Bradley Estates Nursing and Rehab LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure notification of coverage change and the financial liability for continued stay at the facility was provided timely when Medicare Part A benefits ended for 2 residents (R) (R22 and R113) of 3 sampled residents.The facility did not have documentation that an Advanced Beneficiary Notice (ABN) (which documents daily rate liability for continued cost of stay) or a Notice of Medicare Non-Coverage (NOMNC) form with appeal rights was provided to R22's representative when R22's Medicare Part A coverage ended and R22 remained in the facility.The facility did not have documentation that an ABN or NOMNC form was provided to R113's Guardian when R113's Medicare Part A covrerage ended and R22 remained in the facility.Findings include:The Centers for Medicare and Medicaid Services (CMS)-10123 form indicates a Notice of Medicare Non-Coverage (NOMNC) form must be delivered at least two calendar days before Medicare-covered services end or the second to last…

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 resident interview and record review, the facility did not document, investigate, or thoroughly resolve a grievance for 1 resident (R) (R79) of 29 sampled residents. R79's reported missing clothing to staff. The facility did not appropriately document, investigate, or thoroughly resolve R79's grievance.Findings include: The facility's Grievance Guideline policy, revised 4/23/23, indicates: It is the practice of this facility that each resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment that has been furnished as well as that which has not been furnished, the behavior of staff and other residents, and other concerns regarding their stay. The facility will ensure prompt resolution within five calendar days to all grievances, keeping the resident and resident representative informed throughout the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure timely transmittal of a Resident Assessment Information (RAI)/Minimum Data Set (MDS) assessment for 1 resident (R) (R105) of 29 sampled residents.R105 discharged from the facility on 5/7/25. R105's Discharge MDS assessment was not completed/transmitted as required.Findings include:The RAI Manual pages 2-19 indicate a Discharge MDS Assessment-Return Not Anticipated is to be completed no later than the discharge date plus 14 calendar days and transmitted 14 calendar days from the completion of the MDS Discharge Assessment. From 9/16/25 to 9/17/25, Surveyor reviewed R105's medical record. R105 was admitted to the facility on [DATE] with a diagnosis of non-traumatic brain injury and was discharged from the facility on 5/7/25. R105's medical record did not include a Discharge MDS Assessment.On 9/17/25 at 12:43 PM, Surveyor interviewed MDS Coordinator (MDSC)-G who stated R105 was sent to the hospital and a Discharge MDS assessment should have been…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure a Pre-admission Screening and Resident Review (PASRR) Level I Screen was updated to initiate a PASRR Level II Screen when a newly evident mental disorder and/or change in medication was identified for 2 residents (R) (R5 and R94) of 5 sampled residents.R5 was prescribed Seroquel (an antipsychotic medication). The facility did not update R5's PASRR Level I Screen and submit for PASRR Level II reevaluation.R94 was prescribed Abilify (an antipsychotic medication) for major depressive disorder, buspirone (an antianxiety medication) for anxiety disorder, trazodone (an antidepressant medication), Lexapro (an antidepressant medication), and Wellbutrin (an antidepressant medication) for major depressive disorder. The facility did not update R94's PASRR Level I Screen to include all psychotropic medications that R94 was prescribed. In addition, the facility did not have a PASRR Level II Screen for R94.Findings include:1.From 9/15/25 to 9/17/25,…

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 Preadmission Screening and Resident Review (PASRR) requirements were met for 1 resident (R) (R103) of 7 sampled residents.R103 had a diagnosis of schizophrenia. R103's PASRR Level I Screen indicated R103 did not have a mental illness. R103 did not have a PASRR Level II Screen. According to the State of Wisconsin Department of Health Services, PASRR is a federal requirement that all applicants to Medicaid-certified nursing facilities be assessed to determine whether they might have an intellectual disability (ID)/developmental disability (DD) and/or mental illness (MI). This is called a Level I Screen. The purpose of a Level I Screen is to identify individuals whose total needs require they receive additional services for their ID/DD and/or MI. Individuals who test positive at Level I are then evaluated in depth to confirm the determination of an ID/DD and/or MI for PASRR purposes. This is a Level II Screen. This assessment produces a set 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, staff and resident interview, and record review, the facility did not ensure 3 residents (R) (R5, R116, and R161) of 3 sampled residents who were unable to carry out activities of daily living (ADLs) were provided nail care, oral hygiene, or shower assistance. R5 and R116 did not receive consistent nail care or oral hygiene assistance. R161 did not receive showers per R161's request. In addition, R161's shower documentation was incorrect.Findings include: The facility's Activities of Daily Living (ADLs) policy, dated 5/7/20, indicates: The facility provides care and services taking into consideration residents' needs and choices for the following activities: hygiene, bathing, dressing, grooming, and oral care. The facility's Care of Fingernails/Toenails policy, revised 10/2010, indicates: The purpose of the procedure is to clean the nail bed, keep nails trimmed, and prevent infection .1. Nail care includes daily cleaning and regular trimming. 2. Proper nail care can aid in the prevention 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, staff interview, and record review, the facility did not ensure the provision of care and treatment to prevent pressure injuries from developing and/or promote healing for 2 residents (R) (R50 and R7) of 4 sampled residents.R50 had a history of facility-acquired pressure injuries. R50's plan of care indicated R50's heels should be floated. The intervention was not consistently followed.R7 had a history of a facility-acquired pressure injury due to a medical device. R7's plan of care indicated R7 should wear a left heel bootie at all times. The intervention was not consistently followed. Findings include: The facility's Pressure Injury/Skin integrity policy, dated 10/21/24, indicates: It is the policy of this facility to enable nursing staff to manage wounds and select appropriate interventions according to the National Pressure Ulcer Advisory Panel (NPUAP). Based on the comprehensive assessment of a resident, this facility will ensure: A resident receives care consistent with professional…

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 neuro checks were completed after unwitnessed falls for 1 resident (R) (R42) of 4 sampled residents.R42 had unwitnessed falls on 6/12/25, 6/19/25, 6/27/25, 7/10/25 and 8/26/25. Following the falls, staff did not ensure neuro checks were completed in accordance with the facility's policy. Findings include:The facility's Falls Investigation Guideline, dated 12/20/20, indicates: .4. If the fall was unwitnessed or involved a resident who hit their head, initiate neurological evaluation .Monitor the resident and observe for changes for a minimum of 72 hours.The facility's Neurological Flow Sheet indicates: Vital Signs and Neuro Checks: Every 15 minutes x 1 hour, then every 30 minutes x 1 hour, then every hour x 4 hours, then every 4 hours x 24 hours.On 9/15/25, Surveyor reviewed R42's medical record. R42 had diagnoses including hemiplegia and hemiparesis following a stroke, vascular dementia, and polymyalgia rheumatica. R42's Minimum Data Set (MDS) assessment, dated 8/6/25, had a Brief Interview for 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure monitoring for adverse reactions to high-risk medication was in place for 3 residents (R) (R3, R5 and R132) of 6 sampled residents.R3 was prescribed opioid and anticoagulant medication. The facility did not monitor R3 for adverse reactions to the medications.R5 was prescribed diuretic and anticoagulant medication. The facility did not monitor R5 for adverse reactions to the medications. In addition, the facility did not update R5's care plan to indicate R5 received diuretic and anticoagulant medication.R132 was prescribed antibiotic medication for osteomyelitis (a bone infection) on 9/5/25. The facility did not monitor R132 for adverse reactions to the medication.Findings include: According to Medlineplus.gov, oxycodone may cause side effects including, but not limited to: dry mouth, stomach pain, drowsiness, flushing, headache, mood changes, changes in heartbeat, agitation, hallucinations, fever, sweating, confusion, shivering, severe…

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 resident interview and record review, the facility failed to prevent resident-to-resident abuse for 2 residents (R) (R8 and R4) of 13 sampled residents.On 7/6/25, R3 hit R8 in the face in the dining room.On 7/14/25, R2 held R4's arm down and punched R4 in the face and hand.Findings include:Review of the facility's Abuse, Neglect, and Exploitation policy, with a revised date of 1/5/24, revealed it was the facility's policy to provide protections for the health, welfare, and rights of each resident by developing and implementing policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property.1. A document titled Misconduct Incident Report, a State of Wisconsin Department of Health form signed by the Administrator, stated it was submitted to the State Agency (SA) on 7/11/25 at 3:21 PM. According to the report, on 7/6/25 at 9:30 AM, R3 was sitting in the dining room eating breakfast when the nurse noted R3 hit R8 in the face causing R8 to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, record review, and policy review, the facility failed to ensure an allegation of missing money was reported to the State Agency (SA) for 1 resident (R) (R10) of 3 sampled residents. R10 reported $650 was missing from a pill bottle in R10's dresser drawer. The allegation of misappropriation was not reported to the SA.Findings include:Review of the facility's policy titled Abuse, Neglect, and Exploitation, with a revised date of 1/5/24, revealed it is the facility's policy to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Under the reporting/response section of the policy it states alleged violations will be reported to the required agencies no later than 24 hours if the events do not involve abuse.Review of a grievance form for R10, dated 6/25/25, revealed R10 stated when R10 came back from dialysis 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 staff and resident interview, record review, and policy review, the facility failed to thoroughly investigate an allegation of missing money for 1 resident (R) (R10) of 3 sampled residents.R10 reported $650 was missing from a pill bottle in R10's dresser drawer. The allegation of misappropriation was not thoroughly investigated. Findings include:Review of the facility's policy titled Abuse, Neglect, and Exploitation, with a revised date of 1/5/24, revealed it is the facility's policy to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Under the reporting/response section of the policy it states alleged violations will be reported to the required agencies no later than 24 hours if the events do not involve abuse.Review of a grievance form for R10, dated 6/25/25, revealed R10 stated when R10 came back from dialysis 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.

Based on observation and interview, the facility did not provide a safe, clean, comfortable, and homelike environment for 4 (R2, R4, R5 and R6) of 6 residents reviewed for environment.Findings include:On 7/11/25, at 9:45 AM, R2 and R5's room was observed. The window was observed to have a rolling window shade crooked and held up with 2 plastic hangers exposing half the window. The north wall, opposite the beds, had large patches of paint missing with one area being approximately 8 feet long by 6 inches. On 7/11/25, at 9:45 AM, Surveyor observed the bathroom shared by R2, R4, R5, and R6. A linen cart filled to the top, uncovered and a very strong smell of feces was present. There was also another linen cart and a large garbage can.On 07/11/2025, at 10:59 AM, Surveyor observed R2's wheelchair to have dried, crusty food particles and other unknown brown and crusty matter, on the seat, between the cushion, on the arm rests, by the lock handle and noted the left arm rest to be missing parts of the cushion beginning to expose the metal underneath. Surveyor asked Assistant Director 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, interviews and record review the facility did not ensure all alleged violations of misappropriation were thoroughly investigated for 1 (R1) of 1 residents reviewed.Findings include:R1 admitted to the facility on [DATE]. Diagnoses include Diabetes Mellitus Type 2, Atherosclerosis, morbid obesity, Congestive Heart Failure, lymphedema, Chronic Obstructive Pulmonary Disease, encephalopathy, femur fracture, Hypertension and Paraplegia.The facility policy titled Abuse, Neglect and Exploitation dated 1/5/24, documents (in part) . It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. A. An immediate investigation is warranted when allegation or suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.B. Written procedures for investigations…

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 received adequate supervision and assistive devices to prevent accidents for 1 (R2) of 2 residents reviewed for falls.*R2 was observed not wearing non-slip footwear during a transfer from R2's wheelchair into R2's bed. *R2 was observed to not have a scoop mattress which was documented on R2's care plan as a fall prevention intervention.*R2's Certified Nursing Assistant informed Surveyor R2 requires the assist of 2 staff and a stand pivot transfer using a gait belt and was transferred the morning of 07/11/2025 using this technique. R2's care plan documents R2 requires the use of a sit to stand device for transfers. Findings include:The Facility's Policy titled Sit to Stand Mechanical Lift Equipment and Guideline, with no revised date, documents, . Make sure the person has nonskid shoes on . R2 was admitted to the facility on [DATE] with diagnoses which include Dementia (the loss of cognitive function, including memory, thinking, 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, record review, and review of resident council meeting minutes, the facility failed to act upon the grievances raised during resident council and demonstrate their response and rationale for such response. This failure had the potential to affect the quality of life of more than 4 of the 132 residents residing in the facility. Findings include: 1. Resident Council Meeting Minutes, dated 1/22/25, indicated: .New Business and Concerns: a. Snacks not being passed; b. Call lights are not being answered on 1st and 3rd shift; c. Giving care while on the phone; d. Sitting in the hallway on the phone while call light on; e. Staff are rarely on the units . Resident Council Meeting Minutes, dated 2/20/25, indicated: .Old Business: a. Staff on the phone while giving care and passing food trays . Resident Council Meeting Minutes, dated 3/25/25, indicated: .Old Business: a. Staff are still on the phone while giving care or just sitting in room on phone . Resident Council Meeting Minutes, dated 4/28/25,…

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, facility policy review, and insulin pen manufacturer's instructions, the facility failed to ensure 2 residents (R) (R6 and R7) of 2 residents observed during medication administration were provided insulin from an insulin pen per the manufacturer's instructions. This failure had the potential for R6 and R7 to receive an incorrect dose of their insulin. Findings include: The facility's Administering Medications policy, revised 5/2025, indicates: .Medications shall be administered in a safe and timely manner, and as prescribed . The insulin pen manufacturer's patient instructions, located at http://uspl.lilly.com/humalog/humalog.html#ug1, indicate: .Step 11: Insert the needle into your skin. Push the dose knob all the way in. Continue to hold the dose knob in and slowly count to 5 before removing the needle 1. R6's Annual Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 2/19/25, revealed R6 was admitted to the facility on [DATE] and had a diagnosis 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, facility policy review, and manufacturer's instructions, the facility failed to ensure multi-dose insulin pens were labeled with the date and time when first opened for 2 residents (R) (R6 and R7) of 2 residents observed during medication administration. This failure had the potential to expose R6 and R7 to expired medications. Findings include: The facility's Administering Medications policy, revised 5/2025, indicates: .Medications shall be administered in a safe and timely manner, and as prescribed .The expiration/beyond use date on the medication label must be checked prior to administration. When opening a multi-dose container, the date opened shall be recorded on the container . The facility's Insulin Administration policy, revised 9/2014, indicates: .Check expiration date if drawing from an opened multi-dose vial. If opening a new vial, record expiration date and time on the vial (follow manufacturer recommendations for expiration after opening) . The Humalog Pen manufacturer's patient instructions, located at…

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 review of facility policy, the facility failed to perform hand hygiene and administer medications in a manner to prevent cross-contamination for 1 resident (R) (R6) of 2 residents observed during medication administration. This failure had the potential to spread of pathogens in the facility. Findings include: The facility's Handwashing/Hand Hygiene policy, dated 8/2014, indicates: .Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations .After removing gloves .Hand hygiene is the final step after removing and disposing of personal protective equipment . During an observation on 6/10/25 at 5:21 PM, Licensed Practical Nurse (LPN) 2 discarded a pair of gloves in the trash and immediately picked up a mouse on the medication cart and began to type on the computer. When asked if LPN 2 should have performed hand hygiene after discarding gloves, LPN 2 continued to chart and stated LPN 2 would after LPN 2 was done. When asked to provide LPN 2's…

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

Based on staff interview and record review, the facility did not designate a person to serve as the food and nutrition services director who was a certified Dietary Manager, had a national certification for food service management and safety from a national accrediting body, or had an associates or higher level degree in food service management or hospitality. This had the potential to affect all 147 residents residing in the facility. Dietary Manager (DM)-I did not complete and was not enrolled in an approved dietary manager or food service manager certification course or other related education. Findings include: On 3/31/25 at 1:30 PM, Surveyor interviewed DM-I who indicated DM-I had worked at the facility for a little over a year and had completed ServSafe Managers training. DM-I indicated DM-I was not yet enrolled in an approved Dietary Manager course but was thinking about taking the Certified Dietary Manager (CDM) training. DM-I indicated DM-I had recently hired an Assistant Dietary Manager who had a State Food Safety Food Manager Certification. On 4/1/25 at 11:00 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, staff interview, and record review, the facility did not provide pharmaceutical services to ensure the accurate administration of medication for 9 residents (R) (R21, R24, R25, R18, R14, R17, R15, R16, and R9) of 11 sampled residents. R21, R24, and R25's controlled substance medications were not documented in the controlled substance log at the time the medications were administered on 3/31/25. R18, R14, and R17's 9:00 AM medications were not administered timely on 3/31/25. R21's tramadol was not administered in accordance with the physician order on 3/31/25. R14's bumetanide and carvedilol were not administered in accordance physician orders on 3/31/25. R15's Abilify, amlodipine, atorvastatin, lisinopril, sertraline, and hydralazine were not administered in accordance with physician orders on 3/31/25. R16's hydralazine and sodium chloride were not administered in accordance with physician orders on 3/31/25. R17's Lantus and Humalog were not administered in accordance with physician orders…

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

Based on observation, staff interview, and record review, the facility did not ensure drugs and biologicals were stored in accordance with the facility's policy. This practice had the potential to affect more than 4 of the 147 residents residing in the facility. The 100 wing medication cart was unlocked and unattended on 3/31/25. Medication stored in an unlabeled and uncovered medication cup was administered to R23 on 4/1/25. Findings include: The facility's Storage of Medications policy, dated 4/2007, indicates: .1. Drugs and biologicals shall be stored in the packaging, containers, or other dispensing system in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers .7. 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 potentially available to others . On 3/31/25 at 10:46 AM, Surveyor observed Licensed Practical…

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 follow the menu for residents who ate in the dining room or follow serving sizes for residents who ate in their rooms. This practice had the potential to affect more than 4 of the 147 residents residing in the facility. On [DATE], residents who ate in the dining room were not served cut potatoes that were on the lunch menu. On [DATE], residents who ate in their rooms on the first floor were not served the correct amount of potatoes. Findings include: The facility's Meal Distribution policy, dated [DATE], indicates: 1. All meals are assembled in accordance with the individualized diet order, plan of care, and preferences. On [DATE], Surveyor observed the lunch menu posted in the dining room. The menu contained herb roasted pork loin, candied sweet potatoes, buttered cabbage, apple cobbler, and a beverage. On [DATE], the facility provided the production sheet for the lunch menu. The menu indicated residents should receive 4 ounces 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, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect more than 4 of the 147 residents residing in the facility. Dietary Aide (DA)-K did not follow hand hygiene and hairnet requirements while plating food on the second floor. Appropriate scoop sizes were not followed for residents residing on the first floor. Scoops were observed inside ice bin coolers on the first floor. Findings include: On 3/31/25 at 2:30 PM, Surveyor interviewed Dietary Manager (DM)-I who indicated the facility follows the State of Wisconsin Food Code. Hand Hygiene: The Wisconsin Food Code at Chapter 2 Personal Cleanliness 2-301.14 When to Wash indicates: Food employees shall clean their hands and exposed portions of their arms as specified under 2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: (A) After touching bare human body parts other than…

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 resident representative interview and record review, the facility did not ensure a Power of Attorney for Healthcare (POAHC) was notified of pharmacogenomic testing for 1 resident (R) (R1) of 25 sampled residents. POAHC-M was not notified of pharmacogenomic testing that was completed for R1. In addition, R1 signed a consent form which was obtained by Lab Company (LC)-P without POACH-M's knowledge. Findings include: The facility's Notification of Changes Guideline policy, revised 7/24/19, indicates: Nurses and other care staff are educated to identify changes in a resident's status and define changes that require notification of the resident and/or their representative and the resident's physician to ensure best outcomes of care for the resident. From 3/31/25 to 4/1/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including anxiety disorder, major depressive disorder, psychosis, and insomnia. R1's Minimum Data Set (MDS) assessment, dated…

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 activities of daily living (ADLs) needs were met for 1 resident (R) (R9) of 22 sampled residents. R9 did not receive weekly showers as specified in R9's plan of care and was not regularly transferred to the toilet. In addition, R9's medical record did not contain consistent ADL documentation. Findings include: The facility's Activities of Daily Living (ADL) policy, dated 5/7/20, indicates: Our collaborative professional team, together with the resident and/or resident's representative: .2. Develop and implement interventions in accordance with the resident's evaluated need and goal for care preferences and will address the identified limitation in ability to perform ADLs . The facility's Shower/Tub Bath policy, revised 10/2010, indicates: The following information should be recorded on the resident's ADL record and/or in the resident's medical record: 1. The date and time the shower/tub was performed. 2. The name and title of the individual…

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

Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to help prevent the development and transmission of communicable disease and infection for 2 residents (R) (R22 and R23) of 3 residents observed during medication administration. On 4/1/25, staff did not complete hand hygiene during medication preparation and administration for R22 and R23. Findings include: The facility's Handwashing/Hand Hygiene policy, dated August 2014, indicates: This facility considers hand hygiene the primary means to prevent the spread of infections .7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .c. Before preparing or handling medications . On 4/1/25 at 8:10 AM, Surveyor observed Licensed Practical Nurse (LPN)-F prepare medication for R22. Surveyor noted LPN-F did not complete hand hygiene prior to preparing and administering medication to R22. On 4/1/25 at 8:20 AM, Surveyor observed LPN-F prepare…

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 notify a resident representative when 1 resident (R) (R3) of 1 resident accessed a loaded gun from a staff's purse and carried the gun onto a secured memory care unit. In addition, the facility did not notify the physician of a new skin concern for 1 (R2) of 1 resident R3 was on 1:1 direct supervision for aggressive behavior. On 1/22/25, R3 gained access to a loaded gun in a staff's purse and carried the gun onto a secured memory care unit. R3's Power of Attorney (POA) was not updated following the incident. On 12/20/24, a portable oxygen tank was placed on a blanket near R2's right leg while R2 was getting ready for dialysis. R2 complained of irritation to the right ankle. An assessment indicated a reddened area was present. R2's physician was not notified. Findings include: The facility's Notification of Changes Guideline, revised 7/24/19, indicates: It is the practice of this facility that changes in a resident's condition or treatment are…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident representative interview and record review, the facility did not ensure a bed hold notice was provided for 1 resident (R) (R1) of 6 sampled residents. R1 went to the emergency room (ER) with family on 1/8/25. The facility did not provide R1 with a bed hold notice. Findings include: The facility's Bed Hold and Return Guideline policy, dated 4/25/19, indicates: It is the practice of this facility that residents who are transferred to the hospital or go on a therapeutic leave are provided with written information about the state's bed hold duration and payment amount before the transfer. Residents and their representatives will be provided with bed hold and return information at admission and before a hospital transfer or therapeutic leave. The facility will maintain contact with the resident and representative while the resident is absent from the facility and arrange for their return if appropriate .The objective of the bed hold and return to facility guideline is to ensure the…

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

Based on staff, resident, and family interview and record review, the facility did not ensure 1 resident (R) (R1) of 6 sampled resident was permitted to return to the facility after a hospital visit. R1's Family Member ((FM)-H) took R1 to the emergency room (ER) on 1/8/25. When R1 returned to the facility on 1/9/25, the facility informed R1 that R1 had been discharged and could not return. The facility then contacted R1 on 1/10/25 and indicated R1 could return, however, R1 was eating dinner and was settled at FM-H's for house for the night. R1 returned to the facility on 1/11/25. Findings include: The facility's Bed Hold and Return Guideline policy, dated 4/25/19, indicates: Residents and their representatives will be provided with bed hold and return information at admission and before a hospital transfer or therapeutic leave. The facility will maintain contact with the resident and representative while the resident is absent from the facility and arrange for their return if appropriate .C. readmission or Return to the Facility: The facility will readmit or allow the opportunity…

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

Based on staff interview and record review, the facility did not implement their written policies and procedures to prohibit and prevent abuse for 3 of 9 staff reviewed for caregiver background checks. This practice had the potential to affect more than 4 of the 141 residents residing in the facility. The facility did not ensure a thorough background check was completed for Dietary Aide (DA)-H who had substantiated findings of caregiver misconduct on DA-H's record and was prohibited from working as a caregiver in Department of Health Services (DHS) regulated facilities. In addition, DA-H did not report felony convictions on DA-H's Background Information Disclosure (BID) form. The facility did not have a completed Department of Justice (DOJ) letter or Government Findings Report for Certified Nursing Assistant (CNA)-J. The facility did not ensure DA-L's BID, DOJ and Government Findings Report were completed timely. Findings include: The facility's Abuse Neglect and Exploitation Policy, dated 1/5/24, indicates it is the policy of the facility to provide protections for the health,…

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) (R3) of 9 sampled residents was free from verbal abuse. On 11/2/24, multiple staff witnessed Dietary Aide (DA)-H call R3 a derogatory name and threaten to take away and hit R3 with R3's walker. In addition, the facility did not ensure a thorough background check was completed for DA-H who had substantiated findings of caregiver misconduct and was prohibited from working as a caregiver in Department of Health Services (DHS) regulated facilities. Findings include: The facility's Abuse Neglect and Exploitation Policy, dated 1/5/24, indicates it is the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .Screening: A. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation 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 and staff interview, the facility did not provide adequate supervision for 1 resident (R) (R2) of 1 resident who required direct supervision. R2 had a history of yelling, threatening, and hitting peers and staff. R2's care plan contained an intervention for 1:1 staff supervision. On 1/7/25, Surveyor observed R2 without 1:1 supervision on multiple occasions. Findings include: On 1/7/25, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including dementia, congestive heart failure, insomnia, and atrial fibrillation. R2's most recent Minimum Data Set (MDS) assessment, dated 10/6/24, had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated R2 had severely impaired cognition. R2's comprehensive care plan, revised 11/27/24, indicated R2 had a behavior problem related to yelling, threatening, and hitting peers and staff. Interventions included 1:1 supervision/monitoring for behaviors and to avoid triggers such as large…

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, resident interview, and record review, the facility did not allow 1 resident (R) (R1) of 1 resident to remain in the facility after the resident returned from the hospital and planned to move into an apartment 11 days later. R1 was admitted to the hospital on [DATE] and returned to the facility on [DATE]. R1 planned to discharge to an apartment that was undergoing renovation and would be ready for move in on 10/20/24. Following an argument with staff on 10/9/24, R1 was told R1 had to leave the facility and was discharged to a relative's home without medication and a discharge plan. Findings include: On 10/28/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including acute on chronic diastolic heart failure, cardiomegaly (an enlarged heart), chronic kidney disease stage 3, morbid obesity, diabetes, and non-pressure chronic ulcer other part of right foot. R1's admission Minimum Data Set (MDS) assessment, dated 7/25/24, had a Brief…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not ensure 1 resident (R) (R2) of 1 resident received assistive devices to maintain vision. The facility did not ensure R2 obtained replacement glasses after R2's glasses were lost in the facility. Findings include: On 10/28/24, Surveyor reviewed the facility's grievance file which included a grievance, filed by R2's family member on 8/28/24, that stated R2's prescription glasses were missing. A follow-up grievance, filed by R2's family member on 8/29/24, asked for follow-up on the missing glasses. Surveyor noted the grievance did not include corrective action taken, resolution, or follow-up regarding R2's missing glasses. On 10/28/24, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including dementia, type 2 diabetes, cataract, glaucoma, hyperopic astigmatism and presbyopia, retinopathy, and hypertension in both eyes. R2's Minimum Data Set (MDS) assessment, dated 9/3/24, had a Brief…

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

Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 2 residents (R) (R4 and R13) of 27 residents. On 10/28/24, Certified Nursing Assistant (CNA)-O carried clean towels against CNA-O's scrub top and delivered the towels to R4. In addition, CNA-O carried clean towels into 2 residents' rooms before delivering them to R13. Findings include: The facility's Infection Prevention and Control Program policy, with a revision date of 7/25/23, indicates: This facility has established and maintains an infection prevention and control program designed to provided a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections as per accepted national standards of practice .11. Linens: Laundry and direct staff shall handle, store, process and transport linens to prevent the spread of infection. Standard Precautions Infection Control Protocol: Textiles…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not provide the opportunity for 2 (R600 and R601) of 3 Residents reviewed to participate in the development and implementation of their person-centered plan of care by not facilitating the inclusion of R600 and R601 in the care planning process. *R600 was admitted on [DATE], and there is no documentation in R600's electronic medical record that R600 and/or representative participated in the development and implementation of R600's person-centered plan of care. *R601 did not have a care conference, that included R601 or R601's representative, in order to develop, implement, or revise a plan of care between 3/19/2024 and R601's discharge on [DATE]. Findings Include: The facility's undated policy Care Management Guideline documents: .Guideline: The purpose of the initial Care Management Meeting is to communicate to the patient and patient representative, within 48 hours of admission, the baseline plan of care, barriers to the discharge plan, and care and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the Facility did not ensure 1 (R600) of 1 Resident's representative was notified when there was a need to alter treatment. R600's electronic medical record (EMR) has no documentation that R600's representative was notified of R600's colonoscopy being rescheduled to 1/3/25. On 8/28/24, R600 was sent to the emergency room (ER) for leg swelling and R600's representative was not notified. On 9/10/24, R600's physician was updated due to lab results and new order to discontinue Levothyroxine re-check TSH (thyroid stimulating hormone) and T4 (Thyroxine) in 5 weeks and Start Potassium (K+) 40Meq (milliequivalents) daily for 4 days due to decreased K+ re-check BMP (basic metabolic panel) and Mg in one week. On 9/12/24, R600's physician ordered new Lab TSH AND T4 and new orders for Levothyroxine 25 Mcg Daily. R600's representative was not notified about the labs and medication changes. Findings Include: The facility's policy Notification of Changes Guideline effective 11/28/17 and last…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review the facility did not address and resolve grievances conveyed on behalf of 1 (R609) of 1 residents reviewed for grievances. On 9/3/24 a grievance was initiated for R609 related to wanting a comfortable mattress and/or a recliner for sleeping. The facility indicated the grievance was resolved when R609 was told the facility does not provide recliners for residents, but the resident could bring one from home and she could not have an air mattress because of a lack of wounds and R609 accepted the explanation. Part of the resolution of the grievance was telling R609 to pursue an air mattress on their own by contacting the Physician. The facility did not attempt to come up with an alternative option or resolution other than stating R609 does not have wounds, therefore, they cannot have an air mattress. R609 has a diagnosis of Amyotrophic Lateral Sclerosis (ALS). As of 9/17/24 R609 was still not provided a resolution to allow them to sleep in a comfortable chair or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility did not ensure that 2 allegations of injuries of unknown origin involving 2 Residents (R603 and R606) were reported immediately to the State Survey Agency. *R606 was noted to have bruising and swelling to right eye on 8/20/24. The injury of unknown origin was not immediately reported to Nursing Home Administrator (NHA)-A and to the State Survey Agency. *On 7/27/24, R603's x-ray results showed a left hand fracture which was not reported immediately to the State Survey Agency. Findings Include: The facility's Abuse, Neglect and Exploitation policy implemented 9/2020 and last revised on 1/5/24 documents: .III. Prevention of Abuse, Neglect and Exploitation B. Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of Resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff to meet the needs of Residents, and assure that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility did not ensure that 1 allegation of injury of unknown origin involving 1 Resident (R606) of 2 allegations of injury of unknown origin reviewed were thoroughly investigated. *R606 was noted to have bruising and swelling to R606's right eye on 8/20/24. The injury of unknown origin was not thoroughly investigated including obtaining statements from staff. Findings Include: The facility's Abuse, Neglect and Exploitation policy implemented 9/2020 and last revised on 1/5/24 documents: .III. Prevention of Abuse, Neglect and Exploitation B. Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of Resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff to meet the needs of Residents, and assure that the staff assigned have knowledge of the individual Residents' care needs and behavioral symptoms D. The identification, ongoing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure 2 (R602 & R606) of 9 residents care plans were revised. * On 7/30/24 at 5:56 a.m. R602 was observed on the floor. The IDT (interdisciplinary team) determined an intervention of: If resident is awake offer resident to get up and dressed for the day. This intervention was not added to either R602's at risk for falls or had an actual fall care plan. * R606's care plan and Kardex were not individualized to address R606's care needs. Additionally, items on the comprehensive care plan were not included on the Kardex. R606's care plan was not updated with fall interventions including crawling on a mat. Findings include: The facility's policy titled, Careplan Standard Guideline with an effective date of 11/28/2017 documents under Procedure #6. The care plan is to be revised to reflect the current status of the resident and #7 The care plan will be reviewed throughout the resident's stay upon admission, quarterly and with changes in condition. 1.) R602's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the Facility did not ensure residents maintained acceptable parameters of nutritional status for 1 (R601) of 1 residents reviewed for weight loss. R601 sustained severe weight loss over a period of 7 months. The Physician was not notified, weight loss was not prescribed and no new interventions were implemented. Findings include: The Facility Policy titled, Nutritional Status Management last revised 4/2/2018, documents, in part: Purpose: It is the practice, in accordance with advanced directives to provide interventions to maintain, improve and respond to nutritional needs. Measures will be taken to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balances, unless the residents clinical condition demonstrates that this is not possible or resident preferences indicate otherwise . The interdisciplinary team together with the resident and/or resident representative will identify, evaluate risk factors…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure 1 (R606) of 3 Residents reviewed who was receiving a psychotropic medication, was free from unnecessary medications. * R606 has a PRN (as needed) order for Ativan, an anti-anxiety medication that did not have a documented rationale in R606's medical record that indicated the duration for the PRN order beyond 14 days. Findings Include: The facility's policy 14 Day PRN Psychotropic Medication Guideline Effective 11/28/17 documents: .A psychotropic medication order with instructions for PRN dosing shall be discontinued after 14 days. For PRN non-antipsychotic psychotropic orders: The PRN order may be extended beyond 14 days if the prescriber believes it is appropriate to extend the order. The Prescriber must document the rationale for the extended treatment in the medical record and indicate a specific duration of therapy. The Director of Nursing (DON)-B or designee shall be responsible for ensuring the order discontinuation of any psychotropic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review the facility did not provide functional furniture appropriate to the resident's needs in each resident's room to attain or maintain his or her highest practicable level of independence and well-being, including a clean, comfortable mattress for 1 of 1 (R609) residents reviewed. R609 was not provided a comfortable mattress. Findings include: R609 admitted to the facility on [DATE] and has diagnoses that include Amyotrophic Lateral Sclerosis (ALS), Anxiety Disorder, Adjustment Disorder with Depression, Gastro-Esophageal Reflux Disease, Hypertension and Insomnia. R609's admission Minimum Data Set (MDS) dated [DATE] documents: Mobility - roll left and right: The ability to roll from lying on back to left and right side and returning to lying on back on the bed - Dependent. R609's Braden dated 9/4/24 documents a score of 12, indicating high risk for pressure injuries. At present, R609 has no pressure injuries. On 9/17/24 at 9:00 AM, as Surveyor was walking in the…

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

Based on observations, interviews and record review, the facility did not establish and maintain an infection prevention and control program based upon current standards of practice, designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections. This deficient practice has the potential to affect all 148 residents. The facility's Water Management Plan (WMP) was not based on current standards of practice and did not: ~Reflect changes in program members. ~Include water management team members who were knowledgeable about the facility's water system. ~Identify control measures based on where Legionella could grow and spread and identify how to monitor the control measures and risks. ~Identify acceptable ranges of control limits (temperature ranges) and corrective actions to take when control limits are not met. The Facility's Infection and Control Program Surveillance did not have: ~ monthly infection percentage rates for each infection type. ~urinary tract infections (UTI) separated into catheter associated 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 maintain mechanical and/or electrical equipment in safe operating condition. Surveyor observed the following: * A leaking, full grease tank from the kitchen next to the dryers in the laundry area. * Dryer vent with copious amounts of lint. * Washer for residents personal clothing leaking water. This deficient practice has the potential to affect all 148 residents residing in the facility. Findings include: On 06/26/24 11:31 AM, Surveyor observed towels and 2 caution wet signs on the floor in the dryer room. Surveyor was informed by Maintenance Assistant (MA)-W the kitchen grease trap tank is leaking as a result of staff hitting the pipe with carts. MA-W informed Surveyor that the tank needs to be emptied before it can be fixed, and that they are unable to get this fixed as the contractor requires immediate payment. MA-W stated this has been known for several weeks. On 06/26/24, at 12:00 PM, Surveyor asked MD-X about the grease tank leaking. MD-X stated he is calling around to get quotes and find a different…

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

Based on interview and record review, the facility did not ensure that facility staff received required Quality Assessment and Performance Improvement (QAPI) program training for 2 of 5 sampled Certified Nursing Assistants (CNAs). This has the potential to affect the148 Residents who reside at the facility and have the potential to receive care from both CNAs. Findings Include: On 07/12/24 at 3:16 PM, Surveyor reviewed CNA-II and CNA-JJ's completed trainings for the past year and noted there was no documentation that CNA-II and CNA-JJ's received wertraining on the facility's QAPI program which outlined and informed staff of the elements and goals of the facility's QAPI program. On 7/12/24 at 4:02 PM, Surveyor requested documentation from NHA (Nursing Home Administrator)-A for CNA-II and CNA-JJ that included training of the facility's QAPI program which outlined and informed staff of the elements and goals of the facility's QAPI program. On 7/12/24 at 4:05 PM, Nursing Home Administrator (NHA)-A confirmed the facility has not provided CNA-II and CNA-JJ with the mandatory QAPI…

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

Based on interview and record review, the facility did not ensure that 2 of 5 sampled Certified Nursing Assistants (CNAs received annual training on the facility's compliance and ethics program. This has the potential to affect the148 Residents who reside at the facility and have the potential to receive care from both CNAs. Findings Include: On 07/12/24 at 3:16 PM, Surveyor reviewed CNA-II and CNA-JJ's completed trainings for the past year and noted there was no documentation that CNA-II and CNA-JJ's received training of the facility's compliance and ethics program. On 7/12/24 at 4:02 PM, Surveyor requested documentation from NHA (Nursing Home Administrator)-A for CNA-II and CNA-JJ that included training of the facility's compliance and ethics program. On 7/12/24 at 4:05 PM, Nursing Home Administrator (NHA)-A confirmed the facility has not provided CNA-II and CNA-JJ with the facility's compliance and ethics program. NHA-A informed Surveyor the facility was working on providing training on the facility's compliance and ethics program to all CNAs. No additional information was…

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

Based on record review, the facility did not properly complete a BID (Background Information Disclosure) form, DOJ (Department of Justice) form, and IBIS (Integrated Background Information System) form for 2 of 8 employees reviewed for the sufficient and competent staffing tasks. This has the potential to affect a pattern of residents whom may recieve care from both staff members. Findings include: On 6/27/24 at 8:11 AM, Surveyor reviewed CNA-KK's and Activity Aide-LL's employee files to validate that the facility completed a BID (Background Information Disclosure) form, DOJ (Department of Justice) form, and IBIS (Integrated Background Information System) form for upon hire and within the last 4 years. Surveyor noted: CNA-KK was hired by the facility on 11/6/23. The facility completed the following for CNA-KK: The BID was completed on 2/12/24. The DOJ was completed on 6/26/24. The IBIS was completed on 6/26/24 Surveyor noted the facility did not complete a BID, DOJ, and IBIS upon hiring CNA-KK. Activity Aide-LL was hired by the facility on 8/19/18. The facility completed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to prevent further potential abuse for 1 (R118) of 2 residents reviewed. On 6/9/24, R118 was discovered with his hands down R73 pants. R118 and R73 are roommates. Med tech- R separated both residents and reported the incident immediately. The facility moved R73 to a different room and placed a different resident in the room with R118. NHA-A stated the reason for placing a different roommate with R118 is because the new roommate was more verbal and able to voice if R118 would touch him. R118's care plan was not updated to reflect the inappropriate sexual behavior. The facility did not have structured monitoring of R118 and no evidence of supervision of R118 after discovering his hands down R73 pants. The facility failed to prevent further potential abuse through supervision and structured monitoring which allowed R118 to act out sexually and touch R73 inappropriately. Findings include: Surveyor reviewed the facility's Abuse, Neglect 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 4.) R106 nurses notes dated 6/22/24 documents R106 was sent to the hospital due to an unresponsive episode and seizure like activity. There is no evidence, in the medical record, of a transfer notice completed for R106. On 6/27/24 at 3:00 p.m. during the daily exit meeting with NHA-A and DON-B, Surveyor asked for the transfer notice for R106's transfer to the hospital on 6/22/24. As of 7/1/24 Surveyor did not receive any additional information regarding R106 transfer notice. Based on record review and interview, the facility did not ensure residents received the required transfer notices, in writing, with a transfer from the facility. This was observed with 10 (R31, R47, R124, R106, R13, R15, R27, R64, R110 and R81) of 10 resident transfer's reviewed. * R31, R47, R124, R106, R13, R15, R27, R64, R110 and R81, were transferred from the facility to a hospital. There was no documentation in the medical record of receiving the notice requirements. Findings include: There is not a facility policy and procedure for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 4.) On 6/22/24, R106 was sent to the hospital due to an unresponsive episode and seizure like activity. There is no evidence, in the medical record, of a bed hold notice completed for R106. On 6/27/24 at 3:00 p.m. during the daily exit meeting with NHA-A and DON-B, Surveyor asked for the bed hold policy for R106's transfer to the hospital on 6/22/24. As of 7/1/24 Surveyor did not receive any additional information regarding why R106 did not recieve a bed hold notice on 6/22/24 when he was transfered to the hospital. Based on record review and interview, the facility did not ensure residents received the required bed-hold information, in writing, with a transfer from the facility. This was observed with 10 (R31, R47, R124, R106, R13, R15, R27, R64, R110 and R81) of 10 resident transfer's reviewed. * R31, R47, R124, R106, R13, R15, R27, R64, R110 and R81, were transferred from the facility to a hospital. There was no documentation in the medical record of receiving the required bed-hold information. Findings…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not ensure Preadmission Screening was completed or accurate for individuals with a mental disorder for 6 (R102, R140, R31, R47, R54, and R91) of 9 residents reviewed for PASARR (Preadmission Screening and Resident Review). *R102, R140, R31, R47, R54, and R91 had diagnoses mental disorders and medications to treat those disorders. A Level I PASARR should have triggered a Level II PASARR to be completed by the State Agency, but no Level II PASARRs were completed for these residents. Findings include: The facility policy and procedure entitled PASARR Guideline dated 11/28/2017 documents: PROCEDURE: 1. admission and readmission: a. The facility will participate in or complete a Level I screen for all potential admissions regardless of payer source to determine if the individual meets the criterion for mental disorder (SMI/SMD), intellectual disability (ID) or related condition. b. Based upon the Level I screen, if an individual is determined to meet the above…

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 comprehensive care plans were implemented and included participation by the resident or resident representative for 2 (R102 & R124) of 32 resident care plans reviewed. *R102 did not have any documented care conferences since admission on [DATE] and did not have a care plan developed that included R102's preferences. *R124 did not have any care conferences to discuss discharge planning and the care plan was not revised after elopement attempts or refusals to take antidepressant medication. Findings include: The facility policy and procedure entitled Care Management Guideline undated documents: Guideline: Care Management is implemented when a qualifying change in condition occurs which require skilled services, interdisciplinary (IDT) collaboration, and timely proactive communication beyond the standard practices of communication established in the facility. Care Management is conducted upon admission or readmission from an acute setting. 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 resident was free from misappropriation of property for 1 (R64) of 1 residents reviewed for misappropriation. * R64 had eight (8) oxycodone tablets go missing when facility staff did not complete a shift change narcotic count on 6/10/2024. The facility did not thoroughly investigate the missing narcotic tablets and the investigation did not include a conclusion of where the missing 8 oxycodone tablets went. Findings include: The facility policy entitled Abuse, Neglect and Exploitation revised on 1/5/2024 documents It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent, use of a resident's belongings or money…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure 2 (R499 and R118) of 3 abuse allegations reviewed were reported to the State Agency. * On 4/16/2024, R499 filed a grievance indicating she did not receive care. R499 alleged she did not receive cares overnight on 4/16/2024. The facility did not report this allegation to the State Agency. * On 6/9/24, R188 was found with his hand down R73's pants. The facility failed to submit the initial self-report within the 2-hour timeframe for an allegation of sexual abuse to the state agency and the police were not notified of this allegation of sexual abuse until the next day. Findings include: The facility's policy Abuse, Neglect and Exploitation dated as last revised on 1/5/24 documents: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident…

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

Based on record review and interview, the facility did not document in a resident's medical record the reason for a transfer to the hospital for 1 (R124) of 9 resident hospital transfers from the facility that were reviewed. * R124 was transferred to the hospital on 3/3/24. There is no documentation in the medical record, of reason and location of what hospital R124 was transferred to. Findings include: The facility's policy Change in a Resident's Condition or Status, dated as revised 11/2015 documents: 7. The Nurse Supervisor/ Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status 1.) R124 progress note by (Licensed Practical Nurse) LPN-N on 3/3/24, at 11:35 PM, states Writer received a call from Officer-V regarding the resident's wear about. Writer was told that the resident was found safe at their sister's house, after the resident left the hospital on foot. the Officer-V also stated that the resident had caught 3 buses from the hospital to arrive at their sister house. The Officer-V stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview the facility did not develop and implement a comprehensive person-centered care plan for 1 (R72) of 29 residents to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment. *R72 was assessed to be at high risk for falls and only had one intervention on his care plan to prevent falls. Findings include: On 6/27/24 the facilities policy and procedure titled Care Plans-Comprehensive dated 10/10 was reviewed and documented: each residents comprehensive care plan after each assessment is designed to: Incorporate identified problem areas, incorporate risk factor identified with problem areas, reflect currently recognized of practice for problem areas and conditions. 1. R72 was admitted to the facility on [DATE] with diagnoses that included Anxiety and Degenerative Disease of the Nervous system. R72's annual Minimum Data Set (MDS) dated [DATE] was reviewed and indicated R72 had a Brief Score for Mental Status score…

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 (R10) of 4 residents reviewed received ADLs (Activities of Daily Living) including personal hygiene per plan of care. *R10 was observed to be disheveled, having a strong body odor and untrimmed fingernails with a brown substance underneath R10's nails throughout the survey. Findings Include: R10 was admitted to the facility on [DATE] with diagnoses of cerebral vascular accident and left upper and lower extremity contractures. Surveyor reviewed R10's Quarterly MDS (Minimum Data Set) dated 5/15/24. R10 is rarely to never understood. R10 has limitations in range of motion to their left upper and lower extremities. R10 requires total assistance with personal hygiene and bathing. On 6/25/24 at 9:25 AM, Surveyor observed R10 in bed in a hospital gown. R10 was positioned on their back. R10 was non interviewable due to their cognitive status. R10 was noted to be disheveled with uncombed hair, body odor and untrimmed fingernails with a dark…

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 assess the risk of entrapment and review the risk & benefits for 1 (R10) of 1 residents observed having bilateral half bed rails. Findings include: R10 was admitted to the facility on [DATE] with diagnoses of cerebral vascular accident and left upper and lower extremity contractures. Surveyor reviewed R10's Quarterly MDS (Minimum Data Set) dated 5/15/24. R10 is rarely to never understood. R10 has limitations in range of motion to their left upper and lower extremities. Surveyor reviewed R10s medical record including physician orders, progress notes, therapy notes, and comprehensive care plan. On 6/25/24 at 9:25 AM, Surveyor observed R10 in bed in a hospital gown. R10 was positioned on their back with 2 half bed rails up. R10 was non interviewable due to their cognitive status. On 6/25/24 at 11:15 AM, Surveyor observed R10 in bed in a hospital gown. R10 was positioned on their back with 2 half bed rails up. On 6/26/24 at 8:35 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.

Based on interview and record review, the facility did not ensure each resident's drug regimen was free from unnecessary medication for 1 (R54) of 2 Residents reviewed. * R54 received an antibiotic but did not meet the facility's criteria for the administration of the antibiotic. R54 also did not receive final dose of an antibiotic after returning to the facility from the hospital. Findings include: R54's diagnosis includes acute and chronic respiratory failure, chronic obstructive pulmonary disease (COPD), asthma and sleep apnea. On 06/08/2024, R54 was admitted to the hospital and discharged on 06/10/2024. Per R54's Patient Discharge Summary, R54 discharge diagnoses documents, Acute hypoxic/hypercapnic respiratory failure 2/2 COPD exacerbation. R54's Discharge Medication List documents, continue these medications which have changed azithromycin 250 mg (milligrams) tablet Take 1 tablet (250 mg total) by mouth daily for 1 dose. Surveyor noted no orders documented on R54's Medication Administration Record (MAR) for R54 to receive azithromycin after returning from the hospital. R54 did…

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 coordination of care and the hospice communication process was followed for 1 (R119) of 4 residents reviewed for hospice services. The facility did not ensure hospice required documentation was maintained in R119's medical record. The facility did not have R119's hospice plan of care with the delineation of hospice's responsibilities and services provided, and communication process between the facility and hospice. Findings include: Surveyor reviewed the Nursing Facility Services Agreement with [hospice company] with the effective date of 7/20/2023. The agreement documents: . In consideration of the Recitals and mutual agreements that follow, the parties agree to the following terms and conditions: . 2. Responsibilities of the facility: (d) Coordination of Care: (i) General- Facility shall participate in any meetings, when requested, for the coordination, supervision, and evaluation by hospice of the provision of facility services. Hospice and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure 1 (R499) of 32 residents reviewed based on the comprehensive assessment of a resident, residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. R499 developed Moisture Associated Skin Disorder (MASD) while residing in the facility. The facility did not perform skin checks throughout R499's stay from 4/15/24 through 5/3/24. Findings include: The facility's policy Skin Management Guideline dated 11/28/17 documents: Purpose: To ensure residents that are admitted to the facility are evaluated to determine appropriate measures to be taken by the interdisciplinary care team to determine appropriate measures and individualized interventions to prevent, reduce and treat skin breakdown. Monitoring of Skin Integrity: Weekly skin observation on the bath/shower day will be performed by a Licensed Nurse. If a skin concern is noted, refer to the skin 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 observations, interview, and record review, the facility did not help prevent the transmission of COVID-19, that had the potential to affect 161 of the 161 residents at the facility. The facility had a COVID-19 outbreak [DATE] to 3/2/ 2024 that caused positive test results for 40 residents and 8 staff members with one resident, R33, testing positive and passing away during the outbreak. Agency staff members were not fit-tested for N95 masks, and 57 agency staff members provided services at the facility from [DATE] to [DATE]. Residents that were COVID-19 positive continued to congregate in the smoking area, passing through the hallways with face masks not worn appropriately or at all per interview. Findings include: The facility policy and procedure entitled COVID-19 Prevention, Response and Reporting dated [DATE] states: Policy Explanation and Compliance Guidelines: . 14. Resident placement considerations: a. If possible, residents with suspected or confirmed SARS-CoV-2 infection should be placed in a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review, the facility did not ensure 1 (R24) of 1 residents reviewed for planning and implementing care were given the right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care and treatment. R24 had an activated Healthcare Power of Attorney (POA) for decision making. R24 was prescribed Seroquel (Antipsychotic medication) in December 2023 and R24's activated POA was not made aware of the prescribed medication and a consent for the medication was not signed by the activated POA. Findings include: Surveyor reviewed the facility's Change in Resident's Condition or Status policy with revised date of November 2015. Documented was: Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) . 6.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the Facility did not ensure 2 (R32 & R23) of 4 Resident's reviewed had consultation with a physician when a change in treatment and care occurred. * R32's physician was not consulted with when R32 missed multiple doses of Divalproex Sodium during December 2023 & January 2024. On 1/3/24 the Facility was consulted with R32's Valproic acid level was low at 17 (reference range 50-100). There is no evidence R32's physician was consulted with regarding this lab and on 1/4/24 R32 experienced two seizures and was transferred to the hospital. * R23's diagnosis includes Crohn's disease. R23's physician was not consulted with when R23 missed multiple doses of Diphenoxylate-Atropine, a medication to treat diarrhea, during October 2023 & November 2023. On 11/23/23 R23 was vomiting all evening shift and into the night shift. R23's physician was not consulted with. Findings include: 1.) R32 was admitted to the facility on [DATE] and discharged on 1/4/24. The hospital discharge summary for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY UNCORRECTED AT REVISIT Based upon observation, interview, and record review, the facility did not ensure a grievance submitted for 1 (R24) of 16 residents reviewed was resolved and the resolution was implemented. A grievance was filed on behalf of R24 indicating the facility staff do not get R24 out of bed. R24 was to be up and out of bed by 8:00 am. During the survey R24 was observed to not be up and out of bed throughout the day, including by 8:00 am. Facility staff indicated R24 refuses to get up, there is no indication this has been assessed as part of the grievance process or care planned if the behavior occurs. Findings include: R24 was admitted to the facility on [DATE] with diagnoses that included Cerebral Infarction, Nontraumatic Intracerebral Hemorrhage, Spastic Hemiplegia Affecting Right Dominant Side, and Other Speech and Language Deficits following Cerebral Infarction. Surveyor reviewed R24's MDS (Minimum Date Set) annual assessment with an assessment reference date of 1/28/24. Documented under…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the Facility did not ensure 1 (R23) of 1 Residents discharged to the community received a completed discharge summary. R23 was discharged on 11/24/23. The Facility did not complete a discharge summary including a recapitulation of R23's stay. Findings include: The Transfer and Discharge Guidelines with an effective date of 11-28-2017 under the section H. Documentation includes documentation of a. The resident's physician and facility staff will document in the resident's record: ii. Reason that the services provided by the facility are no longer needed; document discharge needs and discharge plan. Under section I Orientation for transfer/discharge includes documentation of : a. The facility will provide the resident with sufficient preparation and orientation to the upcoming discharge to ensure that the discharge is safe and orderly. The orientation will be provided to the resident and resident representative in a form and manner that can be understood. g. The facility will…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY UNCORRECTED AT REVISIT Based on observation, interview, and record review, the facility did not ensure 1 (R4) of 4 residents reviewed for Activities of Daily Living who was unable to conduct activities of daily living receives the necessary services to maintain good nutrition, grooming, personal and oral hygiene . R4 was not provided oral care while at the facility. Findings include: Surveyor reviewed facility's Activities of Daily Living (ADLs) policy with an effective date of 05/07/2020. Documented was: Purpose: Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, our facility provides necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. Responsible Party: All staff Guideline In accordance with the comprehensive assessment, together with respect for individual resident needs and choices our…

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 VERIFICATION VISIT Based on observation, interview, and record review, the facility did not ensure that residents with a pressure injury or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 2 (R16 & R4) of 3 residents reviewed for pressure injuries. * The weight for R16's air mattress was not set according to physician orders. Treatment to R16's heel was not completed on 3/2/24 & 3/3/24. R16 developed a pressure injury above the right heel which was identified in a picture on 3/4/24. As of 3/7/24, this area was not comprehensively assessed and there was no treatment until 3/7/24. R16's sacrum pressure injuries were not comprehensively assessed individually but measured and assessed as one area. * R4's heels were not offloaded according to the plan of care. Findings include: The Skin Management Guidelines with an effective date of 11-28-17 under the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the Facility did not ensure 1 (R23) of 1 Residents reviewed for an indwelling catheter had a valid medical justification for continued use of the indwelling catheter and received the necessary services for monitoring of the indwelling catheter. R23 was originally admitted to the Facility with a Foley catheter on 10/19/23 & upon return from the hospital on [DATE]. There is no medical justification for the continued use of the indwelling catheter as Facility documentation indicates R23's Foley catheter is in place for healing of excoriation buttocks due to Crohn's disease. R23 had MASD (moisture associated skin damage) and did not have any pressure injuries. There was no physician order for the Foley catheter, no monitoring of R23's urinary output, and when R23 was transferred to the hospital on [DATE] following a fall, the hospital determined the Foley catheter balloon was in the prostrate. Findings include: The Urinary Indwelling Catheter Management Guidelines with an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the Facility did not ensure 2 (R23 & R21) of 4 Residents reviewed for nutrition maintained acceptable parameters of nutritional status. * R23's nutritional needs were not assessed while R23 resided in the Facility, weights were not obtained per Facility guidelines and a nutritional care plan was not developed. * R21's weights were not obtained per Facility guidelines. Findings include: The Nutritional Status Management with an effective date of 11-28-17 under Purpose documents It is the practice, in accordance with advanced directives to provide interventions to maintain, improve and respond to nutritional needs. Measures will be taken to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balances, unless the residents clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. The facility with both evaluate and record meal intake and document within 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 failed to ensure hemodialysis care and services were provided consistent with professional standards of practice which included the development of policies and procedures, development of a comprehensive dialysis care plan, ongoing assessments, monitoring for complications before & after dialysis treatments received at a certified dialysis center, and ongoing communication and collaboration with the dialysis center for 2 (R4 & R21) of 2 Residents reviewed for dialysis. *R4 receives dialysis 3 times a week and did not have completed communication reports by the facility prior to going to dialysis. R4 does not have a person-centered focused care plan addressing then need for dialysis. *R21 received dialysis 3 times a week and did not have completed communication reports by the facility prior to going to dialysis. R21 did not have a person-centered care plan addressing the need for dialysis. Findings Include: Surveyor reviewed the facility's undated Dialysis policy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility did not ensure the physician wrote, signed, and dated progress notes at each visit for 2 (R24 and R4) of 2 residents reviewed for Medical Doctor (MD) visit notes. Resident visit notes for R24 and R4 were not available in Electronic Medical Records (EMR) for Nurse Practitioner (NP)-D. Findings include: R24 was admitted to the facility on [DATE] with diagnoses that included Cerebral Infarction, Nontraumatic Intracerebral Hemorrhage, Spastic Hemiplegia Affecting Right Dominant Side and Other Speech and Language Deficits Following Cerebral Infarction. Surveyor reviewed R24's Progress Notes. Documented on 12/13/2023 at 3:30 PM was NP-[D] came to this writer and stated that she will start the pt (patient) on Prednisone 60 mg (milligrams) daily x (for) 4 weeks for bilateral eyes . Surveyor noted there was no NP visit note in R24's chart. Surveyor reviewed R24's Progress Notes. Documented on 12/26/2023 at 2:55 PM, was resident continues to be monitored due to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure that 3 ( R21, R31 and R25) of 15 Residents reviewed were provided medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being. *R21 and R31 engaged in a Resident to Resident altercation on 1/13/23. The facility did not initiate behavior monitoring, psychiatric evaluations, follow up after the incident, or create person-centered care plans with individualized interventions keep all Residents in the facility safe. *The facility did not ensure R25 received therapy services upon admission, initiate ancillary referrals, initiate and update discharge planning which included options counseling for R25. The facility failed to monitor R25's mood status which includes updates to R25's care plan with person centered interventions. Findings Include: 1) R21 was admitted to the facility on [DATE] with diagnoses of End Stage Renal Disease, Epilepsy, Wernicke's Encephalopathy, Hemiplegia and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that 3 (R24, R27 and R20) of 6 residents reviewed for medications were not adequately monitored for insulin administration. ~ R24 was receiving fast acting insulin prior to meals. The facility was not checking for therapeutic blood glucose (BG) levels before administering the fast acting insulin per documentation. Surveyor observed staff providing a meal prior to administration of insulin. ~ R27 had orders for 4 times daily BG monitoring. This was not completed per order. On discharge from the hospital, it was recommended R27 have Sliding Scale (SS) insulin ordered until diabetes was controlled which was not completed. ~ R20 was admitted with orders for three times daily blood glucose levels. The order was not transcribed into the orders and was not completed. ~R20 returned to the facility from a hospital stay on 2/14/24. The medication, Levetiracetam (Keppra), was started in the hospital for seizure prevention. The Discharge Summary from 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 interviews and record review, the facility did not ensure that 1 (R24) of 6 sampled residents reviewed for medications were free from unnecessary psychotropic medications. R24 was prescribed Seroquel for behaviors. R24 did not have an appropriate diagnosis for the medication, was not properly monitored for specific behaviors, did not have a care plan addressing the psychotropic medication or any interventions for R24's behaviors. Findings include: Surveyor reviewed facility's Behavioral Management Program policy and procedure with an effective date of 11/22/2017. Documented was: Purpose: The purpose of the Behavior Management Program is to promote and provide the highest practicable quality of life and a safe environment for residents and staff. Responsible Party: Nursing, Social Services, Activities, Therapy, Pharmacy Guideline This facility will maintain a strong commitment to the safety and welfare of all residents under our care. We will assess residents for risk factors for the development of mood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure that Residents received specialized rehabilitative services that were ordered upon admission to the facility for 2 (R21 and R25) of 2 Residents reviewed for rehabilitation services. *R21 had physician orders upon admission dated 11/22/23 for physical (PT), occupational (OT), and speech (ST) therapy. R21 was admitted to the facility on [DATE] and discharged from the facility on 2/16/24 and did not receive PT, OT, and ST during their stay at the facility. *R25's hospital Discharge summary dated [DATE] documented R25 was to receive PT and OT and to be up in chair 3 times daily. On 2/21/24, ST was to evaluate R25 for potential difficulty with chewing and/or swallowing. R25 has not received PT, OT, or ST since their 12/29/23 admission. Findings Include: 1) R21 was admitted to the facility on [DATE] with diagnoses of End Stage Renal Disease, Epilepsy, Wernicke's Encephalopathy, Hemiplegia and Hemiparesis Following Cerebral Infarction, 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 establish an infection prevention and control program (IPCP) that included an antibiotic stewardship program with protocols and a system to monitor antibiotic use for 1 (R24) of 1 resident reviewed for antibiotic use. R24 was prescribed Rocephin IM (intramuscularly) antibiotic for an infection without verification that the infection met McGeer's criteria per protocol. Findings included: Surveyor reviewed the facility's Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes policy and procedure with a revised date of July 2016. Documented was: Policy Statement Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship. Policy Interpretation and Implementation 1. As part of the facility Antibiotic Stewardship…

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 with staff and residents, the facility did not always ensure that they made prompt efforts to resolve grievances brought forward by residents or family members for 2 (R4 and R5) of 5 residents reviewed for grievances. The facility does not follow grievance policy and procedures to document, investigate and resolve grievance promptly. Grievance signage on first and second floor have incorrect contact information for the Grievance Official. R4 expressed concerns to Scheduler-H that they did not want to work with Certified Nursing Assistant (CNA)-Q anymore due to an incident that occurred on 11/2/23. This care concern was not documented, investigated and not resolved promptly by the facility. R3 has had missing clothing since admission. There is no documented grievance for R3 and the missing clothes. Findings Include: The facility policy, entitled Grievance Guideline, revised 4.23.2018, states: The intent of the grievance process is to support each resident's right to voice…

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

Based on record review and interview, the facility did not ensure training to their staff that at a minimum educates staff on- Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property. Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property. Dementia management and resident abuse prevention. During review of the facility's staff training, 1 of 5 Certified Nursing Assistants (CNAs) did not complete dementia training and 3 of 5 CNAs did not complete Abuse training. This had the potential to affect a pattern of the 155 residents in the facility based upon unit assigned. Findings include: Surveyor reviewed facility's Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property policy with an effective date of 9/11/2020. Documented was: Purpose: It is the practice of the facility to encourage and support all residents, staff, families, Visitors, volunteers and resident representatives in reporting any suspected acts of abuse, neglect, exploitation, involuntary…

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 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. Findings include: 1. On 1/17/24 at 11:30 a.m., Surveyor reviewed the required educational training hours for CNA-BB who was hired by the facility on 1/2/2021. Surveyor noted that CNA-BB had not completed the required 12 educational training hours in the last 12 months. Surveyor noted that CNA-BB had only completed 3.25 hours of educational training hours in the last 12 months. 2. Surveyor reviewed the required educational training hours for CNA-CC who was hired by the facility on 12/8/2021. Surveyor noted that CNA-CC had not completed the required 12 educational training hours in the last 12 months. Surveyor noted that CNA-CC had only completed 8.25 hours of educational training hours in the last 12 months. 3. Surveyor reviewed the required educational training hours for CNA-DD who was hired by the facility on 8/3/2022. Surveyor noted that CNA-DD had not completed the required 12…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately (but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury) to the administrator of the facility and to the State Survey Agency in accordance with State law through established procedures and report the investigation results within 5 working days of the incident. R9 and R10 were involved in an allegation of sexual assault on 12/18/23. The Director of Nursing was made aware of the incident and did not report the incident to administration. Multiple staff heard rumors of the incident and did not report it to the administration. The incident was not reported to the State Agency or the police until the Surveyor brought the concern to the Nursing Home Administrator's attention. R2 had…

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 thoroughly investigate 2 of 6 reportable incidents reviewed for abuse and misappropriation. R9 and R10 were alleged to have been involved in a sexual assault on 12/18/23. The Director of Nursing was made aware of the incident and did not notify Facility Administration or the State Agency and the incident was not investigated. R2's Power of Attorney reported R2 was missing eighty eight dollars and soda and the alleged misappropriation of resident property was not thoroughly investigated. Findings include: Surveyor reviewed facility's Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property policy with an effective date of 9/11/2020. Documented was: Purpose: It is the practice of the facility to encourage and support all residents, staff, families, Visitors, volunteers and resident representatives in reporting any suspected acts of abuse, neglect, exploitation, involuntary seclusion or misappropriation of resident property from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interviews, the facility did not ensure 1 (R16) out of 4 residents, who are unable to carry out activities of daily living, received assistance to maintain grooming and personal hygiene. Findings include: R16 was originally admitted to the facility on [DATE] and has diagnoses that include Dementia, Anxiety, and muscle weakness. The most recent, quarterly MDS (Minimum Data Set), dated 11/13/23, states that R16 has a BIMS (brief interview for mental status) score of 10. This indicates that R16 has modernly impaired cognition. The MDS also states that R16 does not display any behaviors and has not had any rejection of cares. R16 is said to need substantial/ maximal assist for shower and bathing and needs touching assistance for personal hygiene. R16's preference indicate that it is very important to choose between a tub bath, shower, bed bath or sponge bath. R16 also has adequate hearing, makes herself understood and able to understand others. A review of the current…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review the facility did not provide a safe, clean, comfortable home-like environment which had the potential to affect all 167 residents residing in the facility. The 100, 200, 300, 400 unit hallways and multiple resident rooms contained damaged and missing ceiling tiles, dusty fans, dirty bedside tables, soiled privacy curtains, dirty wheelchairs, sticky floors, and urine odors. In addition, the floors in multiple hallways and resident rooms contained debris, clutter, used linens, and bags of garbage. Common areas on the first and second floors contained missing and stained ceiling tiles, bags of garbage, and clutter. Multiple staff and residents reported the facility did not have enough supplies, including Styrofoam cups, briefs, wash cloths, towels, and soap. The facility had extra supplies in a supply cage downstairs; however, staff did not know how to access the supplies when management was not in the building. Fruit flies were observed on a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review the facility did not ensure meals were served at regular times. This practice had the potential to affect all 167 residents residing in the facility. On 10/16/23 and 10/17/23, the facility began the breakfast and lunch meal service more than 30 minutes after the posted meal time. On 10/17/23, the facility began the dinner meal service more than 40 minutes after the posted meal time. Findings include: On 10/16/23 at 5:20 AM, Surveyor observed a meal time posting outside the small dining room that contained the following meal and tray pass times: First floor small dining room: Breakfast 8:00 AM, Lunch 12:00 PM, Dinner 5:00 PM First floor large dining room: Breakfast 8:15 AM, Lunch 12:15 PM, Dinner 5:15 PM Second floor dining room: Breakfast 8:30 AM, Lunch 12:30 PM, Dinner 5:45 PM 100/200/300 unit room trays: Breakfast 8:30 AM, Lunch 12:30 PM, Dinner 5:00 PM 400 unit room trays: Breakfast 9:05 AM, Lunch 12:15 PM, Dinner 5:00 PM 500 unit room…

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

Based on observation, staff and resident interview, and record review, the facility did not ensure staff wore name badges to identify themselves. This had the potential to affect multiple residents residing in the facility. On 10/16/23, 10/17/23, and 10/18/23, multiple facility, agency, and contracted staff were observed on resident units, in resident rooms and/or providing care without name badges. Findings include: The facility's undated Acceptable Attire policy indicated: Authorized Company identification badges must be worn based on facility requirements. On 10/16/23 at 2:25 PM, Surveyor interviewed R19 regarding care and treatment in the facility. R19 stated a big issue for me is that staff don't wear name tags and sometimes they don't want to give your their name. On 10/16/23 at 2:20 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-MM and CNA-SS who were not wearing name badges. CNA-MM and CNA-SS stated they did not receive new name badges when the facility changed ownership. On 10/16/23 at 2:22 PM, Surveyor interviewed contracted Dietary Staff (DS)-VV who was not…

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 grievances were documented, thoroughly investigated, and resolved for 4 Residents (R) (R19, R18, R21, and R20) of 4 sampled residents. The facility's monthly grievance logs contained three grievances for R19 between 5/2/23 and 7/28/23. The grievances were not thoroughly investigated. The facility's monthly grievance logs contained two grievances for R18 between 7/6/23 and 8/1/23. The grievances were not thoroughly investigated. The facility's monthly grievance logs contained two grievances for R21 between 6/13/23 and 9/18/23. One grievance was not documented on a grievance form, and both grievances were not thoroughly investigated. The facility's monthly grievance logs contained one grievance for R20, dated 6/14/23. The grievance was not thoroughly investigated. Findings include: The facility's Grievance Guideline policy, dated 11/28/17, indicated: It is the right of this facility that each resident has the right to voice grievances to the facility .Such grievances include those with respect to care and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not ensure residents received treatment and services in accordance with professional standards of practice for 4 Residents (R) (R8, R28, R29, and R4) of 7 sampled residents. R8's Treatment Administration Record (TAR) did not indicate surgical wound care was provided for 5 of 12 scheduled treatments. R28's and R29's blood pressure was not assessed in accordance with the facility's standard of practice. R4's TAR did not indicate wound care was provided for 11 of 50 scheduled treatments between August and September of 2023. In addition, R4's right lower extremity drainage was not documented for 49 of 105 shifts between August and September of 2023. Findings include: An article titled Wrist blood pressure cuffs, are they accurate? states: Using a wrist blood pressure monitor at home often gives falsely high readings due to poor positioning. If you use one, place it directly over the wrist (radial) artery, where you can feel the pulse. Don't…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review, the facility did not ensure there was adequate supervision to prevent accidents and the environment was as free of accident hazards as possible for 1 Resident (R) (R25) of 5 residents reviewed as well as 29 out of 29 residents who resided on the secured dementia unit. R25 had a diagnosis of congestive heart failure (CHF) and used oxygen via nasal cannula. On 10/16/23 and 10/17/23, cigarettes, lighters and a vape pen were observed in R25's room which was not in accordance with the facility's smoking policy. The facility did not ensure 29 of 29 residents on the secured dementia unit were supervised at all times. Findings include: The facility's Smoking Guideline policy, dated 11/28/17, indicated: Residents who want to smoke are evaluated and assessed for smoking safety. Each resident will be informed prior to, or upon admission, about any limitations on smoking . Procedure: 1. The Social Worker or designee will complete the smoking evaluation…

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

Based on observation, staff interview, and record review, the facility did not provide services to prevent a urinary tract infection (UTI) for 5 Residents (R) (R2, R38, R39, R46, and R21) of 7 sampled residents. R2's urinary catheter (a tube inserted into the bladder to drain urine into a collection bag) tubing was draped over R2's mattress and above the level of R2's bladder. On 10/16/23, 10/17/23, and 10/18/23, R38, R39, R46, and R21's catheter bags were uncovered, in contact with the floor, and visible from the hallway. Findings include: 1. On 10/16/23, Surveyor reviewed R2's medical record. R2 had diagnoses including multiple sclerosis (MS) (a disease where the immune system damages nerve communication between the brain and body), history of UTIs, malignant neoplasm of prostate, acute prostatitis, and epididymitis (inflammation of the tube at the back of the testicle that carries sperm and can cause a swollen scrotum, painful urination, blood in the semen, pain in the testicle and discharge from the penis). On 10/18/23 at 8:40 AM, Surveyor observed Certified Nursing Assistant…

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, resident and staff interview, and record review, the facility did not provide pharmaceutical services to meet the needs of each resident for 6 Residents (R) (R21, R19, R22, R29, R28, R50) of 18 sampled residents reviewed for medications. On 10/16/23 at 9:15 AM, Surveyor observed an uncapped insulin pen on R21's bedside table which staff indicated was left there on the previous PM shift. On 10/16/23, Surveyor observed Licensed Practical Nurse (LPN)-KK administering AM medications on the 200 unit at 10:25 AM. LPN-KK indicated 4 residents on the unit had not yet received their AM medications. On 10/16/23, R19's AM and 12:00 PM medications were administered late and/or not provided with breakfast and lunch as indicated. In addition, LPN-H left the room before R19 took the 12:00 PM medications. R19 did not have a physician's order to self-administer medication. On 10/16/23, LPN-H gave R22 an inhaler to self-administer in LPN-H's presence. LPN-H did not encourage R22 to rinse or spit after R22…

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

Based on observation, staff and resident interview, and record review, the facility did not ensure menus and dietary instructions were followed for 6 Residents (R) (R21, R22, R36, R19, R56, and R26) and multiple residents who were prescribed carbohydrate-controlled diets. On 10/16/23 at 9:25 AM and 10/17/23 at 9:08 AM, Surveyor observed R21's breakfast room tray and noted R21's meal ticket was not followed. On 10/17/23 at 12:33 PM, Surveyor observed R22's lunch tray and noted R22's meal ticket was not followed. On 10/17/23 at 1:35 PM, Surveyor observed R36's lunch tray and noted R36's meal ticket was not followed. On 10/17/23 at 1:42 PM, Surveyor observed R19's lunch tray and noted R19's meal ticket was not followed. On 10/17/23 at 9:23 AM, Surveyor observed R56's breakfast tray and noted R56's meal ticket was not followed. On 10/18/23 at 9:13 AM, Surveyor observed R26's breakfast tray and noted R26's meal ticket was not followed. During a continuous observation of lunch service on 10/17/23, Surveyor noted all trays were served with the same size piece of corn bread and did not…

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 and resident interview, the facility did not ensure food was palatable and served at an appetizing temperature for 6 Residents (R) (R37, R19, R40, R42, R41, and R52) of 20 residents reviewed. R37, R19, R40, R42, R41, and R52 indicated the food was not palatable, appetizing, or served at a temperature they preferred. Findings include: The facility's undated Notice of Resident Rights document contained in the facility's admission packet indicates under Living Accommodations and Care: Receive care in a manner which promotes and enhances your quality of life. This includes food the quantity and quality to meet your needs and preferences. On 10/16/23 at 8:51 AM, Surveyor interviewed R37 who was in the small dining room waiting for breakfast. R37 indicated the food is not appetizing, does not taste good, does not have an appetizing texture, and is cold when served. At 9:24 AM, Surveyor observed staff serve R37's breakfast tray which contained one hard boiled egg, and an uncut, untoasted English muffin. R37 refused to eat the meal and stated the egg was…

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

Based on observation, staff and resident interview, and record review, the facility did not ensure the provision of water in a timely manner for 6 Residents (R) (R22, R27, R25, R18, R33, and R40) of 13 sampled residents. Staff did not ensure R22, R27, R25, R18, R33, and R40 were provided water in a timely manner. Findings include: The facility's undated Serving Drinking Water policy indicated: The purpose of this procedure is to provide the resident with a fresh supply of drinking water and to provide adequate fluids for the resident. Preparation: 6. Assemble the equipment and necessary supplies to perform the procedure. Arrange them on the rolling cart. The following equipment will be necessary: 1. Movable serving cart; 2. Ice chest and cover; 3. Ice; 4. Scoop; 5. Water pitcher and cup; 6. Flexible straw . Steps in the Procedure: 3. Go to the resident's bedside stand and pick up the water pitcher. 4. Take the water pitcher into the bathroom. Empty the contents in the commode . 5. Rinse the water pitcher with tap water. Pour the water down the sink. 6. Fill the water pitcher…

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 provide a sanitary environment to help prevent the transmission of communicable disease and infection for 4 Residents (R) (R55, R51, R2, and R19) as well as multiple other residents residing on the first floor of the facility. From 10/16/23 through 10/18/23, fruit flies were observed on multiple items in common areas, including trays of uneaten food and a bucket of snacks. In addition, fruit flies were observed on multiple items in R55, R51, and R2's rooms. On 10/16/23, Surveyor observed Licensed Practical Nurse (LPN)-H check R19's blood sugar with a glucometer. Following the accucheck, LPN-H placed the glucometer on R19's bedside table without a barrier and then placed the glucometer in the medication cart. When asked if the glucometer was shared among residents, LPN-H removed the glucometer from the medication cart, and cleansed the glucometer with a hand sanitizer wipe. Findings include: According to the Environmental Protection…

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) (R2) of 1 resident who had a Guardian received services to ensure court-ordered protective placement was obtained. R2's medical record indicated R2 was under guardianship. The facility did not ensure R2 had a court-order to be protectively placed at the facility. Findings include: On 10/16/23, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis (MS) (a disease in which the immune system damages nerve communication between the brain and body), and unspecified signs and symptoms involving cognitive functions and awareness. R2 was under the guardianship of a corporate Guardian since 7/16/18 (which was prior to R2's admission on [DATE]). R2's medical record did not contain evidence of court-ordered protective placement at the facility. On 10/17/23 at 5:15 PM, Surveyor interviewed Social Services Coordinator (SSC)-JJ who stated SSC-JJ was not aware residents…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review, the facility did not ensure 1 Resident (R) (R19) of 6 sampled residents had a self-administration of medication assessment, or a physician's order to self-administer medication and keep medication at the bedside. R19 kept an inhaler and nasal spray on R19's bedside table and stated R19 self-administered both medications. R19 did not have a physician's order to self-administer medication or a self-administration of medication assessment that indicated R19 could safely and accurately self-administer medication. Findings include: The facility's Administering Medications policy, revised December 2012, indicated: Medications shall be administered in a safe and timely manner, and as prescribed .24. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. 1. On 10/16/23, 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.

Based on observation, resident and staff interview, and record review, staff did not ensure call lights were within reach for 3 Residents (R) (R25, R18, and R2) of 7 sampled residents. On 10/16/23, Surveyor observed R25's call light on the floor and not within reach. On 10/17/23, Surveyor observed R18's call light on the floor and not within reach. On 10/17/23, Surveyor observed R2's call light on the floor and not within reach. Findings include: The facility's undated Answering the Call Light policy indicated: The purpose of this procedure is to respond to the resident's requests and needs .5. When the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident. 1. On 10/16/23, Surveyor reviewed R25's medical record. R25's risk for falls care plan, dated 8/18/23, contained an intervention to ensure R25's call light was within reach and encourage R25 to use the call light for assistance. R25's activities of daily living (ADL) performance deficit care plan, dated 8/18/23, contained an intervention to encourage R25 to use the call light for…

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

Based on staff interview and record review, the facility did not ensure their abuse policy was implemented for 2 of 8 employees reviewed for background checks. Licensed Practical Nurse (LPN)-Z's last completed background check forms were dated 4/13/18. Certified Nursing Assistant (CNA)-K's last completed background check forms were dated 6/11/19. Findings include: The facility's Abuse, Neglect, Exploitation, Mistreatment and Misappropriation Resident Property policy, dated 9/11/20, indicated: It is the policy of this facility to screen employees and volunteers prior to working with residents. Screening components include verification of references, certification and verification of license, and criminal background check. On 10/17/23, Surveyor reviewed a sample of employee background checks and noted LPN-Z's most recent Background Information Disclosure (BID) form was dated 3/21/14. LPN-Z's Department of Justice (DOJ) and Integrated Background Information System (IBIS) letters were dated 4/13/18. LPN-Z was hired by the facility on 12/2/94. On 10/17/23, Surveyor also noted CNA-K's…

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

Based on staff interview and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 1 Resident (R) (R5) of 22 sampled residents. R5 alleged a staff member hit R5 and stomped on R5's foot in March of 2023. The facility did not thoroughly investigate the allegation of abuse. Findings include: The facility's Abuse, Neglect, Exploitation, Mistreatment and Misappropriation Resident Property policy, dated 9/11/20, indicated: It is the policy of this facility that reports of abuse (mistreatment, neglect, or abuse including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated. On 6/15/23, the facility submitted a facility-reported incident (FRI) to the State Agency (SA) regarding an allegation of abuse in which R5 reported staff hit R5 and stomped on R5's foot on 3/15/23. The FRI was submitted on 6/15/23 after the facility discovered Social Worker (SW)-DDD was aware of the allegation, but did not report the allegation to anyone else. A summary of events on 3/15/23 indicated a care…

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 1 Resident (R) (R14) of 1 resident 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 7/10/23 and was not provided a bed hold notice upon transfer. In addition, R14 could not return to R14's original room when R14 returned to the facility on 7/19/23. Findings include: The facility's Bed Hold and Return Guideline policy, dated 4/25/19, indicated: The facility will provide written information to the resident or resident representative before the resident is transferred to a hospital .If prior to discharge the resident resided within a composite distinct part of the facility, the resident will be permitted to return to an available bed in the particular location .in which he or she resided previously. The facility's Bed Hold Notice document indicated: Your bed will be held at no cost to you (your room/bed will be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review, the facility did not follow an intervention on a skin integrity care plan for 1 Resident (R) (R19) of 6 sampled residents. R19 was at risk for impaired skin integrity. A care plan intervention indicated linens should not be creased or folded under R19 and staff should keep R19's bedding as smooth as possible. The intervention was not consistently implemented. Findings include: The facility's Skin Management Guideline policy, dated 11/28/17, indicated: It is the practice of this facility to properly identify and evaluate residents whose clinical conditions increase the risk for impaired skin integrity, and pressure ulcers; to implement preventative measures . A comprehensive individual evaluation guides the: ~ Identification of interventions to stabilize, reduce or remove underlying risk factors ~ Evaluate the effectiveness of interventions ~ Modify the interventions as appropriate 1. On 10/16/23, Surveyor reviewed R19's medical record. R19…

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 review and revise the plan of care for 2 Residents (R) (R21 and R25) of 6 sampled residents. R21's plan of care indicated R21 had an unstageable pressure injury on the left heel and contained interventions for a left heel boot and to elevate heels while in bed. R21's right and left lower extremities were amputated. R25's plan of care indicated R25 had a pressure injury on the sacrum. R25's pressure injury was healed. Findings include: 1. On 10/16/23, Surveyor reviewed R21's medical record. R21 was readmitted to the facility on [DATE] and had diagnoses including diabetes with circulatory complications and peripheral vascular disease (PVD). A care plan, dated 5/19/23, indicated R21 had an unstageable pressure injury on the left heel and sacrum related to immobility, diabetes and PVD. The care plan contained a goal that indicated R21's pressure injury will show signs of healing and remain free from infection and contained an intervention…

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

Based on observation, staff and resident interview, and record review, the facility did not ensure call lights were answered and/or care was provided timely for 3 Residents (R) (R52, R34, and R28) of 4 sampled residents. On 10/16/23 at 6:02 AM, Surveyor noted R52's call light was activated. Staff answered the call light 30 minutes later at 6:32 AM and responded to R52's needs. On 10/17/23 at 9:09 AM, Surveyor noted R34's call light was activated. Staff entered the room and shut off R34's call light multiple times before care was provided 65 minutes later at 10:14 AM. On 10/16/23 at 12:31 PM, Surveyor noted R28's call light was activated. Staff answered the call light 27 minutes later at 12:58 PM and responded to R28's needs. Findings include: The facility's Answering the Call Light policy, last revised October 2010, indicates: General Guidelines: 8. Answer the resident's call as soon as possible. Steps in the Procedure: 1. Turn off the signal light. 3. Listen to the resident's request. 4. Do what the resident asks of you, if permitted . 5. If you have promised the resident you 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 observation, staff interview, and record review, the facility did not provide nephrostomy care consistent with professional standards of practice for 1 Resident (R) (R28) of 1 resident who required nephrostomy care. Staff did not follow R28's physician orders related to nephrostomy care which resulted in one missed left and right nephrostomy dressing change. In addition, staff incorrectly measured R28's left and right nephrostomy output. Findings include: The facility's Nephrostomy Tube, Care of policy, revised October 2010, indicated: .6. Measure output from the right and left kidneys separately . On 10/16/23, Surveyor reviewed R28's medical record. R28 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, urinary retention, and encounter for attention to other artificial openings of urinary tract (one right and one left nephrostomy tube). R28's hospital Discharge summary, dated [DATE], included the following orders: ~Discharge instructions from IR (Interventional…

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

Based on observation, staff interview, and record review, the facility did not ensure it was free of a medication error rate of 5% or greater. During medication administration observations, 8 errors occurred during 32 opportunities which resulted in a 25% medication error rate affecting 1 Resident (R) (R29) of 5 residents observed during medication pass. On 10/17/23, R29's 9:00 AM medications were administered at 1:15 PM. Findings include: The facility's Administering Medications policy, revised December 2012, indicated: 3. Medications must be administered in accordance with the orders, including any required time frame. 4. Medications must be administered within one hour of their prescribed time, unless otherwise specified. 1. On 10/17/23 at 12:30 PM, Surveyor observed Licensed Practical Nurse (LPN)-H administer the following medications to R29: aspirin 81 mg (milligrams), losartan potassium 25 mg (high blood pressure medication), vitamin D 400 mcg (micrograms), gabapentin 300 mg (nerve pain medication), metoprolol ER 50 mg (high blood pressure medication), potassium chloride 10…

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

Based on observation, staff interview, and record review, the facility did not ensure a safe and comfortable environment for multiple residents residing on both floors of the facility. The second floor common area near the elevator contained missing ceiling tiles and two large biohazard pails with water in the middle of the hallway. The area was used by multiple residents to access the first and second floors of the facility. Findings include: The facility's undated Notice of Residents Rights document, contained in the facility's admission packet, indicated: Living Accommodations and Care: A safe, clean comfortable home-like environment. On 10/16/23 at 5:10 AM, Surveyor noted the second floor hallway near the reception desk contained approximately four missing ceiling tiles, brown stains on three surrounding tiles, and installation, duct work, and wires that were visible through the missing tiles. Surveyor observed two approximately 20 gallon red garbage pails labeled biohazard, a yellow caution sign folded in between the pails, and a wheelchair pushed against the pails that were…

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 policy review, the facility did not store food in accordance with professional standards for food service safety. This deficient practice had the potential to effect 161 of the 166 residents who receive food from the facility kitchen. Facility kitchen observations include: Food in unsealed bags in which the food item was exposed to the air, and without an open or use by date label on bag. Packages of food that ripped open and debris fallen onto floor. Food in bags that had mold on it. Open cans of soda mixed in with facility food. Staff coat hanging on a rack with facility food. Shiny wet substance on floor under rack. Findings include: The facility policy, entitled Food and Nutrition Services: Nutrition Quality: Food Storage, dated 9/1/2021, states: All dry goods will be appropriately stored will be appropriately stored [sic] in accordance with the FDA (food and drug administration) Food Code. All time/ temperature control for safety (TCS) foods, frozen, and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that 4 of 5 Residents (R128, R17, R66, R151) reviewed for hospitalizations received a notice of transfer which includes, reason for transfer, location of transfer, appeal rights and contact information of the State Long-Term Care Ombudsman. R128 was transferred to the hospital on 2/13/23, 2/22/23, 3/19/23 and 4/13/23. R128 and the legal representative was not provided with the transfer notice. R17 was transferred to the hospital on 3/2/23 and R17 and the legal representative was not provided with a transfer notice. R66 was transferred to the hospital on 3/24/23 and R66 and the legal representative was not provided with a transfer notice. R151 was transferred to the hospital on 4/4/23 and R151 and the legal representative was not provided with a transfer notice. This is evidenced by: Surveyor reviewed the facility policy: Transfer and Discharge Guideline. Effective date 11/28/2017 Purpose: It is the practice of this facility that each resident has…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that 4 of 5 Residents (R17, R66, R151, R128) reviewed for hospitalizations received a written notice of the bed hold policy upon transfer to the hospital. R128 was transferred to the hospital on 2/13/23, 2/22/23, 3/19/23 and 4/13/23. R128 or the legal representative was not provided with a written copy of the bed hold notice. R17 was transferred to the hospital on 3/2/23 and R17 or the legal representative was not provided with a written copy of the bed hold notice. R66 was transferred to the hospital on 3/24/23 and R66 or the legal representative was not provided with a written copy of the bed hold notice. R151 was transferred to the hospital on 4/4/23 and R151 or the legal representative was not provided with a written copy of the bed hold notice. This is evidenced by: Surveyor reviewed the facility policy which indicated: Bed Hold and Return Guideline. Effective date: 4/25/2019 Purpose: It is the practice of this facility that residents who…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility did not develop and implement a comprehensive person-centered care plan for 4 (R43, R81, R25 and R95) of 33 residents reviewed. * R43 did not have a comprehensive plan of care addressing smoking. * R81 did not have a comprehensive plan of care addressing hospice services. * R24 did not have a comprehensive plan of care addressing the use of anticoagulant medication. * R95 did not have a comprehensive plan of care addressing pain. Findings include: The facility policy, entitled Smoking Guideline, revised on 9/24/2020, States: Residents who want to smoke are evaluated and assessed for smoking safety. Each resident will be informed prior to, or upon admission, residents shall be informed about any limitations in smoking including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences. Procedure: 1. Nursing or designee will complete the smoking evaluation form with input for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility did not always ensure that 7 out of 11 residents (R95, R93, R130, R76, R140, R90, R15) reviewed for potential weight loss, received treatment and services to maintain acceptable parameters of nutritional status. R95, R93, R130, R76, R140, R90 and R15 were assessed to be at nutritional risk and had documented weight loss. The facility did not provide additional assessment or care plan interventions to assist in residents maintaining their nutritional status. This is evidenced by: Policy review: Weight Monitoring Guideline. Effective date 4/6/2018. Revised 7/1/2019. Purpose: The facility measures and records weights to ensure accuracy and provide information for the evaluation of clinical status unless clinically contraindicated with physician justification. To provide guidance on timely consultation and weight parameters. The licenses nurse: -Will verify the accuracy of the weight by comparing the weight with the most recently recorded weight - Direct a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility did not ensure drugs and biological's used in the facility were stored with currently acceptable principles, including proper temperature controls. This deficient practice has the potential to affect 83 of 83 residents residing on the 400, 500 and 600 unit. The facility did not ensure drugs and biological's used in the facility were labeled with an applicable expiration date and not used past the expiration date. This deficient practice affected 11 residents (R121, R92, R36, R32, R89, R87, R131, R2, R31, R136, R173). *The medication refrigerator in the second floor medication room did not have a thermometer or a temperature log. * R121, R92, R31, R87 and R36 had open and used eye drops which had expired. * R92, R131, R136, R173, R2, R32, and R89 had open and used eye drops that were not dated when opened. *The medication cart for the 500 unit contained an opened and used bottle of Fluticasone nasal spray which was not labeled and not dated. Findings 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 observations, interview and record review, the facility did not maintain an infection prevention and control program to help prevent the development and transmission of commuicable disease and infection such as COVID-19, when facility staff did not follow standards of practice in the sanitizing a shared glucometer and when staff were not either wearing the appropriate Personal Protective Equipment (PPE) and/or was not wearing PPE correctly. This deficient practice had the potential to affect the 8 residents who share the glucometer on the 300 and the 2 residents who share a glucometer on the 500 unit, as well as those residents residing on the 300 and 600 units. *Surveyor noted facility staff not disinfecting shared glucometers at the facility for obtaining resident blood sugars. On 4/24/23 on the 300 unit, Licensed Practical Nurse (LPN) H did not properly sanitize the glucometer after taking R71's blood sugar and before taking R69's blood sugar. On 4/25/23, on the 500 unit, LPN-G did not properly…

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 reviewthe facility did not ensure 2 (R2 and R66) of 2 residents with catheters were treated with dignity and respect. * R2's urinary catheter bag was left uncovered with yellow urine in the catheter bag visible to peers, staff, and visitors for 3 days of the survey. A strong odor of urine was smelled in R2's room on 4/24/23. * R66's urinary catheter bag was left uncovered with yellow urine in the catheter bag visible to peers, staff, and visitors for 3 days of the survey. Findings include: On 4/25/23 the facility policy titled, Urinary Indwelling Catheter Management Guideline dated 11/26/2017 was reviewed and read: Drainage collection devices will have a dignified intervention ensuring elimination is covered. 1. R2 was admitted to the facility on [DATE] with diagnosis that include Quadriplegia. R2 also developed a stage 4 pressure injury to her sacrum for which the urinary catheter was placed to promote healing. R2's Significant Change Minimum Data Set, dated [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not include resident participation in the development and implementation of the person-centered plan of care for 1 (R112) of 33 sampled residents. R112 did not have a care conference, that included R112 or R112's representative, in order to develop, implement, or revise a plan of care since 2/11/2022 (over a year ago), the day after R112 was admitted to the facility. Findings: The facility policy and procedure entitled Care Management Guideline not dated states: Guideline: Care Management is implemented when a qualifying change in condition occurs which requires skilled services, interdisciplinary (IDT) collaboration, and timely proactive communication beyond the standard practices of communication established in the facility. Care Management is conducted upon admission or readmission from an acute setting. The purpose of the Initial Care Management Meeting is to communicate to the patient and patient representative, within 48 hours of admission, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not formulate an advanced directive that the resident requested for 1 (R112) of 33 sampled residents. R112's Care Plan stated R112 had an advanced directive of being a full code; the electronic medical record indicated R112 had a status of Do Not Resuscitate (DNR). No DNR form had been completed with a physician signature indicating R112 was a DNR. Findings: The facility policy and procedure entitled CPR- Cardiopulmonary Resuscitation dated [DATE] states: Nursing staff are educated to initiate CPR, as recommended by the American Heart Association (AHA) unless: -A valid Do Not Resuscitate order is in place -Resident presents with obvious signs of clinical death (e.g. rigor mortis, dependent lividity, decapitation, transection or decomposition) are present -Initiating CPR could cause injury or peril to the rescuer . The objective of the CPR guideline is to provide basic life support based until emergency medical services arrives, consistent with the resident…

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

Based on record review and staff interviews, the facility did not always ensure that they implemented their abuse policies by permitting 3 out of 8 employees reviewed, to work without being properly screened by passing the criminal background check. In addition, the facility did not implement its abuse policies by conducting an updated background check on employees every four years. CNA- AA was originally hired on 3/1497. The facility did not complete all 3 components of an updated, every four-year, background check by obtaining Background Information Disclosure (BID) form from CNA- AA in 2021 or thereafter. CNA- BB was hired on 2/14/23. The facility did not obtain the BID form prior to CNA- BB being permitted to work with residents at the facility. CNA- CC was hired on 8/3/22. The facility did not obtain the BID form prior to CNA- CC being permitted to work with residents at the facility. This is evidenced by: Policy review: Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property. Effective date: 11/28/2017 It is the policy of this facility to screen…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not report an allegation of misappropriation to the police for 1 (R228) of 1 Facility Reported Incidents reviewed. R228 alleged $120 was missing and the police were not called to investigate the allegation. Findings: The facility policy and procedure entitled Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property dated 11/28/2017 states: Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located, any reasonable suspicion of a crime against any individual who is a resident of or is receiving care from, the facility, and each covered individual shall report immediately, and not more than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury or not later than 24 hours in the events that cause the suspicion do not result in serious bodily injury. Law Enforcement: All reports of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, 1 Resident (R107) of 33 sampled residents reviewed did not receive required assistance with Activities of Daily Living (ADLs). * On 4/23 and on 4/24/23, R107 appeared disheveled, with unkempt hair, long facial hair and body odor. There was no indication R107 receive a shower in the past 30 days or that R107 was provided with services that maintained good grooming and personal hygiene. Findings include: R107 was admitted to the facility on [DATE] with a diagnosis of Dementia. R107's admission MDS (Minimum Data Set) assessment dated [DATE] indicates that R107 requires extensive assistance of 1 staff with bathing and personal hygiene. R107's admission MDS indicates that R107 did not receive any showers or bathing during the seven day look back period. R107 has a BIMS (Brief Interview of Mental Status) score of 06, indicating R107 is unable to participate in daily decision making and is not cognitively intact. Surveyor was not able to engage R107 in conversation.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, 1 Resident (R478) of 33 sampled residents reviewed did not receive quality of care in accordance with their physician orders * R478 was not provided with elastic tubi-grip stockings to treat their lower extremity edema per physician orders. Findings include: R478 was admitted to the facility on [DATE] with diagnoses of chronic kidney disease, lymphedema and dementia. On 4/23/23 at 1:58 PM, Surveyor made observations of R478. R478 was observed in the doorway of their room in a wheelchair. Surveyor was not able to engage R478 in conversation. Surveyor noted R478's bilateral lower extremities to be edematous and reddened. Surveyor was unable to conduct an interview with R478 due to their diagnosis of dementia. On 4/24/23 at 9:02 AM, Surveyor made observations of R478. R478 was observed in the facility dining room in their wheelchair. Surveyor noted R478's bilateral lower extremities to be edematous and reddened. On 4/24/23, Surveyor reviewed R478's physician…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility did not ensure pressure injury preventive measures were implemented. This was observed with 2 (R49 and R151) of 6 residents reviewed for pressure injury. * R49 was observed with their heels against the mattress and not off-loaded. * R151 was observed to have her air mattress at an improper setting for effectiveness. On 4/23 and 4/24/23, R151's air mattress was set incorrectly at 210 mm/hg (millimeters/mercury) rather than in accordance with manufacturer instructions which would have been according to R151's weight and which should have been set at 120 mm/hg. Findings include: The facility's policy and procedures for Skin Management dated 11/28/17 was reviewed by Surveyor. The policy for Interventions for prevention, removing and reducing predicting factors and treatment for skin may include: Elevating heels- for residents that cannot turn and reposition themselves; offloading devices based on resident comfort and positioning needs. Pressure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility did not ensure a resident with a limited range of motion received appropriate equipment to maintain or improve mobility with the maximum practicable independence for 1 (R53) of 4 residents reviewed for limited range of motion. R53 had contractures to both hands and Occupational Therapy had recommended the use of a palm protector to the left hand, a rolled washcloth to the right hand, and red foam built up on feeding utensils to promote independence with eating. A palm protector, a washcloth, and the red foam adaptive device was not in use by R53 as recommended. Findings: The facility policy and procedure entitled Order Entry by Therapy Staff dated 8/1/2017 states: Purpose: To streamline the process of order entry for Therapy Orders. Trained therapy staff may complete order entry in (computer charting system) and enter clarification orders after the general order for therapy to evaluate and treat has been processed. These orders will export into the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the Facility did not ensure pharmaceutical services including accurate acquiring and timely administering of medications to meet the needs of each Resident for 1 (R130) of 33 Residents reviewed and 1 (R51) supplemental resident. *R130 did not receive their morning medications until 1:30pm on 04/24/2023 which resulted in a missed dose of at least one medication. *R51 returned from the hospital on [DATE] with an order for Hydralazine. The Medication Administration Record indicated the medication was administered on 4/23 and 4/24/23 at 12:00 am, 8:00 am and 4:00 pm however, the pharmacy never dispensed the medication due to a listed allergy which needed clarification, and the medication was not in contingency. R51's physician was not notified until 04/25/23. Findings include: Facility policy entitled, Administering Medications documented, .Medications must be administered within one hour of their prescribed time . 1. R130 was admitted to the facility on [DATE] 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 record review and staff interviews, the facility did not always ensure that 1 out of 3 residents (R69) reviewed for the use of psychotropic drugs was assessed for adverse drug reactions and side effects. * R69 has received antipsychotics on a routine basis. The facility did not regularly conduct an AIMS (Abnormal Involuntary Movement Scale) assessment to measure for involuntary movements known as tardive dyskinesia, a possible side effect for the use of psychotropic medication. This is evidenced by: Review of facility policies; Behavior Management Program, effective date 11/28/2017 Purpose: The purpose of the Behavior Management Program is to promote and provide the highest practicable quality of life and a safe environment for residents and staff. Responsible party: Nursing, Social Services, Activities, Therapy, Pharmacy. Procedure: (includes) 1. Complete the following forms for each resident requiring a behavior management program: - Behavior Tracking Log - Behavior and Psychotropic Medication…

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 medical records were complete, and accurately documented for 1 (R175) of 36 residents sampled. * On [DATE] R175 had a change in condition while at the inhouse dialysis. R175 coded while in dialysis with both dialysis and facility staff responding and providing CPR. The paramedics arrived and while in transport to the hospital, R175 expired. R175's medical record was not complete in that the facility staff did not document on R175's change of condition and their involvement with R175's change in condition prior to expiring on [DATE]. Findings include: The facility policy, entitled Charting and Documentation, dated [DATE], states: All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. Policy Interpretation and Implementation 1. All observations, medications administered, services performed, etc. must be documented in the resident's clinical records.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility did not ensure collaboration with hospice representatives and facility staff to coordinate the care planning process and did not ensure hospice was notified of a significant change in the resident's physical status for 1 (R81) of 3 hospice residents reviewed. * R81 did not have any care conferences with the facility and the hospice agency to coordinate a plan of care between the two entities and when R81 developed COVID-19, no documentation was found showing the hospice agency was notified of the change in condition. Findings: The facility policy and procedure entitled Hospice Program from MED-PASS ©2001 with a revision date of 1/2014 states: 4. When a resident participates in the hospice program, a coordinated plan of care between the facility, hospice agency and resident/family will be developed and shall include directives for managing pain and other uncomfortable symptoms. The care plan shall be revised and updated as necessary to reflect the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not offer the influenza and/or pneumococcal immunizations for 3 (R53, R93, and R24) of 5 residents reviewed for immunizations. * R53 was not offered the influenza immunization on admission to the facility and did not document if the immunizations were offered and declined. * R93 was not offered the influenza immunization for the 2022 influenza season and did not document if the immunizations were offered and declined. * R24 was not offered the Prevnar 13 immunization on admission to the facility and did not document if the immunizations were offered and declined. Findings include: On 4/25/23 the facility policy and procedure entitled Influenza Vaccine dated 11/2012 was reviewed and read: 1. Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents, unless the vaccine is medically contraindicated or the resident has already been immunized. 4. Prior to vaccination, the resident (or residents legal representative) will be…

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