Meadowbrook At Chetek

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not report an incident of potential neglect to the state agency immediately upon learning of an incident wherein resident (R) received the wrong medication which required administration of Narcan and hospitalization, nor did the facility submit the 5-day investigation within 5 days as required. The facility practice had the potential to affect 1 of 8 residents (R1). The facility policy titled Abuse prevention program facility procedures training program and staff materials undated, states under Option 5: Possible Neglect: Means the failure to provide goods or services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress or could be reasonably expected to cause, pain, injury or deathR1 was admitted to the facility on [DATE], with diagnoses that include orthostatic hypotension (condition, which is defined as low blood pressure (hypotension) that occurs upon standing) and neurocognitive disorder with Lewy…

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 interviews, the facility failed to conduct a thorough investigation and implement corrective action in a timely manner for 1 of 8 residents (R) R3, resulting in 2 additional significant errors to occur for R1 and R5.R3 was administered incorrect opioid pain medication on 07/02/25.R1 was administered medications for R2, which required receiving Narcan and hospitalization on 07/04/25.R5 was administered medication that was discontinued and wrong dosage form on 07/06/25.The facility's policy, titled Medication Administration last revised on 12/2025, states: Resident medications are administered in an accurate, safe, timely and sanitary manner.Under section labeled Procedure states in part the following: Verify the medication label against the medication sheet for accuracy of drug frequency, duration, strength and route. If the label and medication sheet are different .or any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage…

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 a system was in place to establish disposition of destroying controlled drugs for 2 of 6 residents (R) (R2 and R5) reviewed for medication errors.R2's Lyrica was not destroyed in a timely fashion and by 2 licensed nurses.R5's Lorazepam medication was discontinued and not removed from circulation.The facility policy titled, Destruction of Unused Drugs, revised [DATE], states: All unused, contaminated, or expired prescription drugs shall be disposed of in accordance with state laws and regulations. This includes having a witness to medications being destroyed.Example 1On [DATE] at 1:25 PM, Surveyor reviewed R2's Narcotic sheet that states, .[R2] is to be given Pregabalin (Lyrica) 50 mg capsule by mouth two times a day ordered on [DATE]. Surveyor observed R2's narcotic sheet to have a crossed of X over top the whole sheet with Destroyed RN on [DATE] with one signature at the bottom.On [DATE] at 3:44 PM, Surveyor interviewed DON B about destruction 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 interview, observation and record review, the facility did not ensure that a system was in place to ensure residents receive medications that are properly labeled and administered accordingly for 2 of 8 residents (R5, R6) reviewed for medication errors. R5 was administered medication that was discontinued and incorrect dosage form. R6 was administered medication without proper labeling.The facility's policy, titled Medication Administration last revised on 12/2025, states: Resident medications are administered in an accurate, safe, timely and sanitary manner.Under section labeled Procedure states in part the following: If the label and medication sheet are different .or any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule. Never administer medications from an unmarked container.Example 1R5 was admitted to facility on 03/21/25 with diagnoses that include chronic obstructive pulmonary disease, chronic pancreatitis and generalized anxiety disorder.On 06/02/25, R5 was placed on hospice care. On 06/02/25, R5…

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 accurate reporting of the mandatory submission of staffing information based on payroll data to the Centers for Medicare and Medicaid Services (CMS). The facility failed to enter accurate data in their Payroll Based Journal (PBJ) system which triggered that they have excessively low weekend staffing. This has the potential to affect all 71 residents residing in the facility. This is evidenced by: Centers for Medicare & Medicaid Services (CMS) Electronic Staffing Data Submission Payroll-Based Journal, Long-term Care Facility Policy Manual, dated June 2022, states in part: Chapter 1: Overview, 1.1 introduction .(U) mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS.1.2 Submission Timelines and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure residents (R) who were prescribed psychotropic medication were comprehensively assessed for qualitative and quantitative data for individualized targeted behaviors, no gradual dose reductions (GDR) for the first year were completed, and non-pharmacological interventions were implemented, for use of the medications for 5 of 7 residents (R6, R21, R32, R53 and R261) reviewed. R6 receives psychotropic medications. R6 does not have a care plan identifying individualized targeted behaviors, tracking of behaviors, or non-pharmacological interventions in place for anti-psychotic and anti-anxiety medications use. R21 receives psychotropic medications. R21 does not have a care plan for individualized targeted behaviors, tracking of behaviors, or non-pharmacological interventions in place for anti-psychotic medication use. R53 receives psychotropic medications. R53 does not have a care plan for individualized targeted behaviors, tracking of behaviors, 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 observation, interview and record review, the facility did not ensure residents received services in the facility with reasonable accommodation of resident needs for 1 of 18 residents (R) (R34) reviewed. R34's call light was observed to be out of reach. This is evidenced by: Facility policy titled, Fall Management, with a revised date of October 2024, states in part: The facility assists each resident in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive device, and/or functional programs, as appropriate, to minimize the risk for falls. R34 was admitted to the facility on [DATE] with pertinent diagnoses of monoplegia of upper limb affecting left non-dominant side (paralysis/weakness of one limb) and chronic obstructive pulmonary disorder (COPD). R34's most recent Minimum Data Set (MDS) quarterly assessment completed on 01/18/25 noted a Brief Interview of Mental Status (BIMS) score of 15/15, indicated cognition intact. R34…

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 the necessary treatment and services consistent with professional standards, to prevent pressure injuries (PI) from developing infection and promote healing for 1 of 1 resident (R) R20, reviewed for PIs. R20 was not provided PI treatment as ordered, and staff did not perform hand hygiene during PI treatment to prevent infection. This is evidenced by: R20 was admitted to the facility on [DATE]. R20's current diagnoses include in part, sepsis, surgical aftercare, muscle weakness, end stage renal disease, dependence on renal dialysis, diabetic mellitus type 2, peripheral vascular, infection of skin and subcutaneous tissue, acquired absence of right leg below knee, and venous insufficiency chronic peripheral. Minimum Data Set (MDS), dated [DATE], a 5 day assessment documented R20 having a brief interview of mental status score of 13/15 meaning R20 is cognitively intact. R20 is dependent on staff for toileting hygiene,…

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 resident environment remained as free of accidents as possible for 2 of 4 residents (R) R23, R20, reviewed for accidents/falls. R23 had a fall in the bathroom after being left unsupervised for an extended period of time. R20 vapes and was not assessed to vape/smoke independently and a smoking care plan was not developed. This is evidenced by: Example 1 Facility policy titled, Fall Management, with a revised date of October 2024, states in part: The facility assists each resident in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive device, and/or functional programs, as appropriate, to minimize the risk for falls. The Interdisciplinary Team (IDT) evaluates each resident's fall risk. A Care Plan is developed and implemented, based on this evaluation, with ongoing review. R23 was admitted to the facility on [DATE] with pertinent diagnoses of cerebral…

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 a resident who requires dialysis receives such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences for 1 of 1 sampled resident (R20) reviewed for dialysis. The facility failed to provide ongoing assessment of R20's condition and monitoring for complications before and after dialysis treatments. This is evidenced by: Facility's policy titled Hemodialysis with the revision date of March 2023, read in part, The ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. 8. The nurse will monitor and document the status of the resident's access site(s) upon return from the dialysis treatment to observe for bleeding or other complications. 9. The facility will communicate with the dialysis facility, attending physician and/or nephrologist any significant…

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 for 3 of 18 residents (R) (R20, R6, and R26) observed. Facility staff did not conduct appropriate hand hygiene when providing wound care for R20 and personal cares for R6. R20 has open wounds, and the facility did not implement enhanced barrier precautions (EBP), and staff did not wear personal protective equipment (PPE) when providing wound care. R26's urinary bag was observed on the floor. This is evidenced by: Facility policy titled: Hand hygiene last revised on 09/22 states: Purpose: To provide guidelines to staff for proper and appropriate hand washing and hygiene techniques that will aid in the prevention of the transmissions of infections. Under the procedure sections titled Washing hands with Soap and Water states: 1. Staff will…

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 prepare, distribute, and serve food in a manner that prevents foodborne illness for 57 of 59 residents reviewed. Findings include: Facility policy titled Storage, Prepare, Distribute, and Serve Food, last revised April 2020, stated in part, .-#3. Storage (Refrigerated) c. All refrigerated and prepared food must be covered, labeled, and dated with use-by date . Facility policy titled Labeling Food and Date Marking, last revised February 2020, stated in part, .-#2. Recommended that all items placed in refrigeration units be labeled with the name of the item, the date the item is placed in the refrigerator and/or the date it is to be used .-#6. Refrigerators and storage areas are routinely checked for temperatures, labeling, and dating of food items with food being discarded when beyond the use-by date . Facility policy titled Food from Outside Sources, last revised 04/13/20, stated in part, .-#4. All food items that are already prepared by family or visitor brought into the facility must: a. Be labeled 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 staff interview and record review, the facility did not ensure 1 resident (R), R1, of 3 sampled residents reviewed for conveyance of resident funds, had funds returned to the Power of Attorney (POA), family, or estate within 30 days of resident death. The facility did not refund R1's trust funds to POA within 30 days of death. Findings include: The facility policy entitled, Resident Trust Accounts, dated 08/2022, states in part: .#7. Upon the death of a resident with a personal fund deposited with the facility, the facility will convey promptly the residents' funds and final accounting of those funds, to the individual administering the residents estate . On [DATE] at 8:40 a.m., Surveyor toured facility. After tour was completed, a sample of residents was chosen from a list of discharged /expired residents during time frame of [DATE] to [DATE]. This list included R1. Surveyor reviewed R1's record. R1 was admitted to the facility on [DATE]. Resident expired [DATE]. Surveyor reviewed R1's account history.…

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 report to the physician on call post falls for 2 of 3 residents (R) reviewed for falls (R1 and R2). Findings include: The facility policy titled, Change in Condition Policy, dated 08/2024, states in part: .-#1: The physician and durable power of attorney/ responsible party will be notified when there has been a change that is sudden in onset, a change that is a marked difference in usual signs/symptoms and/or the signs/symptoms are unrelieved by measures already prescribed. -#2: a. significant change g. change in level of consciousness j. A discovery of injuries if an unknown source . Example 1 R1 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, cerebral infarction, hemiplegia and hemiparesis affecting left non-dominant side, frontal lobe and executive function deficit following cerebral infarction, and muscle weakness. R1's minimum data set (MDS) assessment, completed on 08/27/24, confirmed R1 scored 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 observations, interviews and record reviews, the facility did not provide care and treatment by professional standards of practice to maintain a resident's highest practicable level of physical well-being for 2 of 3 residents (R) reviewed. (R1 and R2) R1 and R2 did not receive accurate assessments and treatment following falls. Findings include: The facility policy titled, Fall Management, dated 07/2020, states in part: .#1. When a fall occurs, the resident is assessed for injury by the nurse. -#2. The nurse will enter the event information into risk console, complete an incident report, complete the SBAR communication form and progress note, add the fall even to the 24 hour report, and initiate the interdisciplinary post fall review. -#3. The nurse communicates the fall to the attending physician and the residents representative. -In the event a resident has a fall and it has been determined they hit their head, or it cannot be determined if they hit their head (unwitnessed), the nurse initiates 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 new care planned fall interventions were put into place post falls to prevent further incidents from occurring for 3 of 3 residents (R) R1, R2, and R3 reviewed for falls. R1 was at risk for falls and had a fall on 09/09/24. Facility did not implement new interventions post fall. R2 was at risk for falls, and had two falls, one on 10/09/24 and one on 10/24/24. Facility did not implement new interventions post fall. R3 was at risk for falls and had a fall on 10/21/24. Facility did not implement new interventions post fall. Findings include: Example 1 R1 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, cerebral infarction, hemiplegia and hemiparesis affecting left non-dominant side, frontal lobe and executive function deficit following cerebral infarction, and muscle weakness. R1's minimum data set (MDS) assessment, completed on 08/27/24, confirmed R1 scored 5 out of 15 during a brief interview for mental status…

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 proper hand hygiene with food handling in accordance with professional standards for food service safety. Dietary staff did not use hand hygiene after touching dirty surfaces and continued to serve food; also hair nets were not used in areas that require hair nets. This has the potential to affect one resident who would receive the coffee, and 4 plates prepared in an unsanitary manner. Findings include: The facility policy, entitled Personal Cleanliness and Hygienic Practices, dated February 2020, States in part, 4. All dietary staff, including the Dietary Manager, and any person entering the kitchen, must wear an approved hair restraint to keep hair and particles in the hair from falling into the food. Hair restraints must entirely cover all hair . 6. Single-use gloves shall be worn as necessary to prevent bare hand contact with ready-to-eat food and shall be changed when they become soiled. Hands must be washed before putting on gloves and after removing gloves. On 04/21/24 at 9:28 AM, Surveyor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review. the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 1 of 16 sampled residents (R161). The facility did not follow physician orders for R161, to obtain a follow up oncology appointment after a newly diagnosed condition requiring further evaluation, within 2-4 days after admission. Findings: The facility's admission checklist included, in part . Admitting nurse begin the process, orders, assessment, introduction, progress notes. 2nd nurse continues checking of items on the list. 3rd nurse completes, the checklist then goes to the DON/ADON for final checks and review. All orders need to be 2nd check by a nurse and 2 signatures are needed on each page. To be done within the first 4-8 hours of admission. 1st nurse enters in queue, 2nd nurse verifies. Note appointments, labs, etc. in appropriate place. R161 was admitted to the facility on [DATE]. Diagnoses included lesion noted on the left ninth rib, possible…

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 evaluate for hazards or risks related to oscillating percussion vest for a resident with a diagnosis of quadriplegia and assessed as high risk for aspiration. Deficiency identified for 1 of 6 residents (R26) reviewed for accidents. Findings: R26 was admitted to the facility on [DATE]. Diagnoses included quadriplegia, traumatic brain injury, diaphragmatic hernia with obstruction, dysphagia, feeding tube for nutrition, history of aspiration pneumonia, aphasia, contractures of bilateral hands, epilepsy, muscle spasms, and tremors. Minimum data set (MDS) assessment completed on 03/27/24, confirmed staff assessment indicated R26's cognition was severely impaired. R26 is dependent on all staff for activities of daily living (ADLs). R26's physician orders included: Start date, 11/23/2023. Afflo Respiratory Vest, use x 30 minutes twice daily (BID) while sitting up in w/c. Stop tube feeding during session. Check mouth after session and suction as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interview, the facility did not ensure that residents who are medicated by enteral means received the appropriate treatment to prevent complications during medication administration through a Gastric tube (G-tube). This was observed with 1 of 1 resident (R38) observed for medication administration through a G-tube. R38 received medication without ensuring the G-tube was appropriately placed prior to medication administration. Findings include: The American Association of Critical Care Nurses, April 2016, Initial and Ongoing Verification of Feeding Tube Placement in Adults advises, .Checking Tube Location at Regular Intervals After Feedings Are Started, Unfortunately, feeding tubes can become dislocated during use. For this reason, it is necessary to monitor tube location at regular intervals while the tube is being used for feedings or medication administration. Observing for change in external tube length .Reviewing routine chest and abdominal radiography reports…

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. Staff did not perform proper hand hygiene during medication administration with Resident (R) 32 and the facility removed droplet precautions on R10 before the required isolation period was complete. This has the potential to affect 2 of 9 residents (R32, R10) observed for medication administration and contact precautions. Staff did not perform proper hand hygiene during medication administration with R32. Facility removed droplet precautions on R10 before the required isolation period was complete. Findings: The facility's policy titled, Hand Hygiene revised September 2022 states in part: .Using Alcohol-Based Hand Gel 1. If hands are not visibly soiled, use an alcohol-based hand rub for all the following situations: .b. Before preparing or handling medications; .f. After providing direct resident care; R32 was admitted on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not provide necessary respiratory care and services related to Trilogy, (an all-in-one device, capable of delivering both invasive and non-invasive ventilation) consistent with professional standards of practice for 1 of 1 resident (R1). *R1's hospital referral received on [DATE] stated R1 used a BiPAP while in the hospital. Facility did not question hospital if BiPAP was to be continued once discharged to the skilled nursing facility. *R1's discharge orders on [DATE] stated BiPAP at night for OSA (Obstructive Sleep Apnea), which was transcribed under laboratory orders by the facility upon admission. *R1 did not receive BiPAP until family brought machine in on [DATE]. R1 went 3 days without BiPAP machine. This is evidenced by: R1 was admitted to the facility on [DATE] with diagnoses including but not limited to acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure, COPD (chronic obstructive pulmonary disease) with acute…

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.