Madison Health and Rehabilitation Center

Number of residents sampled: 2Number of residents cited: 1Based on observation, interview, and record review, the facility did not ensure that all residents are clinically appropriate to self-administer medications for 1 of 2 residents (R48) reviewed for self-administration of medications. Surveyor observed R48 to have a cup of medications left on her bedside table on her meal tray for her to take independently. R48 did not have an assessment for self-administration of medications and did not have an active physician's order. R48's care plan does not indicate R48 can self-administer medications. This is evidenced by: The facility's policy Resident Self-Administration of Medication dated 4/17/25, includes it is the guideline of this facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. Each resident is offered the opportunity to self-administer medications during the routine assessment by licensed nurse and/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 failed to ensure that every resident had an Advance Directive, including Code Status (Do Not Resuscitate or Full Code (resuscitate)), this affected 1 of 21 residents (R58).R58 did not have a code status determination in her medical record.This is evidenced by:The Facilities Policy and Procedure entitled Resident's Rights Regarding Treatment and Advance Directives dated [DATE], documents in part: 1. On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive .9. Any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care .R58 admitted to the facility [DATE], went out to the hospital [DATE] and re-admitted to the facility [DATE]. R58 has the following diagnoses: acute and chronic respiratory failure with…

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 adequate supervision and safety to prevent accidents from occurring for 2 of 3 residents reviewed (R53 and R85). R53 began smoking at the facility and was not assessed to be a safe, independent smoker once the facility was aware R53 began smoking. R85 was assessed to be at risk for falls. The facility did not assure that the care plan interventions were in place for R85. Evidenced by: The facility's policy titled Resident Smoking dated 12/15/23 states in part .6. Residents who smoke will be further evaluated using the Smoking Evaluation to determine supervision need and intervention.10. All safe smoking measures will be documented on the care plan and communicated to all staff, visitors, and volunteers who will be responsible for supervising residents while smoking. Supervision will be provided as indicated on the care plan.15. Documentation to support decision making will be included in the medical record, including but not limited…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility did not ensure the provision of routine biologicals for 1 of 9 residents observed for medication pass (R15). RN V (Registered Nurse) did not prime R15's insulin pen prior to administering 2 units of insulin. Evidence by:Facility policy entitled 'insulin pen,' states in part: .it is the guideline of this facility to use insulin pens in order to improve the accuracy of insulin dosing provide increased resident comfort and serve as a teaching aid to prepare residents for self-administration of insulin therapy upon discharge. Explanation and compliance guidelines: .2. Insulin pens must be clearly labeled with the resident name, physician name, date dispensed, type of insulin, amount to be given, frequency and expiration date.6. insulin pens will be primed prior to each use to avoid collection of air in the insulin reservoir.9. insulin pens should be disposed of after 28 days or according to manufacturer's recommendations. 11. Procedure: .e. Check 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 not ensure food allergies, intolerances and preferences were accommodated and/or individualized meal tickets were followed for 2 residents (R90 and R70) reviewed for food allergies/intolerances. R90 is allergic to eggs and milk. Staff served R90 an egg muffin sandwich and offered milk for breakfast on 8/21/25. R70 is lactose intolerant. Staff did not provide a milk alternative on 8/21/25. This is evidenced by: The facility's policy Food Preparation Guidelines, dated 12/17/24, includes: It is the policy of this facility to prepare foods in a manner to preserve or enhance a resident's nutrition and hydration status. Staff shall accommodate resident allergies, intolerances, and preferences, providing appropriate alternatives when needed. The facility's policy Menus and Adequate Nutrition, dated 5/26/24, includes: The facility will provide residents with nourishing, palatable, well-balanced diets that meet his or her daily nutritional and special…

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 interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. This has the potential to affect all 66 residents. Nutritional supplements were observed without the appropriate thaw dates. Dietary staff did not report when the dishwasher did not reach the necessary PPM (Parts Per Million). Findings include: Example 1 On 3/5/25 at 10:42 AM, Surveyor observed 7 Sysco Mighty Shakes in one of the facility kitchen's refrigerators. The shakes were completely thawed and did not have any thaw dates noted. The shakes state on the container that they need to be discarded within 14 days of being thawed. On 3/5/25 at 10:43 AM, Surveyor interviewed DM V (Dietary Manager) who stated that she thought the shakes were dated when pulled from the freezer but noted they had not been. Example 2 The facility uses a low-temperature, sanitizing dishwasher. A document, titled, Dish Machine Temperature Log, hangs near the dishwasher and states that the PPM for the chlorine needs to be 50-100…

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 ensure garbage and refuse was disposed of properly. This has the ability to affect all 66 residents. Garbage and litter was found near the facility's main dumpster area. Findings include On 3/5/25 at 10:31 AM, Surveyor observed in the facility's main exterior garbage area, along with DM V (Dietary Manager), 13 used gloves strewn around the two dumpsters, two bags of garbage lying on the ground (one was halfway lodged under one of the dumpsters), and what appeared to be hundreds of cigarette butts on the ground. At this time, Surveyor interviewed DM V who stated that the garbage had been there for over a week and needed to be removed.

Based on observation, interview, and record review, the facility did not ensure the facility-wide assessment developed by the facility included all relevant details to ensure the facility provided care and services to residents to meet their individual needs within the facility's identified resources. This has the potential to affect all 66 residents residing at the facility. The facility assessment must reflect the resident population, the resources needed to care for this population as well as staff competencies to care for the resident population residing within the facility. The facility has several residents who do not speak English as their primary language, the staff did not have the competencies to communicate with these residents or to ensure their ethnic, cultural, and activity needs were being met. The facility has residents who require dialysis; the staff did not have the skill set or competencies to care for residents post dialysis. The facility has an infection prevention and control program (ICIP) however several breaches were identified within the IPCP; the Infection…

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 that each resident has a safe, clean, comfortable and homelike environment for daily living for 1 of 24 sampled Residents (R51), 2 of 2 supplemental residents (R424 & R67) and 5 of 6 shower rooms. This had the potential to affect more than a limited number of residents in the facility. Surveyor observed R51's footboard on her bed and the wall next to her bed to contain many dried particles and not homelike. R424 and R67 voiced concerned about the shower cleanliness. Surveyor observed 5 out of 6 shower rooms as being unkept with visible black and brown substance in the shower area. As evidenced by: The facility policy, Safe and Homelike Environment, dated 10/23/24, indicates, in part, as follows: In accordance with residents' rights, the facility will provide a safe, clean, comfortable, and homelike environment . Environment refers to any environment in the facility that is frequented by residents, including, (but not limited 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.

Based on interview and record review, the facility did not ensure that a review of the residents' total program of care to include signing monthly physician orders were completed for 9 of 11 residents (R17, R9, R20, R65, R6, R24, R2, R25, and R61) reviewed. R17 did not have Physician Orders signed monthly. R9 did not have Physician Orders signed monthly. R20 did not have Physician Orders signed monthly. R65 did not have Physician Orders signed monthly. R6 did not have Physician Orders signed monthly. R24 did not have Physician Orders signed monthly. R2 did not have Physician Orders signed monthly. R25 did not have Physician Orders signed monthly. R61 did not have Physician Orders signed monthly. This is evidenced by: The Facilities Policy and Procedure entitle Physician Visits and Physician Delegation dated 10/16/24 documents the following, in part: f. Remind the physician to date and sign all orders .2. The Physician should .c. Review the resident's total program of care including medications and treatments at each visit . Example 1 R17 had no signed Physician Orders for October…

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 complete a performance review of every nurse aide at least once every 12 months for 4 of 5 Certified Nursing Assistants (CNAs) reviewed. CNA ZZ did not have an annual performance evaluation completed. CNA AAA did not have an annual performance evaluation completed. CNA BBB did not have an annual performance evaluation completed. CNA CCC did not have an annual performance evaluation completed. This is evidence by: The Facilities Policy and Procedure entitled Annual Employee Evaluation dated 5/2/23 documents, in part: Purpose: To comply with federal regulations, all employees will receive an annual evaluation of their work performance . Example 1 CNA ZZ's hire date was 11/28/22. CNA ZZ did not have an annual performance evaluation completed. Example 2 CNA AAA's hire date was 12/29/22. CNA AAA did not have an annual performance evaluation completed. Example 3 CNA BBB's hire date was 9/28/21. CNA BBB did not have an annual performance evaluation completed. Example 4 CNA CCC's hire date was 10/11/22. CNA CCC did not have an…

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 that all residents are clinically appropriate to self-administer medications for 1 of 2 sampled residents (R25) and 1 of 1 (R7) supplemental residents reviewed for self- administration of medications. R7 was observed during medication administration to have his medications put into a Mighty Shake and left with R7 in the dining room to take independently. R7 does not have an assessment for self-administration of medications. R25 was observed to have a cup of medications left on her bedside table for her to take independently. R25 does not have an assessment for self-administration of medications. Evidenced by: The facility's policy titled Resident Self- Administration of Medication dated 5/1/24 states in part, .3. When determining if self- administration is clinically appropriate for a resident, the interdisciplinary team should, at a minimum consider the following: a. The medications appropriate and safe for self- administration; b.…

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 immediately notify and consult with the resident's physician when a change in the resident's physical, mental, or psychosocial status occurred for 1 of 24 residents (R71) reviewed for change in condition. R71 was was sent to the ED (Emergency Department) with a change in condition. The ED documented, Skin: Severe candidal rash around SP (suprapubic) cath (catheter) and into bilateral groin. R71 was diagnosed with Candidiasis intertrigo (a fungal infection that occurs in skin folds) involving the groin and area around SP (suprapubic) catheter and prescribed Nystatin. The facility did not document the rash nor notify the provider. As evidenced by The facility policy, Notification of Change, dated 10/24/23, documents, in part, as follows: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is 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 make prompt efforts to document, investigate, and resolve grievances a resident may have for 1 of 8 residents reviewed for grievances (R73). R73 and her family voiced grievances to the facility. The facility did not complete appropriate interviews, audits, education, or provide follow up with to R73 or her family after the conclusion of the investigation. Evidenced by: The facility's policy titled Resident and Family Grievances, no date, states in part .10. Procedure: .d. The Grievance Official will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form. i. Steps to resolve the grievance may involve forwarding the grievance to department manager for follow up .g. In accordance with the resident's rights to obtain a written decision regarding his or her grievance, the Grievance Official will issue a written decision on the grievance to the resident or representative at the conclusion 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, interview and record review, the facility must ensure the assessment accurately reflects the resident's status, this affected 2 of 20 residents (R17 and R8) reviewed for Minimum Data Set (MDS). R17's most recent MDS indicates that R17 is receiving hospice services. R17 has not signed up for nor received hospice services. R8's MDS indicated that R8 had a pressure injury. R8 has not had a pressure injury since being admitted to the facility. This is evidenced by: The facility policy titled MDS 3.0 Completion dated 1/18/23 states in part: Policy: Residents are assessed, using a comprehensive assessment process to identify care needs and to develop an interdisciplinary care plan .4. Care Plan Team Responsibility for Assessment Completion: a. Interdisciplinary Responsibility for Completion of MDS Sections: i. The responsibility of all sections of the MDS will be clearly assigned .ii. Persons completing part of the assessment must attest to the accuracy of the section they have completed by…

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 a resident who is unable to carry out Activities of Daily Living (ADL's) received the necessary services to maintain personal hygiene for 1 of 20 residents (R51) reviewed for ADLs. R51 is scheduled to receive a shower on Mondays and Thursdays. The facility has no documentation that R51 was offered or declined a shower on the following dates: 2/6/25, 2/24/25, 3/3/25, and 3/6/25. Evidenced by: R51 was admitted to the facility on [DATE] with diagnoses including, but not limited to, the following: Alzheimer's disease, dementia, delusional disorders, restlessness and agitation. R51's most recent Minimum Data Set (MDS) dated [DATE] documents R51 is severely cognitively impaired. R51 has an Activated Power of Attorney for Health Care (APOAHC). R51's comprehensive care plan documents the following: (Date Initiated: 8/14/23) Focus: The resident has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) Dementia. Goal: 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 not provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each resident. This has the potential to affect 1 of 21 sampled residents (R74) reviewed for activities. R74 does not speak English, Spanish only. Facility does not offer R74 activities appropriate for R74's culture/ethnicity. Evidenced by: The facility policy entitled, Activities, dated 12/23/22, states, in part: .Policy: It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being. Activities will encourage both independence and interaction within the community. Definitions: Activities refer to any…

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 that the residents environment remained free of accidents and hazards for 1 of 7 residents (R61) reviewed for accidents. Surveyor observed R61's bed was not in the lowest position and staff reported the bed was broken. Surveyor observed R61's fall mats and call light not in place. Evidenced by: The facility policy, Accidents and Supervision, dated 12/22, states, in part; .The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents .3. Implementing interventions to reduce hazard(s) and risk(s) . R61 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, stroke, anxiety disorder, and other seizures. R61's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 3/5/25, indicates R61 has a Brief Interview for Mental Status (BIMS) score of 04, indicating R61 is severely…

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 that residents with an indwelling catheter received the appropriate care and services to prevent a urinary tract infection (UTI) for 1 of 2 residents (R65) reviewed for catheters as catheter bags were observed to be uncovered and resting on the floor. Surveyor observed R65's indwelling urinary catheter bag to be resting in direct contact with the floor. Evidenced by: The Centers of Disease Control and the Healthcare Infection Control Practices Advisory Committee - Guidelines for Prevention of Catheter-Associated Urinary Tract Infections 2009 indicate in part: . III. Proper Techniques for Urinary Catheter Maintenance . B. Maintain unobstructed urine flow. 1. Keep the catheter and collecting tube free from kinking. 2. Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. R65 was admitted to the facility 11/4/24 with diagnoses including, but not limited to, the following: cerebral…

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 a resident who requires dialysis receives such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 1 sampled resident (R24) reviewed for dialysis. The facility failed to provide ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. The facility staff were not fluent in the emergency plan for a resident bleeding from their dialysis fistula site. This is evidenced by: The facility's policy titled Hemodialysis with an implementation date of 2/15/23, includes, in part: Policy: This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and…

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

Based on interview and record review, the facility did not ensure that residents were seen by a physician or physician extender (NP- Nurse Practitioner, PA- Physician Assistant) for 3 of 11 residents (R9, R20, and R2) reviewed. R9 did not have Provider visits timely. R20 did not have Provider visits timely. R2 did not have Provider visits timely. This is evidenced by: The Facilities Policy and Procedure entitled Physician Visits and Physician Delegation dated 10/16/24 documents, in part: .h. Ensure a progress note is present to reflect the date and time of the physician visit, an indication as to whether new orders were written or no new orders were received and any special discussions between the resident and/or family and physician during the visit .2. The Physician should .d. Date, write and sign progress note for each visit .h. At the option of the physician, required visits in SNFs (Skilled Nursing Facilities), after the initial visit, may alternate between personal visits by the physician and visits by a physician assistant, nurse practitioner or clinical nurse specialist .…

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 does not have nursing staff with the appropriate cultural competencies to communicate effectively while providing care to residents with communication needs and ensuring that devices are utilized per the care plan. This has the potential to affect 2 of 20 sampled residents (R74 & R423) and 1 of 12 supplemental residents (R9). The Facility does not ensure R74 is receiving communication in a language she can understand. The Facility does not ensure R423 is receiving communication in a language she can understand. The Facility does not ensure R9 is receiving communication in a language she can understand. Evidenced by: The facility policy entitled, Non-Discrimination-Language Assistance Services, dated 2/1/25, states, in part: .Policy: It is the policy of this facility to take reasonable steps to ensure that individuals with Limited English Proficiency (LEP) (including companions with LEP) are not discriminated against and have access to language…

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 they followed their antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for 2 of 10 sampled Residents (R11 and R21) and 1 of 1 supplemental (R73) reviewed for antibiotic stewardship. R73 was treated with an antibiotic for a urinary tract infection (UTI) and urinalysis (UA) showed R73 did not have a UTI. R11 and R21 were treated prophylactically with antibiotics. Evidenced by: The facility policy entitled, Antibiotic Stewardship Program, dated 12/23/22, states, in part: . Policy: It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. Policy Explanation and Compliance: . 1a. Infection Preventionist- coordinates all antibiotic stewardship activities, maintains…

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 adequate supervision, monitoring, and evaluation for 2 of 4 sampled residents (R2 and R3) after the residents had a fall. R2 had a fall on 11/1/24 at 1:00 PM (day shift). The facility did not document post-fall clinical findings or new fall intervention effectiveness after R2's fall. R3 had a fall on 10/28/24 at 4:55 PM (evening shift). The facility did not document relevant post-fall clinical findings or new fall intervention effectiveness after R3's fall. This is evidenced by: The facility policy titled Accidents and Supervision dated 12/29/22, states, in part: .Each resident will receive adequate supervision and assistive devices to prevent accidents . Monitoring for effectiveness and modifying interventions when necessary . Ensuring the interventions are put into action . Monitoring and Modification - Monitoring is the process of evaluating the effectiveness of care plan interventions. Modification is the process of adjusting interventions as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure 1 of 19 residents (R4) were treated with respect and dignity. The facility did not provide laundry services timely for R4. R4's personal laundry was in the laundry department for three weeks before being returned to R4. Evidenced by: The Resident Rights in the facility's admission packet, states, in part: . Resident rights. The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility . 4. Respect and dignity. The resident has a right to be treated with respect and dignity, including: . b. The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents. c. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences, except when to do so would endanger the health…

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 immediately consult with a resident's physician or update resident's guardian when there was a change in resident's condition and need to alter treatment for 1 resident (R4) out of 3 reviewed for notification of changes. R4 was sent to the emergency department on 5/4/24 and R4's guardian was not immediately notified. R4 had three falls on 5/11/24 and R4's guardian was not notified of one of those falls. Evidenced by: The facility policy entitled Notification of Changes, dated 10/22/23, states, in part: . Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification . Compliance Guidelines: The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include: 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on photographic evidence and interview, the facility failed to keep residents' personal health information confidential for 1 of 3 residents reviewed for health information (R18). R18's private health care information was found in R4's room. Evidenced by: The facility policy entitled Confidential of Personal and Medical Records, dated 5/15/24, states, in part: . Policy: This facility honors the resident's right to secure and confidential personal and medical records. This includes the right to confidentiality of all information contained in a resident's records, regardless of the form of storage or location of the record. Policy Explanation and Compliance Guidelines: . 2. Keep confidential is defined as safeguarding the content of information including written documentation, video, audio, or other computer stored information from unauthorized disclosure without the consent of the individual and/or the individual's surrogate or representative . 8. Paper notes or reminders with resident's personal or medical…

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 each resident had a baseline care plan developed and implemented, within 48 hours, with needed instructions to provide effective and person-centered care for 1 of 18 residents (R3) reviewed. R3 did not have a baseline care plan completed. This is evidenced by: The facility policy, entitled Baseline Care Plan, dated 11/2023, states in part: the facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan will be developed within 48 hours of the residence admission, will include the minimum health care information necessary to properly care for a resident including, but not limited to: initial goals based on admission orders, physician orders, dietary orders, therapy orders, social services, and PASRR (Preadmission Screening and Resident Review) recommendations…

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 2 residents (R4 & R15) reviewed for Activities of Daily Living (ADL) out of a total sample of 19 received the necessary services to maintain good nutrition, grooming, personal and oral hygiene. R4 did not receive weekly scheduled showers in April, May, and June 2024. R15 did not receive weekly showers as scheduled in April, May, and June 2024. Evidenced by: The facility policy entitled Activities of Daily Living, undated, states, in part: Policy: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs (activities of daily living) do not deteriorate unless deterioration is unavoidable. Cares and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care . 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure the resident environment remains as free of accident hazards as is possible. This affected 2 of 19 sampled residents (R5 and R14) R5's electric wheelchair charges in her room with her roommate, R14, also present. This is evidenced by: Facility policy, entitled Power Mobility Device, reviewed 1/1/24, includes, in part: Battery charging installations shall be located in areas designated for that purpose . Example 1 R5 admitted to the facility on [DATE]. R5's most recent Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 6/7/24, indicates R5 is impaired on both sides of her upper and lower extremities and utilizes an electric wheelchair for mobility. On 6/18/24 at 3:21 PM, Surveyor observed R5's wheelchair power charging cable plugged in next to her nightstand. R5 demonstrated to Surveyor that she was able to charge it without assistance of staff. R5 confirmed that she always charges her wheelchair in her room using the cord currently…

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 Example 2 R5 consistently takes her as needed (PRN) Hydromorphone every 4 hours for breakthrough pain. The facility ran out of R5's hydromorphone. R5's progress notes indicate that this facility ran out of R5's medications twice in the span of four days. R5 was admitted to the facility on [DATE], and has diagnoses that include: multiple sclerosis (degenerative disorder causing nerve damage which leads to paralysis, vision loss, fatigue, and mood disturbance) , sickle cell disorder with acute chest syndrome (red blood cells become crescent-shaped causing severe pain with occlusion of arteries and veins around the lungs), idiopathic aseptic necrosis of right femur (death of bone tissue related to loss of blood supply), idiopathic aseptic necrosis of left femur, and other chronic pain. R7's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 6/7/24 includes a Brief Interview of Mental Status (BIMS) of 15, indicating that she is cognitively intact. R5's Physician Orders, active as of 6/18/24,…

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, record review, and facility policy review, the facility failed to notify the physician of elevated blood glucose levels for 1 of 3 residents (Resident (R) 9) reviewed for diabetes in a total sample of 25 residents. Findings include: Review of the undated facility's policy titled, Blood Glucose Monitoring, indicated, Report critical test results to physician timely. Review of R9's admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 01/12/24 with medical diagnoses that included type 1 diabetes. Review of R9's Orders, dated 01/12/24 and located in the EMR under the Orders tab, indicated, Call MD [Medical Doctor] if BGL [blood glucose level] less than 70 or greater than 350. Review of R9's Blood Sugar Summary, located in the EMR under the Wts [weights] and Vitals tab revealed a blood glucose level of 421 mg/dl [milligrams per deciliter] on 02/24/24. Review of R9's February Medication Administration Record [MAR] located in the EMR under the Orders tab revealed no indication of physician notification.…

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, record review, and facility policy review, the facility failed to ensure a resident was free from misappropriation of the resident's property when Registered Nurse (RN)1 diverted the resident's Oxycodone for 1 of 6 residents (Resident (R) 19) reviewed for misappropriation in a total sample of 25 residents. Findings include: Review of the undated facility policy titled, Abuse, Neglect and Exploitation, indicated, The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Review of R19's admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 06/29/21 with medical diagnoses that included chronic pain syndrome and diabetes. Review of R19's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 01/16/24, revealed a Brief Interview for Mental Status (BIMS) score was 13 out of 15, indicating R5 was cognitively intact.…

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 failed to store and serve food in accordance with professional standards for food service safety for 1 (R1) of three residents reviewed for food storage. Surveyor observed 6 unopened Magic Shakes on R1's windowsill. This is evidenced by: The facility policy entitled, Food Safety Requirements, dated 3/20/23, states in part: . 1. Food safety practices shall be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with delivery of the food to the resident. Elements of the process include the following: . b. Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms . According to https://www.hormelhealthlabs.com/wp-content/uploads/HHL-Code-Date_Handling-Sheet-11_2022.pdf Mighty Shakes Shelf Life: Unopened: 15 months (450 days) frozen, refrigerated: 14 days thawed. Opened/bedside: Up to 2 hours…

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 for 9 of 12 residents (R12, R15, R16, R17, R18, R19, R13, R14, and R15), each resident received food with at a palatable temperature. Residents have voiced concerns related to cold food. Test tray found food was not served hot. Evidenced by Facility policy, Record of Food Temperatures, revised 12/1/23, states, as follows: It is the policy of this facility to record food temperatures daily to ensure food is at the proper serving temperature(s) before trays are assembled. 2. Hot foods will be held at 135 degrees Fahrenheit or greater. 4. Potentially hazardous cold food temperatures will be kept at or below 41 degrees Fahrenheit. The facility has dining in two (2) dining rooms and residents also eat in their rooms. The facility serves the dining rooms first and then delivers trays to the wings in the following order: 1. [NAME] 2. Birch 3. Aspen 4. Cedar 5. Elm 6. Pine The facility documents: All wings will be served between the times of 12:00 - 12:30 PM. Surveyor requested a room test tray after 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 interview and record review, the facility did not maintain medical records on each resident that are complete and accurately documented in accordance with accepted professional standards and practices in 1 of 6 residents reviewed (R3). R3's Medication Administration Record (MAR) did not have all medications administered documented. This is evidenced by: The facility policy titled, Medication Administration, with a reviewed/revised date of 12/4/23, indicates, in part: .Policy Explanation and Compliance Guidelines: .11. Compare medication source (bubble pack, vial, etc) with MAR to verify resident name, medication name, form, dose, route and time .17. Sign MAR after administered . R3 was admitted to the facility on [DATE] with diagnoses that include, in part: schizophrenia, weakness, and other specified forms of tremors. R3's quarterly Minimum Data Set (MDS) with a target date of 10/26/23, documents a Brief Interview of Mental Status (BIMS) score of 7, indicating R5 has a severe cognitive impairment. R3's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not maintain personal privacy during personal cares for 1 of 4 residents (R4). The facility updated R4's care plan to include Cares in Pairs so there are 2 staff in the room. R4 voiced that he does not like non-direct care staff in his room during cares. CNA D (Certified Nursing Assistant) pulled non-care staff to the room to be the second person, including Hskp E (Housekeeper), SS F (Social Services), and Rec G (Receptionist). Hskp E, SS F and Rec G stated, they all have been in R4's room as the second person when R4 is either using the urinal or commode. Hskp E and SW F indicated they are uncomfortable being the second person during cares. Evidenced by: R4's was admitted to the facility on [DATE] with diagnoses including, but not limited to: chronic pain syndrome, muscle weakness, lack of coordination, severe morbid obesity, sensorineural hearing loss, and repeated falls. R4's is his own person and is cognitively intact. R4's Certified Nursing Assistant…

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 maintain medical records on each resident that are complete and accurately documented for 1 of 3 residents (R4). R4's Medication Administration Record (MAR) was blank on 8/21/23 for Novolog administration and the Treatment Administration Record (TAR) was blank on 8/12/23 for wound care. Evidenced by: The facility policy Medication Administration, undated, states, as follows: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards or practice Review MAR to identify medication to be administered. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. Sign MAR after administered. R4 was admitted to the facility 6/29/21, with diagnoses including, but not limited to: type 2 diabetes mellitus, pressure ulcer of sacral region and acute kidney failure. R4 is his own person and is his…

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.