Middleton Village Nursing And Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 1 reportable incidents involving 1 of 3 residents reviewed for abuse (R1).An allegation of abuse was made involving facility staff inappropriately touching R1, this was not reported to the State Agency.Evidenced by:The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not have evidence that all alleged violations are thoroughly investigated and did not report the results of all investigations to officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident for 1 of 1 allegations of abuse involving 1 of 3 residents reviewed for abuse (R1).An allegation of sexual abuse was made in which a staff member was accused of inappropriately touching R1's genitals and the facility did not conduct a thorough investigation and report the results to the state survey agency.Based on interview and record review, the facility did not have evidence that all alleged violations are thoroughly investigated and did not report the results of all investigations to officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident for 1 of 1 allegations of abuse involving 1 of 3 residents reviewed for abuse (R1).An allegation of sexual abuse was…

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

Based on observation, interview, and record review, the facility did not ensure the preparation, storage, and serving of food in a clean and sanitary environment. This has the potential to affect all 67 residents in the facility. Surveyor observed partially eaten meal trays from the previous meal sitting on tables in the dining room while residents were eating breakfast. Surveyor observed 3 wall dispensers of hand sanitizer in the dining room to not be in working order. Surveyor observed a table in the dish room to be covered with stacked boxes mixed with a tray of glasses, a dirty towel, dirty coffee pots, and a fleece jacket laying on top of a metal pot which was inside of a box of white aprons. Surveyor observed a microwave in the kitchen which was covered with multi-colored splatters all over the inside walls. Surveyor observed an opened package of butter with half of the wrapper removed and butter was sitting on a cart by the stove exposed to air, not covered. Surveyor observed multi-colored stains on the wall to the right and left of the dish room entrance and stains on 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 Example 3 On 5/5/25 at 2:49 PM Surveyors interviewed R5 who indicated she had a shower that morning and that she feels the shower room is cluttered, congested, not clean, and does not feel homelike. R5 indicated she does not always get her shower on Depot and sometimes is taken to [NAME] hall. R5 indicated last week was the last time she had been to the one on [NAME] and indicated it is more homelike than depot but still cluttered and indicated they need to take some of that stuff down to the basement. Example 4 On 5/5/25 at approximately 8:15 AM Surveyors began observations of the facility shower rooms and completed staff interviews regarding the shower rooms which included the following: [NAME] Hall shower room: 1) Two lifts and Multiple shower chairs were present with some shower chairs being stacked on top of each other. 2) Wet white paper like substance on the tile by the shower as well as other white substance noted on floor. 3) A shelving unit containing the following: Multiple bottles of open, unlabeled…

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 failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made for 2 of 6 residents (R2 and R5) reviewed for abuse. R2's POA (Power of Attorney) reported an alleged sexual abuse allegation and did not report this to the State Agency or Law Enforcement. R5 reported an allegation of abuse that was not reported to other officials (including to the State Survey Agency) within two hours of discovery. This is evidenced by: The Facilities Policy and Procedure entitled Abuse, Neglect, and Exploitation dated 1/5/24 documents, in part: .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. Sexual Abuse is non-consensual sexual contact 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.

Based on interview and record review the facility did not thoroughly investigate an allegation of abuse this has the potential to affect 1 of 6 investigations reviewed affecting resident (R5). R5 reported an allegation of abuse that was not thoroughly investigated by the facility. R5's most recent Minimum Data Set (MDS), target date 3/8/25, indicates a Brief Interview of Mental Status (BIMS) of 13. Indicating that R5 is cognitively intact. On 5/5/25 at 2:49PM Surveyors interviewed R5 who indicated last week when she was in activities R9 said to her If I had a gun, I'd shoot you. R5 indicated she did not believe any staff witnessed the event. R5 indicated she did not tell anyone until the next day when she reported it during her therapy session to OT K (Occupational Therapist) who told her she would report it to NHA A (Nursing Home Administrator). R5 indicated it makes her feel anxious. On 5/5/25 at 3:42PM Surveyors interviewed OT K who indicated that R5 did report to her that R9 had said to her If I had a gun, I would shoot you. At 3:50PM PT L (Physical Therapist) joined the…

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

Based on interview and record review, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (R2) reviewed for elopement. R2 did not have an order to check the function of his elopement device. This is evidenced by: The Facilities Elopement/Unsafe Wandering Policy and Procedure dated 1/4/24 does not speak to monitoring the function of the elopement device. R2 is short-term resident of the facility. R2 has the following diagnoses: cerebral infarction, nontraumatic intracerebral hemorrhage in cerebellum, psychosis not due to a substance or known physiological condition, mood disorder, alcohol dependence with unspecified alcohol-induced disorder, psychoactive substance abuse, anxiety disorder, personality disorder, and encephalopathy (disease in which the functioning of the brain is affected by some agent or condition). R2's Physician Orders include: Wander Device, Check placement and location on right ankle dated 4/28/25. It is important to note that R2's TAR (treatment authorization request) does…

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

Based on interview and record review, the facility did not ensure that they provided pharmaceutical services (including procedures that assures the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. This affected 1 (R2) of 6 residents reviewed for medication administration. R2 had 2 dates in May 2025 that were blank for his thyroid medication. This is evidenced by: The Facilities Administering Medications Policy and Procedure dated 12/24 documents, in part: .3. Medications must be administered in accordance with the orders, including any required time frame .19. The individual administering the medication must initial the resident's MAR (Medication Administration Record) on the appropriate line after giving each medication and before administering the next ones . R2 is short term resident of the facility. R2 has the following diagnoses: cerebral infarction, nontraumatic intracerebral hemorrhage in cerebellum, psychosis not due to a substance or known physiological condition, hypothyroidism (thyroid gland…

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 prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect all 75 residents. Moldy food was found in a resident's room. Food items were found without dates in multiple locations. A scoop was observed in an ice machine. Findings include The facility's policy titled Personal Food Guidelines, states, Food brought from outside sources by residents, friends or family will be stored in a designated location and labeled as such, separately from facility food. Labeling will include: 1) Product name 2) Received date 3) Use by date (no longer than 3 days) 4) Staff member's initials and 5) Resident's name. Example 1 R48 was admitted to the facility on [DATE]. Her most recent Minimum Data Set (MDS) includes a Brief Interview for Mental Status (BIMS) score of 14, indicating she is cognitively intact. On 10/22/24 at 11:59 AM, Surveyor noted a putrid smell coming from R48's room.…

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

Based on observation and interview, the facility did not ensure that garbage and refuse was disposed of properly. This has the potential to affect all 75 residents. On 10/21/24 at 10:10 AM, surveyors observed the facility's main dumpster (located outside) lid open and the following on the ground near the dumpster: *Surgical Masks *8 sealed condiment packets *2 pre-made condiment containers with lids *Numerous used disposable gloves *Plastic straws and plasticware *Paper towels *Various pieces of scattered cardboard On 10/21/24 at 10:11 AM, DM Y (Dietary Manager) stated that facility tries to keep the area clean whenever garbage is brought out and stated it should be cleaned up and it would get done immediately.

Based on interview and record review, the facility did not ensure that staff background checks were completed thoroughly or timely for 3 of 8 staff (Medication Technician K, Certified Nursing Assistant R (CNA), and CNA S) background/Background Information Disclosure (BID) checks reviewed. MT K's (Medication Technician) BID had not been run since her initial one on 12/10/19. CNA R's (Certified Nursing Assistant) BID had not been run since his initial one on 11/25/19 and this did not include the Wisconsin results. CNA S's BID was dated 8/15/24, however, there were no questions on this document that were answered. This is evidenced by: The Facilities Policy and Procedure entitled Background Screening Investigations dated 2008 documents, in part: .1. The Personnel/Human Resources Director, or other designee, will conduct employment background checks, reference checks and criminal conviction checks (including fingerprinting as may be required by state law) on persons making application for employment with this facility. Such an investigation will be initiated within two days of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility for 1 of 1 resident's reviewed for mobility (R58). The facility was not walking R58 in accordance with his plan of care. Findings include. R58 was admitted to the facility on [DATE] and has diagnoses that include Type 2 diabetes, atherosclerotic heart disease, respiratory failure, chronic pain syndrome and morbid obesity. His most recent Minimum Data Set (MDS), dated [DATE], shows a Brief Interview for Mental Status (BIMS) score of 15, indicating R58 is cognitively intact. His care plan states, Focus: Resident requires restorative nursing. Resident has a behavior of refusing to participate in walking program .Goal: Ambulation - resident will maintain current functionality (Target Date: 10/30/2024) .Interventions: CNAs (Certified Nursing Assistant) to assist resident to ambulate once during each AM and PM shift daily using…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that residents (R) receiving psychotropic medication were free from unnecessary medication for 1 of 5 residents (R23) reviewed for unnecessary medications. R23 receives psychotropic and antipsychotic medications. R23 does not have an appropriate diagnosis for antipsychotic medication. Consent was not obtained prior to administration of psychotropic and antipsychotic medications. Verbal consent was obtained without follow up signature. Findings include: Facility policy entitled, Psychotropic Medication Management, dated 11/28/2017, states, in part; Purpose: It is the practice of this facility that a resident will not receive unnecessary medications including psychoactive medications, unless non-pharmacological interventions have failed to sufficiently modify a resident's target behavioral, mood, or sleep disturbance.Residents prescribed psychoactive medications will receive adequate monitoring . Antipsychotics: An antipsychotic (or neuroleptic) is…

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 that it was free of medication error rates of 5% or greater. There were 2 errors out of 26 opportunities that affected 1 out of 12 residents (R477) included in the medication pass task, which resulted in an error rate of 7.69%. LPN HH (Licensed Practical Nurse) did not give R477 the correct dosing of his calcium carbonate (antacid). LPN HH omitted R477's Pyridoxine HCl (Vitamin B6). This is evidenced by: The facility policy entitled, Administering Medications, dated 12/2012, states in part: Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: . 3. Medications must be administered in accordance with the orders, including any required time frame. R477's Physician Orders state, in part: Calcium Carbonate Oral Tablet Chewable 600 MG (Milligrams) (Calcium Carbonate/ (Antacid). Give 1 tablet by mouth two times a day for indigestion. Pyridoxine HCl Oral Tablet 100 MG (Pyridoxine HCl) Give 100 mg by mouth in the morning 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.

Based on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, affecting 1 of 21 sampled residents (R41). Surveyor observed CNA KK (Certified Nursing Assistant) don gloves (put on), assist R41, and then exit R41's room. CNA KK went into the clean linen storage, gathered an armful of bedding, and enter another resident's room wearing the same pair of gloves. Surveyor observed dirty linens to be stored in R41's room on the floor. R41 voiced concerns regarding the cleanliness of her room. Evidenced by: Facility policy, titled Handwashing/Hand Hygiene, dated 8/2014, includes: all personnel shall follow the hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Use an alcohol-based hand rub containing at least 62% alcohol or soap and water for the following situations: before and after direct contact with residents . after contact with the residents intact skin . the use of gloves does not replace hand…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not develop, implement, and maintain an effective emergency training program for all facility and contracted staff consistent with their expected roles and based on the facility assessment for 8 of 8 facility staff and 1 of 1 contracted staff. Eight facility staff and one contracted staff had not received training on electric power outages and emergency outlets. Staff stated they have not received emergency training regarding severe thunderstorm or tornado warnings. 3 of 8 Residents stated the staff where rattled, scurrying, and struggled during the severe weather and power outage. This is evidenced by: The facility's policy, revised 1/2011, titled Disaster Training states in part; This facility has established training and education programs that provide specific guidance and instruction on the proper handling of a crisis or disaster situation. 1. All training programs pertaining to emergency management shall address the general principles of the National…

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 a Resident (R) who is fed by enteral means receives the appropriate treatment and services for 1 of 1 Residents (R) with a tube feeding (R7). R7 had two different enteral feeding orders that were being signed out as administered and R7's enteral feeding bottle was observed to be without a name, date, and time it was hung for use. This is evidenced by: Facility policy entitled Enteral tube Feeding via continuous pump, revised March 2015, states in part: .General guidelines: .3. Check the enteral nutrition label against the order before administration. Check the following information: a. Resident name, ID, and room number. b. Type of Formula. C. Date and time formula was prepared .g. Rate of administration (ml/hour).Initiate feeding .5. on the formula label document initials, date, and time the formula was hung/administered and initial that the label was checked against the order . R7 was admitted on [DATE] with diagnoses that include…

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 Continuous Positive Airway Pressure (CPAP) orders were obtained or transcribed upon admission and consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 2 (R5 and R8) of 4 residents reviewed for CPAP use. R5's hospital discharge orders dated 4/18/22 state OSA (obstructed sleep apnea) continue CPAP. R5 did not have an order for CPAP in her medical record until 5/24/24. Orders for R8's CPAP were not obtained or entered upon admission. This is evidenced by: Example 1 R5 was admitted to the facility 4/18/22 with diagnoses of morbid obesity, Obstructed Sleep Apnea (OSA), and general weakness. R5's hospital discharge orders dated 4/18/22 state in part; OSA continue with CPAP. R5's care plan dated 4/18/22 Focus: resident has altered respiratory status/difficulty breathing related to OSA. Interventions: BIPAP/CPAP to be in place at bedtime dated initiated 4/18/24. R5's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, are reported immediately to the administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law though established procedures for 1 of 7 abuse investigations (R2) reviewed of a total sample of 10 residents. Facility became aware of an abuse allegation on 4/18/24 and did not report to state. Evidenced by: The facility policy, entitled Abuse, Neglect and Exploitation, dated 1/5/24, states, in part: . Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation and misappropriation of resident property . Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies 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 interview and record review, the facility failed to thoroughly investigate an accusation of verbal abuse for 1 of 7 residents (R2) reviewed for abuse out of a total sample of 10 residents. Facility became aware of an abuse allegation on 4/18/24 and did not report to state. Evidenced by: The facility policy, entitled Abuse, Neglect and Exploitation, dated 1/5/24, states, in part: . Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation and misappropriation of resident property . Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, b. Establish policies and procedures to investigate any such allegations; and . The components…

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 3 (R3, R10, R5) of 5 residents reviewed for Activities of Daily Living (ADL) out of a total sample of 10 received the necessary services to maintain good nutrition grooming, personal and oral hygiene. R3 voiced concern of not receiving showers as scheduled. R10 voiced concerns of not receiving showers as scheduled. R5 did not receive showers as scheduled. Evidenced by: The facility policy entitled, Shower/Tub Bath, dated October 2010, states, in part: . Purpose: The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin . Documentation: The following information should be recorded on the resident's ADL record and/or in the resident's medical record: 1. The date and time the shower/tub bath was performed. 2. The name and title of the individual(s) who assisted the resident with the shower/tub bath . 5. If the resident refused the shower/tub bath,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 3 of 10 residents reviewed for quality of care (R1, R3, and R5). R1 was noted to have a history of aspiration pneumonia and refusal to comply with thickened liquid recommendations and the facility did not care plan his refusals or need to assess R1 more frequently due to increased risk of aspiration pneumonia. Facility staff were not monitoring R5's bowel movements. R3 did not receive wound care two times in one week for two wounds. Findings include: The facility's Therapeutic Diets policy states: *Therapeutic diets shall be prescribed by the attending physician. *Therapeutic diets include: .altered consistency diet *If the resident or the residence representative declines the recommended therapeutic diet, the interdisciplinary team will collaborate with the resident or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and review of professional standards of practice, the facility did not ensure that the services provided by nursing personnel met the professional standards of quality for 1 of 6 residents (R1). R1 was admitted to the facility with orders for Point of Care glucose testing (POCT) 4 times daily before meals and at bedtime. Facility did not monitor blood glucose levels while R1 was a resident in facility. Evidenced by: The facility's policy entitled, Diabetes Management, dated 6/29/17, states, in part: . Purpose: To develop a practice in which our facility consistently provides care for the resident with diabetes . Admission, Quarterly and Change in Condition Evaluations . Individualized approaches for protection must be initiated upon admission .Additional evaluations to be included upon admission and throughout stay: Upon admission and Throughout Stay: . Blood Glucose Monitoring, parameters for Care . Management of Diabetes Mellitus (DM): Blood glucose monitoring: -Ideal range…

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 the provision of pharmaceutical services (including procedures that assure that accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 out of 3 sampled residents (R1). R1 did not receive her ordered amlodipine on 3/23/24. R1 did not receive her ordered Ezetimibe on 3/23/24. R1 did not receive her ordered dose of carbamazepine on 3/23/24. Evidenced by: The facility policy, entitled Administering Medications, with a revision date of December 20212, states, in part: . Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: . 3. Medications must be administered in accordance with the orders, including any required time frame. 4. Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meals) . 18. If a drug is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and policy review, the facility failed to prevent staff to resident abuse for 1 (Resident (R) 4) of 1 resident reviewed for physical abuse when allegedly Licensed Practical Nurse (LPN)3 physically grabbed R4's arm and removed a dab/vape pen from R4's hand. Findings include: Review of R4's admission Record, located in the Profile tab of the electronic medical record (EMR) revealed admission to the facility on [DATE] and readmission was on 08/04/21 with diagnoses of multiple sclerosis, bipolar disorder, and anxiety disorder. Review of R4's annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 03/12/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated resident was cognitively intact. Review of R4's Care Plan, located under the Care Plan tab of the EMR dated 04/25/23, revealed The resident has a behavior of ordering items that are potentially harmful to self or others. Interventions in place were to monitor for unsafe items…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and policy review, the facility failed to report 1 of 1 allegations to the State Agency (SA) that Licensed Practical Nurse (LPN)3 physically grabbed R4's arm and removed a dab/vape pen from R4's hand. Findings include: Review of the facility's policy titled Abuse, Neglect, and Exploitation revised 01/05/2024, revealed, it is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes, immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. Review of R4's admission Record, located in the Profile tab of the electronic medical record (EMR)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and policy review, the facility failed to thoroughly investigate 1 of 1 allegation's that Licensed Practical Nurse (LPN)3 physically grabbed R4's arm and removed a dab/vape pen from a resident's hand for one (Resident (R 4) of one resident reviewed for physical abuse. Findings include: Review of the facility's policy titled Abuse, Neglect, and Exploitation revised 01/05/2024, revealed, it is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. Examples include but are not limited to: Responding immediately to protect the alleged victim and integrity of the investigation. The Administrator will follow up with government agencies to report the results of the investigation when final within five…

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 failed to ensure 1 of 10 residents (R8) was using a continuous positive airway pressure (CPAP) machine as ordered by R8's Physician. Findings include: Review of R8's electronic medical record (EMR), census tab revealed an admission date of 02/05/24. Review of Physician orders in the EMR under the orders tab revealed an order for the resident to use . Review of R8's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/22/24 revealed a Brief Interview for Mental Status score of 15 out of 15 which indicated the resident was cognitively intact. Observation of R8's room on 03/25/24 at 10:30 AM revealed there was no CPAP near the resident's bedside. Interview 03/25/24 at 10:40 AM, R8 stated that she did not have a CPAP machine in her room to use at night. Interview on 03/26/24 at 1:30 PM, Licensed Practical Nurse (LPN)1 stated that R8 did not have a CPAP machine and that the physician was not notified of the inability to follow the physician's orders for the CPAP. LPN 1 confirmed the physician was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not immediately report alleged violations of abuse to the State Agency for 1 of 3 reports incidents (R1). On 1/28/24 at 11:47 AM, R1 and his Activated Power of Attorney for Health Care (APOAHC) contacted the police department regarding a theft of R1's backpack which contained his wallet, identification card, debit card, and FoodShare/[NAME] card (a public assistance card used to purchase food). R1's APOAHC reported this allegation to NHA A (Nursing Home Administrator), the Grievance Officer, told R1's APOAHC he was unable to do anything about this. NHA A failed to report this Suspicion of a Crime to law enforcement and the State Agency. This is evidenced by: The facility's policy and procedure, Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property, dated 9/11/20, documents in part, the following: Purpose: It is the practice of the facility to encourage and support all residents, staff, families, visitors, volunteers and 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 interview and record review the facility failed to thoroughly investigate an allegation of abuse for 1 out of 3 sampled Residents (R1). On 1/28/24 at 11:47 AM, R1 and his Activated Power of Attorney for Health Care (APOAHC) contacted the police department regarding a theft of R1's backpack which contained his wallet, identification card, debit card and FoodShare/[NAME] card (a public assistance card used to purchase food). R1's APOAHC reported this allegation to NHA A (Nursing Home Administrator), the Grievance Officer, who told R1's APOAHC he will be unable to do anything about this. NHA A failed to investigate this Suspicion of a Crime. This is evidenced by: The facility's policy and procedure, Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property, dated 9/11/20, documents in part, the following: Purpose: It is the practice of the facility to encourage and support all residents, staff, families, visitors, volunteers and resident representatives in reporting any suspected acts of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, review of facility policy, and staff interviews, the facility failed to develop a person-centered comprehensive plan of care with measurable goals and plans for one of 18 residents (Resident (R) 2) reviewed for care plans. Findings include: Review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, dated October 2019, indicated, . Care Area Assessment (CAA) Process. This process is designed to assist the assessor to systematically interpret the information recorded on the MDS . The CAA process helps the clinician to focus on key issues identified during the assessment process so that decisions as to whether and how to intervene can be explored with the resident . Specific components of the CAA process include: - Care Area Triggers (CATs) are specific resident responses for one or a combination of MDS elements. The triggers identify residents who have or are at risk for developing specific functional problems and require further assessment . The MDS…

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

Based on observation, interview, and record review, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect all 70 residents who reside at the facility. Surveyor observed the following: - Food items were not dated to reflect open and/or use by date. - Crumbs, debris, and spilled food on the floor of the kitchen. - 2 garbage cans with no lids near the food prep area. - Microwave splattered with substance and crumbs. - Scoops left in the flour and sugar bins. - A bag of onions directly on the floor with 3 moldy onions. - Observation of staff not wearing beard nets and entering the kitchen without a hair net on. - Improper hand hygiene during dishwashing, going from dirty items to clean items. - Food items not labeled or dated in the nourishment room refrigerator. - Nourishment room refrigerator and freezer food crumbs and spilled substance. Evidenced by: The facility policy, titled, Quick Resource Tool: QRT Food Storage, dated 9/1/21, states, in part; Guidelines: 1. All 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.

Based on observation and interview, the facility did not ensure that garbage and refuse was disposed of properly. This has the potential to affect all 70 residents. On 10/23/23, Surveyor observed garbage not properly contained in the dumpsters. Evidenced by: On 10/23/23, at 8:30 AM, during the initial tour of the kitchen, Surveyor and [NAME] R observed the following outside, on the ground near the facility's main garbage dumpster: Used gloves. Wet cardboard boxes A garbage bag that was ripped open and debris laying on ground. Plastic spoons Plastic wrap and used food containers. Cook R indicated she was not sure who was responsible for ensuring garbage was disposed of properly. On 10/24/23 at 9:22 AM, DM J (Dietary Manager) indicated the kitchen is responsible for ensuring garbage is in the dumpsters. DM J indicated the expectation is that garbage is put in the dumpsters and not laying outside. Waste was not properly contained in dumpsters resulting in an unsanitary condition which may lead to harboring or feeding of pests.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility does not have a system for preventing, identifying, reporting, investigating, and controlling infections and communicable disease for all residents. This has the potential to affect the census of 70. The facility's line lists for Infection Control are not being completed contemporaneously as the dates are not in any order. The line lists only include residents receiving antibiotic therapy, no residents with only signs or symptoms (S/Sx) are on the line lists. August through October line lists are not accurate compared to the McGeer's documentation (i.e., HAI or CAI, type of infection, etc.) and all are documented as Healthcare Associated Infection (HAI), none are Community Associated Infection (CAI). The line list does not contain any S/Sx, organism, or colony counts. McGeer's forms are either on paper in IP's (Infection Preventionist) office or in each resident's Electronic Health Record (EHR); it is not clear how tracking and trending is occurring. This is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure that residents that use psychotropic drugs have appropriate assessments, behavioral interventions, and consent. This affected 4 of 5 residents (R18, R26, R60, R36) reviewed for unnecessary medications. R18 receives medication for insomnia and has no sleep assessment. R18 does not have specific individualized targeted behaviors in place for staff to monitor to ensure the effectiveness of her psychotropic medications. R18 does not have the appropriate consents for her psychotropic medications. R26 receives medication for insomnia and has no sleep assessment. R26 does not have the appropriate consents for her psychotropic medications. R60 does not have the appropriate consents for her psychotropic medications. R36 does not have the appropriate consents for his psychotropic medications. This is evidenced by: The Facility does not have a Policy and Procedure related to Psychotropic medications per DON B (Director of Nursing). Example 1 R18 is a…

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

Based on interview and record review the facility did not ensure they followed their antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for 5 of 14 supplemental residents (R226, R23, R3, R225, R272). R226 treated for Urinary Tract Infection (UTI) per line list, no urinalysis (UA) culture and sensitivity (C/S) provided. R23 per line list received antibiotic for prophylaxis but did not indicate for what. R3 treated for respiratory illness when CT chest did not show infectious process. R225 treated for UTI when C/S results indicate probable contamination and antibiotic treated with in same family as antibiotic listed as resistant. R272 McGeer's documentation indicates there is physician diagnosis or lab confirmation; neither was provided. This is evidenced by: The Facilities Policy and Procedure entitled Infection Prevention and Control Program dated 7/25/23, documents in part: .6. Antibiotic Stewardship: a. An antibiotic stewardship program will be implements as part of the overall infection prevention and control program. b.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not facilitate resident self-determination through support of resident choice for 1 of 15 supplemental residents (R24). R24 did not know the facility's menu choices and was not given the opportunity to choose his meals before receiving them. Findings include: R24 was admitted to the facility on [DATE] and has multiple diagnoses that include Multiple Sclerosis. His most recent Minimum Data Set (MDS), dated [DATE], shows a Brief Interview for Mental Status (BIMS) score of 15, indicating R24 is cognitively intact. On 10/26/23 at 9:37 AM, R24 stated to Surveyor that he has not filled out a meal ticket in a month. R24 stated that he got a hard-boiled egg earlier in the morning, but he does not like hard boiled eggs. R24 stated he got oatmeal, which he does not like and then asked staff for cold cereal, which he received but it took a while. R24 stated he does not have a monthly menu in his room. R24 stated that in the past, CNAs (Certified Nursing Assistants)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure the environment was safe, clean, comfortable, and homelike for 1 (R51) of 20 sampled residents during mealtime out of a total sample of 27 Residents. Surveyors observed R51 during lunch time on 10/23/23. R51 was sitting at the table closest to the dishwashing room. Kitchen staff had the dishwashing door propped open during mealtime. Kitchen staff was standing outside of the dishwashing room next to R51. Kitchen staff had a garbage can, a cart with stacks of dirty plates, and the staff was scraping off food from the dirty dishes into the garbage can. As kitchen staff was doing this, R51 was flinching. R51 is unable to verbally indicate if there is something that bothers R51. Evidenced by: R51 was admitted to the facility on [DATE] with diagnoses including but not limited to, unspecified lack of expected normal physiological development in childhood, altered mental status, speech disturbances, limitation of activities due 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.

Based on interview and record review, the facility did not ensure allegations of abuse were reported to the State Survey Agency for 1 of 27 sampled residents (R65.) R65 shared an allegation of abuse with Surveyor. R65 alleged CNA V (Certified Nursing Assistant) was verbally abusive to him and would throw his meal trays on his over bed table for three (3) days after he reported a concern to her. R65 also reported this concern to CNA H. Neither CNA V nor CNA H reported this allegation of abuse to the facility. Subsequently, the facility did not report this allegation of abuse to the State Agency until Surveyor brought this allegation to the attention of facility. Evidenced by: The facility's Policy and Procedure entitled Abuse and Neglect dated 9/11/20, documents in part: .Internal Reporting: a. Employees must always report any abuse or suspicion of an abuse immediately to the Administrator. Note: Failure to report can make employee just as responsible for the abuse in accordance with State Law. The Administrator will involve key leadership personnel as necessary to assist 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 interviews and record review, the facility did not provide an ongoing, individualized, and meaningful program to support the residents in their choice of activities, which was designated to meet their interests and support their physical, mental, and psychosocial well-being. This affected 1 of 2 residents (R51) out of a sample of 20 residents reviewed for activity participation out of a total sample of 27 Residents (R). The facility failed to offer a variety of activities that meet the interests and support all residents' physical, mental, and psychosocial well-being. Evidenced by: The facility policy, Activity Programs, with a revised date of 8/06, states, in part; .1. Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs. 2. Activities are scheduled 7 (seven) days a week and residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup, and critique of the programs G. At least two group…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 2 of 27 total sampled residents (R37 and R27). R37 has diagnosis of congestive heart failure and facility staff did not complete daily weights as ordered, nor did they update the Nurse Practitioner when R37 had a weight gain. R27 has diagnoses of Adult Failure to Thrive and Severe Protein-Calorie Malnutrition and facility staff did not complete weights as ordered. Evidenced by: The facility's policy titled Weight Monitoring Guideline last revised on 7/1/2019, states in part: .Residents will be weighed; documentation will be recorded in PCC (Point Click Care): *Upon admission and re-admission. Hospital weights should be verified and compared to facility admission/ re-admission weight. *Daily for three days *Weekly for four weeks post admission .*Monthly by the 7th of each month .*As specified the physician or mid-level practitioner .The Licensed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure a resident (R) with a pressure injuries/ulcers receives necessary treatment and services, consistent with professional standards of practice. The facility did not implement immediate robust care plan interventions for 1 (R73) of 4 residents reviewed for pressure ulcers out of a total sample of 27. R73 admitted to the facility with pressure ulcers. The facility did not implement a robust care plan in place for R73. This is evidenced by: The facility policy, entitled Wound Care, dated October 2010, states, in part: . Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation: . 2. Review the resident's care plan to assess for any special needs of the resident. a. For example, the resident may have PRN (as needed) orders for pain medication to be administered prior to wound care . The facility policy, entitled Care Plans- Comprehensive, dated October 2010, states, in part: . Policy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility did not ensure that a resident with limited range of motion (ROM) receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 1 Resident's (R57) reviewed for limited range of motion of 27 sampled residents. R57 is not receiving his walking program. This is evidenced by: The facility does not have a Restorative Program. The facility has a binder labeled Daily Skilled Schedule - Walking Program Schedule - Section GG The facility's Walking Program, dated 10/3/23, that indicates the following: CNAs (Certified Nursing Assistants) to assist resident to ambulate once during each AM and PM shift daily using 2ww (wheeled walker), gait belt and wheelchair to follow (1 assist). Distance as tolerated. Please see therapy staff with any questions. R57 is listed as participating in the walking program. R57 was admitted to the facility on [DATE]. R57 has the following diagnoses: laceration of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure the resident environment remains as free of accident hazards as is possible for 1 of 1 resident (R39) reviewed for smoking out of a total of 27 sampled residents. R39 requires supervision while smoking. Surveyor observe R39 put out his cigarette on the wheel on his wheelchair, on a leaf he had picked up off the ground, and then placed the used butt back in the empty pack of cigarettes. CNA N (Certified Nursing Assistant) who was supervising the smoking session did not notice how R39 put out his cigarette nor how he disposed of it. As evidenced by The facility's policy, Smoking Guideline, dated 11/28/17, states in part, the following: Residents who want to smoke are evaluated and assessed for smoking safety. Each facility establishes its own smoking policy that addresses how, when, and where to allow smoking. Any resident with restrictions will have direct supervision during smoking unless contraindicated within the facility smoking…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that a resident with an indwelling catheter receives services and assistance. This affected 1 of 4 residents with catheters (R48) out of a sample of 27 Residents (R). R48's catheter was leaking on 9/2/23; the facility did not have the size catheter that R48 needed. A different size catheter was inserted, and no Provider notification was done. This is evidenced by: The Facilities Policy and Procedure entitled Urinary Indwelling Catheter Management Guideline dated 11/28/17, documents in part: .Medically justified indwelling catheters will require physician orders for: Catheter size and type- Current standards indicate catheterization should be accomplished with the narrowest, softest tube that will serve the purpose of draining the bladder. Changing indwelling catheters and drainage bags at routine or fixed intervals is not recommended. Rather, catheters and drainage bags should be changed based on clinical indications such as: infection,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure that a resident who is fed by enteral means receives the appropriate treatment and services. This affects 1 of 1 resident (R51) reviewed for G/T (gastrostomy tube) out of a total sample of 27 residents. The facility did not properly check placement of R51's gastronomy tube (G/T; surgically placed device used to give direct access to the stomach for supplemental feeding, hydration, or medicine). This is evidenced by: The Facilities Policy and Procedure entitled Tube Feeding dated 6/29/21, documents in part: .Refer to [NAME] Clinical Nursing Skills and Techniques (or alternated facility evidence-based standards for practice guide) for: Site Care, Observation, Flushing Feeding, Placement Checking: NOTE Auscultation is no longer recommended for checking placement of the feeding tube. Movement of air would likely be heard whether the tube was in the correct or incorrect location. X-ray confirmation is the most accurate method for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that it provided pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, this affected 1 of 27 sampled residents (R48). R48 did not receive her Actos medication on 10/8/23 and 10/9/23. R48 did not receive her Glipizide medication on 8/5/23, 8/6/23, and 9/9/23. R48 did not receive her Oxycodone medication on 10/6/23. This is evidenced by: The Facilities Policy and Procedure entitled Adverse Consequences and Medication Errors dated 4/14, documents in part: .5. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. 6. Examples of medications errors include: a. Omission- a drug is ordered but not administered .…

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 ensure laboratory services were obtained as ordered by the physician for 1 of 20 residents (R37) reviewed for laboratory services out of a total sample of 27 residents (R). R37's laboratory orders were not carried out as ordered. Evidenced by: R37 was admitted to the facility on [DATE] with diagnoses that include: congestive heart failure (impairment of the heart's blood pumping function), major depressive disorder, type 2 diabetes mellitus, and fracture of neck of right femur (leg bone). On 10/19/23, R37 was seen by the NP (Nurse Practitioner). The NP's note states in part: .Upon entering room, foul odor noted. Overall patient reports feeling well but spouse is concerned that she may have a UTI (Urinary Tract Infection). She endorses foul odor, dysuria, frequency, and urgency. Orders for UA (Urinalysis) with C&S (Culture and Sensitivity) if indicated .Plan of care discussed with the nurse who will obtain UA and update provider with results . On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure the resident's medical record includes documentation that indicates, at a minimum, the following: (A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza and/or pneumococcal immunization; and (B) That the resident either received the influenza and/or pneumococcal immunization or did not receive the influenza and/or pneumococcal immunization due to medical contraindications or refusal. This affected 3 of 5 residents (R36, R57, R60) reviewed for immunizations. R36 did not receive influenza vaccine consent or declination for last year, 2022. R57 was not offered next dose of pneumococcal vaccine. R60 was not offered pneumococcal vaccine. This is evidenced by: The Facilities Policy and Procedure entitled Infection Prevention and Control Program dated 7/25/23, documents in part: .7. Influenza and Pneumococcal Immunization: a. Residents will be offered the influenza vaccine…

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.