Luther Manor

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY UNCORRECTED ON VERIFICATION VISIT Based on record review and staff interview, the facility did not ensure all allegations involving potential abuse (R58) and Resident to Resident altercation (R3 and R4) were thoroughly investigated for 3 of 3 reviewed self reports. * R58's Facility Reported Incident (FRI) dated 9/12/24 documents an allegation of R58 being raped along with R58 sustaining blunt force trauma to the chest. The FRI does not contain other resident statements, all staff statements, or a root cause analysis of the circumstances of the allegation. The FRI does not contain an investigation of the blunt force trauma. Facility Reported Incident (FRI) dated 10/16/24 documents an allegation of R58 being raped by a male caregiver. The FRI does not contain other resident statements, all staff statements, or a root cause analysis of the circumstances of the allegation. On 10/15/24, R58 called the police alleging an assault had taken place over the weekend. The facility did not submit an Alleged Nursing Home…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not incorporate the recommendations from the Preadmission Screen and Resident Review (PASARR) Level 2 determination and evaluation report into a Resident's assessment, care planning, and transitions of care for 1 (R58) of 1 Resident reviewed with PASARR level 2 recommendations. *R58's PASARR dated 10//21/24 determination states R58 requires specialized psychiatric rehabilitation services to address R58's mental illness. Findings Include: The facility's policy Resident Assessment-Coordination with PASARR Program dated 10/22/21 documents: Policy: This facility coordinates assessments with the preadmission screening and resident review(ASA) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receive care and services in the most integrated setting appropriate to their needs. Policy Explanation and Compliance Guidelines: 1. All applicants to this facility will be screened for serious mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not complete a Preadmission Screening and Resident Review (PASARR) for individuals with a mental disorder for 1 (R58) of 1 residents reviewed for PASARR screening. * R58 was admitted on [DATE] and the Level I PASARR was completed indicating R58 would be in the skilled nursing facility for less than 30 days. R58 is currently a Resident in the facility. A Level I PASARR was not resubmitted/updated indicating R58 was going to be at the facility longer than the 30 exemption period triggering a Level II PASARR to be completed until 10/16/24. On 10/21/24, it was determined that R58 requires services called 'specialized psychiatric rehabilitation services' for R58's mental illness. Findings include: The facility's policy Resident Assessment-Coordination with PASARR Program dated 10/22/21 documents: Policy: This facility coordinates assessments with the preadmission screening and resident review(ASA) program under Medicaid to ensure that individuals with a mental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ON VERIFICATION VISIT Based on interview and record review, the facility did not update the person-centered care plan and ensure the comprehensive care plan was implemented to meet a resident's psychosocial needs for 1 (R58) of 1 resident. * R58's comprehensive care plan has not been updated with person-centered interventions including incorporating Level II PASARR recommendations of requiring 'specialized psychiatric rehabilitation services'. Findings Include: The facility policy titled Comprehensive Care Plans revised 9/23, documents: .Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: . 3. The comprehensive care plan will describe, at a minimum, 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 develop and implement an effective discharge planning process focusing on resident discharge goals, and preparation for transition for 1 (R58) of 1 residents reviewed for discharge planning. * R58 was admitted to the facility on [DATE] with a Left Femur Fracture with the goal to discharge home and/or a lesser restrictive environment. R58 has not had consistent and active discharge planning since admission. Findings Include: The facility's policy Transfer and discharge date d 10/21 documents: .The comprehensive, person-centered care plan shall contain the Resident's goals for admission and desired outcomes and shall be in alignment with the discharge. 1.) R58 was admitted to the facility on [DATE] with diagnoses of Depression, Fracture of Left Femur, Unspecified Severe Protein-Calorie Malnutrition, Polyneuropathy, and Anemia. R58 currently has an activated Health Care Power of Attorney(HCPOA). Surveyor notes the facility was not able to provide 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 interview and record review the facility did not ensure residents who are unable to carry out activities of daily living receive the necessary services to maintain good grooming for 1 (R150) of 8 residents reviewed for ADL's (Activity of Daily Living). On 10/29/24, R150 was not provided with incontinence care every two hours and was observed with a saturated incontinence product. Findings include: The facility's policy titled, Incontinence and dated 10/21 under Policy Explanation and Compliance Guidelines documents 4. Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible. 1.) R150's was admitted to the facility with a diagnosis that includes diabetes mellitus, chronic kidney disease, history of malignant neoplasm of prostate, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominate side, quadriplegia and depression. The functional bladder incontinence care plan initiated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon observation, interview and record review, the facility did not ensure 1 (R58) of 4 residents reviewed received medically related social services to address individual Resident needs in order to maintain the highest practicable physical, mental, and psychosocial well-being. * R58 has a history of trauma as identified in a trauma assessment completed on [DATE]. The facility social worker (SW)-C did not establish an individualized plan of care to address R58's trauma. On [DATE], a Level II PASARR screen determined that R58 requires specialized psychiatric rehabilitation services to promote the highest practicable psychosocial well-being for R58. The facility did not update R58's comprehensive care plan with person-centered interventions. SW-D has not actively assisted R58 to identify and prepare for alternate placement. Findings include: 1.) Surveyor requested a medically related social service policy and procedure and the facility was not able to provide a policy to Surveyor. The facility's assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility did not ensure the Covid 19 outbreak reflected accurate data, the surveillance of infections were not identified on the infection line list and the monthly infections rates did not accurately identify infections. Visual alerts such as signs at the entrance to notify everyone of the current outbreak and instructions about current recommendations was not done. * CNAs (Certified Nursing Assistants) were observed not using hand hygiene appropriately during meal service. These deficient practices have the ability to affect all 90 residents residing at the facility at the time of the survey. Findings include: 1.) A Covid 19 outbreak was identified on 8/6/24 when two facility staff members developed symptoms and tested positive for Covid 19. The outbreak line list identified two residents that tested positive for Covid on 8/12/24. The last person that tested positive with Covid was a staff member on 8/14/24. On 8/20/24, R65 tested positive for Covid and was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 4.) R59 was admitted to the facility on [DATE] with a diagnoses that includes chronic kidney disease, anemia, osteoarthritis, and constipation. R59's Quarterly MDS (Minimum Data Set) dated 8/19/24, documents that R59 has short and long-term memory problems, impairments to both upper extremities, and is dependent with toileting, dressing, and transferring. R59 was documented as not having a BIMS (Brief Interview for Mental Status) evaluation due to R59 is rarely/never understood. R59's care plan, dated 12/15/23, documents: ~ R59 has an Activities of Daily Living (ADL) self-care performance deficit related to impaired mobility and osteoarthritis (date initiated 12/15/23, revised on 8/23/24). Interventions include: 1. Provide appropriate level of assistance for ADL care needs to R59 (date initiated 12/15/23). 2. R59 requires a set up for eating (date initiated 5/22/24). 3. R59 requires max assistance with upper body dressing and is dependent with lower body dressing (date initiated 5/22/24). 4. R59 requires total…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 2 of 2 medication storage rooms did not have expired stock medication and expired & not dated insulin for R11. * Expired 0.9 sodium chloride irrigation 500 ml (milliliter) bottle, stock Systane lubricant eye drops and tear eye drop advanced were observed in the 2900 unit medication storage room. * Expired stock tear eye drop advance and a bottle of Lantus insulin was expired for R11. A second bottle of Lantus, which was open & used, was not dated when opened. This has the potential to affect 9 residents residing on the 2700 unit and 14 residents residing on the 2900 unit who may have eye drops ordered. Findings include: 1.) On [DATE], at 9:35 a.m., Surveyor observed the 2900 unit medication storage room with Med Tech (Medication Technician)-F. On the wire rack Surveyor observed a bottle of 0.9% sodium chloride irrigation usp 500 ml with the expiration date of 02-01-2024. In the cabinet to the left there is a stock bottle of Systane…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents on psychotropic medications received monitoring, and dose reductions, to minimize use of these medications. This was observed with 4 (R50, R62, R38 and R49) of 6 resident medication reviews. - R50 receives an antipsychotic medication, and did not have a AIMS (abnormal involuntary movement scale) assessment, to monitor for side effects. - R62 receives an antipsychotic medication, and did not have a AIMS assessment, to monitor side effects. - R38 receives Cymbalta and Sertraline once daily for depression. The facility has no evidence of AIMS (abnormal involuntary monitory scale) monitoring and no evidence of an attempted dose reduction. - R49 receives an psychotropic medication that was not reviewed for a gradual dose reduction. Findings include: The facility's policy and procedure Use of Psychotropic Medication dated 10/22. The procedures include: 6.) Residents who use psychotropic drugs shall receive gradual dose reductions, unless…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the Facility did not report 2 (R5 and R77) of 3 allegations of abuse or neglect to the State Survey Agency during the required timeframe. A report of abuse or neglect was not reported to the Nursing Home Administrator (NHA)-A for 1 (R77) of 3 allegations during the required timeframe. * An accusation of abuse was made involving R77 which was not reported to the NHA-A during the required timeframe. * The Facility did not report a resident-to-resident altercation involving R77 to the State Survey Agency. * On 7/9/24, R5 returned to the facility from a hospitalization on 7/3/24 - 7/9/24. R5 was discovered to have a femur fracture and the facility did not conduct an investigation or report the injury of unknown origin to the State Agency. Findings include: The Facility Policy titled Alleged Incidents of Abuse, Neglect, Exploitation and Mistreatment-Reporting and Investigation revised 2/2020, documents: Purpose -Facility will prohibit and prevent abuse, neglect, exploitation,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure 2 (R5 and R77) of 3 residents reviewed had thorough investigations into allegations of abuse or injuries of unknown origin. * On 7/9/24, R5 returned to the facility from a hospitalization. R5 was discovered to have a femur fracture and the facility did not conduct an investigation into R5's femur fracture. * An accusation of abuse was made involving R77 which was not investigated thoroughly * A resident-to-resident altercation took place involving R77 which was not investigated thoroughly Findings include: The facility's Alleged Incidents of Abuse, Neglect, Exploitation and Mistreatment Reporting and Investigation policy dated August 1995, last revised on February 2020 documents: ~ The facility is in compliance with the reporting and investigation guidelines specific to each program area governed by the Division of Quality Assurance (DQS)/Office of Caregiver Quality (QOC). ~ All alleged incidents of abuse, neglect, exploitation, 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 3 (R5, R34, and R32) of 3 residents reviewed that required hospitalizations were given written reason for transfer to the hospital and the facility did not send this notification to the Ombudsman. R5 was transferred to the hospital on 8/23/24, 8/12/24, 7/3/24, 5/24/24, and 5/15/24 for changes in condition. R5 or their representative did not receive written notification of transfer to the hospital and the State Ombudsman was not sent a copy of this notice. R34 was transferred to the hospital on 4/6/24 while residing in the facility and evidence was not provided R34 or their representative were given the required transfer notice information including appeal rights. On 8/12/24, R32 had a change in condition and was sent to the hospital. R32 was admitted to the hospital and a bed hold notice was given. R32 did not receive a transfer notice for the hospitalization on 8/12/24. Findings include: The facility's policy Transfer and discharge date d 10/2021…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Minimum Data Set (MDS) accurately reflected the resident's status at the time of the assessment for 1 (R77) of 24 residents reviewed. R77's Quarterly Minimum Data Set (MDS) with an assessment reference date of 6/19/24, did not accurately reflect R77's occurrence of behaviors. Findings include: The Facility Policy titled MDS 3.0 Completion implemented 10/21, documents (in part): Policy: Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan . Policy Explanation and Compliance Guidelines: 1. According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI specified by the State. 4. Care Plan Team Responsibility for Assessment Completion: . ii. Persons completing part of the assessment must attest to the accuracy of the section they…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 update the comprehensive person-centered care plan for 3 (R29, R49, and R64) of 24 residents to meet a resident's medical, nursing and psychosocial needs that are identified in the comprehensive assessment. * R64's care plan was not updated when foley catheter was removed. * R49's care plan was not updated to address condom catheter use. * R29's care plan was not updated for compression sleeve use. Findings include: The Facility Policy titled Comprehensive Care Plans revised 9/23, documents: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . Policy Explanation and Compliance Guidelines: . 3. The comprehensive care plan will describe, at a minimum,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 follow up on pharmacist recommendations reports, with the monthly medication reviews for 2 (R62 and R77) of 5 residents reviewed. - R62 and R77's pharmacy irregularities reports documented by the pharmacist for the physician were not acted upon. Findings include: The facility's policy and procedure Pharmacy Services dated 10/22. The policy documents: It is the policy of the facility to ensure that pharmaceutical services, whether employed by the facility or under an agreement, are provided to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice. 1.) R62 was admitted to the facility on [DATE] with diagnosis of Alzheimer's dementia. R62 had Pharmacy Review on 6/8/24 that documents a pharmacy note was written. There was no documentation in the medical record regarding the pharmacy report. R62 had Pharmacy Review on 7/1/24 that documents a pharmacy note was written. There was no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure 1 (R64) of 1 residents reviewed were free from significant medication errors. *R64 had a physician order to receive Plavix Oral Tablet 75mg (anticoagulant) one time a day. R64 did not receive 6 administrations of Plavix between 7/28/2024 and 8/11/2024. Findings include: The Facility Policy titled, Unavailable Medications last reviewed 6/23, documents: Policy: This facility shall use uniform guidelines for unavailable medications. Policy Explanation and Compliance Guidelines: 1. The facility maintains a contract with a pharmacy provider to supply the facility with routine, prn, and emergency medications. 2. A STAT supply of commonly used medications is maintained in-house for timely initiation of medications. 3. The facility shall follow established procedures for ensuring residents have a sufficient supply of medications. 4. Medications may be unavailable for a number of reasons. Staff shall take immediate action when it is known 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.

Based on interview and record review the facility did not ensure 1 of 5 Certified Nursing Assistants (CNAs) reviewed received the required 12 hours of continuing competence training. This deficient practice has the ability to affect 90 residents whom could receive care from the CNA. CNA-M was hired on 10/31/22 and received only 4.5 hours of continuing competence training. Findings include: 1.) On 9/10/24, Surveyor obtained a sample of 5 CNAs to review for their 12 hours of continuing competence training. Surveyor reviewed CNA-M's training record. CNA-M was hired on 10/31/22 and her training hours indicate she only received 4.5 hours of continuing competence training. On 9/10/24 at 11:45 a.m., Surveyor interviewed DON (Director of Nursing)-B regarding CNA-M's continuing competence training. Surveyor asked DON-B if this the in-service hours provided for CNA-M were accurate. DON-B stated yes there isn't any other in-service hours for CNA-M. On 9/10/24 at 11:49 a.m., Surveyor interviewed NHA (Nursing Home Administrator)-A. Surveyor asked NHA-A who is responsible for ensuring CNAs attain…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an allegation of abuse involving 1 (R3) of 2 residents reviewed for allegations of abuse were reported immediately to the State Survey Agency. *On 4/17/24 an allegation of R3 being choked by a certified nursing assistant(CNA) was not reported to the state survey agency within 2 hours and local law enforcement was not notified of the allegation immediately. Findings Include: Surveyor reviewed the facility's Alleged Incidents of Abuse, Neglect, Exploitation and Mistreatment-Reporting and Investigation policy and procedure last revised 2/2020 and notes the following in regards to reporting: .Purpose .Facility is in compliance with the reporting and investigation guidelines specific to each program area governed by the State Survey and Compliance Agencies(Division of Quality Assurance(DQA)/Office of Caregiver Quality(OCQ)). .All alleged incidents of abuse, neglect, exploitation, and misappropriation must be reported and investigated 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 record review and staff interview, the facility did not ensure all allegations involving potential abuse, neglect and misappropriation of Resident property were thoroughly investigated for 2 (R3 and R4) of 2 sampled residents. *R3's Facility Reported Incident(FRI) dated 4/17/24 documents an allegation of R3 being choked. The FRI does not contain other Resident statements, all staff statements, the reasoning for why the local law enforcement was not notified and a root cause analysis of the circumstances of the allegation. *R4's Facility Reported Incident(FRI) dated 4/1/24 documents an allegation of R3 being choked. The FRI does not contain other Resident statements, all staff statements, and a root cause analysis of the circumstances of the allegation. Surveyor reviewed the facility's Alleged Incidents of Abuse, Neglect, Exploitation and Mistreatment-Reporting and Investigation policy and procedure last revised 2/2020 and notes the following in regards to a thorough investigation: Thorough investigation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 1 (R3) of 1 residents reviewed received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. *R3's hospital discharge paperwork dated 12/20/23 has instructions for R3 to follow-up for an orthopaedic consult to be scheduled within 6 weeks after discharge. R3 did not have a consult until 3/11/24. The consult documented that R3 was to return in 1 month for repeat x-rays. R3 did not have that appointment. R3 was scheduled for an orthopaedic appointment on 5/7/24 which R3 did not attend. Findings Include: 1.) On 6/5/24 at 11:54 AM, Administrator(NHA-A) informed Surveyor the facility does not have a policy and procedure for Resident appointments. R3 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, Dementia with Psychotic Disturbance, Generalized Anxiety Disorder, Essential Hypertension, Type 2 Diabetes, Pulmonary Fibrosis, 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 interview, the facility did not ensure a system of records of receipt and disposition of all controlled drugs in sufficient detail enabled an accurate reconciliation affecting 1 unit of 2 units. * Licensed Practical Nurse Unit Manager (LPN UM)-K diverted narcotic medications from discharged and expired residents. LPN UM-K did not follow the procedure to have two nurses sign the narcotic record form when narcotics were destroyed and shredded narcotic record forms so narcotic medications could not be reconciled. Findings: The facility policy and procedure entitled Medication Administration: Destruction of Controlled Schedule II Medications dated 9/2023 states: Purpose: 1. The destruction of controlled substance Schedule II Medications is required by Wisconsin Administrative Code HFS 132.65(6)(c)2. 2. All controlled substance Schedule II medications must be destroyed once the order is discontinued or upon the death or permanent discharge of a resident. Guidelines: 1. Schedule II…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 report the results of abuse/neglect investigations to the state agency within 5 working days for 1 (Resident 2) of 5 sampled investigations. The facility reported an initial allegation of abuse/neglect to the state agency but did not report the full investigation within five working days as required by state law. Findings include: The facility's policy and procedure for Alleged Incidents of Abuse, Neglect, Exploitation and Mistreatment-Reporting and investigation, with a revision date of 02/20020, indicated for every report submitted, a follow report detailing the Investigation must be submitted to Division of Quality Assurance/Office of Caregiver Quality within 5 working days even if it is determined that a violation did not occur. The facility received a concern from R2's family member indicating that R2 was sent to a doctor's appointment without an escort. R2 was nonverbal and has severe cognitive deficits. Registered Nurse (RN) allowed R2 to leave the facility unattended and was aware that R2's family member 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 and staff interview, the facility did not have evidence that alleged violations were thoroughly investigated for 3 (Residents 3, 4 and 6 ) of 5 sampled allegations of abuse/neglect. The facility submitted allegations of abuse/neglect for Residents (R) 3, 4 and 6, but there was not evidence that the allegations were thoroughly investigated nor did the facility complete training to staff to ensure they should not take money for any residents in attempt to prevent exploitation. Findings include: The facility's policy and procedure for Alleged Incidents of Abuse, Neglect, Exploitation and Mistreatment-Reporting and investigation, with a revision date of 02/20020, directed the following: ~ Obtain written statements from all witnesses or persons with information. ~ Obtain a written, signed statement from the accused individual ~ Contact law enforcement or other regulatory agency if appropriate. 1. On 10/28/2023, the facility submitted a Facility Reported Incident (FRI), that indicated Certified Nursing Assistant (CNA) L had received money via a cash app to purchase…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, the facility did not ensure that 1 (Resident 8) of 1 sampled residents received appropriate treatment and services to restore continence to the extent possible. * R8 was incontinent of bladder. The facility did not complete a comprehensive assessment for bladder incontinence. The facility did not complete a voiding study in attempt to determine a voiding pattern and develop a toileting schedule based on the voiding study. The facility developed a toileting schedule but was not based on a voiding study. The plan of care directed staff that R8 was to be checked and change every 3 hours during the AM and PM shift. This was not consistently followed. Findings include: The facility's policy and procedure for Continence Management with a revision date of 06/2020 indicated that a resident who is incontinent of bladder will receive appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. The policy 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 3. R76 was admitted to the facility 6/8/23 with diagnoses that include Fracture of Right Femur, Fracture of Left Femur, Fracture of Shaft of Right Humerus, Fracture of Lower End of Left Humerus, Fracture of Head of Left Radius, Fracture of Lower End of Left Radius, Fracture of Upper End of Left Ulna, Fracture of Right Forearm, Fracture of Olecranon Process, Fracture of Trapezium, Fracture of Right Patella, Fracture of Left Patella, Bimalleolar Fracture of Left Lower Leg, Multiple Fractures of Ribs, Fracture of Sternum, Acute Pain Due to Trauma, and Bipolar Disorder. Surveyor reviewed R76's Minimum Data Set (MDS) admission assessment with an assessment reference date of 6/15/23. Documented under Cognition was a Brief Interview for Mental Status (BIMS) score of 15 which indicated cognitively intact. Documented under Medications was .Medications Received: Indicate the number of DAYS the resident received the following medications by pharmacological classification, not how it is used, during the last 7 days or since…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 allegations of abuse involving 2 residents (R138 and R76) of 3 residents reviewed for abuse were reported in accordance with regulatory time frames. The facility did not ensure R138's allegation of abuse was reported immediately, but no later than 2 hours, to the Administrator and to the State Agency. The facility did not ensure the results of their investigation involving R76's allegation of abuse was reported to the State Agency within 5 working days of the incident. *R138 reported to Licensed Practical Nurse (LPN)-D on the evening of 4/12/23, that R138 was physically assaulted during a shower. LPN-D did not report the alleged allegation of abuse to the Administrator. The Administrator was notified of the alleged abuse on 4/13/23 when on 4/13/23, R138 reported the allegation to Receptionist-C during discharge from facility. This alleged abuse was then reported to the State Agency. *R76 was named in a facility self-report alleging an allegation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility did not ensure all allegations of abuse was thoroughly investigated for 1 (R138) of 3 self-reports reviewed for abuse, neglect, and mistreatment. The facility did not have evidence of preventing further abuse while the investigation was in progress. * On 4/12/23, R138 reported to Licensed Practical Nurse (LPN)-D that Certified Nursing Assistant (CNA)-H was physically assaulting her during a shower. On 4/12/23, LPN-D reported to Registered Nurse (RN) G that R138 was upset but did not specify the allegation of abuse. The facility did not prevent the potential for further abuse from occurring as the accused CNA-H continued performing resident cares after the allegation was first made on 4/12/23. The facility did not initiate an investigation into this allegation of abuse until the following day on 4/13/23. CNA-H was allowed to conduct resident cares once the investigation was initiated on 4/13/23. Findings include: The facility policy, entitled Alleged incidents…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 3 Residents (R20, R29, and R26) of 4 residents reviewed for hospitalization received a transfer notice to include date of transfer, reason for transfer, location of transfer, appeal rights, and contact information for the State Long-Term Care Ombudsman. In addition, the facility did not notify the State Long-Term Care Ombudsman of hospital transfers for 3 Residents (R20, R29, and R26) of 4 residents reviewed for hospitalization. R20 was transferred to the hospital on 6/22/23, 6/23/23, 6/29/23, and 7/24/23. The facility did not provide R20, their representative, and the Ombudsman notice of transfer. R29 was transferred to the hospital on 4/18/23 and 5/23/23. The facility did not provide R29, their representative, or the Ombudsman notice of transfer. R26 was transferred to the hospital on 5/7/23. The facility did not provide R26, their representative, and the Ombudsman notice of transfer. Findings include: The facility could not provide 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 record review and interview, the facility did not provide written notice of the facility bed-hold policy for 3 (R20, R29, R26) of 4 residents reviewed for hospital transfers. R20 was transferred to the hospital on 6/22/23, 6/23/23, 6/29/23, and 7/24/23. A bed hold notice was not provided to R20 and their resident representative. R29 was transferred to the hospital on 4/18/23 and 5/23/23. A bed hold notice was not provided to R29 and their representative. R26 was transferred to the hospital on 5/7/23. A bed hold notice was not provided to resident and their resident representative. Findings include: The facility policy, entitled Health Care Center Bed Hold and Return, revised 6/2018, states: It is the policy of [NAME] manor 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. 1. R20 was admitted to the facility on [DATE] with diagnoses that include chronic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the comprehensive assessment of a resident, the facility did not ensure that a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder (PTSD), receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for 1 of 1 (R76) residents reviewed with a history of trauma. * R76 was admitted to the facility on [DATE] after a prolonged hospital stay from multiple fractures and complications related to a gunshot wound (GSW) and a fall out of a window from a 4th story building and bipolar disorder. R76 had multiple complications and was admitted to the facility with identified trauma and related behaviors. The facility completed a Brief Trauma Questionnaire Assessment with R76. Information gathered through this assessment was not incorporated into R76's care plan in order to reduce stressors triggering trauma induced…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 it maintained a medication error rate below 5 percent during observations of medication administration affecting 1 (R36) of 4 residents observed. Two medication errors were observed out of twenty-eight opportunities, for a total error rate of 7.14%. * R36 was administered 2 medications whole with applesauce that should not be chewed. R36 was observed chewing Januvia and Memantine ER (extended release) and drug manufacturers recommendations are not to chew the medication. Findings include; On 07/27/23 the facility's policy and procedure titled, Medication Administration dated 03/21 read: Crushing oral medication. Non-crushable medications cannot be without a specific medical doctor order documented on the medical record for a specific resident and specific medication. Long acting or enteric coated dosage forms should generally not be crushed: an alternative should be sought. R36 was admitted to the facility on [DATE]. On 07/26/2023 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.