North Ridge Health and Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not ensure 1 resident (R) (R1) of 6 sampled residents received the appropriate care and services to promote healing and/or prevent pressure injuries from developing. R1 had a stage 3 presure injury on the coccyx upon admission. R1's wound care was not provided in accordance with a physician's order on 7/6/25. R1 developed a wound infection that required intravenous (IV) antibiotics and debridement.Findings include: The facility's Wound Treatment Management policy, revised 12/3/24, indicates: .1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change .On 8/6/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including metabolic encephalopathy due to carbon monoxide poisoning, hemiplegia and hemiparesis, tracheostomy, and pressure ulcer of sacral region stage 3. R1's Minimum Data Set (MDS)…

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

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect 39 of the 54 residents residing in the facility. There were 15 residents who received nutrients exclusively via tube feeding. Staff did not wear hair restraints consistently throughout the kitchen. Kitchen equipment and food services areas were not in a clean and sanitary condition. Staff did not follow appropriate hand hygiene procedures when they prepared and served food. Resident food and beverages were not served at appropriate temperatures. Findings include: Hair Restraints: The 2022 Federal Food and Drug Administration (FDA) Food Code documents at 2-402.11 Hair Restraints: (A) Except as provided in (B) of this section, Food Employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils and linens, and unwrapped…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident representative interview and record review, the facility did not ensure a resident representative was notified of a change in condition for 1 resident (R) (R4) of 13 sampled residents. R4 was diagnosed with yeast in the urine and had an order for antibiotic treatment. R4's Power of Attorney for Healthcare (POAHC) was not notified of the change in condition or antibiotic treatment. In addition, R4 had low blood pressure readings on 5/10/25 and 5/11/25. R4's physician and POAHC were not notified. Findings include: The facility's Notification of Changes policy, revised 3/31/25, indicates: The purpose of this guideline 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. Changes of condition require an evaluation .and ensures proper documentation and notification has been made .2. Significant change in the resident'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 2. On [DATE], Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] and had diagnoses including malignant neoplasm of glottis, chronic obstructive pulmonary disease (COPD), chronic respiratory failure, and tracheostomy status. A care plans, initiated on [DATE], indicated R6 had a Clostridioides difficile (C. diff) infection (a highly contagious bacterium that causes diarrhea and colitis) and was on contact precautions. On [DATE] at 1:25 AM, Surveyor observed CNA-R and CNA-S enter R6's room without donning PPE. Surveyor observed a sign posted on R6's door that indicated R6 was on contact precautions. Surveyor observed CNA-R and CNA-S prepare to transfer R6 from bed to wheelchair. CNA-S applied R6's socks and shoes while CNA-R retrieved R6's wheelchair and a gait belt. CNA-R then applied the gait belt and assisted R6 to the wheelchair. CNA-R unhooked R6's trach hose, assisted R6 to a sitting position, then reapplied the hose. Registered Nurse (RN)-M then entered room without donning PPE…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure guardianship and protective placement orders were obtained and advance directive wishes were followed for 4 Residents (R) (R31, R43, R39, and R30) of 17 sampled residents. R31 had a legal guardian at the time of admission on [DATE]. R31's medical record contained petitions for guardianship and protective placement, dated 9/28/22; however, R31's medical record did not contain guardianship or protective placement orders. R43 had a legal guardian at the time of admission on [DATE]. R43's medical record contained an Order and Notice of Hearing on Guardianship and Protective Placement, dated 3/23/24, with a hearing date of 5/6/24; however R43's medical record did not contain guardianship or protective placement orders. R39 had a legal guardian at the time of admission on [DATE]. R39's medical record contained petitions for guardianship and protective placement, dated 6/27/23; however, R39's medical record did not contain guardianship 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.

Based on observation, staff interview, and record review, the facility did not ensure all drugs and biologicals were stored in accordance with the facility's policy. Three of 4 medication carts were observed unlocked and unattended. In addition, 2 of 2 medication carts and 1 of 2 mediation storage rooms contained expired medication and medical supplies. This practice had the potential to affect multiple residents in the facility. Medication carts on the 500, 600, and 300 wings were unlocked and unattended on 8/12/24 and 8/13/24. Medication carts and the medication storage room on the 200 and 300 wings contained expired medications and medical supplies. Findings include: The facility's Medication Storage policy, dated 1/2024, indicates: Medications and biologicals are stored properly, following manufacturers' or provider pharmacy recommendations, to keep their integrity and to support safe, effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medication .4.…

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

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect 33 of 47 residents residing in the facility. (Fourteen residents received nutrition exclusively via tube feeding.) Kitchen equipment and food service areas were not kept in a clean and sanitary condition to prevent cross contamination. Staff did not perform appropriate hand hygiene and safe food handling practices when cooking and serving food. Staff did not document food holding temperatures. The resident refrigerator and reach-in cooler contained food and beverages that were past the discard date or not labeled with a discard date. Findings include: On 8/12/24 at 8:55 AM, Surveyor began an initial tour of the kitchen with the Dietary Manager (DM)-E who stated the facility followed the State and Federal Food Codes. Cleanliness: The 2022 Food and Drug Administration (FDA) Food Code documents at 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils: (A) Equipment food-contact…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to help prevent the development and transmission of disease and infection as observed during the provision of care for 7 Residents (R) (R36, R2, R9, R17, R11, R16, and R4) of 10 residents. On 8/12/24, staff did not complete appropriate hand hygiene during wound care for R36. On 8/12/24 and 8/13/24, staff did not wear masks or complete hand hygiene appropriately during the provision of care for R2. On 8/13/24, staff did not wear appropriate personal protective equipment (PPE) during a therapy session with R9 who was on enhanced barrier precautions (EBP). On 8/13/24, staff did not complete appropriate hand hygiene or wear required PPE during a transfer for R17 who was on EBP. On 8/12/24, staff did not complete proper hand hygiene while administering medication to R11, R16, and R4. Findings include: The facility's Hand Hygiene policy, dated October 2022, indicates: All staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review, the facility did not ensure 3 Residents (R) (R11, R16, and R41) of 3 sampled residents were assessed as able to safely and accurately self-administer medication. On 8/12/24, License Practical Nurse (LPN)-U left medication with R11 for R11 to self-administer after breakfast. R11 did not have a physician's order, self-administration of medication assessment, or care plan that indicated R11 could safely and accurately self-administer medication. On 8/12/24, LPN-U left medication at R16's bedside for R16 to self-administer. R16 did not have a physician's order, self-administration of medication assessment, or care plan that indicated R16 could safely and accurately self-administer medication. On 8/12/24, Registered Nurse (RN)-K prepared a nebulizer treatment for R41 to self-administer. R41 did not have a physician's order, self-administration of medication assessment, or care plan that indicated R41 could safely and accurately self-administer…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review, the facility did not ensure 1 Resident (R) (R9) of 9 sampled residents had a call light within reach. R9's plan of care contained an intervention to be sure R9's call light was within reach. During an observation on 8/12/24, R9's call light was not within reach. Findings include: The facility's undated Call Lights: Accessibility and Timely Response policy indicates: .4. Staff will ensure the call light is within reach of resident and secured . From 8/12/24 to 8/14/24, Surveyor reviewed R9's medical record. R9 was admitted to the facility on [DATE] with diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction affecting the right dominant side, type 2 diabetes mellitus, and muscle weakness. R9's Minimum Data Set (MDS) assessment, dated 6/28/24, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R9 had intact cognition.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interview and record review, the facility did not ensure the medical record contained advance directives for 1 Resident (R) (R13) of 17 sampled residents. R13 was admitted to the facility on [DATE]. R13's medical record did not contain advance directives, including a Power of Attorney for Healthcare (POAHC) document. Findings include: The facility's Resident's Rights Regarding Treatment and Advance Directive policy, dated on 8/9/24, indicates: It is the policy of this facility to support and facilitate a resident's right to request, refuse, and/or discontinue medical or surgical treatment and to formulate an advance directive .Advance directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law, relating to the provision of health care when the individual is incapacitated .1) On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interview and record review, the facility did not ensure 3 Residents (R) (R12, R23, and R31) of 3 residents reviewed for hospitalization received the proper notice of transfer, reason for transfer, location of transfer, appeal rights, and contact information for the State Long-Term Care Ombudsman. R12 was transferred to the hospital on 7/23/24. R12's activated Power of Attorney for Healthcare (POAHC) did not receive a written transfer notice. R23 was transferred to the hospital on 1/11/24. R23 was not provided with a written transfer notice. R31 was transferred to the hospital on 9/12/23, 10/21/23, 3/8/24, and 4/20/24. R31's court-appointed guardian did not receive written transfer notices. Findings include: The facility's Transfer and Discharge policy, dated 10/26/22, indicates: .4. The facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and way they can understand. The notice will include all the following at the time…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interview and record review, the facility did not ensure 3 Residents (R) (R12, R23, and R31) of 3 residents reviewed for hospitalization received written information of the duration of the bed hold policy, the reserve bed payment policy, and the right to return to the facility. R12 was transferred to the hospital on 7/23/24. R12's activated Power of Attorney for Healthcare (POAHC) was not provided with a written notice of the bed hold policy. R23 was transferred to the hospital on 1/11/24. R23 was not provided with a written notice of the bed hold policy. R31 was transferred to the hospital on 9/12/23, 10/21/23, 3/8/24, and 4/20/24. R31's court-appointed guardian was not provided with written notices of the bed hold policy. Findings include: The facility's Transfer and Discharge policy. dated 10/26/22 indicates: .4. The facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and way they can understand. The notice will…

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

Based on observation, staff interview, and record review, the facility did not ensure 1 Resident (R) (R31) of 5 residents reviewed for pressure injuries received the necessary care and services to promote healing and/or prevent pressure injuries from developing. R31 had multiple healed pressure and deep tissue injuries and received wound care to prevent the injuries from re-opening. During observations on 8/12/24, R31's wound care orders and care plan interventions were not implemented as ordered. Findings include: The facility's Pressure Injury Prevention Guidelines, dated 2/14/23, indicate: To prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries, it is the policy of this facility to implement evidence-based interventions for all residents who are assessed at risk or who have a pressure injury present .1. Individualized interventions will address specific factors identified in the resident's risk assessment, skin assessment, and any pressure injury assessment .8. Compliance with interventions will be documented in the 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.

Based on staff and resident interview and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for 1 Resident (R) (R38) of 1 resident reviewed for smoking. R38 was known by the facility to smoke cigarettes. The facility did not assess R38's ability to safely smoke on a quarterly basis in accordance with the facility's policy. Findings include: The facility's Smoking Safety policy, with a revision date of 5/13/24, indicates: .1. Residents who smoke tobacco products shall have a smoking assessment completed upon admission, quarterly, and as needed. During the entrance conference on 8/12/24 at 9:10 AM, Nursing Home Administrator (NHA)-A confirmed the facility had 3 residents who smoked. From 8/12/24 to 8/14/24, Surveyor reviewed R38's medical record. R38 was admitted to facility on 6/2/23 and had diagnoses including emphysema and chronic obstructive pulmonary disease (COPD). R38's Minimum Data Set (MDS) assessment, dated 7/17/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R38 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure vital signs and weights were consistently completed pre- and post-dialysis and communicated to the dialysis facility for 1 Resident (R) (R30) of 1 resident reviewed for dialysis. Staff did not consistently complete R30's dialysis communication sheets and did not consistently obtain R30's pre- and post-dialysis vital signs and weights. Findings include: The facility's Hemodialysis policy, dated 2/15/23, indicates: 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 psychosocial needs of residents receiving hemodialysis .The facility will assure that each resident receives care and services for the provision of hemodialysis and peritoneal dialysis consistent with professional standards of practice. This will include: The ongoing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure monthly medication reviews were completed or followed-up on for 2 Residents (R) (R36 and R39) of 5 residents reviewed for unnecessary medication. R36 had a pharmacist recommendation from R36's October 2023 monthly medication review (MMR). The recommendation was not addressed until 2/5/24. In addition, R36 did not have an MMR documented for March of 2024. R39 had a pharmacist recommendation from R39's November 2023 MMR. The recommendation was not addressed at the time of the annual survey. Findings include: The facility's Medication Regimen Review and Reporting policy, dated 2007, indicates: The consultant pharmacist reviews the medication regimen and medical chart of each resident at least monthly to appropriately monitor the medication regimen and ensure the medications each resident receives are clinically indicated .Medication Regimen Review recommendations and findings are documented and acted upon by the nursing center within 30…

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

Based on observation, staff interview, and record review, the facility did not ensure it served pasta salad at a safe and appetizing temperature. This practice had the potential to affect multiple residents residing in the facility, excluding 19 of 50 residents who received nutrition via enteral feeding. On 7/9/24, the temperature of cold pasta salad was 61.7 degrees Fahrenheit (F). Findings include: The Wisconsin Food Code documents at 3-501.16 Potentially Hazardous Food (Time/Temperature Control for Safety Food), Hot and Cold Holding: (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under § 3-501.19, and except as specified under (B) and in (C) of this section, Potentially Hazardous Food (Time/Temperature Control for Safety Food) shall be maintained: (1) At 57°C (Celsius)(135°F) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11 (B) or reheated as specified in 3-403.11 (E) may be held at a temperature of 54°C (130°F) or above; or (2) At 5°C (41°F) or less. (B) Eggs that have…

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

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect multiple residents residing in the facility, excluding 19 of 50 residents who received nutrition via enteral feeding. Staff did not perform proper hand hygiene prior to donning/doffing gloves, while preparing food, prior to touching ready to eat food, and while throwing away garbage. Findings include: On 7/9/24 at 11:19 AM, Surveyor began an initial kitchen tour of the kitchen with Dietary Manager (DM)-F who stated the facility follows the Wisconsin Food Code. The Wisconsin Food Code documents at Chapter 2 Personal Cleanliness at 2-301.14 When to Wash: Food employees shall clean their hands and exposed portions of their arms as specified under 2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: (A) After touching bare human body parts other than clean hands and clean,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure appropriate care and treatment were provided when 1 resident (R) (R1) of 12 sampled residents experienced a change of condition. On 5/5/24, R1 experienced a change of condition. Staff did not document complete and accurate assessments regarding R1's change of condition or notify R1's physician in a timely manner. Findings include: The facility's Notification of Changes policy, dated 10/22/22, indicates: The purpose of this policy is to ensure the facility 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 .Need to alter treatment significantly means a need to stop a form of treatment because of adverse consequences (such as adverse drug reaction) or commence a new form of treatment to deal with a problem (for example, the use of any medical procedure, or therapy that has not been used on that resident before)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure 2 residents (R) (R10 and R11) of 4 residents with a percutaneous endoscopic gastrostomy (PEG) tube (a medical procedure in which a tube is passed into the stomach through the abdominal wall) received treatment and services to prevent adverse consequences of enteral feeding. Staff did not obtain weights for R10 and R11 in accordance with physicians' orders. Findings include: The facility's Weight Monitoring Policy, dated 11/1/23, indicates: Based on the resident's comprehensive assessment, the facility will ensure all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise .Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not ensure menu items were prepared according to the recipe and served according to the extended menu for 1 resident (R) (R13) of 1 resident who was on a pureed diet. During lunch service on 7/9/24, staff did not follow the pureed food recipe and did not use an appropriate serving size to serve pureed chicken. Findings include: The facility's Food Preparations Guidelines policy, with an implementation date of 10/24/22, indicates: 1. The cook, or designee, shall prepare menu items following the facility's written menus and standardized recipes. 2. Food shall be prepared by methods that conserve nutritive value, flavor, and appearance. This includes .b. Preparing foods as directed. On 7/9/24, Surveyor reviewed R13's medical record. R13 was admitted to the facility on [DATE] with diagnoses including dysphagia (difficulty swallowing). R13 had an order for a pureed diet. In addition, R13 received nutrition via tube feeding. On 7/9/24 at 11:30…

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

Based on observation, staff interview, and record review, the facility did not ensure it served milk at a safe and appetizing temperature. This practice had the potential to affect multiple residents residing in the facility, excluding 19 of 52 residents who received nutrition via enteral feeding. On 5/20/24, the temperature of milk served on a test tray was 53.6 degrees Fahrenheit (F). Findings include: The facility's Food Preparation Guidelines policy, dated 10/24/22, indicates: It is the policy of this facility to prepare food in a manner to preserve or enhance a resident's nutrition and hydration status .3. Food and drinks shall be palatable, attractive, and at a safe and appetizing temperature. Strategies to ensure resident satisfaction include: .c. Serving hot food/drinks hot and cold food/drinks cold . The facility's undated Food Temperature log indicates: .Temperatures must be taken on a daily basis .Cold food 41 (degrees) F and below . On 5/20/24 at 11:36 AM, Surveyor observed kitchen staff prepare room trays for the lunch meal. Surveyor observed [NAME] (CK)-C obtain 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, staff interview, and record review, the facility did not ensure staff performed appropriate hand hygiene during food preparation. This practice had the potential to affect multiple residents residing in the facility, excluding 19 of 52 residents who received nutrition via enteral feeding. On 5/20/24, [NAME] (CK)-C did not consistently perform appropriate hand hygiene during food preparation. Findings include: The facility provided a Centers for Disease Control and Prevention (CDC) document titled Food Worker Handwashing and Food Preparation, dated September 2011, that indicated: The spread of germs from the hands of food workers to food is an important cause of foodborne illness outbreaks .Proper handwashing can reduce germs on workers' hands. It can also reduce the spread of germs from hands to food and from food to other people. The U.S. Food and Drug Administration (FDA) advises that hands be washed before making food .The FDA also advises that hands be washed after handling dirty equipment . On 5/20/24 at 10:47 AM, Surveyor observed CK-C prepare coffee cake…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure care and treatment was provided in accordance with professional standards of practice for 1 Resident (R) (R2) of 2 sampled residents. R2 was not monitored after a change in condition which resulted in a hospitalization for septic shock. Findings include: R2 was admitted to the facility on [DATE] with diagnoses including anoxic brain damage, persistent vegetative state, chronic respiratory failure, chronic obstructive pulmonary disease, neuromuscular dysfunction of bladder, tracheostomy and gastrostomy status. R2 had an activated Guardian. On 11/8/23, Surveyor reviewed R2's medical record. A nursing assessment, dated 10/10/23, indicated R2 had bilateral increased upper extremity edema (swelling). On 10/11/23, R2 was evaluated by Nurse Practitioner (NP)-D who initiated a plan to monitor R2's edema and weight. R2's medical record did not indicate R2's edema or weight was monitored between 10/11/23 and 10/16/23. On 10/16/23, R2's medical record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interview, and record review, the facility did not ensure a grievance was filed, investigated and resolved for 1 Resident (R4) of 7 residents reviewed. R4 informed Director of Nursing (DON)-B of a care concern. A grievance form was not filled out and the grievance was not thoroughly investigated or resolved. Findings include: The facility's Grievances/Complaints Filing from 2001 Med-Pass, Inc (Revised April 2017) document indicated: .1. Any resident .may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members .Grievances may also be voiced or filed regarding care that has not been furnished. 3. All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing, including a rationale for the response. 8. Upon receipt of a grievance and/or complaint, the Grievance Officer will review and investigate…

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

Based on staff interview and record review, the facility did not designate a person to serve as the director of food and nutrition services who was a certified dietary or food service manager, who had a national certification for food service management and safety from a national certifying body, or who had an associate level or higher degree in food service management or hospitality. This had the potential to affect 44 out of 57 residents who resided in the facility. (Thirteen residents were exclusively tube fed.) Findings include: During an initial tour of the kitchen on 6/12/23 at 8:15 AM, Dietary Manager (DM)-L stated DM-L did not know what standard of practice the facility followed for food safety. DM-L stated DM-L was hired several years ago as a cook and was promoted to the Dietary Manager role approximately two years ago. DM-L stated during the time DM-L worked as the Dietary Manager, DM-L took a leave of absence for six months and returned to the role in approximately February 2023. Surveyor reviewed documentation provided by the facility and noted DM-L was hired as a cook…

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

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect 44 of 57 residents residing in the facility. (Thirteen residents received nutrition exclusively via tube feeding.) Staff did not test Quaternary sanitizing solution per manufacturer's instructions. Cook (CK)-N did not wait two minutes to take microwave reheated food temperature to ensure food was heated evenly. Staff did not ensure food-contact and non-food contact equipment, including a can opener, stove griddle, oven, and double oven were clean and dry for storage or use. The facility did not monitor and document hot holding temperatures. The facility did not cool foods with an approved food cooling method. Findings include: During an initial tour of the kitchen on 6/13/23, Dietary Manager (DM)-L stated DM-L was unsure which standard of practice the facility followed for food safety. On 6/13/23 at 2:45 PM, Surveyor interviewed Registered Dietician (RD)-H who was also unsure which standard of practice the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not provide Pre-admission Screening and Resident Review (PASRR) services for 4 Residents (R) (R30, R53, R44 and R50) of 5 sampled residents. The facility did not accurately complete PASRR Level I Screens and/or submit PASRR Level II Screens for R30, R53, R44, and R50. Findings include: The facility's Resident Assessment: Coordination with PASRR Program policy, dated 5/8/23, contained the following information: This facility coordinates assessments with the preadmission screening and resident review (PASRR) program under Medicaid to ensure individuals with a mental disorder, intellectual disability or a related condition receive care and services in the most integrated setting appropriate to their needs .ii. Positive Level I Screen necessitates a PASRR Level II evaluation prior to admission .2. The facility will only admit individuals with a mental disorder or intellectual disability who the State mental health or intellectual disability authority has…

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

Based on observation, staff interview, and record review, the facility did not ensure menu serving sizes for pureed and mechanically altered diets were followed for 8 Residents (R) (R58, R20, R10, R43, R8, R4, R3, and R41) of 44 residents. The facility served smaller serving portions than the menu indicated for pureed green beans, pureed polish sausage on a bun and mechanically altered polish sausage during the lunch meal on 6/13/23. Findings include: The facility's extended menu documented the lunch meal serving size as 6 ounces (oz) (black handle food scoop) for regular portions of pureed green beans and pureed polish sausage on a bun. The menu also contained a serving size of 1 polish sausage and 1 bun for mechanically altered meat. Lunch menu for 6/12/23: Polish sausage Corn Potato salad Cookie BBQ (barbecue) pork on a bun (alternative) During a continuous lunch preparation and meal service observation on 6/12/23 beginning at 11:20 AM, Surveyor noted [NAME] (CK)-N did not reference an extended menu while placing scoops in food on the steam table. Surveyor observed CK-N pour…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure a complete baseline care plan was developed within 48 hours of admission for 1 Resident (R) (R35) of 2 sampled residents reviewed for new admission. R35 was admitted to the facility with diagnoses including tracheostomy (an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs), gastrostomy (an artificial external opening into the stomach for nutritional support) and ventilator (a machine used medically to support or replace the breathing of a person) dependence. R35's baseline care plan did not address the diagnoses. Findings include: From 6/12/23 through 6/14/23, Surveyor reviewed R35's medical record. R35 was admitted to the facility on [DATE] with diagnoses to include persistent vegetative state, tracheostomy status, gastrostomy status, dependence on ventilator status, and diabetes. R35's Minimum Data Set (MDS) assessment, dated 5/24/23, indicated R35 received nutrition through a feeding…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure 2 Residents (R) (R50 and R58) of 5 residents reviewed for Activities of Daily Living (ADLs) were provided weekly showers. R50 was admitted to the facility on [DATE] and had four documented showers since 4/1/23. R58 was admitted to the facility on [DATE] and had one documented shower since 5/1/23. Findings include: 1. R50 was admitted to the facility on [DATE]. R50's Minimum Data Set (MDS) assessment, dated 5/23/23, indicated R50 had severe cognitive impairment and required the assistance of one staff for bathing. On 6/12/23 at 10:14 AM, Surveyor observed R50 in R50's room. Surveyor noted R50's hair was unkept and appeared greasy. Between 6/12/23 and 6/14/23, Surveyor reviewed R50's medical record and noted R50 received showers on 4/30/23, 5/6/23, 5/16/23, and 6/6/23 and refused showers on 4/18/23, and 4/29/23. R50's weekly shower was scheduled on the Tuesday AM shift. R50 had seven missed opportunities for showers. 2. R58 was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not obtain weights as part of nutritional monitoring for 2 Residents (R) (R58 and R35) of 4 sampled residents reviewed for nutrition. R58 did not have an order on admission for weight monitoring. The facility's policy stated to obtain weights weekly for four weeks and monitor residents with weight loss weekly. R35 had an order for weekly weights and a tube feeding (TF) rate of 60 ml/hr (milliliters/hour). The facility did not consistently monitor R35's weight on a weekly basis or ensure the TF rate was followed per physician order. Findings include: The facility's undated Weight Monitoring policy contained the following information: a. A weight monitoring schedule will be developed upon admission for all residents; b. Newly admitted residents - Monitor weight weekly for 4 weeks; c. Residents with weight loss - monitor weight weekly. 1. From 6/12/23 through 6/14/23, Surveyor reviewed R58's medical record. R58 was admitted to the facility on [DATE] 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 staff interview and record review, the facility did not ensure high-risk medications were monitored for 2 Residents (R) (R33 and R44) of 5 residents reviewed for unnecessary medications. R33 and R44's medical records did not contain documentation that R33 and R44 were monitored for potential side effects of diuretic medication. Findings include: According to the Davis's Drug Guide for Nurses 18th edition copyright 2023, adverse reactions/side effects of diuretic medication such as thirst, dry mouth, lethargy, weakness, hypotension, or oliguria may occur .Monitor daily weight, intake and output ratios, amount and location of edema, lung sounds, skin turgor, and mucous membranes .Monitor blood pressure and pulse before and during administration. 1. On 6/6/23, Surveyor reviewed R33's medical record and noted an order for Lasix (a diuretic (water pill) that prevents the body from absorbing too much salt) 20 mg daily related to essential (primary) hypertension. R33's plan of care did not contain medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure potential side effects and adverse reactions for a psychotropic medication were monitored for 1 Resident (R) (R44) of 5 residents reviewed for unnecessary medications. R44 was prescribed lorazepam (an anti-anxiety medication). The facility did not include monitoring for side effects or adverse reactions to the medication in R44's plan of care. Findings include: On 6/14/23, Surveyor reviewed R44's medical record. R44 was admitted to the facility on [DATE] with diagnoses to include anxiety and depression. R44 had an order for lorazepam tablet 1 milligram, give 1 tablet by mouth two times a day for anxiety. R44's plan of care did not contain monitoring for potential side effects or adverse reactions to lorazepam. On 6/14/23 at 12:31 PM, Surveyor interviewed Director of Nursing (DON)-B who verified R44's plan of care did not contain monitoring for side effects or adverse reactions to lorazepam. DON-B stated side effect and adverse reaction…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not ensure Residents (R) on a pureed diet had meals prepared by a method that conserved nutritive value for 2 (R20 and R58) of 2 residents with pureed diets. Kitchen staff used water to puree multiple food items which did not conserve the nutritive value of the food. Findings include: During an initial kitchen tour that began at 8:12 AM on 6/13/23, Dietary Manager (DM)-L stated R20 and R58 had orders for a pureed diet. The facility's Menu Matrix, dated 9/19/18, contained the recipe for pureed cooked green beans .liquids should be added gradually and may need to be increased or decreased slightly to ensure foods are served at a proper consistency. Other fluids deemed more appropriate may be substituted to improve the taste quality of the food without impacting the overall nutritional quality of the meal .Note: cooking liquid, broth or other suitable liquid may be used when pureeing this food. According to the publication All About Recipes,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. On 6/12/23 at 11:24 AM, Surveyor observed CNA-K and CNA-E provide perineal care for R17. CNA-K and CNA-E cleansed hands and donned the appropriate personal protective equipment (PPE). CNA-K opened the tabs of R17's soiled brief and tucked the front end of the brief underneath R17's buttocks. CNA-K provided perineal care with a wet, soapy washcloth. With the same gloved hands, CNA-K dried R17's perineal area with a towel. CNA-K then removed and disposed of R17's soiled brief. With the same gloved hands, CNA-K touched furniture, cream, powder and a clean brief. CNA-K then removed gloves. Without cleansing hands, CNA-K donned clean gloves, placed a clean brief under R17's buttocks and applied cream to R17's buttocks. CNA-K then removed gloves. Without cleansing hands, CNA-K donned clean gloves and closed the tabs on R17's brief. CNA-K put a clean gown on R17 and both CNAs positioned R17 in bed. After removing gloves and PPE, CNA-K did not perform hand hygiene prior to exiting the room and touching the door knob.…

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.