Meadowbrook At Black River Falls

Based on interview and record review, the facility did not designate a person to serve as the director of food and nutrition services who had completed the minimum qualification requirements for the position. This practice could potentially affect all 31 residents residing in the facility. The facility's Dietary Manager (DM) is currently enrolled but has not started classes to be a Certified Dietary Manager. The Dietary Manager has been in the position for approximately two weeks. The facility does not have a full-time Registered Dietician at the facility. Findings include: On 12/17/24 at 9:40 AM, Surveyor toured the kitchen with DM D and asked what qualifications they held that allowed them to assume the role of Dietary Manager. DM D stated they had just started in the position approximately two weeks ago and did not hold any certifications to be a dietary manager. DM D stated they were supposed to be enrolled in a training program but did not think that had happened yet. On 12/17/24 at 2:33 PM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked if DM D was qualified…

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 the preparation of food in a clean and sanitary environment. This has the potential to affect all 31 residents in the facility. Staff did not consistently date or label food items when opened. Staff did not consistently test or document parts per million (PPM) of the quaternary sanitizing solution. Staff did not consistently document refrigerator and freezer temperatures. Staff did not consistently test or document dish machine temperatures. Staff observed touching ready to eat food with contaminated gloves. Staff observed delivering trays to resident rooms with uncovered food items on the tray. Findings include: Labeling open foods: According to facility policy and procedure entitled, Labeling Food and Date Marking, .Foods from processing plants are marked at the time the original container is opened and if the food is held for more than 24 hours, the date or day by which the food is to be consumed or discarded is indicated . On 12/17/24 at 9:40 AM, Surveyor conducted a tour of the kitchen with Dietary…

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

Based on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Staff did not follow proper personal protective equipment (PPE) procedures when doing wound care for a resident (R) on enhanced barrier precautions (EBP) and did not sanitize bandage scissors and marking pen prior to and after use. This affected 1 of 2 residents (R) observed for wound care. (R3) Findings include: According to CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, last revised April 12, 2024, to prevent cross-contamination ensure all wound care equipment is properly cleaned and disinfected between patients. On 12/17/24 at 1:22 PM, Surveyor observed Registered Nurse (RN) H provide wound care for R3. Surveyor observed a sign on R3's door identifying that R3 was on Enhanced Barrier Precautions. The sign indicated all staff must wear a gown and gloves for high-contact resident cares. RN H used hand…

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 the safety of food handling in accordance with professional standards for food service safety. Milk and juice, placed in the walk-in-cooler, had been opened but were not labeled with an opened date or use by date. Daily temperature logs for recording refrigerator and freezer temperatures had missing entries, resulting in the potential for foodborne illness to spread. This had the potential to affect 31 out of 32 residents that eat orally. Findings include: The facility's policy entitled Storage, Prepare, Distribute and Serve Food dated April 2020, states in part, 1. Temperatures a. Refrigerator/Freezer Temperature Log (FS-04/A) must be completed and reviewed on a daily basis . 3. Storage (Refrigerated) .c. All refrigerated and prepared food must be covered, labeled, and dated with a use-by date that is the maximum of 7 days from date of preparation. Label must include the name of the food and the date by which it should be used. On 10/06/24 at 10:33 AM during initial kitchen tour with Dietary Manager (DM)…

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 formulate an advance directive for the resident. Resident (R) 236 did not have orders for the advanced directive they elected for on file, or in a place for emergency personnel to retrieve the information if needed. This had the ability to effect 1 of 12 residents surveyed (R236). Findings include: The facility policy, entitled Advanced Directives, dated [DATE], states: Documentation . 1. Copied of any advanced directives are maintained in the residents clinical record. 2. The facility must document in a prominent part of the residents clinical record whether the resident has issues an advanced directive R236 was admitted on [DATE] to the facility and is able to be understood by peers and understands. On [DATE] at 1:39 PM, record review of R236's hard charts and electronic record could not produce an order for a Cardiopulmonary Resuscitation (CPR) or Do - Not - Resuscitate (DNR). Surveyor could not find a provider order related to advanced directives. On…

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

Based on observations, interviews, and record reviews, the facility did not consult with a physician for 1 of 3 residents (R) R26 who had experienced a significant weight gain. This is evidenced by: The facility policy entitled Change in Condition Policy: dated August 2024 states: The purpose of this policy is to ensure the facility promptly consults the physician when there is a change requiring notification. Procedure - .The physician will be notified when there has been a change that is marked a difference in usual sign/symptoms. Specific information that requires prompt notification include . significant weight change gain or loss of 5% or more in the past 30 days, 7.5% or more in past three months, or 10% or more in the past six months. R26 was admitted to facility on 11/15/23, and has diagnoses that include Alzheimer's disease, hypertension, and chronic pain. R26 has a BIMS of 7, indicating moderately impaired cognitive level. R26's Quarterly Minimum Data Set (MDS) with target date of 05/23/24, Section K: weight 178#. R26's MDS with target date of 08/23/24, Section K: weight…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure each resident is free from physical restraints that are not required to treat the resident's medical symptoms for 1 of 1 resident reviewed for restraints (R3). R3 had a lap belt in his wheelchair without a physician order for use, the medical symptom the lap belt was being used to treat, or an assessment to determine appropriateness of its use. The device was not indicated in R3's care plan. This is evidenced by: The facility's policy titled Restraint Management, read in part .If indicated, the least restrictive restraint is used for the least amount of time. In cases where restraints are implemented based on the resident's assessment, the facility will make reasonable efforts to reduce their use systematically and gradually. Physical restraints include, but are not limited to, leg restraints, arm restraints, soft ties, lap cushions, and lap trays the resident cannot remove easily. Also included as restraints are facility…

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

Based on interview and record review, the facility did not report an incident of potential misconduct to the state agency immediately upon learning of the incident and did not submit the 5-day investigation within 5 days as required. The facility practice had the potential to affect 1 of 2 residents (R) reviewed for abuse (R187). This is evidenced by: The facility police entitled Abuse prevention Facility Procedures Training Program and Staff Materials defines Neglect: Means the failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, or mental anguish. Neglect is the intentional carelessness, negligence, or disregard of policy or care plan which could cause or could be reasonably expected to cause pain injury or death. Section VII. External Reporting. 1. Initial Reporting of Allegations. When an allegation of abuse exploitation neglect, mistreatment or misappropriation of resident property has been made the administrator or designee shall complete a submit and submit a DQA form (F-62617), notifying DQA that an occurrence of potential…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility did not ensure 3 of 12 sampled residents (R11, R28, R20) reviewed for hospitalizations, received the proper notice of transfer, reason for transfer and location of transfer. Findings: Example 1 and 2 R11 was hospitalized on [DATE] and was not provided with a written notice of transfer. R28 was hospitalized on [DATE] and was not provided with a written notice of the transfer. R28 was hospitalized on [DATE] and was not provided with a written notice of transfer. Example 2 On 10/08/24, Surveyor reviewed R20's record. Record review identified R20 had a change in condition on 08/05/24. R20 was transferred to the emergency room and later admitted to the hospital with a diagnosis of a complicated urinary tract infection (UTI) with chronic indwelling Foley catheter. R20 remained in the hospital until 08/08/24. On 10/08/24, Surveyor requested written notice of transfer from facility administration and no notice of transfer was received. Surveyor was unable to find…

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 of 12 sampled residents (R28 and R20) reviewed for hospitalization, received notification of the facility's bed hold policy when they were transferred to the hospital. Findings include: The facility's policy titled, Bedhold Notification, read in part, When a resident is transferred to a hospital or requests a therapeutic leave, the center will provide written notice to the resident and/or resident representative regarding the resident's bed hold rights and the centers bed hold policy. When hospitalization or a therapeutic leave is necessary, the Resident's bed will be held automatically for 15 days at a rate of 100% of the Resident's current daily rate, unless the Resident or Resident Representative notifies the Facility's Business Office or Social Work Department or unless a condition of involuntary removal has been met. A statement will be given to the Resident outlining the Facility's bed hold policy at the time of transfer to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not complete a Significant Change in Status Assessment (SCSA) for 1 resident (R11) of 12 sampled residents. R11 experienced a significant change in physical condition and cognition, identified on 09/12/24; the facility did not complete a SCSA for R11. This is evidenced by: According to the Resident Assessment Instrument (RAI) manual, a significant change is defined as: -A decline or improvement that will not resolve itself without staff intervention or standard clinical interventions. -A change that affects more than one area of the resident's health. -A change that requires a revision or interdisciplinary review of the care plan. Examples of a significant change in the resident's status include, in part: -A decline in two or more areas. -A decline in an Activities of Daily Living (ADLs) physical functioning. -A new pressure ulcer at Stage II or higher. -The resident's condition deteriorates overall. -The resident receives more support. -The resident…

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 treatment and care in accordance with professional standards of practice for 1 of 12 sampled residents (R11). The facility did not follow hospital discharge orders to complete laboratory testing five days after R11 discharged from the hospital. The facility did not follow hospital discharge orders to complete a sleep medicine evaluation to determine possible interventions related to R11 refusing to wear continuous positive airway pressure (CPAP) device. Findings: R11 was admitted to the facility on [DATE]. Diagnoses included dependence on supplemental oxygen, shortness of breath, obstructive sleep apnea, history of nicotine dependence, chronic obstructive pulmonary disease (COPD), respiratory failure with hypercapnia (elevated carbon dioxide levels), and respiratory failure with hypoxia (low levels of oxygen in the body's tissues). R11's Minimum Data Set (MDS) assessment, completed on 07/29/24, confirmed R11 scored 15/15 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 record review and interviews, the facility did not ensure acceptable parameters of nutritional status, such as usual body weight or desirable body weight range by obtaining routine weights routinely for 1 resident (R26) who had a significant weight gain. This is evidenced by: The facility policy entitled Weight Management dated September 2024 states: Resident's nutritional status will be monitored on a regular basis to aid in the maintenance of acceptable parameters, such as body weight, unless the resident's clinical condition demonstrates that this is not possible. Accurate weights are obtained by having staff follow a consistent approach to weighing and by using an appropriately serviced and functional scale. Weight can be a useful indicator of nutritional status when in evaluated within the context of the individual's personal history and overall condition. Significant unintended changes in weight loss or gain, may indicate a nutritional problem. Practice Guidelines: Weights will be obtained by nursing staff using the following process: Identify a consistent day 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, observation and record review, the facility did not ensure that a resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding. The facility did not follow current standards when checking feeding tube placement for 2 of 3 residents (R) investigated for feeding tube use (R24, R13). Findings Include: Example 1 The facility policy, entitled Care and Treatment of Feeding Tubes, dated April 2024, states: 6. In accordance with facility protocol, licensed nurses will monitor and check that the feeding tube is in the right location (e.g., stomach or small intestine, depending on the tube): . a. Tube placement will be verified before beginning a feeding and before administering medications. Of note: Nowhere in facility policy does it note that auscultation is no longer recommended for checking placement of the feeding tube. Movement of air would likely be heard whether the tube was 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Example 2 On 10/07/24 at 11:02 AM, Surveyor entered R29's room to check the labeling on the oxygen tubing that R29 used regularly. Upon entering, Surveyor encountered Assistant Director of Nursing (ADON) G with new oxygen tubing in hand and R29 still using the original tubing. Surveyor asked ADON G if the tubing that R29 was currently using was labeled to which ADON G stated no it was not, this is why I decided to change the tubing. Surveyor then asked if they would expect there to be a label on R29's oxygen tubing to which ADON G said yes, they would expect that to be completed every time there is an oxygen tubing change. Based on observation, interview and record review, the facility did not ensure that 2 of 2 residents (R11 and R29) reviewed for respiratory care were provided care consistent with professional standards of practice. R11 and 29 require oxygen and have a physician's orders to change oxygen tubing weekly. These were not changed as ordered. This is evidenced by: Example 1 The facility's policy…

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 have a reliable system to account for the receipt, usage, disposition, and reconciliation of controlled medications for 4 out of 4 residents (R) reviewed and receiving controlled medications (R29, R1, R31, R286). Record review of the Controlled Substance Logs identified the logs were not accurate, as the quantity remaining of controlled medications was not accurately recorded. Sufficiently detailed records of receipt and disposition of controlled medications were not maintained to enable accurate reconciliation. Findings include: The facility's policy titled, Controlled Substance Management, dated January 2023, that states in part, It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure F. ii. All controlled substances obtained from a non-automated medication cart or cabinet are recorded on the designated…

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 all drugs and biologicals were stored and labeled in accordance with currently accepted professional principles and did not ensure expired medications and biologics were removed from stock supply in the medication storage room. This occurred for 1 of 3 medication carts/storage rooms observed. An opened multidose medication/solution in the medication storage room refrigerator was not labeled with an opened date and stocked biologics located in the medication storage room were expired. Findings include: The facility's policy entitled Medication Storage dated January 2023, states in part, .all medications housed on our premises will be stored in the pharmacy and /or medication rooms according to the manufacturers' recommendations . The facility's guidelines entitled Medication Storage Guidance dated 2021, states in part, Tuberculin Tests: Aplisol Injection; Tubersol Injection- Store in refrigerator at 36 degrees to 46 degrees. Protect from light. Do not freeze. Date when opened and discard unused portion…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Staff did not wear proper personal protective equipment for enhanced barrier precautions (EBP) when providing care. This had the potential to affect 2 of 12 residents (R) observed for infection control practices (R24, R27). Findings include: Example 1 The facility policy, entitled Enhanced Barrier Precautions, dated September 2024, states: 3. Implementation of Enhanced Barrier Precautions . b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities . 4. High-contact resident care activities include: a. Dressing b. Bathing c. Transferring d. Providing hygiene e. Changing linens f. Changing briefs or assisting with toileting g Device care or use: central lines, urinary catheters, feeding tubes,…

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, facility procedure and documentation review, facility did not have the appropriate competencies and skill sets to provide care for 1 of 1 resident, out of a sample of 3, who had PI management (R2). Facility failed to have a qualified staff member trained in wound care management and wound vac experience onsite during R2's wound care. Findings: R2 was re-admitted to the facility on [DATE] with diagnoses including, in part, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, pressure ulcer stage 4, type 2 diabetes mellitus, and osteomyelitis of vertebrae, sacral, and sacrococcygeal region. Surveyor reviewed R2's physician orders include: .-08/10/24 Wound vac dressing changes on Monday. Wednesday, and then Fridays at wound clinic. Remove old dressing and foam. Cleanse thoroughly with anapest or vashe topical solution. Apply wound vac drape and foam to wound and track pad to right anterior thigh or abdomen. No over bony prominence. Set to 125mmHg. 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 record review and interview, the facility did not consult with and notify the resident's (R) physician when the resident had a significant weight loss. This had the potential to affect 1 of 3 residents reviewed for weight loss (R4). Findings include: The facility policy entitled, Weight Management, with a revision date of November 2021 reads in part, The director of nursing or designee will notify the attending physician of significant weight changes and document in the resident progress notes. Significant weight variance is defined as 5% in one month (30 days); 7.5% in three months (90 days); 10% in six months (180 days). R4 was admitted to the facility on [DATE] and has diagnoses that include type 2 diabetes, moderate protein - calorie malnutrition, and pressure ulcer of right elbow stage 4. On admission R4 weighed 258.2 pounds (lbs). 07/31/23 ~ 237.6 lbs 08/04/23 ~ 218 lbs. 08/11/23 ~ 205.6 lbs 08/28/23 ~ 200 lbs. 09/02/23 ~ 196 lbs. 09/08/23 ~ 187.2 lbs. 09/25/23 ~ 196.8 lbs. 10/12/23 ~ 196.6 lbs.…

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

Based on observation, staff interview and record review, the facility did not follow proper food handling practice. This practice had the potential to affect all 35 of 39 residents residing in the facility. Staff are not documenting all temperatures on refrigerator/freezer temperature logs. Staff are not documenting all dishwasher temperatures on monthly temperature logs. Staff are not documenting all sanitization levels on the sanitization logs. Kitchen staff apply single use gloves without hand hygiene in the kitchen, touch ready to eat foods with bare hands and touch ready to eat foods with contaminated gloves Findings include: Example 1 The facility policy, entitled Storage, Prepare, Distribute and Serve Food, revised April 2020, which states in part, .1. Temperatures .a. Refrigerator/Freezer Temperature Log (FS-04/A) must be completed and reviewed on a daily basis. On 10/16/23 at 8:00 AM, Surveyor reviewed Refrigerator/Freezer Temperature Log, Month: October, Year: 2023. There were temperatures missing on the following dates and times in October: 1st PM shift for refrigerators…

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 alleged violations involving abuse and misappropriation of property are reported immediately to the appropriate agencies for 1 of 2 residents reviewed (R14). An incident regarding R14 occurred on 10/01/23 and was reported to Social Worker (SW) O by R14 on 10/02/23. The incident of alleged abuse was not reported to State Agency (SA) within 2 hours. The abuse was not reported to the state agency until 10/05/23. This is evidenced by: The facility policy entitled, Abuse Prevention Program, states: Any allegation of abuse or any incident that results in serious bodily injury will be reported to the required regulatory agencies immediately, but not more than two hours of the allegation of abuse. Any incident that does not involve abuse and does not result in serious bodily injury shall be reported within 24 hours. R14 was admitted to the facility on [DATE] and has diagnoses that include Parkinson's disease, bipolar disorder, and traumatic brain…

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

Based on observation, record review and interview, the facility did not ensure drugs and biologicals used in the facility are labeled in accordance with current accepted professional principles and include the appropriate accessory and cautionary instructions and the expiration date when applicable. This occurred for 3 of 4 residents, Residents (R) R28, R1, and R29. R28, R1, and R29 have in-use insulin pens that were not dated at the time the insulin pen was first opened. This was evidenced by: On 10/17/23 at 9:00 AM, Surveyor observed medication pass with Licensed Practical Nurse (LPN) H and observed R28's Lantus insulin pen had a use by sticker on it, but it was not filled out. There was no date when the pen needed to be discarded. Surveyor asked LPN H if there were any other insulin vials or pens in the medication cart that could be checked for the date opened sticker. LPN H provided R1's insulin pen Degludec that did not have a use by sticker on it. There was no date when the pen needed to be discarded. Surveyor asked LPN H what the process to date insulin when first opened 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.

Based on observation and interview, the facility did not 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. Staff did not sanitize shared equipment for 2 of 7 residents (R) R24, R13. Staff observed not sanitizing the mechanical lift between use for R24 and R13. This was evidenced by: The facility's policy, entitled Cleaning and Disinfection of Resident Care Equipment, dated March 2020, states: .Reusable equipment will be cleaned and disinfected after use of one resident and before use of another resident . On 10/17/23 at 3:05 PM, Surveyor observed Certified Nursing Assistant (CNA) C and CNA D move R24 from the Broda chair to bed using the Hoyer lift. Neither CNA wiped down the Hoyer lift after use and placed it in the hall. An empty bag was hanging from the Hoyer lift. There were no disinfectant containers in the bag hanging from the lift. On 10/17/23 at 3:22 PM, Surveyor observed 2 Hoyer lifts and 2 sit 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.