Fond du Lac Lutheran Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure protective placement was obtained for 1 resident (R) (R43) of 2 residents reviewed for guardianship. R43 had a legal guardian. The facility did not ensure R43 had court-ordered protective placement in the least restrictive environment at the facility. Findings include: Statute Chapter 55.03(4) states the law requires court-ordered protective placement for any resident admitted to a nursing home who has a legal guardian and whose nursing home stay exceeds ninety days. Between 7/8/24 and 7/10/24, Surveyor reviewed R43's medical record. R43 was admitted to the facility on [DATE] with diagnoses including unspecified intellectual disability, senile degeneration of brain, bipolar disorder, and dementia with behavioral disturbance. R43's Minimum Data Set (MDS) assessment, dated 6/5/24, indicated R43 was severely cognitively impaired. R43 had a guardian as a decision maker. R43's medical record contained R43's Letters of Guardianship for a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not ensure 1 resident (R) (R45) of 1 sampled resident had a self-administration of medication assessment or a physician's order to self-administer medication. R45 did not have a self-administration of medication assessment that indicated R45 could safely and accurately self-administer medication. In addition, R45 did not have a physician's order to self-administer medication. Findings include: The facility's Policies and Procedures: Pharmacy Services Section II Medication Administration Policy (effective date: May 2018) Preparation and General Guidelines Section B. Administration 14 indicates: Residents can self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medication. On 7/9/24, Surveyor reviewed R45's medical record. R45 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus and dementia. R45's Minimum Data Set (MDS)…

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 an environment that was free from abuse for 1 resident (R) (R305) of 1 sampled resident. The facility did not protect R305's right to be free from verbal and mental abuse by R14. Findings include: The facility's Comprehensive Abuse, Neglect, Mistreatment and Misappropriation of Resident Property policy, dated 11/8/24, indicates: It is the policy of the facility that each resident will be free from abuse .Abuse is the willful infliction of .intimidation .or mental anguish .Abuse includes verbal abuse .Verbal abuse involves the use of speech, sound, writing, or gestures when communicating with residents or their families or within their hearing or sight, regardless of their age, ability to comprehensive, or disability .Mental abuse is the use of verbal or nonverbal conduct which causes, or has the potential to cause, the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation .It is…

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

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 an allegation of abuse was reported to the State Agency (SA) for 1 resident (R) (R305) of 1 sampled resident. The facility did not report an allegation of verbal abuse to the SA for R305. Findings include: The facility's Comprehensive Abuse, Neglect, Mistreatment and Misappropriation of Resident Property program, dated 11/8/24, indicates: It is the policy of this facility that all staff monitor residents and will know how to identify potential signs and symptoms of abuse. Occurrences, patterns and trends that may constitute abuse will be investigated .The facility will ensure that all alleged violations involving abuse .are reported immediately, but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse .to the Executive Director of the facility .Employees must always report any abuse or suspicion of abuse immediately to the Executive Director .If an incident 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, staff interview, and record review, the facility did not ensure the comprehensive care plan was implemented for 1 resident (R) (R50) of 19 sampled residents. R50's comprehensive care plan indicated R50 was at risk for developing pressure injuries. The facility did not implement R50's care plan intervention to ensure the prevention of skin breakdown. Findings include: The Facility Assessment, titled Bowel and Bladder Management, dated 8/10/23, indicates: The facility will put prevention measure in place to promote bowel and bladder health. Staff will adopt a person-centered interdisciplinary care plan and implement interventions/approaches to bowel and bladder management to meet the goals of the individual. Per Nursing Home Administrator (NHA)-A, the facility does not have a specific policy for repositioning. Between 7/8/24 through 7/10/24, Surveyor reviewed R50's medical record. R50 was admitted to the facility on [DATE] with diagnoses including unspecified dementia, severe with agitation,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff and resident interview, the facility did not ensure assistance with activities of daily living (ADLs) was provided care in a timely and consistent manner for 1 resident (R) (R2) of 19 sampled residents. R2 waited 31 minutes for staff to provide care. In addition, staff turned R2's call light off prior to providing care. Findings include: 1. On 7/8/24, Surveyor reviewed R2's medical record. R2 had a urinary catheter and was admitted to the facility on [DATE] with a diagnosis of neurogenic bladder. R2's Minimum Data Set (MDS) assessment, dated 5/17/23, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R2 had intact cognition. On 7/8/24 at 10:27 AM, Surveyor interviewed R2. Surveyor noted R2's call light had previously been activated, but was off during the interview. R2 stated R2 had activated the call light because R2 wanted to get up. R2 stated staff had come in and R2 told staff what R2 wanted, but staff turned the call light off. R2 stated R2…

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 the resident environment remained free of accident hazards for 1 resident (R) (R14) of sampled 19 residents. An unsecured oxygen cylinder was stored in R14's room. Findings include: The facility's Safe Use of Oxygen policy, dated 11/8/23, indicates: .ii. If oxygen cylinders are in use, oxygen cylinders shall be secured in an upright position. If stored up upright, cylinders must be secured. On 7/8/24, Surveyor reviewed R14's medical record. R14 was admitted to the facility on [DATE] and had a diagnosis of chronic obstructive pulmonary disease (COPD). On 7/8/24 at 9:29 AM, Surveyor observed an unsecured oxygen cylinder with an oxygen regulator that was connected stored upright in R14's closet. On 7/9/24 at 12:43 PM, Surveyor interviewed RN-D who verified there was an unsecured oxygen tank in R14's closet and indicated the oxygen cylinder should be in a secured holder or secured in the closet. On 7/9/24 at 12:50 PM, Surveyor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #12 Bladder and Bowel Incontinence 07/08/24 01:07 PM Reports Friday & sunday: ostomy was not emptied in timely fashion. Ostomy bag overfilled & Leaked. Resident reports sitting in stool for several hours. Resident claims this has happened numerous times. Facility runs out of the appropriate ostomy bags, when wrong size is used she has issues with leakage. 07/10/24 09:36 AM Type: Nurse's Note Focus: Effective Date: 6/10/2024 01:04:00 Department: *Nursing Position: *Registered Nurse Created By: [NAME] Created Date : 6/10/2024 01:05:45 Record review: 6/10/2024 01:04 Nurse's Note Note Text: colostomy wafer & bag changed d/t blowout. Tolerated procedure well 07/10/24 11:19 AM Record review: No tasks for ostomy care. No regular documentation of ostomy care. No orders for ostomy dressing or care. 07/10/24 12:07 PM Interview with [NAME]: Has never had to change [NAME] ostomy, would check orders for ostomy dressing change. Typically ostomys are changed weekly. Has changed ostomy for another resident ([NAME]) 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 staff and resident interview and record review, the facility did not ensure 1 resident (R) (R12) of 1 sampled resident received appropriate ileostomy care. R12's ileostomy care was not care planned which resulted in stool leakage from R12's ileostomy dressing. Findings include: From 7/8/24 to 7/10/24, Surveyor reviewed R12's medical record. R12 was admitted to the facility on [DATE] and had a medical history which included a colectomy with end ileostomy. R12's Minimum Data Set (MDS) assessment, dated 2/23/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R12 had intact cognition. On 7/8/24 at 1:07 PM, Surveyor interviewed R12 who stated R12's ileostomy collection bag was not emptied in a timely manner over the weekend (7/5/24 to 7/7/24) which caused the bag to overfill and leak multiple times. R12 also stated the facility does not consistently use the appropriate ostomy supplies and R12's ileostomy appliance leaked stool when the facility used ill-fitting ostomy…

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 use of bed rails was assessed and care planned for 1 resident (R) (R38) of 1 sampled resident. R38 had half rails on R38's bed. R38 did not have a risk assessment for the use of half rails. In addition, a risk versus benefits statement was signed by R38, however, R38 had an activated Power of Attorney for Healthcare (POAHC). Findings include: The facility did not have a policy for the use of bed rails. On 7/9/24, Surveyor reviewed R38's medical record. R38 was admitted to the facility on [DATE] with diagnoses including dementia, anxiety, depression, and encounter for palliative care. R38's Minimum Data Set (MDS) assessment, dated 5/29/24, had a Brief Interview for Mental Status (BIMS) score of 5 out of 15 which indicated R38 had severely impaired cognition. R38 had an APOAHC since 10/25/23. On 7/9/24 at 10:15 AM, Surveyor observed R38 in bed with half rails in place. On 7/9/24, Surveyor requested an assessment for R38's half…

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 a controlled drug was disposed of appropriately for 1 resident (R) (R22) of 15 sampled residents reviewed for medication administration. Nurse Extern (NE)-O disposed of oxycodone (a schedule IV opioid medication used to treat severe pain) in the medication cart trash bin. In addition, NE-O did not document the destruction of the oxycodone and did not have a second witness present. Findings include: The facility's Disposal of Medication and Medication Related Supplies policy and procedure states: A. Unused, unwanted, and non-returnable medications should be removed from their storage area and secured until destroyed .C. Options to dispose of non-flushable prescription drugs include: .2. B. Mix drugs with an undesirable substance, such as cat litter or used coffee grounds .E. Medication destruction occurs only in the presence of at least two licensed healthcare professionals or according to regulation and applicable law. F. The licensed healthcare professional witnessing the destruction ensures that…

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 medications were labeled and dated appropriately for 6 residents (R) (R38, R1, R32, R45, R19, and R9) of 15 sampled residents observed during medication administration. In addition, the facility also did not ensure medications in the second floor mediation refrigerator were dated when opened and disposed of when expired. During multiple observations of medication administration, Surveyor observed staff administer open and undated medications to R38, R1, R32, R45, R19, and R9. During an observation of medication administration, Nurse Extern (NE)-O administered the wrong dose of medication to R38 due to an incorrect label. In addition, NE-O administered a medication to R45 at the wrong time due to an incorrect label. The second floor medication refrigerator contained an open and undated multi-dose vial of octreotide acetate and 4 syringes of expired influenza vaccine. Findings include: The facility's Medication Storage in the Facility policy indicates: C. Certain medications or package types, such 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 FACILITY Infection Control Sample one staff to verify compliance with requirements for educating and offering COVID-19 immunization (select one staff from the actual working schedules for all staff provided during entrance conference). 1. [NAME] CNA : INTV 0906- Educated on COVID w pamphlets. Received COVID vax x2. no boosters. Received info on IC in Relias like Donning & Doffing PPE & res who might be at risk Reviewed COVID Vax Pfizer 9/26/22 & 12/12/22 INTV DON 1244: in AM mtg will go over which res is on what precaution & when they come of it.no list of what res are on what precautions currently but will put together a list Sample three residents on transmission-based precautions (TBP) for purposes of determining compliance with infection prevention and control national standards, as well as resident care, screening, testing, and reporting. 1. [NAME] Per DON Not on Contact 2. [NAME] 3. [NAME] 4. [NAME] Sample five residents for influenza, pneumococcal, and COVID-19 immunizations review. 1. [NAME] R38 RM [ROOM…

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 in accordance with professional standards of practice for 1 resident (R) (R2) of 21 sampled residents. The facility did not obtain detailed physician orders for R2's insulin and blood sugar monitoring. The facility also did not assess R2 for self-administration of insulin or accuchecks. In addition, the facility did not monitor R2's insulin use and blood sugar levels or monitor for signs and symptoms of hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar). Findings include: The facility's undated Standard Diabetes Mellitus (a disease in which blood sugar levels are too high) Protocol indicates: .Patient has potential for fluctuating blood sugar and/or complications of diabetes mellitus .Monitor meal and fluid intake. Check blood sugars/labs as ordered. Monitor for compliance . On 4/10/24, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses including diabetes…

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 fall was thoroughly investigated to determine root cause, implement appropriate interventions to prevent reoccurrence, or ensure the environment was as free from accident hazards as possible for 1 resident (R) (R7) of 3 sampled residents. On 3/19/24, a Hospice Registered Nurse (RN) documented that R7 had a witnessed fall. The facility did not complete a follow up investigation and did not implement safety precautions to prevent further reoccurrence. R7 had additional falls on 3/23/24 and 3/27/24. Findings include: The facility's Falls policy, with a review date of 6/24/22, indicates the facility has preventative measures put in place to reduce the occurrence of falls and the risk of injuries due to falls. This includes completion of a Fall Incident Report, care plan updates with identified interventions, and follow up assessments. On 4/10/24, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE], received Hospice…

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 intravenous (IV) therapy treatment was administered by competent staff for 1 resident (R) (R1) of 1 sampled resident. On 11/18/23, Licensed Practical Nurse (LPN)-D administered IV fluids to R1 through R1's implanted port; however, LPN-D was not qualified to administer IV fluids through an implanted port. Findings include: Wisconsin State Legislature Chapter N 6 titled Standards Of Practice For Registered Nurses And Licensed Practical Nurses indicates: .'Direct supervision' means immediate availability to continually coordinate, direct, and inspect at first hand the practice of another .In the performance of acts in basic patient situations, the LPN. shall, under the general supervision of an RN or the direction of a provider: (a) Accept only patient care assignments which the LPN is competent to perform .Performance of acts in complex patient situations. In the performance of acts in complex patient situations the LPN shall do…

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 maintain an infection prevention and control program to help prevent the transmission of communicable disease and infection. This had the potential to affect multiple residents residing in the facility. In addition, staff did not perform proper hand hygiene during the provision of care for 3 Residents (R) (R1, R5 and R4) of 8 sampled residents. The facility did not follow current Centers for Disease Control and Prevention (CDC) guidance for COVID-19 positive residents when they discontinued transmission-based precautions (TBP) (also referred to as isolation which indicates staff are to wear personal protective equipment (PPE), including a gown, gloves, N95 mask, and eye protection upon entering the room of a resident on TBP for COVID-19) before the recommended ten days for 9 residents (R9, R10, R11, R12, R1, R7, R4, R13, and R14) who resided on one unit. Certified Nursing Assistant (CNA)-F did not consistently perform appropriate hand hygiene on 11/27/23 when CNA-F worked the unit on which R1, R5 and R4…

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 resident and staff interview, and record review, the facility did not ensure grievances were thoroughly investigated and resolved for 1 Resident (R) (R6) of 8 sampled residents. On 10/3/23, R6's significant other filed a grievance regarding call light response times and incontinence care. R6 denied R6 received follow up and resolution of the grievance. On 10/20/23, R6 filed a grievance regarding care received by Certified Nursing Assistant (CNA)-I. R6 denied R6 received follow up and resolution of the grievance. Findings include: The facility's Grievance Policy and Procedure, with a revision date of 3/8/23, indicated the facility fosters an environment of prompt resolution. The policy stated an assigned manager will investigate the grievance and follow up with the individual filing the grievance within 5 business days unless further investigation is needed. The Grievance Policy and Procedure did not identify a Grievance Official. On 11/27/23, Surveyor reviewed the facility's grievance log. At 11:15 AM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure care and treatment were provided in accordance with professional standards of practice for 1 Resident (R) (R2) of 12 sampled residents. R2 vomited on 11/10/23 and 11/11/23. The facility did not administer physician ordered anti-nausea medication. Findings include: On 11/27/23, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] on Hospice services with diagnoses including vascular dementia (a general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to the brain). R2's Minimum Data Set (MDS) assessment, dated 9/29/23, contained a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated R2 had severe cognitive impairment. R2's Power of Attorney for Healthcare (POAHC) document, dated 5/16/19 and activated on 6/19/19, indicated R2's POAHC was responsible for R2's healthcare decisions. R2 passed away at…

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 was free from a medication error. On 7/11/23, R2's medication was found in R1's room. Later that day, R1 was sent to the emergency room (ER) for a change of condition. The facility did not conduct a thorough investigation to determine if a medication error occurred. Findings include: The facility's Medication Error policy, revised 6/13/23, contained the following information: 1. Any individual suspecting a potential medication error, shall report it to a Licensed Nurse. 2. Licensed Nurse is responsible for: a. completing an investigation, b. if confirmed, complete medication error assessment in Electronic Medical Record (EMR) 3. Medication errors will be reviewed through the Quality Assurance Performance Improvement Process. R1 was admitted to the facility on [DATE] with diagnoses that included left sided hemiplegia (paralysis) following a stroke, hypertension, atrial fibrillation, and depression.…

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 sufficient staffing to meet residents' care needs. This had the potential to affect all 59 residents residing in the facility. Thirteen of seventeen staffing shifts reviewed did not meet the Certified Nursing Assistant (CNA) to resident staffing ratios outlined in the Facility Assessment which was updated in April 2023. Residents and staff interviewed expressed concerns with receiving and providing timely and complete care. Observations indicated call lights weren't answered timely, resident care was not provided timely and a resident who returned from the hospital was not attended to in a timely manner. Findings include: The Facility Assessment, dated April 2023, contained the following information: ~Staffing Plan: There are 2 Registered Nurses (RNs) and 1 Licensed Practical Nurse (LPN) scheduled for the AM/PM shift and 1 RN for the night (NOC) shift. One Medication Administration Assistant is scheduled for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review, the facility did not ensure 2 Residents (R) (R12 and R29) of 21 residents were assessed as able to safely and accurately self-administer medication. R12 did not have a current self-administration of medication assessment for medications to be left at the bedside. R29 did not have a self-administration of medication assessment or a physician order to self administer medication. Findings include: The facility's Self-Administration of Medications policy, dated May 2018, contained the following information: In order to maintain residents' highest level of independence, residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility and there is a Prescriber's order to self-administer .C. For those residents who self-administer, the interdisciplinary team verifies the resident's ability to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interview, and record review, the facility did not ensure prompt resolution of a grievance for 1 Resident (R) (R47) of 21 residents. In addition, the grievance was not contained in the facility's grievance file. The facility did not document, investigate, and follow up with R47 or R47's Power of Attorney (POA) when the facility was notified of R47's missing hearing aid. Findings include: The facility's Policy and Procedure for Grievance, dated 3/8/23, contained the following information: I. Policy: Individual, guardian, and/or individual representative will be informed of the process to file a grievance or complaint and the facility's process to make prompt efforts to resolve grievances. II. Procedure: The facility fosters an environment of direct communication, prompt resolution, and continuous process improvement. Grievances may be brought to any staff member at any time orally, in writing, or made anonymously. Grievances will be forwarded to the designated Grievance Officer and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interview, and record review, the facility did not ensure an allegation of abuse for 1 Resident (R) (R6) of 21 sampled residents was reported to the State Agency (SA) in a timely manner. R6 reported an allegation of abuse to staff on 5/19/23. The allegation of abuse was not reported to the SA in a timely manner. Findings include: The facility's Comprehensive Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property Program, dated 12/1/22, contained the following information: The facility will ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the executive…

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 resident and staff interview, and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 1 Resident (R) (R6) of 21 sampled residents. On 5/19/23, R6 reported an allegation of abuse. The allegation of abuse was not thoroughly investigated. Findings include: The facility's Comprehensive Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property Program, dated 12/1/22, contained the following information: Section A. Investigation of Abuse: When an incident or suspected incident of abuse is reported, the Executive or designee will investigate the incident with the assistance of appropriate personnel. The investigation will include: i. Who was involved. ii. Resident's statement. iv. Involved staff and witness statement of events. v. A description of the resident's behavior and environment at the time of the incident. vi. Injuries present including a resident assessment. ii. Observation of resident and staff behaviors during the investigation. Section F.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interview, and record review, the facility did not ensure 3 Residents (R) (R2, R153, and R154) of 21 residents who required assistance of staff for activities of daily living (ADLs) were provided care in a timely and consistent manner. R2 was admitted to the facility on [DATE] and had one documented shower and three skin evaluations since admission. R153 was admitted to the facility on [DATE] and had one documented shower since admission. R154 was admitted to the facility on [DATE] and had no documented showers since admission. Findings include: 1. R2 was admitted to the facility on [DATE]. R2's Minimum Data Set (MDS) assessment, dated 4/11/23, indicated R2 required the assistance of two staff for bathing. On 5/23/23 at 9:16 AM, R2 stated to Assistant Director of Nursing (ADON)-C during morning cares that R2 had not received a shower in two weeks and would like one. On 5/23/23 at 1:55 PM, Surveyor interviewed R2 regarding showers. R2 was unable to recall when R2 was last offered a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review, the facility did not provide the necessary care and services to maintain the highest practicable physical and mental well-being for 1 Residents (R) (R102) of 21 sampled residents. R102's Admit/Readmit Screener, dated 5/19/23, did not contain documentation of a cyst R102 had surgically drained in the hospital prior to admission. R102 was not provided care for the cyst for three days after admission. Findings include: The facility's Policy and Procedure for Pressure Injury Prevention and Managing Skin Integrity contained the following information: .3. Skin Check Frequency: i. Upon admission or readmission 1. Skin check will be done upon admission and then done every shift for 72 hours after admission . 1. R102 was admitted on [DATE] with diagnoses of muscle weakness, need for assistance with personal care, and symptoms and signs involving cognitive functions and awareness. R102 had an activated Power of Attorney for Healthcare (POAHC). On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not ensure 2 Residents (R) (R102 and R22) of 3 residents reviewed for pressure injuries received the necessary care and services to promote healing. R102 was admitted to the facility on [DATE] with a stage 2 pressure injury. A treatment order was not obtained until 5/22/23 when Wound Nurse Practitioner (NP)-Q assessed R102 and determined the pressure injury was unstageable. R22's medical record indicated R22 had a stage 3 pressure injury on the buttocks. During an observation of care, Assistant Director of Nursing (ADON)-C stated R22 had a foam dressing over the pressure injury which was not in accordance with R22's treatment order. Findings include: The facility's Policy and Procedure for Pressure Injury Prevention and Managing Skin Integrity contained the following information: .2. Identify Interventions and Care Plan .i. The care and intervention for any identified skin breakdown or wound is intended to prevent any further advancement…

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 resident environment was as free of accident hazards as possible for 2 Residents (R) (R102 and R29) of 21 sampled residents. R102 and R29 stored cigarettes and lighters in their rooms which was not in accordance with the facility's protocol. Findings include: The facility's Policy and Procedure for Individual Smoking contained the following information: Policy: Any individual requesting to smoke while residing in the facility will be assessed and interventions will be put in place for safety. 1. On 5/22/23 at 3:37 PM, Surveyor noted a strong odor of cigarette smoke outside R102's closed door and asked Registered Nurse (RN)-N to check on R102. RN-N knocked and entered R102's room and also noted an odor of cigarette smoke. When RN-N asked R102 about the odor, R102 denied smoking in R102's room. When RN-N asked if R102 had cigarettes and a lighter in R102's room, R102 stated R102 had cigarettes. When RN-N…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure 2 Residents (R19 and R16) of 5 residents reviewed for immunizations were offered a pneumococcal vaccine. R19's medical record did not contain documentation that R19 was offered a 2nd pneumococcal vaccine. R16's medical record did not contain documentation that R16 was offered a pneumococcal vaccine. Findings include: The facility's Individual Immunizations policy, dated 7/22/22, contained the following information: 1a. Upon admission, the organization will verify the individual's immunization status, update Primary Care Provider (PCP) as indicated, and administer immunizations as ordered. B. Individual will be offered immunizations based upon the Centers for Disease Control and Prevention (CDC) recommendations and guidelines and as prescribed by their PCP. 2a. Vaccination Information Sheet (VIS) will be provided and reviewed with individuals including benefits, risks, and potential side effects associated with vaccination. 3b. Immunization…

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