Amethyst Health of Brown Deer

Based on interview and record review, the facility did not ensure a designated Infection Preventionist works at least part time at the facility for the responsibility of the facility's Infection Prevention Control Program. Director of Nursing (DON)-B was designated as the facility's Infection Preventionist (IP) in addition to performing DON responsibilities and working on the Ventilator Unit as a floor nurse, which resulted in the inability to implement an effective Infection Prevention Control Program. Findings include: Surveyor reviewed the Facility assessment dated 10/2023, last reviewed 02/2026, which documents the facility as having one (1) full-time Director of Nursing and one (1) full-time Infection Preventionist. On 2/26/26, at 12:19 PM, Surveyor interviewed Director of Nursing (DON)-B who stated she dedicates Mondays to the Infection Prevention Program. DON-B stated she works two (2) days a week on the Ventilator Unit as a floor nurse and three (3) days a week as the DON. Surveyor expressed concerns with DON-B not having enough dedicated time to perform the IP…

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 7 (R6, R3, R55, R7, R36, R8, and R78) of 7 residents reviewed for transfers or discharges received the proper written notice of transfer, written bed hold policy with reserve bed payment identified and that proper notification was sent to the State Long-Term Care Ombudsman. *R6 was transferred to the hospital 10/25/25, 11/9/25, and 1/5/26. The facility was unable to locate a written notice of transfer or bed hold notice from 10/25/25 or 11/9/25 transfers to the hospital. The bed hold notice dated 1/5/26 did not list the bed payment rate. The facility did not notify the State Ombudsman of R6's hospitalizations. *R3 was transferred to the hospital on [DATE]. The bed hold notice dated 12/16/25 did not list the bed hold payment rate. The facility did not notify the State Ombudsman of R3's hospitalization. *R55 was transferred to the hospital on [DATE], 12/3/25, and 1/12/26. The bed hold notices dated 10/9/25, 12/3/25, and 1/12/26 did not list the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not complete and transmit entry tracking, Medicare 5 day, quarterly, or discharge assessments as required for 6 (R25, R28, R40, R44, R64, and R73) of 8 residents reviewed for Minimum Data Set (MDS) assessments and transmission.1.). R25's entry MDS dated [DATE] and quarterly MDS dated [DATE] were not transmitted.2.). R28's quarterly MDS dated [DATE] was not transmitted timely.3.). R40's quarterly MDS dated [DATE] was not transmitted timely. 4.). R44's modification to quarterly MDS dated [DATE] was not transmitted. 5.). R64's entry MDS dated [DATE] was not transmitted timely. 6.). R73's discharge MDS dated [DATE] was not transmitted timely. Findings include:The Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.19.1 dated October 2024, documents long-term care facilities participating in Medicare and Medicaid programs must meet the following conditions: Completion timing: -For all non-admission OBRA (Omnibus Budget…

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 in observation, interview, and record review, the facility did not ensure each resident received adequate supervision and assistance to prevent accidents for 3 (R56 R36, and R73) of 5 residents reviewed for falls and 1 (R39) of 1 resident reviewed for smoking. *R56 was observed walking without a 2 wheeled walker in the hallway. R56's care plan was not revised to indicate accurate transfer status for R56. *R36 had falls on 12/4/2025 and 1/27/2026 that were not thoroughly investigated. *R39 did not have a quarterly smoking assessments completed and R39's smoking care plan was not revised to indicate if R39 was to be supervised or unsupervised when smoking or if R39 was safe to hold onto own smoking materials. *R73 had a fall out of bed on 2/15/2026 that was not thoroughly investigated. Findings include: The facility policy titled Care Plan Goals, Objectives, Revisions dated 8/1/2025 documents: Purpose: Care plans shall incorporate goals and objectives that lead to the resident's/ patient's highest obtainable…

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 the storage of drugs and biologicals were stored in locked compartments and permit only authorized personnel to have access to the keys. 1 of 5 medication carts were observed to be unlocked and unattended in access to a public area of the facility. The deficient practice had the potential to affect 10 (vent unit) residents whose medications are stored in the medication cart. Findings include: The facility's policy titled Medication Labeling and Storage, dated 8/1/25, documents the following:The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner.Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. On 2/24/26, at 8:21 AM, Surveyor observed Licensed Practical Nurse (LPN)-R passing medications to residents 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.

Based on observation and interview, the facility did not ensure that food was stored, prepared and served under sanitary conditions in 3 of 3 unit refrigerators. On 2/24/26, at 12:35 PM, a refrigerator was observed to have multiple food and drink items opened and not dated. This deficient practice has the potential to affect 10 residents on the Vent Unit of the facility. On 2/26/26, at 8:39 AM, a refrigerator was observed to have multiple food and drink items opened and not dated. This deficient practice has the potential to affect 14 residents on the Rehabilitation (Rehab) Unit of the facility. The Rehab Unit refrigerator temperature log was noted to have the following missing dates 2/16/26, 2/18/26, 2/21/26, and 2/24/26. On 2/25/26, at 8:44 AM, a refrigerator was observed to have multiple food and drink items opened and not dated. This deficient practice has the potential to affect 34 residents on the North and [NAME] Unit of the facility. Findings include: The facility's policy titled Food Storage, dated 8/1/25, documents:Foods shall be received and stored in a manner that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure 1 (R6) of 1 resident was assessed to self-administer medications. On 2/24/26, Surveyor observed Licensed Practical Nurse (LPN)-R set R6's medications down on R6's bedside table and exit the room. R6 did not have a self-administration assessment completed to identify if R6 was able to safely self-administer medications. Findings include:The facility policy titled Self Administer Medications with an effective date of 8/1/25 documents the following: . Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. The IDT considers the following factors when determining whether…

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 medical record reflected the resident's accurate advanced directive wishes for 1 (R55) of 16 residents reviewed.*R55's Do Not Resuscitate form was signed on [DATE] and scanned into R55's medical record. On [DATE], at the start of Survey, R55's active MD order and Electronic Medical Record (EMR) dashboard documented R55 to have elected a full code status. Findings include: The facility policy with an effective date of [DATE], and titled, Cardiopulmonary Resuscitation and Automated external defibrillation, documents, in part: The purpose of this policy and procedure is to provide guidelines for the initiation of Cardiopulmonary Resuscitation (CPR) in victims of sudden cardiac arrest. Determine and record a code status for each resident in his or her [electronic medical record (EMR)], along with obtaining an order. The newest form will be kept in a binder at the nurse's station. When checking a resident for their code status, this binder will be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure residents whose Medicare part A benefits ended, was provided with written beneficiary protection notifications for 1 (R83) of 3 residents sampled for beneficiary notifications. The facility did not provide R83 with a written Advanced Beneficiary Notice (ABN), which includes financial liability information and appeal rights, at the time Medicare Part A coverage ended. Findings include: Notice of Medicare Non-Coverage (NOMNC) (Form CMS 10123-NOMNC) is utilized to provide written notification to resident or resident representative that Medicare Part A coverage is ending in two or more days. The notification includes appeal rights and provides the third-party reviewer name and phone number to begin an immediate appeal. Advance Beneficiary Notice (ABN) (Form CMS-10055) is utilized to provide written notification to resident or resident representative of services Medicare A will no longer cover, an estimated cost of those services, and three options…

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 who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record and residents who use psychotropic drugs receive behavioral interventions in an effort to discontinue these drugs for 1 of 1 (R9) residents reviewed for psychotropic medications.R9 was hospitalized and re-admitted to the facility with an order for Zyprexa. The facility did not follow up as to why the medication was prescribed and there were no indications for use. R9 admitted to the facility on [DATE] and has diagnoses that include unspecified dementia, unspecified severity with psychotic disturbance, and depression.The facility policy titled Psychotropic Medication Use dated 8/1/25 documents (in part) .Residents will not receive medications that are not clinically indicated to treat a specific condition.1. A psychotropic medication is any medication that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure all alleged violations were reported immediately to the State Agency, but not later than 2 hours after the allegation is made if the events that caused the allegation involved abuse, for 1 of 2 Facility Reported Incidents (FRI) reviewed involving R6. On 2/9/26 at 11:00 PM, the Nursing Home Administrator (NHA)-A was made aware of an alleged instance of physical abuse involving R6 and Certified Nursing Assistant (CNA)-BB. NHA-A did not report the alleged incident to the State Agency until 2/10/26 at 6:16 AM. Findings include: The facility policy titled Abuse Prevention Program with effective date 1/23/26 and review date 1/23/26 documents: . As part of the resident abuse prevention, the facility's administration will: . protect our residents from abuse by anyone including, but not necessarily limited to facility staff . All covered individuals will receive annual written notification of their obligation to report reasonable suspicion of a crime…

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 an alleged violation of abuse was thoroughly investigated for 1 of 2 Facility Reported Incidents (FRI) reviewed involving R6. On 2/9/26 at 11:00 PM, the Nursing Home Administrator (NHA)-A was made aware of an alleged instance of physical abuse involving R6 and CNA-BB. The investigation of the allegation of abuse did not include interviews with witnesses and staff the allegations were originally reported to.Findings include: The facility policy titled Abuse Prevention Program with effective date 1/23/26 and review date 1/23/26 documents: . As part of the resident abuse prevention, the facility's administration will: . protect our residents from abuse by anyone including, but not necessarily limited to facility staff . The individual conducting the investigation will, as a minimum: . interview the person(s) reporting the incident; . interview any witnesses to the incident; . interview staff members (on all shifts) who have had contact with 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 ensure Minimum Data Set (MDS) assessments were coded correctly for 2 (R3 and R5) of 16 residents reviewed for MDS accuracy. *R3's MDS for December 2025 was not coded accurately for receiving dialysis. *R5's quarterly MDS for December 2025 was not coded accurately for receiving an antiplatelet medication. Findings include: 1.) R5 was identified as being prescribed an anticoagulant (inhibits clotting factors reducing blood clot formation) medication on the MDS indicators. Surveyor reviewed R5's medications and noted R5 was not taking an anticoagulant medication. R5 was prescribed Plavix 75mg (milligrams) on 2/8/2018 to take daily. Surveyor noted Plavix is an antiplatelet (prevents blood cells sticking/clumping together) medication, not an anticoagulant. Surveyor reviewed R5's quarterly MDS dated [DATE]. Surveyor noted R5's MDS section N (Medications) documented 'YES for R5 taking an anticoagulant and documented NO for not taking and antiplatelet…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not provide the necessary Activities of Daily Living (ADL) services for 1 (R55) of 16 residents who were dependent on staff to provide ADL care.R55 is dependent on staff for bathing and toileting. R55 did not receive showers as care planned. R55 was not checked and changed every 2 hours as care planned.Findings include:The facility policy with an effective date of 8/1/25 and titled, ADL support, documents, in part: . Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming and oral care) . elimination (toileting) . R55 was admitted to the facility on [DATE] and has…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility did not ensure that 1 of 17 residents (R3) reviewed received treatment and care in accordance with professional standards of practice.*On 1/17/26, facility staff found a right buttock abrasion that was not comprehensively assessed when found. On 1/22/26, facility staff documented a new skin issue on R3's upper right gluteus. A treatment order was not placed for this new skin issue until 2/25/26. On 2/2/26, Wound MD-Q assessed R3's wounds for the first time. Wound MD-Q could not assess R3's wounds weekly because R3 is out at an off-site dialysis center when wound rounds take place. Facility staff did not complete comprehensive weekly assessments when wound appointments were missed.Findings include:R3 was admitted to the facility on [DATE] with diagnoses that include Type 2 Diabetes (chronic condition characterized by insulin resistance and high blood sugar levels,) Paraplegia (a form of paralysis, the inability to voluntarily move or control the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility did not ensure that 1 (R7) of 2 residents reviewed for bladder incontinence received the appropriate care and services to help restore continence, prevent urinary tract infections, and receives appropriate treatment and services to restore continence to the extent possible.R7's urinary incontinence was not assessed and care plan interventions for care and treatment of R7's incontinence needs were not accurately documented. This is evidenced by:The facility's catheter care, urinary policy and procedure with a review date of 11/2025 documents:Catheter Evaluation1. Review and document the clinical indications for catheter use prior to inserting. 2. Nursing and the interdisciplinary team should assess and document the ongoing need for a catheter that is in place. Use a standardized tool for documenting clinical indications for catheter use.3. Remove the catheter as soon as it is no longer needed.ComplicationsObserve the resident for complications associated…

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 Number of residents sampled: 2Number of residents cited: 2Kristine Based on Concerns with weight loss and no interventions, inconsistent weightsBased on observation, interview, and record review the Facility did not ensure 2 (R33 and R9) of 2 residents received the necessary services for weight loss and acceptable nutrition. * R33 had a 5.14% weight loss in one month that was not desired. A comprehensive assessment was not completed regarding the weight loss. The physician and dietitian were not notified regarding R33's weight loss. R33's care plan was not updated, and interventions were not implemented. * R9's weights were inconsistent with documented weights indicating significant weight loss and/or gain. There is no evidence that the facility or Dietitian questioned the accuracy of the weights entered. No re-weights were completed, the physician was not notified, and no interventions were implemented. Findings include: The Facility policy entitled, Weight Assessment, dated 8/1/25, documents, Policy Statement:…

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 2 (R5 and R6) of 2 residents reviewed for post-traumatic stress disorder (PTSD) received trauma informed care in accordance with professional stands of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization. R5 and R6 were admitted to the facility with a diagnosis of PTSD. The facility did not complete a trauma assessment or develop a person-centered care plan identifying triggers, interventions, or monitoring for PTSD for R5 or R6. Findings include: The facility policy titled Trauma-Informed and Culturally Competent Care with revised date August 2022 documents: . Assessment involves an in-depth process of evaluating the presence of symptoms, their relationship to trauma, as well as the identification of triggers . Resident Care Planning . Develop individualized care plans that address past trauma in collaboration with the resident and family . Identify 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 did not ensure the facility implemented monitoring or support of 1 (R6) of 2 sampled residents psychosocial well-being and ongoing safety after an allegation of abuse violation of abuse was made.On 2/24/26 R6 alleged Certified Nursing Assistant (CNA) BB was abusive to R6 during cares. R6 alleged the abuse was physical and verbal in its nature. R6 has a history of post traumatic stress disorder.Findings include:The facility policy titled Identifying Types of Abuse with revised date September 2022 documents: . Psychosocial outcomes . abuse may result in psychological, behavioral, or psychosocial outcomes including, but not limited to, the following: . fear of a person or place, of being left alone, of being in the dark, and/or disturbed sleep and nightmares; . extreme changes in behavior, including aggressive or disruptive behavior toward a specific person; . running away, withdrawal, isolating self, feelings of guilt and shame, depression, crying, talk of suicide…

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 physician acted upon recommendations by the pharmacist for 1 (R33) of 5 residents reviewed with pharmacy recommendations.R33 had no documented physician response to pharmacist recommendations after medication regimen review on 1/26/26. Findings include:The facility policy titled Medication Regimen Review with effective date 8/1/25 documents: The consultant pharmacist performs a medication regimen review (MRR) for every resident in the facility receiving medication.The MRR involves a thorough review of the resident's medical record to prevent, identify, report and resolve medication related problems, medication errors and other irregularities, for example: . duplicative therapies or omissions of ordered medications . Within 24 hours of the MRR, the consultant pharmacist provides a written report to the attending physicians for each resident identified as having a non-life threatening medication irregularity. The report contains: . 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 ensure 1 (R72 and R57) of 5 residents were offered/administered the influenza vaccine.R72 was admitted to the facility on [DATE]. There is no documentation indicating R72 was offered or administered the influenza vaccine.Findings include:R72 was admitted to the facility on [DATE]. R72 is an [AGE] year old with diagnoses that include Type 2 Diabetes (chronic disorder where the body develops insulin resistance), Osteomyelitis (infection of the bone), colostomy (a surgical opening connecting part of the intestines to the outside of the body), anemia (decreased blood cells), quadriplegia (permanent partial or total loss of motor and sensory function in the legs and arms), and cognitive deficit (disruptions in mental processes).Surveyor reviewed R72's Electronic Medical Record (EMR) and was unable to locate whether R72 was offered, received, or declined the influenza immunization.On 2/26/26, at 12:19 PM, Surveyor interviewed Director of Nursing (DON)-B who…

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 interview, the facility did not provide a working call light system for 1(R3) of 16 sampled residents.*R3 informed Surveyor that R3's call light above R3's room door does not light up when R3 pushes the call light for help. R3 stated that the light has been like this since last week.Findings include:The facility policy with an effective date of 8/1/25 and titled, Answering Call Lights, documents: The purpose of this procedure is to ensure timely responses to the resident's requests and needs. Upon admission and periodically as needed, explain and demonstrate use of the call light to the resident. Be sure that the call light is plugged in and functioning at all times. Report all defective call lights to the nurse supervisor promptly .R3 was admitted to the facility on [DATE] with diagnosis that include Paraplegia (a form of paralysis. The inability to voluntarily move or control the lower parts of the body), Muscle weakness and End stage renal disease with dependence on renal dialysis…

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 did not have a full-time DON (Director of Nursing) from 7/22/25 to 10/19/25 and 11/25/25 to date.The facility failed to meet staffing requirements, resulting in the DON having to work as the Clinical Manager/Floor Nurse filling regularly scheduled shifts.This deficient practice had the potential to affect all 65 residents in the facility. Findings include:On 2/4/26 at 12:01 PM, Surveyor received Facility assessment from Nursing Home Administrator (NHA)-A. Surveyor reviewed the Facility Assessment, dated, developed October 2023 and reviewed, January 2026, documents, in part. This document is used to inform staffing decisions to ensure there are a significant number of staff with the appropriate competencies and skill sets necessary to care for its member needs as identified through resident assessments and plans of care. For instance, The Ventilator Unit, staff with a higher staff to member ratio due to increased care needs. Each member care unit is evaluated for need and staffing levels adjusted to meet those needs. Staffing needs…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not develop and implement a comprehensive person-centered care plan for 9 (R1, R3, R5, R6, R7, R8, R9, R11, R12) of 13 residents reviewed to meet a resident's medical, nursing and psychosocial needs that are identified in the comprehensive assessment. *R1 has Atrial Fibrillation (A-Fib) and receives anticoagulant therapy. R1 has history of Intracranial Hemorrhage and hypertension and receives Amlodipine, Carvedilol, Lisinopril, and Hydrochlorothiazide for hypertension. R1 does not have a comprehensive care plan that addresses anticoagulant or blood pressure management. R1's goals for altered neurological status and impaired physical mobility do not reflect appropriate goals. *R3 was assessed to be at risk for pressure injury. Facility staff did not document the start of a skin integrity/pressure injury care plan until 10 weeks after admission. When a skin integrity care plan was placed, it did not include interventions on how often R3 should be turned and…

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

Based on observation and interview, the facility did not ensure sufficient nursing staff to meet resident care needs for residents residing in the ventilator unit. This has the potential to affect 11 ventilator residents and 2 residents with tracheostomies.On 2/5/26 the facility's ventilator unit was staffed with Respiratory therapist (RT)-DD, Licensed Practical Nurse (LPN)-BB and Certified Nursing Assistant (CNA)-J. Facility staff assigned to the vent unit work 12-hour shifts. Times of the shifts are 6:00 a.m. to 6:00 p.m. and 6:00 p.m. to 6:00 a.m. On 2/5/26 Surveyor conducted continuous observations on the ventilator unit starting at 8:36 a.m. and until 1:40 p.m. During this observation Surveyor did not observe R5 being provided with incontinence cares & repositioning until 12:31 p.m. at which time R5 incontinence product was saturated with urine and R5 had a bowel movement. R12 was not provided with incontinence cares & repositioning until 12:57 p.m. R7 was not provided with incontinence care & repositioning until 1:18 p.m. R7's incontinence product was saturated with urine 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 interview and record review the facility did not ensure nursing staff working on the ventilator unit had the competency and skill set necessary to care for 13 (R3, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, & R16) of 13 residents who utilize ventilators and/or tracheostomies.Findings include:The facility assessment reviewed February 2026 under the Education and Training section for Registered Nurse (RN), Licensed Practical Nurse (LPN) & Certified Nursing Assistant (CNA) for Competencies Obtained/Evaluated Education Provided documents *Annual Skills checks through Staff Development. *As needed training from vendor, professional group or other for new/unique skill sets required for member care.Surveyor reviewed the facility's daily nursing schedule from 1/11/26 to 2/9/26. The nursing staff on the ventilator unit work 12-hour shifts. Surveyor noted the following nursing staff worked the on the ventilator unit:Licensed Practical Nurse (LPN)-HH on 1/11/26 & 1/13/26.Certified Nursing Assistant (CNA)-K on 1/11/26, 1/15/26, 1/16/26, 1/19/26, 1/20/26, 1/21/26, 1/24/26,…

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 reduce the transmission of disease and infection for 7 (R13, R10, R3, R6, R5, R12, & R7) of 7 residents.* Staff did not wear appropriate PPE (personal protective equipment) when administering R13's medication via the feeding tube and providing personal cares on 2/5/26. R13 is on EBP (enhanced barrier precautions).*Staff did not wear appropriate PPE when suctioning R10 and during therapy on 2/5/26. R10 is on EBP.*Staff did not wear appropriate PPE when repositioning R3 on 2/5/26. R3 is on EBP and contact isolation.*There is no EBP sign posted outside R6's room and staff did not wear appropriate PPE when transferring R6 from the Broda chair into bed on 2/5/26. *Staff did not wear appropriate PPE (personal protective equipment) when providing incontinent cares for R5, R12, & R7. R5, R12, & R7 are on EBP (enhanced barrier precautions).Findings include:The facility's policy titled, Enhanced Barrier Precautions and dated 3/25/24 under policy documents It…

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 baseline care plan was developed and implemented within 48 hours of a resident's admission for 1 (R1) of 1 resident. R1's baseline Activities of Daily Living (ADL) care plan was not completed within the required 48 hours timeframe. The facility did not provide evidence that the baseline care plan was reviewed with R1. Findings include: R1 was admitted to the facility on [DATE]. R1 was hospitalized [DATE] - 1/9/26 due to left cerebellar intracranial hemorrhage (a critical life-threatening medical emergency involving bleeding inside the skull which can rapidly destroy brain cells by causing pressure and oxygen deprivation). R1's diagnoses include intracranial hemorrhage, dysphagia (difficulty swallowing), morbid obesity, atrial fibrillation (irregular heart rate), heart disease, transient ischemic attack (TIA) (temporary blockage of blood flow to the brain), and cognitive impairment (decline in mental abilities). R1's admission Minimum Data Set…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure 1 (R2) of 1 received the necessary care and treatment for a venous wound. On 1/10/25, the nurses note document R2 developed a wound to the left heel. There is no comprehensive assessment or treatment order for the left heel wound until 1/12/26. There was no baseline care plan related to skin integrity until 1/12/26.Findings include:The facility's Skin Tears-Abrasions and Minor Breaks, Care of policy dated 10/2025 documents:Documentation:Record the following information in the resident's medical record:1. Complete in house investigation of causation2. Generate non pressure form3. Document physician and family notification, and resident education (if completed) in medical record.4. How the resident tolerated the procedure5. Any problems or resident complaints related to the procedure.6. Any complications related to the abrasion (e.g. pain, redness, drainage, swelling, bleeding, decreased movement)7. If the resident refused the treatment, the reason…

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 1 (R5) of 3 residents who are fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding.During personal care observations on 2/5/25 R5's head of the bed was lowered flat while the tube feeding continued to be running.Findings include:On 2/9/26 Surveyor requested the facility's Tube Feeding policy. On 2/10/26 Regional Nurse-D informed Surveyor she can't locate a Tube Feeding policy and provided an audit form. The facility's Tube Feeding Audit Form not dated under Criteria documents, Head of bed elevated to 30-45 degrees during feedin [sic] (feeding).R5's diagnoses includes anoxic brain damage (brain is deprived of oxygen leading to cell death), dysphagia (difficulty swallowing), chronic respiratory failure (long term condition where the lungs cannot adequately exchange oxygen and carbon dioxide), quadriplegia (paralysis of all four limbs), and pneumonitis (inflammation of the alveoli or air sacs in the lungs) due to inhalation of food and vomit.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 1 (R1) of 2 residents reviewed for medications were provided pharmaceutical services to meet the needs of the resident. R1 was admitted to the facility on [DATE] and did not receive multiple scheduled medications in January 2026 and February 2026, did not receive as needed (PRN) Hydralazine as ordered for elevated blood pressure (BP), and did not receive multiple scheduled BP checks in January 2026 and February 2026. Findings include: The facility's policy titled Medication Orders, dated 8/2/22, last reviewed 10/21/25, documents:The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders.A current list of orders must be maintained in the clinical record of each resident.Orders must be written and maintained in chronological order.Physician Orders/Progress Notes must be signed and dated every thirty (30) days.Recording Orders:Medication Orders - When recording orders for medication, specify…

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 therapy services were provided in a timely manner for 2 (R1 and R2) of 2 residents reviewed for therapy services. *R1 was admitted to the facility on [DATE] for rehabilitation after hospitalization for intracranial hemorrhage requiring Physical Therapy (PT). R1 did not start PT until 1/12/26. *R2 was admitted on [DATE] for rehabilitation. R2 did not receive physical therapy services until 1/8/26. R2 was discharged to the hospital on 1/12/26 and received only 2 physical therapy sessions. Findings include: The facility's policy titled Therapy Services, that is not dated, documents the following: Facility will schedule and conduct therapy evaluations and services in accordance with the resident's treatment plan and Medicare guidelines. The therapist shall interview the resident and consult with the attending physician as to the type of treatment to be administered. Therapy is scheduled in coordination with nursing service and is documented in 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, interview and record review the facility did not ensure residents with non-pressure wounds received treatment and care in accordance with professional standards of practice for 1 (R6) of 1 residents with a non-pressure wound; and based on interview and record review the facility did not thoroughly complete neurological checks in accordance with professional standards of practice for 1 (R4) of 2 residents reviewed for unwitnessed falls.*R6 has a diagnosis of diabetes and a care plan intervention to inspect feet daily for open areas, sores, pressure areas, blisters, edema or redness. Facility did not provide documentation that daily foot checks were being completed. R6 developed a right heel diabetic wound on 9/22/25. R6's wound MD ordered a treatment that was not put in place by facility staff. Facility staff did not document any additional wound assessments and did not document the completion of wound care after 9/22/25. On 10/9/25, Surveyor observed R6's right heel and noted R6's heel…

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 necessary care and services to provide respiratory care for 1 (R6) of 2 Residents receiving oxygen care. *R6's tracheotomy tube was removed on 2/12/25. After removal, R6 was placed on oxygen (O2) via nasal cannula. R6 did not have a physician order for oxygen. R6's care plan was not updated to document the specifics related to R6 receiving O2 via nasal cannula. Findings include: The undated facility policy titled, Oxygen Administration documents, in part: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation- Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. R6 was admitted to the facility on [DATE] with diagnosis that include: acute respiratory failure with hypoxia, chronic respiratory failure, chronic obstructive pulmonary disease (COPD), asthma, and tracheostomy. R6's Quarterly Minimum Data Set (MDS)…

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

Based on interview and record review, the facility did not develop, implement, and maintain an effective 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. * Dietary Aide (DA)-J, Housekeeper (HK)-K, Registered Nurse (RN)-I, Registered Dietitian (RD)-L and Certified Nursing Assistants (CNA) CNA-M, CNA-N, CNA-O, CNA-P and CNA-Q did not have documentation that they completed the required training. This practice had the potential to affect all 59 Residents in the facility. Findings include: The facility's In-Service Training, All Staff revised August 2022 documents: Policy Statement All staff must participate in initial orientation and annual in-service training. Policy Interpretation and Implementation 1. All staff are required to participate in regular in-service education. 2. For the purposes of this policy, staff means all new and existing personnel, individuals providing services under contractual agreement, and volunteers. 3. The primary objective of the in-service training 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 interview and record review, the facility did not ensure 6 of 6 direct staff chosen at random received effective communication training. * Registered Nurse (RN)-I, Registered Dietitian (RD)-L, and Certified Nursing Assistants (CNA) CNA-M, CNA-N, CNA-O, CNA-P and CNA-Q did not receive effective communication training. This practice had the potential to affect all 59 Residents in the facility. Findings Include: The facility's In-Service Training, All Staff revised August 2022 documents: Policy Statement All staff must participate in initial orientation and annual in-service training. Policy Interpretation and Implementation .1. All staff are required to participate in regular in-service education. 2. For the purposes of this policy, staff means all new and existing personnel, individuals providing services under contractual agreement, and volunteers. 3. The primary objective of the in-service training is to ensure that staff are able to interact in a manner that enhances the Resident's quality of life and quality of care and can demonstrate competency in the topic areas 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 ensure 8 of 8 facility staff chosen at random received either abuse prevention, activities that constitute abuse, procedures for reporting abuse and/or dementia management training. * Dietary Aide (DA)-J, Housekeeper (HK)-K, Registered Nurse (RN)-I, and Certified Nursing Assistants (CNA) CNA-M, CNA-N, CNA-O, CNA-P and CNA-Q did not receive behavioral health training. In addition, contracted employee, Registered Dietitian (RD)-L did not receive abuse prevention, activities that constitute abuse, procedures for reporting abuse and dementia management training. *DA-J has no documentation that DA-J received abuse prevention, activities that constitute abuse, procedures for reporting abuse and dementia management training. *HK-K has no documentation that HK-K received abuse prevention, activities that constitute abuse, procedures for reporting abuse and dementia management training. *RN-I has no documentation that RN-I received abuse prevention, activities that constitute abuse, and procedures for reporting abuse. *RD-L has no…

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 8 of 8 facility staff chosen at random received QAPI training. Dietary Aide (DA)-J, Housekeeper (HK)-K, Registered Nurse (RN)-I, and Certified Nursing Assistants (CNA) CNA-M, CNA-N, CNA-O, CNA-P and CNA-Q did not receive QAPI training. In addition, contracted employee, Registered Dietitian (RD)-L did not receive QAPI training. This practice had the potential to affect all 59 Residents in the facility. The facility did not provide staff with the required annual QAPI training which included the elements and goals of QAPI for 5 CNAs, CNA-M, CNA-N, CNA-O, CNA-P, CNA-Q, DA-J, HK-K, RN-I, and RD-L. Findings Include: The facility's In-Service Training, All Staff revised August 2022 documents: Policy Statement .All staff must participate in initial orientation and annual in-service training. Policy Interpretation and Implementation .1. All staff are required to participate in regular in-service education. 2. For the purposes of this policy, staff means all new and existing personnel, individuals providing services under…

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 8 of 8 facility staff chosen at random received infection control training. Dietary Aide (DA)-J, Housekeeper (HK)-K, Registered Nurse (RN)-I, and Certified Nursing Assistants (CNA) CNA-M, CNA-N, CNA-O, CNA-P and CNA-Q did not receive infection control training. In addition, contracted employee, Registered Dietitian (RD)-L did not receive infection control training. The facility did not provide staff with the required annual infection control training which included standards, policies, and procedures of the facility's infection control program for 5 CNAs, CNA-M, CNA-N, CNA-O, CNA-P, CNA-Q, DA-J, HK-K, RN-I, and RD-L. This practice had the potential to affect all 59 residents in the facility. Findings Include: The facility's In-Service Training, All Staff revised August 2022 documents: Policy Statement All staff must participate in initial orientation and annual in-service training. Policy Interpretation and Implementation .1. All staff are required to participate in regular in-service education. 2. For the purposes 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 ensure 8 of 8 facility staff chosen at random received compliance and ethics training. Dietary Aide (DA)-J, Housekeeper (HK)-K, Registered Nurse (RN)-I, and Certified Nursing Assistants (CNA) CNA-M, CNA-N, CNA-O, CNA-P and CNA-Q did not receive compliance and ethics training. In addition, contracted employee, Registered Dietitian (RD)-L did not receive compliance and ethics training. The facility did not provide staff with the required compliance and ethics training which included standards, policies, and procedures of the facility's compliance and ethics for 5 CNAs, CNA-M, CNA-N, CNA-O, CNA-P, CNA-Q, DA-J, HK-K, RN-I, and RD-L. This practice had the potential to affect all 59 residents in the facility. Findings Include: The facility's In-Service Training, All Staff revised August 2022 documents: Policy Statement All staff must participate in initial orientation and annual in-service training. Policy Interpretation and Implementation .1. All staff are required to participate in regular in-service education. 2. 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.

Based on interview and record review, the facility did not ensure that 5 of 5 CNAs (Certified Nursing Assistants)(CNA) reviewed completed the required annual 12 hours of educational training hours. CNA-M, CNA-N, CNA-O, CNA-P and CNA-Q did not receive annual 12 hours of educational training. This had the potential to affect all 59 residents who reside in the facility. Findings include: The facility's Facility Assessment last reviewed July 2024 documents: Staff training/education and competencies A competency approach is used to determine the knowledge and skills required among staff and contracted employees. .on-going monitoring of staff care and work conducted to ensure Residents are able to maintain or attain their highest practicable physical, functional, mental and psychosocial well-being and meet current professional standards of practice . .Competencies Obtained/Evaluated Education Provided for CNAs -Annual skills checks through staff development -As needed training from vendor, professional group or other for new/unique skill sets required for member care -Minimum of 12 credit…

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 8 of 8 facility staff chosen at random received behavioral health training. Dietary Aide (DA)-J, Housekeeper (HK)-K, Registered Nurse (RN)-I, and Certified Nursing Assistants (CNA) CNA-M, CNA-N, CNA-O, CNA-P and CNA-Q did not receive behavioral health training. In addition, contracted employee, Registered Dietitian (RD)-L did not receive behavioral health training. The facility did not provide staff with the required behavioral health training for 5 CNAs, CNA-M, CNA-N, CNA-O, CNA-P, CNA-Q, DA-J, HK-K, RN-I, and RD-L This practice had the potential to affect all residents with a psychiatric diagnosis and/or that have the potential to experience behavioral health issues in the facility. Findings Include: The facility's In-Service Training, All Staff revised August 2022 documents: Policy Statement All staff must participate in initial orientation and annual in-service training. Policy Interpretation and Implementation .1. All staff are required to participate in regular in-service education. 2. For the purposes of this…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility did not ensure that 1 (R4) of 4 residents reviewed at risk for the development of pressure injuries receives care, consistent with professional standards of practice, to prevent pressure ulcers. * R4 was observed to have heels resting directly on the mattress and not wearing heel boots to offload pressure per R4's plan of care. Findings include: 1.) R4 was readmitted to the facility on [DATE] with a diagnosis that included Acute Respiratory Failure, Tracheostomy Status, Encephalopathy and Anoxic Brain Damage. R4's Annual MDS (Minimum Data Set) dated 12/29/24 documents short and long term memory problems for R4. Section G documents that R4 is dependent on facility staff for all mobility and self-care needs. Section M (Pressure Injuries) documents that R4 is at risk for the development of pressure ulcers/injuries. R4's Pressure Ulcer/Injury CAA (Care Area Assessment) dated 12/29/24, documents under the Care Plan Considerations section, At risk 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 observation, record review and interview, the facility did not ensure that 1(R4) of 1 residents with with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable. * R4 was observed not to have on splints on either hand to prevent further contractures and maintain mobility. Findings include: 1.) R4 was readmitted to the facility on [DATE] with a diagnosis that included Acute Respiratory Failure, Tracheostomy Status, Encephalopathy and Anoxic Brain Damage. R4's Annual MDS (Minimum Data Set) dated 12/29/24 documents short and long term memory problems for R4. Section G documents that R4 is dependent on facility staff for all mobility and self-care needs. R4's Therapy to Recommendation form dated 9/5/24 documents, Patient to wear carrot splint on LUE (left upper extremity), resting hand splint (soft) on RUE (right upper extremity). Monitor skin integrity,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility did not ensure that 1(R4) of 1 residents reviewed received adequate supervision and assistance devices to prevent accidents. * R4's call light was not observed not to be in reach and R4's room door was observed closed despite R4's plan of care documenting that R4's room door had to remain open to ensure R4's safety and supervision. Findings include: 1.) R4 was readmitted to the facility on [DATE] with a diagnosis that included Acute Respiratory Failure, Tracheostomy Status, Encephalopathy and Anoxic Brain Damage. R4's Annual MDS (Minimum Data Set) dated 12/29/24 documents short and long term memory problems for R4. Section G documents that R4 is dependent on facility staff for all mobility and self-care needs. R4's Falls CAA (Care Area Assessment) dated 12/29/24, documents under the Care Plan Considerations section, Has fall risks and requires monitoring and preventative measures. R4's Therapy to Recommendation form dated 9/5/24 documents, Patient…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility did not ensure that 1 (R4) of 1 residents reviewed that are fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. * R4 was observed to recieve enteral feeding with the head of the bed at less than 30 degrees. Findings include: 1.) R4 was readmitted to the facility on [DATE] with a diagnosis that included Acute Respiratory Failure, Tracheostomy Status, Encephalopathy and Anoxic Brain Damage. R4's Annual MDS (Minimum Data Set) dated 12/29/24 documents short and long term memory problems for R4. Section G documents that R4 is dependent on facility staff for all mobility and self-care needs. R4's Feeding Tube CAA (Care Area Assessment) dated 12/29/24, documents under the Care Plan Considerations section, Ongoing…

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

Based on observation, interview, and record review, the facility did not implement an effective infection control program. This was observed in the facility laundry and preventative outbreak measures. This had the potential to effect the 61 residents currently in the facility. * The facility's soiled laundry area did not have handwashing/hand hygiene accessibility for staff after handling soiled linens. * The facility did not have a process to track staffs' N95 mask fit testing. There was not a system to identify what staff were fit tested to work with residents requiring staff to wear N95 mask PPE (Personal Protective Equipment). Findings include: 1.) On 10 /28/24, at 1:48 PM, Surveyor observed the Laundry Services with (Housekeeping Supervisor) HS-H and (Laundry Aide) LA-I. Surveyor observed the soiled linen area did not have accessible handwashing. There was a non-working, residential size, washing machine in front of the utility tub sink. There were no hand soap products, no hand drying towels, and a utility hose attached to the spigot. HS-H and LA-I stated they wash their hands…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2.) R38 was admitted to the facility on [DATE] with diagnosis that include Schizoaffective Disorder, Bipolar Disorder, Dependence on Respirator [Ventilator], Status. R38's Quarterly MDS (minimum data set) assessment dated [DATE] documents: Functional Limitation in Range of Motion: Impairment of both sides of the upper and lower extremity; contractures of the bilateral hands; uses a wheelchair with total assistance from staff for mobility; requires total assist with all cares from staff; Requires 2 assist and mechanical lift for transfers; hearing is adequate. R38 is unable to perform a BIMS (Brief interview for Mental Status) and has been documented by the facility as rarely understood and rarely understands. On 10/29/24, at 10:20 AM, Surveyor completed a record review and noted R38 was being followed by psychiatric services related to the use of Zyprexa. R38 is documented to be prescribed Zyprexa for Schizoaffective Disorder and Bipolar Disorder with behaviors. R38's mood and behavior plan of care initiated…

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 accurately complete the PASARR (Preadmission Screening and Resident Review) Level I for residents with a possible serious mental disorder on admission to the referring agency to complete the PASARR Level II for 1 (R27) of 5 residents reviewed for PASARR completion. *R27 had a PASARR Level I completed on admission that did not indicate the use of an antipsychotic medication. A PASARR Level II was not triggered or completed. Findings include: The facility policy and procedure entitled PASARR Guideline dated 11/28/2023 documents: PROCEDURE: 1. admission and readmission: a. The facility will participate in or complete the Level I screen for all potential admissions regardless of payer source to determine if the individual meets the criterion for mental disorder (SMI/SMD), intellectual disability (ID) or related condition. b. Based upon the Level I screen, if an individual is determined to meet the above criterion, the facility will not admit an 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not develop and implement a comprehensive person-centered care plan for each resident for 1 (R46) of 17 sampled residents. *R46 did not have a Care Plan for the use of quetiapine, an antipsychotic medication, when it was initiated. Findings include: The facility policy and procedure entitled Psychotropic medication, use of dated 5/1/2023 documents: PROCEDURE: . 7. Residents who use psychotropic drugs shall also receive non-pharmacological interventions to facilitate reduction or discontinuation of the psychotropic drugs. R46 was admitted to the facility on [DATE] with diagnoses of anoxic brain damage, acute respiratory failure with dependence on a respirator, encephalopathy, and congestive heart failure. R46's admission Minimum Data Set (MDS) assessment dated [DATE] documented R46 was severely cognitively impaired per staff assessment and unable to verbalize to answer questions. R46 had a tracheostomy and was ventilator dependent requiring suctioning and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility did not ensure 1 (R 14) of 2 Residents reviewed for pain management, received pain management consistent with professional standards of practice. *R14 had multiple observations of expressive pain with no effective pain relief, PRN medications available for 4 days until brought forward by Surveyor. Findings include: The Facility's policy titled, Pain-Clinical Protocol revised March 2018. . Assessment and recognition: 1. The physician and staff will identify individuals who have pain or who are at risk for having pain. 5. The staff and physician will evaluate how pain is affecting mood, activities of daily living, sleep, and the resident's quality of life, as well as how pain may be contributing to complications such as gait disturbances, social isolation, and falls. Treatment and Management: 1. With input from the resident to the extent possible, the physician and staff will establish goals of pain treatment, for example, freedom from pain 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 record review and interview, the facility did not act upon the pharmacy medication regimen review reports when received. This was observed with 1 (R34) of 5 resident medication reviews. * R34's monthly pharmacy reviews noted an irregularity reported on 6/19/24, 7/29/24 and 10/29/24 (same concerns from previous month's readmission review 9/23/24). There was not documentation the identified irregularities were acted upon by the attending physician. Findings include: The facility's policy and procedure Medication Regimen Reviews dated May 2019, documents: . 12.) The attending physician documents in the medical record that the irregularity has been reviewed and what (if any) action was taken to address it. R34's medical record was reviewed for monthly pharmacy medication reviews. R34 was admitted to the facility on [DATE] with a trach and gastronomy tube. R34 does not take anything by mouth. -R34's pharmacy review dated 6/19/24 documents an irregularity report was generated. This was for Lipid Panel…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure residents who receive psychotropic medications received behavioral interventions and medication side effect monitoring for 2 (R46 and R27) of 5 residents reviewed for unnecessary medications. *R46 did not have documentation of monitoring for side effects of the antidepressant, antianxiety, and antipsychotic medications. R46 did not have a diagnosis for the use of quetiapine on the medication consent form, and an Abnormal Involuntary Movement Scale (AIMS) test was not completed every six months. Behavior monitoring was not documented with individualized behaviors R46 exhibits. *R27 did not have monitoring of side effects for the use of antidepressant and antipsychotic medications. Findings include: The facility policy and procedure titled Psychotropic medication, use of dated 5/1/2023 documents: POLICY: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and…

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

Based on observation, interview, and record review, the facility did not ensure the medication error rate was not 5 percent or greater. 2 (R14 and R31) of 4 residents observed during medication pass were affected. The medication error rate was 5.26 percent, 2 errors out of 38 opportunities. Findings include: 1.) R14 had an order for Vitamin D 5,000 units once daily. On 10/29/2024, at 7:44 AM, Medication Technician (MT)-J administered Vitamin D 50,000 units. In an interview on 10/29/2024, at 8:40 AM, Surveyor asked MT-J to show the stock medication bottle of Vitamin D to Surveyor to verify what dose of Vitamin D was administered. MT-J stated MT-J just saw that MT-J should have given 5,000 units of Vitamin D and MT-J gave 50,000 units. MT-J provided the bottle of Vitamin D with 5,000 units and 50,000 units and agreed MT-J had administered the wrong dose. MT-J stated the doctor would be notified and R14 would be placed on the 24-hour board for monitoring of any side effects. 2.) R31 had an order for Lantus glargine (insulin) 34 units twice daily. On 10/29/2024, at 8:06 AM, 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 upon interview and record review, the facility's governing body failed to fulfill the responsibilities of the governing body to include establishing an implementing policies and procedures regarding the operations of the facility. This has the potential to affect all 56 residents present in the facility at the time of the survey. The facility's governing body did not ensure contracted vendors were reimbursed and paid in accordance with established contracts or billed amounts causing the facility's fiscal accounts to be in arrears. This has created the likelihood where good and services necessary to maintain operations of the facility along with care and treatment of the residents may be impacted by the failures of the governing body. Findings include: Policy Number: CP 1.1.0 A Rev. Date 7/2019, documents in part: Governing Body Duties and Responsibilities: A. Policies and Procedures: The Governing Body is legally responsible for establishing and implementing policies regarding the management and operation…

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 maintain an infection prevention and control program according to professional standards of practice having the potential to affect all 37 residents residing in the facility at the time of the survey. *The facility did not have a comprehensive water management program including text and/or diagram detailing the facility's water system. The water management plan did not identify control measures the facility would take related to areas that could potentially house Legionella or other waterborne bacteria. Findings include: Facility policy entitled, Legionella Water Management Program, revised 09/2022 documented, .3) The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow, and to reduce the risk of Legionnaire's disease .5) The water management program includes the following elements: .b) A detailed description and diagram of the water system in the facility, including the following: 1) Receiving 2) Cold water distribution 3) Heating 4) Hot Water distribution 5)…

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 record review and interview the Facility did not ensure 1 (R7) of 12 Resident's physician was consulted with regarding medication parameters for a resident. R7 receives Humalog on a sliding scale three times a day with instructions if R7's blood sugar is above 450 to receive 12 units of Humalog and call MD (medical doctor). On 9/2/23 R7's blood sugar was 455. R7 received Humalog 12 units but there is no evidence R7's physician was consulted with. Findings include: R7's physician orders with an order date of 6/22/23 documents Humalog Solution Cartridge 100 unit/ml (milliliter) (Insulin Lispro) per sliding scale Inject subcutaneously three times a day for DM (diabetes mellitus) note: if accu check reading is < (less than) 70 repeat accu check in 15 min. (minutes) if it remains low call MD. if > (greater than) 70 follow sliding scale. R7's September 2023 MAR (medication administration record) documents Humalog Solution Cartridge 100 unit/ml (Insulin Lispro) Inject as per sliding scale: if 70-90 = (equals) 2; 91-130=4; 131-150=5; 151-200=6; 201-250=7; 251-300=8; 301-400=10;…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the Facility did not ensure 1 (R241) of 1 Residents discharged to the community received a completed discharge summary. R241 was discharged on 8/8/23. The discharge summary information which includes a recapitulation of R241's stay documents the summary is in progress and has not been completed. Findings include: R241 was admitted to the facility on [DATE] and discharged on 8/8/23. Diagnoses includes hypertension, diabetes mellitus, status post lumbar fusion, scoliosis of lumbar region, and fibromyalagia. The nurses note dated 7/21/23 documents Resident arrived to facility transported via ambulance and 2 EMT (emergency medical technician) assist. Resident is alert and orient (orientated) x (times) 4. Skin is warm and dry. Lungs cta (clear to auscultation) bilateral. Bowel sounds active x4. Resident transferred off gurney with assist of 2 and wheeled walker. She also ambulated to the bathroom with staff assist of 1. Resident had spinal fusion with 10 staples intact to lower…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the Facility did not ensure 1 (R17) of 12 Residents reviewed received required assistance with their ADL's (activities daily living). R17 did not receive incontinence cares according to his plan of care and was observed with two incontinence briefs on. Findings include: R17's diagnoses includes diabetes mellitus, cerebral infarction, metabolic encephalopathy, spinal stenosis, and quadriplegia. The ADL (Activities Daily Living) Self care deficit care plan initiated 4/14/22 & revised 8/16/23 includes interventions of: * Transfers: Mechanical lift Hoyer. Initiated 4/14/22 & revised 2/15/23. * Bowel Movement: Incontinent, wears briefs. Initiated 4/14/22 & revised 2/15/23 * Toileting: assist one to two, apply barrier cream with incontinence care. Initiated 4/14/22 & revised 2/15/23. * Voiding: incontinent, wears briefs. Initiated 4/14/22 & revised 2/15/23. The falls care plan initiated 4/26/22 & revised 6/12/23 includes an intervention of *Toileting: I prefer to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure that the residents received care consistent with professional standards of practice to prevent pressure injuries and residents did not receive necessary treatment and services, consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 2 (R26 and R26) of 4 residents reviewed for pressure injuries. * R26 did not have a comprehensive assessment and measurements of wounds upon readmission from the hospital. *R27 was observed with heels not being offloaded and offloading heels intervention was not included in R27's care plan. Findings include: The facility policy entitled Pressure Injury Risk Assessment revised March 2020 states: The purpose if this procedure is to provide guidelines for the structured assessment and identification of residents at risk of developing new pressure injuries or worsening of existing pressure injuries. General Guidelines 1. The purpose of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility did not ensure that residents received proper foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s) and assisting the resident in making necessary appointments with qualified healthcare providers such as podiatrists for 1 of 1 (R12) residents reviewed for foot care. Findings include: R12 admitted to the facility on [DATE] and has diagnoses that include: Chronic Respiratory Failure with hypoxia, Chronic Obstructive Pulmonary Disease, anoxic brain damage, unspecified severe protein-calorie malnutrition, Epilepsy, Diastolic (Congestive) Heart Failure, Anxiety Disorder, tracheostomy status, dependence on respirator (ventilator), major depressive disorder, gastrostomy and malignant neoplasm of prostate. The facility policy titled Foot Care (revised October 2022) documents (in part) . .Policy statement: Residents receive appropriate care and treatment in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the Facility did not provide 2 (R17, R12) of 5 Residents reviewed for falls and 1 (R17) of 2 Residents reviewed with thickened liquids the supervision and assistance to prevent accidents. * R17's falls on 3/15/23, 4/13/23, & 6/4/23 were not thoroughly investigated to help prevent further falls. On 9/11/23 R17 received nectar thick juice. R17's physician orders document honey thick consistency. * R12's fall was not thoroughly investigated and the root cause was not determined to help prevent further falls. Findings include: 1.) R17's diagnoses includes diabetes mellitus, dysphagia, cerebral infarction, metabolic encephalopathy, spinal stenosis, and quadriplegia. The quarterly MDS (minimum data set) with an assessment reference date of 7/29/23 has a BIMS (brief interview mental status) score of 9 which indicates moderate cognitive impairment. R17 is assessed as requiring extensive assistance with two plus person physical assist for bed mobility & toilet use, 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 observations, interview and record review the facility did not ensure 2 of 2 residents (R244 and R7) reviewed for Dialysis received Dialysis care in accordance with professional standards of practice. *R244 did not have physician's orders for dialysis and the staff were not assessing R244's fistula site on a regular basis. *R7 did not have a physician's order for dialysis and the staff were not assessing R7's dialysis access site on a regular basis. Findings include: 1.) R244 was admitted to the facility on [DATE] with diagnoses including end stage renal failure on hemodialysis. R244's admission Minimum Data Set Assessment was still in progress at the time of this survey due to R244 being hospitalized from [DATE] to 09/04/23. R244's care plan, dated 08/31/23, documented, The resident receives dialysis [sic] hemodialysis R/T (related to) end stage renal dialysis. [name of dialysis center and address], and had interventions including, Monitor Dialysis site Left AVF (Arteriovenous Fistula) for s/s (signs…

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 each Resident's drug regimen was free from unnecessary drugs for 1 (R7) of 5 Residents reviewed. * R7's Midodrine HCl 10 mg three times a day was not consistently held for systolic blood pressure above 110. Findings include: R7's physician orders include with an order date of 6/22/23 Midodrine HCI Oral Tablet 10 mg (milligrams) (Midodrine HCI) Give 10 mg by mouth three times a day for hypotension. Take 1 tablet by mouth three times daily. * Hold for systolic blood pressure above 110. Surveyor reviewed R7's August 2023 MAR (medication administration record) and noted for Midodrine HCI 10 mg the following: On 8/4/23 at 1600 (4:00 p.m.) R7's blood pressure is documented as 128/90. R7's Midodrine HCI 10 mg was administered and should have been held. On 8/5/23 at 0800 (8:00 a.m.) R7's blood pressure is documented as 123/76. R7's Midodrine HCI 10 mg was administered and should have been held. On 8/5/23 at 1200 (12:00 p.m.) R7's blood pressure is documented as 123/76. R7's Midodrine HCI 10 mg was administered and should have…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the Facility did not ensure there was a medication error rate below 5 percent. There were 5 medication errors in 34 opportunities which resulted in a medication error rate of 14.71%. Medication errors were identified for R6, R8 & R12. * R6's Mucinex Allergy Tablet was not available to be administered & Artificial Tears Lubricant was not dated when opened. * R8's Colace 100 mg and Cyancobalamin (Vitamin B12) not available. * R12 was administered Guaifenesin liquid versus Guaifenesin oral tablet 100 mg as ordered. Findings include: 1.) On [DATE] at 7:30 a.m. Surveyor observed LPN (Licensed Practical Nurse)-F prepare R6's medication which included Buspirone HCI 10 mg (milligram) one tablet, Divalproex Sodium ER (extended release) 500 mg one tablet, Multivitamin one tablet, Clear Lax 17 grams with water and Artificial Tears lubricant eye drops. At 7:36 a.m. Surveyor inquired if this was all of R6's medication. LPN-F informed Surveyor she has to see if Mucinex…

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 interview the Facility did not ensure medications were disposed of when expired and dated when opened in 2 of 2 medication carts and 1 of 1 medication rooms affecting R37 & R21. * R37's Semglee insulin vial was not dated when opened & used. * R21's Lantus pen was not dated when open & used and a dose of Hydralazine HCI 25 mg was expired on [DATE]. * Stock Bisacodyl 5 mg was expired 7/23 in the [NAME] medication cart. * Two white pills were not in a container and were laying in a drawer to the left of the white refrigerator in the north/west medication room. Findings include: 1.) On [DATE] at 7:58 a.m. Surveyor observed in the third drawer on the right side in the Vent unit's medication cart Semglee 100 units/ml (milliliters) insulin vial which was opened & used and not dated for R37. On [DATE] at 8:01 a.m. Surveyor asked RN (Registered Nurse)-J if Resident's insulin should be dated when opened. RN-J replied yes. Surveyor showed RN-J R37's Semglee insulin vial which was opened & used 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 interview, and record review the Facility did not promptly refer a Resident to a oral surgeon for 1 (R7) of 1 Residents reviewed for dental services. The [Name of Dental Company] dentist, who examines Residents in the Facility, on 6/9/23 documents Facility staff needs to set up oral surgery appointment. This appointment was not set up until 9/11/23. Findings include: R7's quarterly MDS (minimum data set) with an assessment reference date of 7/8/23 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. R7 is assessed as being independent with set up help only and for personal hygiene which includes bushing teeth is assessed as requiring extensive assistance with two plus person physical assist. The dental consult dated 6/9/23 under treatment notes documents Reviewed Medical History; Exam done in patient's room; Instructed patient on daily oral care; Patient has plaque and calculus buildup and would benefit from a cleaning every 3 months; Recommend fluoride varnish due to patient's moderate risk for caries; Patient is afebrile and covid…

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.