Lindengrove Menomonee Falls

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure that based on the comprehensive assessment of a resident, residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident's choices for 3 (R1, R2, & R3) of 4 residents. *R1 receives an anticoagulant twice a day. On 10/16/25 R1 sustained an unwitnessed fall hitting her head. R1 sustained a large purplish hematoma on the left side of the R1's forehead and a skin tear on the left hand. While R1 was laying on the floor, Licensed Practical Nurse (LPN)-N obtained vital signs and Nurse Practitioner (NP)-K assessed R1's range of motion. NP-K informed Surveyor after assessing R1's range of motion she left R1's room as multiple staff were coming into the room. NP-K informed Surveyor she planned on returning to R1's room. NP-K did not complete a comprehensive assessment and did not return until sometime after lunch. When NP-K returned sometime after 2:00 p.m., there was…

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

Based on observation, interview, and record review the facility did not provide the necessary respiratory care and services for 1 (R1) of 2 residents receiving oxygen therapy.R1did not receive oxygen via nasal cannula per physician orders. On 10/16/25, the ambulance crew observed R1's oxygen tubing was disconnected at the connector and R1's oxygen level was 80%. The facility's intervention to prevent this from occurring in the future was to not use extension tubing. On 11/4/25, R1's oxygen tubing was observed to have extension tubing.Findings include:The facility's policy titled, Safe Use of Oxygen and last reviewed 11/8/23 under policy documents Entity will provide individuals who are in need of oxygen safe storage, use, and transportation in regulated health care settings.The facility's, Standard Respiratory Protocol not dated under the sections Registered Nurse (RN), Certified Nursing Assistant (CNA) & (Med Tech) MAA all include Apply oxygen as ordered.R1's diagnoses include chronic respiratory failure with hypoxia (long term condition where the lungs cannot supply enough oxygen…

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 provide routine and emergency drugs and biologicals to its residents (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (R2) of 4 residents reviewed.R2's Mirtazapine was not given as ordered.Findings include:R2 admitted to the facility on [DATE] with diagnoses that included right femur fracture, atrial fibrillation, chronic kidney disease stage 4, type 2 diabetes mellitus, hypothyroidism and depression. R2's Brief Interview for Mental Status score was 15, indicating no cognitive impairment.The facility policy titled Medication administration - general guidelines dated May 2018 documents:Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. The facility has sufficient staff and a medication distribution system to ensure safe administration 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 interview and record review, the facility failed to report an injury of unknown origin (IUO) within required timeframes to the State Survey Agency (SSA) for one of three residents (Resident (R) 2) reviewed for abuse out of a total sample of six. Failure to report injuries of unknown origin places all residents at risk of abuse. Findings include:Review of R2's ''admission Record,'' located in the ''Profile'' tab of the EMR, revealed R2 admitted to the facility on [DATE] with diagnoses including spastic hemiplegia affecting right dominant side and quadriplegia. Review of R2's quarterly ''Minimum Data Set (MDS),'' with an Assessment Reference Date (ARD) of 07/21/25, revealed R2 had a Brief Interview for Mental Status (BIMS) score of eight out of 15, which indicated the resident was moderately cognitively impaired. Review of R2's ''Nurse's Notes, dated 08/07/25 at 1:57 PM, located in the EMR under the ''Notes'' tab and written by Licensed Practical Nurse (LPN) 1, revealed, . resident complained of right…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to thoroughly investigate an injury of unknown origin for one of three residents (Resident (R) 2) reviewed for abuse out of a total sample of six. Failure to thoroughly investigate injuries of unknown origin places residents at risk of continued abuse. Findings include:Review of R2's ''admission Record,'' located in the ''Profile'' tab of the EMR, revealed R211 admitted to the facility on [DATE] with diagnoses including spastic hemiplegia affecting right dominant side, and quadriplegia. Review of R2's quarterly ''Minimum Data Set (MDS)'' with an Assessment Reference Date (ARD) of 07/21/25, revealed R2 had a Brief Interview for Mental Status (BIMS) score of eight out of 15, which indicated R2 was moderately cognitively impaired. Review of a ''Nurse's Note,'' dated 08/07/25 at 1:57 PM, located in the EMR under the ''Notes'' tab, and written by Licensed Practical Nurse (LPN) 1, revealed, . resident complained of right ankle pain and requested…

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 provide the opportunity for 1 (R3) of 3 Residents reviewed to participate in the development and implementation of their person-centered plan of care by not facilitating the inclusion of R3 and/or their representative in the care planning process. *R3 was admitted to the facility on [DATE] for short term rehabilitation, and there is no documentation in R3's electronic medical record (EMR) that R3 and/or their representative participated in the development and implementation of R3's person-centered plan of care on a quarterly basis.Findings Include:The facility's Individual Care Plan Conferences policy and procedure last reviewed 3/8/23 documents: . I. Policy: A written Care Plan is developed and maintained directing a course of comprehensive care specific to the individual's needs from all appropriate disciplines and the individual's primary care provider.II. Procedure:A. Evaluations and Updates.1.The care of each individual shall be reviewed by each 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 interview and record review, the facility did not ensure 1 (R1) of 3 residents reviewed received a prompt resolution of grievances filed, including documentation of steps taken to investigate the grievance, and corrective actions taken by the facility as a result of the grievance.R1's POA filed three grievances with the facility, and there is no evidence of the grievances being thoroughly investigated or a resolution obtained and shared with the complainant. Findings include: The facility policy and procedure entitled Grievance dated 5-8-91 with review date of 2-21-2024 documents:. Policy: individual, guardian, and/or individual representative will be informed of the process to file a grievance or complaint and the facility's process to make prompt efforts to resolve grievances.Procedure: The facility fosters and environment of direct communication, prompt resolution, and continuous process improvement.B. Formal Grievance:1. All staff has access to the formal Grievance Form. Formal Grievance is to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure 1 (R1) of 3 residents' care plans reviewed were revised as needed based on preferences and needs of the resident.R1's care plan was not revised to include interventions for the safe storage of R1's dentures.Findings include:On 7/14/25, at 9:51 am, Surveyor spoke with R1's Power of Attorney (POA)-O via phone call. POA-O stated the facility lost R1's dentures.The facility policy titled Comprehensive Person-Centered Care Plan with implementation date of 7/9/19 and reviewed date of 5/8/25, documents:.Policy: the Comprehensive Person-Centered Care Plan will reflect the individual's needs and preferences to facilitate care.Procedure:A. Within 48 hours after admission: a Baseline Care Plan will be completed and reviewed with Individual and/or Individual Representative.B. Within 21 consecutive days after admission, and in correlation with the Minimal Data Set (MDS), a comprehensive assessment will be completed and a written care plan will be developed…

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 1 (R1) of 3 residents reviewed received the appropriate treatment and services to maintain the ability to carry out activities of daily living, including mobility and elimination.R1 was not provided assistance walking in hallways or to the bathroom, was not transferred at the highest practicable level, and was not provided toileting care as indicated in R1's care card and care plan.Findings Include:The facility policy titled Safe Individual Handling Program, with implementation date of 2/8/17 and reviewed date of 5/8/25 documents: . Procedure:A. Transfer Assessment1. Individuals will be assessed according to ability per transfer and movement objective criteria. Nursing will perform this assessment in collaboration with therapy as applicable.2. Once the assessment is completed, the appropriate transfer status will be determined.B. Care Plan1. Individual-specific transfer status will be addressed on the Care Plan to include specific…

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 interviews and record review, the facility did not ensure therapy services were provided in a timely manner for 1 (R1) of 1 resident reviewed for therapy services.R1 received orders to start physical therapy (PT) and occupational therapy (OT) dated 4/29/25. PT and OT services were not initiated until 7/14/25.Findings Include: R1 was admitted to the facility on [DATE], with diagnoses that include hemiplegia and hemiparesis (weakness) following cerebral infarction (stroke) affecting right dominant side, anxiety, chronic diastolic (congestive) heart failure, chronic obstructive pulmonary disease, and type 2 diabetes mellitus.R1's most recent Quarterly Minimum Data Set (MDS) assessment completed 4/29/25 documents R1 requires partial assistance for showers, dressing, bed mobility, transfers, and to walk ten feet. R1 has a Brief Interview of Mental Status (BIMS) score of 03, indicating severe cognitive impairment. R1 has an activated healthcare power of attorney (POA). Surveyor requested a policy and…

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

Based on observation, interview, and record review, the facility did not designate a licensed nurse to serve as a charge nurse on each tour of duty. * The facility did not designate a charge nurse for each tour of duty on each daily nursing schedule. This deficient practice has the potential to affect all 49 residents residing in the facility. Findings include: On 2/11/25, Surveyor requested nursing schedules and nurse staff postings for Quarter 4 (July 1st-September 30th, 2024) due to Payroll Based Journal reporting and 1/20/25-2/10/25. Surveyor was provided with the nursing schedules and nurse staff postings and noted the facility's nursing schedules did not designate who the charge nurse was for each tour of duty. On 2/17/25, at 10:15 AM, Surveyor conducted an interview with Scheduler-HHH. Scheduler-HHH is responsible for coordinating the facility's nursing schedule and preparing the facility's nurse staff postings. Surveyor asked Schedule-HHH if they were aware there was not a charge nurse designated on the facility's nursing schedules for Quarter 4 (July 1st -September 30th,…

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 review of daily staff postings, staffing schedules, and interview, the facility did not use the services of a RN (Registered Nurse) for at least 8 consecutive hours a day, 7 days a week. * On multiple dates, there was no RN who worked at the facility for 8 consecutive hours. This deficient practice has the potential to affect 49 of 49 residents residing in the building. Findings include: 1.) On 2/11/25, Surveyor requested nursing schedules and nurse staff postings for Quarter 4 (July 1st-September 30th, 2024) due to Payroll Based Journal reporting and 1/20/25-2/10/25. Surveyor was provided with the nursing schedules and nurse staff postings and noted the facility's nursing schedules did not indicate the presence of an RN in the facility on the following dates: July 2024: July 4, 5, 9, 11, 18, 20, 24, 25, 26, 27, 28. August 2024: August 1, 2, 5, 6, 15, 16, 19, 20, 21, 25, 29, 30. September 2024: September 3, 8, 12, 13, 16, 21, 22, 26, 30. January 2025: January 13, 18, 19, 20, 23, 30. February 2025: February 3. On 2/17/25, at 10:15 AM, Surveyor conducted an interview 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 food was prepared, and served, in a sanitary manner. This was observed in 2 of 2 food preparation and serving areas and with the meal tray service to resident rooms on 1 (Unit A) of 4 units. * The facility did not ensure the facility kitchen dish machine was functioning to sanitize dishware. * The dietary staff was observed without hair restraints in the 1st floor kitchen preparation and serving area and the main kitchen. * On Unit A resident meal trays items were not covered during delivery to resident rooms. * The facility kitchen dish machine was not monitored, and checked, to ensure appropriate sanitization of dishware. Findings include: On 2/11/25, at 12:16 PM, the Food Service Director (FSD)-W provided policy and procedures to Surveyor. There is no date of review, or revision, on the policy and procedures. The FSD-W does not know the dates and this what they use. The facility's policy and procedure with no date and titled, Hair…

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 [NAME], [NAME] & [NAME] [NAME]-Water management program not implemented/not mentioned in facility, Staff not wearing proper PPE for enhanced barrier, No baseline rates of infection for prevalent infections and analysis of 2 outbreaks, The facility assessment does not include information on how facility Infection Preventionist [NAME]'s duties are being fulfilled as she conducts dual roles, [NAME]- [NAME] catheter bag laying on floor, enhanced barrier precautions PPE not followed [NAME] staff lack of hand hygiene during incontinence care [NAME]- Observations of [NAME]'s catheter bag on floor, emptying catheter without proper technique/hygiene Resident #12 FTag Initiation 02/11/25 09:28 AM 11/27/24 significant change mds bims 1 mood 00 no behavior upper & lower extremity one side eating supervision, toileting hygiene, roll left and right, chair/bed to chair transfer & toilet transfer all dependent always incontinent of urine and bowel no falls since prior assessment yes for antidepressant hospice yes…

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 interviews and record review, the facility did not ensure a safe, clean, comfortable and homelike environment as evidenced by having a linen shortage in order to properly take care of residents with the potential to affect a pattern of Residents who prefer to wear hospital gowns at night. * R196 informed Surveyor that hospital gowns were not available all weekend, Monday, and Tuesday (2/8-2/11/25) for bedtime and that is R196's preference to wear a hospital gown for bed. Findings include: R196 was admitted to the facility on [DATE] with diagnoses of Hypothyroidism, Type 2 Diabetes Mellitus, Obstructive Sleep Apnea, Essential Hypertension, and Displaced Comminuted Fracture of Shaft of Right Femur. R196's admission Minimum Data Set(MDS) dated [DATE] was in the process of being completed. The Brief Interview for Mental Status (BIMS) has been completed and the score is 15, indicating R196 is cognitively intact for daily decision making. The MDS documents R196 has no mood behavior issues.…

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 Facility not having ability to provide gowns to residents Has ability to effect a pattern of resident who prefer to wear gowns FACILITY FTAGDIR Based on observation, staff interviews and record review, the facility did not ensure a safe, clean, comfortable and homelike environment as evidenced by having a linen shortage in order to properly take care of Residents with the potential to affect 1 of 4 residents interviewed () as well as those residents who receive linens from the linen carts on A,B,C,D units. *R196 informed Surveyor that hospital gowns were not available all weekend, Monday, and Tuesday for bedtime and that is R196's preference to wear a hospital gown for bed. Findings include: R196 02/10/25 10:09 AM Had to sleep in shirt last night because was told there was no gowns all wkend, did not get out bed Sat or Sun because was told the hoyer was broke so I was bedridden all weekend 02/10/25 01:42 PM States only got up with therapy briefly and then back to bed 02/11/25 08:57 AM Did not have a gown to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure 1 (R197) of 1 residents reviewed were assessed by the interdisciplinary team to determine it was clinically appropriate to self administer medication. * R197's as needed (PRN) Albuterol inhaler was observed in R197's drawer without a self-administration assessment and physician order to self-administer. Findings include: The facility's policy Preparation and General Guidelines for Self-Administration of Medications last revised 1/2018 documents: Policy: In order to maintain the Residents' high level of independence, Residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the Resident and other Residents of the facility and there is a prescriber's order to self-administer. Procedures A. If a Resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of 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 Based on interview and record review, the facility did not develop and implement a baseline care plan that includes the instructions needed to provide effective and person centered care for 2 (R197 and R350) of 5 residents reviewed. * R197 was admitted to the facility on [DATE] and did not have a baseline care plan initiated upon admission. * R350 was admitted on [DATE] and did not have a baseline care plan initiated upon admission. Findings include: The facility's policy Comprehensive Person Centered Care Plan dated 7/19/2019 and last revised on 8/10/23 documents: 1. Policy: The Comprehensive Person Centered Care Plan will reflect the individual's needs and preferences to facilitate care. 2. Procedure: A. Within 48 hours after admission: a Baseline Care Plan will be completed and reviewed with Individual and/or Individual Representative. D. Individual and/or Individual Representative and direct care staff will participate in development of the comprehensive person centered care plan. 1.) R197 was admitted to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure a comprehensive person centered care plan was developed for 1 (R297) of 13 residents. * R297's foley catheter was discontinued on 6/7/24. The facility did not develop a urinary care plan after R297's foley catheter was discontinued. Findings include: The facility's policy titled, Comprehensive Person Centered Care Plan and last reviewed 8/10/23 under Procedure documents C. Care Plan shall be reviewed and revised quarterly, upon change of condition, and/or as needed. 1.) R297 was admitted to the facility on [DATE] with a diagnoses that includes depression, benign prostatic hyperplasia, urinary retention, diabetes mellitus, and Alzheimer's Disease. R297's POA (power of attorney) was activated on 4/1/22. R297's admission MDS (minimum data set) with an assessment reference date of 5/31/24 has a BIMS (brief interview mental status) score of 7, which indicates severe cognitive impairment. Yes is checked for indwelling catheter placement for R297. R297'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.) R23's diagnoses includes obstructive & reflux uropathy and neuromuscular dysfunction of the bladder. R23 is receiving hospice services. R23's admission MDS (minimum data set) with an assessment reference date of 11/8/24 is checked for an indwelling catheter. R23's urinary incontinence and indwelling catheter CAA (care area assessment) dated 11/11/24 documents under the analysis of findings for nature of problem/condition: neurogenic bladder obstructive urop (uropathy) foley cath (catheter) retention. Under the care plan considerations section it documents: Proceed to plan of care. Maintain Foley cath-cath places at risk for infection. Goal for no complications/infections r/t (related to) cath. R23's indwelling catheter care plan initiated 11/1/24 & revised 11/11/24 includes an intervention of monitor and document intake and output as per facility policy. This intervention is documented as initiated & revised on 11/1/24. R23's physician order dated 11/1/24 documents monitor catheter output three times a day.…

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 provide the necessary respiratory care and services for 1 (R23) of 2 residents receiving oxygen therapy. * R23's oxygen tubing was dated 12/7/24 and was not changed weekly according to R23's physician orders. Findings include: The facility's policy with no date and titled, Standard Respiratory Protocol documents under the RN (Registered Nurse) section: Replace DME (durable medical equipment) as ordered. R23's diagnoses includes interstitial pulmonary disease, heart failure, and chronic respiratory failure with hypoxia. R23's physician orders dated 11/1/24 documents Change oxygen tubing -Date Tubing every night shift every 7 days(s). R23's admission MDS (minimum data set) with an assessment reference date of 11/8/24 documents that R23 requires oxygen. On 2/10/25, at 11:37 a.m., Surveyor observed R23 sitting in a wheelchair receiving oxygen via a nasal cannula at 2 liters per minute. Surveyor observed the oxygen tubing to be dated 12/7/24. On 2/10/25, at 3:43 p.m., Surveyor observed R23 sitting in a wheelchair in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not provide dialysis services consistent with professional standards of practice for 1 (R39) of 1 Residents reviewed for dialysis. * R39 receives dialysis three times per week. R39's dialysis center communication records are not being consistently completed by Facility nurses. Findings include: 1. R39 was admitted to the facility on [DATE] with diagnoses of Protein Calorie Malnutrition, End Stage Renal Disease and Dependence on Renal Dialysis. Surveyor reviewed R39's medical record, including physician's orders and comprehensive care plans. R39's care plan with an initiation date of 7/12/24 documents: Alteration in nutrition poor oral intake, abnormal labs, gradual weight loss, decline in chewing ability R/T (related to) ESRD (End Stage Renal Disease, edentulous (without teeth), Anemia (low iron level in blood, weakness A/E/B (As Evidenced By): new dx: PCM (Plasma Cell Myeloma), beginning IDPN (Intradialytic Parenteral Nutrition), Dialysis 3 x (times) a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure adequate monitoring for adverse reactions of high-risk medications for 1 (R7) of 6 residents reviewed for unnecessary medications in accordance with standards of practice. *R7 has physician's order for Warfarin (an anticoagulant) for chronic embolism and thrombosis of unspecified deep veins of unspecified lower extremity. The facility did not implement care plans to monitor for any adverse side effects that could result from taking an anticoagulant. 1.) R7 was admitted to the facility on [DATE] with diagnoses that includes Atrial Fibrillation, Cerebral Infarction and Hyperlipidemia. R7's Quarterly MDS (Minimum Data Set) Assessment with an assessment reference date of 12/23/2024 indicates that R7 received an Anticoagulant medication during the assessment period. Surveyor reviewed R7's electronic medical record and could not locate a person-centered care plan to monitor for adverse side effects related to the use of an anticoagulant and diuretic.…

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 3 (R350, R3 and R36) or 6 residents reviewed for medications were free from unnecessary psychotropic medications. * R350 was prescribed Risperidone (anti-psychotic medication) for bipolar disorder. R350 does not have a diagnosis of bipolar disorder. R350 was prescribed Escitalopram (anti-depressant medication) without a documented diagnosis in the physician order. Facility staff did not document behavior monitoring and side effect monitoring for Risperidone and Escitalopram from 2/6/25 through 2/13/25. * R3 is prescribed an anti-depressant medication. Facility staff did not document side effect monitoring from 1/27/25 through 2/15/25. * R36 is prescribed an anti-depressant medication. Facility staff did not document side effect monitoring from 11/4/24 through 2/15/25. Findings include: The undated facility policy titled, Standard Psychoactive Medication Protocol, documents, in part: Problem-Individual is prescribed a psychotropic 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 observation, interview and record review, the facility did not provide 3 (R196, R197, and R347) of 3 residents reviewed for dietary services, with food accommodations and preferences as listed on the Resident's meal tickets. * R196 meal ticket states no oatmeal and received oatmeal on 2/11/25 and 2/12/25. R196 did not received the berries for breakfast on 2/13/25. * R197's meal ticket states dislikes eggs but received denver eggs on 2/11/25 for breakfast. *On 2/11/25, residents received a peanut butter cookie instead of the frosted pumpkin bar listed on the posted menu. On 2/12/25, the Residents received beef barley soup instead of french onion soup listed on the posted menu. * R347 did not received a banana per meal ticket on 2/13/25. Findings Include: Surveyor reviewed the facility's dining policies and procedures. The undated Meal Identification policy documents: Policy: .A electronic meal identification and food preferences slip is used to properly identify each individual's needs and desires for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure they followed their antibiotic stewardship program for 1 (R23) of 1 residents reviewed for antibiotic use. * R23 was treated with an antibiotic for a UTI (urinary tract infection) without meeting criteria. Findings include: The facility's policy titled, Infection Prevention and Control Program dated as last reviewed on 12/5/24 under the Identification section documents: Staff will follow McGeers criteria for infection identification. The CDC (Centers for Disease Control and Prevention) Core Elements of Antibiotic Stewardship for Nursing Homes Appendix A: Policy and Practice Actions to Improve Antibiotic Use under the section Infection specific interventions to improve antibiotic use documents Reduce antibiotic use in asymptomatic bacteriuria (ASB). The prevalence of ASB, bacteriuria without localizing signs or symptoms of infections, ranges from 25% to 50% in non-catheterized nursing home residents and up to 100% among those with long-term urinary…

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 provide quality care in accordance with physician orders for one of four sample residents (Resident (R) 2). Specifically, the facility failed to perform a post void residual on R2 every shift as ordered. Findings include: Review of the admission Record, found in the Electronic Medical Record (EMR) under the Profile tab, documented R2 was admitted to the facility on [DATE] with diagnoses of benign prostatic hyperplasia (BPH) (prostate gland enlargement that can cause urination difficulty) without lower urinary tract. Review of the Admit/Readmit Screener form, found in the EMR under the Assessment tab, dated 05/10/24, documented R4 was alert and oriented, required limited assist with toilet use, was continent of bowel and bladder functions, and had no increased frequency, or difficulty initiating flow. Review of the Physician Orders, dated 05/11/24, documented tamsulosin and finasteride for BPH. Review of the Nurse's Note, dated 05/13/24,…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to follow the facility's pain policy to ensure effective pain management for one of four residents (Resident (R) 4), reviewed for pain out of a total sample of four residents. This failure resulted in harm when R4 had increased pain and cried and screamed for 3.5 hours awaiting administration of her narcotic pain medication Findings include: Review of the policy titled, Pain, dated 08/10/23 provided by the Director of Nurses (DON) documented, The Pain Tool shall be completed upon admission and quarterly. The Pain Tool shall be completed upon change in condition or if indicated. Staff will manage an individual-centered interdisciplinary care plan and implement interventions/approaches to pain management including non-pharmacological interventions .The medical provider will be consulted if pain interventions are not effective . Review of the policy titled, Medication Orders Controlled Substance Prescriptions, dated May 2018 provided by 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 and record review, the facility did not maintain documentation of a comprehensive infection control program including infection surveillance and the facility did not have a comprehensive water management plan. This deficient practice has the potential to affect 38 of the 38 residents residing in the facility at the time of the survey. * The facility was not able to show evidence of an infection control surveillance system designed to identify infections before they can spread to others in the facility, prior to December 1, 2023, when the facility identified the deficit and implemented a Performance Improvement Plan. While on survey, the facility was able to provide a line list about the Covid outbreak that occurred around August 7 & 8, 2023. * The facility had a water management policy entitled Water Management Program which listed components of what needed to be included in the water management program. The facility's water management program consisted of a water flow diagram with 4 sheets…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility did not develop a comprehensive plan of care for assessed medical needs. This was discovered with 5 (R25, R3, R43, R32, and R39) of 21 medical record reviews. - R25 was admitted with medication of an antidepressant and anticoagulant. There was not a comprehensive plan of care developed for these medical concerns. -R3 was admitted with anticoagulant medication. There was not a comprehensive plan of care developed for this medical concern. -R43 eloped from the facility. There was no comprehensive plan of care developed for R43's elopement. -R39 is diabetic and receives hospice services. There was no comprehensive plan of care developed for diabetes and hospice care. -R32 receives oxygen for respiratory concerns. There was no comprehensive plan of care developed for oxygen use. Findings include: The facility's policy and procedure for Comprehensive Person Centered Care Plan, revised 8/10/23, was reviewed by Surveyor. The policy indicates the Comprehensive Person…

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 eye drops and insulin were dated when opened, medications were not expired, medications belonging to residents who no longer resided in the facility were disposed of properly, and the medication refrigerator was being monitored for appropriate temperature. This deficient practice has the potential to affect R1, R29, R4 and a pattern of residents residing on the first floor who utilize refrigerated medications and/or stock medications. *R1, R29 and R4 had medications in the Unit D medication cart that were either not dated and/or expired. *The first-floor medication room contained expired stock medications. *The first-floor medication room refrigerator contained medications belonging to residents no longer in the facility and insulin that was opened but not dated. *The first-floor medication room refrigerator temperature log was not filled out. Findings include: Surveyor reviewed the facility policy entitled Medication Storage in the Facility, dated May 2018, stated: Medications and biologics are stored safely, securely,…

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 (R43) of 7 residents reviewed for discharge received a thorough discharge summary in order to communicate necessary information to the resident *R43 discharged from the facility on 5/19/23. The facility did not complete a discharge summary or a recapitulation of their stay that was available to R43 or R43's representative upon consent. Findings include: R43 was admitted to the facility on [DATE] with cognitive communication deficit. On 5/19/23 R43 had a planned discharge from the facility into the community. A discharge- return not anticipated assessment dated [DATE] was completed by the facility. R43's admission Minimum Data Set (MDS) dated [DATE] documents R43 has a BIMS (Brief Interview for Mental Status) score of 10, indicating R43's cognitive skills for decision making were moderately impaired. Surveyor reviewed R43's comprehensive care plan and could not identify any care plan addressing R43's discharge planning. Surveyor reviewed R43'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 interviews and record reviews the facility did not conduct a root cause analysis of resident falls in order to determine whether current interventions were implemented at the time of the fall, whether current interventions were effective and to determine appropriate ongoing interventions and supervision needed for 2 (R43 and R39) of 6 residents reviewed for falls. *R43 sustained a fall on 5/7/23. The facility did not thoroughly investigate R43's fall. *R39 sustained a fall on 2/28/23. The facility did not thoroughly investigate R39's fall. Findings include: 1. R43 was admitted to the facility on [DATE] with cognitive communication deficit. R43 discharged from the facility on 5/19/23. Surveyor reviewed R43's closed medical record including progress notes. Per medical record, R43 sustained a fall outside of the facility on 5/7/23 without injury. Surveyor noted a progress note dated 5/7/23 which reads Resident exited building and was found by hospital staff on the ground appeared to have abrasion on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not offer the pneumonia vaccine for two (R11 and R12) of five residents reviewed for vaccinations. Findings include: Facility policy entitled, Individual Immunizations, last reviewed 09/20/2023, stated, Prophylactic immunizations will be offered to individuals to promote the absence of Health Care Acquired Infections. Procedure: 1. Immunization a. Upon admission, the organization will verify the individual's immunization status, update the Primary Care Provider (PCP) as indicated, and administer immunizations as ordered. b. Individuals will be offered immunizations based upon the Center for Disease Control (CDC) recommendations and guidelines and as prescribed by their PCP . 3. Documentation .b. Immunization consent and or refusal shall be documented within the Electronic Medical Record . 1. Surveyor reviewed R12's Electronic Medical Record (EMR) for immunization status and noted R12 did not have documentation of any pneumonia vaccines. Surveyor reviewed…

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 a resident with a pressure injury received necessary treatment and services, consistent with professional standards of practice, to promote healing for 1 of 7 (R17) residents reviewed for pressure injuries. *R17 was admitted on [DATE] to the facility with a stage III pressure injury on their coccyx and the facility did not initiate the appropriate pressure reducing mattress until 9/13/22. Findings include: The Facility Policy and Procedure, entitled Wound Care Prevention, Management and Documentation, dated 8/2018, documents (in part) . Policy .It is the facility's policy to identify residents at risk for impaired skin integrity. Residents who have wounds will receive the necessary treatment and services to promote healing, prevent infection, and prevent further skin breakdown . Procedure .3. All residents at risk for developing skin breakdown have an appropriate care plan in place identifying preventive measures . .Pressure…

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 it's medication error was was not 5 percent or greater, when 2 errors out of 28 opportunities for error was observed affecting R29 & R11, with a medication error rate of 7.14 percent. * R29 was not administered eye drops as ordered. * R11 was administered insulin beyond the expiration date. Findings include: The facility policy and procedure titled Medication Administration dated revised October, 2021 documents (in part) . .Policy: (Facility) maintains a medication administration process to safely prepare, administer, and store resident medication. Procedure: 1. Medication Administration is based on the 6 rights: Right resident, right dose, right time, right route, right drug and right documentation. 2. Medications will be administered to residents as prescribed and by persons lawfully authorized to do so in a manner consistent with appropriate infection prevention and standards of practice. F. If the medication has a date opened…

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.