Avina on Division

Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection. This practice had the potential to affect more than 4 of the 33 residents residing in the facility. R17 was on contact precautions. On 5/19/25, Licensed Practical Nurse (LPN)-K twice entered R17's room and administered medication without wearing the appropriate personal protective equipment (PPE). On 5/19/25, Laundry Aide (LA)-C transported uncovered clean clothes in hallways and delivered them to residents' rooms. On 5/20/25, LA-C wheeled a cart of clean linens from the clean side of the laundry room through the dirty side and into the housekeeping closet. In addition, a soiled linen hamper was observed in the clean area of the laundry room. Findings include: The facility's Personal Protective Equipment (PPE) policy, revised 11/2024, indicates: PPE refers to a variety of barriers used alone or in combination to protect mucous membranes, skin, and clothing from contact 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, staff and resident interview, and record review, the facility did not ensure a call light was within reach for 1 resident (R) (R17) of 15 sampled residents. On 5/20/25, R17's call light was out of reach and not accessible to R17. Findings include: The facility's Call Lights: Accessibility and Timely Response policy, dated 3/6/25, indicates staff will ensure the call light is within reach of the resident and secured as needed. The call system will be accessible to the resident while in their bed or other sleeping accommodations within the resident's room. On 5/20/25, Surveyor reviewed R17's medical record. R17 was admitted to the facility on [DATE] and had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. R17's Minimum Data Set (MDS) assessment, dated 4/8/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R17 had intact cognition. The MDS assessment also indicated R17 had impairment on one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review, the facility did not ensure the accurate administration of medication for 2 residents (R) (R8 and R11) of 15 sampled residents. On 5/19/25, Surveyor observed medication at R8's bedside hours after the morning medication pass. Staff did not return and check on R8 to ensure the medication was taken but documented the medication as administered. In addition, R8 did not have a quarterly self-administration of medication assessment. On 5/19/25, Surveyor observed Medication Technician (MT)-E prepare mediation for R11 and leave the medication at the bedside. R11 had an order to self-administer medication but did not have a current self-administration of medication assessment. Findings include: The facility's Resident Self-Administration of Medication policy, dated 4/9/25, indicates: It is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer medication after 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.

Based on staff interview and record review, the facility did not designate a person to serve as the food and nutrition services director who was a certified dietary manager, had a national certification for food service management and safety from a national accrediting body, or had an associates or higher level degree in food service management or hospitality. This had the potential to affect all 31 residents residing in the facility. Dietary Manager (DM)-D did not complete an approved dietary manager or food service manager certification course or other related education. Findings include: On 3/26/24 at 11:27 AM, Surveyor interviewed DM-D who indicated DM-D completed a ServSafe course in October of 2023. DM-D indicated DM-D started as the Dietary Manager approximately 2 years prior and had no prior experience or training in food service management. DM-D indicated DM-D was learning what needs to be done to meet the regulations and acknowledged there were things DM-D was not aware DM-D should be doing, including cleaning and disinfecting the filter on the ice machine, maintaining 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 observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect all 31 residents residing in the facility. The ice machine contained black slime on the back inside filter. Two microwaves contained dried food debris. The freezer in the solarium did not contain a thermometer and a temperature log was not maintained. Multiple food items did not contain open or use-by dates. Logs that contained parts per million (PPM) testing of the sanitizer buckets were not maintained. Findings include: On 3/25/24 at 8:27 AM, Surveyor began an initial kitchen tour with Dietary Aide (DA)-E. On 3/26/24 at 11:27 AM, Dietary Manager (DM)-D indicated the facility follows the Wisconsin Food Code. Ice Machine: The Wisconsin Food Code documents at 4-602.11 Equipment Food Contact Surfaces and Utensils: (E) .Surfaces of utensils and equipment contacting food that is not time/temperature control for safety food shall be cleaned: (4) In equipment such as ice bins and beverage dispensing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure Pre-admission Screen and Resident Review (PASRR) requirements were met for 4 Residents (R) (R24, R26, R5, and R133) of 5 sampled residents. R24 was admitted to the facility with a diagnosis of spastic diplegic cerebral palsy. R24's PASRR Level I Screen did not indicate R24 had a suspected intellectual disability/developmental disability (ID/DD). The facility did not obtain county exemption for R24's admission and the facility was unable to provide documentation that R24 was referred for a PASRR Level II Screen. R26's PASRR Level I Screen was not completed timely and a county exemption was not obtained. R5's PASRR Level I Screen indicated R5 had a mental illness (MI) and received medications to treat the symptoms/behaviors of the MI. The facility did not obtain county exemption for R5's admission and R5's PASRR Level II Screen was not completed timely. R133's PASRR Level I Screen indicated R133 had an MI and received medications to treat the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure the wishes of 2 Residents (R) (R23 and R25) of 14 residents were followed when they admitted R23 and R25 whose Power of Attorney for Healthcare (POAHC) paperwork indicated R23 and R25 did not want to be admitted to a nursing home. R23 had an activated POAHC prior to admission to the facility on 3/13/23. R23's POAHC paperwork indicated R23 did not want R23's POAHC to admit R23 to a nursing home. R25 had an activated POAHC prior to admission to the facility on [DATE]. R25's POAHC paperwork indicated R25 did not want R25's POAHC to admit R25 to a nursing home. Findings include: Wisconsin Chapter 155.20(2)(c)2 indicates: A health care agent may consent to the admission of a principal to the following facilities, under the following conditions: a. To a nursing home, for recuperative care for a period not to exceed 3 months, if the principal is admitted directly from a hospital inpatient unit, unless the hospital admission was for psychiatric…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure a physician and Power of Attorney for Healthcare (POAHC) were notified of a change in condition for 1 Resident (R) (R25) of 14 sampled residents. R25's physician and POAHC were not notified when staff observed a bump and bruise on R25's head on 2/26/24. Findings include: On 3/25/24, Surveyor reviewed R25's medical record. R25 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease. R25's Minimum Data Set (MDS) assessment, dated 3/6/24, contained a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated R25 had severe cognitive impairment. R25 had an activated POAHC (POAHC-M and POAHC-P) and received Hospice services. A hospice communication form, dated 2/26/24, contained handwritten and highlighted information on the bottom of the form that indicated: Noticed bruise/bump right eye/cheek/eyebrow. Spoke to (Certified Nursing Assistant) (CNA-N) who noticed the injuries at lunch. R25's medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not accurately code Minimum Data Set (MDS) 3.0 assessments correctly for 2 Residents (R) (R23 and R24) of 14 sampled residents. R23's MDS assessment, dated 3/19/24, did not indicate R23 smoked. R24 had a physician order for continuous positive airway pressure (CPAP) therapy. R24's MDS assessment, dated 2/11/24, did not indicate R24 used a CPAP machine. Findings include: 1. R23 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke). Between 3/25/24 and 3/27/24, Surveyor reviewed R23's medical record. R23's medical record contained a smoking care plan and R23 was observed smoking outside. R23's Annual MDS assessment, dated 3/19/24, indicated R23 did not use tobacco. On 3/27/24 at 12:10 PM, Surveyor interviewed Minimum Data Set Coordinator (MDSC)-J who indicated MDSC-J codes residents' MDS assessments, works in the facility approximately 2 days per week, and also works at a sister facility. MDSC-J indicated MDSC-J…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not ensure smoking materials were safely stored for 1 Resident (R) (R23) of 2 residents. R23's care plan indicated staff should store R23's smoking materials when not in use. On multiple occasions from 3/25/24 through 3/26/24, Surveyor observed cigarettes and a lighter on R23's bedside table. Findings include: The facility's undated Smoking/Vaping Safety policy indicates: The facility has the right to enforce a policy prohibiting residents from keeping any smoking materials in his/her possession for health, safety, and security reasons. A smoking assessment will be completed to determine the level of assistance and supervision needed during smoking, the ability to carry and store smoking materials, and if a smoking apron is indicated. The plan of care shall reflect the results of this assessment. This assessment will be completed upon admission, quarterly, and with significant change. The facility's undated Smoking/Vaping guidelines…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review, the facility did not ensure 1 Resident (R) (R11) of 2 residents received the necessary care and services for respiratory therapy. The facility provided R11 with respiratory therapy via continuous positive airway pressure (CPAP) without a physician's order. In addition, R11's need for and use of CPAP therapy was not care planned, assessed, or monitored. Findings include: The facility's CPAP Therapy policy, dated 5/3/22, indicates: .CPAP is used to treat obstructive sleep apnea (OSA). The goals of this therapy include improve ventilation, improve quality of sleep, decrease hospitalizations, improve cognitive function, improve oxygen saturation during sleep, decrease work of breathing, and improve lung compliance. Procedure: 10) Verify physician orders .18) If ordered, adjust ramp to prescribed time. Cleaning and Maintenance: 4) Follow these steps for cleaning your CPAP patient circuit .I. Remove the headgear from the mask or nasal pillows…

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 food preferences were honored for 1 Resident (R) (R4) of 14 sampled residents. R4's meal card stated NO GRAVY and no mashed potatoes. On 3/26/24, R4 was served mashed potatoes with gravy for lunch. Findings include: On 3/25/24, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE]. R4's Minimum Data Set (MDS) assessment, dated 12/10/23, contained a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R4 had intact cognition. R4's care plan indicated R4 was at risk for nutritional problems due to a diagnosis of adult failure to thrive and tolerated a general diet with soft or pureed foods per R4's preference. R4's activities of daily living self-care performance deficit related to osteoarthritis care plan, initiated on 3/6/23 and revised on 7/18/23, indicated R4 was able to eat items per choice with set up assistance and was allowed to choose pureed or soft foods.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure a medical record contained accurate and complete information for 1 Resident (R) (R25) of 14 sampled residents. On 2/26/24, staff discovered a bump and bruise on R25's head. R25's medical record did not contain information regarding the injury. Findings include: On 3/25/24, Surveyor reviewed R25's medical record. R25 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease. R25's Minimum Data Set (MDS) assessment, dated 3/6/24, contained a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated R25 had severely impaired cognition. R25 had Activated [NAME] of Attorney for Healthcare (POAHC-M and POAHC-P) and received Hospice services. Surveyor reviewed a Hospice note, dated 2/26/24. The note was handwritten, scanned into R25's medical record, and contained highlighted information at the bottom that indicated: Noticed bruise/bump right eye/cheek/eyebrow. Spoke to Certified Nursing Assistant…

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 establish and maintain and infection control program designed to provide a safe and sanitary environment to help prevent the development and transmission of disease and infection for 1 Resident (R) (R8) of 2 residents observed during the provision of care. During an observation of peri and Foley care for R8, CNA (Certified Nursing Assistant)-G did not appropriately remove gloves and cleanse hands. Findings include: The facility's Hand Hygiene/Handwashing policy indicates: Hand hygiene means cleaning your hands by using either handwashing (washing hands with soap and water), antiseptic hand wash, or antiseptic hand rub (i.e. alcohol-based hand sanitizer including foam or gel). Examples of when to perform hand hygiene (either alcohol-based hand sanitizer or handwashing): ~Before and after having direct contact with a patient's intact skin (taking a pulse or blood pressure, performing physical examinations, lifting the patient in bed). ~After contact with blood, body fluids or excretions, mucous membranes,…

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 interview, the facility did not ensure a Registered Nurse (RN) worked at the facility for at least eight consecutive hours per day, seven days per week on multiple dates from April of 2022 to March of 2023. The facility did not have an RN in the facility for at least eight consecutive hours on multiple days and weekends dating back to April of 2022. Findings include: State of Wisconsin DHS (Department of Health Services) 132.62 contains the following information: Nursing services .(2) Nursing administration .(b) Charge nurses in skilled care facilities and intermediate care facilities. 1. Staffing requirement. A skilled nursing facility shall have at least one charge nurse on duty at all times, and: a. A facility with fewer than 60 residents in need of skilled nursing care shall have at least one Registered Nurse, who may be the director of nursing services, on duty as charge nurse during every daytime tour of duty . From 3/5/23 to 3/7/23, Surveyor reviewed the facility's nurse staffing schedules dating back to April of 2022. The following dates…

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 resident interview, and record review, the facility did not ensure a written notification of transfer was provided for 4 Residents (R) (R188, R14, R3, and R20) of 4 residents reviewed for transfer notification. The facility did not provide written notification of transfer, including advocacy information, to R188, R14, R3, and R20 (or their representatives) when transferring care responsibilities to the hospital. Findings include: 1. On 3/5/23, Surveyor reviewed R188's closed medical record which indicated R188 was transferred to Hospital-R on 2/14/23 with shortness of breath, bilateral lower extremity edema, and urethral pain. On 3/5/23 at 1:51 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-F regarding notification provided at the time of R188's hospital transfer. LPN-F verified written notice of transfer was not provided to R188 on 2/14/23 when R188 was transferred to Hospital-R. On 3/5/23 at 2:25 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A regarding…

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.

4. On 3/5/23 at 10:52 AM, Surveyor entered R8's room and observed a charger connected to an outlet in the room. R8 stated the charger was for a motorized scooter and verified the motorized scooter was always charged in R8's room. See interview under example 2. Based on observation, resident and staff interview, and record review, the facility did not ensure the safety of 4 Residents (R) (R14, R17, R18 and R8) of 6 residents reviewed for accidents and hazards related to motorized scooters, smoking and unwitnessed falls. The facility did not complete neurological checks to monitor for nervous system issues after R14's unwitnessed falls. The facility did not charge R17's motorized scooter in an area to minimize damage from risk of fire. The facility did not provide supervision per R18's assessment and care plan or ensure R18's smoking materials were stored safely when not in use. The facility did not charge R8's motorized scooter in an area to minimize damage from risk of fire. Findings include: The facility did not provide a requested neurological checks policy. The facility's form…

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

Based on observation, staff interview, and record review, the facility did not ensure food was stored under sanitary conditions. This practice had the potential to affect multiple residents, including R11 and R12. In November 2022, staff stopped monitoring the temperature of a refrigerator and freezer that contained resident food and beverages. Staff did not apply dating practices to opened time and temperature controlled foods for safety. Staff did not discard expired foods and beverages, including items labeled for R11 and R12. Findings include: On 3/5/23 at 8:50 AM, Dietary Manager (DM)-K stated DM-K was uncertain which standard guided facility practices and indicated DM-K was in the process of completing dietary manager training online. Refrigerator/Freezer Temperature Monitoring FDA Food Code 2022 documented at 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under §3-501.19, and except as specified under ¶ (B) and in ¶ (C) of this section,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure a legal guardian exercised rights within the limits set by Wisconsin (WI) state statute chapter 55 for 3 Residents (R) (R14, R27, and R4) of 6 sampled residents. The facility did not file a petition for protective placement for R14, who had a legal guardian, when R14's stay at the facility exceeded 60 days from admission on [DATE]. The facility did not file a petition for protective placement for R27, who had a legal guardian, when R27's stay at the facility exceeded 60 days from admission on [DATE]. The facility did not ensure R4's protective placement was annually reviewed by the county department and deemed appropriate. Findings include: WI state statute chapter 55.055(1)(b) contains the following information: The guardian of an individual who has been adjudicated incompetent may consent to the individual's admission to a nursing home or other facility not specified in par. (a) for which protective placement is otherwise required 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.

Based on staff interview and record review, the facility did not ensure a legal guardian was provided written notification of a payer source change with appeal rights information in the recipient's preferred language when Medicare Part A benefits ended for 1 Resident (R) (R27) of 3 residents reviewed for advanced beneficiary notifications. The facility did not provide R27's legal guardian (Legal Guardian (LG)-E) with written notification in R27 and LG-E's preferred language (Spanish) and a professional translator to explain the information verbally when presented via telephone. Findings include: Surveyor reviewed R27's Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) forms and noted the NOMNC was not signed by LG-E; however, telephone notification to LG-E was documented. Surveyor noted translator information was not included and both forms were printed in English. R27's care plan documented R27's primary and preferred language was Spanish. On 3/6/23 at 11:00 AM, Surveyor interviewed Social Worker (SW)-C…

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 and resident interview, and record review, the facility did not ensure written notification of the facility's bed-hold policy was provided for 2 Residents (R) (R188 and R14) of 4 residents reviewed for bed-hold policy notification. The facility did not provide written notification of the bed hold policy to R188 when the facility transferred R188's care to Hospital-R. The facility did not provide written notification of the bed hold policy to Legal Guardian (LG)-D when the facility transferred R14's care to a local. hospital. 1. On 3/5/23, Surveyor reviewed R188's closed medical record which indicated R188 was transferred to the hospital on 2/14/23. R188's medical record did not contain a written bed-hold notification. On 3/5/23 at 1:51 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-F regarding written bed-hold notification provided at the time of R188's transfer to Hospital-R. LPN-F verified a bed-hold notification was not provided to R188 at the time of the transfer because providing a written notification slipped LPN-F's mind at the time of the non-emergent…

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) (R20) of 5 sampled residents met the Pre-admission Screen and Resident Review (PASRR) requirements. R20's Level 1 PASRR documented R20 had a current diagnosis of a major mental disorder. No further PASRR screens were completed for R20. Findings include: From [DATE] to [DATE], Surveyor reviewed R20's medical record. Surveyor noted R20's medical record contained a Level I PASRR; however, a Level II PASRR was not submitted as required. R20 had a diagnosis of paranoid schizophrenia and was prescribed the antipsychotic medications Clozaril and fluphenazine. Surveyor noted a Level I PASRR screen was completed on [DATE] and indicated R20 was suspected of having a serious mental illness. In Section A of the PASRR Level I, Question 1 asks, Does the person have a major mental disorder under the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition, revised (DSM III-R) or DSM 5? The yes box was checked. In Section B,…

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 activities were designed and provided to meet interests for 1 Resident (R) (R14) of 1 resident reviewed for activities. The facility did not comprehensively assess, care plan, and provide activities for R14 since R14's admission on [DATE]. Findings include: From 3/5/23 through 3/7/23, Surveyor reviewed R14's medical record which documented R14 was admitted with diagnoses including expressive aphasia (the inability to vocally express one's self). Legal Guardian (LG)-D was responsible for R14's decision making. R14's admission Minimum Data Set (MDS) activities assessment, dated 8/7/22, indicated R14 was not interviewable and LG-D was not interviewed as part of the assessment. R14's activities care plan documented R14 had little or no activity involvement related to depression, disinterest, immobility, physical limitations, and poor adjustment to the facility/unit. R14's activity care plan documented R14 preferred to stay in R14's room alone…

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 treatment and care were provided in accordance with professional standards of practice for 2 Resident (R) (R11 and R24) of 3 sampled residents reviewed for weight monitoring. R11 had an order for daily weights and to update the physician with weight changes of plus or minus 3 pounds per day or plus or minus 5 pounds per week. The facility did not consistently monitor R11's weight and/or notify R11's physician of weight changes. R24 had an order for monthly weights. The facility did not consistently monitor R24's weight on a monthly basis. Findings include: The National Library of Medicine, in a web-based article published in 2022 regarding Furosemide, indicated: A boxed warning suggests the cautious use of Furosemide as it is a potent diuretic, which can predispose to excessive loss of water and electrolytes, resulting in dehydration with electrolyte depletion .Careful monitoring of the patient's clinical condition, daily weight, fluids…

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 creation of a culturally competent, trauma-informed care plan for 1 Resident (R) (R14) of 1 resident with an identified trauma history and assessed as having intermittent issues with coping and functioning related to surviving trauma. The facility did not develop a trauma-informed care plan after assessing R14 as a trauma survivor on 10/27/22. Findings include: According to Substance Abuse and Mental Health Services Administration (SAMHSA, 2014) (https://www.ncbi.nlm.nih.gov/books/NBK207191/), The impact of trauma can be subtle, insidious, or outright destructive. How an event affects an individual depends on many factors, including characteristics of the individual, the type and characteristics of the event(s), developmental processes, the meaning of the trauma, and sociocultural factors. SAMHSA explains trauma causes immediate and delayed emotional, behavioral, physical, cognitive, and existential reactions. From 3/5/23 through 3/7/23, Surveyor reviewed R14's medical record which documented Legal Guardian…

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) (R14) of 3 residents reviewed for behavioral health with a diagnosed mental health disorder and trauma history was provided with a Medical Doctor (MD) ordered psychiatric consult. The facility did not obtain a psychiatric consult for R14 after an MD ordered the consult on 9/14/22. Findings include: From 3/5/23 through 3/7/23, Surveyor reviewed R14's medical record which documented Legal Guardian (LG)-D was responsible for R14's decision making. R14's diagnoses included schizoaffective disorder and expressive aphasia (the inability to verbally communicate). R14 was prescribed escitalopram oxalate (a psychotropic medication used to treat anxiety and depression). R14's care plan did not identify target behaviors or non-pharmacological interventions for R14's mental health. On 10/27/22, the facility completed a brief trauma questionnaire with R14 based on head nodding and shaking (due to expressive aphasia) that indicated R14 experienced a serious accident, was in a natural or technological disaster,…

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 behavioral interventions and psychotropic medication monitoring was implemented for 1 Resident (R) (R14) of 5 residents reviewed for medications. The facility did not develop R14's psychotropic medication care plan, identify target behaviors, develop non-pharmacological interventions, or implement monitoring for target behaviors and medication side effects. Findings include: From 3/5/23 through 3/7/23, Surveyor reviewed R14's medical record which documented Legal Guardian (LG)-D was responsible for R14's decision making. R14's diagnoses included schizoaffective disorder and expressive aphasia (the inability to verbally communicate). R14 was prescribed escitalopram oxalate (a psychotropic medication used to treat anxiety and depression). R14's plan of care did not identify target behaviors or non-pharmacological interventions for R14's mental health. On 3/7/23 at 10:50 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A regarding R14. NHA-A reviewed R14's care plan with Surveyor and confirmed the only…

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.