Wheaton Franciscan HC - Terrace at St Francis

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection for 1 (R3) of 1 Resident.* Staff did not perform hand hygiene before, during, and after transferring R3 with the mechanical lift. Staff did not wipe down the mechanical lift after transferring R3.Findings include:The facility's Hand Hygiene last revised 6/25 documents:Policy Statement: This community considers hand hygiene the single most important practice to prevent infections and promote resident safety. Evidence based hand hygiene guidance is practiced to reduce the risk of transmission of pathogenic microorganisms to residents, associates, and visitors.Policy Interpretation and ImplementationA. Supplies necessary for adherence to hand hygiene are readily accessible in all areas where resident care is being delivered.E. Hand hygiene is practiced:1.Immediately before touching a resident4. After touching a resident or 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 that 1 of 5 Certified Nursing Assistant (CNA) reviewed received registry verification that the individual has met competency evaluation requirements. CNA-L's Wisconsin Nurse Aide Registry certification expired and CNA-L continued working in the facility. This deficient practice has the ability to affect 41 of 41 residents residing at the facility whom have the potential to and or received cares from CNA-L.Findings include:According to the Wisconsin Nurse's Aide Training and Registry, Nurse Aides must be listed on the Wisconsin Nurse Aide Registry in order to be employed in any federally eligible health care setting in Wisconsin. The registry ensures that that the individual has met competency evaluation requirements to work as a CNA. On [DATE], Surveyor reviewed CNA registry information for 5 randomly CNAs. CNA-L was listed on the registry. Surveyor noted that CNA-L's CNA certification expired on [DATE] and was not renewed. CNA-L had worked 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 observation, interview and record review, the facility did not provide pharmaceutical services that assure proper dispensing of medications, did not ensure drug records are in order, or all controlled drugs are maintained and periodically reconciled.*The facility does not have a process for medications that should be returned to the pharmacy for possible reimbursement or otherwise destroyed; and keeping a log of those medications.*The facility did not ensure that controlled medication logs were accurate and reconciled.This deficient practice has to potential to affect 41 of 41 residents residing at the facility whom have the potential to and or receive pharmaceutical services. Findings:The Facility's policy, titled Discarding and Destroying Medications, dated 01/2024, documents . C. Unless otherwise prohibited under applicable federal or state laws, individual resident medications supplied in sealed unopened containers may be returned to the issuing pharmacy for disposition provided that: 1. No medications covered under the Federal Comprehensive Drug Abuse Prevention 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 4 (R8, R5, R42 and R11) of 6 residents and/or their representative that were reviewed, were provided the risks and benefits for prescribed psychotropic medication. * R8 received an antidepressant and antipsychotic medication with no evidence that the risks and benefits were explained, reviewed or provided. * R5 received an antidepressant medication with no evidence of risks and benefits were explained, reviewed or provided. * R42 received an antidepressant and antipsychotic medication with no evidence of risks and benefits were explained, reviewed or provided. *R11 received an antipsychotic medication with no evidence of risks and benefits were explained, reviewed or provided. The facility's policy and procedure, Psychotropic Medication, dated 6/2025 documents under Section T, Consents for Psychotropic Medications: 1. If a resident is admitted on a psychotropic medication, nursing will obtain appropriate and necessary written consent. 2. 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 and record review the facility did not ensure 5 (R1, R2, R5, R33, and R44) of 5 residents reviewed for hospitalizations received the proper notice of transfer, reason for transfer, location of transfer, appeal rights, and name and address (including mail and email) with the telephone number of the Office of the State Long-Term Care Ombudsman, were notified of the reason for transfer/discharge & bed hold policy in writing to the resident & their representative and the rate to reserve the residents bed, and there was no documentation that the ombudsman was being notified of hospitalizations. *R1 was transferred to the hospital on 3/20/2025, 5/20/2025, and 6/27/2025. A transfer notice and bed hold rate was not provided in writing to R1 and/ or R1's representative. There is not evidence that the ombudsman was notified of R1's hospitalizations. *R2 was transferred to the hospital on 5/12/2025 and 6/2/2025. A transfer notice and bed hold rate was not provided in writing to R2 and/or R2'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 interviews and record review, the facility did not complete neurological (neuro) checks in accordance with policy and procedure for 5 (R27, R5, R42, R8 and R11) of 5 residents reviewed for falls. *R27 had an unwitnessed fall on 08/10/2025, no neurological checks were completed. *R5 had 5 unwitnessed falls, 2 of the falls had incomplete neurological checks and 1 fall had no neuro checks documented. *R42 had had 4 falls, 2 of the falls had incomplete or missing neurological checks. *R8 had 1 unwitnessed fall with incomplete neurological checks. *R11 had 1 unwitnessed fall with no documented neurological checks completed. Findings include: 1.) On 08/18/2025, at 10:08 AM, Surveyor observed R27 with a large bruise to the right side of R27's forehead that extended down under R27's right eye. Surveyor Reviewed R27's Electronic Health Record (EHR) and noted a progress note dated 08/10/2025, indicating R27 had an unwitnessed fall on 08/10/2025 and a neurological assessment was completed. Surveyor requested R27'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 record review and interview, the facility did not timely act upon recommendations based on a pharmacist medication regimen review report for 4 (R6, R5, R8 and R42) of 5 residents reviewed for unnecessary medications. Findings include: The facilities policy titled Pharmacy Services-Role of the Consultant Pharmacist dated 2/25 was reviewed and documented: The Director of Nurses (DON), or designee will ensure the recommendations are followed through on a timely basis, which does not exceed 30 days. Irregularities will be addressed as soon as possible, but not to exceed 24 hours. The attending physician will document in the resident's medical record that the irregularity was received and what action was taken to accommodate it. 1) R6 was admitted to the facility on [DATE] with diagnosis that included Depression and Schizophrenia. R6's Pharmacist's Medication Regimen Recommendations (MRR) documented: * 3/19/25: R6 is currently receiving clozapine, for which the following lab oratory monitoring is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility did not ensure resident's right to personal privacy and confidentiality of his or her personal and medical records for 1(R9) of 41 residents reviewed.*On 08/19/2025, at 7:23 AM, R9's personally identifiable information (PII) or Personal Health Information (PHI) was observed to be thrown into the regular garbage during medication pass.Findings:The Facility's policy, titled Health Insurance Portability and Accountability Act (HIPPA) Privacy Program last revised 06/01/2023, documents in part, . [Name] Health Alliance is committed to protecting the privacy rights of our patients and residents ( individuals). In compliance with Health Insurance Portability and Accountability Act of 1996 ( HIPPA), the Health Information Technology for Economic and Clinical Health Act ( HITECH) and applicable federal and state laws and regulations (together, HIPPA Rules), this [Name] Procedure ( Procedure) sets forth the HIPPA Privacy Program policies, procedures, and standards (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 that an alleged violation involving misappropriation was thoroughly investigated for 1 of 1 Facility Reported Incidents reviewed.*The facility could not provide documentation that weekly audits of narcotic medication counts were preformed, following a narcotic discrepancy identified on [DATE].Findings:Surveyor reviewed the Facility Reported Incident (FRI) submitted to the State Agency on [DATE] regarding a discrepancy in the appearance of R27's liquid Morphine (a controlled, narcotic medication), indicating the Morphine was lighter in color instead of the usual dark blue hue.The facility indicated the police were notified, the medication was removed from the medication cart, pain assessments were completed for residents, residents were interviewed as well as staff, weekly audits during medication counts for the next six weeks and medication audit found medication were properly stored.On [DATE], Surveyor requested the full investigation for the FRI…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 for 2 (R11, R6) of 2 residents reviewed for PASARR (Preadmission Screening and Resident Review) screenings had a PASARR level two screening completed after triggering for it on the level one PASARR. *R11 had a completed level 1 PASARR, which indicated a level 2 was needed and the facility did not ensure a level 2 PASARR was completed within the required time frame after the 30-day extension was exceeded. *R6 had a completed level 1 PASARR, which indicated a level 2 was needed and the facility did not ensure a level 2 PASARR was completed after the 30-day extension was exceeded. Findings include: The facility policy and procedure titled PASARR (Pre admission Screening & Resident Review) dated 4/2025 documents: Policy Statement. The purpose of this policy is to outline the screening of residents with a history of serious mental illness in developmental disability. Procedure A. Complete level I screen of the PASARR on new admissions. 3. Those…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (R8) of 2 residents reviewed whom is at risk for the development of pressure injuries received the necessary care and services for prevention and healing of pressure injuries/wounds.*R8 was at risk for developing pressure injuries. Surveyor had multiple observations R8 without pressure relieving interventions in place on 8/18/25 and 8/19/25.Findings include:R8 was admitted to the facility on [DATE] with diagnoses of Vascular Dementia (a decline in mental abilities), Anemia (a lack of oxygen rich red blood cells in one's body which may result in tiredness or weakness) and Depression. R8's Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 4/19/25 documents a Brief Interview for Mental Status (BIMS) score of 9, indicating that R8's is moderately cognitively impaired. The MDS documents that R8 requires extensive to total assist with Activities of Daily Living (ADLs) including transfers, toileting,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 3 (R8, R19 & R27) of 4 residents reviewed were free from accidents and hazards as possible. *R8 was observed without fall interventions in place in accordance with their comprehensive care plan on on 8/18/25 & 8/19/25. *R19 sustained an unwitnessed skin tear to their elbow. The facility did not investigate the root cause of R19's unwitnessed skin tear or implement new interventions to prevent further accidents. *R27 sustained a fall. The facility did not implement comprehensive care plan interventions, including therapy services, to prevent future falls and accidents. Findings Include: 1.) R8 was admitted to the facility on [DATE] with diagnoses of Vascular Dementia (a decline in mental abilities), Anemia (a lack of oxygen rich red blood cells in one’s body which may result in tiredness or weakness) and Depression. R8’s Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 4/19/25 notes R8with 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 interview and record review, the facility did not ensure consistent communication for 1 (R2) of 1 resident who receives dialysis services.R2's dialysis communication tools were missing for 5 days of 14 days reviewed.Findings include:The facility's Dialysis policy with origination date 12/2017 and last approved date 01/2025 documents: Policy Statement: It is the policy of this community to provide coordination of care with the resident's dialysis provider. Policy Interpretation and Implementation:-Residents needing dialysis services will be admitted with the co-ordination of their dialysis provider off site with a predetermined schedule-Communities are to review contracts to assure resident's needs are met while residing at the facility -The community will co-ordinate care with the dialysis provider in developing an appropriate plan of care to include, but not limited to:a. Specific days of the week resident will attend dialysis .f. Dialysis center's expectation of care to be completed by SNF (skilled…

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

Based on observation, interview, and record review, the facility did not ensure the medication rate was not 5 percent or greater. This deficient practice was observed in 2 (R32 and R9) of 6 residents receiving medications. The facility medication error rate was 18.52 percent.*R32 was given 15 milliliters (ml) of liquid Potassium Chloride, but is only ordered to receive 3.75ml. R32 received medication through an enteral feeding tube. The Enteral Tube was not flushed prior to administering the medications and was not flushed after administering the medications, until approximately 1 hour later.*R9 was administered Insulin that was past the discard by date.Findings include:The Facility policy titled, Administering Medications dated 12/2024 documents: .C. Medications shall be administered in accordance with the orders and within the allowable time frame per best practice/regulatory guidelines. H. The expiration/beyond use date on the medication label is to be checked prior to administering. The Facility policy titled, Medication Administration vis Enteral Tube dated 12/2024 documents: .…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, policy review and interviews, the facility failed to ensure that two residents (Resident (R) R2 and R3) out of a total sample of 13, were protected from abuse when, R2 and R3 were observed holding hands and kissing by staff members. Findings include: Review of the facility's policy titled, Abuse Prevention, dated 08/2024 stated, Our residents have the right to be free from abuse .This includes, but is not limited to .sexual or physical abuse .'Sexual abuse' is 'non-consensual sexual contact of any type with a resident.' . Generally, sexual contact is non-consensual if the resident either: a. Appears to want the contact to occur, but lacks the cognitive ability to consent; or .Reported sexual activity involving residents scoring below cognitively intact, ?12 on a BIMS, shall be investigated per Abuse Investigation Policy . Review of the facility's Capacity to Consent for Sexual Intimacy assessment provided by the Business Operations Manager revealed assessments were not completed for R2…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reviews, policy review and interviews, the facility failed to ensure that two residents (Resident (R)2 and R3) out of a total sample of 13 had accurate care plans. This failure increased the risk of the resident's safety and monitoring. Specifically, R2 had a history of sexually inappropriately touching other residents and was observed kissing/holding hands with R3 on 05/02/25. Findings include: Review of the facility policy titled, Care Plans- Comprehensive Person-Centered revised 10/2021 stated A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs, that are identified through evaluation and assessment, is developed and implemented for each resident .The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment .The comprehensive, person-centered care plan will: 1. Include measurable objectives and time frames .J. Areas…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, record review, observations, and interviews, the facility failed to ensure transmission based precaution (TBP) and/or Enhanced Barrier Precaution (EBP) procedures were consistently followed by staff for six residents (Resident (R)23, R6, R25, R36, R34, and R27); the facility failed to ensure infection prevention procedures related to the cleaning/sanitizing of glucometers were followed for eight residents (R4, R5, R3, R18, R15, R16, R19 and R20) out of a total of 33 residents reviewed in the sample; and the facility failed to ensure the facility's overall program for infection tracking and trending/data analysis procedures were consistently followed. These failures created the potential for increased risk of infection for all residents residing in the facility. Findings include: Review of the facility's policy titled, Infection Prevention and Control dated 08/2024 indicated, Prevention of Infection: Important factors of infection prevention include: a. identifying possible…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure residents with non-pressure wounds received treatment and care in accordance with professional standards for 3 (R7, R16, and R9) of 3 residents reviewed for non-pressure wounds. Additionally, the facility did not ensure residents had emergency medical equipment available to provide treatment and care in accordance with professional standards of practice due to 3 of 3 crash carts not maintained and fully supplied potentially affecting 39 of the 62 residents that elected to be full code status. * R7 developed a non-pressure wound to the lower mid spine on 2/6/2025. A comprehensive assessment was not completed; no wound measurements or descriptors of the wound were documented. R7 was seen by the wound physician on 2/12/2025 when a treatment was ordered to the wound; the treatment was not initiated until 2/19/2025. R7 was seen by a dermatologist on 3/3/2025 and no assessment of the wound was documented after 3/20/2025. Observation of…

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

Based on observation, interview, and policy review, the facility failed to ensure medications were secured properly for three of three medication carts (first, second and third floor medication carts). This failure placed residents' medication to be at risk for diversion and/or at risk to be taken by cognitively impaired residents. Findings include: Review of the facility's policy titled, Administering Medications revised 12/2024 revealed, .O. During administration of medications, the medication cart will be kept closed and locked when out of sight of the medication nurse or aide. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or other passing by . 1. During an observation of the third floor on 03/25/25 at 4:30 PM, the medication cart was observed to be unlocked and unattended at the nurses station. No nursing staff was observed in the area. During an interview with Licensed Practical Nurse (LPN)-S on 03/25/25 at 4:35 PM, he confirmed he was responsible…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility's policy, the facility failed to ensure residents' physician was notified when the residents were not administered their medications per the physician's order for 7 of 7 residents reviewed for physician notification Resident (R) R10, R18, R19, R23, R22, R21 and R17. This failure placed the residents at risk for unmet treatment needs and the physician notified to address the resident's treatment. Findings include: Review of the facility's policy titled, Administering Medications, revised 12/2024 revealed, Q. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall document on the MAR or eMAR [electronic medication administration record] for that drug and dose .3. Notify health care provider (physician) of 2 consecutive refused doses .Y The policy did not address notification of the physician for mediation not being available to be administered. 1. Review of R10's Profile Face…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews, and review of facility procedure, the facility failed to ensure routine bathing services were provided for one resident (R9) of a total of 33 residents reviewed in the sample. This failure created the potential for R9 to experience hygienic complications related to going without care planned bathing for extended periods of time. Findings include: Review of the facility's Shower/Tub Bath Procedure dated 02/2024 indicated, The purpose of this procedure is to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin .Documentation: The following information should be recorded on the resident's ADL (Activities of Daily Living) record and/or in the resident's medical record: A. The date and time the shower/tub bath was performed; and D. If the resident refused the shower/tub bath, the reason why and the intervention taken; and E. The signature and title of the person recording the data; and Reporting: A. Notify the supervisor if 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 review of facility policy, record review and interviews, the facility failed to ensure root cause analysis was conducted and an updated care plan put into place after falls were experienced by three residents (R)13, R14 and R17) out of 33 residents reviewed in the sample. This failure created the potential for these resident to continue to experience falls. Findings include: Review of the facility's policy titled, Accidents ad Incidents - Investigation and Reporting dated 01/2024 indicated, Accidents and incidents involving resident shall be investigated and reporting completed, .federal requirements .The Health Care Administrator, or designee and interdisciplinary team will review the incident at the next scheduled meeting. Review of the facility's policy titled, Falls dated 01/2024 indicated, Fall should be reviewed at the Daily Stand-Up Meeting following the fall for identification of any additional individualized interventions to reduce the risk of falls. 1. Review of R13's Profile Face Sheet 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 interview, record review, and review of the facility's policy, the facility failed to maintain pharmaceutical services by ensuring medications were available to be administered as ordered by their physician to meet their medical needs for nine of nine residents (R)18, R19, R9, R5, R17, R21, R22, R23 and R24 reviewed for medication availability. This failure placed the residents at risk for unmet pharmacological interventions to maintain or improve their medical conditions. * Failure to ensure the availability of ordered medications for R9, R18, and R19 * Medication administration observed for R23, R22, R21, and R17 with an error rate of 97.05% * R5's physician ordered Imatinib medication unavailable * R24 had a delay in the start of physician ordered ertapenem intravenous antibiotic medication * R22 has medications that are EC (enteric coated) and ER (extended release) that were crushed and R22's levetiracetam was observed being crushed as well. Findings include: Review of the facility's policy titled,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, record review, observations and interviews, the facility failed to ensure three residents (R10, R5 and R24) out of a total of 33 residents reviewed in the sample was free from a significant medication error. This failure created the potential for residents to experience negative physical and/or psychosocial effects related to the omission of necessary ordered medication. * R5 had a physician order to receive one 400mg Imatinib tablet (Per Mayoclinic.org Imatinib is used to treat different types of cancer or bone marrow conditions. It prevents or stops the growth of cancer cells.) daily. R5 did not receive Imatinib between 3/19/2025 and 4/1/2025, nine were marked as Med not administered and five administrations were signed out even though the Facility did not have the medication in stock. Hence, 14 administrations were unavailable for administration and still not available at the time of Surveyor's exit from the Facility. * R24 returned from the hospital on 3/26/25 with 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, record review, and review of the facility's policy, the facility failed to ensure a trough level result was received timely from their laboratory for one of one resident reviewed for laboratory results (Resident (R) 18.) R18's physician ordered a laboratory trough level be obtained for R18 for the resident to be able to continue antibiotic infusions; however, there was a delay in the laboratory results and the resident missed four antibiotic infusions. This failure placed the resident at risk of the infection worsening. Findings include: Review of the facility's policy titled, Laboratory, Radiology, and other Diagnostic Test Results dated 01/2024 revealed, .The resident's Attending Physician will be notified of the results of laboratory Policy Interpretation and Implementation .A. Results of laboratory .tests shall be reported in writing to the resident's Attending Physician or to the community. B. Should the test results be provided to the community; the Attending Physician shall be promptly…

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

Based on observation, interview and record review, the facility did not ensure the medication error rate was below 5% for 2 residents (R6 and R7) of 2 residents observed receiving medications. The facility medication error rate was 32%. *R6 received a Folic Acid supplement and the order was discontinued on 12/9/24. Five medications were given more than 60 minutes after the scheduled time. *R7 has an order for Fluticasone Propionate, one spray per nostril, two sprays were observed being given in each nostril. A medication to control blood pressure was also given more than an hour after the scheduled time. Findings include: The Facility Policy and Procedure titled, Medication Administration Schedule last approved 9/2023, states in part: Policy Statement: Medications shall be administered according to established schedules and per resident preference, as appropriate. Policy Interpretation and Implementation A. Health Care Provider order and/or a pharmacy recommendation may specifically define administration intervals such as every 6 hours, or a specific administration time. The nursing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Survey Based on observation, interview, and record review the facility did not ensure 2 (R16, R44) of 3 Residents reviewed for pain management, received pain management consistent with professional standards of practice. *R16 did not receive topical pain relief medication as ordered by the physician. R16 did not have complete pain assessments, or evaluation of the effectiveness of pain interventions. *R44 did not have complete pain assessments, or evaluation of the effectiveness of pain interventions. Findings include: The Facility's policy titled, Pain Assessment and Management, with a last approved date of 01/2024, documents in part, the purpose of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying cause of pain. General Guidelines A. The pain management program is based on a community-wide commitment to resident comfort. B. Pain management is defined as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the Facility did not provide pharmaceutical services that assure the accurate dispensing of medications to meet the needs of residents and did not have sufficient detailed records for controlled drugs to enable an accurate reconciliation for 2 (R369, R44) of 4 residents reviewed. *R44's Medication Administration Record (MAR) did not accurately reflect the controlled medication narcotic count sheet. R44's had an order for Protonix to be administered 30 minutes prior to meals, that order was not transcribed to R44's Medication Administration Record, as ordered. *R369's personal glucose monitor was not properly labeled to identify the glucose monitor belonged to R369. Findings include: 1.) R44 was admitted to the facility on [DATE]. R44 has relevant diagnoses of Multiple Sclerosis, pain in right hip, pain in left hip, Gastro-Esophageal Reflux Disease (GERD) and Barrett's esophagus. R44's annual Minimum Data Set (MDS), dated [DATE], documents R44 having 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 ensure food was stored, prepared and served in a sanitary manner. This practice had the potential to affect 47 of 47 Residents residing in the facility. *On 7/15/24 and 7/16/24, Surveyor observed Food Service Associate (FSA)-C not wearing a beard net while preparing plates and trays for Residents in the second floor kitchenette. *On 7/15/24 and 7/16/24, Surveyor observed the facility's low temperature dish machine not reach the minimum required temperature of 120 F and Food Service Aide (FSA)-C, FSA-D, and FSA-E all stated they do not use test strips to test the sanitizer solution concentration (50-100ppm-parts per million sodium solution hypochlorite [chlorine]), thus not ensuring proper sanitation. Findings Include: The facility's policy Sanitation and Infection Prevention/Control; Dish Machine Temperatures Issued 5/95, and Last Revised on 1/24 documents: .:Policies: Dishmachine wash and rinse water should be maintained at temperatures that meet the guidelines established by the Food and Drug…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility did not establish and maintain an infection prevention and control program 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 47 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 the Facility's Infection Preventionist (IP). ~revise WMP control measures after the closure of wing 1 ~have a defined flush program for little used outlets. ~have logs to monitor water temperatures. ~ include eye washing stations and ice machines in risk assessment. ~measure and record residual (free) disinfectant (Chlorine) levels. The Facility's Surveillance of the Infection and Control Program did not have: ~ a defined policy and procedure for staff illness. ~ a list of reportable…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 quarterly assessments were completed as required for 6 (R27, R5, R44, R29, R25, & R50) of 12 residents reviewed for MDS (minimum data set). R27, R5, R44, R29, R25, & R50 did not have a quarterly MDS assessment completed within 92 days of their last MDS assessment. Findings include: On 7/17/24, at 1:13 p.m., Surveyor met with RN/MDS (Registered Nurse/Minimum Data Set)-G to inquire about the MDS's. Surveyor asked who completes the MDS. RN/MDS-G explained social service does sections C, D, & Q, the Dietitian does section K and activities does section F if the MDS is a comprehensive assessment. RN/MDS-G indicated she thinks she does all the rest of the sections. Surveyor inquired who submits the completed MDS. RN/MDS-G informed Surveyor Regional Consultant-H. Surveyor asked RN/MDS-G how Regional Consultant-H is aware of the MDS's that need to be submitted. RN/MDS-G informed Surveyor she usually checks or she tells her. Surveyor asked RN/MDS-G about 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 2.) R42 was originally admitted to the facility on [DATE] and most recently re-admitted on [DATE]. R42's diagnosis include congestive heart failure, type 2 diabetes, unstageable pressure ulcer to left heel, dependence on supplemental oxygen, weakness and acquired absence of right leg below knee. R42's plan of care states that R42 has diseases and conditions which are treated with medications. The goal is medication will be overseen and managed by the nursing and Physician team during the stay. Will remain free from any adverse effects due to medication over the next review period. Surveyor conducted a review of R42's medication regimen and reviewed the monthly pharmacy reviews. Surveyor requested to review the monthly reviews from pharmacy on 7/16/24. A copy of the June, 2024 pharmacy review was provided. The review was not signed or dated. Surveyor requested to review April and May, 2024 pharmacy reviews. 07/18/24 08:12 AM Surveyor was provided with copies of the MRR recommendations for R42 for April, May 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 (R44) of 12 residents was given the opportunity to be a part of their care planning process in regards to their personal belongings. Findings include: R44's diagnoses include multiple sclerosis, hypertension, anxiety, and is blind in the left eye. The quarterly MDS (minimum data set) with an assessment reference date of 2/16/24 assesses R44's short and long term memory as ok. R44 has modified independence for cognitive skills for daily decision making. R44 is assessed as not having any behavior. R44 is independent with her activities of daily living. The potential of impaired psychosocial well being care plan documents the following approaches: * Provide emotional support and validate concerns/feelings PRN (as needed). Start date of 6/26/24. * Encourage/Facilitate development of peer relationships/participation in activities PRN. Start date of 6/26/24. The at risk for impaired adjustment to new environment care plan documents the following…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (R29) of 12 Residents reviewed, notified R29's representative of R29 being transferred to the emergency room for an x-ray on 6/3/24 and the facility did not have consultation with R29's physician when scheduled pain medications were not being administered and the development of R29's stage 1 pressure ulcer to the coccyx. Findings Include: The facility's policy Change in a Resident's Condition or Status for Residents dated 12/2016 and last revised on 2/2022 documents: .Policy Statement Our community shall promptly notify the Resident, his or her health care provider, and representative of changes in the Resident's medical/mental condition and/or status\. Policy Interpretation and Implementation A. The nurse will notify the Resident's Health care provider or physician on call when there has bee a(an): 1. accident or incident involving the resident 2. discovery of injuries of an unknown source 3. adverse reaction to medication 4. significant change…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 1 (R29) of 1 Residents with an injury of unknown origin was reported to the State Survey Agency. *Bruising to R29's left eye and left breast was noted on 5/2/24. On 5/16/24, bruising to the right eye, right foot, and a laceration between the right great toe and second toe is noted. R29's x ray documents that R29's right great toe is fractured and R29 required 2 stitches between the right great toe and second toe. The facility did not report the injuries of unknown origin from 5/2/24 and 5/16/24. Findings Include: The facility's policy Abuse Investigation and Reporting for Residents dated 9/2017 and last revised on 11/2023 documents: .Policy Statement All reports of Resident abuse, neglect, exploitation, misappropriation of Resident property, mistreatment, electronic mail, social media, videotaping, photographing, and other imaging of Residents, and/or injuries of unknown source(abuse) shall be promptly reported to local, state, and federal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 allegation involving potential abuse, neglect, and misappropriation of Resident property were thoroughly investigated for 1 (R29) of 4 reported events to the state survey agency. *Bruising to R29's left eye and left breast was noted on 5/2/24. On 5/16/24, bruising to the right eye, right foot, and a laceration between the right great toe and second toe is noted. R29's x ray documents that R29's right great toe is fractured and R29 requires 2 stitches between the right great toe and second toe. The facility did not report the injuries of unknown origin from 5/2/24 and 5/16/24 and a thorough investigation of the injuries was not completed. Findings Include: The facility's policy Abuse Investigation and Reporting for Residents dated 9/2017 and last revised on 11/2023 documents: .Policy Statement All reports of Resident abuse, neglect, exploitation, misappropriation of Resident property, mistreatment, electronic mail, social media,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews, facility document review, and review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, it was determined that the facility failed to complete a comprehensive annual Minimum Data Set (MDS) assessment for 2 (R18 and R21) of 12 Residents reviewed for RAI regulatory timeframe's. *R18's Annual MDS was due 5/15/24, and was not completed and submitted until 7/18/24, during the recertification survey. *R21's Annual MDS was due 5/8/24, and was not completed and submitted until 7/15/24, during the recertification survey Findings included: A review of the Centers for Medicare & Medicaid Services [CMS] Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, dated October 2019, revealed an annual assessment is a comprehensive assessment for a resident that must be completed on an annual basis (at least every 366 days). The RAI Manual specified the MDS completion date must be no later…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (R315) of 2 residents reviewed with an indwelling catheter received appropriate treatment and were provided dignity. Surveyor had several observations during survey of R315's catheter bag not covered in a privacy bag and was visible from the hallway. R315's care plan was not revised to indicate if R315 did not mind if R315's catheter bag was visible to others. Findings include: R315 was admitted to the facility on [DATE] and has diagnoses that include encounter for surgical after care (placement of urostomy) following surgery on the digestive system, bowel obstruction, ESBL (extended spectrum beta-lactamase) infection, and weakness. R315's baseline care plan initiated on 7/12/2024 indicated R315 had intact cognition with a Brief Interview of Mental Status (BIMS) score of 15. R315 used a wheeled walker and limited assist of 1 staff member for transferring, mobility, and toileting. R315 was admitted with a urostomy and right arm PICC…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 necessary services to provide respiratory care were consistent with professional standards of practice for 1 (R11) of 2 residents reviewed for respiratory care. R11's oxygen tubing was not labeled during survey. On 7/17/2024 R11's oxygen humidification was dry/empty. Findings include: The facility policy, entitled PROCEDURE: Oxygen Administration, last approved 12/2022, documents: Purpose- The purpose of this procedure is to provide guidelines for safe oxygen administration.Steps in the Procedure- . K. Check the mask, tank, humidifying jar, etc., to be sure they are in good working order and are securely fastened. Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through. L. Label and date the humidifier bottle and oxygen tubing. N. Periodically re-check water level I the humidifying jar. R11 was admitted to the facility on [DATE] and has diagnoses that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure that 1 (R29) of 2 Residents reviewed for pain management received pain management consistent with professional standards of practice and Resident choice related to pain management. R29 was admitted to hospice on 4/24/23. R29 did not receive requested and prescribed pain medication as scheduled during a time that R29 had a right great toe fracture and a right distal femur fracture. Findings Include: The facility was unable to provide a policy and procedure in regards to pain management. R29 was admitted to the facility on [DATE] with diagnoses of Heart Failure, Anemia, Unspecified Dementia and Anxiety Disorder. R29 has an activated Health Care Power of Attorney (HCPOA) effective 9/16/2019. R29 has been receiving hospice service since 4/24/23. R29's Annual Minimum Data Set (MDS) dated [DATE] documents R29 has short and long term memory impairment and demonstrates severely impaired skills for daily decision making. R29's MDS also documents that R29 is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure 1 (R5) of 5 residents did not receive unnecessary psychotropic medications. R5 has an order for Ativan 0.5 mg every eight hours as needed. There is no stop date and no documented rationale from the physician as to why it is appropriate to extend the PRN (as needed) order past 14 days. Findings include: The facility's policy titled, Psychotropic Medication last revised 11/2022 under Policy Interpretation and Implementation documents: N. The need for continued PRN (as needed) orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The specific duration of the PRN order will be indicated in the order. O. PRN orders for psychotropic medications will not be renewed beyond 14 days unless the health care practitioner has evaluated the resident for the appropriateness of that medication. R5 was admitted to the facility on [DATE] with diagnoses which include multiple sclerosis,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assist 1 (R29) of 1 resident reviewed for obtaining routine dental care. R29 has very few teeth, most are black in color and was not offered and did not receive dental services, resulting in being on a mechanically soft altered diet with tube feeding. Findings Include: The facility's policy Dental Services for Residents dated 6/2016 and last revised on 9/2018 documents: .Policy Statement Routine and emergency dental services are available to meet the Resident's oral health services in accordance with the Resident's evaluation and plan of care. Policy Interpretation and Implementation 1. Oral health services are available to meet the Resident's needs. 3. Our community has a contract with a dentist that comes to the community and provides dental services. 4. Dental services are under the supervision of a licensed dentist retained by this community. 8. A complete record of the Resident's dental care and services are maintained in accordance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility did not provide special assistive eating equipment for 1 of 1 sampled resident (R40) reviewed for assistive devices. R40 did not receive special assistive devices needed for assistance when consuming meals to maintain or improve their ability to eat or drink independently. Findings include: R40 was originally admitted to the facility on [DATE]. R40's medical diagnosis include: Parkinson's Disease, weakness, protein-calorie malnutrition, and Dysphasia. Surveyor reviewed R40's most recent comprehensive Minimum Data Set (MDS), dated [DATE], which documents the following: R40 has a Brief Interview for Mental Status (BIMS) score of 15, which identifies R40 as being cognitively intact. R40 requires partial to moderate assistance with eating. R40 had a recent prolonged hospitalization from 03/24/24 through 05/10/2024 and was again hospitalized from [DATE] through 06/14/2024. Surveyor reviewed a document titled: nutrition risk assessment, signed on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the Facility did not ensure hospice services were coordinated for 2 (R5 & R29) of 2 residents reviewed for hospice. * Hospice visit notes were not kept in R5's medical record or in R5's hospice binder which was located in the nurses station. * R29's recertification was not complete and there was not list of assigned staff from hospice with contact information. There is not a designated facility liaison with hospice. Findings include: The facility's policy titled, Hospice Program last revised 12/2017 under Policy Interpretation and Implementation documents: D. When a resident participates in the hospice program, a coordinated plan of care between the community, hospice agency and resident/representative 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 resident's current status. 1.) R5 was admitted to the facility on [DATE] with diagnoses which include…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure pharmaceutical services including accurate acquiring and administering of medications to meet the needs of each Resident for 1 (R8) of 3 Residents reviewed. R8 returned to the facility from the emergency room (ER) on 2/24/24 with a MD (Medical Doctor) order for Ciprofloxacin HCL (an antibiotic medication used to treat infection) to be given 2 times a day for 10 days. R8 did not receive the morning dose of Ciprofloxacin (Cipro) on 2/25/24. On the morning of 2/26/24, the nurse caring for R8 was an agency nurse and did not have access to the Cubex (automated medication dispensing system) where they could have retrieved the necessary medication. R8 did not receive the morning dose of Cipro on 2/26/24. Findings include: The facility policy, entitled Administering Medications, with a revision date of 12/2021, states, in part: Medications shall be administered in a safe and timely manner, and as prescribed . Medications shall be administered in accordance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for 1 (R2) of 5 residents reviewed for weights. R2's weight was not being monitored according to facility policy or dietary technician and R2's edema was not consistently monitored to see if edema was getting worse. Findings include: The facility policy entitled Weight Monitoring revised on 1/2023 states: It is the policy of [Facility Name] that appropriate nutritional care shall be provided to residents who have significant weight change. A significant weight change is identified as a weight loss or gain of 5% in 30 days, 7.5% in 90 days, or 10% in 180 days. Policy Interpretation and Implementation: A. Each resident should be weighed daily for the first three days of admission, weekly for the first four…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents who are fed by enteral means received the appropriate treatment to prevent complications of enteral feeding for 1 (R4) of 2 residents reviewed for receiving enteral feeding. R4 received a bolus tube feeding and the gastrostomy tube (G tube) was not checked for placement prior to the feeding. Findings: The facility policy and procedure entitled Procedure: Enteral Feeding - Safety Precautions dated 1/2024 states: . Preventing aspiration: A. Check enteral tube placement prior to each feeding and administration of medication. R4 was admitted to the facility on [DATE] with diagnoses of cancer of the oropharynx resulting in getting the majority of nutrition through a G-tube with some oral intake, depression, dementia, Wernicke's encephalopathy, anxiety, and renal cancer. R4's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R4 was severely cognitively impaired; receives tube feeding and a mechanically altered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the Facility did not ensure 2 (CNA-S and CNA-T) of 5 randomly sampled CNAs (Certified Nursing Assistant), who are currently employed, had documented annual performance evaluations. This deficient practice has the potential to affect all 53 residents residing in the facility. Findings Include: On 1/17/23, CNA-S and CNA-T's performance evaluations were requested. CNA-S was hired 11/15/23 and did not complete any required performance evaluations, such as dementia training and abuse prevention training. CNA-T was hired on 2/4/19 and did not complete any required annual performance evaluations, such as dementia training and abuse prevention training. On 1/17/24, at 11:00 a.m., Surveyor asked Nursing Home Administrator (NHA)-A if there were any more training or in-services conducted because CNA-S and CNA-T did not have their required evaluations completed. NHA-A stated he would look for more. On 1/17/24, at 12:00 p.m. NHA-A stated he understands the concern but did not have any additional information.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, and record review, the facility did not ensure appropriate and safe administration of medication for 1 Resident (R) (R3) of 10 sampled residents. On 10/3/23, Surveyor observed Certified Nursing Assistant (CNA)-G apply topical Hydrocortisone (a medication used to treat skin conditions) on R3. In addition, R3 kept the Hydrocortisone in a bag on R3's bed. R3 did not have a physician's order for Hydrocortisone. Findings include: The facility's Administering Medications policy, last revised on 12/2021, indicates: Medications shall be administered in a safe and timely manner, and as prescribed .A. Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so .C. Medications shall be administered in accordance with the orders .W. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the nurse assessment, has determined that they have the capacity to do…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, 22 errors occurred during 26 opportunities which resulted in a 84.6% medication error rate affecting 3 Residents (R) (R6, R7 and R8) of 3 residents observed during medication pass. R6's 8:00 AM medications (8 medications) were administered at 10:16 AM. R7's 8:00 AM medications (9 medications) were administered at 10:23 AM. R8's 8:00 AM medications (5 medications) were administered at 9:59 AM. Findings include: The facility's Administering Medications document, revised 12/2021, indicates: Medications shall be administered as ordered .The individual administering the medications must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. 1. On 10/4/23 at 10:16 AM, Surveyor observed Licensed Practical Nurse (LPN)-C administer the following medications to R6: Midodrine 5 mg…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, staff did not perform proper hand hygiene during the provision of cares for 2 Residents (R) (R3 and R1) of 3 residents. On 10/3/23, Certified Nursing Assistant (CNA)-G did not consistently perform hand hygiene during the provision of care for R3. On 10/5/23, CNA-E did not consistently perform hand hygiene during the provision of care for R3. On 10/4/23, CNA-D did not consistently perform hand hygiene during the provision of care for R1. Findings include: The facility's Hand Hygiene policy, last revised on 5/2023, indicates: This community considers hand hygiene the single most important practice to prevent infections and promote resident safety. Evidence based hand hygiene guidance is practiced to reduce the risk of transmission of pathogenic microorganisms to residents, associates, and visitors .A. Associates are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policy review, it was determined the facility failed to implement their facility policy and procedure to safeguard residents from abuse by monitoring visitation for 1 (R118) of 3 residents who was previously abused by a visitor. Findings included: Review of the facility's policy, titled, Abuse Prevention, last revised in June 2020, indicated, Ensure the health and safety of each resident with regard to visitors such as family members or resident representatives, friends or other individuals subject to the resident's right to deny or withdraw consent at any time and to reasonable clinical and safety restrictions. The policy indicated in the section titled, Reporting/Response, that the facility would, D. Implement interventions as a result of the investigation. In the section titled, Monitoring and Follow Up, the policy indicated, A. Monitoring, documentation and applicable interventions will be completed by clinical associates. Review of R118's Profile Face Sheet indicated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews, facility document review, and review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, it was determined that the facility failed to complete a comprehensive annual Minimum Data Set (MDS) assessment for 1 (R32) of 22 residents reviewed for RAI regulatory timeframe's. Findings included: A review of the Centers for Medicare & Medicaid Services [CMS] Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, dated October 2019, revealed an annual assessment is a comprehensive assessment for a resident that must be completed on an annual basis (at least every 366 days). The RAI Manual specified the MDS completion date must be no later than 14 days after the ARD [Assessment Reference Date] (ARD + 14 calendar days). A review of the facility's Incomplete MDS List for the time period of 03/01/2022 through 03/31/2023 revealed R32's comprehensive annual MDS assessment, with an ARD of 02/22/2023, was not completed until 03/30/2023, which was 36 days after…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews, and review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, it was determined that the facility failed to complete a significant change in status Minimum Data Set (MDS) assessment for 1 (R275) of 22 residents reviewed for RAI regulatory timeframe's. Findings included: A review of the Centers for Medicare & Medicaid Services [CMS] Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, dated October 2019, revealed a significant change in status MDS assessment is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD [Assessment Reference Date] must be within 14 days from the effective date of the hospice election. A review of R275's Profile Face Sheet revealed the facility admitted the resident with diagnoses which included multiple sclerosis and severe protein-calorie…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews, facility document review, and review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, it was determined that the facility failed to complete quarterly Minimum Data Set (MDS) assessments for 2 (R12 and R47) of 22 residents reviewed for RAI regulatory timeframe's. Findings included: A review of the Centers for Medicare & Medicaid Services [CMS] Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, dated October 2019, revealed a quarterly assessment is a non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA [Omnibus Budget Reconciliation Act] assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. The RAI Manual specified the MDS completion date must be no later than 14 days after the ARD [Assessment Reference Date] (ARD + 14 calendar days). A review 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, interview, and record review, the facility failed to provide timely incontinence care and fingernail care for 2 (R8 and R36) of 5 sampled residents reviewed for activities of daily living (ADL) care. Findings included: On 04/01/2023 at 8:29 AM, facility policies addressing nail care, frequency of incontinence care, and ADLs were requested. The Administrator-A stated the facility did not have policies addressing these areas. 1. A review of R8's Profile Face Sheet indicated the facility admitted R8 with diagnoses that included acute and chronic respiratory failure with hypoxia, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), hypertension, and anemia. A review of R8's admission Minimum Data Set (MDS), dated [DATE], revealed R8 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The resident required extensive assistance of one staff member for bed mobility, dressing, and toilet use. The resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, interviews, and facility policy review, it was determined the facility failed to ensure physician-ordered medications were provided by the pharmacy and available for administration for 2 (R6 and R274) of 7 residents reviewed for medication administration. Findings included: A review of the facility policy, titled, Medication Administration, with an effective date of 06/21/2017, indicated, 9. If a medication is unavailable, contact the pharmacy and document accordingly. 1. A review of the Profile Face Sheet indicated the facility admitted R6 with diagnoses that included a displaced spiral fracture of the left femur, type 2 diabetes mellitus, chronic kidney disease, restless leg syndrome, and weakness. A review of the admission Minimum Data Set (MDS) dated [DATE], indicated R6 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. According to the MDS, R6 received scheduled and as needed pain medication. A review 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 observations, interviews, record reviews, and facility policy review, it was determined the facility failed to maintain a medication error rate of 5% or less for 2 (R6 and R26) of 7 residents observed during medication administration. Observation of medication passes revealed two medication errors out of 26 opportunities, which resulted in a medication error rate of 7.69%. Findings included: A review of a facility policy titled, Medication Administration Policy - 5.3 General Guidelines for Medication Administration, dated of 06/21/2017, revealed, Medication will be administered by legally authorized and trained persons in accordance to [sic] applicable State, Local and Federal laws and consistent with accepted standards of practice. Step 4 of the Procedure section of the policy indicated, Read the label comparing to the MAR [Medication Administration Record] before preparing the medication. If the medication is discontinued or outdated, remove medication for proper disposal. Facility should follow any State specific regulatory requirements in regard [sic] 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.