Muskego Health and Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of residents property by having a system in place to ensure nurses have a current nursing license and allegations of verbal abuse are reported and investigated and/or investigated timely. * The facility did not have a system in place to check licensed nurses to ensure their license remain valid. Licensed Practical Nurse (LPN)-Q held a multistate license from Texas. On [DATE] the Texas Board of Nursing revoked LPN-Q's license. LPN-Q worked at the facility on [DATE] & [DATE] after her license was revoked. * R7 reported an allegation of verbal abuse by LPN-Q and the allegation of verbal abuse was not reported immediately to Nursing Home Administrator (NHA)-A and to the State Survey Agency. The allegation of verbal abuse was not investigated in a timely and thorough manner. * 3 staff members reported to NHA-A allegations of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection for 4 (R3, R4, R7, & R2) of 4 Residents. * There was not an enhanced barrier precaution sign on R3's door, (Licensed Practical Nurse) (LPN)-N did not wear appropriate PPE (personal protective equipment) during a treatment observation and appropriate hand hygiene was not observed during the treatment observation. * R4 was admitted to the facility on [DATE] with multiple non pressure areas. An enhanced barrier sign was not observed on R4's door on 2/20/25 until 2:56 p.m. * Appropriate hand hygiene was not observed during treatment and incontinent cares for R7. * The nurse did not wear appropriate PPE for R2 who is on enhanced barrier precautions when flushing R2's tube and did not perform hand hygiene prior to leaving R2's room. Findings include: The facility's policy titled, Enhanced Barrier Precautions and dated 12/23/22 under…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure that 1 (R1) of 1 Residents reviewed for a room change within the facility, were provided with prior written notice, including reason for the room change. *R1 transferred to another room on an unknown date and there is no documentation R1 and/or guardian received prior written notice and gave consent for the reason for the transfer. On 2/14/25, R1 was transferred to yet another room and there is no documentation R1 and/or guardian received prior written notice and gave consent for the reason for the transfer. Findings Include: The facility's policy Change of Room or Roommate implemented 3/7/23 documents: .Policy: It is the policy of this facility to conduct changes to room and/or roommate assignments when considered necessary and/or when requested by the Resident or Resident representative. Policy Explanation and Compliance Guidelines: 4. Prior to making a room change or roommate assignment, all persons involved in the change/assignment, such 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 interview and record review the facility did not ensure 1 (R2) of 5 Residents reviewed sought consultation with the physician regarding significant weight loss, possible thrush, and the prescribed formula not being available for administration to R2. Findings Include: The facility's policy and procedure Notification of Changes implemented 10/24/23 and last revised 8/27/24 documents: Policy: .The purpose of this policy is to ensure the facility promptly informs the Resident, consults the Resident's physician; and notifies, consistent within his or her authority, the Resident's representative when there is a change requiring notification. Changes of condition require an evaluation, using the situation, background, assessment, and recommendation (SBAR) Communication Form and Progress Note Evaluation ensures proper documentation and notification has been made. Circumstances requiring notification include: 2. Significant change in Resident's physical, mental or psychosocial condition such as deterioration 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 did not protect 1 (R2) of 4 Residents by not implementing their written policies and procedures to prohibit and prevent the right to be free from verbal abuse from Certified Nursing Assistant (CNA)-H. *Staff did not report allegations of verbal abuse immediately of a Resident by CNA-H, and consequently R2 was subjected to verbal abuse a couple of weeks later by CNA-H. Findings Include: The facility's Abuse, Neglect and Exploitation policy and procedure implemented 9/18/23 documents: .It is the policy of this facility to provide protections for health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of Residents and Misappropriation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility did not ensure that 3 allegations of abuse/misappropriation involving 3 Residents (R6, R8 and R7) of 4 allegations of abuse/misappropriation were reported immediately to the Nursing Home Administrator (NHA)-A and to the State Survey Agency within the required reporting timeframe . * 3 staff members reported late to Nursing Home Administrator (NHA)-A allegations of Certified Nursing Assistant (CNA)-H being verbally abusive to R6. The allegation of verbal abuse was not reported immediately to Nursing Home Administrator (NHA)-A and to the State Survey Agency. * R8 reported to a CNA that R8 was missing money on 2/19/25. The allegation of misappropriation was not reported immediately to Nursing Home Administrator (NHA)-A and to the State Survey Agency. * R7 reported an allegation of verbal abuse and the allegation of verbal abuse was not reported immediately to Nursing Home Administrator (NHA)-A and to the State Survey Agency. Findings Include: The facility's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure 3 (R7, R6, & R2) of 4 allegations of abuse were investigated or thoroughly investigated timely. * The facility did not conduct a thorough investigation timely for R7's allegation of verbal abuse. * The facility did not conduct a thorough investigation timely for R2's allegation of verbal abuse. * The facility did not conduct an investigation for R6's allegation of verbal abuse. Findings include: The facility policy titled Abuse, Neglect, and Exploitation and dated 9/18/2023 documents: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Under section V Investigation of Alleged Abuse, Neglect an Exploitation documents A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 based on the comprehensive assessment of a resident, residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident's choices for 2 (R3 & R4) of 2 residents. * R3 was admitted to the facility on [DATE] with a left scrotum surgical wound and right fifth digit wound. The facility did not complete weekly assessments on these areas. On 2/20/25 R3's treatment to the right fifth digit was not completed and the left scrotum treatment was not completed according to physician orders. * R4 was admitted to the facility on [DATE] with multiple non pressure areas. These non pressure areas were no assessed until 2/19/25, six days later by Wound Physician-T. Daily treatments to R4's bilateral buttocks, left 2nd toe, left medial foot, and right plantar foot were not initiated until 2/15/25, two days after admission. Findings include: The facility's policy titled, Wound…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 Residents with a pressure injury received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 1 (R7) of 1 Residents reviewed for pressure injuries. On 2/6/25 the facility discontinued the treatment to R7's left fifth toe even though Wound Physician-T continued the treatment of skin prep. On 2/12/25 Wound Physician-T changed treatment orders for R7's left hip pressure injury, left lateral knee pressure injury, & right heel pressure injury. The facility did not pick up these orders until 2/20/25, 8 days later. On 2/20/25 R7's right heel treatment was not completed according to physician orders as the nurse informed R7 her treatment had been discontinued. R7's heels were observed not to be offloaded and R7's air mattress was set to the incorrect setting. Findings include: The facility's policy titled, Pressure Injury…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure 1 (R1) of 1 Residents reviewed received adequate supervision and assistance devices to prevent accidents. * R1 has been assessed as a high risk for falls. R1 had unwitnessed falls on 1/17, 2/2, and 2/9/25 and a thorough investigation was not completed including a root/cause analysis. R1 is nothing by mouth (NPO) and receives all nutrition through a Peg Tube. On 2/13/25, R1 was given a regular diet with thin liquids on a food tray in the dining room and the facility did not complete an investigation. On 2/14/25, R1 attempted to exit the facility. The facility did not complete a thorough investigation. R1 was not re-evaluated for an elopement risk until 2/18/25 which determined R1 required a wanderguard to be placed. An elopement risk care plan was not implemented until 2/24/25. Findings Include: The facility's Accidents and Supervision policy and procedure implemented 12/29/22 documents: Policy: .The Resident environment will remain…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure resident (R2) maintained acceptable parameters of nutritional status for 1 (R2) of 1 resident reviewed for weight loss. On 1/24/25, Licensed Practical Nurse (LPN)-E documented in R2's electronic medical record (EMR) that R2 missed 4 bolus feedings due to Nepro not being available. Per R2's Medication Administration Record, there were 7 total missed feedings. R2 had a significant weight loss identified on 1/28/25 times one week of -5.4% (9 pounds). On 2/11/25, R2 was identified as having a significant weight loss times 30 days of -6.9% (11 pounds). The physician was not notified. Cross Reference (F580). On 1/25/25, weights 2 times a week on Tuesday and Saturday were initiated per physician's order. On 2/11/25, weights were recommended by Registered Dietitian (RD)-G to be obtained 3 times a week. No new physician order was obtained. 9 weights were not obtained. On 2/4/25, R2's swallow study recommended to treat R2's tongue thrush and a 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 interview and record review the facility did not ensure 1 (R3) of 1 residents have consistent pre and post dialysis communication for R3 who receives dialysis three times a week. Findings include: The facility's policy titled, Hemodialysis and dated 2/15/23 under under purpose documents The facility will assure that each resident receives care and services for the provision of hemodialysis and/or peritoneal dialysis consistent with professional standards of practice. This will include: The ongoing evaluation of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. Ongoing evaluation and oversight of the resident before, during and after dialysis treatments, including monitoring of the resident's condition during treatments, monitoring for complications, implementation of appropriate interventions, and using appropriate infection control practices and Ongoing communication and collaboration with the dialysis facility…

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

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 to help prevent the development and transmission of communicable diseases and infections potentially affecting all 39 residents in the facility and Enhanced Barrier Precautions were not in place or followed for 2 (R37 and R8) of 2 residents observed receiving wound care. *Enhanced Barrier Precautions (EBP) were not posted on doors as required for residents with invasive devices or wounds. *Rates of infection were not calculated and documented monthly to monitor trends of infection. *R37 had an indwelling urinary catheter in place and wound care was completed with no Enhanced Barrier Precautions in place. *R8 had wound care completed and staff did not follow the Enhanced Barrier Precautions. Findings include: The facility policy and procedure titled Enhanced Barrier Precautions dated 12/23/2022 documents: Policy: It is the policy of this facility to implement enhanced barrier precautions…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 remain as free of accident hazards as is possible and that each resident received adequate supervision and assistance devices to prevent accidents for 5 (R8, R12, R23, R29, and R31) of 6 residents reviewed for falls and 1 (R29) of 2 residents reviewed for smoking. * R29 had a fall on 8/31/2024 that was not thoroughly investigated and R29's care plan was not revised until 9/3/2024. * R29 had a smoking evaluation completed on 8/13/2024. The smoking evaluation indicated that the facility holds onto R29's smoking supplies and should be a supervised smoker. R29 did not have a smoking care plan and had smoking supplies located in R29's purse in her room. R29 did not have any additional smoking evaluation assessments completed. * R23 had a fall on 10/29/2024 that was not thoroughly investigated. The facility failed to revise the plan of care post R23's fall on 10/29/2024. * R31 had a fall on 1/5/2025 that was not thoroughly investigated. *…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility did not ensure 1 (R235) of 2 allegations of neglect were reported to the State Survey Agency. * R235 had an allegation of neglect that occurred during the night shift of 1/8/2025. This allegation of neglect was not reported to the State Agency. Findings include: The facility policy entitled Abuse, Neglect, and Exploitation implemented on 9/18/2023 documents: It is the policy of this facility to provide protections for health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Policy Explanation and Compliance Guidelines: . 2. The facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law. 3. The facility will provide ongoing oversight 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 a resident to resident altercation was thoroughly investigated for 2 (R7 and R30) 3 residents reviewed for abuse and 1 (R235) of 2 allegations of neglect. * The facility did not thoroughly investigate a resident to resident altercation between R7 and R30 that was reported on 12/16/2024 to the State Survey Agency. * R235's family member reported an allegation of abuse to the nursing home administrator on 1/9/2025 and was not thoroughly investigated. Findings include: The facility policy entitled Abuse, Neglect, and Exploitation implemented on 9/18/2023 documents: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure 2 (R12 and R23) of 2 residents reviewed for hospitalizations received a written transfer/discharge notice that included the date of transfer, reason for transfer, location of transfer, appeal rights and contact information of the State Long-Term Care Ombudsman. Findings include: The facility policy entitled, Transfer and Discharge (including AMA), dated 10/26/22, documents, in part: The facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided: The specific reason and basis for transfer or discharge. The effective date of transfer or discharge. The specific location . to which the resident is to be transferred or discharged . An explanation of the right to appeal the transfer or discharge to the State. The name, address (mailing and email) and telephone number of the State…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 1 (R8) of 2 residents reviewed with pressure injuries. * R8 did not receive treatment of R8's lower back pressure injury 20 days out of 71 days. R8 did not have documentation of multiple skin discolorations over boney prominence areas where pressure injuries are likely to occur. Findings include: R8 was admitted to the facility on [DATE] with diagnoses which include malnutrition, osteoporosis, peripheral vascular disease, vascular dementia, and major depressive disorder. R8 has a Legal Guardian. R8's Annual Minimum Data Set (MDS), dated [DATE], documents R8 has a Brief Interview for Mental Status (BIMS) score of 01, did not exhibit behaviors, had impairment in upper and lower extremities, partial/moderate assistance with rolling left 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 observations, interview and record review, the facility did not ensure that 1 (R12) of 1 residents reviewed with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. * R12 has a physician order for a splint to be worn on the right hand. Surveyor observed R12 wearing a palm guard on R12's right hand on the first day of survey. Surveyor had multiple observations of R12 not wearing a splint or a palm guard on R12's right hand during the remainder 2 days of the survey. Findings include: 1.) R12 was admitted to the facility on [DATE] with diagnosis that include Hemiplegia (muscle weakness or partial paralysis on one side of the body) following stroke affecting right dominant side, Aphasia (language disorder that affects ability to understand and express language), and Vascular Dementia. R12's Quarterly Minimum Data Set (MDS) assessment dated [DATE], documents R12's cognition is moderately impaired. R12 uses 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 interviews and record review the facility did not ensure 1 (R5) of 1 residents reviewed for colostomy, urostomy or ileostomy services, received care consistent with professional standards of practice. * R5 was admitted to the facility with a colostomy on 10/25/2024. R5's Physician orders did not contain any orders for the care and treatment of R5's colostomy until an order was placed on January 7th, 2025. There is not consistent documentation that the necessary care and services needed for R5's colostomy were provided between R5's admission to the facility through 1/7/25. Findings include: The Facility policy dated 5/1/24 and entitled, Pouch Changes-Colostomy, Urostomy, and Ileostomy, documents, in part: It is the policy of this facility to ensure that residents who require colostomy, urostomy, or ileostomy services receive pouch changes consistent with professional standards of practice to minimize occupational exposure and the resident's skin exposure to fecal matter or urine . Ostomy care will be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that residents who require dialysis receive such services, consistent with professional standards of practice, including the ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility for 1 (R485) of 1 residents reviewed for dialysis. * R485 was admitted to the facility needing dialysis and did not have physician orders for hemodialysis and frequency of the dialysis. Assessments were not completed before or after dialysis sessions. No care plan was in place for monitoring and care of R485 related to dialysis and complications. There was no evidence of ongoing communication between the Facility and the dialysis center with each visit. Findings include: The Facility Policy titled Hemodialysis implemented 2/15/2023 documents (in part): Policy: This facility will provide the necessary care and treatment, consistent with professional standards of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure nursing staff had the specific competencies and skill sets necessary to care for resident's needs affecting 1 (R29) of 12 residents reviewed. R29 indicated Resident Assistant (RA)-T pivots transfers R29 into a wheelchair and takes R29 outside to smoke. RA-T is employed with the community based residential facility (CBRF) and is not a certified nursing assistant (CNA) or certified to care for residents in the long-term care facilities. R29 was assessed to require the use of a sit to stand mechanical lift for transfers. Findings include: R29 was admitted to the facility on [DATE] and has diagnoses that include multiple sclerosis, generalized anxiety disorder, and recurrent depressive disorder. R29's quarterly minimum data set (MDS) dated [DATE] indicated R29 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 15 and the facility assessed R29 as being dependent on 1 staff member for personal and toileting hygiene, lower body…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 accurate and safe administration of medication for 1 Resident (R485) of 12 residents reviewed. R485 has a physician order for Epoetin Alfa Injection Solution 4000 UNIT/ML. Inject 1 vial subcutaneously at bedtime every Tue (Tuesday), Thu (Thursday), Sat (Saturday) for anemia related to human immunodeficiency virus [hiv] disease. This medication was not available to be given after R485 admitted to the Facility, resulting in 5 missed doses. Findings include: R485 was admitted to the facility on [DATE], with diagnoses that include, human immunodeficiency virus [hiv] disease. R485's admission Minimum Data Set (MDS) with an assessment reference date of 1/17/2025 documents R485 had a Brief Interview for Mental Status score of 15, indicating R485 is cognitively intact. R485 scored a 24 on the patient depression questionnaire indicating severe depression present. R485's progress note dated 1/14/2025, at 8:17pm, documents Medication Administration Note…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 act upon the pharmacy medication regimen review reports when received. This was observed with 1 (R21) of 5 resident medication reviews. R21's monthly pharmacy reviews noted a recommendation reported on 9/10/2024 and 11/11/2024 (same concern from 9/10/2024 recommendation). There was no documentation the attending physician acted upon the recommendations from pharmacy until Surveyor requested to see the physician signed reviews that were dated the same day requested. Findings include: R21 was admitted to the facility on [DATE] and has diagnoses that include dementia, traumatic brain injury, epilepsy (seizure disorder), anxiety, and depression. R21 is enrolled to receive Hospice services and care. On 1/23/2025, at 3:32 PM, Surveyor requested to see R21's pharmacy medication review recommendations for the last six months. On 1/27/2025, at 10:07 AM, Surveyor received R21's pharmacy medication review recommendations. Surveyor noted the documents were not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the Facility did not ensure monitoring for adverse reactions of high risk medications for 2 residents (R31 and R485) of 5 residents reviewed for unnecessary medications. *R31 has orders for Eliquis (anticoagulant) twice daily for chronic embolism and thrombosis of unspecified deep veins of unspecified lower extremity and Furosemide (diuretic) once daily for hypertension. The Facility did not implement care plans to monitor for any adverse side effects that could result from taking an anticoagulant or diuretic. *R485 has orders for Apixaban (anticoagulant) twice daily for end stage renal disease and Furosemide (diuretic) once daily for hypertension. The Facility did not implement care plans to monitor for any adverse side effects that could result from taking an anticoagulant or diuretic. Findings include: The Facility Policy titled High Risk Medications implemented 10/1/2023 documents (in part): Policy: This facility recognizes that some medications are associated with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 receive psychotropic medications had medication side effect monitoring and non-pharmological interventions identified for 1 (R485) of 5 residents reviewed for unnecessary medications. The Facility did not ensure 1 (R21) of 5 residents reviewed did not receive a PRN medication beyond 14 days without a documented rational and indicated duration. R485 did not have orders for monitoring of adverse consequences from the use of Mirtazapine (antidepressant) and SEROquel (antipsychotic) medications or orders for non-pharmacological interventions to improve R485's well being. R21 was prescribed an anti-anxiety medication, Lorazepam oral concentrate 2 mg/ml- give 0.25 ml by mouth every 1 hours as needed without an end date. Findings include: The Facility Policy titled Use of Psychotropic Medication implemented 10/1/2023 documents (in part): Policy: Residents are not given psychotropic drugs unless the medication is necessary 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.

Based on interviews and record reviews, the facility did not ensure residents received the influenza immunization and the pneumococcal immunization for 2 (R37 and R23) of 5 residents reviewed for immunizations. *R37 consented to the influenza immunization and did not receive it. *R23 consented to the pneumococcal immunization and did not receive it. Findings include: The facility policy and procedure titled, Infection Prevention and Control Program, dated 5/16/2023 documents: .7. Influenza and Pneumococcal Immunization: a. Residents will be offered the influenza vaccine each year between October 1 and March 31, unless contraindicated or received the vaccine elsewhere during that time. b. Residents will be offered the pneumococcal vaccines recommended by the CDC upon admission, unless contraindicated or received the vaccines elsewhere. c. Education will be provided to the residents and/or representatives regarding the benefits and potential side effects of the immunizations prior to offering the vaccines. d. Residents will have the opportunity to refuse the immunizations. e.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 (R235) of 1 resident's reviewed for communication were fully informed in a language they can understand of their total health status, including but not limited to, their medical condition and care to be furnished. * R235's primary and only language spoken is Serbian. The facility did not identify methods of communication or provide education to staff related to methods of communication that should be used with R235. The facility depended on R235's family members for translation between the facility staff and R235. The facility documented that R235 to be their own person and a power of attorney for R235 was not activated. Findings include: The facility policy titled Translation and/or Interpretation of Facility Services dated as revised May 2017 documents: This facility's language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to ensure enhance based precautions (EBP) were implemented for five of five residents (Resident (R)4, R5, R6, R7, R8) reviewed for EBP due to presence of a wound requiring care, indwelling urinary catheter, or gastrostomy tube. The facility failed to ensure that when a resident's incontinence brief change occurred, staff's gloves were changed between cleaning the urine or stool and placing a clean incontinence brief on the resident for one of one residents (R9) observed for incontinence care. As a result of this deficient practice the residents had the potential for harm of cross contamination (from one resident to another) by transmission of multidrug-resistant organisms (MDRO). Findings include: Review of the facility's policy titled Enhanced Barrier Precautions implemented 12/23/22, revealed, Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required personal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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, document review and record review, the facility failed to ensure professional standards of care were provided when transferring physician wound care orders. The failure to ensure physician orders for antibiotics were transcribed and administered for one of three residents (Resident (R)2) reviewed for antibiotic administration. The facility failed to have documentation of skin conditions during nursing assessments for one of three residents (R1) reviewed for skin assessments and treatment. Specifically, the wound physician wrote treatment orders for R1's skin wounds. However, nursing staff failed to review the wound physician's notes and receive clarification of the orders if necessary, prior to documenting the orders in the record. As a result of this deficient practice, residents receiving care for healing of wounds had the potential to decrease healing potential and harm for lack of treatment and administering antibiotics as ordered for treatment of infection. Findings include: 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 observation, interview and record review the facility did not ensure that all resident rooms have at least 80 square feet of space per resident in multiple rooms. This deficient practice has the potential to affect 10 of 12 residents (R3, R7, R28, R20, R2, R389, R9, R14, R16, R29) currently residing in these rooms. rooms [ROOM NUMBERS] both had 3 residents in each room, were observed to be tight for the residents residing in these rooms. rooms [ROOM NUMBERS] both of these rooms currently had 2 residents in each room along with a an empty bed in each room so that each room could have the capacity of 3 residents. The resident in each of these rooms indicated that when the 3rd bed is occupied, the space in the room is tight. Findings include: 1. room [ROOM NUMBER]- On 9/27/23 at 10:50 am, Surveyor observed this room which currently has 3 residents living in this room, (R3, R28, and R7.) This room is equipped to provide living space for 3 residents which requires 240 square feet of usable living space. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure the call light was within reach for 1 (R1) of 12 residents reviewed. R1 was observed on multiple occasions in R1's room without a call light within reach. Findings include: The facility policy, entitled Call Lights: Accessibility and Timely Response, no date, states: #2. All residents will be educated on how to call for help by using the resident call system. #3. Each resident will be evaluated for unique needs and preferences to determine any special accommodations that may be needed in order for the resident to utilize the call system. #4. Special accommodations will be identified on the resident's person-centered plan of care, and provided accordingly. (Examples include touch pad, larger buttons, bright colors, etc.). #5. Staff will ensure the call light is within reach of resident and secured, as needed. R1 was admitted to the facility on [DATE] with diagnoses that include dysphagia following cerebral infarction, functional…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 failed to protect 1 (R7) of 12 residents of the right to be free from physical abuse by R4 On 7/23/23, R4 attended a church service in which staff were not able to attend. As a result, staff was not able to provide supervision to ensure R4 was an arm's length away from other residents. During this church service on 7/23/23 at 11:45 am, R4 punched R7 in the arm. Findings include: Review of the facility policy, dated 09/18/2023, titled, Abuse, Neglect and Exploitation, revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .Abuse means the willful infliction of injury .which can include .certain resident to resident altercations .Willful means the individual must have acted deliberately, not that the individual must have intended…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 develop and implement a baseline care plan that includes the instructions needed to provide effective and person-centered care for 2 (R20 and R389) of 2 newly admitted residents. R20's baseline care plan did not address hospice services, pressure injuries, or psychotropic medications that R20 was admitted with. R389's baseline care plan did not address the monitoring of psychotropic or anticoagulant medications that were ordered on admission. Findings: The facility policy and procedure entitled Care Plans - Baseline from MED-PASS, Inc. ©2001 revised 12/2016 states: 1. To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission. 2. The Interdisciplinary Team will review the healthcare practitioner's orders (e.g., dietary needs, mediations, routing treatments, etc.) and implement a baseline care plan to meet the resident's immediate needs…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 develop and implement a comprehensive person-centered care plan with measurable objectives that were identified in the comprehensive assessment for 1 (R20) of 12 sampled residents. R20 was admitted with an order for an antianxiety medication lorazepam 0.5 mg every hour as needed. The use of lorazepam was not comprehensively assessed on the admission Minimum Data Set (MDS) assessment and no care plan addressing R20's anxiety or use of lorazepam was implemented. Findings: The facility policy and procedure entitled Care Plans, Comprehensive Person-Centered from MED-PASS, Inc. ©2001 revised 12/2016 states: 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 12. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not develop and implement a discharge planning process that included preparation for discharge, ensuring discharge needs are identified and incorporated into a discharge planning care plan for 1 (R38) of 1 resident reviewed for discharge planning. * R38 was admitted into the facility with the expectation of discharging to another facility (an assisted living). The facility did not develop a discharge plan for R38. There was no documentation regarding the progress on discharge planning goals. There was no documentation of the assisted living application status or progress. There was no further documentation regarding conversations with R38, the activated Power of Attorney A(POA), or the Assisted Living Facility (ALF) related to discharging from the facility. R38 was discharged on 6/28/23. Findings include: The facility policy, entitled Discharge Summary and Plan, by MED-PASS, Inc revised December 2016, states: #4. Every resident will be evaluated for his or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility did not ensure that 1 out of 1 resident (R38) who was discharged from the facility had a discharge summary that included all the pertinent information, a final summary of the resident; status at the time of discharge and a post-discharge plan of care developed with the participation of the resident and/ or representative. R38 was discharged from the facility on 6/28/23. The facility's Discharge summary form which documents a recapitulation of R38's stay was incomplete and the medical record did not include information pertaining to R38's discharge. Findings include: The facility policy, entitled Discharge Summary and Plan, by MED-PASS, Inc revised December 2016, states: #1. When the facility anticipates a resident's discharge to a private residence, another nursing care facility (i.e. skilled, intermediate care, ICF/IID, etc.), a discharge summary and a post-discharge plan will be developed which will assist the resident to adjust to his or her new living…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 received care consistent with professional standards of practice when admitted with pressure ulcers for 1 (R20) of 2 residents reviewed for pressure injuries. R20 was admitted to the facility with a Stage 4 pressure injury to the right hip, a Stage 4 pressure injury to the left hip, and an Unstageable pressure injury to the sacrum that was not assessed on admission by a Registered Nurse (RN) and treatment was not provided daily as ordered by the Wound Physician. Findings: The facility policy and procedure entitled Pressure Injury Prevention and Management dated 2/14/2023 states: 3.c. Licensed nurses will conduct a full body skin assessment on all residents upon admission/rea-admission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. R20 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, malnutrition, cerebral infarction, diabetes, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews the facility did not ensure adequate supervision to prevent falls for 2 (R27 and R36) of 3 residents reviewed for falls. *R27 sustained multiple falls. The facility did not thoroughly investigate 3 of R27's 16 falls. *R36 suffered multiple falls. The facility did not thoroughly investigate R36's falls and did not initiate appropriate interventions. Findings include: The Facility policy entitled Accidents and Supervision, dated 12/29/2022, documented: The facility shall establish and utilize a systemic approach to address resident risk and environmental hazards to minimize the likelihood of accidents . 2. Evaluation and Analysis-the process of examining data to identify specific hazards and risks and to develop targeted interventions to reduce the potential for accidents. Interdisciplinary involvement is a critical component of this process. a. Analysis may include, for example, considering the severity of hazards, the immediacy of risk, and trends such as time…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 (R38) of 7 residents reviewed for medication who were receiving psychotropic medication were free from unnecessary drugs. R38's PRN (as needed) Lorazepam/Ativan (antianxiety)) does not have a stop date or rationale to extend the use of this medication past 14 days. Finding include: The facility policy, entitled, Use of Psychotropic medication, no date, states: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medications(s). #9 PRN orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e. 14 days). a. If the attending physician or prescribing practitioner believe…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 each resident received adequate supervision or assistance devices to prevent accidents for 3 (R30, R16, and R25) of 4 residents reviewed for falls. *R30 was left unsupervised on the toilet and fell. A root cause analysis was not completed and the Fall Care Plan was not revised with appropriate interventions to prevent future falls. *R16 was observed by Surveyor being transferred with a mechanical lift with only one Certified Nursing Assistant (CNA) when a mechanical lift requires two staff members when transferring a resident. *R25 was observed by Surveyor to not have the call light in reach and fall interventions were not in place per care plan. Findings: 1. R30 was admitted to the facility on [DATE] with diagnoses of cardiovascular accident with left-sided hemiplegia, post stroke pain, and diabetes. R30 was transferred to the hospital on 4/23/2022 and returned to the facility on 4/26/2022. The admission Minimum Data Set (MDS)…

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