Odd Fellow Home

Based on observation, staff interview, and record review, the facility did not ensure the accurate administration of medication for 1 resident (R) (R13) of 4 residents observed during medication administration During the AM medication pass on 5/5/25, R13 received Senna-Plus instead of Senna. Findings include: The facility's Administrating Medications policy, dated 2001, indicates: .4. Medication are administered in accordance with prescriber orders .10. The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. On 5/5/25 at 9:20 AM, Surveyor observed Registered Nurse (RN)-F administer R13's medication. One of the medications administered was Senna-Plus (which is a mixture of sennosides (a stimulant laxative) and docusate sodium (a stool softener)). On 5/6/25 at 8:00 AM, Surveyor reviewed R13's Medication Administration Record (MAR) which indicated R13 should have received Senna 8.6 milligrams (mg) daily for constipation.…

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 implement their antibiotic stewardship program to ensure the accurate use of antibiotics for 3 residents (R) (R19, R122, and R264) of 6 sampled residents. R19 did not meet McGeer's criteria for a urinary tract infection (UTI) but received antibiotic therapy. The physician was not asked if the antibiotic should have been continued when R19 did not meet the criteria for a UTI. R122 did not meet McGeer's criteria for a skin and soft tissue infection (SSTI) but received antibiotic therapy. The physician was not asked if the antibiotic should have been continued when R122 did not meet the criteria for an SSTI. R264 did not meet McGeer's criteria for a respiratory tract infection (RTI) but received antibiotic therapy. The physician was not asked if the antibiotic should have been continued when R264 did not meet the criteria for an RTI. Findings include: The facility's Antibiotic Stewardship policy, revised 12/2016, indicates: .11. When a culture 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 [NAME] 1/9/25 Based on observation, staff interview, and record review, the facility did not ensure care plans were reviewed and revised for 3 residents (R) (R11, R5, and R3) of 13 sampled residents. R11, R5, and R3's care plans were not updated with interventions related to leaving Hoyer slings underneath R11, R5, and R3. Findings include: The facility's Lifting Machine, Using a Mechanical Policy, dated July 2017, indicates: The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device .Steps in procedure: .20. Carefully remove the sling from under the resident. Be mindful of the resident's position and balance, and skin . 1. On 1/9/25, Surveyor reviewed R11's medical record. R11 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, history of left above the knee surgical amputation, osteomyelitis of left foot, and diabetes. R11's Minimum Data Set (MDS) assessment, dated 11/21/24, had a Brief Interview for Mental Status…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure the adequate use of assistive devices to prevent injury for 1 resident (R) (R3) of 2 sampled residents. R3 indicated the lift battery often died while R3 was mid-transfer and R3 was left hanging in the lift while staff replaced the battery. Findings include: On [DATE], Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and had diagnoses including hemiplegia (weakness on one side of the body) and hemiparesis (paralysis on one side of the body) following nontraumatic intracranial hemorrhage affecting the left non-dominant side, weakness, type 2 diabetes, acquired absence of right leg above the knee, and need for assistance with personal care. R3's Minimum Data Set (MDS) assessment, dated [DATE], had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R3 was not cognitively impaired. R3's care plan indicated R3 was a 2 person Hoyer lift transfer when R3's left leg prosthesis was off. If…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not provide appropriate care and services for 2 residents (R) (R10 and R12) of 6 sampled residents with an indwelling catheter. On 1/9/25, R10 and R12's catheter drainage bags were observed in contact with the floor. Findings include: The facility's Catheter, Urinary Policy, dated August 2022, indicates: The purpose of this procedure is to prevent urinary-associated complications, including urinary tract infections .Infection Control: .2. Be sure the catheter tubing and drainage bag are kept off the floor . 1. On 1/9/25, Surveyor reviewed R10's medical record. R10 was admitted to the facility on [DATE] and had diagnoses including history of supracondylar fracture of the left femur, right tibial fracture, and hypertension. R10's Minimum Data Set (MDS) assessment, dated 12/23/24, had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R10 had moderate cognitive impairment. R10's medical record indicated R10 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not ensure a prescribed diet was followed for 1 resident (R) (R3) of 3 sampled residents. R3 was prescribed a consistent carbohydrate hydro-oligomeric diet (CCHO) (a diet designed to manage blood sugar levels in individuals with diabetes or prediabetes). R3's diet order was not consistently followed. Findings include: The facility did not have a policy regarding following diets. On 1/9/25, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and had diagnoses including type 2 diabetes. R3's Minimum Data Set (MDS) assessment, dated 12/26/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R3 was not cognitively impaired. R3's medical record indicated R3 was prescribed a CCHO diet. During in interview with R3 on 1/9/25 at 12:06 PM, staff delivered R3's meal tray. R3 took the dessert but declined the rest of the tray because R3 had ordered out for lunch. Surveyor reviewed R3'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 for 1 resident (R) (R13) of 13 residents observed during the provision of cares. R13 was on enhanced barrier precautions (EBP) which required staff to wear personal protective equipment (PPE) during high-contact cares. On 1/9/25, staff transferred and provided wound care for R13 without wearing PPE. In addition, Surveyor observed staff exit R13's room with a vital signs machine. Staff did not appropriately disinfect the machine after use. Findings include: The facility's Enhanced Barrier Precautions (EBP) policy, dated 5/1/24, indicates: .EBP: Infection control practices requiring the use of personal protective equipment (PPE) for certain high-contact resident care activities, even in the absence of standard indications for isolation. 2. High-Contact Resident Care Activities: Activities that involve potential…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 2 residents (R) (R5 and R6) of 13 sampled residents. The facility did not report a resident-to-resident altercation between R5 and R6 to the State Agency (SA) in a timely manner because staff did not report the incident timely to administration. The facility could not provide proof of education for the staff who were working when the resident-to-resident altercation occurred. Findings include: The facility's Patient Protection Program Freedom from Abuse, Neglect, and Exploitation policy, dated 3/2025, indicates: The facility must take the following actions in response to an alleged violation of abuse, neglect, exploitation, and mistreatment: Take appropriate corrective action, because of investigation findings .Internal Reporting. A. Employees must always report any abuse or suspicion of abuse immediately to the Administrator or Abuse Coordinator Designee. External Reporting: Initial…

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

Based on observation and staff interview, the facility did not ensure garbage and refuse were properly disposed of in outside garbage receptacles. This practice had the potential to affect all 50 residents residing in the facility. On 3/10/24, the lids on 3 outside refuse dumpsters were open and there was garbage on the ground. Findings include: During an initial kitchen tour on 3/10/24 at 10:13 AM, Surveyor and Dietary Manager (DM)-O observed 3 outside refuse dumpsters with open lids. Surveyor and DM-O observed a bag of garbage on the ground behind the middle dumpster and scattered pieces of paper on the ground around the 3 dumpsters. On 3/10/24 at 10:14 AM, Surveyor interviewed DM-O who indicated the lids were most likely open for ease of use, but should be shut to keep rodents out. DM-O went between the dumpsters and looked at the bag of garbage on the ground. DM-O stated the garbage was CNA (Certified Nursing Staff) stuff and left the bag of garbage on the ground behind the dumpster.

Based on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program based on current standards of practice, designed to provide a safe environment and to help prevent the development and transmission of communicable disease and infection. This practice had the potential to affect all 50 residents residing in the facility. The facility did not have a system for preventing the growth and spread of Legionella in the facility's water system. The facility's Water Management Plan (WMP) was not based on current standards of practice and did not: Describe the building's water system using text and an accurate flow diagram of the system; Include an assessment of the facility's water system to identify all locations where Legionella could grow and spread; Maintain acceptable ranges of control limits (temperature ranges) and corrective actions when control limits are not met; Include a process to confirm the WMP is being implemented and is effective. Findings include: The 7/6/18 revised Centers for Medicaid &…

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 promote and facilitate resident self-determination for 6 Residents (R) (R1, R4, R10, R25, R27, and R39) of 6 residents. Staff did not allow R1, R4, R10, R25, R27 and R39 to make choices regarding their meals. Finding include: 1. R1 was admitted to the facility on [DATE] with diagnosis including dementia, anxiety, and malignant neoplasm of transverse colon. R1's Minimum Data Set (MDS) assessment, dated 1/24/24, contained a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated R1 had moderate cognitive impairment. R1 had an activated power of attorney for healthcare (POAHC). R1's plan of care indicated R1 had a 2 gm (gram) (2000 mg (milligrams)) NA (sodium), CCHO (carbohydrate-controlled), mechanical soft diet with regular/thin liquids. R1's plan of care indicated R1 should consume adequate caloric intake and the nutrients should meet R1's metabolic needs. According to the lunch menu on 3/11/24,…

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 make a prompt effort to resolve grievances for 5 Residents (R) (R210, R211, R28, R209 and R13) of 7 sampled residents. R210 reported to staff that R210 was missing numerous articles of clothing. The facility did not resolve the grievance in a timely manner. R211 reported to staff that R211 was missing a nightgown. The facility did not resolve the grievance in a timely manner. R209 reported to staff that R209 was missing numerous articles of clothing. The facility did not resolve the grievance in a timely manner. R28 reported to staff that R28 was missing bed linens. The facility did not resolve the grievance in a timely manner. R13 reported to staff that R13 was missing numerous articles of clothing. The facility did not resolve the grievance in a timely manner. The facility's grievance log contained missing clothing items or laundry concerns for 1 resident in September 2023, 1 resident in November 2023, and 2 residents in December 2023. The facility was unable to provide Surveyor with grievance…

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 their abuse policy was implemented for 1 of 8 employees reviewed for background checks. Certified Nursing Assistant (CNA)-J's background check information did not contain an out-of-state criminal or caregiver background check. Findings include: The facility's Patient Protection Program: Freedom from Abuse, Neglect, and Exploitation document indicates: Screening components: .It is the policy of this facility to screen employees and volunteers prior to working with residents. Screening components include verification of references, certification and verification of license and criminal background check .Employee screening and training: Before new employees are permitted to work with residents, references provided by the prospective employee will be verified as well as appropriate board registrations and certifications regarding the prospective employee's background. The facility will not employ or otherwise engage individuals who have been found guilty of abuse, neglect, exploitation, misappropriation of property,…

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 3 Residents (R) (R204, R36, and R19) of 4 residents reviewed for hospitalizations received a written notice of transfer, including the reason for the transfer, location of the transfer, appeal rights, and contact information for the State Long-Term Care Ombudsman. In addition, the facility did not notify the Ombudsman of the transfers. R204 was transferred to the hospital on 2/27/24. R204 was not provided a written transfer notice and the Ombudsmen was not notified of the transfer. R36 was transferred to the hospital on [DATE] and 11/27/23. R36 was not provided written transfer notices and the Ombudsmen was not notified of the transfers. R19 was transferred to the hospital on [DATE] and 2/27/24. R19 was not provided written transfer notices and the Ombudsmen was not notified of the transfers. Findings include: The facility's Transfer or Discharge Documentation document, revised 12/2016 indicates: When a resident is transferred or discharged…

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 3 Residents (R) (R204, R36 and R19) of 4 residents reviewed for hospitalizations received written information of the duration of the facility's bed hold policy, the reserve bed payment policy, and the right to return to the facility. R204 was transferred to the hospital on 2/27/24 and was not provided a copy of the facility's bed hold policy. R36 was transferred to the hospital on [DATE] and 11/27/23 and was not provided copies of the facility's bed hold policy. R19 was transferred to the hospital on [DATE] and 2/27/23 and was not provided copies of the facility's bed hold policy. Findings include: The facility's Bed-Holds and Returns policy, revised 3/2022, indicates: Resident and/or representative are informed (in writing) of the facility and state (if applicable) bed hold policies .1. All residents/representatives are provided written information regarding the facility bed-hold policies, which address holding or reserving a resident's bed…

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 each resident received adequate supervision and assistive devices, did not ensure fall assessments were completed, and did not ensure interventions to prevent falls were implemented for 2 Residents (R) (R12 and R19) of 18 sampled residents. On 3/11/24, staff used a lift with defective brakes and a defective sling to transfer R12. Staff did not appropriately assess R19 following a fall with head injury on 2/26/24. In addition, the facility did not update R19's care plan with interventions to prevent future falls. Findings include: The facility's Safety and Supervision of Residents policy, dated 12/2007, indicates: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Resident Risks and Environmental hazards: Due to their complexity and scope, certain resident risk factors 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 observation, staff and resident interview, and record review, the facility did not ensure 1 Resident (R) (R34) of 1 resident received the necessary care and services for respiratory therapy. The facility provided R34 with respiratory therapy via CPAP (continuous positive airway pressure) without a physician's order. In addition, R34's need for and use of CPAP therapy was not care planned for assessment, evaluation, or monitoring. Findings include: The facility's CPAP Therapy policy, revised 10/2010, indicates: Purpose: 1) To provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen. 2) To improve arterial oxygenation in residents with respiratory insufficiency, obstructive sleep apnea (OSA), or restrictive/obstructive lung disease .apnea .Preparation: .3) Review the physician's orders .Document the following in the resident's medical record: 1) General assessment prior to procedure; 2) Time CPAP was started and duration of the therapy; 3)…

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 monitoring of a high risk medication was provided for 1 Resident (R250) of 5 residents reviewed for unnecessary medication. R250 had physician orders for short-acting and long-acting insulin (used to treat high blood sugar). R250's plan of care did not contain interventions to monitor R250 for signs and symptoms of hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar). Findings include: On 3/12/24, Surveyor reviewed R250's medical record. R250 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (a disease in which blood sugar levels are too high). R250's medical record contained the following physician orders: ~ Humalog Injection Solution 100 unit/ml (units per milliliter) (Insulin Lispro) (short-acting insulin) Inject as per sliding scale: if 120-149 = 2 units; 150-199 = 4 units; 200-249 = 6 units; 250-299 = 8 units; 300-349 = 10 units 350 or more *12 units & call MD (Medical Doctor),…

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 stored and prepared in a sanitary manner. This practice had the potential to affect all 50 residents residing in the facility. Staff did not ensure time/temperature control foods were labeled with open or use-by dates. Staff did not wear hair restraints consistently throughout the kitchen. Kitchen equipment and food services areas were not in a clean and sanitary condition. Staff did not properly heat food in the microwave that was served to residents. Staff did not follow safe food cooling protocols. Staff were unaware of temperature requirements when testing parts per million (PPM) of the sanitizing solution. Staff did not perform appropriate hand hygiene and safe food handling practices while cooking and serving food Findings include: On 3/10/24 at 9:25 AM, Dietary Manager (DM)-O indicated the facility follows the Wisconsin Food Code as their standard of practice. 1. Open/Unlabeled/Undated/Expired Food: 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 ensure it completed mandatory submission of staffing information based on payroll data in a uniformed format to the Centers for Medicare & Medicaid Services (CMS). This practice had to the potential to affect all 50 residents residing in the facility. Staffing information for Quarter 1 (October 1-December 31), Quarter 2 (January 1-March 31), Quarter 3 (April 1-June 30), and Quarter 4 (July 1-September 30) of the Payroll Based Journal (PBJ) was not submitted to CMS. Findings include: The Centers for Medicare & Medicaid Services (CMS) Electronic Staffing Data Submission Payroll-Based Journal, Long-term Care Facility Policy Manual, dated June 2022, indicates: Chapter 1: Overview, 1.1 introduction .(U) mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform…

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 of 5 Certified Nursing Assistants (CNAs) was eligible to work in a federally certified facility. This practice had the ability to affect multiple residents in the facility. CNA-I was employed by the facility. CNA-I was not currently eligible to work in federally certified nursing homes because CNA-I's certification had lapsed. Findings include: The facility's Patient Protection Program: Freedom from Abuse, Neglect, and Exploitation document indicates: Screening components: Abuse Policy Components: It is the policy of this facility to screen employees and volunteers prior to working with residents. Screening components include verification of references, certification and verification of license and criminal background check. Procedure .employee screening and training: before new employees are permitted to work with residents, references provided by the prospective employee will be verified as well as appropriate board registrations 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.

Based on observation, staff interview, and record review, the facility did not follow menu serving sizes, individualized diets, and food preparation recipes to ensure nutritional needs were met for multiple residents residing in the facility. During the 3/10/24 lunch meal, staff did not follow menu serving sizes for residents who received chicken drumstricks as their main entree. During the 3/11/24 lunch meal, staff did not follow R1, R4, and R10's individualized diets. During the 3/11/24 lunch meal, staff did not follow a recipe when making mashed potatoes for 4 residents who received pureed diets. Findings include: The facility's contracted company's Standardized Recipes policy, dated 2/19/24, indicates: Standardized recipes will be used when preparing the menu items .3. Cooks/chefs are expected to use and follow the recipes provided. The facility's extended menu contained the lunch meal serving sizes for regular portions and mechanically altered food. Per the 3/10/24 lunch menu, the serving size for baked chicken drumsticks was 2 baked chicken drumsticks for residents on 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 an allegation of neglect was thoroughly investigated for 1 Resident (R) (R204) of 1 sampled resident. The facility did not thoroughly investigate R204's allegation of neglect. Findings include: The facility's Patient Protection Program, Freedom from Abuse, Neglect and Exploitation policy indicates: It is the policy of the facility to maintain an environment where residents are free from abuse, neglect, exploitation and misappropriation of resident property and all resident, staff, families, visitors, volunteers and resident representatives are encouraged and supported in reporting any suspected acts of abuse, neglect, misappropriation of resident property or exploitation .The resident has the right to bee free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart .This regulation was written to provide protections for the health, welfare and rights of each resident residing in the facility. To provide these protections, the facility must develop written policies…

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 written policies and procedures to prohibit mistreatment, neglect and abuse of residents for 3 staff (Certified Nursing Assistant (CNA)-C, CNA-D and Registered Nurse (RN)-E) of 8 staff reviewed during the caregiver program compliance check. CNA-C was hired on 8/14/15. The facility did not have a current completed Background Information Disclosure (BID) form for CNA-C. CNA-D was hired on 2/28/19. The facility did not have a current completed BID form for CNA-D. RN-E was hired on 3/4/16. The facility did not have a current completed BID form for RN-E. Findings include: The facility's undated Abuse Prohibition Policies and Procedures states the facility will encourage and support all residents, staff, families, visitors, volunteers and resident representatives in reporting any suspected acts of abuse, neglect, exploitation, involuntary seclusion or misappropriation of resident property. One of the components of the policy includes screening of potential employees. Upon a decision to hire an employee, all…

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 an allegation of abuse was thoroughly investigated for 1 Resident (R) (R2) of 9 residents. The facility did not conduct a thorough investigation of an allegation of abuse involving R2 when the facility did not prevent further potential abuse of R2 and other residents while the investigation was in progress. Certified Nursing Assistant (CNA)-F was not removed from resident care while the potential allegation of abuse was investigated. In addition, R2's plan of care was not changed as indicated by the facility. Findings include: The facility's undated abuse policy and procedure indicates all residents will be treated with courtesy and respect in full recognition of their dignity and individuality by all they encounter, including, but not limited to employees. Once an allegation of abuse is reported to a staff supervisor or nurse on duty, the supervisor/nurse begins the investigation after assuring safety of resident. The alleged staff member or other person may have no further contact with residents, and may be…

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 establish and maintain an infection control program designed to help prevent the development and transmission of disease and infection. This practice had the potential to affect all 52 residents residing in the facility. The facility did not conduct continuous infection surveillance including tracking and trending of illnesses, potential infectious agents, and monitoring of resident signs and symptoms of infection or potential infection. In addition, the facility did not maintain surveillance logs to help the facility recognize and track trends or patterns of infections and help prevent the spread of communicable diseases within the facility. Findings include: The facility's Surveillance for Infections policy, dated September 2017, contained the following information: The Infection Preventionist will conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and other epidemiologically significant infections that have substantial…

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 maintain an infection prevention and control program (IPCP) that included a functional antibiotic stewardship program. This had the potential to affect all 52 residents residing in the facility. Findings include: The facility's Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcomes document contained the following information: Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship. Policy Interpretation and Implementation: 1. As part of the facility's Antibiotic Stewardship Program, all clinical infections treated with antibiotics will undergo review by the Infection Preventionist, or designee. 2. The IP, or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with 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 ensure the facility's Infection Preventionist (IP) completed specialized training in infection prevention and control. This had the potential to affect all 52 residents residing in the facility. IP-C started as the facility's designated IP on 8/22/22; however, IP-C did not complete specialized training for infection prevention and control until 2/20/23 and IP-C's employment at the facility ended on 2/27/23. Director of Nursing (DON)-B, Nursing Home Administrator (NHA)-A and Minimum Data Set Coordinator (MDS)-D became the facility's designated full-time IPs on 2/27/23; however, DON-B, NHA-A and MDS-D did not complete specialized training for infection prevention and control. Findings include: CMS (Centers for Medicare and Medicaid Services) Ref: QSO-22-19-NH last revised date: June 29, 2022 contains the following information: In 2016, CMS overhauled the Requirements for Participation for Long-Term Care (LTC) facilities (i.e., nursing homes), which was implemented in three phases: Phase 3 - November 28, 2019 .Phase 3…

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 conduct testing of residents and staff consistent with current standards of practice for COVID-19 testing. This had the potential to affect all 52 residents residing in the facility. The facility did not initiate an outbreak investigation, conduct COVID-19 testing or complete contract tracing when a new case of COVID-19 was identified among residents or staff. Findings include: CMS (Centers for Medicare and Medicaid Services) Memo QSO-20-38-NH, dated 8/26/2020 and revised 9/23/22, provides guidance for COVID-19 testing of nursing home staff and residents and contains the following information: To enhance efforts to keep COVID-19 from entering and spreading through nursing homes, facilities are required to test residents and staff based on parameters and a frequency set forth by the HHS (Health and Human Services) Secretary .2. An outbreak investigation is initiated when a single new case of COVID-19 occurs among residents or staff to determine if others have been exposed .In an outbreak investigation, rapid…

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 the resident environment remained free of accident hazards for 1 Resident (R) (R26) of 13 sampled residents reviewed for safety. R26 did not have access to a call light when R26's door was closed and R26 was calling out for help. Findings include: R26 was admitted with diagnoses to include Alzheimer's disease with late onset, asthma, dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance, major depressive disorder recurrent, anxiety disorder, overactive bladder, and weakness. On 3/7/23 at 8:53 AM, Surveyor walked past R26's room and noted the door was closed all the way. Surveyor continuously observed R26's door from across the hall beginning on 3/7/23 at 8:53 AM. R26's call light was not activated. Staff were observed in the hall, but none at the same time as R26 was yelling. Surveyor noted staff did not check on R26 until 9:59 AM. Surveyor noted the following: On 3/7/23 at 8:56 AM, R26 yelled, Can somebody open the door please! On 3/7/23 at 8:57…

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

Based on interview and record review, the facility did not ensure a resident or resident's representative was provided education regarding the risks versus benefits of COVID-19 immunization and did not obtain consent or refusal for COVID-19 immunization for 1 Resident (R) (R29) of 5 residents reviewed for immunizations. R29's medical record did not contain documentation to indicate R29 or R29's representative was provided education by the facility regarding COVID-19 immunization and offered the opportunity to receive or decline COVID-19 immunization. Findings include:: The Centers for Medicare and Medicaid Services (CMS) Quality, Safety & Oversight Group (QSO) Memo (Ref: QSO-21-19-NH) released on May 11, 2021, addresses the Interim Final Rule related to COVID-19 Vaccine Immunization Requirements for Residents and Staff, which includes requirements for educating residents or resident representatives and staff regarding the benefits and potential side effects associated with the COVID-19 vaccine, and offering the vaccine. Additionally, the facility must maintain appropriate…

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.