Homestead Health Services

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure the Infection Preventionist (IP) had current certification for specialized infection prevention and control training. This had the potential to affect all 31 residents residing in the facility. IP-J's certification in a specialized infection prevention and control program was expired and no longer valid. Findings include: Centers for Medicare & Medicaid Services (CMS) Memo QSO-22-19-NH, revised [DATE], indicates: In 2016, CMS overhauled the Requirements for Participation for Long-Term Care (LTC) facilities which was implemented in three phases: .Phase 3 ([DATE]) .regulations which require nursing homes to have an Infection Preventionist who has specialized training onsite at least part-time to effectively oversee the facility's infection prevention and control program. On [DATE] at 8:15 AM, Surveyor requested IP-J's certificate of completion for specialized training in infection prevention and control from Nursing Home Administrator (NHA)-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.

Based on staff interview and record review, the facility did not ensure their abuse policy was implemented for 4 of 8 employees reviewed for caregiver background checks. The facility did not complete background checks within a 4-year time frame for Certified Nursing Assistant (CNA)-L, CNA-M, CNA-N, and CNA-P. Findings include: The facility's Abuse, Neglect and Exploitation policy, revised 7/15/22, indicates: .I. Screening: A. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference, and credentials checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. Background checks including re-checks, will be completed consistent with applicable state laws and regulations. Responsibility of performance of compliance checks on contracted temporary staff will be established via contractual agreement . On 12/3/24 Surveyor requested background check and registry information for CNA-L, CNA-M, CNA-N, 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.

Based on observation, staff interview, and record review, the facility did not ensure drugs and biologicals were stored in accordance with the facility's policy in 2 of 2 medication storage rooms. This practice had the potential to affect more than 4 of the 31 residents residing in the facility. On 12/2/24, Surveyor observed expired syringes and medications in 2 of 2 medication storage rooms. Findings include: The facility's Administering Medication Storage/Storage of Medication policy, dated 1/2024, indicates: Medications and biologicals are stored properly following manufacturers' or provider pharmacy recommendations to keep their integrity and to support safe, effective drug administration .Procedures: 14) Outdated, contaminated, discontinued or deteriorated medications .are immediately removed from stock, disposed of according to procedures for medication disposal .15) Medications awaiting destruction that cannot be disposed of immediately should be recorded on a log to include the name of the individual(s) storing the medication, resident name, the prescription number 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, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to help prevent the development and transmission of disease and infection for 4 residents (R) (R18, R2, R11, and R80) of 4 residents. R18 had suspected Clostridium difficile (C. diff) but was not on the facility's infection surveillance line list. R2 was treated for a urinary tract infection (UTI) with antibiotic medication but was not on the facility's infection surveillance line list. R11 had diagnoses including infection and inflammatory reaction due to indwelling urethral catheter and a stage 3 pressure ulcer of the sacral region. R11 was not on enhanced barrier precautions (EBP). R80 was treated for osteomyelitis (bone infection) with intravenous antibiotics administered through a peripherally inserted central catheter (PICC). R80 was not on EBP. Findings include: The facility's Enhanced Barrier Precautions (EBP) policy, revised 8/8/24, indicates: It is…

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

Based on staff, resident, and resident representative interview and record review, the facility did not ensure 1 resident (R) (R17) of 1 resident reserved the right to make choices about an aspect of their life that was significant to them. R17 was removed from the dining room table where R17 usually sat and moved to a table where staff assisted residents with eating. The facility did not consult with R17 or R17's Power of Attorney (POA) prior to the change. Findings include: The facility's Resident Rights policy, revised 7/2022, indicates: To ensure that resident rights are respected, protected, and promoted. To inform a resident of their rights and provide an environment in which they can be exercised .Residents do not leave their individual personalities or basic human rights behind when they move to a long-term care facility. Residents will be treated with respect and dignity and care for each resident will be given in a manner and an environment that promotes maintenance or enhancement of his/her quality of life and recognizes each resident's individuality .17. The resident has…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure the medical record for 1 resident (R) (11) of 13 sampled residents contained a signed advance directive. R11 was admitted to the facility on [DATE]. R11's medical record contained a signed statement of incapacity (SOI). R11's medical record did not contain a signed advance directive. Findings include: The facility's admission agreement indicates: .E. Provision of Advanced Directive and Legal Representative Designation. You are asked to participate in advance care planning discussions, including providing a complete and current copy of any advance directive or any other written statement of your desires regarding treatment options or designation of health care agent or other person with any authority to make healthcare decisions on your behalf, and any document authorizing an attorney in fact, health care agent, or guardian to act on your behalf . From 12/2/24 to 12/4/24, Surveyor reviewed R11's medical record. R11 was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident representative interview and record review, the facility did not notify a Physician, Guardian and/or Power of Attorney for Healthcare (POAHC) of changes in condition for 2 residents (R) (R3 and R4) of 13 sampled residents. R3 did not received prescribed Depakote for seizures on 11/13/24, 11/17/24, 11/25/24 and 11/26/24. R3 had seizures on 8/30/24 and 11/26/24. R3's Physician and Guardian were not notified of R3's change in condition. R4's Physician and POAHC were not notified when the facility was not able to provide R4 with prescribed seizure medication. Findings include: The facility's Change in Condition of the Resident policy, revised 9/20/22, indicates: A facility should immediately inform the resident, consult with the resident's Physician, and notify consistent with his or her authority, the resident representatives when there is an accident which results in injury, and has the potential for requiring Physician intervention, a significant change in the resident's physical,…

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 staff interview and record review, the facility did not ensure 3 residents (R) (R231, R81, and R26) of 4 sampled residents received a timely copy of a Notice of Medicare Non-Coverage (NOMNC) form when their Medicare services ended. The facility did not provide a NOMNC form (used to inform Medicare beneficiaries when their covered services are ending and their appeal rights) to R231, R81, and R26 at least two calendar days before their Medicare services ended. Findings include: The Centers for Medicare and Medicaid Services (CMS) form CMS-10123 indicates a NOMNC form must be delivered at least two calendar days before Medicare-covered services end or the second-to-last-day of service if care is not being provided daily. Note: The two-day advance requirement is not a 48-hour requirement .The provider must ensure the beneficiary or representative signs and dates the NOMNC form to demonstrate the beneficiary or representative received the notice and understands the termination decision can be disputed. On 12/4/24, Surveyor reviewed a NOMNC form for R231 that indicated R231'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 staff interview and record review, the facility did not report injuries of unknown origin to the State Agency (SA) for 2 residents (R) (R3 and R4) of 2 residents. R3's medical record indicated R3 had multiple injuries of unknown origin that were were not reported to the SA. R4's medical record indicated R4 had an injury of unknown origin that was not reported to the SA. Findings include: The facility's Abuse, Neglect and Exploitation policy, revised 7/15/22, indicates: 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 .B. Possible indicators of abuse include, but are not limited to: Resident, staff or family report of abuse .2. Physical marks such as bruises or patterned appearances such as a hand print or ring mark on a resident's body. 3. Physical injury of a resident, of unknown source .Protection of resident: .A. Respond immediately 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 staff interview and record review, the facility did not ensure injuries of unknown origin were thoroughly investigated for 2 residents (R) (R3 and R4) of 2 sampled residents. The facility did not thoroughly investigate multiple injuries of unknown origin for R3. The facility did not thoroughly investigate an injury of unknown origin for R4. Findings include: The facility's Abuse, Neglect and Exploitation policy, revised 7/15/22, indicates: 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 .Identification of abuse, neglect and exploitation: .B. Possible indicators of abuse include .2. Physical marks such as bruises or patterned appearances such as a hand print or ring mark on a resident's body. 3. Physical injury of a resident of unknown source .Investigation of alleged abuse, neglect 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 staff interview and record review, the facility did not ensure 1 resident (R) (R11) of 5 sampled residents met the Pre-admission Screening and Resident Review (PASRR) requirements. R11 had a negative PASRR Level I Screen upon admission. A Level II Screen was not completed when R11 received a qualifying diagnosis and was prescribed medication. Findings include: The Wisconsin Department of Health Services' (DHS) PASRR for current or prospective nursing home residents-Level II Screen facesheet indicates: .Nursing home should retain a copy of this facesheet and attached documentation in the person's current medical record. If the person's condition or diagnoses change so that he/she later may meet the federal definition of a developmental disability or a serious mental illness, the nursing home will need to submit an updated Level II Screen to the appropriate PASRR contract agency . From 12/2/24 to 12/4/24, Surveyor reviewed R11's medical record. R11 was admitted to the facility on [DATE] and had diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not provide the necessary care and services to maintain the highest practicable physical well-being for 2 residents (R) (R17 and R11) of 5 sampled residents. Staff did not follow through on lab orders or complete an appropriate assessment when R17 had symptoms of generalized weakness, pain with urination and pericare, and low urine output. As a result, R17 did not receive the necessary care and services to diagnose and treat an infection of vulvovaginitis (vaginal inflammation). R11 was hospitalized for heart failure from 3/11/24 to 3/13/24 and had orders for daily weights. Staff did not consistently complete daily weights for R11. Findings include: The facility's Change in Condition of the Resident policy, revised 9/20/22, indicates: The facility should immediately inform the resident, consult with the resident's physician, and notify consistent with his or her authority, the resident's representative when an accident involving the resident results 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 observation, staff and resident interview, and record review, the facility did not ensure adequate assistive devices were in place to prevent falls for 1 resident (R4) of 2 sampled residents. R4 had a care plan intervention to add anti-rollback bars to R4's wheelchair after R4 had a fall that resulted in a head laceration. The facility did not install the anti-rollback bars in a timely manner. Findings include: The facility's Fall Prevention and Management Guidelines policy, with a review date of 7/18/24, indicates: .7. When any resident experiences a fall, the facility will: d. Review the resident's care plan and update with any new interventions put in place to try to prevent additional falls. 8. Review each fall/fall investigation the next morning meeting/clinical meeting with the Interdisciplinary Team (IDT). Actions of the IDT may include: .c. Additional revisions to the plan of care including including any physical adaptation to room, furniture, wheelchair, and/or assistive devices. From 12/2/24…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interview and record review, the facility did not provide pharmaceutical services to ensure medications were received as ordered for 3 residents (R) (R3, R4, and R18) of 13 sampled residents. R3's Depakote (an anticonvulsant medication used to treat seizures) order was increased to two 500 milligram (mg) tablets to equal 1000 mg at bedtime (HS) on 5/28/24 following a hospital discharge. The Depakote order was not sent to the pharmacy which caused R3 to miss multiple doses of the medication until 11/26/24. The facility did not consistently have R4's prescribed medications available for administration. In addition, staff documented medications were given when the medications were not available. R18 refused R18's prescribed sertraline (an antidepressant medication and refused to sign consent for sertraline. The facility continued to provide R18 with sertraline. Findings include: The facility's Medication Reconciliation policy, revised 10/24/22, indicates: This facility reconciles…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure 2 residents (R) (R11 and R14) of 5 sampled residents were monitored for adverse reactions or the effectiveness of antipsychotic medication. R11 was prescribed Seroquel (an antipsychotic medication) for dementia with behaviors. Staff did not monitor R11 for side effects, adverse reactions, or the effectiveness of the medication. R14 was prescribed lorazepam as needed (PRN) with a start date of 7/19/24. R14's lorazeapm order did not contain a stop date and was not reviewed by R14's provider after 14 days. Findings include: The National Institute for Health, www.ncbi.nlm.nih.gov Tardive Dyskinesia, updated 4/24/23, indicates: Numerous rating scales determine the presence and severity of tardive dyskinesia. The most widely used instrument is the Abnormal Involuntary Movement Scale (AIMS). It is recommended to administer the AIMS at baseline before initiating antipsychotic medications, with a follow-up screening performed no longer than three…

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 staff interview and record review, the facility did not ensure lab services were provided timely for 1 resident (R) (R18) of 5 sampled residents. The facility did not send a stool sample for testing in a timely manner for R18 who was diagnosed with Clostridium difficile (C. diff). A repeat test was ordered but not completed. Findings include: On 12/4/24, Surveyor reviewed R18's medical record. R18 had diagnoses including cognitive communication deficit, legal blindness, and vascular dementia with mild anxiety. R18's Minimum Data Set (MDS) assessment, dated 8/28/24, had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R18 had moderately impaired cognition. R18 was R18's own decision maker. R18's medical record contained an order, dated 11/1/24, for OVA (parasitology examination) and C. diff testing. On 11/1/24, the results were faxed from the laboratory and indicated C. diff testing would be conducted; however, an OVA test could not be completed because the sample was not sent for testing within the required two-hour time frame. A repeat OVA…

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 staff interview and record review, the facility did not ensure required nurse aid training was completed for 2 of 5 Certified Nursing Assistants (CNAs). CNA-Q was hired on 1/31/22. CNA-Q did not have 12 hours of in-service training during the most recent anniversary of hire year. CNA-R was hired on 7/26/23. CNA-R did not have 12 hours of in-service training during the most recent anniversary of hire year. Findings include: The facility's Facility Assessment, dated 9/3/24, states: .d. Skill competencies are assessed upon hiring and reviewed annually during staff performance evaluations .if any skill deficiencies are identified, the Director of Nursing (DON) or supervisor will provide the necessary training .Required in-service training for Nurse Aides: In-service training must: Be sufficient to ensure the continuing competency of Nurse Aides but must be no less than 12 hours per year. Include dementia management training and resident abuse prevention training. Address areas of weakness as determined in Nurse Aides' performance reviews and Facility Assessment. Address the…

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

Based on observation, staff interview and record review, the facility did not ensure food was stored and served in a safe and sanitary manner. This practice had the potential to affect all 37 residents residing in the facility. Food items were not covered and did not meet temperature safety requirements prior to lunch service on 8/14/23. Staff did not complete hand hygiene prior to donning gloves during lunch service on 8/14/23. Microwaves located in the dining room and kitchen contained dried food debris. Mixing bowls on a storage shelf were not stored upside down. Findings include: On 8/14/23 at 8:39 AM, Surveyor began an initial kitchen tour with Dietary Manager (DM)-H who indicated the facility follows the Federal Food Code. Uncovered Food/Temperature: The Federal Food and Drug Administration (FDA) Food Code 2022 at 3-305.14 Food Preparation indicates: During preparation, unpackaged food shall be protected from environmental sources of contamination. The FDA Food code 2022 at 3-501.16 Time/Temperature Control for Safety Food, for hot and cold holding indicates: Bacterial growth…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not make a prompt and thorough effort to resolve a grievance for 1 Resident (R) (R17) of 14 residents. A grievance was filed on behalf of R17 on 8/7/23. The grievance was not thoroughly investigated, and the complainant did not receive a prompt response or resolution. Findings include: The facility's Grievance policy, with a reviewed/revised date of 7/2022, contained the following information: The facility will seek to resolve concerns, complaints or grievances and provide residents, responsible parties, staff and others feedback and resolution in a timely manner .The Department Head that is assigned the concern form is responsible for investigating the issues and following up to provide a resolution to the issue within 72 hours of being assigned the grievance. On 8/14/23, Surveyor reviewed R17's medical record. R17 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, major depressive disorder, and anxiety. R17's Annual…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure 1 Resident (R) (R29) of 2 sampled residents reviewed for hospitalization received the required information when transferred. R29 was transferred to the hospital on 6/25/23 and was not provided a written transfer notice. Findings include: The facility's Transfer and Discharge policy, dated 7/15/22, indicates: It is the policy of this facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility except as initiated by resident, necessary for the health and safety of resident or other individuals are endangered, or as otherwise permitted by applicable law. Emergency Transfer/Discharges - Initiated by the facility for medical reasons, or for the immediate safety and welfare of a resident (nursing responsibilities unless otherwise specified). b. Notify resident and/or resident representative. d. Complete and send with the resident (or provide as soon as practicable) a Transfer form. f.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure assessments were accurate for 3 Residents (R) (R17, R29, and R35) of 14 sampled residents and 1 closed record review. R17 had diagnoses of major depressive disorder and anxiety. R17's Annual Minimum Data Set (MDS) assessment, dated 1/17/23, indicated R17 did not have a serious mental health diagnosis. In addition, R17's Brief Interview for Mental Status (BIMS) was not assessed and the 9-question Patient Health Questionnaire (PHQ-9) (a diagnostic tool used to screen for the presence and severity of depression) was not completed. R29 had diagnoses of major depressive disorder and anxiety. R29's MDS assessment, dated 4/24/23, indicated R29 did not have a serious mental health diagnosis. In addition, R29's Return to Community Assessment (Section Q) was not completed. R35's MDS assessment, dated 1/24/23, did not contain a completed Return to Community Assessment (Section Q). Findings include: The Centers for Medicare and Medicaid Services (CMS)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not establish and maintain an infection control program designed to provide a safe and sanitary environment to help prevent the development and transmission of disease and infection for 1 Resident (R) (R5) of 1 resident observed during the provision of cares. Certified Nursing Assistant (CNA)-C did not appropriately remove gloves and cleanse hands during the provision of cares for R5. Findings include: The facility's Hand Hygiene policy, dated 11/2/22, indicates: All staff will perform proper hand hygiene procedures to prevent the spread of infections to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility .Hand Hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited 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.