Newcastle Place

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. The practice had the potential to affect all residents residing in the facility. Staff did not wear hair or beard restraints in the kitchen and kitchenettes. Staff did not have ensure the dishwasher rinse cycle reached the required temperature. In addition, staff did not document dishwasher surface temperatures to ensure proper sanitization. Staff did not test the quaternary sanitizing solution per manufacturer's instructions. Findings include: During an initial kitchen tour that began at 9:11 AM on 2/24/25, Director of Culinary Service (DCS)-D indicated the facility follows the Food and Drug Administration (FDA) Food Code. Hair/Beard Restraints: The 2022 FDA Food Code documents at 2-402.11: Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that cover body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, 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 staff interview and record review, the facility did not implement their abuse policy and procedure for 4 of 4 employees reviewed for caregiver background checks. The facility did not complete reference checks for Certified Nursing Assistants (CNA)-J, CNA-K, CNA-L, and CNA-M. Findings include: The facility's Abuse, Neglect and Exploitation policy, revised 9/20/24, indicates: .I. Screening: A. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference, and credentials checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. Checks include attempting to obtain information from the previous or current employer of potential team members. 2. Screenings may be conducted by the Community itself, a third-party agency, or academic institution. 3. The Community will maintain documentation of proof that the screening occurred On 2/25/25, Surveyor requested background check information, including…

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 vaccinations were offered or administered for 4 residents (R) (R12, R30, R148, and R346) of 5 sampled residents. The facility did not offer R12, R30, R148, or R346 the PCV20 vaccine. Findings include: Abbreviations (www.cdc.gov): PCV13: 13-valent pneumococcal conjugate vaccine (Prevnar13®) PCV15: 15-valent pneumococcal conjugate vaccine (Vaxneuvance®) PCV20: 20-valent pneumococcal conjugate vaccine (Prevnar 20®) PPSV23: 23-valent pneumococcal polysaccharide vaccine (Pneumovax23®) The most recent Centers for Disease Control and Prevention (CDC) recommendations for pneumococcal vaccinations indicate: For adults 65 years or older who have only received PPSV23, the CDC recommends: Give 1 dose of PCV15 or PCV20. The PCV15 or PCV20 dose should be administered at least 1 year after the most recent PPSV23 vaccination. Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. For those…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review, the facility did not ensure 1 resident (R) (R248) of 1 sampled resident received care and treatment based on the resident's needs and medical orders. R248 was not provided wound care for a right below-the-knee amputation (BKA) as ordered. In addition, staff did not monitor R248's vital signs in accordance with the facility's policy, Findings include: The Facility's Wound Care policy, dated October 2010, indicates: The purpose of this procedure is to provide a guideline for the care of wounds to promote healing. Preparation: 1. Verify that there is a physician order for this procedure .13. Dress wound .Mark tape with initials, time, and date and apply to dressing .Documentation: The following information should be recorded in the resident's medical record: 1. The type of wound care given. 2. The date and time the wound care was given .6. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. 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, staff interview, and record review, the facility did not ensure a fall intervention was implemented for 1 resident (R) (R17) of 2 sampled residents. R17 had a history of falls and a care plan intervention that stated R17's walker should be within reach. The intervention was not consistently followed. Findings include: The facility's Falls-Clinical Protocol policy, dated 2001, indicates: For an individual who has fallen, the staff and practitioner will try to identify possible causes within 24 hours of the fall .The staff and physician will continue to collect and evaluate information until either the cause of the fall is identified, or it is determined that the cause cannot be found or is not correctable .Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling .If underlying causes cannot be readily identified or corrected, staff will try…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, facility did not ensure proper care and treatment for 2 residents (R) (R250 and R148) of 4 sampled residents who received medication through a peripherally inserted central catheter (PICC) line. R250 and R148's PICC line dressings and injection caps were not changed as ordered. Findings include: The facility's Central Venous Catheter Care and Dressing Changes policy, dated March 2022, indicates: The purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings .1. Perform site care and dressing change at established intervals or immediately if the integrity of the dressing is compromised (e.g., damp, loosened, or visibly soiled). 1. On 2/25/25, Surveyor reviewed R250's medical record. R250 was admitted to the facility on [DATE] and had diagnoses including metabolic encephalopathy, endocarditis, hypoxia, and diabetes.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 1 resident (R) (R12) of 3 sampled residents. R12 had a wound and was on enhanced barrier precautions (EBP). On 2/24/25 and 2/26/25, staff provided care for R12 without wearing the proper personal protective equipment (PPE). Findings include: The facility's Enhanced Barrier Precautions policy, revised 4/5/24, indicates: Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that expand the use of personal protective equipment (PPE) and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multi-drug resistant organism (MDROs) to staffs' hands and clothing .1. Enhanced Barrier Precautions will be implemented for the following (including new admissions) .Wounds: 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.

Based on staff interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 1 resident (R) (R1) of 3 sampled residents. On 11/4/24, staff witnessed Licensed Practical Nurse (LPN)-C verbally abuse R1. The facility did not report the verbal abuse to local law enforcement. Findings include: The facility's Abuse Neglect and Exploitation Policy, revised 9/20/24, indicates: Abuse means the willful infliction of . intimidation .pain or mental anguish, which can include staff and resident abuse .it includes verbal abuse .and mental abuse .Verbal abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability .A. The community will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, State Agency, 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.

Based on staff interview and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 1 resident (R) (R1) of 3 sampled residents. On 11/4/24, staff witnessed Licensed Practical Nurse (LPN)-C verbally abuse R1. The facility did not thoroughly investigate the allegation of abuse. Findings include: The facility's Abuse Neglect and Exploitation Policy, revised 9/20/24, indicates: Abuse .includes verbal abuse .III. Prevention of Abuse, Neglect, and Exploitation .D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect .IV. Identification of abuse .Possible indicators of abuse include: .5. Verbal abuse of a resident overheard .V. Investigation of Alleged Abuse .B. Written procedures for investigations include .4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses .6. Providing complete and thorough documentation of the investigation .VI. Protection of Resident: The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not provide pharmaceutical services to ensure prescribed medication was available and administered correctly for 1 resident (R) (R1) of 8 sampled residents. R1 had an order for heparin sodium injection solution 5000 unit/milliliter (ml) inject 1 ml subcutaneously every 8 hours for blood thinner for 14 days. R1 was not administered heparin as ordered. Findings include: The facility's Administering Medications policy, revised April 2019, indicates: Medications are administered in a safe and timely manner, and as prescribed .6) Medications errors are documented, reported, and reviewed by the Quality Assurance Performance Improvement (QAPI) committee to inform process changes and or the need for additional staff training .13) Vials labeled as single use are not used on multiple residents, such vials are used only for one resident in a single procedure .21) If a drug is withheld, refused, or given at a time other than the scheduled time, the individual…

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

Based on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable disease and infection for 1 resident (R) (R8) of 1 resident observed during the provision of incontinence care. During an observation of perineal care for R8 on 10/28/24, Certified Nursing Assistant (CNA)-K did not appropriately remove gloves and cleanse hands. Findings include: The facility's Hand Hygiene Policy, revised 6/5/22, indicates: Hand Hygiene is the most effective measure for preventing the spread of infections .Hand hygiene will be practiced by all team members working in a licensed health care entity or health center. Indications for hand hygiene: after any contact with blood or other body fluids-even if gloves are worn; any time a team member removes protective gloves or personal protective equipment (PPE); between performing different procedures on the same resident. Note: Wearing gloves does not replace the need for hand hygiene. On 10/28/24 at 1:08…

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

Based on staff interview and record review, the facility did not implement their abuse policy for 3 of 8 employees reviewed for background checks. Registered Nurse (RN)-K did not have a background check completed within the last 4 years. The facility was unable to provide background check information for Dietary Manager (DM)-L and Certified Nursing Assistant (CNA)-M who were contracted employees. Findings include: The facility's Resident Abuse Neglect Exploitation and Reporting Requirements policy, with a review date of 9/8/22, indicates: Lifespace complies with and conducts pre-employment and other background and abuse registry checks as required by local, state, and federal regulation and law. On 5/29/24, Surveyor reviewed RN-K's Background Information Disclosure (BID) form, Department of Justice(DOJ) report, and Integrated Background Information System (IBIS) report. RN-K was hired on 5/6/04. RN-K's BID form was dated 3/6/19. RN-K's DOJ and IBIS reports were dated 3/7/19. Surveyor requested updated BID, DOJ, and IBIS information for RN-K that was completed within the last 4…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure appropriate care and treatment was provided for 1 resident (R) (R2) of 7 sampled residents. R2 experienced a low irregular heart rate on 5/1/24 and low blood pressure on the morning of 5/3/24. Staff did not notify a physician of R2's change in condition in a timely manner. In addition, staff did not obtain R2's daily weights as ordered. Findings include: The facility's Change in a Resident's Condition or Status policy, with a revised date of February 2021, indicates: Our community promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition .1. The nurse will notify the resident's attending physician or physician on-call when there has been a(an): .d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly .3. Prior to notifying the physician or healthcare provider, 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, staff interview, and record review, the facility did not ensure staff used a gait belt during transfers for 4 residents (R) (R4, R5, R6, and R7) of 5 sampled residents. R6's baseline care plan indicated R6 required assistance with transfers. The facility's practice was to use a gait belt for transfers. On 5/29/24, Certified Nursing Assistant (CNA)-G transferred R6 from recliner to wheelchair without a gait belt. In addition, R4, R5, and R7 stated staff did not consistently use a gait belt during transfers. Findings include: On 5/29/24, Surveyor requested the facility's transfer policy and was provided a policy titled Back Safety from Life Space Incorporated, with a review date of 12/1/21, that indicated team members should use proper body mechanics when performing daily tasks. A policy for transferring residents was not provided. On 5/29/24, Surveyor reviewed R6's medical record. R6 was admitted to facility on 5/28/24 (the day prior to the survey) and did not have an activated power 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 staff interview and record review, the facility did not ensure the accurate administration of medication for 3 residents (R) (R1, R3, and R5) of 5 sampled residents. R1 had an order for oxycodone (an opioid pain medication) as needed (PRN). R1's narcotic count sheet and medication administration record (MAR) did not match. As a result, R1 did not have follow-up documentation for the effectiveness of the medication. In addition, the facility ran out of R1's oxycodone and staff accepted oxycodone brought from R1's home. R3 did not receive 4 doses of prescribed medication because the medications were not available upon admission. R5 did not receive 2 doses of prescribed medication because the medications were not available upon admission. Findings include: The facility's Medication Administration policy, with a review date of 12/1/21, indicates: All medications will be monitored by nursing personnel to determine: .response to drug therapy. Under Controlled Substances: Each medication is to be accounted 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 a medication was administered for its intended use for 1 resident (R) (R1) of 5 sampled residents. R1 was prescribed Benadryl (an analgesic medication) as needed (PRN) for itching. R1 requested and was administered Benadryl for reasons other than itching. Findings include: The facility's Medication Administration policy, with a review date of 12/1/21, indicates: Medications, dose, route, and frequency should be considered generally reasonable and acceptable therapy for the condition for which they are prescribed. On 5/29/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility from the hospital on 4/30/24 following a fall at home. R1 had diagnoses including fracture of the lower end of the radius, type 2 diabetes mellitus with diabetic polyneuropathy, insomnia, and low back pain. R1's Minimum Data Set (MDS) assessment, dated 5/7/24, documented R1 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which…

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 allegations of abuse were reported timely to the State Agency (SA) or local law enforcement for 5 residents (R) (R5, R6, R7, R3, and R4) of 8 sampled residents. On 2/27/24, R5 and R6 reported allegations of abuse. The facility did not report the allegations of abuse to the SA in a timely manner. On 3/6/24 between 6:30 AM and 6:45 AM, R7 reported an allegation of abuse with injury. The initial report was not submitted to the SA until 3/7/24 at 1:48 PM. On 3/28/24, the facility discovered R3 had a dislocation of the right humerus head. The facility did not report the injury of unknown origin to the SA in a timely manner. On 2/25/24, R4 reported an allegation of abuse. The facility did not report the allegation of abuse to the SA in a timely manner and did not notify local law enforcement. Findings include: The facility's Resident Abuse/Neglect/Exploitation and Reporting Requirements policy, with a review date of 9/8/22, indicates: Team members…

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 4. On 4/23/24, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, dementia, neurocognitive disorder with Lewy bodies, and aphasia (a language disorder that affects a person's ability to communicate). On 3/28/24, the facility discovered R3 had a right humerus head dislocation which was an injury of unknown origin. The facility interviewed staff and residents, assessed R3, and sent R3 to the Emergency Department (ED). The facility also notified local law enforcement, R3's family, and R3's physician. The facility did not summarize the investigation or identify the cause of injury for R3. On 4/23/24 at 1:31 PM, Surveyor interviewed DON-B who indicated DON-B was not sure of the cause of injury and thought the injury was due to movement when getting dressed. DON-B indicated the facility did not have a summary or conclusion to the investigation. 5. On 4/23/24, Surveyor reviewed R4's medical record. R4 was admitted to facility on 2/5/24 with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure 1 resident (R) (R7) of 11 sampled residents was free from abuse. The facility did not ensure interventions were implemented after staff members voiced concerns regarding Certified Nursing Assistant (CNA)-E's interactions with residents on 2/27/24. On 3/13/24, the facility submitted a facility- reported incident (FRI) regarding an allegation of abuse that identified CNA-E as the accused staff member. Findings include: The facility's Resident Abuse/Neglect/Exploitation and Reporting Requirements policy, with a review date of 9/8/22, indicates it is the policy of the facility to provide a safe environment free from all types of resident abuse, by all persons, including team members. The policy indicates team members will receive training on freedom of abuse at time of hire, annually, and on an as needed basis. On 4/23/24, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] with diagnoses including urinary tract…

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 review, the facility failed to ensure 1 Resident (R) (R2) of 3 sampled residents reviewed for discharge requirements was allowed to return to the facility. On 12/13/23, R2 was evaluated in the emergency room and deemed appropriate to return to the facility. The facility did not allow R2 to return. Findings include: R2's admission Record indicated the facility admitted R2 on 11/22/23 with diagnoses that included anxiety disorder and major depressive disorder. R2's admission Record Contacts included Registered Nurse Case Manager (CM)-T who was identified as R2's case worker, and a family member who was identified as R2's Responsible Party (RP). According to R2's admission Record, R2 discharged to an acute care hospital on [DATE]. R2's admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 11/27/23, indicated R2 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R2 had intact cognition. According to the MDS, during the…

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

Based on interviews and record review, the facility failed to ensure 1 Resident (R) (R2) of 3 sampled residents reviewed for behavioral health services received a psychiatric evaluation as ordered by the physician. Findings included: The facility's Mood and Behavior Management policy, effective 10/16/17, indicates: .6. Care Coordination. a. The Interdisciplinary Team will initiate and continue care coordination for each resident by reviewing with the resident, resident representative and review of the medical record, making recommendations as applicable for: i. Referrals to behavior management committee; ii. Behavioral health services; iii. Psychological evaluations and clinical evaluations based on assessment . R2's admission Record indicated the facility admitted R2 on 11/22/23 with diagnoses that included anxiety disorder and major depressive disorder. R2's admission Record Contacts included Registered Nurse Case Manager (CM)-T who was identified as R2's case worker. R2's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/27/23, indicated R2 had 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.

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 41 residents residing in the facility. The kitchen cooler and dry storage area contained multiple open, undated, and/or expired food items. In addition, one food item was stored uncovered and open to air. The facility did not follow safe food cooling protocol. Staff did not follow appropriate hand hygiene procedures when they prepared/served food. Findings include: On 12/12/23, Sous Chef (SC)-M verified the facility follows the Food and Drug Administration (FDA) Food Code as their standard of practice. 1. Food Labeling/Storage: The FDA Food Code 2022 documents at 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when packaging food using a reduced oxygen packaging method as specified under § 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, ready-to-eat, time/temperature control for food safety food prepared and held in a food…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program to help prevent the transmission of communicable disease and infection. Staff did not perform appropriate hand hygiene during the provision of care for 1 (R19) of 2 sampled residents. In addition, staff did not offer hand hygiene prior to meal service for 9 Residents (R) (R7, R14, R21, R25, R26, R28, R192, R194, and R195) of 9 residents. Staff did not appropriately wash or sanitize hands during the provision of perineal care for R19. Staff did not offer or provide hand hygiene to R7, R14, R21, R25, R26, R28, R192, R194 and R195 prior to the lunch meal on 12/11/23 and/or 12/12/23. Findings include: The facility's Hand Hygiene Policy and Procedure, with a review date of 12/1/21, indicates: Hand Hygiene is the most effective measure for preventing infections. Hand hygiene includes several actions intended to decrease colonization with transient flora. This objective can be achieved…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure a legal representative for 1 Resident (R) (R6) of 5 residents was informed of the risks and benefits of prescribed psychotropic medication and signed consent forms for the medication. R6 was prescribed lorazepam for anxiety and trazadone for depression. (Lorazepam and trazadone are psychotropic medications with a black box warning which is the Food and Drug Administration's (FDA's) most stringent warning that alerts the public and health care providers to serious side effects, such as injury or death). R6's medical record did not contain medication consent forms signed by R6's Power of Attorney for Healthcare (POAHC). Findings include: R6 was admitted to the facility on [DATE] and had diagnoses including other recurrent depressive disorder and anxiety. R6's Minimum Data Set (MDS) assessment, dated 9/23/23, contained a Brief Interview for Mental Status (BIMS) score of 4 out of 15 which indicated R6 had severe cognitive impairment. R6 had an…

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

Based on staff interview and record review, the facility did not ensure their abuse policy was implemented for 1 (Culinary Director (CD)-E) of 8 employees reviewed for background checks. CD-E was a contracted staff member. The facility was unable to provide a Background Information Disclosure (BID) form, Wisconsin Department of Justice (DOJ) letter, or Integrated Background Information System (IBIS) letter for CD-E. Findings include: The facility's Resident Abuse/Neglect/Exploitation and Reporting Requirements policy, with a review date of 9/8/22, indicated: (Facility) complies with and conducts pre-employment and other background and abuse registry checks as required by local, state, and federal regulation and law. On 12/12/23, Surveyor requested CD-E's BID, DOJ, and IBIS information for review. On 12/13/23, Surveyor received a general background export for CD-E. Surveyor did not receive CD-E's BID form, DOJ letter, or IBIS letter. On 12/13/23 at 4:11 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated the facility used a contracted company for 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 staff interview and record review, the facility did not ensure 2 Residents (R) (R19 and R26) of 2 residents reviewed for hospitalization received a transfer notice that included the date of the transfer, the reason for the transfer, the location of the transfer, appeal rights, and contact information for the State Long-Term Care Ombudsman. R26 was transferred to the hospital on [DATE] due to a change in condition. R26 was not provided with a written transfer notice. R19 was transferred to the hospital on [DATE] following a fall. R19 was not provided with a written transfer notice. Findings include: The facility's Notice of Transfer with Bedhold/Discharge form, dated 10/29/19, indicated: (Facility) is licensed by the State of Wisconsin, and we are required to comply with their regulations. In order to do so, we must provide a written notice to the resident and/or responsible party whenever the resident is transferred or discharged . Surveyor noted the form had fillable space that included: Resident name,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure 2 Residents (R) (R19 and R26) of 2 residents reviewed for hospitalization received the proper bed hold notice when transferred to the hospital. R26 was transferred to the hospital on [DATE] due to a change in conation. R26 was not provided with a written Notice of Transfer with Bedhold/Discharge form. R19 was transferred to the hospital on [DATE] after a fall. R19 was not provided with a written Notice of Transfer with Bedhold/Discharge form. Findings include: The facility's Notice of Transfer with Bedhold/Discharge form, dated of 10/29/19, indicated: (Facility) is licensed by the State of Wisconsin, and we are required to comply with their regulations. In order to do so, we must provide a written notice to the resident and/or responsible party whenever the resident is transferred or discharged . Surveyor noted the bed hold portion of the form had spaces to check yes or no for a bed hold. The form also had signature and date lines for 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, staff and resident interview, and record review, the facility did not ensure adequate assistive devices and fall interventions were in place for 1 Resident (R) (R19) of 2 residents reviewed for falls. R19 had a fall on 12/3/23. Fall interventions added to R19's care plan following the fall were not implemented timely. Findings include: R19 was admitted to the facility on [DATE] and had diagnoses including weakness and difficulty in walking. R19's Minimum Data Set (MDS) assessment, dated 12/4/19, contained a Brief Interview for Mental Status Score (BIMS) score of 10 out of 15 which indicated R19 had moderate cognitive impairment. R19's Power of Attorney for Healthcare (POAHC) was activated on 12/7/23. The facility's Falls Prevention and Management Program policy, with a review date of 9/23/19, indicated: ~Evaluation and Care Planning: Development of the Fall interventions Plan is based on results of the Fall Risk Evaluation as well as investigation of all circumstances and related resident…

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 pharmacy recommendations were acted on by a physician for 1 Resident (R) (R6) of 5 residents reviewed for unnecessary medications. Irregularities identified on R6's monthly pharmacist review were not responded to appropriately or timely by the physician. Findings include: The facility's Psychotropic Medication Use policy, dated July 2022, indicated: Resident Re-evaluations: 1. Situations which may prompt an evaluation or re-evaluation of the resident include: g. an irregularity identified in the pharmacist's medication regimen and review. R6 was admitted to the facility on [DATE] and received Hospice services. R6's Minimum Data Set (MDS) assessment, dated 9/23/23, contained a Brief Interview for Mental Status (BIMS) score of 4 out of 15 which indicated R6 had severe cognitive impairment. R6 had an activated Power of Attorney for Healthcare (POAHC) as of 6/16/23. R6 had a physician's order for as needed (PRN) lorazepam (an anti-anxiety…

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 monitoring for adverse consequences of high-risk medications was completed for 2 Residents (R) (R7 and R6) of 5 residents reviewed for unnecessary medications. R7 was prescribed tramadol (an opioid medication used to help relieve moderate to severe pain). R7's care plan did not contain monitoring for adverse consequences of tramadol. R6 was prescribed tramadol and morphine (an opioid medication used to help relieve moderate to severe pain). R6's care plan did not contain monitoring for adverse consequences of tramadol and morphine. Findings include: The facility's Pain Management policy, effective 10/25/22, indicated: .Monitoring and Modifying Approaches .3. Monitor the following factors to determine if the resident's pain is being adequately controlled: .c. The presence of adverse consequences to treatment .4. The Centers for Disease Control and Prevention (CDC) describes several side effects which prescription opioids can cause even when…

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 staff interview, the facility did not ensure pureed meals were prepared by methods that conserve nutritive value, flavor, and appearance for 1 Resident (R) (R2) of 1 resident. Kitchen staff did not follow pureed food recipes. Findings include: According to the publication All About Recipes, Part II from the College of Agriculture, Biotechnology and Natural Resources [NAME], A., and [NAME], S. 2021, It is important to follow a recipe to ensure accurate nutrition content, which is important for schools, hospitals, and nursing homes. Modifying a recipe by adding water lowers the nutritional quality of the food. On 12/12/23 at 11:18 AM, Surveyor observed [NAME] (CK)-O use an unmeasured serving spoon to gather cooked and cut potatoes from a container and place them in a food processor. CK-O then added an unmeasured amount of mayonnaise and an unmeasured amount of mustard. CK-O then poured an unmeasured amount of milk into the food processor and pureed the potato salad. On 12/12/23 at 2:45 PM,…

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.