Menomonee Falls Health Services

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure medical records contained documentation related to COVID-19 immunizations for 3 (R5, R4, and R2) of 5 residents reviewed for immunizations. * R5’s medical record does not contain any documentation as to whether R5 was offered, received, or declined the COVID-19 immunization. * R4’s medical record does not contain any documentation as to whether R4 was offered, received, or declined the COVID-19 immunization. *R2’s medical record does not contain any documentation as to whether R2 was offered, received, or declined the COVID-19 immunization. Findings include: The facility's policy and procedure dated as revised 9/17/2024 and titled, Covid-19 Vaccination documents: “Policy: It is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complications from COVID-19 (SARS-CoV-2) by educating and offering our residents and staff the COVID-19 vaccine… 8. COVID-19 vaccinations will be offered to residents when supplies…

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 (R5) of 7 residents reviewed were notified when there was a change in condition and a need to alter treatment. * R5's representative was not notified when R5 developed an open area below the left pinky toes on 11/5/24 and when R5 developed an area on the left outer ankle on 11/5/24. Findings Include: On 11/26/24, at 1:01 PM, Director of Nursing(DON) DON-B notified Surveyor there is no facility policy for notification. The facility's policy Pressure Injuries and Non pressure Injuries implemented 8/2/21 and last revised on 7/20/22 documents: .Resident/Responsible Party Education 1. Provide Residents/responsible parties education regarding risk of pressure injuries based on the overall Resident risk. 2. Inform Residents/responsible parties on the presence of wounds. 3. Inform Residents/responsible parties on the status of wound progression. R5 was admitted to the facility on [DATE] has diagnoses that include Dementia with Mood Disturbance, Adult…

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 medical record review, facility staff did not provide care and treatment in accordance with professional standards of practice and the comprehensive person-centered care plan for 1(R5) of 4 residents reviewed. * R5's current physician orders, Certified Nursing Assistant (CNA) bedside [NAME], and comprehensive care plan document R5 is to wear size D double tubigrips to bilateral lower extremities (BLEs), worn toes to knees 23 hours/day as tolerated. Surveyor observed R5 to not be wearing the tubigrips during the survey process. On 11/14/24 an arterial open area was identified on R5's right 1st toe. R5's person-centered care plan was not updated with new interventions as well as R5 was not wearing physician ordered off-loading bilateral heel boots during the survey process. Findings Include: The facility's policy Pressure Injuries and Non pressure Injuries implemented 8/2/21 and last revised on 7/20/22 documents: Policy: This center will complete a comprehensive assessment 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, interviews, and record review, the facility did not ensure a resident (R) with hearing and vision impairment received proper treatment and assistive devices including arrangements for an audiology (ear doctor) for 1 (R5) of 1 residents reviewed for hearing and eyesight loss. * Surveyor observed R5 to not be wearing R5's glasses and bilateral hearing aides during the survey process. R5's Medication Administration Record(MAR) documented in August 2024, R5 had a referral for audiology consultation to evaluate need for or appropriate type of treatment relating to hearing deficits or medical problems. A consult was not completed. Findings Include: The facility's policy Use of Assistive Devices implemented 9/19/22 documents: .The purpose of this policy is to provide a process for the proper and consistent use of assistive devices for those Residents requiring equipment to maintain or improve function and/or dignity. 1. Assistive devices are tools, products, types of equipment, or technology that…

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 medication administration records were complete and accurate for 2 (R1 and R3) of 5 residents reviewed for medication administration. * R1's Medication Administration Record (MAR) had empty signature boxes for multiple medications from 9/2024 through 11/2024. The signature boxes indicate the medication was administered by a nursing professional assigned to R1. * R3's MAR had empty signature boxes for multiple medications from 9/2024 through 11/2024. The signature boxes indicate if the medication was administered by a nursing professional assigned to R3. Findings include: The facility policy and procedure titled Medication Administration General Guidelines dated 1/2024 document: Documentation: 1. The individual who administers the medication dose, records the administration on the resident's MAR immediately following the medication being given. In no case should the individual who administered the medications report off-duty without first recording…

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 sufficient nursing staff was provided to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Residents expressed concerns to surveyors that the facility does not have sufficient staff, resulting in delayed call light responses. This deficient practice has the potential to affect all 30 residents residing in the facility at the time of the survey. Findings include: The facility is composed of 3 units and had a census of 30 residents on 4/28/24. On 4/30/24 at 8:17 am, Surveyor interviewed Director of Nursing (DON)-B regarding the facility staffing levels and triggering for low weekend staffing on the Payroll Based Journal (PBJ) report for Fiscal Year 2023 (October 1 - December 31). Surveyor asked DON-B how the facility determines the amount of staffing needed to meet resident's needs. DON-B notified Surveyor that the facility determines the amount of staffing needed to meet…

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

Based on observation, interview, and record review the facility did not ensure food was stored or served in accordance with professional standards for food service safety potentially affecting all 30 residents residing in the facility. *During the initial tour Surveyor noted a jug of barbeque sauce sitting on the floor of the dry storage area, an open bag that had white powder in it that was unlabeled as to what it was, the freezer had an open bag of cheese omelets that was not dated, the lunch prep refrigerator had a container of several hot dogs sitting in liquid that was not dated or labeled, and a pitcher was not dated or labeled that was 1/3 full with brown liquid. Findings include: The facility policy entitled Food Storage: Dry Goods revised on 2/2023 states: All dry goods will be appropriately stored in accordance with the FDA Food Code. Procedures: 1. All items will be stored on shelves at least 6 inches above the floor. 5. All packaged and canned food items will be kept clean, dry, and properly sealed. 6. Storage areas will be neat, arranged for easy identification, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility policy review the facility did not ensure the garbage and refuse were properly disposed in the outside garbage storage receptacles. This deficient practice had the potential to affect all 30 residents residing at the facility. Findings include: The facility policy entitled Dispose of Garbage and Refuse dated 8/2017 states: All garbage and refuse will be collected and disposed of in a safe and efficient manner. Procedures: 1. The Dining Services Director coordinated with the Director of Maintenance to ensure that the are surrounding the exterior dumpster area is maintained in a manner free of rubbish or other debris. On 4/29/2024 at 9:59 AM Surveyor observed the garbage area with Dietary Manager (DM)-V. The area had a dumpster for garbage and a dumpster for recycling. Surveyor observed behind the dumpster there were about 20 wood pallets stacked along the back of the fencing, 1 refrigerator, and an accumulation of pine needles, pinecones, dirt, and garbage bags mixed…

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 provided consistent staff on weekends to meet the resident needs for the 30 residents residing in the facility. During review of the payroll-based-journal (PBJ) staffing data for the facility, the facility was triggered in the fiscal year quarter 1, 2023 (October-December) for low weekend staffing. Findings include: Review of the facility PBJ data, as part of the survey offsite process, indicates during the 1st quarter of the federal fiscal year 2023 (October 1 - December 31) the facility was triggered for excessively low weekend staffing. Surveyor reviewed the Facility assessment dated [DATE], which states the following: ~ Average daily census is 28 - 32 residents. ~ 5 Licensed Nurses providing direct care are needed ~ 8 Nurses Aides (CNA) are needed ~ 1 Registered Nurse (RN) or Licensed Practical Nurse (LPN) needed for each shift ~ 1 RN or LPN needed per 20 residents on days and PM shift. ~ 1 RN or LPN needed per 30 residents on night (NOC)…

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 6. On 4/28/2024 at 12:21 PM Surveyor was observing staff and residents in the dining room. Surveyor observed certified nursing assistant (CNA)-M assisting a resident to eat. Surveyor observed CNA-M turn towards another resident and assist them to eat. Surveyor noted that CNA-M did not wash CNA-M's hands in between assisting the residents to eat. Surveyor observed the same routine throughout the noon meal and CNA-M not washing CNA-M's hands between residents when assisting them to eat. On 4/30/2024 at 4:02 PM Surveyor shared concerns with director of nursing (DON)-B regarding Surveyors observation of CNA-M not washing hands in between assisting two residents to eat. DON-B stated CNA-M should have washed CNA-M's hands or asked another staff member to assist the other resident to eat. No further information was provided. 5. The facility policy titled Medication Administration dated 1/24 documents (in part) . .2. An adequate supply of disposable containers (such as souffle cups and calibrated medication cups) are…

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 provide a safe, clean, comfortable homelike environment which had the potential to affect all residents eating in the dining room and 2 (R282, R26) of 4 residents observed for cares. Surveyor observed residents being served meals placed in front of them on trays in the dining room. R282 had a strong urine odor in R282's bedroom and observations of yellow stains on the bed sheet on 4/29/2024 and 5/1/2024. Surveyor noted a urine odor and observed a yellow stain on the bed sheet for R26 when observing cares. Findings include: 1.) On 4/28/2024 at 12:08 PM Surveyors observed dining room staff bring out noon meal food that was set up on trays and started to place the trays in front of residents in the dining room. On 4/29/2024 at 8:23 AM Surveyors observed dining room staff bring out breakfast meal set up on trays and started to place the trays in front of resident in the dining room. On 5/1/2024 at 11:44 AM Surveyor shared concerns with director of nursing (DON)-B about residents being served their meals on trays in the dining…

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 proper code status documentation for 5 (R5, R10, R21, R23, and R26) of 5 residents reviewed for code status. R5's medical record indicated there was no form reviewed or signed by R5 indicating her code status wishes. R10's medical record indicated there was no form reviewed or signed by R10 indicating her code status wishes. R21's medical record indicated there was no Do Not Resuscitate (DNR) form signed by R21 indicating their code status wishes. R23's medical record did not have a code status order or indication of R23's wishes for resuscitation. R26's medical record indicated there was no DNR form reviewed or signed by R26 indicating their code status wishes. Findings include: The facility policy titled Cardiopulmonary Resuscitation (CPR) revised [DATE] documents (in part) . .It is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, this facility 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon interview and record review the facility did not ensure recommendations made through the medication regime review were addressed for 5 (R19, R25, R2, R4, and R7) of 30 sampled residents. *R19 had pharmacy recommendations on 11/9/2023, 12/8/2023, and 2/26/2024 to add a dose in grams for R19's order for Diclofenac sodium external gel 1%. The pharmacy recommendations were never followed up on. *R25 had pharmacy recommendations that were not followed up on. *R2 had pharmacy recommendations that were not followed up on. *R4 had pharmacy recommendations to decreased ferrous sulfate and complete an AIMS assessment that were never followed up on. *R7 had pharmacy recommendations that were not followed up on. Findings include: The facility policy entitled Medication Monitoring: Medication Regimen Review and Reporting revised 1/2024 states: Medication Regimen Review (MRR) or Drug Regimen Review is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the Facility did not ensure that self administration of medications was determined to be clinically appropriate for 2 (R7 & R25) of 2 Residents. * On 4/28/24 a bottle of artificial tears eye drops and Fluticasone Propionate nasal spray was observed on R7's over bed table. R7 does not have a self administration of medications assessment or physician order to self administer medications. * R25 does his own perineum wound treatment without being assessed as being capable of doing the treatment himself. R25 does not have a self administration assessment or physician order. Findings include: The Self-Administration by Resident policy and procedure dated 1/23 under policy documents Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe and the medications are appropriate and safe for self-administration. Under Procedures…

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

Based on interview and record review, the facility did not ensure residents whose Medicare part A benefits ended, was provided with written beneficiary protection notifications for 1 (R7) of 3 residents sampled for beneficiary notifications. The facility did not provide R7 a written Advanced Beneficiary Notice (ABN), which includes financial liability information and appeal rights, at the time Medicare Part A coverage ended. Findings include: Notice of Medicare Non-Coverage (NOMNC) (Form CMS 10123-NOMNC) is utilized to provide written notification to resident or resident representative that Medicare Part A coverage is ending in two or more days. The notification includes appeal rights and provides the third party reviewer name and phone number to begin an immediate appeal. Advance Beneficiary Notice (ABN) (Form CMS-10055) is utilized to provide written notification to resident or resident representative of services Medicare A will no longer cover, an estimated cost of those services, and three options which include each choice's effect on appeal rights. On 4/30/2024 at 10:28 AM the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the Facility did not notify residents and resident representatives of a transfer & the reasons for the transfer in writing to include the date, the location to which the resident is being transferred, a statement of the resident's appeal rights including the name, mailing and email address, and telephone number of the entity to which the appeal would be submitted, and information on how to obtain an appeal form, and the name, mailing and email address, and telephone number of the Office of the State Long-Term Care Ombudsman for 3 (R7, R21, and R5) of 3 residents reviewed for hospitalization. * R7 was hospitalized on [DATE] and no written transfer notice was provided to R7 and R7's representative. * R21 was hospitalized on [DATE] and no written transfer notice was provided to R21 and R21's representative. * R5 was hospitalized on [DATE], 4/1/24, & 4/5/24 and no written transfer notices were provided to R5 and R5's representative. Findings include: The Transfer and Discharge…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the Facility did not notify residents and resident representatives of the duration of the bed-hold policy during which the resident was permitted to return to the facility and the reserve bed payment policy for 3 (R7, R21, and R5) of 3 residents reviewed for hospitalization. * R7 was hospitalized on [DATE] and no bed hold notice was provided to R7 and R7's representative. * R21 was hospitalized on [DATE] and no bed hold notice was provided to R21 and R21's representative. * R5 was hospitalized on [DATE], 4/1/24, & 4/5/24 and no bed hold notices were provided to R5 and R5's representative. Findings include: The Transfer and Discharge (including AMA (against medical advise)) policy last reviewed/revised 7/15/22 under Policy Explanation and Compliance Guidelines for Emergency Transfers/Discharges documents i. Provide a notice of the resident's bed hold policy to the resident and representative at the time of transfer, as possible, but no later than 24 hours of the transfer. 1.)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the Facility did not ensure 1 (R21) of 3 residents reviewed for Preadmission Screen and Resident Review (PASARR) had an updated level 1 screen or a level II referral when R21 was diagnosed with psychotic disorder with delusions on 6/26/23. Findings include: The Facility does not have a PASARR policy. R21 was originally admitted to the facility on [DATE]. Diagnoses on admission were chronic kidney disease, stage 3, hypertensive heart, heart failure, gastroesophageal reflux disease, atrial fibrillation, nonrheumatic aortic (valve) stenosis, and hypothyroidism. R21's level 1 PASARR dated 6/23/22 checks no for mental illness and checks no for all questions on the Level one screen. Surveyor noted at this time a level 2 screen was not required for R21. The physician orders dated 3/27/23 documents Venlafaxine HCI oral tablet 37.5 mg (milligrams) (Venlafaxine HCI) Give 37.5 mg by mouth two times a day for depression, anxiety give with brk (breakfast) and after noon meal. On 6/23/23…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure residents who are unable to carry out activities of daily living receive the necessary services to maintain good grooming for 1 of 1 (R10) residents reviewed for ADL's (Activity of Daily Living). R10 did not consistently receive showers. Findings include: R10 admitted to the facility on [DATE] and has diagnoses that include: Aftercare following surgical amputation, Type 2 Diabetes Mellitus, Chronic Kidney Disease, Hypertensive Heart Disease, chronic Congestive Heart Failure, dependence on renal dialysis, Cardiomyopathy, morbid obesity, lumbago with sciatica and spinal stenosis. The facility policy titled Activities of Daily Living (ADLS) revised 7-26/22 documents (in part) . .The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record, and interview, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for assessing non-pressure wounds for 3 (R25, R19, and R26) of 13 sampled residents. *R19 does not have a comprehensive care plan in place for diuretic use or lymphedema treatments and monitoring for adverse reactions. R19's care plan and care [NAME] were not revised to R19's current treatment, and no orders for R19's treatment or interventions could be located. *R25 has a neoplasm on R25's perineal area that was not being assessed by nursing staff. *R26 has a venous stasis ulcer, treatments were not completed according to orders, there was no comprehensive assessment, and Surveyor had observations of R26's wound not being cleaned during wound treatment. Findings include: The facility policy entitled Pressure Injuries and Non pressure Injuries revised on 7/20/2022 states: The center will complete a comprehensive assessment to identify risk factors…

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 residents who enter the facility with an indwelling catheter is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary for 1 of 1 (R5) residents reviewed for catheters. R5 re-admitted to the facility following hospitalization with a Foley catheter. The facility did not follow up with urology or assess R5 for removal of the catheter. Findings include: R5 admitted to the facility on [DATE]. Diagnoses include: Type 2 Diabetes Mellitus with chronic Diabetic Neuropathy, Diabetic Retinopathy, Chronic Kidney Disease, Restless Leg Syndrome, Rheumatoid Arthritis, Spinal Stenosis lumbar region, Anemia, Atherosclerotic Heart Disease, Major Depressive Disorder. Diagnosis of Hydronephrosis with renal and ureteral calculous obstruction was added 3/20/24. The facility policy titled Catheter Care revised 3/15/23 documents (in part) . .It is the policy of this…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; for 2 of 5 (R5 and R21) residents reviewed for weights. R5 sustained severe weight loss. Neither the Dietician nor Physician was notified and no new interventions were implemented. R21 was not weighed weekly per Physician's orders. Findings include: The facility policy titled Weight Monitoring revised 12/21/22 documents (in part) . .The interdisciplinary team will strive to prevent, monitor and intervene for undesirable weight change for our residents. 1. The nursing staff will measure resident weights upon admission, the next 2 days, and then weekly for 3 additional weeks thereafter. 2. If no weight concerns are noted after the initial 3 days and 3 weeks after, routine weights will be measured monthly…

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 comprehensively assess 1 (R2) of 1 Residents for trauma informed care and care plan approaches to mitigate any triggers to prevent re-traumatization. Findings include: The Trauma Informed Care Policy last reviewed/revised 10/18/22 under Policy documents It is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization. Under Policy Explanation and Compliance Guidelines includes documentation of 2. The facility will use a multi-pronged approach to identify a resident's history of trauma. This will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event, as well as reviewing documentation such as the history and physical, consultation notes, or information…

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 each Resident's drug regimen was free from unnecessary drugs for 3 (R2, R26 & R17) of 5 Residents reviewed. * R2 receives Metoprolol Succinate ER 75 mg once a day. R2's heart rate was not being taken according to physician orders prior to receiving the medication. * R26 received Keflex 500 mg (milligrams), an antibiotic, once daily for 7 days starting on 2/6/24 without adequate signs/symptoms of UTI (urinary tract infection). * R17 receives Metoprolol Succinate ER 25 mg one time a day. R17's heart rate was not being taken according to physician orders prior to receiving the medication. Findings include: 1.) R2's diagnosis includes hypertension. The physician order with an order date of 2/9/23 & start date of 2/10/23 documents Metoprolol Succinate ER (extended release) Tablet Extended Release 24 hour 25 mg (milligrams) Give 3 tablet by mouth one time a day for hypertension. Hold for SBP (systolic blood pressure)< (less than) 100 and/or HR (heart…

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

Based on observation, interview and record review the facility did not ensure medication error rates are not 5 percent or greater. The facility had a medication error rate of 21.05%. R17's Metoprolol Succinate ER (extended release) was crushed. R6's Amlodipine Besylate was held with no parameters to hold the medication. R20 did not receive Farxiga, Isosorbide Mononitrate ER, Metoprolol Succinate ER, Prozac and Spiriva inhaler as ordered. R28 did not receive Bumetanide as ordered. Findings include: The facility policy titled Medication Administration dated 1/24 documents (in part) . .Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. Medication Preparation: 3. Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record (MAR). 5. If it is safe to do so, medication tablets…

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 ensure drugs and biological's used in the facility were labeled in accordance with currently accepted professional principles, and include the expiration date when applicable for 1 of 2 medication carts reviewed. Insulin pens were not labeled, not dated when opened and were expired. Findings include: The facility policy included and appendix of resources titled Medications with Shortened Expiration Dates dated 1/23 which documented (in part) . .Lantus Pen expires 28 days after first use. Levemir pen expires 42 days after first use. Aspart pen expires 28 days after first use. On [DATE] at 8:30 AM Surveyor observed the Deerpath medication cart. Surveyor observed the following insulin pens in the top drawer of the medication cart: Insulin Aspart pen belonging to R20 which was open and used, but not dated when opened. Levemir insulin flex pen which did not contain a label with a residents' name. Surveyor noted a torn white label printed with name/date…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the Facility did not ensure staff had successfully completed a State approved training course that meets the requirements before feeding residents for 1(R26) of 1 Residents. Life Enrichment Specialist-P was observed feeding breakfast to R26 on 4/29/24 & 4/30/24. Life Enrichment Specialist-P is not a CNA (Certified Nursing Assistant) and did not complete the State approved training course prior to feeding R26. Findings include: R26's diagnoses includes chronic kidney disease stage 5, diabetes mellitus, encephalopathy, and epilepsy. The at risk for nutritional/hydration status care plan initiated 10/26/22 & revised 4/9/24 documents the following interventions: * Administer medications as ordered. Initiated 10/26/22. * Administer vitamin/mineral supplements as ordered. Initiated 10/26/22. * Encourage and assist as needed to consume foods and/or supplements and fluids offered. Initiated 10/26/22. * Honor food preferences. Initiated 10/26/22. * Obtain labs as ordered…

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 ensure the facility had a hospice policy and procedure to designate a member of the Interdisciplinary team (IDT) to be responsible for communicating with hospice for coordination of care that has the potential to affect 4 of 4 residents receiving hospice services. * R8 and R26 were reviewed for receiving hospice services. When Surveyors asked to review the facility policy and procedures for hospice services, the facility stated there was not a policy and procedure for hospice services. Findings include: 1.) R8 was admitted to the facility on [DATE] and enrolled into hospice on 5/5/2023 with a diagnosis of severe protein calorie malnutrition. On 4/29/2024 at 3:05 PM Surveyor reviewed the facility survey binder and noted it did not include a hospice contract. Surveyor requested to see the hospice policy and procedure for the facility. On 5/1/2024 at 3:23 PM the director of nursing (DON)-B informed Surveyors that there was not a policy and procedure 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 staff interview and record review the Facility did not ensure 3 (R5, R332, & R26) of 5 Resident reviewed were offered the influenza and/or pneumococcal immunization. * R5's medical record does not contain any documentation as to whether R5 received or refused the influenza and pneumococcal immunizations. * R332's medical record does not contain any documentation as to whether R332 received or refused the influenza and pneumococcal immunizations. * R26's medical record does not contain any documentation as to whether R26 received or refused the pneumococcal immunization. Findings include: The Influenza Vaccination policy last reviewed/revised on 8/31/23 under Policy Explanation and Compliance Guidelines documents: 1. It is the policy of this facility, in collaboration with the medical director, to have an immunization program against influenza disease in accordance with national standards of practice. 2. Influenza vaccinations will be routinely offered annually when it becomes available to the facility,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interviews, the facility did not always ensure that they provided foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition for 1 out of 1 (R2) residents reviewed with a diagnosis of Diabetes. Findings include: Per the American Medical Directors Association - The Society for Post-Acute and Long-Term Care Medicine. Pressure Ulcers. Clinical Practice Guideline, dated 12/9/14, includes, in part: Treatment of foot problems in patients with diabetes is generally stratified into three broad risk categories: at-risk foot . has neuropathy .vascular insufficiency .cannot see, feel, or reach their feet .Treatment Plan . Refer for podiatrist care at least annually and as needed for specific foot problems .Train caregivers to perform daily foot care and inspection . Policy review: Diabetic Nail Care (no date) It is the policy of this facility to ensure residents receive proper…

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 document review, facility policy review, and staff interviews, it was determined that the facility failed to ensure 1 (Certified Nursing Assistant [CNA] L) of 24 facility staff members were fully vaccinated for COVID-19. Findings included: Review of a facility policy titled, Employee COVID-19 Vaccinations, dated 10/24/2022, specified, It is the policy of this facility to ensure that all eligible employees are vaccinated against COVID-19 as per applicable Federal, State and local guidelines. The policy indicated, Individuals are considered fully vaccinated for COVID 14 days after receipt of the second dose of a two-dose primary vaccination series. 5. The facility will ensure that all eligible employees (except for staff who have been granted exemptions to the vaccination requirements, or those staff for whom COVID-19 must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) are fully vaccinated for COVID-19. The policy further indicated, 13. Vaccination documentation will be kept confidential and stored in the employee's 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.