Avina of Milwaukee

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure 1 (R43) of 6 residents had necessary interventions to monitor weight.R43's physician order dated 1/27/26 documents that R43 is to be weighed Monday, Wednesday and Friday for two weeks and then weekly thereafter. R43's medical record reveals R43 has a documented weight on 1/21/26, 2/2/26 and 2/3/26. Weights were not obtained per physician orders.Findings include:R43 was admitted to the facility on [DATE] with diagnoses of dementia, congestive heart failure, chronic obstructive pulmonary disease and cardiomyopathy. R43 was discharged home during the survey on 3/11/25.R43's admission Minimum Data Set (MDS) dated [DATE] documents that R43 is cognitively intact, needs maximum assistance with toileting and moderate assistance with dressing.R43's care plan for potential for altered nutritional status related to diagnoses/history of cardiomyopathy, adult failure to thrive, congestive heart failure (CHF), cardiovascular accident (CVA), chronic obstructive…

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 require dialysis receive such services, consistent with professional standards of practice, including the ongoing communication with the dialysis center before and after dialysis treatments, for 1 (R82) of 2 residents reviewed for dialysis. R82 has a physician order for dialysis on Monday, Wednesday and Friday. Communication between the facility and the dialysis center was not being shared with each dialysis visit.Findings include:The Facility Policy titled Hemodialysis implemented 1/31/2026 documents: Policy- This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis.Purpose:The facility will assure that each resident receives care and services for the provision 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 observation, interview and record review the facility did not ensure its medication error rate was not 5 percent or greater. The medication error rate was 14.81%.Findings include:The facility policy titled Medication Administration dated 1/1/26 documents: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.10. Ensure that the six rights of medication administration are followed:a. Right residentb. Right drugc. Right dosaged. Right routee. Right timef. Right documentationOn 3/10/26 at 7:45 AM, Surveyor observed Medication Technician (MT)-H prepare medications for R7. While preparing the medications, MT-H stated he did not have a 6 mg (milligram) tablet of Austedo and went to talk to nurse. After talking to the nurse, MT-H reported the medication cannot be broken in half because it is not scored, and pharmacy would deliver the medication this afternoon.Surveyor verified the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility did not ensure that drugs and biologicals used in the facility were stored under proper temperature controls, were labeled in accordance with currently accepted professional principles, and include the expiration date when applicable for 1 of 2 medication rooms and 2 of 6 medication carts observed.Insulin was not dated when opened and/or was expired and the medication refrigerator temperature was above the recommended temperature.Findings include:The facility policy titled Storage of Medication Requiring Refrigeration dated [DATE] documents (in part): It is the policy of this facility to assure proper and safe storage of medications requiring refrigeration and to prevent the potential alteration of medication by exposure to improper temperature controls.2. The facility will ensure that all drugs and biologicals used will be labeled in accordance with professional standards, including expiration dates (when applicable).3. The facility will ensure that all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that a resident continued to receive specialized rehabilitative services for 1(R67) of 1 residents reviewed for rehabilitation services.R67 was discharged from Occupational Therapy services on 3/3/26 when goals were not met and R67 was cooperative in participation.Findings include:R67 was admitted to the facility on [DATE] with diagnoses that include hemiplegia (severe or complete paralysis of one side of the body) and hemiparesis (neurological condition characterized by mild to moderate weakness or reduced control of one side of the body) following a cerebral infarction (stroke) affecting the left non-dominant side, chronic obstructive pulmonary disease, mild protein-calorie malnutrition, heart failure and vascular dementia.R67's Minimum Data Set (MDS) assessment, dated 3/28/25, documents R67 has a Brief Interview for Mental Status (BIMS) of 3, indicating severe cognitive impairment. The MDS documents the following assessments: R67 has no upper…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure a resident's hospice notes were readily available for communication and collaboration of care in accordance with professional standards of practice for 1 (R60) of 2 residents reviewed for hospice services.*Hospice visit notes were not updated or ready available in R60's medical record or in R60's hospice binder until Surveyor requested the information.Findings include:The facility's policy and procedure titled, Coordination of Hospice Services, implemented 1/31/26, documents: Policy: When a resident chooses to receive hospice care and services, the facility will coordinate and provide care in cooperation with hospice staff in order to promote the resident's highest practicable physical, mental, and psychosocial well-being.Policy Explanation and Compliance Guidelines:4. The facility will communicate with hospice and identify, communicate, follow and document all interventions put into place by hospice and the facility.5. The facility…

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

Based on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to provide a safe and sanitary environment to reduce the development and transmission of communicable diseases and infections for 2 (R4 & R7) of 2 residents reviewed during medication pass. *Medication Technician (MT)-H was observed dropping a medication cup onto floor, picking it up then using the same medication cup, and placing R7's medications into MT-H's bare hand when administering R7's medications.*Registered Nurse (RN)-F did not wear a gown when administering R4's medication through a gastrostomy tube. Findings include:The facility policy titled Enhanced Barrier Precautions dated 1/1/26 documents:It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms.Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and gloves use during high…

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 3 (R1, R5, & R3) of 4 residents had the right to participate in the development and implementation of their person-centered plan of care. R1, R5, & R3 did not have evidence of quarterly care plan meetings and facility staff did not know when their last quarterly care conference meetings occurred. Findings include: The facility's policy dated 1/5/25 and titled, Care Plan Conference Meeting documents: The facility will conduct a care plan review/conference at least quarterly, and as needed, that is interdisciplinary, provides an in-depth review of the resident's plan of care, and provides an opportunity for resident and family discussions/input. R1 was admitted to the facility on [DATE] with diagnoses which include radiculopathy cervical region (nerve roots in the cervical spine are compressed or irritated causing neck pain, weakness, numbness, and radiating pain in the arms or hands), adult failure to thrive (state of decline that is multifactorial…

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 report 1 (R1) of 1 incident reviewed to the State survey agency and Nursing Home Administrator during the required timeframe.On 1/1/26, Registered Nurse (RN)-G's nurses note documents R1 had complaints regarding the two-night Certified Nursing Assistants (CNAs) who performed ADL (activities daily living) cares for him. RN-G attempted to resolve it but R1 said he wanted it reported. On 2/2/26, R1 informed Surveyor he didn't want to be changed but staff said they had to and R1 alleged his wrists were held down when the staff members provided cares. R1's allegation of potential abuse was not reported to the State agency and Nursing Home Administrator.Findings include:The facility's policy titled, Abuse, Neglect and Exploitation and last reviewed/revised 11/5/25 under section VII. Reporting/Response documents A. The facility will have written procedures that include: 1. Reporting all alleged violations to the Administrator, State agency, adult protective services and to all other required agencies (e.g., law enforcement when…

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

Based on interview and record review, the facility did not have evidence that all alleged violations of mistreatment were thoroughly investigated for 1 (R1) of 1 resident.On 1/1/26, Registered Nurse (RN)-G's nurses note documents R1 had complaints regarding the two-night Certified Nursing Assistants (CNAs) who performed ADL (activities daily living) cares for him. RN-G attempted to resolve it but R1 said he wanted it reported. On 2/2/26, R1 informed Surveyor he didn't want to be changed but staff said they had to and R1 alleges his wrists were held down. The facility did not thoroughly investigate R1's allegation as R1 was not interviewed, CNA-K & CNA-D were not interviewed, and a statement was not received from RN-G. The facility did not interview any residents to see if there were any concerns regarding care provided to them.Findings include:The facility's policy titled, Abuse, Neglect and Exploitation and last reviewed/revised 11/5/25 under section V. Investigation of Alleged Abuse, Neglect, and Exploitation documents A. An immediate investigation is warranted when suspicion of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure a person-centered baseline care plan was developed and implemented containing the minimum of required healthcare necessary to care for a resident within a resident's admission for 1 (R4) of 1 Resident reviewed for new admissions.*A person-centered baseline care plan was not developed with interventions necessary to care for R4 upon admission to the facility on 1/6/26.Findings include:The facility's Baseline Care Plan implemented 1/5/25 documents:Policy: The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care.Policy Explanation and Compliance Guidelines:1. The baseline care plan will:a. Be developed within 48 hours of a resident's admission.b. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to:i. Initial goals based…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility did not complete neurological checks in accordance with policy and procedure for 1 (R4) of 3 residents reviewed for unwitnessed falls.*R4 sustained two unwitnessed falls on 1/7/26. Facility staff did not complete neurological checks in accordance with the facility's policy and procedure.Findings include:The facility's Neurological Assessment policy and procedure effective 5/19/22 documents:Policy: Residents will have a neurological assessment completed when they experience a head injury or a change in condition that deems it necessary or per physician order.Procedure:1.Neurological assessments will be completed upon a physician's order, when indicated for a change of resident's condition, after all head injuries and when nursing judgment deems necessary.Exception: If a resident is sent to the hospital and a head injury is ruled out using diagnostic testing consider discontinuing neuro check monitoring.2.Observe, assess and document the resident's level of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure each resident received adequate supervision and assistance to prevent accidents for 2 (R4 and R2) of 3 residents reviewed for falls. *On 1/7/26, R4 had two unwitnessed falls on 1/7/26 and one witnessed fall on 1/8/26. The facility did not thoroughly investigate the falls and did not establish a root/cause analysis. *On 1/27/26, R2 had an unwitnessed fall, and the facility did not thoroughly investigate the falls and did not establish a root/cause analysis. Findings include: The facility's Fall Policy last reviewed 1/2/26 documents: Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Policy Explanation and Compliance Guidelines: 1.The facility utilizes a risk assessment tool for determining a resident's fall risk. 2.A risk assessment will be completed upon admission, quarterly, or when a significant change is…

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

Based on observation, interview, review of the Food and Drug Administration (FDA) guidelines, and review of Manufacturer's Instructions for Use (MIFU), the facility failed to document inspections and maintenance per the MIFU recommendations of bed frames and bed rails, if present, for any of the 77 resident beds and did not perform FDA entrapment risk measurements for any of the 36 residents the facility identified as having bed rails, mobility bars, or assist bars. These failures created the potential for bed malfunctions and or resident injury.Findings include:Observations of the facility on 01/05/26 revealed resident beds with assist/mobility bars.During an interview on 01/06/26 at 3:37 PM, regarding bed inspections, in response to a complaint regarding dysfunctional or broken beds, the Nursing Home Administrator stated, I don't believe we have any [bed inspections]. Bed MIFUs and an inspection policy were requested. During a follow up interview on 01/07/26 at 3:35 PM, the Nursing Home Administrator stated there was no policy regarding bed inspections. During an interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, interviews, and policy review, the facility failed to maintain and serve food at safe temperatures. This failure created the potential for foodborne illness and compromised nutritional safety for five cognitively impaired residents who were able to self-propel to the activities room/dining area, as well as residents receiving meal trays in their room.Findings include:1. Review of R7's admission Record from the electronic medical record (EMR) Profile tab showed an admission date of 01/07/25, readmission on [DATE], with medical diagnoses that included severe protein-calorie malnutrition, spinal stenosis, history of cerebral infarction (stroke), chronic obstructive pulmonary disease (COPD), poly-osteoarthritis, and anxiety disorder.Review of R7's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/17/25 from the MDS tab of the EMR revealed a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15, indicative of being cognitively…

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, interviews, record review, and policy review, the facility failed to provide meal set-up assistance for one (Resident (R) 17) of three residents reviewed for activities of daily living (ADLs) out of a total sample of 17 residents. This failure could negatively impact residents' psychosocial wellbeing and overall quality of life and may contribute to unintended weight loss.Findings include:Review of R17's admission Record, located under the Profile tab of the electronic medical record (EMR), indicated he was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke), parkinsonism (condition causing movement problems), hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) affecting left non-dominant side.Review of R17's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 12/15/25 and located in the MDS tab of the EMR, revealed he had a Brief Interview for Mental Status (BIMS) score of 11 out 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 record review and interviews, the facility failed to administer a prescribed medication to stabilize post-meal blood glucose as ordered for one resident (Resident (R) 5) of 17 sample residents reviewed. This failure had the potential to impair carbohydrate absorption and increase the risk of hypoglycemia (low blood sugar).Findings include:Review of R5's admission Record from the electronic medical record (EMR) Profile tab revealed a facility admission date of 10/17/25, with a readmission date of 10/31/25, with diagnoses that included hypoglycemia and diabetes.Review of R5's EMR Orders tab revealed an order for acarbose 25 milligrams (mg) by mouth before meals related to hypoglycemia and type two diabetes with diabetic chronic kidney disease, dated 11/20/25, and scheduled for 7:30 AM, 11:30 AM, and 4:30 PM.Review of R5's Medication Audit Report for R7's acarbose for 12/24/25 through 01/07/26, provided by the facility, revealed:12/24/25 the 7:30 AM ordered dose was administered at 9:24 AM12/24/25 the 4:30 PM ordered dose was administered at 8:01 PM12/26/25 the 7:30 AM ordered…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure 1 (R7) of 1 resident reviewed received a prompt resolution of grievances filed, including steps taken to investigate the grievance, a summary of pertinent findings, conclusion, statements as to whether the grievance was confirmed or not confirmed, corrective actions taken by the facility, and the date the written decision was issued.*R7 called the main facility phone number to express concern of the need for incontinence care and had been on the call light for 4-5 hours. Facility staff were aware of the concern but did not initiate a formal grievance in writing and investigate the concern thoroughly.Findings include:The facility's Resident and Family Grievance policy and procedure dated 8/1/25 documents:Policy:It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal.Policy Explanation and Compliance Guidelines1. Nursing Home…

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 are accurately screened for a mental disorder prior to the expiration of a 30-day exemption for 1 (R3) of 1 resident reviewed for the PASARR (Preadmission Screening and Resident Review).*R1 did not have a PASARR level 1 screen resubmitted prior to the expiration of the 30-day exemption documented on the original PASARR level 1.Findings include:The facility's PASARR policy and procedure last revised 4/25 documents:Policy Statement.The purpose of this policy is to outline the screening of residents with a history of serious mental illness and developmental disability.ProcedureA. Complete Level 1 screen of the PASARR on new admissions.3.Those residents whose attending physician has certified, before admission to the community that the individual is likely to require less than 30 days of nursing facility services, do not require a PASRR (sic) to be completed.B. The resident or resident representative will receive a written notice (copy of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff interviews, the facility did not ensure 1 out of 2 residents (R5) reviewed for being at high risk for falls, received adequate supervision and assistance devices to prevent accidents.*R5 is at high risk for falls and had 3 unwitnessed falls at the facility. The facility did not ensure they thoroughly investigated each fall to determine the root cause and to assure that all interventions were in place at the time of the fall and were effective.Findings include:The facility's Fall policy and procedure implemented 2/11/25 documents:Policy: . Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.Policy Explanation and Compliance Guidelines:1. The facility utilizes a risk assessment tool for determining a resident's fall risk.3. An individualized care plan will be implemented according to the risk factors identified on the fall assessment tool.4.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure that each resident maintained acceptable parameters of nutritional status, such as usual body weight unless the resident's clinical condition demonstrates that this is not possible, or resident preferences indicate otherwise for 1 of 1 (R1) resident reviewed for weight loss.R1 sustained a weight loss of 10.1 pounds / 6.61% over a period of 3 weeks with no physician or dietician notification.Findings include:R1 admitted to the facility on [DATE] with diagnoses that included T11-T12 compression fracture, severe protein calorie malnutrition, peripheral vascular disease, legal blindness, hypertensive chronic kidney disease stage 4, urine retention, osteoarthritis, anemia and gastroesophageal reflux disease.The facility policy titled Weight Monitoring last approved 07/2025 documents (in part) .It is the policy of (facility name) that appropriate nutritional care shall be provided to residents who have a significant weight change. A significant weight…

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 report to the State survey agency and/or Law Enforcement in a timely manner timely for 1 (R2) of 1, abuse allegations reviewed.* On 6/2/2025, R2 reported an incident to Physical Therapy (PT)-D of inappropriate touching from R1. Staff did not report the allegation to Nursing Home Administrator (NHA)-A until 6/3/25.Findings include:The facility's policy, titled Abuse Investigation and Reporting, dated as last approved 12/2024, documents:Reporting:A. Alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of property will be reported to the administrator or designee. B. Alleged violations involving abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported: 1. Abuse or serious bodily harm - Immediately but no later than 2 hours. R2 was admitted to the facility on [DATE] with diagnoses of Falls,…

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 received the necessary behavioral health care and services to maintain the highest practicable mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for 1 (R1) of 1 resident reviewed for related to the residents emotional and mental well-being.*Surveyor reviewed a facility self-report from 6/13/2025, which pertained to behaviors of inappropriate touching with R1 being the aggressor. Nurse Practitioner (NP)-E, stated that currently R2's, psychiatric services are being managed by NP-E. NP-E indicated not being updated regarding alleged behaviors of R1's hands going inside of R2's shorts. There was no documentation that R1's POA was contacted in attempt to obtain consent for psychiatric services. Findings include:R1 was admitted to the facility on [DATE] with diagnoses of dementia and depression.R1's quarterly Minimum Data Set (MDS), dated [DATE], documented a brief interview of mental status…

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, document review, interview and facility policy review, the facility failed to prevent misappropriation of resident property for five of five sampled residents (Resident (R) 9, R10, R11, R16, and R17). The facility failed to ensure security resulting in narcotic drug diversion by one of one staff (Registered Nurse 1). Failure to protect residents' property has the potential to affect the residents mental, emotional and financial status. Findings include: Review of facility's policy titled, Personal Property revised on 12/19 indicated that residents are permitted to retain and use personal possessions and appropriate clothing as space permits. A representative of the admitting office will advise the resident, prior to or upon admission, as to the types and amount of personal clothing and possessions that the resident may keep in his or her room. 1. Review of facility's Investigation Summary Folder indicated that on 01/31/25 the former Social Services Director (FSSD) notified the Administrator that R11's envelope containing her wallet, $283.00 in cash, 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 interviews, record review, and facility policy review, the facility failed to notify the resident representative of a fall for one of three residents (Resident (R) 7) reviewed for notification out of a total sample of 17. This has the potential to cause family members to not have the opportunity to be involved in the resident's care. Findings include: Review of the facility's policy titled, Change in a Resident's Condition or Status, revised 02/2022, indicated that the community . shall promptly notify the resident, his or her health care provider, and representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). Unless otherwise instructed by the resident, a nurse will notify the resident's representative, consistent with his or her authority, when . The resident is involved in any accident or incident that results in an injury including injuries of an unknown source . Review of R7's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/18/24 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 review of facility policy, record review, and interview, the facility failed to ensure the right to be free from verbal and potential sexual abuse for two residents (Residents (R) 3 and R12) of four residents reviewed for abuse/neglect out of a total sample of 17. The facility failed to ensure R3 was protected from verbal abuse by Certified Nursing Assistant (CNA1). The facility failed to protect R12 from potential sexual abuse from R13. These failures had the potential to cause physical harm, pain, or mental anguish. Findings include: Review of a facility policy titled, Abuse Prevention, dated 08/2024, indicated, . The community's goal is to achieve and maintain an abuse-free environment. As part of the resident abuse prevention program, the administration will provide a safe resident environment and protect the residents from abuse by anyone including community associates, other residents, consultants, volunteers, associates from other agencies, family members, legal representatives, friends,…

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, record review, and review of facility policy, the facility failed to ensure that allegations of injury of unknown origin, verbal abuse, and neglect were reported to the State Survey Agency (SSA) in a timely manner for three residents (Resident (R) 2, R3, and R5) reviewed in a total sample of 15 residents. Specifically, the facility failed to report timely an allegation of injury of unknown origin involving R2; an allegation of verbal abuse involving R3; and an allegation of neglect involving R5. This failure had the potential for other allegations to not be reported in a timely manner. Findings include: Review of the facility's policy titled Abuse Investigation and Reporting, dated 12/2024 indicated, . Alleged violations involving abuse, neglect, exploitation or mistreatment will be reported immediately but not later than two hours . 1. Review of R2's Profile Face Sheet indicated R2 was admitted to the facility on [DATE] with diagnoses of Alzheimer's, congestive heart failure, and chronic…

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 review of facility policy, record review, and interview, the facility failed to ensure two resident (Resident (R) 3 and R5) out of a sample of three residents reviewed for abuse allegations, had a thorough investigation completed for R5 and the five-day report was not submitted timely to the State Agency (SA) for R3. This failure had the potential to lead to continued episodes of abuse. Findings include: Review of the facility's policy titled Abuse Investigation and Reporting, dated 12/2024, .The Administrator will monitor that any further potential abuse, neglect, exploitation, or mistreatment is prevented while the investigation is in progress .Review the resident's medical record to determine events leading up to the incident .Interview the person reporting the incident, any witnesses, staff on all shifts who had contact with the resident, the resident's roommate, family members, and visitors. Interview other residents to whom the accused employee provides care or services, and review camera footage…

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 UNCORRECTED AT REVISIT Based on record review and interviews, the facility did not ensure they thoroughly investigated and attempted to find the root cause of a fall for 1 (R361) of 3 residents reviewed for being at risk for falls. R361 experienced an unwitnessed fall in her room on 11/12/24. When family entered the room, the wardrobe/dresser was observed to be on top of R361 who was lying on the floor of her room. R361 stated that she lost her balance while attempting to ambulate to the bathroom by herself after calling for help from staff with no response. Post fall, the facility did not review the wardrobe dressers utilized by facility residents to ensure they were safely secured to prevent other residents from having the wardrobe/dresser fall over creating a safety concern. The deficient practice has the potential to effect a pattern of the 76 residents currently residing in the facility with the same wardrobes/dressers. Findings include; Falls Policy: The facility policy, entitled, Falls dated revised,…

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 1 (R38) of 1 sampled resident's potential allegation of misappropriation of property was reported to the State Survey Agency or the Nursing Home Administrator within 24 hours. *R38's family reported a missing necklace on 11/29/24 to a facility staff member. R38's missing gold necklace was not reported to the Nursing Home Administrator until 12/2/24. The investigation into R38's missing gold necklace did not start until 12/2/24. Finding include: The facility policy entitled Abuse Investigation and Reporting revised on 11/2023 documents: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment, ., and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by community management. Conclusions of investigations will also be reported, as defined by the [Facility Name] Abuse Prevention policy. R38's current admission was on 10/21/23. On 12/2/24, at 8:30 AM, Surveyor…

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 store and prepare food in accordance with professional standards for food service safety potentially affecting 65 of the 66 residents in the facility. *Observations were made in the main kitchen of food open to air in the freezer, boxes of food stored on the floor, milk in the refrigerator past the expiration date, the dishwasher was in disrepair, and staff not wearing beard coverings while working in the kitchen preparing food. Findings include: The facility policy and procedure entitled Food Purchasing and Storage dated 1/2023 documents: Policy Interpretation and Implementation: . H. Foods stored in walk in-refrigerators and freezers shall be stored above the floor on shelves, racks, dollies, or other surfaces that facilitate cleaning. J. Food must be date marked if it is prepared on site and refrigerated, or commercially processed after the original container is opened. Food shall be dated with the current date and be used or discarded…

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, interviews, and record review the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 4 (R24, R44, R48 and R60) residents reviewed for infection control. * The shared glucometer on Medication Cart A & D was not cleaned between residents' use. * R48's catheter bag was observed lying on floor on 10/2/2024. Findings include: The facility policy and procedure titled Obtaining a Fingerstick Glucose Level documents (in part) . . The following equipment and supplies will be necessary when performing this procedure. A. Disinfected blood glucose meter (glucometer) with sterile lancet; or single-resident use spring loaded device or automatic or safety type lancet. Steps in the procedure: A. Place the equipment on a clean field. C. Always ensure that blood glucose meters intended for reused are cleaned…

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 report 3 (R5, R111, R45) of 5 allegation to the State Survey Agency, Nursing Home Administrator, or local law enforcement during the required timeframe. R5 had an allegation of abuse and it was not reported to the Nursing Home Administrator until two days later, the alleged employee continued to work at the facility during those two days, and law enforcement was not contacted about R5's potential abuse allegation. R111's family members had a physical altercation in front of R111 and other resident's in the facility main dining room during meal service. Local law enforcement was notified and removed 1 of the individuals involved. The Nursing Home Administrator was not notified about the altercation until two days later at which time it was reported to the State Agency. R45's allegation of abuse was not reported timely. Findings include: The facility policy entitled Abuse Prevention revised on 8/2024 documents . Reporting/Response: A. The community will…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure all allegations involving potential abuse, neglect, and misappropriation of resident property were thoroughly investigated for 3 (R5, R111, R45) of 5 Facility self-reports reviewed. R5's allegation of abuse reported on 7/8/2024 was not thoroughly investigated and residents were not protected from potential abuse during the abuse investigation. R111's family's verbal and physical altercation which occurred in the main dining room during meal time was reported on 6/22/2024 and was not thoroughly investigated. R45's allegation of abuse reported on 6/17/2024 was not thoroughly investigated. Findings include: The facility policy entitled Abuse Prevention revised on 8/2024 documents: . The objective of the abuse policy is to comply with the seven-step approach to abuse and neglect detection and prevention. Injury of Unknown Source is defined as an injury that meets both of the following conditions: 1. The source of the injury was not observed by any…

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 complete a Preadmission Screening and Resident Review (PASARR) for individuals with a mental disorder for 2 (R4 and R52) of 2 residents reviewed for PASARR screening. *R4 was admitted [DATE] and the Level I PASARR was completed indicating R4 would be in the skilled nursing facility for less than 30 days. R4 discharged from the facility 2/21/2024. A Level I PASARR was not resubmitted/updated indicating R4 was going to be at the facility longer than the 30 exemption period triggering a Level II PASARR to be completed. R4 was admitted again to the facility on 4/4/2024 and a Level I PASARR was not completed. *R52 was admitted [DATE] to the facility and the PASARR Level I was not completed accurately to reflect R52's mental illness or psychotropic medications and a Level II PASARR was not completed. Findings include: The facility policy and procedure entitled PASARR (Pre admission Screening & Resident Review) dated 1/2023 documents: PROCEDURE: A. Complete…

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 had an individualized comprehensive plan of care. This was observed with 3 (R48, R55, and R57) of 17 resident comprehensive care plan reviews. * R48 did not have a comprehensive care plan for R48's oxygen/respiratory monitoring/needs. * R55 did not have a comprehensive care plan for bowel monitoring. * R57 did not have a comprehensive care plan for bowel or bladder incontinence. Findings include: The facility policy entitled, Care Planning- Interdisciplinary Team, last approved on 1/2024 documents: Our community's Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. Policy Interpretation and Implementation A. A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident comprehensive assessment (MDS). B. The care plan is based on the resident's comprehensive assessment and is developed by the Interdisciplinary…

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 received treatment and care in accordance with professional standards of practice for 1 (R55) of 2 residents reviewed. * R55 had concerns with feelings of abdominal pain and bloating and is on several bowel medications for management of constipation and diarrhea. The facility was not assessing or monitoring or assessing R55's bowel regimen. Findings include: The facility policy entitled Restorative Nursing- Toileting Program last approved 5.2023 documents: . Procedure: . B. Resident continence is assessed on admission, with significant change, and quarterly: 1. Check resident approximately hourly and document in the resident's medical record as continent, incontinent or soiled and level of assistance. 3. After 3 days analyze data: a. Complete the bowel and bladder evaluation in the resident medical record, to determine type of incontinence and most appropriate program. b. Determine patterns in frequency, volume, duration, and time of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure residents with urinary incontinence were comprehensively assessed to receive appropriate treatment and services to prevent complications and restore continence to the extent possible for 1 (R57) of 2 residents reviewed for incontinence. *R57's admission, quarterly, and significant change Minimum Data Set (MDS) assessments documented R57 was incontinent of bowel and bladder. No comprehensive bowel or bladder assessments were completed to determine a toileting program to decrease incontinence and no care plan was initiated to provide incontinence care on a scheduled basis. Findings include: The facility policy and procedure entitled Clinical Protocol: Urinary Continence and Incontinence - Assessment and Management dated 1/2024 documents: Policy Interpretation and Implementation: A. As part of the initial and ongoing assessments, the nursing staff and physician will screen for information related to urinary continence. C. Periodically (as required…

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 maintained acceptable parameters of nutritional status, such as usual body weight for 1 of 2 (R40) residents reviewed for weight loss. * R40 sustained weight loss which was not identified by the facility and the Dietician was not notified. Findings Include: The facility policy, entitled Weight Monitoring dated revised 1/2023 documents (in part) . . It is the policy of (facility) that appropriate nutritional care shall be provided to residents who have a significant weight change. A significant weight change is identified as a weight loss or gain of 5% in 30 days, 7.5% in 90 days or 10% in 180 days. Policy interpretation and implementation states: A report should be generated from the electronic medical record (EMR) system to identify all residents with a significant weight change in 30 days, 90 days, and/or 180 days. At the weekly Resident at Risk Review huddle, the IDT (Interdisciplinary Team) should discuss residents who trigger…

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 the necessary services to provide respiratory care were consistent with professional standards of practice for 1 (R48) of 1 resident reviewed for respiratory care. * R48's oxygen tubing and humidification were not labeled and dated. On 10/1/2024, R48's humidification was below the line/tubing so R48 was unable to benefit from humidification while R48's oxygen was running, R48's oxygen was set for 3 L (liters)/minute (Liters per minute) during survey and R48 order was for 2L/minute, and R48 did not have orders in place for care of oxygen supplies. Findings include: The facility policy, entitled Oxygen Administration last approved on 12/2022, documents: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: A. Verify that there is a physician's order for this procedure. Review the physician's orders or community protocol for oxygen administration. Steps on the procedure: . K. Be sure there is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility did not ensure Certified Nursing Assistants (CNA) had annual performance reviews at least once every 12 months for 5 of 5 CNA staff reviewed (CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W). This had the potential to affect all 72 residents in the facility as staff assignments float throughout the facility. Findings Include: The facility was unable to provide a policy and procedure in regard to annual performance reviews. The facility's 2023 MyLearning-Required Annual Training Assignment Schedule documents that there should be Year End Review (All annual education needs to be done no later than 12/31/23). In-Person Annual Performance Review with follow up training for areas of weakness and special needs of residents. Surveyor reviewed the facility assessment dated [DATE], and last reviewed/updated 12/28/23, the following is documented under Staff Training/education and competencies: .Required in-service training for nurse aides. In-service training must: -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 staff interview and record review, the facility did not ensure staff received annual Resident Rights training: Dietary (DIET)-Y, Certified Nursing Assistants (CNA), CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W. This practice had the potential to affect all 72 residents in the facility. The facility did not provide staff with the required annual Resident Rights training. Findings include: The facility was unable to provide a policy and procedure in regards to Resident Rights training. The facility's 2023 MyLearning-Required Annual Training Assignment Schedule includes Protecting Resident Rights in Nursing Facilities as a required training. Surveyor reviewed the facility assessment dated [DATE], and last reviewed/updated 12/28/23, the following is documented under Staff Training/education and competencies: .Staff receive education through new hire orientation process, via My learning, and during in-services. If additional training is needed, individual in-servicing is provided. Training Topics -Resident rights…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure staff received annual QAPI training: Dietary (DIET)-Y, Physical Therapist (PT)-X, Registered Nurse (RN)-N, Certified Nursing Assistants (CNA), CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W. This practice had the potential to affect all 72 residents in the facility. The facility did not provide staff with the required annual QAPI training. Findings include: The facility was unable to provide a policy and procedure in regards to QAPI training. The facility's 2023 MyLearning-Required Annual Training Assignment Schedule does not include QAPI as a required training. Surveyor reviewed the facility assessment dated [DATE], and last reviewed/updated 12/28/23, the following is documented under Staff Training/education and competencies: .Staff receive education through new hire orientation process, via My learning, and during in-services. If additional training is needed, individual in-servicing is provided. Training Topics . QAPI is not listed as a training…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure all employed staff received annual training on written policies and procedures of the facility's Infection Control Program. Dietary (DIET)-Y, Physical Therapist (PT)-X, Certified Nursing Assistants (CNA), CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W employee files were reviewed. This practice had the potential to affect all 72 residents in the facility. The facility did not provide the above staff with the required Infection Control training. Findings include: The facility was unable to provide a policy and procedure in regards to Infection Control training. The facility's 2023 MyLearning-Required Annual Training Assignment Schedule documents Infection Control and Prevention should be completed by all staff with a due date of 2/28/23. Surveyor reviewed the facility assessment dated [DATE], and last reviewed/updated 12/28/23, the following is documented under Staff Training/education and competencies: .Staff receive education through new hire…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure staff received annual Compliance and Ethics training: Physical Therapist (PT)-X, Dietary (DIET)-Y, Registered Nurse (RN)-N, Certified Nursing Assistants(CNA), CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W. This practice had the potential to affect all 72 residents in the facility. The facility did not provide staff with the required annual Compliance and Ethics training. Findings include: The facility was unable to provide a policy and procedure in regards to Compliance and Ethics training. The facility's 2023 MyLearning-Required Annual Training Assignment Schedule does not include Compliance and Ethics as a required training. Surveyor reviewed the facility assessment dated [DATE], and last reviewed/updated 12/28/23, the following is documented under Staff Training/education and competencies: .Staff receive education through new hire orientation process, via My learning, and during in-services. If additional training is needed, 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 staff interview and record review, the facility did not ensure staff received annual Behavioral Health training: Physical Therapist (PT)-X, Dietary (DIET)-Y, Registered Nurse (RN)-N, Certified Nursing Assistants (CNA), CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W. This practice had the potential to affect all 72 residents in the facility. The facility did not provide staff with the required annual Behavioral Health training. Findings include: The facility was unable to provide a policy and procedure in regards to Behavioral Health training. The facility's 2023 MyLearning-Required Annual Training Assignment Schedule does not include Behavioral Health as a required training. Surveyor reviewed the facility assessment dated [DATE], and last reviewed/updated 12/28/23, the following is documented under Staff Training/education and competencies: .Staff receive education through new hire orientation process, via My learning, and during in-services. If additional training is needed, individual in-servicing is provided.…

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 privacy and confidentiality of personal health information for 9 (R13, R14, R15, R16, R17, R19, R1, R6, & R18) of 9 residents. On 6/18/24 Cluster C report sheet for R13, R14, R15, & R16 dated 6/17/24, Cluster D report sheet for R17, R19, R1, R6, & R18 dated 6/17/24 and CNA (Certified Nursing Assistant) worksheet dated 6/12/24 for R6, R18, R14, R17, R19, & R1 were observed on the round table in the dining area located on the D unit during multiple observations. These report sheets and CNA worksheets contained personal resident information. Findings include: On 6/18/24, at 10:06 a.m., Surveyor observed on the round table, in the small dining area on the D unit, a C cluster report sheet dated 6/17/24 with R13, R14, R15, & R16's name along with their physician name and if they were their own person. There is also a D cluster report sheet dated 6/17/24 with the same information for R17, R19, R1, R6, & R18. Under the C & D cluster report sheets is a CNA (Certified Nursing Assistant) worksheet for Wednesday 6/12/24. This CNA…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not develop, implement, and maintain an effective 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. (Physical Therapist (PT)-X, Dietary (DIET)-Y, Registered Nurse (RN)-N, Certified Nursing Assistants (CNA), CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W. The facility does not have an effective training program and does not maintain documentation of staff completing the required training's. Findings include: The facility was unable to provide a policy and procedure in regards to the required training's. Surveyor reviewed the facility assessment dated [DATE], and last reviewed/updated 12/28/23, the following is documented under Staff Training/education and competencies: .Staff receive education through new hire orientation process, via My learning, and during in-services. If additional training is needed, individual in-servicing is provided. Training Topics . 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 6 of 6 direct staff chosen at random received communication training. Registered Nurse (RN)-N, Certified Nursing Assistants (CNA) CNA-O, CNA-T, CNA-U, CNA-V and CNA-W did not receive communication training. This has the potential to affect the 8-10 residents who reside on each unit where RN-N, CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W are typically assigned. Findings include: The facility was unable to provide a policy and procedure in regard to Communication training The facility's 2023 MyLearning-Required Annual Training Assignment Schedule does not include Communication training as a required training. Surveyor reviewed the facility assessment dated [DATE], and last reviewed/updated 12/28/23, the following is documented under Staff Training/education and competencies: .Staff receive education through new hire orientation process, via My learning, and during in-services. If additional training is needed, individual in-servicing is provided. Training…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure staff received annual Abuse/Neglect/Exploitation and Dementia training: Dietary (DIET)-Y, Certified Nursing Assistants (CNA), CNA-T, CNA-U, CNA-V, and CNA-W. This practice had the potential to affect 8-10 residents who reside on each unit where CNA-T, CNA-U, CNA-V, and CNA-W are typically assigned. The facility did not provide staff with the required annual Abuse/Neglect/Exploitation and Dementia training. Findings include: The facility was unable to provide a policy and procedure in regard to Abuse/Neglect/Exploitation and Dementia training. The facility's 2023 MyLearning-Required Annual Training Assignment Schedule includes Dementia Care: Understanding Alzheimer's Disease and Preventing, Recognizing and Reporting Abuse as a required training. Surveyor reviewed the facility assessment dated [DATE], and last reviewed/updated 12/28/23, the following is documented under Staff Training/education and competencies: .Staff receive education…

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 5 of 5 CNAs (Certified Nursing Assistants) reviewed completed the required annual 12 hours of educational training hours. (Certified Nursing Assistants (CNA) (CNA-O, CNA-T, CNA-U, CNA-V and CNA-W did not receive annual 12 hours of educational training. This has the potential to affect the 8-10 residents who reside on each unit where CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W are typically assigned. Findings include: The facility was unable to provide a policy and procedure in regard to CNAs receiving 12 hours of educational training Surveyor reviewed the facility assessment dated [DATE], and last reviewed/updated 12/28/23, the following is documented under Staff Training/education and competencies: .Staff receive education through new hire orientation process, via My learning, and during in-services. If additional training is needed, individual in-servicing is provided. Training Topics -Required in-service training for nurse aides.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the Facility did not ensure that an allegation of abuse involving 1 (R5) of 3 Residents reviewed for allegations of abuse were reported immediately to the Nursing Home Administrator and State Survey Agency. *On 4/19/24 R5 informed the facility of an allegation of abuse involving Certified Nursing Assistant (CNA)-M. The facility did not report the allegation of abuse to the State Survey Agency until 4/22/24. The Nursing Home Administrator was not notified of the allegation until 4/22/24. Findings Include: The facility's policy entitled, Abuse Prevention, dated 9/2017 and last revised on 6/2020 documents: . Investigation A. The community will investigate and report any allegations of abuse within timeframe's as required by federal, state, and local requirements. Protection A. The community will protect Residents from further potential abuse, neglect and exploitation, or mistreatment while abuse investigations are in progress; 1. Respond immediately to protect the alleged…

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 3.) R5 was admitted to the facility on [DATE] with diagnoses of Hypertensive Chronic Kidney Disease, Stage 3, Hyperlipidemia, Pulmonary Hypertension, and Pleural Effusion. R5 is currently her own person. R5's Annual Minimum Data Set(MDS) completed on 4/10/24 documents R5's Brief Interview for Mental Status(BIMS) score of 14, indicating R5 is cognitively intact for daily decision making. R5's MDS also documents that R5 has range of motion impairment of upper extremity on one side. R5 requires partial/moderate assistance with upper and lower body dressing. Substantial to maximum assistance for sit to lying, and lying to sitting. R5 requires supervision for transfers and mobility. The facility was informed by R5 on 4/19/24 that R5 requested assistance from Certified Nursing Assistant (CNA)-M. R5 stated that CNA-M responded in a rude and aggressive manner. R5 expressed R5 felt disrespected and mistreated by CNA-M's behavior. R5 reported this to Registered Nurse (RN)-N, Certified Nursing Assistant (CNA)-O, 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 proper foot care for 1 (R3) of 3 Residents. R3's toenails were very long and in need of trimming. Findings include: R3's diagnoses includes hypertension, atrial fibrillation and diabetes mellitus. The quarterly MDS (minimum data set) with an assessment reference date of 5/9/24 has a BIMS (brief interview mental status) score of 12, indicating R3 has moderate cognitive impairment. R3 is assessed as being dependent for putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility including fasteners if applicable. On 6/19/24 at 9:33 a.m. Surveyor observed R3 sitting in a wheelchair in her room with a breakfast tray on an over bed table in front of R3. R3 is wearing gripper socks on her feet. Surveyor asked R3 if Surveyor could look at her feet later. R3 shook her head yes. On 6/19/24 at 9:34 a.m. Surveyor informed CNA (Certified Nursing Assistant)-J Surveyor had observed R3 still has her breakfast tray in front of her and inquired…

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 electronic medical record(EMR) review, and interview, the facility did not ensure adequate supervision and assistance devices, or ensure the environment remained free of accident hazards to prevent accidents for 1 (R4) of 2 Residents reviewed for falls. *R4 had a fall on 4/11/24 where the root cause of the fall was not determined, the facility did not complete documentation of the fall including witness statements and a registered nurse (RN) assessment and interventions were not not reviewed or initiated. Findings Include: The facility's Fall policy dated 12/2017 and last revised 7/2023 documents: .The licensed nurse shall document the fall in the Resident's clinical record. The documentation of the identified interventions should be maintained in the Resident clinical record and available to the direct care associates. The falls should be reviewed at the Daily Stand-up Meeting following the fall for identification of any additional individualized interventions to reduce the risk of falls. An incident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility did not ensure 1 (R1) of 1 residents received medically related social services to attain or maintain their highest practicable physical, mental and psychosocial well being. R1 was admitted to the facility on [DATE] with an order for Seroquel. The Facility was not monitoring the effectiveness of multiple medication changes with R1's Seroquel, Buspar & Depakote. The Facility did not determine the root cause of R1's anxiety and did not develop patient center approaches to help R1 with her anxiety. Findings include: R1 was admitted to the facility on [DATE] with diagnoses which includes right femur fracture and dementia. [R1's first name] is at risk for <increased behavioral expressions||altered mood||elopement||impaired adjustment ability to new environment> care plan with a start date of 4/26/24 documents the following approaches: * Follow community elopement evaluation and monitoring process. Dated 4/26/24. * Identify current mood and behavioral…

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 maintain records that were complete and accurately documented for 3 (R12, R8, & R9) of 6 residents reviewed who expired in the facility. * R12 expired in the facility on [DATE] and there is no documentation in R12's medical record regarding R12's death. * R8 expired in the facility on [DATE] and there is no documentation in R8's medical record regarding R8's death. * R9 expired in the facility on [DATE] and there is no documentation in R9's medical record regarding R9's death. Findings include: The facility's policy titled, Guidelines for Charting and Documentation last revised 1/2018 under policy statement documents Services provided to the resident, or changes in the resident's medical or mental condition, shall be documented in the resident's medical record. Under the section for Purpose documents The purpose of charting and documentation is to provide: A. A complete account of the resident's care, treatment, response to the care, signs, symptoms,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure each resident was offered a COVID 19 immunization for 2 (R6 & R10) of 11 residents reviewed for their COVID 19 immunization. Findings include: The facility's policy titled, Vaccination of Residents (Example: Pneumococcal, Influenza, Covid-19) last revised 7/2023 under policy statement documents: Residents will be educated about and offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated or the resident has current up to date vaccine status. A. Residents will be educated about and offered vaccines in accordance with the CDC (Centers for Disease Control and prevention) and attending physician recommendations to aid in preventing infectious diseases unless the vaccine is medically contraindicated or the resident has current up to date vaccine status. B. Prior to receiving vaccinations, the resident or resident representative will be provided information and education regarding the benefits 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 have a system in place to outline staff response in the event of a resident requiring cardiopulmonary resuscitation (CPR) and the facility did not have a system in place to maintain records documenting agency staff are qualified to perform CPR. This had the potential to affect 34 of 78 residents residing in the facility who have elected their code status to be full code (receive CPR). * On [DATE] R1 had a change in condition which led to CPR being performed. Registered Nurse (RN)-D left R1 to get the automated external defibrillator (AED) and other nursing staff were not aware of R1's change in condition and need to receive CPR until emergency medical technician (EMT) staff arrived at the facility. RN-D did not have a up to date CPR certification on file at the facility at the time of R1's event. Findings include: The facility policy entitled, Procedure: Cardiopulmonary Resuscitation revised 1/2024 states: 1. PURPOSE: To ensure compliance with state 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 staff interview, the facility did not ensure all drugs and biologicals were stored in accordance with the facility's policy. One of 4 medication carts was observed unlocked and not under direct supervision of the nurse in charge of the cart. This had the potential to affect 14 residents whose medications were stored in the cart. The third floor medication cart was observed unlocked and against the wall for approximately 2 minutes. During that time, Resident (R) (R32) was observed opening the unlocked draws. The unlocked medication cart was not in direct supervision of the nurse on duty. Findings include: The facility's Storage of Medications policy, with an approval date of 12/2021, indicates: The community shall store all drugs and biologicals in a safe, secure, and orderly manner .H. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and provider interview, and record review, the facility did not notify a provider of a significant weight loss for 1 Resident (R) (R67) of 4 residents reviewed for weight loss. R67 lost a significant amount of weight (defined as 10% loss in 6 months; 7.5% loss in 3 months; 5% loss in 1 month) between 7/5/23 and 7/26/23. R67's provider was not notified of the weight loss. Findings include: The facility's Weight Monitoring policy, with an approval date of 1/2023, indicates: .F. A nursing or nutrition associate should notify the health care provider of any significant weight change that is unexplainable or in which the RD (Registered Dietitian) has requested a nutritional intervention. From 8/8/23 through 8/9/23, Surveyor reviewed R67's medical record. R67 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, and dementia in other diseases classified elsewhere, unspecified severity with agitation. R67's Minimum Data Set (MDS) assessment, dated 7/26/23, indicated R67…

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

Based on staff interview and record review, the facility did not ensure a written notification of transfer, including the reason for the transfer, location of the transfer, appeal rights, and contact information for the State Long-Term Care Ombudsman was provided for 3 Residents (R) (R14, R21, and R26) of 3 residents reviewed for hospitalization. R14 was not provided a written transfer notice when R14 was transferred to the hospital on 5/9/23. R21 was not provided a written transfer notice when R21 was transferred to the hospital on 6/18/23. R26 was not provided a written transfer notice when R26 was transferred to the hospital on 7/23/23. Findings include: 1. From 8/7/23 through 8/9/23, Surveyor reviewed R14's medical record. R14's medical record did not contain a written notification for R14's hospital transfer on 5/9/23. 2. From 8/7/23 through 8/9/23, Surveyor reviewed R21's medical record. R21's medical record did not contain a written notification for R21's hospital transfer on 6/18/23. 3. From 8/7/23 through 8/9/23, Surveyor reviewed R26's medical record. R26's medical record…

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

Based on staff interview and record review, the facility did not ensure 3 Residents (R) (R14, R21, and R26) of 3 residents reviewed for hospitalization received written information regarding the facility's bed hold policy, including the duration of the bed hold, the reserve bed payment policy, and the right to return to the facility. R14 was transferred to the hospital on 5/9/23 and was not provided a bed hold notice. R21 was transferred to the hospital on 6/18/23 and was not provided a bed hold notice. R 26 was transferred to the hospital on 7/23/23 and was not provided a bed hold notice Findings include: 1. From 8/7/23 through 8/9/23, Surveyor reviewed R14's medical record. R14 was transferred to the hospital on 5/9/23 due to a change in condition. R14's medical record did not include a copy of the bed hold notice for the transfer or documentation that R14 was provided a copy of the bed hold notice. 2. From 8/7/23 through 8/9/23, Surveyor reviewed R21's medical record. R21 was transferred to the hospital on 6/18/23 due to a change in condition. R21's medical record did not include…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure 1 Resident (R) (R42) of 5 residents reviewed for unnecessary medications was monitored for adverse reactions to an antipsychotic medication. R42 was prescribed aripiprazole (an antipsychotic medication). The facility did not complete a tardive diskinesia (TD) (movement disorder characterized by uncontrollable, abnormal, and repetitive movements of the face, torso, and/or other body parts caused by prolonged use of treatments that block dopamine receptors in the brain, such as antipsychotic use) screening assessment to monitor for adverse reactions to the medication. Findings include: The facility's Behavioral Assessments, Intervention and Monitoring policy, with an approval date of 1/2022, indicates: .A. Behavioral symptoms will be identified using community-approved behavioral screening tools and the comprehensive assessment .Procedure: 1. The interdisciplinary team will meet to review and discuss the following: e. AIMS (Abnormal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not establish and maintain an infection control program designed to provide a safe and sanitary environment to help prevent the development and transmission of disease and infection for 2 Residents (R) (R6 and R21) of 7 residents observed during the provision of cares. During the provision of cares for R6, Licensed Practical Nurse (LPN)-G did not appropriately remove gloves and cleanse hands. During the provision of cares for R21, Certified Nursing Assistant (CNA)-H did not appropriately remove gloves and cleanse hands. Findings include: The facility's Hand Hygiene policy, dated 5/2023, indicates: This community considers hand hygiene the single most important practice to prevent infections and promote resident safety. Evidence based hand hygiene guidance is practiced to reduce the risk of transmission of pathogenic microorganisms to residents, associates, and visitors. F. Hand hygiene is practiced: 1. Immediately before touching 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.