New Glarus Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to thoroughly investigate an accusation of physical abuse for 1 of 6 residents (R3) reviewed for abuse. R3 was found in R2's room sitting on edge of bed with R2's depends unfastened, fondling R2 between the butt cheeks. Facility did not put anything in place to prevent this from happening again. Facility did not provide abuse education to all staff. Evidenced by: The facility policy entitled, Abuse, Neglect, and Exploitation Policy & Procedures, dated 2/25/23, states, in part: . Policy Statement: It is the policy of New Glarus (referred to as the facility herein) is 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. Definitions: . Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, 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.

Based on observation, interview, and record review, the facility did not ensure snacks were offered at bedtime daily when there are more than 14 hours between the evening meal and breakfast. This has the potential to affect 90 of 90 residents and 6 of 6 units. R40, R19, R16, R70, and R2 voiced concerns that residents were not consistently being offered a snack at bedtime. These residents reside on the following hallways: 200 hall, 600 hall, and 300 hall Staff on the following hallways reported to the Survey team that bedtime snacks were not being offered to all residents: 500 hall, 300 hall, 600 hall, 400 hall, 200 hall, and 100 hall. There were 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, titled Resident Food Service: Snacks, revised 1/24, includes: .All residents must be offered daily snack at bedtime unless otherwise specified in resident's plan of care. Nursing: Offer bedtime snacks to all residents. Facility's Posted Mealtimes and Locations are as follows: Breakfast…

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

Based on observation and interview, the facility did not maintain a safe and sanitary environment in which food is prepared, stored and distributed. This has the potential to affect all 90 residents who reside in the facility. Surveyor observed multiple staff in food preparation areas, while food was being prepared, without donning hair restraints. Surveyor observed staff not allowing dishes to air dry completely before stacking them. Surveyor observed dented cans in circulation. Surveyor observed opened and undated food. Surveyor observed unclean stored equipment in facility's main kitchen. Evidenced by: Example 1 Facility policy, titled Uniform Dress Code, revised 1/24, includes: . Wear approved hair restraint when on duty regardless of length or presence of hair . On 12/2/24 at 10:11 AM, Surveyor observed DM L (Dietary Manager) in the facility's main kitchen, in the food preparation area without a hair restraint. Surveyor asked DM L about her hair restraint and DM L indicated she should have one on and she is sorry. On 12/5/24 at 8:20 AM, Surveyor observed CNA X (Certified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 90 residents residing within the facility. Quality Assurance and Performance Improvement (QAPI) meetings did not consist of the required attendees/members for the months of February and June, 2024. This is evidenced by: The facility QAPI plan, titled (Facility Name) QAPI Plan, undated, states in part: .(Facility Name) will establish a quality management committee that consists of the following members: Administrator/Executive Director, Director of Nursing/Director of Quality Improvement and Education, Medical Director of designee, Consulting Pharmacist, three general staff members representing disciplines…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 establish and maintain an Infection Control Program designed to provide a safe environment to help prevent the development and transmission of disease and infection (such as Legionella). This has the potential to affect all 90 residents who reside in the facility. The facility did not maintain a water management program to prevent the spread of Legionella. The facility did not ensure laundry services were being conducted according to current standards of practice to prevent the transmission of communicable diseases between residents. One resident was not added to the line list after showing signs and symptoms of an infection according to facility policy and procedure. This is evidenced by: Example 1: The facility policy titled, Infection Prevention and Control Program Policy, dated 2/13/23, states in part: .Water Management: a. A water management program has been established as part of the overall infection prevention and control program.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 grievances and recommendations discussed during resident group meetings (Resident Council) were acted upon promptly, according to facility policy, and that residents were allowed to meet without staff present. This has the potential to affect more than a limited number of residents residing in the home. During Resident Council Task, 10 of 12 members voiced concerns that they do not receive follow up from voiced concerns, complaints, or suggestions for a whole month, until the next meeting. These residents indicated the facility policy states the management team will get back to them in 10 business days. During Resident Council Task, 10 of 12 members indicated the management team comes when they are not invited and at times the council wants to meet without staff present. Evidenced by: Facility policy, entitled Resident Council, undated, includes: All residents become members of Resident Council when they are admitted to the (facility named) . Resident Council is a formal advisory body, independent of the facility and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility did not ensure a sufficient number of trained staff worked in the facility's food service department in order to safely and effectively carry out the meal preparation and other food and nutrition services for 3 of 21 sampled residents (R42, R40, R2) and 3 of 6 supplemental residents (R19, R16, R70). R42 voiced concerns about meals being late. Surveyor observed meals to be 45 minutes or more late. R40, R19, R16, R70, and R2 voiced concerns that their meals were often served late. Evidenced by: Facility meal time schedule reads as follows: Meal Times and Locations Breakfast 0745 - 400 & 500 Wings 0800 - Main Dining Room 0815 - 600 Wing 0830 - Room Service Lunch 1145 - 400 & 500 Wings 1200 - Main Dining Room 1215 - 600 Wing 1230 - Room Service Dinner 1645 - 400 & 500 Wings 1700 - Main Dining Room 1715 - 600 Wing 1730 - Room Service Example 1 R42 was admitted to the facility on [DATE] with diagnoses including: hyperlipidemia, vitamin D deficiency, deficiency of B…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safe, comfortable, and homelike environment for 1 of 21 total sampled residents (R42) and 1 of 6 supplemental residents (R391) reviewed. R42 and R391 voiced concern the water is cold when they take a shower. Evidenced by: The facility policy titled, Safe Water Temperatures Policy and Procedure, dated 12/4/24, states, in part; .6. Maintenance staff will check water heater temperature controls and the temperatures of tap water in all hot water circuits weekly and as needed. 7. Documentation of testing will be maintained for 3 years and kept in the maintenance office . Example 1 R391 was admitted to the facility on [DATE] with diagnoses including: age-related osteoporosis with current pathological fracture, history of falling, muscle weakness, type 2 diabetes mellitus, major depressive disorder, generalized anxiety disorder, chronic pain, and glaucoma. R391's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 make prompt efforts to resolve resident grievances for 1 sampled resident (R40) and 1 supplemental resident (R34) reviewed for grievances. R40 voiced a grievance to NHA E (Nursing Home Administrator) and DON B (Director of Nursing) in August that she would like her morning catheter flush to be scheduled at 8:00 AM (note, the facility has an acceptable range to complete this between 7:00 AM - 9:00 AM) so that she is able to attend activities and church on time. Currently, R40 stated the facility is flushing the catheter after 9:00 AM resulting in her missing activities and being late for church. R40 stated, That should not be. R34 voiced a grievance of receiving her bedtime medications late. The facility did not notify her of a resolution to her grievance until 4 weeks after she voiced the concern. Evidenced by: The facility's policy and procedure, Grievances, updated 8/6/24, indicates, in part, as follows: It is the policy of this facility to support…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported to the State Survey Agency for 1 of 3 residents reviewed for abuse (R16). R16 and R19 reported an allegation of abuse when staff told R16 to keep his mouth shut. The facility staff failed to report the allegation of abuse to NHA A (Nursing Home Administrator) and to the state agency. Findings include: The facility's abuse policy, titled Abuse, Neglect, and Exploitation, reviewed 2/25/23, includes: . Verbal abuse means the use of oral . communication . that willfully includes disparaging and derogatory terms to residents . or within hearing distance . Reporting all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies . within specified timeframes: Immediately, but no later than 2 hours after allegation is made, if events that cause the allegation involve abuse or result in serious bodily…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported to the State Survey Agency for 1 of 3 residents reviewed for abuse (R16). R16 and R19 reported an allegation of abuse when staff told R16 to keep his mouth shut. The facility staff failed to report the allegation of abuse to NHA A (Nursing Home Administrator) and to the state agency. Findings include: The facility's abuse policy, titled Abuse, Neglect, and Exploitation, reviewed 2/25/23, includes: . Verbal abuse means the use of oral . communication . that willfully includes disparaging and derogatory terms to residents . or within hearing distance . Mental abuse includes but is not limited to humiliation nursing home staff . in any manner that would demean or humiliate a resident . Investigation of alleged abuse .: An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation or reports of abuse, neglect, or 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.

Based on interview and record review, the facility did not complete the Preadmission Screening and Resident Review (PASRR) Level II when it was realized that a resident would reside in the facility for more than 30 days. This affected 1 of 19 residents reviewed (R65). R65's PASRR level 1 screen indicated he would only be residing in the facility for 30 days or less and was exempt from needing a PASRR level 2 screen. R65 resided in the facility for longer than 30 days and a PASRR level 2 screen was not performed. Evidenced by: The PASARR Level 1 Screen directions include, in part, the following: 42 CFR 483.128(a) requires that the resident or his/her legal representative receive a written notice (copy of this front page) if the resident is suspected of having a serious mental illness or a developmental delay, and therefore, will require a Level II Screen. You may tell the resident or his/her legal representative that the Level II Screen will determine if the resident does have a serious mental illness or developmental disability, as defined in the federal regulations, and if so, if…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the residents environment remained as free of accident and hazards as possible for 1 of 1 sampled resident (R56) and 2 of 2 supplemental Residents (R54 & R141). Surveyor observed R54's motorized wheelchair (Motorized Assistive Devices) being charged in the 600 hall dining room and not behind a fire safe door. DON B stated, R141's motorized wheelchair battery is charged in the recreational/activity area on the 300 hall. Surveyor observed staff transfer R56 without a gait belt when he was feeling ill and dizzy. Evidenced by: Example 1 The facility does not have a policy and procedure for charging motorized wheelchairs. On 12/4/24 at 10:05 AM, Surveyor observed R54's motorized wheelchair battery being charged in the 600 hall dining room and not behind a fire safe door. On 12/4/24 at 10:40 AM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B, where should batteries be charged. DON B stated she believes they are…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that a resident who displays or is diagnosed with a mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder (PTSD), receives appropriate treatment and services to correct the assessed problem or attain the highest practical mental and psychosocial well-being for 2 of 2 residents (R) (R41 and R65) reviewed out of 21 sampled residents. R41's diagnosis list indicates she has a diagnosis of Post Traumatic Stress Disorder (PTSD). R41's Comprehensive Care Plan does not include known triggers, personalized interventions, and/or goals related to her past history of trauma. R65 has a diagnosis of Post Traumatic Stress Disorder (PTSD) and an initial assessment did not include questions of the origin from which diagnosis was given, what it looks like for R65 when it manifests, triggers that cause R65 to experience the affects of the trauma, or interventions for staff to try if R65 has an…

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

Based on observation, interview, and record review, the facility did not ensure that its medication error rate was 5% or less for 35 medication pass opportunities. The facility's medication error rate was 5.71% with two (2) errors observed for R31 and R2. This is evidenced by: The facility policy, Medication Administration, dated 7/1/24, states in part, as follows: Policy: Medications are administered by licensed nurses or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards Procedure: Ensure the six right of medication administration are followed: a. Right resident, b. Right drug, c. Right dosage, d. Right route, e. Right time, f. Right documentation Januvia reference - https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/021995s023mg.pdf documents: Take Januvia whole. Do not split, crush or chew. Example 1 R31's Physician Orders, signed 12/3/24, include, in part, the following medication: Januvia Tab 100 mg (milligrams) Give 1 tab by mouth one time a day related to Type 2 diabetes mellitus…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility staff treated 1 (R5) of 16 residents reviewed with dignity and respect. Facility staff held R5's arms down and gave R5 medication in a syringe when R5 displayed agitation. R5 has dementia with severe agitation. Facility staff held R5's arms down and gave R5 medication in a syringe when R5 displayed agitation. This is evidenced by: The facility policy Medication Administration Policy date created 9/1/23, states in part: .Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice .18. Report and document any adverse side effects or refusals . The facility policy Dementia Care date created 8/1/24, states in part: It is the policy of this facility to provide the appropriate treatment and services to every resident who displays signs of, or is diagnoses with dementia, to meet his or her highest…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are thoroughly investigated for 1 of 3 residents (R5) reviewed for self-reports. On 7/9/24, the facility reported an allegation of abuse to the state agency. The facility did not complete a thorough investigation for this allegation. This is evidenced by: The facility policy Abuse, Neglect, and Exploitation Policy & Procedure last updated 2/25/23, states in part: .V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur .4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations .6. Providing complete and thorough documentation of the investigation . On 8/1/24, Surveyor reviewed a self-report the facility submitted regarding an allegation of abuse. Surveyor reviewed statements…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure each resident received adequate supervision to prevent accidents for 1 of 4 residents (R2) reviewed for wandering and elopement potential. R2 was noted to have increased exit seeking behaviors and the facility failed to increase supervision to prevent R2 from eloping. Findings include: The facility's policy titled Elopement Policy and Procedure last updated on 6/5/24 states in part, Policy statement: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person- centered plan of care addressing the unique factors contributing to wandering or elopement 4. Monitoring and Managing residents at risk for elopement or unsafe wandering a. Residents will be assessed form risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team .d. The interdisciplinary team…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 all drugs and biologicals were stored and labeled in accordance with currently accepted professional principles and did not ensure expired medications were removed from medication carts. This occurred for 3 of 4 medication carts/storage rooms observed. Staff administered an expired Aspirin tablet to resident (R) R6 during medication administration. During the complaint survey, 3 of 4 observations were made of stock bottles with expired dates on medication carts. Findings include: Surveyor requested and reviewed the facility policy titled Medication Administration dated September 01, 2023. The policy in part reads: #12. Identify expiration date. If expired, notify nurse manager . Surveyor requested and reviewed the facility policy titled Medication Error dated May 22, 2023. The policy in part reads: #1. Facility shall ensure medications will be administered as follows: -c. In accordance with accepted standards and principles which apply 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 that a resident who needs respiratory care is provided such care consistent with professional standards of practice, the Comprehensive Person-Centered Care Plan, the residents' goals, and preferences for 2 of 17 residents (R63 and R56) and 4 of 4 (R325, R61, R327, and R9) supplemental residents reviewed for respiratory care. The facility did not ensure R63, R327m and R9's oxygen tubing and concentrators were cleaned on a regular basis. The facility did not ensure R325 and R61's continuous positive airway pressure (CPAP, a device that is a non-invasive form of therapy for people with sleep apnea) had been cleaned on a regular basis. R56 had two instances in the past 3 months where her oxygen equipment was not changed per Physician Order. This is evidenced by: The facility's policy, Oxygen Concentrator Policy, undated, documents, in part: Policy Statement: The purpose of this policy is to establish responsibilities for the care and use…

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

Based on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. This has the potential to affect 7 residents on the 400, 500, and 600 wings of the facility. Nutritional supplements were not stored in accordance with manufacturer recommendations. Findings include On 9/07/23 at 9:40 AM, Surveyor observed the following: *11 unopened, thawed nutritional shakes in the 500-wing kitchenette refrigerator. These had no thaw dates. *4 unopened, thawed nutritional shakes in the 600-wing kitchenette refrigerator. These had no thaw dates. *5 unopened, thawed nutritional shakes in the 400-wing kitchenette refrigerator. These had no thaw dates. The label affixed to these nutritional shakes states the shakes should be discarded 14 days after being thawed. On 9/12/23 at 2:56 PM, Surveyor interviewed DM C (Dietary Manager), who stated that kitchen staff take the nutritional shakes from the main kitchen's freezer down to the various kitchenettes and then puts them in the freezer in each kitchen. 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 that all residents are clinically appropriate to self-administer medications for 1 of 17 residents (R16). R16 was observed to have a clear medication cup with 1 tablet of Colestid medication in her room on her bedside table. R16 was observed to have a clear medication cup with antifungal medication powder in her room on her bedside table. This is evidenced by: The facility's policy, Self-Administration of Medication Policy, undated, documents, in part: Policy Statement: It is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer medication after the facility's interdisciplinary team has determined which medications may be self-administered safely . 4. The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment Form, which is placed in the resident's medical record. 5. Upon notification of the use of bedside…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain personal privacy for 1 one 1 (R120) supplemental resident out of a total sample of 17 residents reviewed of confidential personal medical records. Surveyor observed R120's Medication Administration Record (MAR) on an open computer located on the medication cart in the hallway. Surveyor observed a clipboard with resident names and personal health information on the medication cart with no staff present. Surveyor observed SW (Social Worker) staff have an open laptop facing the main hallway. Evidenced by: The facility's policy, Confidentiality of Personal and Medical Records, undated, states in part: . 2. Keep Confidential is defined as safeguarding the content of information including written documentation, video, audio, or other computer stored information from unauthorized disclosure without the consent of the individual and/or the individual's surrogate or representative . 8. Paper notes or reminder with resident's personal or medical information…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 limited range of motion (ROM) and mobility maintained or improved function unless reduced range of motion/mobility was unavoidable based on the resident's clinical condition for 1 of 4 residents reviewed for ROM/mobility out of 17 total sampled residents (R11). R11 was admitted to the facility on [DATE] with diagnoses including: Alzheimer's disease, dementia, anxiety, and osteoporosis. R11's quarterly Minimum Data Set (MDS) assessment on 6/1/23 notes R11 is severely cognitively impaired. R11 has an Activated Power of Attorney for Health Care (APOAHC). R11's comprehensive care plans indicates R11's washcloths in bilateral hands was discontinued 3/18/23. R11's Guidelines for Daily Care, dated 9/12/23, indicates the following: Special Instructions: .Rolled up washcloths in hands, prevent contractures/skin breakdown. R11 does not receive Restorative Care such as Passive Range of Motion (PROM) or Active Range of Motion (AROM) to provide…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 2 out of 17 sampled residents (R39 and R16). R39 and R16 had multiple medication errors related to not receiving medication timely as ordered by the physician. This is evidenced by: The facility policy entitled, Medication Administration Policy, undated, states, in part: . 11. b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician . Example 1: R39 was admitted on [DATE] with diagnoses that include: nontraumatic intracerebral hemorrhage (spontaneous bleeding in the brain tissue), saddle embolus of pulmonary artery (when a large blood clot gets stuck in the main pulmonary artery), pseudobulbar affect (a condition that's characterized by episodes of sudden uncontrollable and inappropriate laughing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medication were safely and securely stored for 1 of 17 (R328) sampled residents observed. R328's medications were observed poured into a medication cup, sitting on top of a medication cart on the 600 hallway, unsecured, without staff present. This is evidenced by: The facility's policy, Medication Storage Policy, undated, states, in part: . 1.c. During a medication pass, mediations must be under the direct observation of the person administering medications or locked in the medication storage area/cart . R328 was admitted to the facility on [DATE], with a diagnosis of age-related osteoporosis with current pathological right femur fracture. R328's Minimum Data Set (MDS) was not completed at the time of the survey. R328's Physician Orders include the following: 9/6/23 Aspirin EC (enteric coated) 81mg (milligram) tablet by mouth twice per day. 9/6/23 Colace 100mg capsule by mouth twice per day. 9/6/23 Biotin 1000mcg…

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