Ingleside Manor

Based on observation, interview, and record review, the facility did not provide food that accommodates resident preferences; appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice for 1 of 18 sampled resident's (R19). R19 was known to be a vegetarian and was not given foods of similar nutritive value to replace the meat options on the menu to maintain his assessed protein goals.Evidenced by:R19 was admitted to the facility from the hospital on 6/3/25 with diagnoses of cerebral infarction, type 2 diabetes, and congestive heart failure. His most recent MDS (Minimum Data Set), dated 9/8/25 includes a BIMS (Brief Interview for Mental Status) score of 15, indicating he is cognitively intact. R19 has physician's orders, dated 6/4/25, for a vegetarian diet, no dairy.R19's nutrition care plan states, Problem: Resident has potential for alteration in nutritional status related to diagnoses, medications, fluid balance, diet, intake, physical activity and metabolic demands.Goals: Maintain weight at 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 hospice collaboration and communication processes were established to ensure continuity of care between hospice and the facility for 1 of 1 resident (R28) reviewed for hospice.R28's current hospice plan of care and visit notes were not available to facility staff.The facility did not designate a staff member to coordinate the plan of care with the hospice provider.This is evidenced by: The facility's Hospice Program policy, revised July 2017, states, in part: .9. In general, it is the responsibility of the hospice to manage the resident's care as it relates to the terminal illness and related conditions. 10. In general, it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative and ensure that the level of care provided is appropriately based on the individual resident's needs. d. Communicating with the hospice provider (and documenting such communication) to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not identify issues to which quality assessment and assurance activities are necessary or develop and implement appropriate plans of action to correct identified quality deficiencies for 2 of 2 Residents (R28 & R4). The facility has failed to identify key areas of deficient practice and implement action plans to correct these deficient practices or identify areas needing improvement to develop, implement, monitor, and evaluate action plans to achieve specific goals to improve quality of care for Pressure Injury care and prevention.Evidenced by:The facility's Quality Assurance and Performance Improvement (QAPI) Program-Feedback, Data, and Monitoring policy, dated March 2020, states, in part: The QAPI program is based on the collection of information obtained from data, self assessment and systems of feedback. Information is collected, evaluated and monitored by the QAPI committee. 1. Information obtained about the quality of care and services delivered to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated, or the resident has already been immunized for 2 of 5 residents (R9 and R2) reviewed for immunizations.R9 and R2 were not offered pneumococcal vaccination.Evidenced by:The facility's Pneumococcal Vaccine policy, dated 2001, states, in part: All residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. 1. Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered the vaccine series within 30 days of admission to the facility unless medically contraindicated or the resident has completed the current recommended vaccine series. 2. Routine vaccination consists of the following: a. If the resident has not previously received a dose of PCV13, PCV15, PCV20, or PCV21 or whose previous vaccination history is unknown: 1 dose of…

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

Based on observation, interview and record review, the facility did not ensure each resident had a safe, clean, comfortable, and homelike environment or ensure housekeeping provided necessary services to maintain a sanitary, orderly, and comfortable area for 4 of 4 residents (R6, R4, R12 and R13) reviewed for cleanly environment. R6's room had dried substances and crumbs on the floor and staff identified fecal matter on the outside of the toilet in R6's bathroom. R4 indicates staff come in to clean her room once a week if she is lucky. R12's room was observed to be unclean. R13's room was observed to be unclean. This is evidenced by: The facility policy titled, Cleaning and Disinfecting Residents' Rooms, dated August 2013, states in part… Purpose: The purpose of this procedure is to provide guidelines for cleaning and disinfecting residents' rooms. General Guidelines: 1. Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. 2. Environmental surfaces will be disinfected (or cleaned) on a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure the provision of pharmaceutical services (including procedures that assure that accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 5 out of 16 sampled residents (R14, R9, R6, R3, & R17). R14 did not receive scheduled medications for 8:00 AM & 2:00 PM on 8/28/25 due to the facility's internet being down. R9 did not receive scheduled medication for 4:00 PM on 8/28/25 due to the facility's internet being down. R3 did not receive all of her medications as ordered on 8/20/25, 8/21/25, 8/22/25, 8/23/25, 9/8/25. R17 had medications not administered as ordered. R6 did not receive her 9/11/25 medications within the allowed time frame. Evidenced by: The facility policy titled, “Medication Errors”, dated 9/1/10, states, in part: “… 3. Dispensing errors:… 3.1 Data entry error: Entire order or part of an order was incorrectly entered into computer system by data entry. 3.2 Delivery…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility did not ensure each Resident is treated with dignity and respect that promoted maintenance or enhancement of quality of life for 1 of 1 residents (R6) reviewed for choices.R6 expressed she chooses to eat in the dining room and the facility did not ensure R6's choices were honored.This is evidenced by:The facility's policy titled Resident Rights, version 2/21, includes: Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: e. self-determination; f. communication with and access to people and services, both inside and outside the facility; h. be supported by the facility in exercising his or her rights;The facility's policy titled Care Plans, Comprehensive Person-Centered, revised 3/22, includes: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure each resident received care, consistent with professional standards of practice, to prevent pressure injuries (PI) for 1 of 1 Residents (R6) reviewed for pressure injuries.R6 has a stage 2 pressure injury and pressure injury prevention devices were observed not in place.This is evidenced by:The facility's policy Prevention of Pressure Injuries, dated 4/20, includes: The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Use a standardized pressure injury screening tool to determine and document risk factors. Select appropriate support surfaces based [sic] the resident's risk factors, in accordance with current clinical practice.The facility's policy Pressure Ulcers/Skin Breakdown - Clinical Protocol, dated 4/18, includes: The nursing staff and practitioner will assess and document an individual's significant risk factors for…

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

Based on observation, interview, and record review, the facility did not ensure that a resident with urinary catheters receive appropriate treatment and services for 1 of 1 residents (R6) reviewed for catheters as catheter bags were observed resting on the floor.Surveyor observed R6's urinary catheter bag resting on the floor.This is evidenced by:The facility's policy titled Catheter Care, Urinary, dated 9/14, includes: The purpose of this procedure is to prevent catheter-associated urinary tract infections. Infection control 2. b. Be sure the catheter tubing and drainage bag are kept off the floor.R6's active physician orders, dated 9/11/25, include: SP Catheter (Suprapubic Catheter, a thin, flexible tube inserted directly into the bladder through a small incision in the lower abdomen): cleanse daily with mild soap and water; pat dry with soft towel.R6's resident profile sheet, printed 9/11/25, is used by the CNAs (Certified Nursing Assistant) and includes: indwelling catheter: do not allow tubing or any part of the drainage system to touch the floor.R6's comprehensive care plan,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not provide behavioral health services to ensure a resident received the highest practicable mental and psychosocial well-being. The facility did not create a comprehensive assessment and plan of care to address a substance use disorder (SUD) for 1 of 1 residents (R17) reviewed for SUDs and 1 of 1 Residents reviewed for suicidal ideations (R1). R17 has a SUD. The facility failed to create a care plan related to R17's alcohol consumption and failed to implement interventions for behaviors associated with R17's alcohol consumption. R1's record indicates R1 had a history of suicidal ideation and suicidal attempts. The facility did not develop a Plan of Care with goals and interventions for R1's history of suicidal attempts and ideations. The facility did not have any precautions or monitoring in place related to R1's suicidal ideations and suicidal attempts. This is evidenced by: Surveyor requested a substance abuse policy from the facility. On 9/15/25 at 3:25…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure residents are free of any significant medication errors for 2 of 17 Residents (R14 & R3) reviewed for medications. R14 had 2 seizure medications not administered on 8/28/25 due to the facility's internet being down. R3 did not receive all of her medications as ordered on 8/20/25, 8/21/25, 8/22/25, 8/23/25, and 9/5/25 This is evidenced by: The facility policy entitled, “Administering Medications,” dated 4/2019, states, in part: … “Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: … 4. Medications are administered in accordance with prescriber orders, including any required time frame… 6. Medication errors are documented, reported… 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified…” The facility policy entitled, “Medication Errors,” dated 9/1/2010, states, in part: … “Applicability: This section 10.1 sets forth…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 effective pest control in the facility dining area, hallways and resident rooms for 8 of 10 sampled residents (R4, R6, R11, R12, R13, R14, R15 and R16). Residents voiced concerns with flies in the facility. Surveyor made observation of 6 flies on R4's left lower leg while interviewing R4. Evidenced by: The facility policy, entitled Pest Control, dated 2023, states, in part: . Policy Statement: Our facility shall maintain an effective pest control program. Policy Interpretation and Implementation: 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. 2. Pest control services are provided by Professional Pest Control monthly and as needed. 6. Maintenance services assist, when appropriate and necessary, in providing pest control services. Example 1 R4 admitted to the facility on [DATE] and has diagnoses that include cellulitis of left lower limb (a common 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 immediately notify and consult with a resident's physician when there was a significant change in condition. This occurred for 1 of 10 residents (R9) reviewed for notification of change in condition.R9 had blood sugars above the ordered parameter of 350 without notification of a physician. This is evidenced by: The facility's policy titled Medication and Treatment Orders, revised in July 2016 states in part, Policy Statement: Orders for medications and treatments will be consistent with principles of safe and effective order writing. Policy Interpretations and Implementation: .9. Orders for medications must include: a. name and strength of the drug; b. number of doses, start and stop date, and/or specific duration of therapy; c. dosage and frequency of administration; d. route of administration; e. clinical condition or symptoms for which medication is prescribed; and f. any interim follow-up requirements (pending culture and sensitivity reports, repeat…

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

Based on interview and record review, the facility did not ensure that all alleged violations involving misappropriation of resident property are reported immediately to the administrator of the facility in accordance with State law for 1 of 1 allegation reviewed.LPN H (Licensed Practical Nurse) did not report a suspicion of misappropriation of medication.As evidenced by:The facility's Loss or Theft of Medications policy, dated 9/1/10, states, in part: .Procedure 1. Where the community staff suspect theft or loss of medications, community staff should take such actions as required by Applicable Law and community policy. Appropriate actions should include, but not limited to: 1.1 Immediately reporting suspected theft or loss of medications to a supervisor/manager, the Director of Clinical Services or designee for appropriate investigation and follow-up.The facility's Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy, dated 9/2022, states, in part: .Reporting Allegation to the Administrator and Authorities 1. If resident 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 provide showering assistance for residents requiring assistance for 1 of 6 residents (R2) reviewed for showers.R2 did not receive weekly showers.This is evidenced by:The facility's policy titled Bath, Shower/Tub, dated 2/18, includes: The purpose of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Documentation 1. The date and time the shower/tub bath was performed. 2. The name and title of the individual(s) who assisted the resident with the shower/tub bath. 3. All assessment data (e.g., any reddened areas, sores, etc., on the resident's skin) obtained during the shower/tub bath. 4. How the resident tolerated the shower/tub bath. 5. If the resident refused the shower/tub bath, the reason(s).R2 admitted to the facility on [DATE] with diagnoses that include primary osteoarthritis of bilateral shoulders (arthritis that occurs when flexible tissue at the ends of bones wears…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 1 residents (R5) reviewed for bowel management.R5 was sent to hospital emergency department for constipation. Facility did not monitor bowels and perform abdominal assessments per facility protocol. Evidenced by:The facility's Bowel Management Protocol, undated, states, in part: 1. NOC (night shift) nurse will run the Resident Bowel Management Report in Matrix each NOC shift . 2. Identify all residents who have not had a bowel movement in the last 2 or more days and add them to the Nurse's Daily Bowel Report.5. Follow this procedure for residents with 2 or more days since last bowel movement Day #2 (number) No Bowel Movement-. Day #3 No Bowel Movement . -PM Nurse (evening shift) will complete a full bowel assessment and document a progress note in Matrix. -NOC Nurse will complete a full bowel assessment and administer bisacodyl (stimulant…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (R5) reviewed for falls.R5 was evaluated to be transferred with 2 assist and [NAME]-Steady (transfer device) and was transferred with 2 assist (with no device). Evidenced by:The facility's Safe Lifting and Movement of Residents policy, dated 7/2017, states, in part: In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. 1. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents.3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan.R5 admitted to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility did not ensure residents with G-Tubes (gastrostomy feeding tube) were assisted with nutrition and hydration for 1 of 3 Residents (R2) reviewed for nutritional status.R2 did not receive his G-Tube feeding as ordered.This is evidenced by:The facility policy titled Enteral Tube feeding via Gravity Bag, dated11/18, includes: The purpose of this procedure is to provide nourishment to the resident who is unable to obtain nourishment orally. 1. Verify that there is a physician's order for this procedure. 3. Check the following information: a. Resident name, ID and room number. b. Type of formula. f. Method (pump, gravity, syringe). 5. Check the order to verify the type, amount, method and rate of administration. 9. When correct tube placement has been verified, flush tubing with at least 30 ml warm water (or prescribed amount). 5. Unless otherwise ordered, follow the feeing with 30 -60 ml of warm water. Documentation The person performing this procedure should record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure residents were seen by a physician every 30 days for the first 90 days after admission and every 60 days thereafter for 1 of 15 resident (R4) reviewed. R4 was not seen by a physician once every 30 days for the first 90 days after admission.Evidenced by:The facility policy, entitled Physician Services, dated 2/21, states, in part: . Policy Statement: The medical care of each resident is supervised by a licensed physician.Policy Interpretation and Implementation: .7. Physician visits, frequency of visits, emergency care of residents, etc. are provided in accordance with current OBRA (Omnibus Budget Reconciliation Act) regulations and facility policy. According to OBRA '87, OBRA regulations mandate specific frequencies for physician visits in nursing homes. A resident's attending physician must conduct an initial comprehensive visit within 30 days of admission. Following this, visits must occur at least every 30 days for the first 90 days, and then…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 7 residents (R5 and R10) reviewed for medications.R5 had medications not administered as orderedR10 had medications not administered as ordered This is evidenced by:The facility's policy titled Providing Pharmacy Products and Services, revised on 6/1/2018, states in part: .1. The Pharmacy will provide the community with a community-specific information sheet that details how community staff can contact the Pharmacy twenty-four (24) hours a day, seven (7) days a week.The facility's policy titled Medication Errors, revised on 9/1/10, states in part: .Omission error: Community fails to administer an ordered dose to the resident, unless refused by the resident or not administered because of a recognized contraindication.The facility's policy titled General…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure residents are free of any significant medication errors for 1 of 7 residents (R8) reviewed for medications.The facility did not ensure R8 was provided all doses of her buprenorphine-naloxone (combination medication used to treat opioid addiction) and her cephazolin (antibiotic). This is evidenced by: The facility's policy titled Providing Pharmacy Products and Services, revised on 6/1/2018, states in part: .1. The Pharmacy will provide the community with a community-specific information sheet that details how community staff can contact the Pharmacy twenty-four (24) hours a day, seven (7) days a week.The facility's policy titled Medication Errors, revised on 9/1/10, states in part: .Omission error: Community fails to administer an ordered dose to the resident, unless refused by the resident or not administered because of a recognized contraindication.The facility's policy titled Medication and Treatment Orders, revised in July 2016, states in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility has not established an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 Residents (R4 & R15) of 2 opportunities for hand hygiene. Staff did not perform proper hand hygiene per standards of practice during wound care on R4. CNA K had a breach in infection control when performing pericare (cleansing of the genital area). Evidenced by: The facility policy entitled “Handwashing/Hand Hygiene,” undated, states, in part: … “Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Policy Interpretation and Implementation: -Administrative Practices to Promote Hand Hygiene: 2. All personal are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors……

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 facility crash cart was checked by facility staff to ensure appropriate BLS (Basic Life Support) could be provided to any resident requiring such care prior to arrival of emergency medical personnel in accordance with current standards of practice for 2 of 2 crash carts with the potential to effect 34 of 34 full code (R) residents residing in the facility. The facility did not ensure the necessary supplies and equipment were readily available for residents of the facility who have chosen to receive basic life support if needed. Evidenced by:The facility was not able to provide a crash cart policy. On [DATE] at 11:22AM Surveyor interviewed LPN L (Licensed Practical Nurse). During the interview LPN L indicated that the crash cart was found to be locked during a recent incident when EMS (Emergency Medical Services) were in the building. LPN L indicated that she was walking down the hall with the DON (Director of Nursing) who told…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 failed to complete a performance review of every nurse aide at least every 12 months and failed to provide regular in-service education based on the outcome of these reviews for 5 of 5 staff for evaluations and 4 of 5 staff for education.All 5 staff chosen did not have performance evaluations completed every 12 months.Four of five staff did not have regular in-service education completed every 12 months.This is evidenced by:The Facility's 5.6 Performance Evaluation/Review Policy from the Employee Handbook, undated, documents in part: Performance evaluations/reviews are generally scheduled once a year based on the employee's anniversary date or upon change in assignments The Facility does not have a Policy or Procedure specific to required in-service education.In Wisconsin, CNA's (Certified Nursing Assistants) are required to complete 12 hours of continuing education annually. This requirement is part of maintaining active status on the Wisconsin Nurse Aide Registry. Example 1CNA CC was hired 8/7/13.CNA CC only had 9 of 12 required…

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

Based on interview and record review, the facility did not maintain a Quality Assessment and Assurance Committee consisting of at a minimum, the Director of Nursing Services, the Medical Director, or his/her designee, at least three other members of the facility's staff at least one of whom must be the administrator, owner, a board member or other individual in a leadership role, and the Infection Preventionist, which met at least quarterly. This has the potential to affect all 48 Residents residing within the facility. Quality Assurance and Performance Improvement (QAPI) meetings did not consist of the required attendees/members for the months of June 2024 and July 2025. Two of the meetings over the last 4 quarters did not occur within the appropriate timeframe.This is evidenced by:The facility policy, entitled Quality Assurance and Performance Improvement (QAPI) Program - Governance and Leadership, revised March 2020, states, in part: .6. The following individuals serve on the committee: a. Administrator or a designee who is in a leadership role; b. Director of Nursing Services;…

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

Based on interview and record review the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 3 of 5 reportable incidents.R6 eloped from the facility on 6/6/25, this was not reported to the State Agency.R18 and R2 had a resident-to-resident altercation on //25, this was not reported to the State Agency.R18 and R19 had a resident-to-resident altercation on //25, this was not reported to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that all alleged violations are thoroughly investigated and report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken this affected 2 of 4 investigations (R18 and R2, R18 and R19) reviewed.There is no investigation for the resident-to-resident altercation between R18 and R2.There is no investigation for the resident-to-resident altercation between R18 and R19.This is evidenced by:The Facilities Policy and Procedure entitled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating dated September 2022 documents in part: .1. All allegations are thoroughly investigated. The administrator initiates investigations .4. The administrator is responsible for keeping the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure residents who receiving nutrition and medication by G-tube (Gastrostomy tube, a thin flexible tube inserted through a small incision in the abdomen and into the stomach, used to provide nutrition and fluids) receive the appropriate treatment and services 3 of 4 Residents reviewed for tube feedings (R15, R16 and R17).R15 has a G-tube (Gastronomy tube) is not being checked for placement prior to use.R16 has a G-tube that is not being checked for placement prior to use.R17 has a G-tube that is not being checked for placement prior to use. Evidenced by:Facility policy entitled 'Confirming Placement of Feeding tubes,' states in part: .The purpose of this procedure is to ensure proper placement of an existing feeding tube prior to administering enteral feedings or medication. Preparation 1. Verify that there is a physician's order for this procedure. 2. Verify that placement of the feeding tube was confirmed by x-ray upon initial insertion…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized for 1 of 1 sampled residents (R7) for change of condition.R7's medical record is missing documentation of her change of condition and subsequent passing away on 6/19/25. R18 has no nursing documentation following suicidal ideations documented by Activities.R19 has no documentation regarding the resident-to-resident altercation with R18.Evidenced by:The Facility policy Charting and Documentation, indicates, in part: Policy Statement: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation 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, interview, and policy review, the facility failed to ensure a resident's safety during a transfer when one Resident (R1) of three residents reviewed for accidents sustained a minor injury after falling out of a Hoyer lift during a transfer. Findings include: Review of R1's Face Sheet, located in resident's electronic medical record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses which included acute respiratory failure with hypercapnia. Review of R1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/07/25 and located in the resident's EMR under the MDS tab, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had no cognitive impairment. Review of R1's Care Plan, dated 01/29/24 and located in the resident's EMR under the Care Plan tab, revealed The resident has an ADL [activities of daily living] selfcare…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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, record review, and policy review the facility failed to notify hospice and the resident's representative timely with a change in condition for 1 of 12 sampled residents (R4). R4 had a change in condition evidenced by a change in her eating habits, this was not communicated to hospice or R4's representative. Findings include: Review of the facility's ''Acute Condition Changes - Clinical Protocol'' policy, revised February 2021, revealed, ''Direct care staff, including nursing assistants will be trained in recognizing subtle but significant changes in the resident (for example, a decrease in food intake, .) and how to communicate these changes to the Nurse.'' Review of the facility's ''Change in a Resident's Condition or Status'' policy, revised February 2021, revealed, ''The nurse will notify the resident's attending physician or physician on call when there has been a(an): . significant change in the resident's physical/emotional/mental condition; . refusal of treatment or medications two…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 facility policy review, the facility failed to ensure a resident-to-resident abuse allegation was reported to the administration and the State Agency within two hours for an allegation involving 2 of 12 sampled Residents (R1 & R2). An allegation of resident to resident abuse between R1 and R2 was not reported within the required timeframe. Findings include: Review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating revised September 2022 revealed, If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law . 'Immediately' is defined as: within two hours of an allegation involving abuse . Review of the Face Sheet tab located in the electronic medical record (EMR) revealed R1 was admitted to the facility on [DATE]. R1 had diagnoses including…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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, record review, and facility policy review, the facility failed to interview all staff who may have had knowledge of a resident-to-resident abuse allegation involving 2 of 12 sampled Residents (R1 & R2). Facility did not thoroughly investigate a resident-to-resident abuse allegation involving R1 and R2. Findings include: Review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating revised September 2022 revealed, All allegations are thoroughly investigated. The administrator initiates investigations . The individual conducting the investigation as a minimum: . interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; . documents the investigation completely and thoroughly. Review of the Face Sheet tab, located in the electronic medical record (EMR), revealed R1 was admitted to the facility on [DATE]. R1 had diagnoses including metabolic encephalopathy (condition in which…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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, interview, and facility policy review, the facility failed to administer medications as scheduled for 1 of 12 Residents (R3) reviewed for medication administration. R3's medications were documented as not being administered and/or documented as being administered late. Findings include: Review of the facility's Administering Medications policy, dated April 2019, revealed Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions and Medications are administered in accordance with prescriber orders, including any required time frame. In addition, Medications are administered within one hour of their prescribed time, unless otherwise specified. Review of R3's Face Sheet tab in the electronic medical record (EMR) revealed she was admitted to the facility on [DATE]. R3 had diagnoses which included pulmonary hypertension, hypertension, and localized edema. Review of R3's quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure a medication error rate of 5% or less. During the medication administration task, Surveyors observed 18 errors out of 28 medication opportunities, resulting in an error rate of 64.28% This affected 3 out of 4 Residents (R) observed for medication administration (R10, R11 & R12). R10, R11 and R12 received their 8:00 AM medications more than an hour past their scheduled administration time. Evidenced by: Review of the facility's Administering Medications policy, dated April 2019, revealed Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions and Medications are administered in accordance with prescriber orders, including any required time frame. In addition, Medications are administered within one hour of their prescribed time, unless otherwise specified. Example 1: Review of R10's Face Sheet tab of the EMR revealed she was admitted to the facility on [DATE] and had diagnoses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that the ice machine was cleaned and disinfected properly. This has the potential to affect all 56 residents. On 7/8/24, Surveyor observed a layer of black film on the inside of the ice machine lid. Evidenced by: Facility Ice Machine Policy dated 2/22 with last revision date of 1/24 states in part: Ice Machine and Equipment will be cleaned and sanitized on a regular basis .Maintenance will deep clean the ice machine quarterly and as needed . On 7/8/24 at 9:02 AM, during the initial tour of the kitchen, Surveyor and Dietary Manager (DM) F observed a layer of black film on the inside lid of the ice machine in the right-hand corner. DM F indicated that maintenance was responsible for cleaning the air filter, but she was unsure who was responsible for cleaning the ice machine itself. DM F stated that they do not contract with an outside source to clean the ice machine. On 7/10/24 at 9:09 AM, Surveyor interviewed Maintenance Director G, who indicated he was unsure if anyone comes and cleans out the ice machine…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that garbage and refuse was disposed of properly. This has the potential to affect all 56 residents. On 7/8/24, Surveyor observed garbage not properly contained in the dumpsters. Evidenced by: Facility Trash Disposal and Dumpster Area Policy dated 1/22 with last revision date of 1/24 states in part: Garbage will be disposed of as needed throughout the day and at the end of each day .Trash will be deposited into a sealed container outside the premises.The garbage storage area must be maintained in a sanitary condition to prevent the harborage and feeding of pests. Maintenance will routinely check the premises and keep the dumpster area free of debris . Example 1 On 7/8/24 at 9:02 AM, during the initial tour of the kitchen, Surveyor and Dietary Manager (DM) F observed the following outside, on the ground near the facility's main garbage dumpster: -Multiple used gloves. -Wet cardboard boxes . -A pile of food waste. -A tub of stagnant brown water. -Cigarette butts. -Packing peanuts and other miscellaneous…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 has not established an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This has the potential to affect all 56 residents (R) in the facility. The facility does not maintain a staff infection control line list for illnesses/infections other than Covid-19. The facility's policies have not been updated annually. This is Evidenced by: The Facility's provided the policy, Surveillance for Infections, with a reviewed date of 4/1/24, indicates, in part: Policy Statement - The infection preventionist will conduct ongoing surveillance for health-care associated infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other prefventative interventions. Policy Interpretation and Implementation - 1. The purpose of the surveillance of infections is to identify both…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure 2 (R19 and R25) of 16 sampled residents and 2 (R17 and R23) of 4 supplemental residents had a call light within reach or a means to call staff for assistance. Surveyor observed R19's and R23's call lights not within reach. R25 and R17 voiced concern that their call lights are not always within reach, making it difficult to call for staff assistance. Evidenced by: The facility policy titled, Call System, Residents, dated 9/23, states, in part; .Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station .1. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor . Example 1 R23 was admitted to the facility on [DATE] with a diagnoses including respiratory failure, unspecified dementia, anxiety disorder, chronic pain, cognitive communication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide a comfortable and homelike environment for 1 of 16 total sampled residents (R38) and 3 of 4 supplemental residents (R13, R27, and R17) reviewed. R38 voiced concern that the water in R38's bathroom is always cold. R38 indicated that R38 is not able to take a shower so his main form of washing up and showering is done at his bathroom sink. R13, R27, and R17 indicated that they have had cold showers and that the water in the shower room does not warm up. Evidenced by: The facility policy titled, Water Temperatures, Safety of, dated 12/2009, states, in part; .2. Maintenance staff is responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log . Example 1 R38 was admitted to the facility on [DATE] with a diagnoses including personal history of traumatic brain injury, adjustment disorder with mixed anxiety and depression, weakness, and difficulty in walking. R38's most…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 immediately consult with the resident's physician when there was a need to alter treatment for 2 of 7 residents (R49 and R18) reviewed for physician notification out of a total sample of 16 Residents. R49's provider was not notified of a positive urine culture and sensitivy result therefore delaying a treatment decision by the provider. R18 missed medications and R18's physician was not notifed. This is evidenced by: The facility's policy Lab and Diagnostic Test Results - Clinical Protocol with a review date of 11/27/23, indicates, in part: .Identifying Situations that Warrant Immediate Notification - 1. Nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic tests results: .Whether the result should be conveyed to a physician regardless of other circumstances (that is, the abnormal result is problematic regardless of any other factors). Whether 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 a comprehensive, person-centered care plan for 1 of 16 sampled Residents (R14) reviewed for person centered care plans. The facility failed to develop and implement a care plan that addressed monitoring for side effects such as bruising or bleeding for R14, who is taking Eliquis (Apixaban). Evidenced by: The facility's policy titled Care Plans, Comprehensive Person-Centered with a revision date of March 2022, states in part .3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment .7. The comprehensive, person-centered care plan: a. includes measurable objectives and time frames .e. reflects currently recognized standards of practice for problem areas and conditions . According to the Mayo Clinic, .Apixaban is used to treat or prevent deep venous thrombosis, a condition in which harmful blood clots form in the blood vessels of the legs. These blood clots can travel to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure a resident receives care, consistent with professional standards of practice to prevent pressure injury (PI) development for 1 of 2 residents reviewed for PIs out of a total sample of 16 residents (R49). R49 was assessed to be at risk for pressure injury on 4/28/24. The facility did not implement a repositioning plan. Evidenced by: The facility policy, entitled Pressure Ulcers/Skin Breakdown, dated April 2018, states, in part: Assessment and Recognition 1. The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcer(s) . Cause Identification 1. The physician will help identify factors contributing or predisposing residents to skin breakdown; for example, medical comorbidities such as diabetes or congestive heart failure, overall medical instability, cancer or sepsis causing a catabolic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure a resident maintains acceptable parameters of nutritional status and weight. This affected 1 of 3 Residents (R49) reviewed for nutrition and hydration out of a total sample of 16 residents. The facility failed to monitor R49's meal intake after R49 was assessed at risk for malnutrition and experienced weight loss. Evidenced by: The facility policy, titled, Weight Assessment and Intervention Policy, revised 2/2024, states, in part: Policy: Resident weights are monitored for undesirable or intended weight loss or gain. Procedure: 1. Residents are weighed upon admission and at intervals established by the interdisciplinary team. 2. Weights are recorded in the residents' vitals. 3. Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. 4. Unless notified of significant weight change, the Dietician will review the residents' weights monthly to follow individual weight trends over time. 5. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure all residents receive scheduled medications on time per physician orders for 1 (R18) of 14 residents reviewed for medications. R18 did not receive night time medications on 6/16/24. Evidenced by: The facility policy titled, Administering Medications, dated 4/19, states, in part; .Medications are administered in a safe and timely manner, and as prescribed. 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) . The facility policy titled, Documentation of Medication Administration, states, in part; .The facility shall maintain a medication administration record to document all medications administered .1. A nurse or certified medication aide (where applicable) shall document all medications administered to each resident on the resident's medication administration record (MAR) . R18 was admitted to the facility on [DATE] with a diagnoses including heart…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 drug regimes are free of unnecessary psychotropic medications, and that a resident taking a psychotropic medication has a care plan that includes targeted behaviors for 1 of 5 residents (R11) reviewed for unnecessary medications. R11 was started on Bupropion (antidepressant) for Other symptoms and signs involving cognitive functions and awareness, Quetiapine (antipsychotic) for Bipolar disorder, and Sertraline (antidepressant) for Bipolar Disorder and the care plan contained no behavior monitoring to assess the effectiveness of these medications, Evidenced by: The facility policy, entitled Psychotropic Medication Use, dated 7/2022, states, in part: Policy Statement. Residents will not receive medications that are not clinically indicated to treat a specific condition. Policy interpretation and Implementation. 1. A psychotropic medication is any medication that affects brain activity associated with mental processes. 2. Drugs in 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.

Based on observation, interview, and record review, the facility did not ensure that it was free of medication error rates of 5% or greater. There were 2 errors out of 25 opportunities that affected 1 out of 5 residents (R46) included in the medication pass task, which resulted in an error rate of 8%. RN D (Registered Nurse) did not administer R46's medications according to Physician orders. This is evidenced by: Facility policy entitled 'Adverse Consequence and Medication Errors,' states in part: 1. Residents receiving any medication that has a potential for an adverse consequence will be monitored to ensure that any such consequences are promptly identified and reported.4. The staff and practitioner shall strive to minimize adverse consequences by: a. following relevant clinical guidelines and manufacturer's specification for use, dose, administration, duration, and monitoring of the medication. B. defining appropriate indications for use; .5. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician'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 observation, interview, and record review, the facility did not ensure residents are free of significant medication errors for 2 of 2 Residents out of a total sample of 16 Residents (R7 and R18). R7 had an order for Midodrine (medication used to constrict blood vessels to increase blood pressure) 5 mg (milligrams) to be administered three times per day by mouth and to hold this medication for a systolic blood pressure over 130. This medication was administered with a systolic blood pressure over 130. R18 did not receive nighttime medications on 6/16/24. R18 did not receive insulin per ordered on 6/16/24. Evidenced by: The facility policy titled, Administering Medications, dated 4/19, states, in part; .Medications are administered in a safe and timely manner, and as prescribed. 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) . Example 1: R7 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.

Based on interview and record review the facility must develop policies and procedures to ensure that residents and/or resident responsible party receives education regarding the benefits and potential side effects of the immunization prior to offering the immunization and documentation is noted in the medical record on whether the resident received or declined the immunization, this affected 1 of 5 residents (R41) reviewed for pneumococcal immunizations. R41 received the Pneumococcal 23 vaccine on 7/5/22. R41 became eligible for further pneumococcal vaccinations one year after this date and was not offered the additional vaccines by the facility. Evidenced by: The facility's policy, titled, Pneumococcal Vaccine, with a revised date of, October 2023, states, in part: Policy Statement - All residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Policy Interpretation and Implementation - 1. Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered 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 ensure snacks were offered at bedtime daily when there is more than 14 hours between the evening meal and breakfast. This has the potential to affect 56 of 57 residents and 4 of 4 units. R48, R31, R38, R34, R17, R1, R4, and R39 voiced concerns that residents were not consistently being offered a snack at bedtime. R162 complained of not receiving snacks between meals. There was more than 14 hours between the evening meal and breakfast and the facility staff were not offering snacks to all residents. Evidenced by: Facility policy, entitled Snacks, reviewed 3/23, includes, in part: Snacks will be provided to increase hydration and prevent episodes of hunger. Snacks will be provided between meals in adherence with the resident's diet order . Nursing will be responsible for the delivery of snacks to the residents . On 3/27/23 at approximately 10:00 AM, Surveyor interviewed R162 during the initial screening process. R162 indicated to Surveyor he does not get snacks. R162 reported that he has talked to staff at 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 maintain a safe and sanitary environment in which food is stored and distributed in accordance with professional standards for food service safety. This has the potential to affect 56 of the 57 residents who reside in the facility. Surveyor observed the following: - Food mixer to have cream colored food particles on it. - Microwave has missing coating on the door. - Dirty scoop in drawer. - Walk in freezer ice buildup on the floor, shelves, and on boxes of food. Boxes of food were not factory sealed and ice chips were inside of box. - One dented can of chocolate pudding left in circulation. - Temperature logs for dishwasher had temperatures that were not in accordance with the manufacture's recommendations for January, February, and March 2023. Evidenced by: The facility policy titled, Equipment Cleaning and Operation Instructions, with a reviewed date of 2/23, includes, in part: Policy: Detailed instructions for cleaning and operating each piece of equipment shall be available to every employee. Procedure: 1.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility did not provide feedback as to the steps taken to address Residents' prior concerns voiced at the Resident Council Meetings for 2 of 15 sampled residents (R4 and R31) and 11 supplemental residents (R35, R43, R34, R13, R38, R17, R36, R48, R39, R1, and R109) R4, R31, R43, R35, R1, R34, R13, R38, R17, R36, R48, R39, and R109 voiced concerns in Resident Council with no follow up. Evidenced by Facility policy, entitled Grievances, reviewed 2/6/18, includes, in part: Resident Council the facility will review the grievance policy and procedure with the resident council on annual or as needed basis. the grievance official or designee well attend the resident council meeting as agreed upon by the resident council members. all grievances identified during the resident council meeting will be submitted immediately to the grievance official for investigation and resolution. Reporting of resolution outcome will be given to the resident council . the facility will strive for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure all grievances were promptly resolved for 1 of 15 residents reviewed for grievances (R4) and 3 supplemental residents (R13, R35, and R43). R4, R13, R35, and R43 voiced concerns regarding missing items and the facility did not promptly follow up on concerns. Evidenced by: Facility policy, entitled Grievances, includes, in part: it is the facility policy that each resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their stay. the facility will ensure prompt resolution of all grievances, keeping the resident and resident representative informed throughout the investigation and resolution process. 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 has not established an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This had the potential to affect more than a limited number of residents in the facility. The facility could not produce complete documentation regarding testing for residents during an outbreak of COVID-19. The facility did not thoroughly screen a staff member who reported symptoms that could be associated with COVID-19 for the [DATE] COVID outbreak. The facility's infection control line list for staff contained inaccurate and/or missing information. A staff member with signs and symptoms consistent with COVID-19 returned to work without 2 negative COVID-19 tests completed 48 hours apart. This is evidenced by: The facility policy, Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures, revised [DATE], includes, in part:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure that self-administration of medications was determined to be clinically appropriate for 1 of 1 supplemental resident (R34) reviewed for self-administration of medications out of a total sample 15. R34 was observed unsupervised with medication sitting on the bedside table. This is evidenced by: The facility policy entitled, Administering Medications, revised date, December 2012, indicates, in part: Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 1. Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so . 24. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely . The facility policy entitled,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 notify the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 15 sampled residents (R18). R18's Activated Power of Attorney for Health Care (APOAHC) was not notified promptly of changes with Physician's orders. Evidenced by: The facility's policy titled Change in a Resident's Condition or Status, dated February 2021 states in part, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/ mental condition and/ or status . R18 was re-admitted to the facility on [DATE] following a hospitalization. R18 has diagnoses that include Moyamoya Disease (a rare, progressive cerebrovascular disease caused by blocked arteries at the base of the brain), Bacteremia, Urinary Tract Infection (UTI), Vascular dementia, psychotic disturbance, mood disturbance, seizures, and anxiety disorder. R18's most recent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 residents who are unable to carry out activities of daily living receive the necessary services to maintain good nutrition, this has the potential to affected 1 of 15 residents (R26) reviewed for Activities of Daily Living (ADLs). R26 was observed to have a thick film on her teeth and around her mouth. R26 is dependent on staff for oral care. R26 does not have a comprehensive care plan that includes oral care. The facility failed to develop and implement individualized, patient specific care plans that addressed providing oral care or interventions for when R26 refuses oral care. This is evidenced by: The facility's policy titled Activities of Daily Living (ADL), Supporting dated March 2018, states in part, .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene .4. If residents with cognitive impairment or dementia resist…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide assistive devices and care plan the interventions to ensure safety and prevent accidents for 1 (R5) of 3 residents reviewed for accidents out of a sample of 15 residents. R5 has a history of falls. The facility failed to create a robust person-centered Comprehensive Care Plan to support R5. The facility failed to ensure all staff are educated on interventions to best support R5. Evidenced by: The facility policy titled, Fall Prevention, with a revision date of 3/10/17, includes, in part: It is the policy of this facility to identify residents at risk for fall, develop plans of care that address the risk and implement procedures to assist in preventing falls. The facility will also investigate accidents involving residents sustaining falls to identify possible cause and develop approaches to assist in prevention repeated falls. The facility will provide training to staff regarding the Fall Prevention Program and encourage Responsible Party…

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