Avina of Kenosha

Based on observations, document review, interviews, and facility policy review, the facility failed to ensure proper dishwasher temperature and sanitizer levels, failed to thaw liquid eggs in a safe manner; failed to ensure food in the refrigerator and dry storage was labeled, dated, and not past the use by date; failed to ensure food on the steam table was held at a safe temperature level; and failed to ensure utensils and dishes were clean in one of one kitchen and one of one rehabilitation unit. This had the potential to result in the spread of infections and food born illness for 86 of the 87 residents consuming food in the facility. Findings include: Review of the undated facility's policy titled, Sanitation of Dishes/Dish Machine revealed the low temperature dish machine should have a water temperature of 120 degrees F [Fahrenheit] and the sanitizer level should be 50 PPM [parts per million]. Review of the safe thawing Practice section of the undated facility's policy titled, General HACCP [Hazard Analysis Critical Control Point] Guidelines for Food Safety revealed food could…

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, record review, and interviews, the facility failed to ensure food was served and received at palatable food temperatures for nine of nine residents (Resident (R) R2, R11, R8, R13, R15, R16, R17, R18, and R19) reviewed for palatability of 19 sample residents. This had the potential to result in residents not eating the food and resulting in weight loss. Findings include: Review of R2's quarterly Minimum Data Set (MDS) located in the MDS tab of the electronic medical record (EMR) with an Assessment Reference Date (ARD) of 04/03/25 revealed she had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating she was cognitively intact. During an interview on 05/08/25 at 8:25 AM, R2 stated the food was sometimes cold. Review of R11's quarterly MDS located in the MDS tab of the EMR with an ARD of 03/06/25 and revealed he had a BIMS score of 10 out of 15 which indicated he had moderately impaired cognition. During an interview on 05/09/25 at 5:31 AM, R11 stated the food was not always good and it was cold. During an interview on 05/09/25 at 8:00 AM, R8…

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 failed to ensure appropriate door closure with an operating door latch for one of six residents (Resident (R) 4) reviewed for privacy of 12 sample residents. This failure resulted in the potential to affect resident safety, security, and privacy. Findings include: Review of the admission Record located under the Profile tab in the electronic medical record (EMR) revealed R4 was admitted on [DATE] with diagnoses that included bilateral primary osteoarthritis of knee. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/15/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R4 was cognitively intact. During an interview on 01/07/25 at 11:22 AM, R4's door was observed to have a towel and pillowcase draped over the inside corner of the door. R4 stated, That's to keep it shut because it doesn't stay closed. It's been like that since September. A CNA [Certified Nurse Aide] came…

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, record review, and review of the facility policy, the facility failed to ensure a fingerstick blood sugar test (FSBS), and insulin was documented as administered, per the physician's order for one of three residents (Resident (R) 3) reviewed of 12 sample residents. This failure placed the resident at risk for serious medical consequences. Findings include: Review of the facility's policy titled, Medication Errors, revised February 2023, revealed .Medication errors, once identified, will be evaluated to determine if considered significant or not by utilizing the following three general guidelines .Resident's Condition .If the resident's condition requires rigid control .or monitoring of lab values .Drug Category .If the medication is from a category that usually requires the resident to be titrated to a specific blood level .To prevent medication errors and ensure safe medication administration, nurses should verify the following information .Right medication, dose, route, and time 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 interviews, record review, and review of facility policy, the facility failed to ensure the Medication Administration Record (MAR) and/or treatment administration record (TAR) was complete and accurate for two of 12 sample residents (Resident (R) 10 and R7) reviewed for accurate documentation. - R10's MARs were not accurately documented to show medications werev administered according to physician orders. -R7's TARs were not accurately completed to show consistent application of ordered treatments to R7's pressure injuries. Findings include: Review of the facility's policy titled, Medication Administration-General Guidelines, revised January 2018, revealed .The individual who administers the medication dose records the administration on the resident's MAR/eMAR [electronic medication administration record] directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR/eMAR to ensure necessary doses were administered and documented. In…

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, menu review, and interviews, the facility failed to ensure the menu was followed for all the diets listed on the menu spreadsheet for 81 of 81 residents who receive food from the facility. Failure to follow the spread sheet had the potential to result in weight loss and for residents to feel hungry. Findings include: Review of the Client List Report dated 10/22/24 and provided by the facility, revealed the facility had 60 residents on regular consistency diets, 13 residents on mechanical soft consistency diets, and eight residents on puree consistency diets. The facility did not have any residents who were on tube feedings and did not receive their meals from the dietary department. During lunch observations on the north, south and west units on 10/22/24 from 11:50 AM to 12:40 PM, three unidentified residents stated they often did not get enough food during the meals. During an observation and interview on 10/22/24 at 11:29 AM, the [NAME] was observed serving the noon meal from the steam table in the kitchen. She stated she was serving the residents on all 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, interviews, and facility policy review, the facility failed to ensure water temperatures were maintained at safe and comfortable temperatures with the potential for burn-related injuries or for residents to receive showers at uncomfortable temperature levels for three of four units (South unit, North unit, and [NAME] unit) affecting 36 of 81 residents in the facility. Findings include: Review of the facility's policy titled, Water Temperature Policy with an effective date of 10/22/24 revealed the acceptable range for water temperatures was between 110 degrees Fahrenheit (F) and 120 degrees F. During an interview on 10/21/24 at 12:31 PM a resident wishing to remain anonymous stated the water was cold when they assisted her with a shower but lately it has been working. During an interview on 10/22/24 at 1:46 PM a resident wishing to remain anonymous stated the water at his bathroom sink had been very hot lately. During an interview on 10/22/24 at 10:25 PM a resident wishing to remain…

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 facility policy review, the facility failed to maintain a functioning call system with auditory alarms to alert staff when a resident called for assistance for one of three call light systems (North station). This could result in residents' needs/care being delayed unnecessarily for the 22 residents in the North Hall. Findings include: Review of the facility's policy titled, Call Light Policy revised 01/28/23 revealed, Purpose: To respond to resident's needs and requests in a timely manner .2. Make sure the call light is plugged in and in good working order. Call light system defects will be reported to the Maintenance Department for servicing . During an interview on 10/21/24 at 3:04 PM, Certified Medication Tech (CMT) 1 was behind the nursing station on the North wing and she stated the call light panel behind the nursing station did not work. When asked how long it had not worked, she stated she did not know and I would have to talk to maintenance . Observation on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review, the facility failed to ensure there was a physician's order for oxygen therapy for one of two residents (Resident (R) 3) reviewed for oxygen therapy. The lack of physician's orders for oxygen therapy could lead to inappropriate oxygen therapy and medical compromise. Findings include: Review the facility's undated policy titled, Oxygen Administration, undated, revealed Oxygen will be safely administered per physician's orders .Procedure: If oxygen is continued beyond 24 hours, obtain a physician order. Review of R3's undated admission Record located in the Profile tab of the electronic medical record (EMR) revealed the resident was most recently readmitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD). Review of R3's 5-day Minimum Data Set (MDS) with an assessment reference date (ARD) of 07/18/24 and located under the MDS tab of the EMR revealed the facility assessed the resident to have a Brief…

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, record review, and review of the facility's policy, the facility failed to ensure residents medications were administered in accordance with their policy for one of three residents (Resident (R) 8) reviewed for medication administration out of 20 sampled residents. Specifically, R8 was ordered to be administered his medications via a gastrostomy tube (g-tube). The resident was administered his medications as a cocktail (administer more than one medication at a time); however, there was no physician order for the medications to be administered as a cocktail. This placed the resident at risk for his G-Tube to become clogged. Findings include: Review of the facility's policy titled, Medication Administration-Gastrostomy Tube, dated 05/19/22 revealed Use liquid preparations whenever possible. Check with the pharmacist if in doubt about availability of medication in liquid form or whether tablets are crushable. Enteric-coated medications, sublingual tablets, and sustained release medications should never be crushed. lf more than one medication is being…

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 facility policy review, the facility failed to ensure that items in the reach in cooler and freezer were dated/labeled according to professional standards and ensure a large silver metal exhaust/vent located above the kitchen dishwasher was in good working condition. These failures had the potential to affect 80 of 81 residents who were served food from the facility kitchen. Findings include: Review of the facility's undated policy titled, Food Storage, revealed Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Procedure: Leftover food will be stored in covered containers or wrapped carefully and securely. Each item will be clearly labeled and dated before refrigerated. Leftover food is used within 7 days is discarded .Refrigerated food storage: All foods should be covered, labeled, and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen, or discarded. The initial kitchen inspection was conducted with the Dietary Manager…

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, and facility policy review, the facility failed to ensure the outside garbage dumpster lids remained closed, and the garbage storage area was maintained in a sanitary condition to prevent the harborage of pests with the potential to affect 81 of 81 residents residing in the facility. Findings include: Review of the facility's policy titled, Pest Control, effective 05/19/22, revealed Purpose: To prevent or control insects and rodents from spreading disease. Guidelines: The facility shall be kept in such condition and cleaning procedures used to prevent the harborage or feeding of insects or rodents. Observation made on 04/21/24 at 8:45 AM, of the outside garbage area revealed there to be three large metal garbage bins. At this time, all three garbage bins were observed to be full of garbage and the lids were open. During observations and interview on 04/21/23 at 8:45 AM, the Dietary Manager (DM)-J stated, One of the bins I think is for recyclables, and the other two bins are for garbage. At this time, observation was made of the area around 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 observation and record review, the facility did not 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. The facility did not maintain a system of surveillance, tracking and trending of infections and identifying possible communicable diseases or infections before they can spread to other persons in the facility potentially affecting 81 of 81 residents. ~ The facility had an Infection Control Program that did not accurately track, trend or analyze the infection rate and data to help decrease the rates, numbers and spread of infections in the facility. Line lists did not accurately identify infections in the facility. There was no system of surveillance including maps to identify monthly infections on units. There were no trending analysis of Community Acquired Infections or Healthcare Associated Infections (HAI's). The Infection Preventionist was unaware of how to use the computer based Infection Prevention program…

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, interviews, and facility policy review, the facility failed to ensure dignity was provided for one of eighteen residents (Resident (R) 19) of 39 sampled residents. The facility failed to ensure staff were seated while assisting residents during meals and refrained from calling residents feeders during dining services. Findings include: Review of the facility's policy titled, Dignity, revised 07/21/22, indicated The facility shall promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality .Staff shall carry out activities in a manner which assists the resident to maintain and enhance his/her self-esteem and self-worth .Maintaining a resident's dignity should include but is not limited to the following .promoting resident independence and dignity while dining, such as avoiding: staff standing over residents while assisting them to eat; staff interacting/conversing…

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 allegations of mistreatment that resulted in serious bodily injury were reported to the State Agency for 1 (R65) of 2 reportable incidents reviewed. R65 was transferred from the wheelchair to the bed with the assistance of Certified Nursing Assistant (CNA)-X. R65's Care Plan indicated R65 transferred with the use of a sit-to-stand lift. CNA-X did not follow R65's Care Plan and R65 sustained a fractured right tibia and fibula. This incident was not reported to the State Agency. Findings include: The facility policy and procedure entitled Abuse Policy undated, states: Definitions: . Neglect is defined . as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident(s) requires but the facility failed 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 record review and interview, the facility did not ensure Preadmission Screening and Resident Review (PASARR) Level I screens were resubmitted to the State mental health authority after a 30-day exemption had expired and the resident was still in the facility for 1 (R73) of 3 residents reviewed for PASARR compliance. R73 was admitted [DATE]. A PASARR Level I was completed with a 30-day exemption on [DATE]. On [DATE] with R73 was still a resident at the facility, no PASARR Level I was resubmitted. Findings include: R73 was admitted to the facility on [DATE]. R73 has a diagnosis of Paranoid Schizophrenia and Bipolar Disorder. R73 has an order for Buspar and Depakote for her mental disorders. A Level I PASARR was submitted to the State screening agency on [DATE] indicating R73 had a serious mental illness. Section B: short term exemptions was completed indicating R73 had an exemption from a Level II screen due to a hospital discharge and an expected stay at the facility for less than 30 days. On [DATE]…

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 revise resident care plans for 2 (R65, R235) of 18 resident care plans reviewed and did not ensure care conferences were held quarterly to get resident input in their care. *R235's care plan was not revised to include showers two times a week as discussed with facility and R235's guardian. R235 did not receive a shower two times a week. *R65 did not have care conferences to ensure participation in the development of a care plan on a quarterly basis. Findings include: 1.) R235 was admitted to the facility on [DATE] and has diagnoses that include spastic diplegic cerebral palsy, acute kidney failure, severe protein-calorie malnutrition, expressive language disorder, nontraumatic ischemic infarction of muscle, left ankle, and foot, neuromuscular dysfunction of bladder, peripheral vascular disease, muscle weakness, and cognitive communication deficit. R235's admission minimum data set (MDS) dated [DATE] indicated R235 had severely impaired cognition with a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure 1 (R70) of 5 residents drug regime was free from unnecessary medications *R70 was admitted to the facility with an order for Eliquis twice daily. The facility did not implement a care plan or orders to monitor for any adverse side effects that could result from taking an anticoagulant. Findings include: The facility policy entitled Unnecessary Drugs (General) initiated on 4/1/2008 states: Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug used: . Without adequate monitoring . In the presence of adverse consequences which indicate the dose should be reduced or discontinued R70 was admitted to the facility on [DATE] and has diagnoses that include end stage renal disease, dependence on renal dialysis, left foot toes amputated, type 2 diabetes mellitus (DM) with diabetic neuropathy, atherosclerosis of bilateral legs, peripheral vascular disease, vascular dementia, chronic pain syndrome, major depressive…

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 who receive anti-psychotic drugs were assessed for the potential side effects of the anti-psychotic drugs for 1 (R82) of 5 residents reviewed for unnecessary medications. R82 did not have an Abnormal Involuntary Movement Scale (AIMS) assessment completed on 3/22/24 when prescribed anti-psychotic medication. Findings include: On 4/22/24 the facility's policy titled, Aims Side Effect Monitoring dated 1/24 was reviewed and read: The examination will be performed either at the time of resident's admission or when the medications are initially prescribed. R82 was admitted to the facility on [DATE] with diagnoses that included Anxiety, Depression and Traumatic Brain Injury. On 4/23/24 R82's current physicians orders were reviewed and read: Seroquel 200 milligram (mg) at bedtime with a start date of 3/22/24 for Anxiety. Seroquel is an anti-psychotic medication. On 4/23/24 R82's medical record was reviewed and no Abnormal Involuntary Movement…

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, record review, staff and resident interviews and review of facility policy, the facility failed to ensure a comfortable and environment throughout the building. The facility was without adequate linens to ensure resident needs were met, including washcloths, hand towels, and hospital gowns. A total of 19 residents were reviewed in the sample. Findings include: On 03/12/24 at 1:30 PM Laundry Aide (LA1) was observed stocking the linen closet on the [NAME] Unit. There were no washcloths and no hospital gowns in the closet prior to LA1 stacking the closet. LA1 stocked the closet with 10 wash cloths and eight hospital gowns and stated, We don't have enough (washcloths or hospital gowns). The residents and staff come down (to the laundry room) and ask for them .especially washcloths and we just don't have enough of them. This is all there is. During an interview with Resident (R) 4 on 03/13/24 at 9:15 AM, she stated, They (the facility) did not have any gowns last night. I had to lay here with no gown (because they were out of them). They run out of supplies a lot…

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 policy review, the facility failed to ensure staff prevented accident hazards for 3 (R6, R17, R18) of 3 residents reviewed. after a resident fell out of bed during care, a resident fell during an improper transfer and that two staff transferred a resident when using a mechanical lift for three (Residents (R)6, R17, and R18) out of three residents reviewed for accidents hazards. Findings include: 1. Review of R6's admission Record, located in the Profile tab of the electronic medical record (EMR) revealed admission to the facility on [DATE] with diagnoses of Parkinson's, lack of coordination, and repeated falls. Review of R6's admission Minimum Data Set (MDS) under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 02/13/24, revealed a Brief Interview for Mental Status (BIMS), score of 13 out of 15 which indicated no cognitive impairment. Further review revealed the resident required partial/moderate assistance with bed mobility. Review of R6'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to assess the effectiveness of Tylenol for complaints of pain for one of three residents (Resident (R)5. Findings include: Review of R5's admission Record, located in the Profile tab of the electronic medical record (EMR) revealed admission to the facility on [DATE] at 4:36 PM with diagnoses of cerebral infarction, hemiplegia and hemiparesis, difficulty in walking, aphasia, lack of coordination and muscle weakness. Review of R5's admission Minimum Data Set (MDS) under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 01/27/24, revealed a Brief Interview for Mental Status (BIMS), was unable to be completed due to the resident was rarely understood. Further review revealed the resident required substantial assistance with bed mobility and dependent on staff for transfers. Review of R5's Care Plan, located under the Care Plan tab of the EMR and dated 01/26/24, revealed The resident has pain and receiving as needed (PRN) pain…

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, record review, and policy review, the facility failed to ensure that the kitchen was maintained in an orderly manner to prepare, distribute, and serve food in accordance with professional standards for food service safety. In addition, the facility failed to ensure that kitchen staff followed proper sanitation procedures to help prevent an outbreak of foodborne illness. This has the potential to affect 83 out of 85 residents in the facility who received an oral diet. Findings include: During the initial tour of the kitchen with the Interim Dietary Manager (IDM) on 10/11/23, between 10:00 AM-12:00 PM, the following concerns were observed: 1. The steam table had five wells with brown water in all five of them. Also, in two of the five wells, there was black unknown burnt substance caked on the bottom of the wells. 2. On top of the steam table, steam table pans were observed to have dried food scattered throughout, and a dark tacky unknown substance was noted around the outside 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.

Based on interview and review of employee records, the facility did not ensure CNA (Certified Nursing Assistant)/Med Tech-F was qualified to pass medications to residents residing in the Facility after 12/22/22. This has the potential to affect all 92 residents residing in the Facility. CNA/Med Tech-F has a current CNA certificate, was enrolled at [name of] University for diploma in practical nursing and completed pharmalogical for nurses with lab course during the spring semester 2021. CNA/Med Tech-F graduated from [name of] University on 12/22/21. As of 1/25/23, CNA/Med Tech-F did not obtain her LPN (Licensed Practical Nurse) license and has not applied to take the take the med aide challenge exam. Findings include: On 1/23/23, Surveyor randomly selected 8 facility employees including CNA/Med Tech-F to review their personnel records for background information and CNA certifications. On 1/23/23 at 11:45 a.m., Surveyor provided Administrator-A with the names of the employees including CNA/Med Tech-F, and requested their background information and CNA certifications. On 1/26/23 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 observation and interview the Facility did not have bath towels and wash cloths available for personal cares. Multiple observations of the 4 of 4 linen rooms on 1/26/23 revealed no bath towels or wash cloths. The 4 linen rooms were located on the Rehab unit, West, North and South units. The Facility has a census of 92 Residents. Findings include: On 1/26/23 at 8:41 a.m. Surveyor asked CNA (Certified Nursing Assistant)-FF if there are times when Residents don't receive their scheduled showers. CNA-FF replied yes. Surveyor inquired why. CNA-FF informed Surveyor because there are no towels. Surveyor inquired how often this occurs. CNA-FF indicated quite frequently. On 1/26/23 at 8:47 a.m. Surveyor checked the clean linen room on the rehab unit. Surveyor did not observe any wash cloths or any towels. On 1/26/23 at 8:50 a.m. Surveyor checked the clean linen room on the west unit. Surveyor did not observe any wash cloths or towels in this clean linen room. Surveyor did observe a cart in the room but there wasn't any wash cloths or towels on the cart. On 1/26/23 at 8:52 a.m.…

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 CNA (Certified Nursing Assistant)-E of 5 randomly selected CNAs had a performance review at least once every 12 months. This deficient practice has the potential to affect those residents whom CNA-E provides care to. A performance review was not completed for CNA-E in 2022. Findings include: On 1/23/23 Surveyor randomly selected 5 CNA's (CNA/Med Tech-F, CNA-E, CNA-U, CNA-V, & CNA-W) from the Facility's employee list to review for performance reviews. On 1/23/23 at 11:45 a.m. Surveyor provided CNA/Med Tech-F, CNA-E, CNA-U, CNA-V & CNA-W's names to Administrator-A and requested their performance reviews. On 1/26/23 at 9:52 a.m. Surveyor reviewed the performance reviews for CNA/Med Tech-F, CNA-E, CNA-U, CNA-V & CNA-W. CNA-E was hired on 1/22/19. A performance review was completed on 1/16/21. Surveyor was not able to locate a performance review in 2022 for CNA-E. On 1/26/23 at 10:48 a.m. Surveyor informed HR (Human Resources)-G the last performance review provided to Surveyor for CNA-E is dated 1/16/21 and asked if one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the Facility did not ensure medications were disposed of when expired, stored properly, dated when opened in 2 of 2 medication carts and 1 of 2 medication rooms affecting R72, R12, R41, R16, R59, and new admissions to the rehab unit. 1 (R84) of 1 Resident's hospital orders were not transcribed correctly. * R72 glargine insulin vial & R12's lantus pen was not disposed of when expired. * A med cup not labeled containing 10+ white tablets was observed in the South medication cart. * R41's albuteral inhaler was not dated when opened. * R16's albuteral inhaler was not disposed of when expired. * R59's bag of 0.9% sodium chloride 100 ml (milliliters) was expired in the refrigerator located in the Rehab unit medication room. * 2 vials of stock tuberculin were observed open & used but not dated in the refrigerator located in the Rehab unit medication room. * R84's Vitamin B 12 hospital order dated [DATE] was not transcribed correctly. Findings include: 1. On [DATE] at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure a safe, sanitary environment to help prevent the development and transmission of communicable diseases and infections for 22 of 23 residents on the [NAME] Unit, 2 (R34 and R84) of 7 residents receiving medication, and 4 (R84, R387, R388, and R389) of 4 residents having blood sugars taken. Observations were made of residents on the [NAME] Unit during mealtimes. No hand hygiene was offered to the residents prior to receiving their meals. * An observation was made during medication pass of R34's Benztropine 0.5 mg tablet and 1 mg tablet being in the nurse's bare hand and then placed into the medication cup. R84's Spironolactone 25 mg tablet was on the medication cart; the med tech with gloved hand picked the medication up from the medication cart, placed it in the med cup and then administered this medication to R84. * Observations were made of residents getting their blood sugars checked and the glucometers were not cleaned between…

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 upon observation and interview, the Facility did not ensure Facility equipment was maintained in proper working order. The laundry is located in a smoke compartment which includes the main entrance area/common area, 1 of 2 dining rooms (east dining room), 2 resident rooms and the kitchen. This deficient practice has the potential to affect those residents who may be in the entrance common area, who may be in the east dining room and the residents residing in the 2 resident rooms. * Surveyor observed 4 of 4 dryers in the laundry room had an accumulation of lint on the wires above the screen and under & in the back of the lint screen which is a potential fire hazard. Findings include: On 1/26/23 at 12:40 p.m. Surveyor toured the laundry room with Laundry-EE. While on the dryer side of the laundry room Surveyor asked Laundry-EE how often the lint is cleaned from the dryers. Surveyor observed there are 4 working commercial dryers. Laundry-EE informed Surveyor she checks the dryers when she comes in and cleans the lint at the end of the day. Laundry-EE explained she leaves at 3:00…

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 (R87) of 7 residents reviewed for allegations of abuse reported the allegation to the state agency. On [DATE], R87 had a change in condition, became unresponsive and needed CPR. R87's husband threatened to give R87 antianxiety medications from home if the facility wasn't going to get an order for it. The facility suspected R87's husband may have given R87 some medication prior to R87 becoming unresponsive. The facility called the police to report the suspicion of a crime but did not notify the state agency. Findings include: The facility abuse policy (not dated) documents, Any allegation of abuse or any incident that results in serious bodily injury will be reported to the required regulatory agencies immediately, but not more than two hours of the allegation of abuse. Any incident that does not involve abuse and does not result in serious bodily injury shall be reported within 24 hours. R87 was admitted to the facility on [DATE] with diagnoses…

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 investigate 2 (R37 & R87) of 7 allegations of mistreatment. * The Facility did not investigate R37's missing gold ring. * The Facility did not investigate an incident involving R87 which occurred on [DATE] that caused the Facility to notify the police. Findings include: The Abuse Policy which is not dated under section IV Internal Reporting Requirements and Identification of Allegations includes documentation of All residents, visitors, volunteers, family members or others are encouraged to report their concerns or suspected incidents of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property to the administrator or an immediate supervisor who must then immediately report it to the administrator or the designated individual in the administrator's absence. Such reports may be made without fear of retaliation. Anonymous reports will also be thoroughly investigated. Reports will be documented and a record kept 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 observation, record review and interviews, 3 (R17, R10, R64, R17) of 5 residents reviewed did not receive required assistance with Activities of Daily Living. * On 12/17/22, R17 was hospitalized with diagnoses of COVID and submandibular abscess. The facility could not provide documentation to ensure R17 was getting proper oral hygiene in accordance with R17's plan of care. * R10 did not receive assistance with bathing in accordance with facility protocol. * R64 did not receive assistance with nail care in accordance with facility protocol. Findings include: 1. R17 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, hearing loss and dementia. R17's admission MDS (Minimum Data Set) assessment with a reference date of 4/8/22 does not indicate R17's dental status. The MDS assessment indicates R17 requires extensive assistance of one person for personal hygiene, which includes brushing teeth/oral care. This MDS indicates R17 scored an 8 on the Brief Interview for…

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, that facility did not always ensure that they obtained accurate weights to be able to comprehensively assess 1 out of 9 (R80) residents who were at nutritional risk for weight loss. * A review of R80's weights using multiple methods of obtaining weights reflected R80 had various weight losses and weight gains from one week to another. On 10/30/22 R80 weighed 210 pounds and on 10/30/22 the same date was noted to also weight 269 pounds. R80's weight on 10/30/22 was 269 pounds. On 11/9/22, R80's weight 241.6. On 12/1/22, R80's weight was 230.4 pounds etc. The dietician disputed the weight value with no further follow up. Staff were not consistently using one method to weigh R80. R80's Certified Nursing Assistant (CNA) [NAME] did not indicated in which manner R80 should be weighed. This is evidenced by: Policy Review: Weight Monitoring Program, last revised 9/1/22. Each resident's weight will be monitored consistently and closely by the interdisciplinary team. 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 interview and record review the Facility did not ensure the physician acted upon recommendations by the pharmacist for 1 (R53) of 2 Residents reviewed with pharmacy recommendations. On 12/20/22 Consultant Pharmacist-Z recommended clarification of indications for use for R53's Risperidone 0.25 mg (milligrams) with directions to give one tablet by mouth one time a day for sleep. This recommendations was not acted upon by the physician and on 1/17/23 Consultant Pharmacist-Z drug regimen report recommended the same clarification. Findings include: The Documentation and Communication of Consultant Pharmacist Recommendations policy and procedure from 2006 American Society of Consultant Pharmacists and Med-Pass, Inc. (Revised January 2018) under procedures includes documentation of B.) Comments and recommendations concerning medication therapy are communicated in a timely fashion. The timing of these recommendations should enable a response prior to the next medication regimen review. In the event of a problem requiring immediate attention of the prescriber, the responsible…

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 1 (R53) of 5 Residents were free from unnecessary drugs. * R53 received Risperidone (Risperdal) 0.25 mg (milligrams) once daily without indications for use. Finding include: The Psychotropic Drug Use policy which is not dated under Objective documents All residents have the right to be free from unnecessary medications imposed for the purposes of discipline or convenience and not required to treat medical symptoms. Based on a comprehensive assessment of a resident, the facility will assure the residents are not given psychotropic medications unless psychotropic drug therapy is necessary to treat a specific condition and residents who use psychotropic drugs receive gradual dose reductions and behavioral interventions unless clinically contraindicated, with the ultimate goal to discontinue these drugs as appropriate. Under Policy documents Psychotropic use: Antipsychotic drugs will be used only after identifying and assessing possible…

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 there was a medication error rate below 5 percent. There were 2 medication errors in 32 opportunities which resulted in a medication error rate of 6.25%. Medication errors were identified for R34 & R84. * R34 received the incorrect dose of Sertraline HCL. R34 received 100 mg (milligrams). The physician orders are for 125 mg of Sertraline. * R84 received the incorrect dose of Vitamin B-12. R84 received 200 mcg (micrograms). R84 should have received 500 mcg. Findings include: 1. On 1/23/23 at 8:40 a.m. Surveyor observed RN (Registered Nurse)-O pour 30 ml (milliliters) of Pro Stat into a medication cup for R34 and cleanse her hands. RN-O then prepare R34's medication which consisted of Tylenol 325 mg two tablets, EC (enteric coated) Aspirin 325 mg one tablet, Benztropine Mesylate 0.5 mg one tablet, Benztropine Mesylate 1 mg one tablet, Multivitamin with minerals one tablet, Divalproex Sodium 500 mg two tablets, Duloxetine 60 mg one capsule, Furosemide 40 mg one tablet, Gabapentin 100 mg three capsules,…

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.