Brown CTY Comm Treatment CTR-Bayshore Village

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 61 residents residing in the facility. The facility did not cool pre-cooked leftover food with an approved cooling method. Findings include: The 2022 Federal Food and Drug Administration (FDA) Food Code documents at section 3-501.14 Cooling Methods: (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under § 3-501.14 by using one or more of the following methods based on the type of food being cooled: (1) Placing the food in shallow pans; (2) Separating the food into smaller or thinner portions; (3) Using rapid cooling equipment; (4) Stirring the food in a container placed in an ice water bath; (5) Using containers that facilitate heat transfer; (6) Adding ice as an ingredient; or (7) Other effective methods. During an initial kitchen tour with Dietary Manager (DM)-C on 12/9/24 that began at 8:28 AM, Surveyor noted the freezer contained pre-cooked leftover…

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 3. On 8/30/23, Surveyor reviewed R1's medical record. R1 had to diagnoses including dementia, seizure disorder, anxiety, depression, and schizophrenia. R1's Quarterly MDS assessment, 6/13/23, contained a BIMS score of 4 out of 15 which indicated R1 was severely cognitively impaired. R1's medical record contained the following MDS assessments: ~Quarterly MDS assessments, dated 9/12/22 and 12/12/22, and an Annual MDS assessment, dated 3/13/23, indicated R1 was rarely/never understood. Staff assessment indicated R1 had moderately impaired cognition. The MDS' also indicated there was not an acute change in R1's baseline mental status. A progress note, dated 6/20/23, indicated the following: BIMS score of 4 out of 15. (R1) repeated all three words and recalled none. (R1) stated the correct day of the week, however, was incorrect on the month and year. PHQ-9 (Patient Health Questionnaire) (used to diagnose and monitor the severity of depression) score of 5 (which indicates either no or subthreshold depression). (R1)…

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) (R259) and their Guardian of 20 sampled residents were offered care conferences and involved in continued care planning. R259's last care conference was completed in March of 2023. Staff verified a care conference should be offered every 3 months or more frequently if needed. Findings include: The facility's Resident Assessment, Baseline Care Plan and Care Plan Policy, last reviewed 8/2023, indicated: The facility shall prepare an interdisciplinary comprehensive assessment of the resident's needs, strengths, goals, history and preferences and information required by the resident assessment instrument (RAI) using the Minimum Data Set 3.0 (MDS) and evidence-based, discipline specific assessment tools. The information will be used to develop, with the input and participation of the resident and resident representative, a comprehensive person-centered care plan. Procedure: Upon admission, with a significant change in the resident's status, and annually, the interdisciplinary team (IDT) will complete a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure the medical record of 2 Residents (R) (R54 and R42) of 7 residents reviewed for code status contained an advance directive/code status that was consistent with the residents' wishes. R54 had a code status of do not resuscitate (DNR). R54's care plan identified R54 as a full code. R42 had a code status of DNR. R42's care plan identified R42 as a full code. Findings include: The facility's Code ER, Medical Emergencies, Cardiopulmonary Resuscitation and Defibrillator Use Policy, revised 6/2022, contained the following information: Code Status is verified by observing the legal document in the client/resident chart or electronic medical record prior to performing CPR (cardiopulmonary resuscitation). The code status is reviewed upon admission, quarterly and with a significant change in condition. If the resident/resident representative indicates/signs No CPR in the advanced directives, as defined in Wisconsin State Statute 154.17 (2), a DNR order…

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 complete a comprehensive Annual Minimum Data Set (MDS) assessment within the required timeframe for 1 Resident (R) (R259) of 20 sampled residents. R259's Annual MDS assessment, due on 8/11/23, was marked in process. The Annual assessment was not completed and was 17 days overdue. Findings include: The Resident Assessment Instrument (RAI) Manual, revised October 2019, indicates: The annual assessment is a comprehensive assessment for a resident that must be completed on an annual basis (at least every 366 days .Assuming the resident did not experience a significant change in status, was not discharged , and did not have a Significant Correction to Prior Comprehensive assessment (SCPA) completed, assessment scheduling would then move through a cycle of three Quarterly assessments followed by an Annual (comprehensive) assessment. The facility's Resident Assessment, Baseline Care Plan and Care Plan Policy, last reviewed 8/2023, indicated: The facility shall prepare an interdisciplinary comprehensive assessment of the…

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

Based on staff interview and record review, the facility did not complete a Quarterly Minimum Data Set (MDS) assessment within the required timeframe for 1 Resident (R) (R259) of 20 sampled residents. R259's last Quarterly MDS assessment was completed on 2/10/23. R259's next Quarterly MDS assessment (due in May of 2023) was not completed. Findings include: The Resident Assessment Instrument (RAI) Manual, revised October 2019, indicates: .Assuming the resident did not experience a significant change in status, was not discharged , and did not have a Significant Correction to Prior Comprehensive assessment (SCPA) completed, assessment scheduling would then move through a cycle of three Quarterly assessments followed by an Annual (comprehensive) assessment. The facility's Resident Assessment, Baseline Care Plan and Care Plan Policy, last reviewed 8/2023, indicated: The facility shall prepare an interdisciplinary comprehensive assessment of the resident's needs, strengths, goals, history and preferences and information required by the resident assessment instrument (RAI) using 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 vaccinations were reviewed, offered, and administered for 3 Residents (R) (R18, R8, and R26) of 5 residents reviewed for vaccines. The facility did not review R18's vaccination history or offer R18 the PCV20: 20-valent pneumococcal conjugate (Prevnar 20®) vaccine. The facility did not review R8's vaccination history or offer R8 the PCV20: 20-valent pneumococcal conjugate (Prevnar 20®) vaccine. The facility did not review R26's vaccination history or offer R26 the PCV20: 20-valent pneumococcal conjugate (Prevnar 20®) vaccine. Findings include: Abbreviations (www.cdc.gov): PCV13: 13-valent pneumococcal conjugate vaccine (Prevnar13®) PCV15: 15-valent pneumococcal conjugate vaccine (Vaxneuvance®) PCV20: 20-valent pneumococcal conjugate vaccine (Prevnar 20®) PPSV23: 23-valent pneumococcal polysaccharide vaccine (Pneumovax23®) The most recent CDC (Centers for Disease Control and Prevention) recommendations for pneumococcal vaccinations indicate:…

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 food was prepared, stored, and served under sanitary conditions. Outdated and undated products were stored for 5 Residents (R) (R15, R27, R35, R54, and R157) of 60 residents. Staff did not date or did not discard food and beverages after seven days of constitution or opening for community use beverages and R15, R27, R35, R54, and R157's individually labeled items. Kitchenette ovens had baked food debris, in varying amounts, in the interior of oven. Findings include: On 9/6/22 at 8:36 AM, Surveyor interviewed Dietary Manager (DM)-I who indicated the facility used the Food and Drug Administration (FDA) Food Code as its standard of practice. Undated and Outdated Beverages FDA Food Code 2017 documents at 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § 3-502.12, and except as specified in ¶¶ (E) and (F) of this…

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, staff interview and resident representative interview, the facility did not document or make prompt efforts to resolve grievance for 1 Resident (R) (R306) of 18 sampled residents. Social Worker (SW)-J and Registered Nurse (RN)-L heard R306's Power of Attorney (POA)-M's verbal grievance regarding lack of activities and request for activity calendar but did not document, resolve or report the grievance to grievance official, SW-J. Findings include: The facility's Policy titled Grievance Policy-Bayshore Village revised on 09/2022. Policy: . each Resident has the right to voice grievances to the facility. Definitions: Voice grievances are not limited to a formal, written grievance process but may include a Resident's verbalized complaint to facility staff. Prompt efforts to resolve include facility acknowledgment of complaint/grievances and actively working toward resolution of that complaint/grievances. Grievance Official is an individual who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions.…

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 implement the abuse prevention policy requiring background checks for 1 (Facility Worker (FW)-F) of 8 sampled staff. Facility did not obtain a response from Department of Health Services (DHS) Integrated Background Information System (IBIS) information prior to hiring FW-F. Findings include: Wisconsin (WI) Caregiver Program Manual, revision dated January 2020, documents At a minimum, a complete caregiver background check completed for a caregiver consists of the following three documents: .3. A 'Response to the Caregiver Background Check' letter from DHS that reports the person's status, including administrative finding or licensing restrictions. Facility policy Abuse, Neglect, Mistreatment, and Misappropriation of Resident and Client Property Policy, revision dated 3/2022, Employee Screening and Training. B. Prospective employees will need to have a successful completion of criminal background checks. On 9/6/22 and 9/8/22, Surveyor observed FW-F working in facility. On 9/7/22, Surveyor selected sample of 8 staff 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.

Based on staff interviews and record review, the facility did not ensure a Resident (R) prescribed a high risk medication had a care plan developed to monitor for possible side effects for 3 (R19, R42, and R47) of 18 sampled residents. The facility did not develop a care plan to monitor for possible side effects of R19's opioid (narcotic pain relief) and diuretic (commonly referred to as a water pill) medications. The facility did not develop a care plan to monitor for possible side effects of R42's antidepressant and opioid medications. The facility did not develop a care plan to monitor for possible side effects of R47's antipsychotic medication. 1. From 9/6/22 through 9/8/22, Surveyor reviewed R19's medical record which documented R19's prescriptions included tramadol (opioid medication) twice per day and up to two additional times per day as needed. R19's prescriptions also included hydrochlorothiazide (diuretic medication) daily. Surveyor noted R19's medical record did not contain monitoring for possible negative side effects for opioid (such as respiratory depression) 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 Observations, record review and staff interview, the facility did not ensure 2 Residents (R) (R16 and R34) of 5 sampled residents received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers (injuries) from developing. R16 was observed sitting in chair with cushion and towel over cushion for two days of survey. R34 was observed sitting in recliner without cushion in recliner for 2 of the survey days. Findings include: Facility follows AHRQ (Agency for Healthcare Research and Quality) as a guide for Pressure Injury (PI) prevention. R34 was admitted to facility on 6/18/22 with the diagnosis of dementia, muscle weakness, difficulty walking, Alzheimer and failure to thrive. R34's MDS (Minimum Data Set) assessment dated [DATE] indicated that R34 required extensive assistance with bed mobility, transfers, dressing and hygiene. R34's skin condition record dated 6/18/22 indicated that R34 had an opening on left…

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 was free of accident hazards for 1 Resident (R) (R42) of 4 sampled residents reviewed for fall safety. R42 was not appropriately secured into R42's wheelchair with the seat belt while unsupervised as assessed and care planned. Findings Include: R42 was admitted in 2019 with congestive heart failure (CHF), chronic osteomyelitis, diabetes mellitus type 2, unspecified displaced fracture of second cervical vertebra, major depressive disorder, and dementia without behavioral disturbance. R42's most recent Minimum Data Set (MDS) assessment dated [DATE], indicated R42's Brief Interview for Mental Status (BIMS) was unable to be completed, indicating, No (resident is never/rarely understood.) On 9/7/22 at 7:45 AM, Surveyor interviewed R42's legal guardian (LG)-E . LG-E stated R42 had a seat belt that needed to be applied while R42 is in R42's wheelchair. LG- stated R42 had two irreparable breaks in R42's neck and 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.