. Bedrock corporation's failure to provide sufficient funding to maintain service/vendor contracts resulted in decreased options 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 interview and record review, the facility did not ensure that residents are free of any significant medication error for 1 of 3 (R3) residents reviewed for medication administration. R3 did not receive ordered Nystatin suspension as scheduled on 7/12/24, 7/13/24, 7/14/24, 7/15/24, and 7/16/24. Evidenced by: Facility policy entitled, Medication Reordering dated 4/2023, states in part; It is the policy of this facility to accurately and safely provide or obtain pharmaceutical services including the provision of routine and emergency medications and biologicals in a timely manner to meet the needs of each resident.In the event of new orders, the facility is allowed (24) hours to begin a medication unless otherwise specified by the physician. R3 was admitted to the facility on [DATE] with diagnoses that include metabolic encephalopathy (brain dysfunction caused by chemical imbalance in the blood), morbid obesity due to excess calories, Type 2 Diabetes Mellitus (a condition in which the body has trouble…

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 Example 5: On 6/11/24 at 10:57 AM, Surveyor interviewed R2. Surveyor asked R2 when he uses his call light, do the staff come timely? R2 stated, No, I gotta go to them. Surveyor asked R2 what about when you are in bed? R2 said then I wait 30-45 minutes for my call light to be answered. Example 6: On 6/11/24 at 12:06 PM, Surveyor interviewed FM T (Family Member.) Surveyor asked FM T what concerns she had with R3's care? FM T explained that R3 was admitted for wound care so that was the primary focus for her stay at this facility. Surveyor asked FM T what concerns she had regarding R3's wounds? FM T stated R3 is supposed to be on a special mattress, her sacral wound worsened, she developed 6 other wounds, the condition of her wounds nor the development of 6 other wounds were communicated to her, that the facility was giving her ProStat (high protein supplement) not Ensure, she wasn't being repositioned timely or with the correct amount of assistance, and she had boots on in the hospital but not here 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 observation, interview, and record review, the facility did not provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each resident. This affected 4 of 4 residents reviewed for activities (R5, R8, R9, and R10). The facility failed to create an activity program based on the current residents' interests, preferences, and familiar routines. The facility failed to look at and collect data or activity attendance for R5, R8, R9, and R10 to decide if the program that was in place for each resident was effective or not. Surveyor observed little to no interaction and activities in the location where R5, R8, R9, and R10 reside. Evidenced by: The facility policy titled, Activity, with no date, states, in part; .It is the policy of this facility to prove an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences of each resident. Facility sponsored group 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 interview and record review, the facility did not ensure that resident(s) and/or their families have the right to voice grievances to the facility, and the facility must make prompt efforts to resolve any grievances the resident may have for 1 of 6 residents (R3) reviewed for grievances out of a total sample of 11. R3's family voiced concerns to the facility that were not filed as grievances and the facility did not have evidence of following up. This is evidenced by: The facility's policy and procedure entitled Grievance dated 3/1/23 documents, in part: It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. Prompt efforts to resolve include facility acknowledgement of a complaint/grievance and actively working toward resolution of that complaint/grievance .1. The Grievance Official is responsible for overseeing the grievance process .9. Procedure .b. The staff member receiving the grievance will record the nature and specifics of the grievances on 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, interview, and record review, the facility did not ensure that 1 of 11 residents (R1) reviewed for Activities of Daily Living (ADL) received the necessary services to maintain personal hygiene. R1 voiced concern that R1 did not receive showers as scheduled. R1 voiced concern that R1 does not receive assistance with oral care, and has not had a toothbrush since admission to the facility. Evidenced by: The facility policy titled, Bathing a Resident, with no date, states, in part; .It is the practice of this facility to assist residents with bathing to maintain proper hygiene and help prevent skin issues. The facility policy titled, Oral Care, with no date, states, in part; .It is the practice of this facility to provide oral care to residents in order to prevent and control plaque-associated oral diseases . R1 was admitted to the facility on [DATE] with diagnoses including diabetes, obesity, hypertension, anxiety disorder, abscess of tendon sheath/left lower leg, major depressive disorder,…

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 received sufficient fluid intake or meal intake to maintain proper hydration and health for 1 of 4 sampled residents (R3). R3's fluid and meal intakes were not documented daily to ensure she met her fluid and nutrition needs. This is evidenced by: Facility policy entitled 'Hydration,' implemented 5/24/23 states in part: .The facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health. Definitions: Sufficient fluid means the amount of fluid needed to prevent dehydration (output of fluids far exceeds fluid intake) and maintain health. The amount needed is specific for each resident and fluctuates as the resident's condition fluctuates (i.e., increase fluids if resident has fever or diarrhea). Compliance guidelines: .2. Identification/assessment: a. Nursing staff shall assess hydration status upon admission and throughout 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, interview, and record review, the facility did not ensure residents received food in the appropriate form for 1 of 4 sampled residents (R7). R7 did not receive a mechanical soft textured diet as ordered by his physician. This is evidenced by: The facility therapeutic spread report for altered texture diets is a spreadsheet that, in part, contains four columns labeled regular menu item, mech (mechanical) soft, finger foods, puree. The therapeutic spread report was printed on June 3, 2024, for week 1 Wednesday. The regular menu item column consists of, in part: . for breakfast Sausage patty 1 each . The mech soft column consists of, in part: .Sausage patty-Grnd (ground texture) 1.5 oz (ounces) . It is important to note, for the mechanical soft diet, ground sausage is to be served. R7 was admitted to the facility on [DATE], and has diagnoses that include, epileptic seizures, muscle wasting and atrophy. R7's Comprehensive Minimum Data Set (MDS), dated [DATE], indicates R7 has a Brief Interview…

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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect all 61 residents. Surveyors observed a dusty vent in a food preparation area. A pizza with a questionable use by date was found in a kitchenette refrigerator. Findings include. Example 1 On 3/4/24 at 11:32 AM, Surveyor observed a large exhaust/vent in the facility's main kitchen directly above the food preparation tray line. Surveyor made this observation while staff were actively dispensing food onto plates directly below the vent. The vent had visible clumps of dust on the outside of the vent. Surveyor showed DM P (Dietary Manger). Surveyor touched the vent (on the back side away from tray line) and a clump of dust fell to the floor. DM P then stated, It could be cleaned. We will talk with maintenance. Example 2 The facility's policy titled, Use and Storage of Food Brought in by Family or Visitors, states, Prepared food must be consumed by the resident within 3 days.…

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

Based on interview and record review, the facility has not established 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 has the potential to affect all 61 residents. The facility's resident infection control line lists do not include signs or symptoms (S/Sx), lab reports, culture and sensitivity (C&S) reports, and type of infection for all residents. The facility's policies have not been updated annually. This is evidenced by: The facility policy entitled, Infection Surveillance, dated 10/1/22, states, in part: . Policy: A system of infection surveillance serves as a core activity of the facility's infection prevention and control program. Its purpose is to identify infections and to monitor adherence to recommended infection prevention and control practices in order to reduce infections and prevent the spread of infections . Policy Explanation and Compliance Guidelines: . 6. The facility will collect data to properly…

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 they followed their antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for 1 of 5 sampled residents (R12) and 8 of 8 supplemental residents (R164, R17, R128, R155, R29, R26, R2, and R161) reviewed for antibiotic stewardship. R12 was treated for a urinary tract infection (UTI) with no documentation for criteria and C&S. R164 was put on the resident line list for being treated for pneumonia. Hospital discharge states R164 treated for UTI. There is no urinalysis (UA), or culture and sensitivity (C&S) provided. R17 was treated for a UTI per line list with no documentation for criteria or sensitivity. R128 was treated for a UTI with no documentation for criteria and C&S. R155 was treated for E. Coli septicemia with no sensitivity or criteria documentation. R29 was treated for pneumonia with no documentation of criteria being met. R26 was treated for pneumonia with no documentation of criteria…

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 allow all residents the right to choose their health care provider. This affected 1 of 1 resident's (R45) reviewed for choice of physician. R45 was not allowed to choose his own physician and was assigned a physician determined by the facility. This is evidenced by: R45 admitted to the facility November of 2023. R45 has the following diagnoses: peritoneal abscess, type 2 diabetes mellitus without complications, methicillin resistant staphylococcus aureas (MRSA) infection, and open wound of abdominal wall. R45's most recent Minimum Data Set (MDS) dated [DATE], documents of score of 15 on his Brief Interview of Mental Status (BIMS), which indicates that R45 is cognitively intact. The Facility's Policy and Procedure entitled Choosing a Personal Attending Physician dated 3/26/19, documents in part: .1. Each resident has a right to choose his or her attending physician .3. The physician chosen must be licensed to practice and provide the facility with…

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 make prompt efforts to document, investigate, and resolve grievances a resident may have for 1 of 2 residents reviewed for grievances (R43). R43 reported to staff that she was missing socks. Evidenced by: The facility's policy titled Grievance implemented on 3/1/19 states in part .The facility will ensure prompt resolution to all grievances, keeping the resident and resident representative informed throughout the investigation and resolution process .G. Response: Any employee of this facility who receives a complaint shall immediately attempt to resolve the complaint within their role and authority. If a complaint cannot be immediately resolved the employee shall escalate that complaint to their supervisor and the facility Grievance Official . R43 was admitted to the facility on [DATE] with diagnoses that include dementia and anxiety disorder. R43's most recent Minimum Data Set (MDS) dated [DATE] stating that R43 has a Brief Interview of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made in accordance with State law through established procedures. this affected 1 of 17 residents (R38) reviewed for abuse. R38 reported an allegation of verbal abuse, and it was not reported to the State Agency. This is evidenced by: R38 has the following diagnoses: chronic pain syndrome, major depressive disorder, anxiety disorder, bullous pemphigoid, morbid (severe) obesity due to excess calories, and schizophrenia. R38's most recent Minimum Data Set (MDS) dated [DATE], documents of score of 12 on her Brief Interview of Mental Status (BIMS) which indicates that she is moderately impaired cognitively. The Facilities Policy and Procedure entitled Abuse, Neglect, and Exploitation dated 10/1/19, documents in part: .Verbal Abuse means the use of oral, written, or gestured communication or sounds that willfully includes disparaging…

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 have evidence that all alleged violations were thoroughly investigated. This affected 1 of 1 resident's (R38) reviewed for abuse investigations. R38 reported an allegation of verbal abuse, and it was not thoroughly investigated. This is evidenced by: R38 has the following diagnoses: chronic pain syndrome, major depressive disorder, anxiety disorder, bullous pemphigoid, morbid (severe) obesity due to excess calories, and schizophrenia. R38's most recent Minimum Data Set (MDS) dated [DATE], documents of score of 12 on her Brief Interview of Mental Status (BIMS) which indicates that she is moderately impaired cognitively. The Facility's Policy and Procedure entitled Abuse, Neglect, and Exploitation dated 10/1/19, documents in part: .Verbal Abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to resident or their families, or within their hearing distance regardless of their age,…

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 who are unable to carry out activities of daily living receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. This has the potential to affected 2 of 2 residents (R31 and R46) reviewed for Activities of Daily Living (ADLs). R31 was observed to have long facial hair, to have food on his gown, and have blood-stained sheets. R46 noted to have long and dirty fingernails and reported long toenails in need of trimming. This is evidenced by: The facility's policy titled Shaving with an Electric Razor implemented on 3/1/19 states in part It is the practice of this facility to assist residents with grooming facial hair to help maintain proper hygiene . Example 1 R31 was admitted to the facility on [DATE] with diagnoses that include contracture of muscle, major depressive disorder, mild cognitive impairment, and schizotypal disorder (a type of personality disorder). R31's most recent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents had complete wound care orders, orders were followed, and proper documentation of wound care completion in Treatment Administration Record (TAR). This affected 2 of 17 residents (R7 and R45) with reviewed Physician orders. R7 has incomplete wound care orders and part of wound care was not completed during observation. R45 has incomplete wound care orders and documentation in R45's TAR is inaccurate. This is evidenced by: The Facilities Policy and Procedure entitled Wound Management undated, documents in part: .1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change .7. Treatments will be documented on the Treatment Administration Record . R7's Physician Orders document the following wound care orders: Apply calcium alginate and border gauze to wound on bilateral thighs every day shift for wound care. Apply calcium alginate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure the resident environment remains as free of accidents hazards and each resident receives adequate supervision. This affected 2 of 7 sampled residents (R104 and R454) R104's electric wheelchair charges in his room. R454 has a history of wandering and was not monitored by staff. This is evidenced by: The Facility does not have Policy and Procedure for charging electric wheelchairs. Example 1 On 3/5/24 at 10:17 AM, Surveyor observed R104's electric wheelchair charging in his room. On 3/5/24 at 11:28 AM, Surveyor interviewed R104. Surveyor asked R104 if his electric wheelchair is usually charged in his room, R104 said they usually take it elsewhere to charge but last night I wanted to get into bed. On 3/6/24 at 1:10 PM, Surveyor observed R104's charger for electric wheelchair in room plugged into wall, where it had been on 3/5/24. On 3/7/24 at 11:10 AM, Surveyor observed R104's charger for electric wheelchair in room plugged into wall, where it had…

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 Example 2 R38 was admitted to the facility on [DATE] with diagnoses that include major depressive disorder, anxiety disorder, and schizophrenia. R38 takes the antipsychotic medication Paliperidone ER (Extended Release) oral tablet one time a day for schizophrenia. Surveyor requested that the facility provide a completed Abnormal Involuntary Movement Scale (AIMS) to measure involuntary movements known as tardive dyskinesia- a disorder that develops as a side effect of long-term treatment with antipsychotic medications) for R38. On 3/7/24 Surveyor received an AIMS for R38 that was completed on 3/7/24. On 3/7/24 at 4:07 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if R38 should have had an AIMS completed prior to 3/7/24, DON B stated yes, she probably should have had one. Based on interview and record review, the facility did not ensure that residents who receive psychotropic medication have the appropriate assessments completed and individualized behaviors monitored for 2 of 5…

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 the resident's medical record includes documentation that indicates, at a minimum, the following: (A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza and/or pneumococcal immunization; and (B) That the resident either received the influenza and/or pneumococcal immunization or did not receive the influenza and/or pneumococcal immunization due to medical contraindications or refusal. This affected 2 of 5 residents (R7 & R38) reviewed for immunizations. R7 did not sign, date, or check consent or declination for the influenza vaccination for 2023. R38 did not sign, date, or check consent or declination for the influenza vaccine for 2023. This is Evidenced by: The facility policy entitled Infection Prevention and Control Program, dated 10/1/22, states, in part: . Policy: This facility has established and maintains an infection prevention and control program designed to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and observation, the facility did not maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 17 residents (R2) reviewed for appropriately working equipment. R2's shower chair was observed to be broken and facility staff continued using it. Findings include: R2 was admitted to the facility on [DATE] and has diagnoses that include paraplegia. On 3/5/24 at 2:35 PM, Surveyor interviewed R2 who stated that the shower chair that the facility uses for him has a support for his legs to keep them from touching the floor, as he is unable to use his legs. R2 stated that this shower chair leg support had been broken for quite some time and so staff would make him drag his legs or would pull him from his room, instead of pushing him. On 3/6/24 at 10:40 AM, Surveyor interviewed CNA K (Certified Nursing Assistant) who stated that R2's shower chair had been broken for about 3 months and in order to get R2 down the hall, one staff would push the chair while another…

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.

The facility failed to complete performance reviews of every nurse aide at least once every 12 months, and failed to ensure every nurse aide (12 hours) and medication technician (4 hours) received their required annual training hours, this affected 3 of 5 Certified Nursing Assistants' (CNAs) annual training, 1 of 1 medication aide training, and 3 of 5 CNAs' performance evaluations. CNA W, CNA X, and CNA Y did not have 12 hours of required annual education. MT V (Medication Technician) did not have 4 hours of required medication education. MT V, CNA W, and CNA Y did not have annual performance evaluations completed. This is evidenced by: The facilities Employee Handbook dated 2/1/24 documents the following, in part: .Annual Training. Annual Training is conducted once a year with a due date determined by the Company. This training includes but is not limited to, Annual Compliance Training, Specialized Compliance Training, and any training that is required by local, state and/or federal guidelines, laws and/or regulations. Some training courses are only offered electronically .Annual…

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 the provision of pharmaceutical services (including procedures that assure that accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 4 out of 4 sampled residents (R5, R8, R9\, and R1). R5, R8, R9, and R1 had multiple medication errors related to not receiving medication timely as ordered by the physician. This is evidenced by: The facility policy entitled, Medication Administration, dated 3/1/19, states, in part: .11 . b. Administer with 60 minutes prior to or after scheduled time unless otherwise ordered by physician . Example 1 R5 was admitted to the facility on [DATE]. R5 had the following diagnoses of: schizophrenia (a serious mental disorder in which people interpret reality abnormally), major depressive disorder (a severe and persistent low mood, profound sadness, or a sense of despair), hypertension, acute combined systolic (congestive) and diastolic (congestive)…

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 immediately notify and consult with the resident's physician when a significant change in the resident's physical, mental, or psychosocial status occurred for 1 of 4 residents (R3) of a total sample of 12 residents reviewed. R3 was refusing his antibiotic for an abdominal abscess infected with Methicillin Resistant Staphylococcus Aureus (MRSA) infection. The facility did not continue to notify the Physician of ongoing refusals of antibiotic. As evidenced by The facility does not have a policy for medication refusals and notifying the Physician. R3 was admitted to the facility on [DATE] with diagnoses including, but not limited to: peritoneal abscess with MRSA, diabetes mellitus type 2, rheumatoid arthritis, obstructive sleep apnea, primary hypertension, atherosclerotic heart disease, R3's admission Minimum Data Set (MDS) dated [DATE] indicates R3 has a Brief Interview of Mental Status (BIMS) of a 15 out of 15, which indicates he is cognitively intact. R3…

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 an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each resident. This affects 2 (R6 and R7) of 4 residents reviewed for activities. The facility failed to incorporate social history assessment information into R6's and R7's care plans and their current care plan is not person centered. The facility failed to have measurable activity goals and a system in place for measuring R7 and R6's activity involvement to know if the current plan of care is appropriate and if R7 and R6 are meeting their activity goals. Evidenced by: Facility policy, entitled Activity, undated, includes It is the policy of the facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessments, care plan, and preferences each resident. Facility sponsored group and individual activities and independent activities will be designed 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 and interview, the facility did not ensure that all medications were stored and labeled in accordance with standard of practice in 1 of 4 residents reviewed. Surveyor observed one Lispro Kwik Pen during a medication pass without an open date being administered to R8. Evidenced by: R8 was admitted to the facility on [DATE]. R8 has the following diagnoses of type 2 diabetes mellitus with diabetic chronic kidney disease. R8's Physician Orders: Order date 10/5/23, .Insulin lispro (1 unit dial) 100unit/ml (milliliters) solution pen injector. Inject as per sliding scale: subcutaneously before meals . On 1/10/24 at 12:49 PM, Surveyor observed MT D (Medication Technician) passing medication. Surveyor observed MT D administer Lispro Kwik Pen, subcutaneously to R8. After administration, Surveyor asked MT D if she knew when the Lispro Kwik Pen was first opened, she indicated she did not and that it looked like a fairly new pen so early this week to have been opened. Surveyor asked MT D if Lispro Kwik…

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 hospice collaboration and communication processes were established to ensure continuity of care between hospice and the facility for 1 of 1 hospice residents (R13) reviewed out of a total sample of 5 residents. R13 was admitted to hospice services and the facility did not receive any documentation from the hospice provider in a timely manner. Evidenced by: The facility's policy titled Hospice Services Facility Agreement dated3/1/19 states in part, .5. The facility has designated (the Assistant Director of Nursing or specify the member from the interdisciplinary team) to be responsible for working with hospice representatives to coordinate care to the resident provided by the facility and hospice staff .6. The designated member of the facility working with hospice representative is responsible for: a. Collaborating with hospice representatives and coordinating with LTC (Long Term Care) facility staff participation in hospice care planning process…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to thoroughly investigate and provide education to all staff for six out of seven abuse investigations reviewed for 5 of 7 Abuse investigations involving 8 Residents (R1, R2, R9, R8, R3, R4, R5, & R12). The facility failed to immediately and thoroughly investigate allegations of abuse. The facility failed to educate all staff after multiple abuse allegations were reported. The facility did not report an allegation of abuse to the state agency timely and in its entirety. Evidenced by The facilities Policy and Procedure entitled Abuse/Neglect/Exploitation undated, documents in part: .V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation .3. Investigating different types of alleged violations; 4.…

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 that residents who are unable to carry out ADL's (activities of daily living) receive the necessary services to maintain good nutrition, grooming, personal and oral hygiene; for 6 of 7 residents (R2, R5, R8, R9, R10, R11) reviewed for showers and 1 of 9 residents (R5) reviewed for call light placement. R2 has no evidence of receiving showers documented from November to present (12/11/23). R5 has no evidence of receiving showers documented from November to present. R8 states he receives bed baths but requests showers and does not get them. R9 has no evidence of receiving showers documented from November to present. R10 has missed multiple showers prior to room change. R11 has missed multiple showers. R5 did not have her call light within reach. This is evidenced by: The facility does not have a policy on showers. The facility shower schedule documents the following: *R2's shower is scheduled for Wednesday PM. *R5's shower is scheduled…

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 all allegations of abuse were reported timely to the state survey agency (SSA) for 1 resident (R9) of 9 residents reviewed for abuse. R9 reported an allegation of abuse on 12/4/23. Facility staff completed a grievance form. Facility leadership did not report allegation of abuse to SSA until Surveyor discussed with NHA A (Nursing Home Administrator) on 12/11/23. Evidenced by: The facility policy, titled, Abuse/Neglect/Exploitation, with no date, states, in part; . V11. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if 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 did not ensure that Residents receive treatment and care in accordance with professional stanadards of practice, the comprehensive person-centered care pland and the residents choices for 1 of 5 Residents reviewed for wounds (R8). R8 had orders for wound care that were not completed per Physician orders. This is evidenced by: R8 was admitted to the facility on [DATE]. His most recent MDS (Minimum Data Set), dated 11/9/23, shows a BIMS score (Brief Interview for Mental Status) of 15, indicating R8 is cognitively intact. R8 has diagnoses that include right and left below-knee amputations. R8's physician's orders, state in part: *Left and right stump-clean with wound cleaner, apply calcium alginate and cover with abd (abdominal gauze pads) and kerlix, every night shift for wound care. This order was created on 11/9/23 and was subsequently discontinued on 12/7/23. *Apply zinc barrier cream to bilateral thighs daily. Reapply as needed every day shift for wound 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, interview, and record review the facility did not ensure that a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable for 2 of 5 residents (R5 & R8) with wounds. R5 developed a heel wound, did not have interventions in place, wound wasn't assessed upon discovery, and is missing a week's worth of measurements. R8 did not have wound care orders completed. This is evidenced by: The facilities Policy and Procedure entitled Pressure Injury Prevention and Management, undated, documents in part: .2. The facility shall establish and utilize a systemic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate .d. Assessments of pressure injuries will be performed by a licensed nurse, and documented .4.…

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 assist the resident in making appointment/transportation arrangements to and from the source of service for 1 of 1 resident (R5) reviewed for appointments. R5 did not have an appointment re-scheduled timely, where a procedure and important lab work was to be completed. This is evidenced by: R5 admitted to the facility in April 2023. R5's most recent MDS (minimum data set), dated 10/27/23, documents a score of 15 on her BIMS (Brief interview of mental status), which indicates she is cognitively intact. R5 is currently experiencing a drastic decline in her condition. R5's Nurse's Notes document the following: 11/9/2023 4:50 PM General Note Note Text: Received an update from R5s guardian . Just wanted to update you on the video meeting we had yesterday with the infectious disease doctor . to discuss the culture results from her test. The doctor is concerned that R5 may have bacteria in her brain/shunt (forgot the name and they were supposed to send me 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 failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with sections 1150B of the Act for 2 Residents (R) (R1 and R2) of 3 sampled residents. On 9/10/23, R2 punched R1 in the right arm. The facility did not report the physical assault to the State Agency (SA) or law enforcement. On 10/16/23, R2 was observed hitting R1. The facility did not report the physical assault to the SA or law enforcement. Findings include: The facility's Abuse, Neglect, and Exploitation policy, dated 10/1/22, contained the following information: Reporting of alleged violations to the Administrator, Stage Agency, Adult Protective Services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes. On 10/30/23, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses to include cerebral infarction, aphasia,…

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 allegations of physical abuse were thoroughly investigated for 2 Residents (R) (R1 and R2) of 3 sampled residents. On 9/10/23, R2 punched R1 in the right arm. The facility did not complete a thorough investigation that included staff and resident interviews. On 10/16/23, R2 was observed hitting R1. The facility did not complete a thorough investigation that included staff and resident interviews. Findings include: The facility's Abuse, Neglect, and Exploitation policy, dated 10/1/22, contained the following information: Investigation of alleged abuse, neglect, and exploitation. An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations .Providing complete and thorough documentation of 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 and resident interview, and record review, the facility did not ensure appropriate treatment and services related to communication were provided for 1 Resident (R) (R2) of 3 residents reviewed. R2's preferred language of Spanish was not appropriately assessed, documented, or implemented which resulted in ineffective communication between R2 and non-Spanish speaking staff. Findings include: On 10/30/23, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses to include diabetes mellitus type two, alcohol abuse, major depressive disorder, anxiety, and hypertension. R2's Minimum Data Set (MDS) assessment, dated 9/18/23, contained a BIMS score of 7 out of 15 which indicated R2 had severe cognitive impairment. R2 did not have a communication care plan that indicated R2 was Spanish speaking and outlined ways in which staff could communicate with R2. (Also noted: R2's admission MDS assessment, dated 6/16/23, and Quarterly MDS assessment, dated 9/15/23, did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident representative interview, and record review, the facility did not ensure a resident representative was notified timely of a change in condition for 4 Residents (R) (R6, R7, R8, and R10) of 5 residents reviewed for change in condition. One of R6's resident representatives was not notified when R6 had a fall on 7/7/23. One of R7's resident representatives was not notified when R7 had falls on 6/8/23 and 7/7/23. One of R8's resident representatives was not notified when R8 was hospitalized on [DATE]. One of R10's resident representatives was not notified when R10 had falls on 5/26/23, 6/29/23, 7/2/23, and 7/4/23. Findings include: The facility's Notification of Changes Policy, implemented 3/1/19, indicated: It is the policy of this facility that changes in a resident's condition or treatment are immediately shared with the resident and/or the resident's representative, according to their authority .The resident and/or their representative will be educated about treatment options 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 interview and record review, the facility did not ensure neurological checks were completed per policy for 2 Residents (R) (R7 and R10) of 4 residents reviewed for falls. Staff did not consistently complete neurological checks after R7 fell on 7/7/23 and 7/9/23. Staff did not consistently complete neurological checks after R10 fell on 5/26/23, 7/2/23, and 7/4/23. Findings include: The National Library of Medicine (https://www.ncbi.nlm.nih.gov/) states, The neurological examination in the setting of trauma is a systematic evaluation of important clinical signs that provide evidence to help determine further management and investigation of the patient's condition .In the setting of trauma, a neurologic examination is focused on identifying and assessing the functions of vital portions of the central nervous system. The facility's Fall Management Process, dated 2011, contained the following information: Obtain neurological checks per policy for any unwitnessed fall or any fall with evidence of injury…

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 monitoring of a high risk medication was provided for 1 Resident (R1) of 5 sampled residents. The facility did not ensure required blood tests were completed to determine if appropriate doses of warfarin (an anticoagulant medication used to thin the blood in an effort to prevent blood clots) were administered to R1. Findings include: The facility's High Risk Medications - Anticoagulants policy, dated 3/1/19, contained the following information: This facility recognizes that some medications, including anticoagulants, are associated with greater risks of adverse consequences than other medications. This policy addresses the facility's collaborative systematic approach to managing anticoagulant therapy for efficacy and safety .Target symptoms (i.e., lab values) and goals for use (i.e., prevention or treatment) of anticoagulants shall be documented in the resident's medical record .Routine labs, including baseline and subsequent labs, shall 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.

Based on observation and staff interview, the facility did not ensure safe food handling practices were implemented. This had the potential to affect all 45 residents who resided in the facility. A kitchen hood located over cooking surfaces contained visible peeling paint. Findings include: The Wisconsin Food Code reads as follows: 4-601.11 Equipment, Food--Contact Surfaces, Nonfood--Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. 551 AGRICULTURE, TRADE AND CONSUMER PROTECTION ATCP 75 Appendix Published under s. 35.93, Wis. Stats. by the Legislative Reference Bureau. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published. Register July 2020 No. 775 (C) NONFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. On 12/12/22 at 9:40…

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 maintain an Infection Prevention and Control Program designed to provide a safe and sanitary environment and prevent the transmission of communicable disease and infection. This had the potential to affect all 45 residents who resided in the facility. The facility did not appropriately monitor for infections and outbreaks and did not maintain an Infection Prevention and Control Program. DON (Director of Nursing)-B did not maintain infection control standards or adequately perform hand hygiene during wound care for R24. Laundry Aide (LA)-Z did not appropriately wear personal protective equipment (PPE) which resulted in contamination of LA-Z's clothing and residents' clean linens and personal clothing. Maintenance Staff (MS)-Q did not appropriately wear PPE while in R219 and R220's room while R220 was on contact and droplet precaution. In addition, Hospitality Aide (HA)-S did not perform hand hygiene after taking off PPE and exiting R219…

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 Infection Preventionist dedicated a minimum number of part-time hours and was provided the necessary training to adequately manage an Infection Prevention and Control Program. This had the ability to affect all 45 residents who resided in the facility. Director of Nursing (DON)-B was designated as the facility's Infection Preventionist in addition to performing full-time DON duties, working as a floor nurse and completing weekly wound rounds which resulted in DON-B's inability to adequately maintain an Infection Prevention and Control Program. Findings include: The facility's document titled Infection Prevention and Control Program, implemented 10/01/2022, stated: Policy: This facility has established and maintains 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 as per accepted national standards and guidelines . 1. The designated Infection Preventionist…

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.

3. On 12/12/22 at 2:47 PM, Surveyor interviewed R56 who stated during the night shift on 12/7/22, R56 requested pain medication from LPN-MM. R56 was offended when LPN-MM stated to R56, You eat these things like candy. You don't have any pain. You just want the pills. You're an addict. R56 stated R56 informed Housekeeping Staff (HS)-RR on 12/8/22. HS-RR left R56's room, returned a few minutes later and stated HS-RR reported R56's allegation to NHA-A. R56 also informed Certified Occupational Therapist Assistant (COTA)-Y of the incident. Surveyor reviewed R56's medical record and noted the incident was not documented. On 12/13/22 at 12:24 PM, Surveyor interviewed HS-RR who verified R56 informed HS-RR of the incident. HS-RR stated HS-RR informed NHA-A that R56 requested to speak to NHA-A to report an allegation regarding a nurse. HS-RR confirmed R56 was updated. On 12/13/22 at 12:29 PM, Surveyor interviewed COTA-Y who verified R56 informed COTA-Y of the incident. COTA-Y stated COTA-Y did not report the incident to anyone, but told R56 to report the incident to nursing staff and NHA-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.

Based on resident and staff interview and record review, the facility did not ensure all allegations of abuse were thoroughly investigated for 4 Residents (R) (R12, R20, R54 and R56) of 5 residents reviewed for abuse. On 12/12/22, Surveyor observed R20 call R12 a name and tell R12 to shut up. Surveyor reported the resident-to- resident altercation to staff. The facility did not complete an investigation of the altercation. On 12/5/22, R54 eloped from the facility through a window. The facility did not conduct a thorough investigation of the elopement. On 12/8/22, R56 reported to staff that when R56 requested pain medication from Licensed Practical Nurse (LPN)-MM on the 12/7/22 night shift, LPN-MM said, You eat these things like candy. You don't have any pain. You just want the pills. You're an addict. The facility did not complete an investigation of the allegation of abuse. Findings include: The facility's Abuse, Neglect and Exploitation policy, with a revision date of 10/01/22, reads as follows: Definitions: Verbal Abuse: Means use of oral, written or gestured communication 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure 4 Residents (R) (R31, R12, R20 and R45) of 23 sampled residents met the PASRR (Pre-admission Screen and Resident Review) requirements. R31's Level I PASRR on admission indicated serious mental illness, a current major mental disorder diagnosis and psychotropic medications. Evidence of referral to the Screening Agency was not located or provided. R12's Level I PASRR on admission indicated R12 had a serious mental illness, a current major mental disorder diagnosis, psychotropic medications and severe cognitive deficits. Evidence of referral to the Screening Agency was not located or provided. R20's Level I PASRR on admission indicated the use of psychotropic medications. Evidence of referral to the Screening Agency was not located. A new Level I screen, dated 12/14/22, which indicated a serious mental illness, a major mental disorder diagnosis and no psychotropic medications was sent for screening on 12/14/22. R45's Level I PASRR on admission…

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 staff employed at the facility received required annual training for Resident Rights. Failure to provide the required training had the potential to impact multiple residents in the facility. Facility provided documentation indicated only 70 percent of staff received annual Resident Rights training from 12/1/21 through 12/20/22. Findings include: On 12/19/22 at 1:46 PM, Surveyor interviewed Regional Director of Operations (RDO)-M who stated on-going education was completed via a named Internet-based Continuing Education Format. RDO-M further indicated additional trainings were also provided in-person at times. RDO-M stated in-person all-staff education was provided on 9/22/22 which covered the required annual education. On 12/20/22, Surveyor reviewed facility provided education documents related to the in-person all-staff education held at the facility on 9/22/22. The documents did not include education on the topic of Resident Rights. On 12/20/22, Surveyor reviewed facility provided education documents emailed…

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 staff employed at the facility received required annual training for Abuse, Reporting & Dementia Care Management. Failure to provide the required training had the potential to impact multiple residents in the facility. Facility provided documentation indicated only 6 of 57 employees were assigned and completed annual Abuse Prevention in Persons with Dementia training from 12/1/21 through 12/20/22. Findings include: On 12/19/22 at 1:46 PM, Surveyor interviewed Regional Director of Operations (RDO)-M who indicated on-going education was completed via a named Internet-based Continuing Education Format. RDO-M further stated additional trainings were provided in-person at times. RDO-M indicated an in-person all-staff education was provided on 9/22/22 which covered the required annual education. On 12/20/22, Surveyor reviewed facility provided education documents related to the in-person all-staff education held at the facility on 9/22/22. The documents did not include education on the topic of Abuse Prevention in…

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

Based on staff interview and record review, the facility did not ensure staff employed at the facility received required annual training on the written policies and procedures of the facility's Infection Control Program. Failure to provide the required training had the potential to impact multiple residents in the facility. Facility provided documentation indicated only 8 of 57 staff received annual Infection Prevention and Control for All Staff training from 12/1/21 through 12/20/22. Findings include: On 12/19/22 at 1:46 PM, Surveyor interviewed Regional Director of Operations (RDO)-M who stated on-going education was completed via a named Internet-based Continuing Education Format. RDO-M further stated additional trainings were also provided in-person at times. RDO-M indicated an in-person all-staff education was provided on 9/22/22 which covered the required annual education. On 12/20/22, Surveyor reviewed facility provided education documents related to the in-person all-staff education held at the facility on 9/22/22. The documents did not include education on the topic 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 ensure 4 Certified Nursing Assistants (CNAs) (CNA-I, CNA-J, CNA-K and CNA-L) of 5 sampled CNAs employed at the facility received a performance review every 12 months. Failure to review staff performance had the potential to impact multiple residents in the facility. CNA-I was hired on 12/5/05. The facility was unable to provide documentation that a performance review was completed during the most recent hire date year (12/5/21 through 12/5/22). CNA-J was hired on 3/20/06. The facility was unable to provide documentation that a performance review was completed during the most recent hire date year (3/20/21 through 3/20/22). CNA-K was hired on 10/29/13. The facility was unable to provide documentation that a performance review was completed during the most recent hire date year (10/29/21 through 10/29/22). CNA-L was hired on 8/18/21. The facility was unable to provide documentation that a performance review was completed during the most recent hire date year (8/18/21 through 8/18/22). Findings include: On 12/19/22,…

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) (R18 and R17) of 5 residents reviewed for unnecessary medications had documentation to indicate the resident or resident's legal representative was informed of the risks and benefits of the prescribed psychotropic medications. R18 was prescribed Seroquel (an antipsychotic medication with a black box warning). (A black box warning is the strictest and most serious type of warning the FDA (Food and Drug Administration) gives a medication. A black box warning is meant to draw attention to a medication's serious or life-threatening side effects or risks). R18 did not have a current medication consent form on file. R17 was prescribed Seroquel and Sertraline (an antidepressant with a black box warning) and did not have current medication consent forms on file. Findings include: Department of Health Services (DHS) Form F-24277 (09/2016) Informed Consent for Medication states on page 3 at number 8: This medication consent is for 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 investigate, resolve, and/or record resolution of grievances for 1 resident (R14) of 23 sampled residents. The facility did not have a grievance form for a concern expressed by R14 and family. Findings include: The facility's Grievance policy, with an implementation date of 3/1/19, states: It is the policy of this facility that each resident has the right to voice grievances to the facility .Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their facility stay. The facility will ensure prompt resolution to all grievances, keeping the resident and resident representative informed through the investigation and resolution process. Voice Grievances - is not limited to a formal, written grievance process but may include a resident's verbalized complaint to facility staff. G. Response - Any…

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) (R14 and R31) of 2 residents reviewed for hospitalization received the proper notice to include date of transfer, reason for transfer, location of transfer, appeal rights and contact information for the State Long-Term Care Ombudsman. R14 was transferred to the hospital on [DATE]. The facility did not provide R14 with a transfer notice. R31 was transferred to the hospital on [DATE]. The facility did not provide R31's guardian with a transfer notice. Findings include: 1 R14 was admitted to the facility on [DATE] with diagnoses to include type 2 diabetes mellitus with diabetic chronic kidney disease, hypertension, chronic pain, fibromyalgia and peripheral vascular disease. R14's Minimum Data Set (MDS), dated [DATE], contained a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R14 had intact cognition. R14 did not have an activated decision maker. On 12/14/22, Surveyor reviewed R14'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 ensure 2 Residents (R) (R14 and R31) of 2 residents reviewed for hospitalization received the proper bed hold notice when transferred to the hospital. R14 was transferred to the hospital on [DATE]. The facility did not provide R14 with a bed hold notification. R31 was transferred to the hospital on [DATE]. The facility did not provide R31's guardian with a bed hold notification. Findings include: 1. R14 was admitted to the facility on [DATE] with diagnoses to include type 2 diabetes mellitus with diabetic chronic kidney disease, hypertension, chronic pain, fibromyalgia and peripheral vascular disease. R14's Minimum Data Set (MDS), dated [DATE], contained a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R14 had intact cognition. R14 did not have an activated decision maker. On 12/14/22, Surveyor reviewed R14's medical record and the facility's grievance file as part of a complaint investigation completed 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 1 Resident (R) (R17) of 1 resident reviewed for weight loss received the necessary care and services to meet nutritional goals and prevent continued weight loss. R17 had a 16 pound or 12.62% unintended weight loss within six months. The facility did not follow orders to provide R17 with a dietary supplement or to weigh R17 on a weekly basis. Findings include: On 12/12/22 at 1:30 PM, Surveyor reviewed R17's electronic health record (EHR) which included a dietary progress note, dated 12/7/22 and electronically signed by Registered Dietician (RD)-C, that stated the following: .CBW (current body weight) 112.4 (pounds), height 60, and BMI (body mass index) 21.9. (R17) triggered for a significant weight loss of 11.8% in the past 6 months. This is not desirable given (R17's) low BMI and variable intakes. (R17's) weight has been stable 112-114 (pounds) for the past 2 months. Discussed with IDT (interdisciplinary team), recommend increasing fortified pudding to BID (twice daily) Recommendations: Continue NAS (no added…

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 with the dialysis facility was consistent with professional standards of practice for 1 Resident (R) (R24) of 1 resident reviewed for dialysis care and services. R24 obtained dialysis services from a dialysis center outside the facility. There was no evidence of written communication between the dialysis center and the facility following R24's dialysis appointments. Findings include: R24 was admitted to the facility on [DATE] with diagnoses to include end stage renal disease (a chronic kidney disease causing the kidneys to no longer work), dependence on renal dialysis (requiring dialysis to remove excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform those functions naturally), anemia in chronic kidney disease (common complication of chronic kidney disease causing iron deficiency), essential hypertension, type 2 diabetes mellitus and hyperkalemia (a high potassium level 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 observation, resident and staff interview and record review, the facility did not ensure the accurate acquisition and administration of medication for 1 Resident (R) (R33) of 9 residents reviewed for pharmacy services. The facility did not ensure R33's Combivent Respimat inhaler (medication inhaled to help open the airways in the lungs) was refilled timely resulting in thirteen missed doses between 12/10/22 and 12/13/22. Findings include: R33 was admitted to the facility on [DATE] and had a primary diagnosis of acute respiratory failure with hypoxia (low levels of oxygen in tissues) on 2/22/22. R33's active orders included Combivent Respimat Aerosol Solution 20-100 microgram (MCG/ACT) 1 puff inhale orally four times daily related to acute respiratory failure with hypoxia, dated 8/25/22. On 12/12/22 at 11:53 AM, Surveyor observed Registered Nurse (RN)-T perform medication administration for R33. RN-T looked at R33's Combivent Respimat inhaler dose indicator which showed 0 for number of doses remaining.…

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 pharmacy recommendation reports were acted on by a physician for 3 Residents (R) (R12, R18 and R6) of 5 residents reviewed for unnecessary medications. R12 had 3 pharmacy recommendations. No physician acknowledgement or follow through was noted. R18 had 1 pharmacy recommendation. No physician acknowledgement or follow through was noted. R6's medication regimen was not reviewed monthly by a pharmacist. Findings include: The facility's Addressing Medication Regimen Review Irregularities policy, with an implementation date of 3/1/19, states: Policy Explanation and Compliance Guidance: 2. The medication regimen of each resident must be reviewed by a licensed pharmacist at least once a month (or more frequently, as indicated by the resident's condition). 4. The pharmacist must report any irregularities to the attending physician, the facility's medical director and the director of nursing, and the reports must be acted upon. 4d. The attending…

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 accurate and complete information for 1 Resident (R) (R218) of 16 sampled residents. R218's medical record contained missing documentation related to abdominal wound treatments. Findings include: R218 was admitted to the facility on [DATE] with diagnoses to include laceration of sigmoid colon and received negative pressure wound therapy (also known as a wound vac) to the abdominal surgical site. R218 was their own decision maker. R218's 11/14/22 Minimum Data Set (MDS) contained a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R218 was not cognitively impaired. R218 was discharged to the hospital on [DATE] and was not at the facility during the survey. On 12/14/22, Surveyor reviewed R218's treatment administration record (TAR) which included the following order: Change wound vac Monday-Wednesday- Friday. Cleanse wound bed with 1/4 Dakins solution (used to prevent and treat skin 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 interview and record review, the facility did not ensure medical records contained documentation related to influenza and pneumococcal immunizations for 3 Residents (R) (R36, R49 and R52) of 5 residents reviewed for immunizations. R36's medical record did not contain documentation indicating the facility offered or administered the pneumococcal immunization. R49's medical record contained a signed consent form indicating R49 wished to receive the influenza immunization; however, R49's medical record did not contain documentation the immunization was administered. R52's medical record did not contain documentation indicating the facility offered or administered pneumococcal or influenza immunizations. Findings include: The facility's Pneumococcal Vaccine (Series) policy, implemented 3/1/19, states: Policy Explanation and Compliance Guidelines: .8. The resident's medical record shall include documentation that indicates at a minimum, the following: a. The resident or resident's representative was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure medical records contained documentation related to COVID-19 immunizations for 2 Residents (R) (R8 and R36) of 5 residents reviewed for immunizations. R8 and R36's medical records did not include documentation indicating the facility offered or administered COVID-19 immunizations. Findings include: The facility's COVID-19 Vaccination policy, effective 2/4/22, states: Policy Explanation and Compliance Guidelines: 21. The resident's medical record will include documentation of the following: a. Education to the resident or resident representative regarding the risks, benefits, and potential side effects of the COVID-19 vaccine; b. Each dose of the vaccine administered to the resident, or; c. If the resident did not receive the COVID-19 vaccine due to medical contraindication or refusal. d. Follow-up monitoring of the resident post vaccination. On 12/14/22 at 5:18 PM, Director of Nursing (DON)-B provided Surveyor with requested immunization…

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.