Alden Estates of Countryside, Inc

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure the drug regimen of each resident was reviewed at least once a month by a licensed pharmacist, and that irregularities identified by the pharmacist were reviewed, and action was taken to address them, for 1 (R39) of 5 residents reviewed. R39 did not have regular monthly reviews performed by the pharmacist. Findings include: The facility's policy titled, Medication Regimen Reviews (MMR) Scheduled and Interim and dated 01/2022, documents the following: The consultant pharmacist will review the medication regimen, as required by State and Federal regulations. This review should include a review of the resident's medical record. The consultant pharmacist's MMR report or the interim MMR report will be given to the director of nursing (or designee), upon completion of all medication regimen reviews. The facility nursing staff will follow up with the prescribing physician and record the response on the report and/or the interim review and make changes 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 2.) R94 was admitted to the facility on [DATE]. R94's diagnoses include Atrial Fibrillation (a heart condition that causes an irregular pulse rate) and Hypertension (High blood pressure). R94's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/25/25 documents R94 as being rarely to never understood. R94's Quarterly MDS with an ARD of 4/25/25 documents that R94 received an anticoagulant (a medication that thins ones blood to prevent clotting) medication during the 7 day assessment period. Surveyor reviewed R94's Electronic Medical Record (EMR) which documents R94's current physician orders, Medication Administration Record (MAR), and Treatment Administration Record (TAR). R39 is prescribed Eliquis 5 mg two times a day for Atrial Fibrillation, last ordered on 10/25/24. Surveyor reviewed R94's MAR and TAR. Surveyor noted there is no documented monitoring of R94's Eliquis, an anticoagulant medication, for potential signs and symptoms of an adverse effect from this medication, 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.

Based on observation, interview and record review, the facility did not ensure food was prepared and served in a form designed to meet individual needs for 1 (R25) of 1 residents reviewed for a mechanically-altered diet. R25 has a mechanical soft diet order, R25 was served a regular diet meal. Findings include: The Facility Policy titled Regular Ground/Mechanical Soft dated 7/2023, documents (in part): Purpose The regular mechanical soft diet is for adults who have difficulty chewing. This diet is similar to the regular diet with some modifications to hard to chew foods. This diet is not intended to be used for modifications required by the National Dysphagia Diets. Rationale Foods that are difficult to chew are replaced with foods that have been altered into a form that can be easily swallowed. Food that may be modified because they are tough and difficult to chew include meats, poultry, fish, raw vegetables, and other fibrous foods . According to Healthline.com A mechanical soft diet is a texture-modified diet that restricts foods that are difficult to chew or swallow. It'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, interview, and record review the facility did not provide adaptive eating equipment to 1 (R95) of 1 sampled resident reviewed for assistive eating devices. Surveyor observed R95 did not receive therapy recommended assistive eating devices needed to maintain or improve R95's ability to eat or drink independently during 2 out of 3 Surveyor observed meals. Finding include: Facility Clinical Practice Guidelines titled; Feeding a Resident dated 09/20. Policy: Residents who need assistance will be fed a well-balanced meal, by a nurse, C.N.A. (certified nursing assistant), or an individual who has completed a state approved feeding course Procedure: 3. Check the tray before serving the meal to make sure everything is on the tray and it is accordance with the resident's diet. Correct anything wrong 9. Use appropriate utensil and adaptive equipment to feed the resident R95 was initially admitted to the facility on [DATE] with diagnoses that included Unspecified Dementia (a decline in mental ability…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (R32, R74) of 6 residents observed. *R32 was readmitted to facility on 5/13/25 with a hospital acquired stage 3 pressure injury. R32 was placed on Enhanced barrier precautions (EBP) on 5/13/25. Surveyor observed on 6/9/25 R32 had no indication that R32 was on EBP. Care Plan documents R32 continued EBP until 6/12/25 when the facility discontinued EBP for a stage 3 pressure ulcer not yet healed. Surveyor observed R32's wound care on the stage 3 coccyx pressure ulcer on 6/11/25 with nurse not following EBP during R32's treatment. *R74 was observed by Surveyor on 6/9/25 [NAME] with drainage on R74's bandaged leg wounds and not in Enhanced Barrier Precautions (EBP) until 6/10/25. R74's care plan has no documentation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure residents Pneumococcal immunizations were offered, or refused, as eligible. This was observed with 3 (R19, R109, and R163) of 5 residents whose immunization records were reviewed. *R19, is [AGE] years old, admitted on [DATE] and did not have documentation of Pneumococcal vaccine being offered until 6/11/25, after Surveyor asked for records, then a verbal consent was obtained from R19's Power of Attorney (POA) * R109, is [AGE] years old, admitted on [DATE] and did not have documentation of Pneumococcal vaccine being offered until 6/11/25, after Surveyor asked for records. * R163, is [AGE] years old, admitted on [DATE] and did not have documentation of Pneumococcal vaccine being offered until 6/11/25, after Surveyor asked for records. Findings include: The facility's policy and procedure titled, Pneumococcal Vaccination, dated 01/2025 was reviewed. The policy documents in part: Policy: It is the policy of this facility that residents will be offered…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure medical records contained documentation related to COVID-19 immunizations for 3 (R19, R109, and R163) of 5 residents reviewed for immunizations. *R19's medical record does not contain any documentation as to whether R19 was offered, received, or declined the COVID-19 immunization. * R109's medical record does not contain any documentation as to whether R109 was offered, received, or declined the COVID-19 immunization. * R163's medical record does not contain any documentation as to whether R163 was offered, received, or declined the COVID-19 immunization. Findings include: The facility's policy and procedure titled, Covid-19 Vaccinations, dated 02/2025 was reviewed. The policy documents in part: Policy: When recommended vaccines are available, the facility will ensure COVID-19 vaccines are readily accessible to both residents and staff. COVID-19 vaccinations can be administered to residents and staff at the facility by a contractor provider, 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 interview and record review, the facility did not ensure sufficient nursing staff was provided to allow residents to maintain or attain their highest practicable physical, mental, and psychosocial well-being. This deficient practice has the potential to affect all 109 residents residing at the facility. Surveyor conducted interviews with residents and staff in which they expressed concerns regarding challenging staffing levels. Surveyor conducted a record review of the Facility's staff schedules and verified the Facility is not providing staffing levels that meet the Facility identified staffing needs documented in the Facility Assessment. Findings include: *R4 was admitted to the facility on [DATE]. R4's Quarterly Minimum Data Set (MDS) assessment documents that R4 is cognitively intact. On 4/2/25 at 2:10 PM, Surveyor interviewed R4. R4 stated R4 does use the call light when R4 needs help. Surveyor asked what the average wait time is for R4's call light to be answered. R4 stated that it depends on 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 record reviews and interviews, the Facility did not implement their policies and procedures for reporting allegations of abuse, neglect or injuries of unknown origin for 1 (R1) of 1 residents reviewed with allegations of abuse. R 1 complained of 10/10 left knee pain following a pivot transfer with assist of 1 the evening of 2/7/25. R1 was assessed to require an EZ stand and assist of 1 for transfers. R1 informed Facility staff in the early morning hours of 2/8/25 the 10/10 left knee pain began after the incorrect transfer method was used on 2/7/25. It was later determined R1 sustained a left distal femur fracture. The Facility did not implement their Abuse Prevention policy and procedure as evidenced by not reporting the incorrect transfer resulting in, significant pain, bruising, and swelling to the Nursing Home Administrator or the State Agency. The Facility did not report R1's major injury of the left distal femur fracture following an incorrect transfer and not following R1's care plan to the State…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the Facility did not ensure 1 (R1) of 1 residents reviewed for allegations of abuse, suspected neglect, and/or injury of unknown origin were reported to the Nursing Home Administrator and the State Agency during the required timeframe. On [DATE] R1 was transferred by a pivot transfer and assist of 1 when R1 was assessed to require an EZ stand and assist of 1 for transfers. Following the transfer R1 complained of 10/10 pain, swelling and bruising to the left knee. R1 informed staff the pain started after staff transferred her without the EZ stand. R1 declined physically and cognitively following the incorrect transfer and passed away at the Facility on [DATE]. R1's Responsible Party expressed concern to the Facility they believed R1 was dropped during the transfer. The Facility did not report the incident to the Nursing Home Administrator or State Agency. Findings include: The Facility policy entitled, Abuse Policy, dated 9/20, documents, in part, .Policy: This facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that residents were seen by a physician or physician extender for 2 (R3 & R1) of 3 residents reviewed for physician services. * R3 did not have alternating visits between the physician and physician extender. * R1 was not seen by a physician every 60 days following 90 days after admission. Findings include: The facility's policy titled, Medical Care Services and dated 9/2020 documents under policy Residents will receive medical care and services which meet their individual needs and ensure adequate health care. Under procedures documents 4. Residents will be seen by a physician or delegated physician's assistant or nurse practitioner at least once every thirty (30) days for the first 90 days after admission and at least once every 60 days thereafter. A physician visit is considered timely if it occurs not later than 10 days after the date the visit was required. 5. After the initial physician visit in SNF (skilled nursing facility) a qualified…

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

Based on observation, interview, and record review, the facility did not ensure sufficient nursing staff was provided to allow residents to maintain or attain their highest practicable physical, mental, and psychosocial well-being This deficient practice has the potential to affect all 113 residents residing at the facility. Surveyors conducted interviews with residents and staff in which both expressed concerns regarding low staffing levels. The survey team had observations of resident call lights not being answered for extended periods of time. Surveyors interviewed residents who expressed concerns regarding extensive call light wait times. Surveyors conducted a record review of Facility's nursing schedules and daily staff postings and verified the Facility is not providing staffing levels that meet the Facility identified staffing needs documented in the Facility Assessment. Findings include: * R3's quarterly MDS (minimum data set) with an assessment reference date of 11/21/24 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. On 12/2/24,…

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 interview and observation, the facility did not ensure water was consistently being passed to Residents. This has the potential to affect R3, R4, R5, R6, R7, R9, and other residents residing in the facility who would like water to drink in their rooms. Findings include: The facility's policy titled, Water Passing and dated 9/2020 under purpose documents To maintain fresh drinking water accessible to resident's around the clock. Procedure documents 1. Wash hands. 2. Gather supplies. 3. Fill clean water pitchers/cups with ice and water every shift and as necessary. Resident's on thickened liquids or fluid restrictions will be identified. 4. Knock before entering room. 5. Distribute cups to resident's room. Leave on bedside table with a straw (if able to have straw). 6. Water will not be left at bedside on the dementia unit unless appropriate. 7. Offer each resident a drink. Record on I & O (intake and output) sheet (if applicable). 8. Discard used supplies in appropriate manner. * R3's quarterly MDS (minimum data set) with an assessment reference date of 11/21/24 has a BIMS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the Facility did not have evidence all alleged violations of mistreatment were thoroughly investigated for 1 (R1) of 1 residents. R1's allegation of being yelled at and handled roughly was not thoroughly investigated. Findings include: The facility's policy titled, Abuse Policy (For Wisconsin Facilities) and dated 9/20 under policy documents This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. The facility will report reasonable suspicion of a crime. This facility therefore prohibits mistreatment, neglect or abuse of its residents and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents. This will be done by: .6. Implementing systems to investigate all reports and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure 1 (R3) of 3 residents were free from unnecessary psychotropic medications ordered on an as needed (PRN) basis. On 11/10/24 R3 was prescribed an anti-anxiety medication, Lorazepam 0.5 mg every four hours PRN without an end date. Findings include: The facility's policy titled, Psychotropic Medications - Use Of and dated 9/2020 does not address stop dates for PRN (as needed) psychotropic medications. R3's diagnoses includes multiple sclerosis, chronic inflammatory demyelinating poly neuritis, diabetes mellitus, paraplegia, depressive disorder and anxiety disorder. R3 was readmitted to the facility on [DATE]. Hospital discharge documentation dated 11/10/24 includes under new medications lorazepam (LORazepam 0.5 mg (milligrams) oral tablet) 1 Tabs Gastrostomy tube/PE (percutaneous endoscopic) every 4 hours as needed anxiety. On 12/2/24, at 11:29 a.m., Surveyor reviewed R3's physician orders and noted an order dated 11/10/24 for Lorazepam 0.5 mg. Give 1…

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 1 (R1) of 3 residents received prescribed medication as ordered by the physician to meet residents needs. * R1 did not receive the scheduled Oxycodone 5mg on 7/12/24, 7/13/24, 9/8/24, 9/13/24, 10/8/24, 10/18/24, 10/28/24 and on 11/6/24 at different prescribed times. Findings include: The facility's policy titled, Reordering Medications (Facilities Ordering Refills on Demand) and dated 01/2022 under Policy/Purpose documents Medications are reordered in advance so as not to have lapses in therapy. Under Procedure documents 1. The nursing staff is responsible for reordering medications. 2. Medications should be reordered when, in the judgment of the nurse, a 2-day supply of medication remains. 3. Reorders should be submitted by one of the following methods: a. Using the re-order function in the facility's e-MAR (electronic medication administration record) system (only if there is a pharmacy interface), or b. Removing the barcode label, affixing it to the reorder sheet, and faxing it-in a fax document carrier-to 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, interview, and record review, the facility did implement effective infection prevention measures. This included N95 mask fit testing for staff with the potential to effect all 115 residents in the facility. This includes Foley bag maintenance in 1(R85) of 4 residents observed with Foley bags. * The facility did not ensure all staff exposed to COVID-19 were properly fit tested for a N95 mask to prevent the spread of infection. * The facility did not ensure R85's Foley bag was maintained in a sanitary manner. Findings include: The facility policy and procedure for Management of Residents with Confirmed or Suspected COVID-19 Infection or Identified as a Close Contact, dated 1/5/24, was reviewed by Surveyor. The section: Residents with Confirmed COVID-19 documents: . 3. Isolate using Transmission-Based Precautions, . 10. Staff must wear full PPE (Personal Protective Equipment) (N95 respirator, gown, gloves, eye protection) when providing care. The facility did not have a specific policy 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 record review and interview, the facility did not ensure resident's received the required written notice information related to their transfers out of the facility. This was observed with 7 (R108, R38, R25, R77, R54, R85 and R65) of 7 resident reviewed transfers. *R108, R38, R25, R77, R54, R85 and R65 were transferred to the hospital from the facility. A transfer notice including the following information was not provided: -A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; . (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility did not ensure 1 out of 1 allegations of an injury of unknown source (R38) were reported immediately, but not later than 2 hours after the allegation is made to the State Survey Agency. In addition, the facility did not ensure they reported the results of the investigation, within 5 working days to the State Survey Agency for 1 out of 1 allegations of an injury of unknown source (R38). R38 experienced pain in the left knee although no injury had been reported. An X-ray was obtained and it was noted R38 had suffered a left distal femur fracture and was admitted to the hospital and underwent surgical repair. The facility did not report the injury within 2 hours of being aware of the femur fracture, to the State Survey Agency, when they were not able to determine the cause of the fracture. In addition, the facility did not report, within 5 working days, the outcome of their investigation of the injury of unknown source for R38 following the diagnosis 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility did not ensure residents had an individualized comprehensive plan of care. This was observed with 2 (R85 and R81) of 23 resident comprehensive care plan reviews. 1. R85 was admitted to the facility with an indwelling catheter after a short stay in the hospital and there was no comprehensive plan of care with individualized interventions to address catheter care. 2. R81 was admitted to the facility on anticoagulant medication and there was no comprehensive plan of care with individualized interventions to address monitoring of the anticoagulant. Findings include: The facility policy entitled, Comprehensive Care Plans, dated 11/2017 states: An individualized, person-centered comprehensive care plan, including measurable objectives with timetables to meet Resident physical, psychosocial and functional needs, is developed and implemented for each Resident. #4. Care plan interventions are initiated based on an analysis of information collected…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and observation, the facility did not ensure a resident with an indwelling catheter received consult services. This was observed with 1(R22) of 4 residents reviewed with an indwelling catheter. * R22 was admitted without an indwelling catheter. R22 went out to the hospital due to a change in condition and an indwelling catheter was placed in the hospital due to urinary retention. There was no follow-up with a Urology to determine long term needs of the catheter. Findings include: The facility's policy and procedure Indwelling Catheter, dated 9/20, was reviewed by Surveyor. The procedure includes under 15: A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible. On 03/11/24 at 1:08 PM, Surveyor observed and spoke with R22. R22 was observed to have an indwelling Foley bag hanging below their wheelchair. R22 did not know why they had an indwelling catheter. R22 was admitted to 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, record review and interview, the facility did not ensure 1 Resident (R82) of 1 resident was properly assessed for the use of bed rails and the facility did not have evidence that risks and benefits were discussed with the resident and/or representative. R82's was assessment to not be appropriate for the use of bed rails. R82's bed was observed to have grab bars. Findings include: The facility's policy entitled, Side Rail Assessment, dated 9/2020 states: It is the policy of this facility to properly assess a resident's needs for side rail use. The side rail assessment form will be completed upon admission, readmission, with significant change and annually thereafter. R82 was admitted to the facility on [DATE] for short term rehabilitation with diagnoses that include fracture of unspecified part of neck of left femur, presence of left artificial hip joint, lack of expected normal physiological development in childhood, schizophrenia, moderate intellectual disabilities and history of traumatic…

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

Based on observation, interview, and record review, the facility did not ensure sufficient nursing staff was available to provide nursing and related services to assure residents attained or maintained the highest practicable physical, mental, and psychosocial well-being as determined by the resident assessments and individual plans of care and considering the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment potentially affecting 115 of 115 residents in the facility. Residents voiced concerns there were not enough staff to care for their needs. The facility was identified as having consistently low weekend staffing on the Staffing Data Report submitted to CMS (Centers for Medicare and Medicaid Services) from 10/1/23 through 12/31/23. Staff indicated there were not enough staff on the unit to assist with residents' cares and needs. Findings include: The Facility Assessment stated the following for Licensed Nurses and Certified Nurse Aides (CNA) staffing coverage: Evaluation of overall number of facility staff needed 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 comprehensive assessment of a resident, the facility did not ensure that residents were not given psychotropic drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; residents who use psychotropic drugs received gradual dose reductions, unless clinically contraindicated; and PRN (as needed) orders for psychotropic drugs were limited to 14 days for 3 of 5 residents (R25, 103, and R81) reviewed for unnecessary medications. R25 did not have required gradual dose reduction for Mirtazepine (antidepressant medicaiton). R103 was prescribed PRN Lorazepam (sedative/antianxiety) without documentation of rationale by the Physician to extend beyond 14 days. R81 was prescribed Primidone (Anticovulsant) without clear indication of use. Findings include: R25 admitted to the facility on [DATE] and has diagnoses that include hemiplegia and hemiparesis following Cerebral Infarction, Dysarthria, Dysphagia, Spondylosis lumbar region, Adult Failure 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 review and revise the plan of care for 5 Residents (R) (R5, R10, R2, R12, and R4) of 6 residents reviewed. R5 had a history of wandering and wandered into several residents' rooms. Following an incident on 10/3/23, the facility did not update R5's care plan with interventions to keep R5 and other residents safe. In addition, stop sign banners were placed across the doorways of R10, R2, R12 and R4 after R5 wandered into their rooms. The intervention was not added to R10, R2, R12, and R4's plan of care. Findings include: The facility's Review of Care Plans policy, dated 11/2017, indicated: The Interdisciplinary Team is responsible for periodic review and adjustments of the plan of care: d. When there is a change to the plan of treatment goals or interventions. On 12/8/23, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] with diagnoses including unspecified dementia without behavioral disturbance. R5'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 staff interview and record review, the facility did not thoroughly investigate an injury of unknown origin for 1 Resident (R) (R6) of 10 residents reviewed. On 10/25/23, R6 had an injury of unknown origin that was reported to the State Agency (SA). The facility did not thoroughly investigate the injury of unknown origin when they did not interview residents regarding abuse concerns following the unwitnessed injury. Findings include: The facility's Abuse Policy for Wisconsin Facilities, dated 9/20, indicated: The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect, or abuse of our residents. This will be done by: 3. Establishing an environment that promotes resident sensitivity, resident security, and prevention of mistreatment. 4. Identifying occurrences and patterns of potential mistreatment. 5. Immediately protecting residents involved in identifying reports of possible abuse 6. Implementing systems 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 observations, interviews, record review, and facility policy review, the facility did not ensure 2 Resident (R8 & R11) of 8 sampled residents were assessed and had physician orders to self administer respiratory treatment medications and to keep the medications bedside. Findings included: A review of a facility policy titled, Self-Administration of Medications, dated August 2023, revealed, Policy: Residents may be allowed to self-administer medication according to physician's order unless such practice for the resident is deemed unsafe. 1. A review of R8's admission Record revealed the facility admitted the resident on 06/06/2022. A review of R8's Medical Diagnosis document revealed the resident had diagnoses that included chronic obstructive pulmonary disease (COPD) and need for assistance with personal care. A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/28/2023, revealed R8 had a Brief Interview for Mental Status (BIMS) score of 11, indicating the resident had moderate cognitive impairment. A review of R8's care plan…

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 observations, interviews, record reviews, and review of manufacturer's information the facility failed to ensure they followed appropriate infection control procedures for the storage of oxygen tubing and nasal cannula's and the storage and cleaning of CPAP equipment for 3 (R3, R8, and R11) of 4 sampled residents reviewed for respiratory care. Findings include: 1.) A review of R3's admission Record revealed the facility admitted the resident on 06/24/2023 with diagnoses that included obstructive sleep apnea. A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/29/2023, revealed the R3 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. A review of R3's care plan initiated on 06/26/2023, indicated the resident had a potential for respiratory difficulty secondary to sleep apnea. Interventions directed staff to assist the resident with their CPAP machine as ordered. A review of R3's Order Summary Report revealed an order dated 06/30/2023 to apply the resident's CPAP machine 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.

Based on observations, and interviews the facility did not ensure proper infection control measures were completed during medication administration for 1 (R16) of 4 residents observed. During medication administration a Licensed Practical Nurse (LPN) was observed to handle medications with bare hands. Findings included: On 10/24/2023 at 7:57 AM, Licensed Practical Nurse (LPN) T was observed preparing R16's medications for medication administration. LPN T placed the medications into a medication cup and touched the medications with her ungloved hands. At 8:05 AM, LPN T counted the medications in the medication cup by tipping the cup toward a second medication cup and using an ungloved finger to move the medication from one cup into the other. At 8:06 AM, LPN T then moved all crushable medication tablets back into the first medication cup and held the medication that could not be crushed with her ungloved fingers. During an interview on 10/24/2023 at 8:14 AM, LPN T stated she should not have put fingers into the medication cup because it could contaminate the cup and medications from…

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, interviews and record review the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This deficient practice had the potential to affect 7 residents residing on the 200 unit of the facility. The facility utilizes a shared glucometer between residents. The glucometer was not cleaned according to manufacturer's recommendations between residents. Findings include: The facility policy titled Assure Platinum Blood Glucose Monitoring dated 5/28/20 documents (in part) . .12. After each use clean/disinfect outside of the meter with disinfectant wipes. a. All surfaces of Blood Glucose Monitoring Machine if visibly soiled need to be physically cleaned to remove gross soil with one wipe and then a second wipe to disinfect the surface. c. If using Super Sani wipes for treated surface of the blood glucose monitoring machine for Covid 19 should remain wet for 2 minutes. Surveyor review…

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 interviews and record review the facility did not ensure that alleged violations involving neglect were reported to the State Survey Agency within the required time frame for 1 of 3 (R15) residents reviewed for abuse/neglect. R15's nursing progress notes on 10/2/22 documented an allegation of neglect that was not reported to the State Agency. Findings include: R15 admitted to the facility on [DATE] and has diagnoses that include Dementia, severe protein- calorie malnutrition, Chronic Kidney Disease and Major Depressive Disorder. R15's Significant Change MDS (Minimum Data Set) dated 10/25/22 documents a Brief Interview for Mental Status Score (BIMS) score of 7, indicating severe cognitive impairment. The facility policy titled Abuse Policy dated 9/20 documents (in part) . .The facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. The facility will report reasonable suspicion of a crime. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility did not have evidence that allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated for 1 of 3 (R15) residents reviewed for abuse/neglect. R15's nursing progress notes on 10/2/22 documented an allegation of neglect that was not thoroughly investigated. Findings include: R15 admitted to the facility on [DATE] and has diagnoses that include Dementia, severe protein- calorie malnutrition, Chronic Kidney Disease and Major Depressive Disorder. R15's Significant Change MDS (Minimum Data Set) dated 10/25/22 documents a Brief Interview for Mental Status Score (BIMS) score of 7, indicating severe cognitive impairment. The facility policy titled Abuse Policy dated 9/20 documents (in part) . .The facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. The facility will report reasonable suspicion of a crime. This facility therefore…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not notify the resident or resident's representative in writing of the transfer including the location to which the resident is transferred, a statement of the resident's appeal rights with the name, address, and telephone number of the entity which receives the request and information on how to obtain an appeal form for 3 (R29, R72, and R20) of 3 residents reviewed for transfer to the hospital. R29 was transferred to the hospital on [DATE]. No written transfer notification was provided to R29's representative that included the location R29 was being transferred to and information regarding appeal rights and how to obtain them. R72 was transferred to the hospital on [DATE]. No written transfer notification was provided to R72 or R72's representative that included the location R72 was being transferred to and information regarding appeal rights and how to obtain them. R20 was transferred to the hospital on [DATE]. No written transfer notification was provided…

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

Based on record review and staff interview, the facility did not ensure resident's with mental health disorders, and intellectual disabilities, were appropriately screened. This was discovered with 1 (R42) of 3 residents reviewed for PASARR (preadmission screening and resident review) screening. *R42 has a diagnosis of intellectual disability and his PASARR Level I did not indicate this diagnoses upon admission to the facility. The facility's failure to identify R42's diagnoses of intellectual disability on the PASARR resulted in inaccurate completion of R42's PASARR Level 1 Screen. If R42's PASARR was completed correctly a positive Level 1 screen would have been documented. The facility did not identify R42's positive Level 1 screen which would have required the facility to refer R42 for an in-depth evaluation by a state-designated authority, known as a Level 2 screen. Since R42 was not referred for a Level 2 screen it allowed for the potential for R42 to be placed in an inappropriate environment and/or not receive the necessary specialized services related to the diagnoses of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility did not ensure each resident received adequate assistance to prevent accidents for 1 (R5) of 4 residents reviewed for falls. R5 was transferring with the use of a sit-to-stand lift (EZ lift) on 9/3/2022 when R5 slipped out of the sling and sustained a fall. The facility did not do a thorough investigation as to the cause of the fall to prevent future falls. R5 had contradicting transfer statuses: R5's Care Plan stated R5 was a Hoyer lift transfer and the Certified Nursing Assistant (CNA) Care Card stated R5 was an EZ lift transfer. Findings include: The facility policy and procedure entitled Management of Falls dated 9/2020 states: 3. Develop a plan of care to include goals and interventions which address resident's risk factors. 9. Review and/or modify the resident's plan of care at least quarterly and as needed in order to minimize risk for fall incidents and/or injury. The facility policy and procedure entitled Fall Risk Assessment dated 8/2020…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for 1 of 5 residents reviewed for medications (R20). The facility was administering psychotropic medications to R20, but no behaviors were being monitored to assure the medications effectiveness. Findings include: R20 was originally admitted to the facility on [DATE] with diagnoses that included Anxiety Disorder, Depression, Dementia without behavioral disturbance. A review of R20's Individual plan of care noted: R20 is receiving antidepressant medications, Lexapro and Imipramine, antipsychotic medication, Aripiprazole to manage depressive symptoms and anxiousness related to diagnosis of Depression and Anxiety Disorder, unspecified. Date Initiated 11/4/2022. Interventions included: o Will show no adverse side effects of psychotropic medication regimen through next review. o Will show a decrease in depressive symptoms and anxiety through next review. o Assess/record effectiveness of…

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