Medical Suites at Oak Creek (The)

Based on interview and record review the facility did not ensure that 5 of 5 direct care staff reviewed received the required training regarding compliance and ethics.CNA (Certified Nursing Assistant) TT, UU, VV, WW, XX have all worked at the facility for longer than 1 year and have not received the required training.This has the potential to affect all 112 residents as the 5 staff members work on various units of the facility.Findings include:The facility's policy dated as last revised 1/1/25 and titled Training Requirements documents: It is the policy of this facility to develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. 1. The facility has designated the Staff Development Coordinator, or designee, as the contact person for the facility's training program. The person works closely with the Compliance Officer and other facility leaders in developing the program. 2. The amount and types of training necessary are based on a…

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

Based on interview and record review the facility did not ensure that 5 out of 5 Certified Nursing Assistants completed 12 hours of required training annually. CNA (Certified Nursing Assistant)TT, UU, VV, WW, XX have all worked at the facility for longer than one year and have not completed the required annual 12 hours of training. This has the potential to affect all 112 residents as the 5 staff members work on various units throughout the facility.Findings include:The facility's policy dated as revised 1/1/25 and titled Training Requirements documents: It is the policy of this facility to develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. 1. The facility has designated the Staff Development Coordinator, or designee, as the contact person for the facility's training program. The person works closely with the Compliance Officer and other facility leaders in developing the program. 2. The amount and types of training…

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

Based on interview and record review, the facility did not ensure that 5 out of 5 direct care staff reviewed received the required behavioral health training.*CNA (Certified Nursing Assistant)TT, UU, VV, WW, XX have all worked at the facility for longer than 1 year and have not received the required behavioral training.This has the potential to affect all 112 residents as the 5 staff members work on various units of the facility.Findings include:The facility's policy dated as implemented 7/10/24 and revised 1/1/25 and titled Training Requirements documents: It is the policy of this facility to develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. 1. The facility has designated the Staff Development Coordinator, or designee, as the contact person for the facility's training program. The person works closely with the Compliance Officer and other facility leaders in developing the program. 2. The amount and types of training…

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 have evidence that all alleged violations of abuse were thoroughly investigated for 1 (R5) of 3 residents reviewed for allegations of abuse.On 4/5/26, Certified Nursing Assistant (CNA)-X performed cares independently with R5, and R5 rolled out of bed. R5 was evaluated in the emergency room (ER) on 4/9/26 with findings that did not correlate to the fall on 4/5/26 and with the bruising identified as potential abuse in the ER.Findings include:The facility's policy titled Abuse, Neglect and Exploitation dated 9/18/23, last reviewed 7/1/25, documents:Guideline:It is the guideline 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. The facility has a zero-tolerance stance around founded abuse, neglect, exploitation and misappropriation of resident…

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

Based on interview and record review, the facility did not ensure 13 (R13, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, & R27) of 13 sampled residents with scheduled medication administrations on 3/6/2026 from 7:00pm to 7:00am were free from significant medication errors.Findings include:The Facility Policy and Procedure titled, Medication Error Reporting and Counseling Procedure, last revised 4/9/2025, documents: Explanation and Compliance Guidelines:1. The facility shall ensure medications will be administered as follows:a. According to physician's orders.4. The facility will consider factors indicating errors in medication administration, including, but not limited to, the following:a. Medication administered not in accordance with the prescriber's order. Examples include, but not limited to:i. Incorrect dose, route, dosage form, time of administration;ii. Medication omission.8. If a medication error occurs, the following procedure will be initiated:a. The nurse assesses and examines the resident's condition and notifies the physician or health care practitioner as soon…

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' physician and/or residents' representative were notified of changes including accidents resulting in injury, need to alter treatment for 3 (R1, R5, and R14) of 30 residents reviewed. R1's physician was not made aware of/ consulted with regarding a 20 lb. weight loss between 3/25/2026 – 4/8/2026. R5's case manager was not notified of a fall with injury that occurred on 4/5/2026. R14's power of attorney (POAHC) was not notified on abnormal lab results or changes to R14's wounds. Findings include: The facility policy titled Notification of Changes last reviewed/revised 3/31/2025 documents: The purpose of this guideline is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident' representative when there is a change requiring notification. Changes of condition require an evaluation, by using the eINTERACT Change in Condition Evaluation ensures…

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's grievance was thoroughly investigated, pertinent findings or conclusions were documented and communicated to the resident. This was observed with 1 (R12) of 16 record reviews.* R12 voiced a grievance to the facility on 1/7/2026 related to R12 requesting referrals to 2 other Skilled Nursing Facility (SNF). There is no documentation the referrals were completed, or that the grievance findings or conclusion was communicated to R12.Findings include:R12 was admitted to the facility on [DATE] and readmitted on [DATE]. R12 is their own person.On 4/14/26, at 12:54 PM, Surveyor interviewed R12 in their room. R12 stated they voiced to facility staff they wanted a referral to move to another facility. R12 stated R12 provided the facility with the names of 2 skilled nursing facilities (SNF) R12 wanted a referral sent to. R12 stated that the facility has not provided R12 with any documentation these referrals were made. R12 stated this has been…

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 upon interview and record review, the facility did not ensure a comprehensive assessment, including an analysis of findings to develop a plan care, was completed for 1 (R14) of 30 sampled residents.R14 had an Annual (comprehensive) Minimum Data Set (MDS) completed with an assessment reference date of 12/3/25. The MDS indicated R14 had changes in bladder continence and mobility. The MDS Care Area Assessments (CAAs) had areas that were not comprehensively reviewed to include a rationale of the R14's individual needs and summary analysis to develop a comprehensive plan of care for R14.Findings include:The facility's policy and procedure for Comprehensive Care Plans dated 2/5/25, revised 5/1/25 documented:Explanation and Compliance Guidelines: .2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure 2 (R11 and R14) of 16 sampled residents had their care plan reviewed and revised by the interdisciplinary team. *R11 experienced falls on 2/13/2026 and 2/14/2026. The facility did not review, revise or update R11's care plan with person centered interventions to prevent additional falls. *R14's Annual Minimum Data Set, dated [DATE] assessed R14 as having a decline in mobility and bladder incontinence. R14's plan of care was not updated to address the change in assistance needed by R14. Additionally, R14's care plan for skin integrity and Activities of daily living were not updated to reflect an individualized plan to reposition R14 despite nursing notes referencing repositioning R14 every 2 hours per protocol. R14 had an unstageable pressure injury with osteomyelitis. Findings include: The facility policy and procedure for comprehensive Care plans implemented 2/5/25, revised 5/1/25 documented for care plans: . Explanation and compliance Guidelines:…

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 always ensure that 1 (R32) of 4 sampled residents reviewed for ADL ( activities of daily living) dependent care received the necessary services to maintain good hand hygiene.R32 is dependent on staff for all activities of daily living. R32 also has significant hand contractures to both the right and left hand. The facility did not ensure that R32 was receiving proper hand hygiene by making sure the length of R32's fingernails would not compromise the skin integrity of the palm of her hand. R32 developed a Stage 3 pressure injury to R32's palm due to her finger nail becoming imbedded into the palm of her left hand. Findings include:R32 was admitted to the facility on [DATE] with diagnosis that included Parkinson's Disease, Contracture of muscle, multiple sites, Muscle Weakness, Contracture of left and right hand and Dementia.R32's Significant Change MDS ( Minimum Data Set), dated 1/26/26 documents that R32 has a BIMS ( brief interview for mental…

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 1(R12) of 2 sample residents with a foley catheter had indications for use, along with care and services.*R12 was observed with a foley catheter and did not have a physician order to indicate use, along with care and services.Findings include:R12 was readmitted to the facility on [DATE] with diagnoses that include urinary tract infection, neuromuscular dysfunction of the bladder and retention of urine.On 4/14/26, at 9:45 AM, Surveyor observed R12 in their room. R12 had a foley catheter bag with urine in it. R12 was asleep at this time in their bed.On 4/14/26, at 12:54 PM, Surveyor interviewed R12 in their room. R12 stated they do not know how long they have had the foley catheter but R12 thought it was over a year. R12 stated they have never seen a urologist and have asked facility staff about seeing one.Surveyor reviewed R12's medical record and noted that R12's current physician orders and plan of care summary does not document that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure residents maintained acceptable parameters of nutritional status for 1 (R1) of 1 residents reviewed for weight loss.* R1 was admitted to the facility on [DATE] and the facility did not obtain an admission weight. On 4/8/2026, the facility weighed R1 and documented a weight loss of 19.9 pounds (lbs.) from R1's hospital discharge weight. R1's weight loss was not prescribed, no new interventions were implemented to prevent further weight loss, and facility did not obtain an additional weight for R1, per Registered Dietician (RD)-G's recommendation. Findings include:The facility policy titled Weight Monitoring last reviewed/ revised 10/30/2024 documents: Guideline: Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not provide medically related social services to a resident to maintain their highest physical, mental, and psychosocial well-being. This was observed with 1 (R14) of 16 residents reviewed for social services.*R14 had an activated Power of Attorney for Healthcare (POAHC) (CCC). In December 2025, R14 developed pressure injuries, a wound infection, a change in nutritional needs, and an order for Hospice services. There is no documentation of Social Service involvement with R14's clinical changes leading to suggestion of hospice services and coordination of the referral to hospice. Findings include:The facility's policy and procedure titled Social Services, undated, states the following guidelines: The facility, regardless of size, will provide medically related social services to each resident to assist in attaining or maintaining the resident's highest practical physical, mental, and psychosocial well-being.Explanation and Compliance Guidelines state:2. 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 accurate and safe administration of medication for 1 resident (R28) of 3 reviewed. R28's Amlodipine Besylate 5mg (milligrams) medication for hypertension was unavailable and facility staff did not check contingency for the medication or notify R28's physician. Findings include:The Facility Policy and Procedure titled, Unavailable Medications, last revised 4/9/2025, documents: Guideline: The facility shall use uniform guidelines for unavailable mediations.Explanation and Compliance Guidelines:1. The facility maintains a contract with a pharmacy provider to supply the facility with routine, prn, and emergency medications. 2. A STAT supply of commonly used medications is maintained in-house for timely initiation of medications. 3. The facility shall follow established procedures for ensuring residents have a sufficient supply of medications. (See Guideline: Medication Reordering.) 4. Medications may be unavailable for a number of…

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

Based on observation, interview and record review, the facility did not ensure the medication error rate was below 5% for 2 (R24 and R29 ) of 6 residents observed receiving medications. The facility medication error rate was 12%. *R29 received one 81mg enteric coated Aspirin. R29's physician order documents Aspirin 81 oral tablet chewable (aspirin). Give 81mg by mouth in the morning for NSTEMI.*R24 received one 81mg chewable Aspirin. R24's physician order documents Aspirin EC (enteric coated) tablet delayed release 81MG (aspirin). Give 1 tablet by mouth in the morning for heart disease. *R24 received Senna 8.6mg. R24's physician order documents Senna-Docusate Sodium oral tablet 8.6-50 mg (sennosides-docusate sodium). Give 1 tablet by mouth two times a day for constipation.Findings include:On 4/14/2026, at 8:49 AM, Surveyor observed medications being administered to R29. Licensed Practical Nurse (LPN)-R prepared six medications to administer to R29. Surveyor observed LPN-R add one 81 mg enteric coated Aspirin to the medication cup that R29 was to receive. Surveyor noted upon review…

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, drugs and biologicals used in the facility were not labeled in accordance with currently accepted professional principles, and include the resident name, opened on or expiration date when applicable for 1 of 1 medication carts reviewed. The medication cart on front Sparkle unit contained insulin pens that were not labeled with a resident name or dated of when the pens were opened.Findings include: The Facility policy titled Insulin Pen with Date Implemented of 04/09/2025, documents: Guideline: It is the guideline of this facility to use insulin pens in order to improve the accuracy of insulin dosing, provide increased resident comfort, and serve as a teaching aid to prepare residents for self-administration of insulin therapy upon discharge.Explanation and Compliance Guidelines:1. Insulin pens contain multiple doses of insulin but are used for a single resident only.2. Insulin pens must be clearly labeled with the resident name, physician name, date dispensed, type of insulin, amount to be given, frequency, and expiration date.3.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not ensure a resident's change in diet consistency was comprehensively assessed, including obtaining supporting physician or Registered Dietician documentation, after a change in condition for 1 (R14) of 6 residents reviewed for nutrition.*R14's diet was downgraded from a mechanical soft ground diet with thin liquids to a pureed diet with nectar thick liquids without evidence of a comprehensive assessment related to the change in condition. There was no physician order or Registered Dietitian order regarding the diet downgrade.Findings include:The facility's policy and procedure Therapeutic Diet Orders revised 3/26/2025. The Guideline: The facility provides all residents with foods in the appropriate form and order the appropriate nutrient content as prescribed by a physician, and or assessed by the interdisciplinary team to support the resident's treatment plan of care, in accordance with his or her goals and preferences.Explanation and Compliance…

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 offer the influenza immunization to 1 (R4) of 1 residents reviewed for immunizations.*R4 requested the influenza vaccine in [DATE], and has not received a influenza vaccine as of April of 2026.Findings Include:The facility's policy titled, Influenza Vaccination dated as last revised on [DATE] documents: Influenza vaccinations will be routinely offered annually from [DATE]st to [DATE]st unless such immunizations is medically contraindicated, the individual has already been immunized during this time period, or refuses to receive the vaccine.Additionally, influenza vaccinations will be offered to residents upon availability of the seasonal vaccine until influenza is no longer circulating in the facility's geographic area.Flowing the assessment for potential medical contraindications, influenza vaccinations may be administered in accordance with physician-approved standing orders.Individuals receiving the influenza vaccine, or their legal representative,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility did not ensure 3 (R159, R2, R170) of 14 residents reviewed received necessary care and treatment. * R159 did not have weekly skin assessments completed for three weeks, there was not a comprehensive assessment completed, treatment initiated, or care plan revision when R159 developed a gluteal fissure on 12/8/2025. * R2 did not have consistent monitoring of daily weights or fluid intakes to monitor for fluid overload. * R170's urinalysis was not processed for one week and required antibiotics for a urinary tract infection. Findings include: The facility policy titled: Specimen Collection last reviewed/ revised on 12/17/2024 documents: It is the guideline of this facility to collect residents' blood and body fluid specimens as per the physician's orders in accordance with current standards of practice and regulatory guidelines. Compliance Guidelines: . d. is labeled accurately and accordingly as per protocol for transport to the laboratory for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not ensure a resident's skin was comprehensively assessed, to identify, and prevent, pressure injuries from developing. This was observed with 1 (R169) of 3 residents reviewed with pressure injuries. * R169 had a current pressure injury (PI) and experienced a decline in their health status. Their skin was not comprehensively assessed with the onset of additional risk factors. R169 was admitted to the hospital on [DATE] with 4 pressure injuries.The facility's policy and procedures titled Pressure Injury Prevention and Management dated 4/17/2025, documents, The Guideline: The facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to prove morning provide treatment and the services to yield the pressure ulcer or injury, prevent infection and the development of additional pressure ulcers or injuries.3. Assessment of pressure Injury Risk.3.a,) Licensed nurses will conduct a pressure injury risk assessment, using…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and facility policy review, the facility did not ensure medication administration was timely for 1 of 1 resident (Resident (R)) 2, reviewed for late medications out of 14 sampled residents. This failure had the potential to interfere with the medication effectiveness.*R2 did not receive 9 doses of an ordered medication due to the medication being unavailable.Findings:R2 was admitted to the facility on [DATE] with diagnoses which include, heart failure, and fluid overload.R2's most recent Minimum Data Set (MDS), dated [DATE], indicates R2 has a Brief Interview for Mental Status (BIMS) score of 15, indicating R2 is cognitively intact and does not exhibit refusals or rejection of care behaviors.On 12/16/2025, at 10:11 AM, Surveyor interviewed R2. R2 informed Surveyor that R2 had concerns regarding an eye drop medication R2 was supposed to receive but it was not ordered and R2 did not get the eye drops for almost 1 week.Surveyor reviewed the facility provided document, titled…

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

Based on observations, document review, interviews, and facility policy review, the facility failed to ensure milk gallons were held at the proper temperature in the 300-hall dining room; failed to ensure the pantry refrigerator and the entire main kitchen were clean for one of two observed pantries and one of one kitchen; failed to ensure food was labeled, dated, and disposed of after expiration for one of two observed pantries; and failed to ensure holding temperatures for the tray line were monitored for proper temperatures for one of one kitchen. The failures had the potential to affect potential food borne illnesses and the potential of contamination for 115 of 116 census residents that take food by their mouth. Findings include: 1.During an observation of 300-hall dining room on 09/30/25 at 12:03 PM, there were two gallons of milk stored on the counter and not held on ice or refrigeration. During an observation of 300-hall dining room on 10/01/25 at 12:22 PM, there were two gallons of milk stored on the counter and not held on ice or refrigeration. The temperature of the milk…

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

Based on observations and interviews, the facility failed to ensure the exterior trash area was free from debris and the doors were closed on two of two trash bins with the ability to affect all 116 census residents. This failure had the potential to contribute to pest infestation. Findings include: During an observation on 10/02/25 at 10:37 AM, with the Food Service Director (FSD) two trash bins were noted outside near the kitchen. One of the trash bins was designated for recycling only. Two of two lids were in an open position and there was trash debris on the ground surrounding the bin. The second trash bin was designated for trash only. Two of two lids were in the open position and there was trash debris (gloves, a mask, and an empty plastic container of V-8) on the ground surrounding the bin. The second trash bin was overflowing with trash bags. The FSD acknowledged that the lids should have been shut, and the debris should have been cleaned. He stated the dietary staff took the trash out after each meal. During an interview on 10/02/25 at 3:00 PM, the Registered Dietitian (RD)…

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.

Base on QAPI record reviews, interviews, and facility policy review, the facility failed to develop and implement a Quality Assurance and Performance Improvement (QAPI) process to address identified deficient practices resulting in continued noncompliance. Lack of developing and implementing improvement plans for identified problems through the QAPI process could lead to prolonged periods of non-compliance affecting residents, staff, and families accordingly thus affecting all 116 residents. Findings include:Review of the facility's 07/15/24 Statement of Deficiencies, CMS-2567 found in the facility's Survey Results binder near the front entrance, revealed the facility was cited for:F804: Food PalatabilityF814: Proper Garbage/Refuse DisposalF880: Infection Prevention and Control During the survey on 09/30/25 through 10/03/25, the facility was again cited for all deficiencies listed above related to similar deficient practices. Cross-reference:F804: The facility failed to serve food at palatable temperatures.F814: The facility failed to dispose of garbage in a sanitary manner.F880:…

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, observations, interview, and review of call light data, the facility failed to ensure that five out of 46 residents (Resident (R) 156, R162, R65, R7, R109) call lights were answered timely. This failure increased the risk of residents not having their needs met.Findings include:Based on record review, observations, interview, and review of call light data, the facility failed to ensure that five out of 46 residents (Resident (R) 156, R162, R65, R7, R109) call lights were answered timely. This failure increased the risk of residents not having their needs met. Findings include: 1. Review of R156's admission Record, located under the Profile tab of the electronic medical record, revealed she was admitted to the facility on [DATE] with diagnoses including femur fracture, asthma, muscle weakness, pain, and history of fall. Review of R156's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/01/25, revealed she scored 15 out of 15 on the Brief Interview for Mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, interviews, and facility policy review, the facility failed to ensure food was palatable and served at a safe and appetizing temperature for five of 30 sampled residents (Resident (R) 7, R22, R48, R90, and R124) reviewed for palatability. This failure had the potential to lead to decreased oral intake and weight loss. Findings include: 1.Review of R7's Face Sheet located under the Profile tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE] and readmitted on [DATE] with diagnoses of unspecified fracture of upper end of right humerus, anemia, and depression. Review of R7's significant change in status Minimum Data Set (MDS) located under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 08/17/25 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R7 was cognitively intact. During an interview on 09/30/25 at 8:37 AM, R7 stated the food was not hot and that they (the kitchen) did not 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and document review, the facility failed to determine one of 30 sampled residents (Resident (R) 132) was safe in the self-administration of physician ordered medications. This failure had the potential for R132 to not take her medication and experience adverse effects of not taking the physician ordered medications. Findings include: Review of R132's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) indicated R132 was readmitted to the facility on [DATE] with diagnoses of congestive heart failure, chronic obstructive pulmonary disease, hypertension, and pain in left arm. Review of R132's quarterly Minimum Data Set (MDS) located under the MDS tab in the EMR, with an Assessment Reference Date (ARD) of 08/09/25, indicated R132 was coded for a Brief interview for Mental Status (BIMS) score of 11 out of 15 which indicated R132 was moderately cognitively impaired. Review of R132's Care Plan located under Care Plan tab in the EMR…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and policy review, the facility failed to ensure code status was accurately reflected in the electronic medical record (EMR) for one of 30 residents (Resident (R) 83) reviewed in the Initial Pool out of a census of 116. This failure had the potential for R83 to receive cardiopulmonary resuscitation (CPR) when the wishes of the resident were to die a natural death, which could contribute to physical injury or emotional anguish. Findings include: Review of R83's admission Record, located under the Profile tab of the EMR, revealed she was admitted to the facility on [DATE] following hospitalization for right tibia and patellar fractures and had diagnoses including depression, anxiety, and bipolar disorder. Review of R83's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE] and located under the MDS tab of the EMR, revealed she scored 14 out of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. Review of R83's Profile…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and document review, the facility failed to notify the ombudsman of discharges and failed to provide a transfer notice and bed hold policy to the resident and/or Resident Representative (RP) for one of three residents (Resident (R)12) reviewed for discharges out of a total of 30 sampled residents. This failure had the potential for the residents and RP to be misinformed of the transfer out of the facility. Findings include:Based on record review, interview, and document review, the facility failed to notify the ombudsman of discharges and failed to provide a transfer notice and bed hold policy to the resident and/or Resident Representative (RP) for one of three residents (Resident (R)12) reviewed for discharges out of a total of 30 sampled residents. This failure had the potential for the residents and RP to be misinformed of the transfer out of the facility. Findings include: Review of R12's undated Face Sheet located under the Profile tab in the electronic medical record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and facility policy review, the facility failed to ensure the Care Plan for one of two residents reviewed for behaviors (Resident (R) 2) out of a total sample of 30 reflected their behavioral health needs. This failure created potential for lack of behavioral intervention for R2.Findings include:Based on interviews, record review, and facility policy review, the facility failed to ensure the Care Plan for one of two residents reviewed for behaviors (Resident (R) 2) out of a total sample of 30 reflected their behavioral health needs. This failure created potential for lack of behavioral intervention for R2. Findings include: Review of R2's admission Record, located under the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses including fibromyalgia, morbid obesity, and depression. Review of R2's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/26/25 and located under the Profile tab…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and facility policy review, the facility failed to ensure baths or showers were provided according to the schedule for three of three residents (Resident (R) 109, R7, and R48) reviewed for bathing out of 30 sample residents. This failure had the potential to result in the residents not maintaining adequate hygiene to prevent odor and skin infections.Findings include: Based on record review, interviews, and facility policy review, the facility failed to ensure baths or showers were provided according to the schedule for three of three residents (Resident (R) 109, R7, and R48) reviewed for bathing out of 30 sample residents. This failure had the potential to result in the residents not maintaining adequate hygiene to prevent odor and skin infections. Findings include: 1.Review of R109's Face Sheet located under the Profile tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE] and readmitted on [DATE] with diagnoses to include end stage renal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to address a significant weight loss of 19% in one month for one of five residents reviewed for nutrition (Resident (R) 3) out of a total sample of 30 residents. This failure had the potential to contribute to further weight loss, malnutrition, muscle wasting, weakness, and death.Findings include:Review of R3's admission Record located under the Profile tab of the electronic medical record (EMR) revealed she admitted to the facility on [DATE] and re-admitted on [DATE]. She had diagnoses including Parkinson's disease, dementia, diabetes, dysphagia, stage IV sacral pressure ulcer, additional unstageable pressure ulcer of back/buttock/hip, additional stage IV pressure ulcer, contractures, and history of stroke. Per R3's EMR under the Census tab R3 was hospitalized from [DATE] through 08/04/25. Review of R3's significant change of condition Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/08/25 located under 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, record review, interview, and review of policy and procedures, the facility failed to follow infection control guidelines for the storage of a nebulizer mask for one (Resident (R)132) of three residents reviewed for respiratory care out of 30 sampled residents. This failure had the potential to increase infections in vulnerable residents receiving respiratory care in the nursing facility.Findings include:Review of R132's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) indicated R132 was readmitted to the facility on [DATE] with the diagnoses to include chronic obstructive pulmonary disease Review of R132's quarterly Minimum Data Set (MDS) located under the MDS tab in the EMR, with an Assessment Reference Date (ARD) of 08/09/25 indicated R132 was coded for a Brief interview for Mental Status (BIMS) score of 11 out of 15 which indicated R132 was moderately cognitively impaired. Review of R132's Physician Orders located under the Orders tab in the EMR…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to ensure ongoing assessment and monitoring for complications before and after dialysis treatments were completed to ensure communication with the dialysis facility for one (Resident (R) 111) of one resident reviewed for dialysis out of a total sample of 30 residents. This failure had the potential to lead to uncommunicated and unassessed changes or complications for R111 and other residents receiving dialysis.Findings include:Review of R111's admission Record located under the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses of end stage renal disease and dependence on renal dialysis. Review of R111's admission Minimum Data Set (MDS) with an Assessment Reference Date of 09/25/25 revealed she scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) indicating intact cognition. The MDS further indicated she received hemodialysis. Review of R111's EMR…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and facility policy review, the facility failed to ensure medication administration was timely for one of one resident (Resident (R) 109) reviewed for late medications out of 30 sampled residents. This failure had the potential to interfere with the medication effectiveness. Findings include: Review of R109's Face Sheet located under the Profile tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE] and readmitted on [DATE] with diagnoses to include end stage renal disease, type two diabetes, ascites, absence of right left knee, and sleep apnea. Review of R109's quarterly Minimum Data Set (MDS) located under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 08/27/25 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R109 was cognitively intact.During an interview on 09/30/25 at 10:04 AM, R109 stated he did not get his medications on time. He stated medication that was due at 7:00 AM, he may…

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 failed to obtain a physician order prior to obtaining laboratory tests for one of one resident (Resident (R)98) out of a total sample of 30 residents. This failure had the potential of obtaining unnecessary laboratory testing from residents.Findings include:Review of R98's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) indicated R98 was readmitted to the facility on [DATE] with the diagnosis of an abdominal hematoma. Review of R98's quarterly Minimum Data Set (MDS) located under the MDS tab in the EMR, with an Assessment Reference Date (ARD) of 06/18/25 indicated R98 had a Brief Interview for Mental Status (BIMS)score of 12 out of 15, which indicated R98 was moderately cognitively impaired. During an interview on 10/02/25 at 3:49 PM, Unit Manager (UM)1 stated, the [Power of Attorney (POA)] for [R98] emailed and stated that when the resident was discharged from the hospital on [DATE], the hospital doctor wanted her [R98]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to collaborate care with the hospice agency for one of one resident (Resident (R)127) reviewed for hospice services out of a total sample of 30 residents. This failure had the potential to increase the risk of resident needs not being addressed.Findings include:Review of R127's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) indicated R127 readmitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease and dementia. Review of R127's significant change Minimum Data Set (MDS) located under the MDS tab in the EMR, with an Assessment Reference Date (ARD) of 08/21/25 indicated R127 had a Brief Interview for Mental Status (BIMS) score of six out of 15 which indicated R127had severe cognitive impairment. Review of R127's Care Plan located under the Care Plan tab in the EMR dated 10/03/25 indicated R127 had a …terminal prognosis and is receiving hospice services. Interventions included …Observe…

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, interview, and review of policies and procedures , the facility failed to wear Personal Protective Equipment (PPE) when entering into a contact isolation room for one of two residents (Resident (R)56) and failed to follow infection control guidelines when administering medications to one of three residents (Resident (R)132) observed during the Medication Administration Observation out one of 30 total sampled residents. The facility also failed to review and/or revise the infection control policies in the facility annually. These failures had the potential for residents to be exposed to infections unnecessarily. Findings include:1.Review of R56's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) indicated R56 was readmitted to the facility on [DATE] with the diagnosis of enterocolitis due to Clostridium Difficile (C. Diff) (an infection of the intestine). Review of R56's Physician Orders located under the Orders tab in the EMR indicated 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, document review, policy review, and review of McGeer's criteria, the facility failed to have an Antibiotic Stewardship Program that followed current standards of practice for prescribing an antibiotic for three of three residents (Resident (R)5, R62, and R96) reviewed for antibiotic stewardship out of total sample of 30 residents. This failure had the potential for residents to be prescribed unnecessary antibiotics.Findings include:1. Review of R5's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) indicated R5 was originally admitted to the facility on [DATE] with the diagnosis of malignant neoplasm of the spinal cord. Review of R5's Provider Progress Notes located under the Progress Notes tab in the EMR dated 08/30/24 indicated, .The patient presents today with complaints of dysuria, urinary frequency, and an odor to her urine. She [R5] reports that these symptoms began approximately on Monday. Review of the Physician's Orders located…

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 interviews, the facility failed to ensure residents who were self-administering medications had a self-administration of medications assessment, a physician's order, and a care plan completed for two (Resident (R) 1 and R2) of two residents reviewed for self-administration of medication.Findings include:The facility's policy titled, Resident Self-Administration of Medication revised on 04/17/25, indicated, under the section Guideline: It is the guideline of this facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. The policy indicated under section, Education and Compliance Guidelines, When determining if self-administration is clinically appropriate for a resident, the licensed nurse and/or interdisciplinary team should at a minimum consider the following:a. The medications appropriate and safe…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility did not complete neurological checks in accordance with policy and procedure for 2 (R3 and R4) of 2 residents reviewed for unwitnessed falls. *R3 sustained an unwitnessed fall on 6/27/25. Facility staff did not complete neurological checks in accordance with the facility's policy and procedure. *R4 sustained an unwitnessed fall on 6/9/25 and 6/23/25. Facility staff did not complete neurological checks in accordance with the facility's policy and procedure. Findings include: The facility policy dated 10/8/2024, titled Head injury (Neuro Checks) documents, in part: It is the guideline of this facility to report potential head injuries to the physician and implement interventions to prevent further injury . Assess resident following a known, suspected, or verbalized head injury. The assessment shall include, at a minimum: Vital signs, General condition and appearance, Neurological evaluation for changes . Evaluation of the head, eyes, ears, and nose for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure each resident received adequate supervision and assistance to prevent accidents for 1 (R4) of 2 residents reviewed for falls. On 6/9/25, R4 was found by facility staff on the floor between R4's bed and wall. The facility did not thoroughly investigate the fall. Findings include: The facility policy dated 7/10/2024, titled Incidents and Accidents documents, in part: It is the guideline of this facility for staff to utilize . [the electronic medical record] to report, investigate and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident . The purpose of incident reporting can include: assuring that appropriate and immediate interventions are implemented, and corrective actions are taken to prevent recurrences and improve the management of resident care . Licensed staff will utilize [the electronic medical record] to report incidents/accidents and assist with completion…

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, clinical record review, and policy review, it was determined the facility failed to ensure one of three residents (Resident(R)1) reviewed for abuse, neglect, and misappropriation was free from physical abuse. This does not ensure the protection of additional residents from abuse. Findings include: Review of the facility's policy titled Abuse, Neglect, and Exploitation, revised 05/19/25 revealed It is the guideline of this facility to provide protection 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. The facility has a zero-tolerance stance around founded abuse, neglect, exploitation and misappropriation of resident property. Review of R1's undated admission Record located in the electronic medical record (EMR) under the Profile tab, indicated the resident was admitted to the facility on [DATE] with diagnoses including…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and facility document review, it was determined that the facility failed to report the allegation of neglect for one of three residents (Resident(R)3) sampled for abuse, neglect, and misappropriation. This failure places all residents in danger of abuse, neglect, and misappropriation. Findings include: Review of the facility's policy titled Abuse, Neglect, and Misappropriation revised 05/19/25, revealed The facility will have written procedures to assist staff in identifying the different types of abuse-mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. This includes staff to resident abuse .The facility will have written procedures that include Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) when specified timeframe's: a. immediately, but not later than 2 hours after the allegation is made, if the events that…

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

Based on observation, interview, medication audit review, and policy review, the facility failed to ensure a medication administration error rate was less than 5 percent (%). There were eight errors out of 28 opportunities observed resulting in a medication error rate of 28.57% for two residents (Residents (R) 30 and R31) of three residents observed out of a total sample of 31. This had the potential for the residents to have unmet health needs. Findings include: 1. During an observation on 04/03/25 at 10:28 AM, Nurse Manager (NM)2 administered the following medications to R30: Pregabalin (for nerve pain) 2 tablets by mouth, Folic acid (B vitamin) 1 tablet by mouth, Tamsulosin (to treat enlarged prostate) 0.4 milligrams (mg) 1 tablet by mouth; and Vitamin B1 (supplement) 1 tablet by mouth. Review of the April 2025 Medication Audit Report provided by the facility revealed the medications should be administered at 9:00 AM. They were documented as administered at 10:29 AM and 10:30 AM. Review of the scheduling details for each order did not indicate the medications could 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.

Based on observation and interview, the facility failed to ensure trash was contained in the dumpsters and the yard was maintained in a sanitary condition with views from resident windows. This failure created a potential sanitation issue for residents, staff, and visitors that may go outside the facility. Findings include: During an observation of the exterior of the facility on 04/01/25 at 9:00 AM revealed a dumpster area surrounded by privacy fencing with building windows on both sides of the alleyway with staff rolling out two open bins of trash with boxes that were blowing off of the top of the bin. It was noted that both of the large green dumpsters had one of the two lids open. Trash (blue exam gloves, plastic bags, plastic bottles) were observed on the ground (cement, grassy area, and in shrubs) and around the dumpsters. At 5:20 PM observation of the area showed no changes in the uncontained trash or open dumpsters. During an observation of the exterior of the facility on 04/02/25 at 8:10 AM showed uncontained trash unchanged in the alleyway. At 6:30 PM, observation of 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 record review, interview, and policy review, the facility failed to ensure three of three residents and or their representatives (Resident (R) 1, R7, and R17) reviewed for facility initiated emergent hospital transfer out of a total sample of 31 were provided with a written transfer notice that contained all required information; or notify the Ombudsman's office of resident transfers. This failure has the potential to affect the resident and their Resident Representative (RR) by not having the knowledge of where and why a resident was transferred and/or how to appeal the transfer, if desired. Findings include: 1. Review of R7's admission Record from the electronic medical record (EMR) showed a facility admission date of 01/23/25. Review of R7's Progress Notes from the EMR Progress Notes tab revealed on 02/24/25 at 9:10 PM R7 had sustained a witnessed fall in her room sustaining a head wound and was transported to the hospital for evaluation. Further review of R7's EMR Progress Notes, Evaluations, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review, the facility failed to ensure three of three residents (Resident (R) 1, R7, and R17) reviewed for hospitalization, from a sample of 31 residents, received a written bed hold policy upon emergent transfer to the hospital. This failure had the potential to contribute to possible denial of re-admission and loss of the resident's home following a hospitalization for residents transferred to the hospital. Findings include: 1. Review of R7's admission Record from the electronic medical record (EMR) showed a facility admission date of 01/23/25. Review of R7's Progress Notes from the EMR Progress Notes tab revealed on 02/24/25 at 9:10 PM revealed R7 had sustained a witnessed fall in her room sustaining a head wound and was transported to the hospital for evaluation. A Nurse's Note on 02/25/25 at 3:43 AM stated R7 was being admitted to the hospital with facial fractures, dislocated shoulder, and a low hemoglobin. Further review of the R7's EMR Progress Notes,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and review of the Infection Prevention and Control Program (IPCP), review of the McGreer's Infection Symptom Tracking criteria, and facility policy review, the facility failed to ensure one of two residents (Resident (R)8) reviewed for antibiotic use out of a sample of 31 residents received an antibiotic with justification for its use. This had the potential for the resident to receive an antibiotic unnecessarily and could potentially contribute to the development of antibiotic-resistant bacteria. Findings include: Review of R8's admission Record from the electronic medical record (EMR) Profile tab showed a facility admission date of 12/05/23, readmission on [DATE], with medical diagnoses that included immunodeficiency, type II diabetes, end stage renal disease with dialysis, and thrombocytopenia. Review of R8's EMR Progress Notes tab dated 10/30/24 revealed the resident said he started having diarrhea yesterday after dialysis which has continued into today. On 10/31/24 the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide physician ordered laboratory testing for one of two residents (Resident (R) 8) reviewed for antibiotic use from a sample of 31. This failure had the potential to affect the appropriate diagnosis and treatment of residents by practitioners. Findings include: Review of R8's admission Record from the electronic medical record (EMR) Profile tab showed a facility admission date of 12/05/23, readmission on [DATE], with medical diagnoses that included immunodeficiency, type II diabetes, end stage renal disease with dialysis, and thrombocytopenia. Review of R8's EMR Progress Notes tab revealed on 10/30/24 the resident stated he started having diarrhea yesterday after dialysis which has continued into today. On 10/31/24 the resident complained of diarrhea with eight episodes of diarrhea per the night. Orders were received to obtain a clostridium difficile (C-diff) PCR stat [polymerase chain reaction immediately] stool culture. On 11/01/24 the Nurses…

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

Based on record review, interview, and facility policy review, the facility failed to provide three of three residents (Resident (R) 5, R15, and R17) written notification of room change as indicated in their facility policy of 17 sample residents. Findings include: Review of the facility's policy titled, Change of Room or Roommate, dated 03/07/23, revealed 5. The notice of a change in room . will be provided in writing .and will include the reason (s) why the move or change is required . Review of the document titled, Action Summary, dated 12/04/24 provided by the Administrator, indicated R5 had a room change on 12/03/24; R15 had a room change on 11/23/24; and R17 had a room change on 11/14/24. Reviews of R5, R15, and R17's electronic medical records (EMR) reviewed no documentation that the residents had been provided with written notification of the room changes. During an interview on 12/03/24 at 2:24 PM, the Social Worker (SW) confirmed that R5's EMR lack written documentation informing the resident of the room change. During an interview with the Administrator and Director 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 failed to implement a physician order for one of one resident (Resident (R) 1) of 17 sample residents, to be Nothing by Mouth (NPO) prior to a scheduled surgery. Specifically, R1 consumed his breakfast meal prior to being transferred to the hospital, which caused the surgery to be canceled. This deficient practice caused the resident to experience emotional stress and delay in having hip surgery. Findings include: Review of R1's electronic medical record (EMR) admission Record under the Profile tab revealed R1 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/01/24 in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of eight out of 15 which indicated R1 had moderate cognitive impairment. Review of R1's Order Summary Report, dated 10/14/24 and provided by the Administrator, revealed NPO at midnight .Procedure scheduled for 10/18/24, arrival…

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, implement, and maintain an effective training program for contracted staff, consistent with contracted staff's expected roles and types of training necessary for 6 of 6 agency staff interviewed. This deficient practice has the potential to affect all 112 residents residing in the facility. * The facility does not have an effective training program consistent with expected roles and did not determine the amount or types of training necessary for agency staff. Findings include: The facility did not provide a policy and procedure for required trainings of agency/contracted staff. Surveyor reviewed staff schedules from 08/16/2024 - 08/31/2024 relating to staffing complaint allegations. Surveyor noted 33 agency staff scheduled during that period. On 09/09/2024, at 12:13 PM, Surveyor interviewed R405. Surveyor noted a sign on R405's wall, directly across from the bed, indicating R405's offloading boot schedule. Surveyor noted R405 did not have boots…

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 2 (R402 and R404) of 4 residents reviewed for showers and who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good hygiene. * R402 and R404 did not receive showers according to their shower schedule. Findings include: The facility policy dated 10/24/22 and titled Activities of Daily Living (ADLs) documents: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: Bathing, dressing, grooming and oral care. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. 1.) R402 was admitted to the facility on [DATE] with diagnoses that included…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not provide the necessary care and services to prevent and/or promote healing of pressure injuries for 1 (R405) of 5 residents reviewed for pressure injury prevention and treatment. *R405 did not have off-loading boots in place per R405's care plan. Findings: 1.) R405 admitted to the facility on [DATE] with diagnoses to include, paraplegia, severe protein-calorie malnutrition, end stage renal disease, and reliance on renal dialysis. R405's admission Minimum Data Set (MDS) dated [DATE], documents that R405 has a Brief Interview for Mental Status (BIMS) score of 13, indicating that R405 is cognitively intact. R405 did not have any behaviors or refusals of care, is dependent on staff with transfers in and out of bed/chair, and is at risk for developing pressure ulcers. R405's care plan documents that R405 has Activities of Daily Living (ADL) self-care performance deficits and limitations in physical mobility and requires assist of 2 people 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 interview and record review, the facility did not ensure an allegation of neglect and verbal abuse for 1 (R83) of 1 residents reviewed, included steps that were taken by the facility to ensure safety of the facility residents. * R83 was transferred without a mechanical lift and fell, fracturing her right ankle. The Certified Nursing Assistants (CNAs) knew they should use a mechanical lift and decided to transfer R83 with an assist of 2 and a gait belt. When R83 fell during the transfer, the CNAs got her off the floor and into her wheelchair. The fall was not reported to the nurse on duty until several hours later. During the transfer, the CNA was heard telling R83, I'm not your bitch, causing R83 to experience anxiety. Neither CNA-JJ nor CNA-KK were suspended pending an investigation and both were allowed to finish their shifts on 6/9/24, the day of R83's fall. There was no evidence that an investigation into the allegations was started until the next day when the Nursing Home Administrator was notified…

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

Based on observations and interview, the facility did not ensure garbage and refuse were properly disposed in the outside garbage storage receptacles. This deficient practice had the potential to affect all 115 residents residing at the facility during the onsite visit. Findings include: On 7/8/24 at 9:15, Surveyor observed the outside garbage storage receptacle area to ensure that garbage and refuse were properly disposed. Surveyor observed the facility's dumpster to be overflowing with refuse with additional garbage bags on the ground next to the receptacle. Surveyor noted swarms of flies surrounding facility's outside garbage storage receptacle area. On 7/9/24 at 10:00 AM, Surveyor observed the facility's dumpster to be overflowing with refuse with additional garbage bags on the ground next to the receptacle. Surveyor noted swarms of flies surrounding facility's outside garbage storage receptacle area. On 7/10/24 at 9:20 AM, Surveyor observed the facility's dumpster to be overflowing with refuse with additional garbage bags on the ground next to the receptacle. Surveyor noted…

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 a staff person designated as the Infection Preventionist (IP) completed specialized training in infection prevention and control. This practice had the potential to affect all 115 residents residing in the facility. * DON (Director of Nursing)-B not complete specialized training for infection prevention and control. Findings include: On 7/9/24 at 10:35 AM, Surveyor interviewed DON-B who verified that the previous IP at the facility had left their position on 7/5/24 without notice. As of 7/8/24, DON-B is currently functioning as the facility's IP. Surveyor requested to review DON-B's specialized training for Infection Prevention and Control. On 7/9/24 at 1:20 PM, DON-B told Surveyor that they are in the process of completing the CDC (Centers for Disease Control) and Prevention training modules. On 7/10/24, Surveyor shared concerns with NHA (Nursing Home Administrator)-A that DON-B who is acting as the facility's IP has not completed specialized training for Infection Prevention and Control. No additional…

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 5 (CNA-CC, CNA-DD, CNA-EE, CNA-FF, and CNA-GG) of 5 sampled CNAs (Certified Nursing Assistant), who had been employed at the facility for over a year, had documented performance reviews. This deficient practice has the potential to affect all 115 residents residing in the facility whom can receive care from the 5 CNAs. Findings Include: The facility's policy titled Annual Employee Evaluations and dated 5/2/23 was reviewed and documented: To comply with federal regulations, all employees will receive an annual evaluation of their work performance. On 7/15/24, CNA-CC, CNA-DD, CNA-EE CNA-FF, and CNA-GG's annual performance evaluations were requested from the facility. On 7/15/24, the list of CNAs that had worked for the facility for longer than a year was reviewed. The employment list documented: - CNA-CC began her employment with the facility on 1/17/23. - CNA-DD began her employment with the facility on 5/10/22. - CNA-EE began her employment with the facility on 2/7/23. - CNA-FF began her employment with 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 3.) R31 admitted to the facility on [DATE] and has diagnoses that include Acute Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Diseases, End Stage Renal Disease, Malignant Neoplasm of Colon, Major Depressive Disorder, Dementia, Anxiety, Colostomy status, Obstructive and Reflux Uropathy, Nephrostomy Catheter, Peripheral Vascular Disease, Hypertension, Acute Pyelonephritis and Sepsis. R31's E-interact dated 3/16/24 documented: Situation: The Change In Condition/s (CIC) reported on this CIC Evaluation are/were: Bleeding (other than GI) Tired, Weak, Confused, or Drowsy. Nursing observations, evaluation, and recommendations are: resident c/o (complained of) increased lethargic, weakness and poor appetite. C/O abdominal pain. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: Recommendations: Send to ER (Emergency Room) for eval (evaluation). R31 was subsequently admitted to the hospital. Surveyor was unable to locate evidence a transfer notice with 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 record review and interview, at the time of transfer of a resident for hospitalization or therapeutic leave, the facility did not provide to the resident or the resident representative written notice which specifies the duration of the bed-hold policy for 4 of 7 (R31, R40, R35 and R59) reviewed for bed hold. Findings include: The facility undated policy titled, Bed hold Policy/Ombudsman Notification documents, in part: This form serves as a written information and notice to the resident or legal representative at the time of admission and in advance of any transfer and at the time of transfer that specifies the duration of the bed hold policy under the Medicare and Medicaid state plan of the facility. Wisconsin: This is to inform the resident/POA that it is the policy of the facility and the State of Wisconsin to hold a bed for a maximum of 15 days per hospital stay . 1. ) R31 admitted to the facility on [DATE] and has diagnoses that include Acute Respiratory Failure with Hypoxia, Chronic Obstructive…

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 medications were labeled and stored in accordance with facility policy and procedures for 2 of 4 medication carts reviewed for medication storage. * Observations of medications stored in medication carts with no dates listed as to when medication had been opened, including ophthalmic and liquid medications. Four ophthalmic medications and one liquid medication were noted by Surveyor with no names or open dates on the first floor medication cart. One expired stock medication was noted on the first floor medication cart. Two ophthalmic medications were noted by Surveyor with no names or open dates on the second floor medication cart. Two expired stock medications were noted on the second floor medication cart. Six expired medications were found in the first floor medication room. Findings include: 1.) On 7/10/24 at 8:30 AM, Surveyor observed the 200 unit medication cart. Surveyor noted R22's lantus insulin was not marked with an open date. On 7/10/24 at 9:30 AM, Surveyor observed the 300 unit medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 residents (R8 and R229) observed for infections and for 2 of 2 units observed in the facility. * R229 was positive for Covid (Coronavirus disease 2019). Staff did not utilize appropriate PPE (personal protective equipment) while in R229's room and staff was observed not wearing masks on the unit. * R8 was suspected for Clostridium Difficile and contact precautions were not implemented. * Uncovered linen was observed on the 300 unit. Findings include: The facility policy titled Covid-19 Prevention, Response and Reporting dated 5/16/23 documents (in part) . .Policy: It is the policy of this facility to ensure that appropriate interventions are implemented to prevent the spread of Covid-19 and promptly respond to any…

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 the right to voice grievances to the facility. The facility did not make prompt efforts to resolve grievances that were voiced for 1 of 23 (R217) resident reviewed for grievances. * R217 informed the APNP (Advanced Practice Nurse Practitioner) of a concern and requested to file a grievance. The APNP did not follow up on R217's request to file a grievance. Findings include: The facility policy titled Grievance Guidance dated revised 5/31/23 documents: Purpose: To provide a process to voice grievances (such as those about treatment, care, management of funds, lost clothing, or violation of rights) and respond with prompt efforts to resolve while keeping the resident and/or resident representative appropriately apprised of progress toward resolution. The grievance policy must include: As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being 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 interview and record review, the facility did not protect 1 (R83) of 3 residents reviewed for abuse/neglect from being verbally abused and neglected. R83 was transferred without a mechanical lift and fractured her right ankle. The Certified Nursing Assistants (CNAs) were aware that they should use a mechanical lift and decided to transfer R83 with an assist of 2 and a gait belt. When R83 fell during the transfer, the CNAs got her off the floor and into her wheelchair. These events were not reported to the nurse on duty until several hours later. During the transfer, a CNA was heard telling R83 I'm not your bitch causing R83 to experience anxiety and resulting in actual harm to R84. Findings include: R83 was admitted to the facility on [DATE] with a diagnoses that included weakness and falls that resulted in a right femur fracture. R83's Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief interview for Mental Status (BIMS) score of 10, indicating that R83 is moderately impaired. The MDS also…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not ensure that 2 (R83 & R23) of 2 reviewed allegations of abuse were immediately reported to the Administrator and that the completed investigation was sent to the state agency within 5 business days. * R83 was transferred without a mechanical lift and fractured her right ankle. During the transfer the Certified Nursing Assistant (CNA) was heard to say to R83 I'm not your bitch causing anxiety to R83. This was not immediately reported to the NHA (Nursing Home Administrator) or the LPN (Licensed Practical Nurse) on duty at the time. * R34's results of an abuse investigation were not reported to the State Survey Agency within 5 working days. Findings include: The facility's policy titled Abuse, Neglect and Exploitation and dated 9/18/23 documents: Verbal abuse means the use of oral written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review the facility did not ensure residents who are unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 of 23 (R15, R64 and R229) residents reviewed for Activity of Daily Living (ADL's). * R229 was not set up for meals and was not toileted, checked or changed for a period of 4 hours. * R15 did not receive scheduled showers. * R64 was observed to have long nails during survey. Findings include: The facility policy titled Activities of Daily Living (ADLs) dated 10/24/22 documents (in part) . .Policy The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Caress and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care; 2. Transfer and ambulation; 3.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not provide an ongoing, individualized, and meaningful activities program designed to meet the residents interest and support their physical, mental and psychosocial well-being for 1 (R11) of 23 residents reviewed for activities. * The facility failed to complete an assessment of activity goals for R11 and no plan of care related to activities was developed. R11 reported that they are bored, nothing to do but watch TV in room, R11 is bed bound and legally blind. Findings include: The Facility Policy titled Activities implemented 12/23/2022, documents (in part) . Policy: It is the policy of this facility to provide on ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being. Activities will…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs) to meet the needs of each resident for 1 (R35) of 23 residents reviewed. *R35 went to the emergency room (ER) on 9/12/2023. R35 was prescribed Prednisone for neck inflammation with no end date or tapered dosing. The facility process of reviewing admission orders was not followed after R35 was readmitted to the facility on [DATE]. R35 received a high dose of Prednisone from 9/12/23 through 9/29/2023 when the provider ordered a Prednisone taper. R35 was hospitalized on [DATE] for a change in condition. Hospital documentation indicated R35 might have an element of adrenal insufficiency considering [R35] was on a high dose of Prednisone for 2 to 3 weeks. Findings include: The facility policy, entitled Non-Controlled Medication Orders, dated 1/2023, documents, in part: Medications are administered only upon 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 record review and interview, the facility did not have evidence that the pharmacist's medication record review of any irregularities were reported to the attending Physician, Medical Director and Director of Nursing and that these reports are acted upon for 2 of 5 residents (R57 & R99) whose drug regimens were reviewed. Findings include: 1. R57 was re-admitted to the facility on [DATE] with a diagnosis that included Cerebral Infraction, Alcohol Abuse with Withdrawal, Cerebral Edema and Alcohol Dependence. R57's Quarterly MDS (Minimum Data Set) dated 5/29/24 documents a BIMS (Brief Interview for Mental Status) score of 12, indicating that R57 has moderate cognitive impaired. Section D (Mood) documents a PHQ-9 (Patient Health Questionnaire) score of 8, indicating mild depressing in R57. Section N (Medications) documents that R57 has indications for and takes antianxiety medication. R57's pharmacist note dated 12/22/23 documents, Pharmacy Note Text: MRR (medication record review) complete-see report. R57'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 that 2 (R57 & R40) of 5 residents reviewed who was receiving a psychotropic medication, was free from unnecessary drugs. * R57 had a PRN (as needed) order for an anti-anxiety medication that did not have a documented rationale in R57's medical record that indicated the duration for the PRN order beyond 14 days. * R40 had a PRN order for an anti-anxiety medication that did not have a documented rationale in R57's medical record that indicated the duration for the PRN order beyond 14 days. Findings include: 1. R57 was re-admitted to the facility on [DATE] with a diagnosis that included Cerebral Infraction, Alcohol Abuse with Withdrawal, Cerebral Edema and Alcohol Dependence. R57's Quarterly MDS (Minimum Data Set) dated 5/29/24 documents a BIMS (Brief Interview for Mental Status) score of 12, indicating that R57 has moderate cognitive impaired. Section D (Mood) documents a PHQ-9 (Patient Health Questionnaire) score of 8, indicating mild depressing 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, interview, and record review the facility did not always provide food that is palatable for 1 (R59) of 23 residents reviewed for food. On 7/8/2024, R59 requested cold cereal and did not receive the cereal. On 7/9/2024, R59 requested oatmeal and did not receive the oatmeal. Findings include: R59 was admitted to the facility on [DATE] and has diagnoses that include kidney failure with dependence on renal dialysis, Type 2 Diabetes, and adult failure to thrive. R59's Quarterly Minimum Data Set (MDS) Assessment, dated 6/2/2024 documents R59 usually is understood and understands. R59's Brief interview for Mental Status (BIMS) score is 12 indicating R59's has a moderate cognitive impairment. On 7/8/2024 at 10:40 AM, Surveyor observed R59's breakfast tray on the bedside table. Surveyor asked R59 about the facility's food. R59 stated that R59 likes cereal (both cold and hot). R59 stated R59 would like cereal every morning but did not receive the cold/dry cereal this morning. Surveyor observed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the Facility did not ensure insulin was dated and/or labeled with a Residents name when opened in 1 of 3 medications carts. This has the potential to affect R12, R13, and any diabetic Resident on the [NAME] unit who have been prescribed Aspart or Levemir insulin. Findings include: On 4/9/24 at 10:34 a.m. Surveyor asked Med Tech-M to see the insulin pens in the [NAME] unit medication cart. Surveyor observed in the top drawer the following insulin pens: * R12's Toujeo Solostar insulin pen was not dated when opened. * R13's Lantus Solostar insulin pen was not dated when opened. * Humalog kwikpen was not dated or labeled with a Resident's name. Surveyor noted R12 had received this insulin during the medication pass observation. * An Aspart flex insulin pen dated 3/20/24 was not labeled with a Resident's name. Surveyor observed there is a white label on the insulin pen which documents E-Kit and for physician documents Emergency. * A Levemir flex insulin pen was not labeled with a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure residents were assessed for self-administration of medications prior to staff leaving medications at bedside for 1 (R7) of 1 residents reviewed for medication self-administration. R7 reported medications were left on the overbed table on 3/8/2024 and R7 was not assessed for the ability to self-administer medications. Findings include: The facility policy and procedure entitled Medication at Bedside dated 11/2018 states: Policy: 1. Self Administration of medications and treatment is a decision by the interdisciplinary team with input from the family or patient. 2. Physicians must provide an order for medication to be kept at bedside. 3. All medications and treatment that are self-administered are signed out in the eMar/eTar with the nurses initials. Procedure: 1. If it is determined by the interdisciplinary team, or resident or family requests to self administer, the interdisciplinary team will ensure a patient is alert and oriented and the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility did not ensure 2 (R2 and R7) of 4 Facility Reported Incidents reviewed were reported to the State Agency as required. * On 3/22/24 at 8:00 pm, R2 alleged a staff member hit her on the left forearm. The facility did not report the allegations of abuse to the State Agency within 2 hours as required and did not call law enforcement. * R7's family reported to the facility an allegation R7 received the wrong medications on 3/16/2024. The facility did not submit the allegation to the State Agency until 3/18/2024. Findings include: 1.) R2 was admitted to the facility on [DATE] with diagnosis of heart disease, dysphagia, type 2 diabetes, chronic leukemia in remission, hypertension, osteoarthritis, and venous insufficiency. R2's annual MDS (minimum data set) dated 2/15/24 indicates a BIMS (brief interview for mental status) score of 7, which indicates R2 has severe cognitive impairment. R2's MDS indicates she has adequate hearing, clear speech, sometimes makes herself…

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 (R9) of 3 Residents reviewed for discharge received a complete discharge summary including post discharge plans, follow up care necessary and medications provided to the Resident in order to communicate necessary information to the resident, continuing care provider, and other authorized persons at the time of the anticipated discharge. *R9 was discharged home on 1/22/24 without a completed discharge summary and list of medications to allow for coordination of care and to effectively transition R9 to post-facility care. Findings Include: Surveyor reviewed the facility's Discharge policy and procedure last revised/reviewed 4/23 and notes the following: .Discharge to Home: 4. A discharge form is completed by all involved members of the interdisciplinary team (IDT) that explain the Resident care needs at home. 5. An order to discharge the Resident is given by the attending MD (Medical Doctor) or NP (Nurse Practitioner) prior to discharge. 6.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not ensure residents received treatment and care in accordance with professional standards of practice when outside appointments are needed for 1 (R5) of 3 residents reviewed for appointments. R5 had discharge instructions from the hospital on 2/15/2024 to schedule a follow up appointment with the nephrologist within one to two weeks. The scheduler for appointments was not given the information to schedule the appointment until 3/4/2024, eighteen days after admission, and R5 did not see the nephrologist until 3/13/2024, one month after admission. Findings include: R5 was admitted to the facility on [DATE] with diagnoses of Multiple Sclerosis, urinary tract infection, trigeminal neuralgia, depression, congestive heart failure, anxiety, and chronic kidney disease. R5's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R5 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. R5 did not have an activated Power 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 each Resident received adequate supervision to prevent accidents for 2 (R3 & R9) of 4 Residents reviewed. * R3 was not transferred according to R3's plan of care which resulted in a fall. * On [DATE] R9 had an outside physician appointment at 9:00 a.m. The Facility did not follow up to determine where R9 was and transportation did not pick R9 up until approximately 4:00 p.m. Findings include: The Facility's Fall Prevention policy and procedure last reviewed/revised 4/2023 under policy documents, Each resident residing at this facility will be provided services and care that ensures that the resident's environment remains as free from accident hazards as is possible and each resident receives adequate supervision and assistive devices to prevent accidents. Each resident will be assessed for the casual risk factors for falling at the time of admission, upon return from a health care facility and after every fall in the facility. For the purpose 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, record review, and interview, residents did not receive medications in a timely manner for 3 (R5, R3, and R12) of 3 residents reviewed for medication administration. R5, R3, and R12 were administered medications outside of the time range when medications were to be administered. Findings: The facility policy and procedure entitled Medication Pass Times dated 5/2023 states: Policy: 1. The following is a list of scheduled medication times: Person-centered liberalized medication pass times will be utilized when possible. Person-centered medication pass time windows are as follows: AM: 7am-10am, Afternoon: 1pm-4pm, PM: 7pm-10pm. If liberalized mediation pass times are contraindicated, the medication pass times below will be utilized according to provider orders. a. QD: 9am b. BID: 9am - 5pm c. TID: 9am - 1pm - 9pm d. QID: 9am - 1pm - 5pm - 9pm e. Q 4hr: 9am - 1pm - 5pm - 9pn - 1am - 5am f. Q 6hr: 6am - 12pm - 6pm - 12am g. Q 8hr: 6am - 2pm - 10pm h. Q 12hr: 6am - 6pm i. AC: 1/2 hours [sic]…

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's drug regimen was free from unnecessary drugs for 1 (R3) of 3 Residents reviewed. R3 receives Metformin twice a day for HTN (hypertension). Hypertension is not an appropriate diagnosis for Metformin. Findings include: R3 was originally admitted to the facility on [DATE]. R3 diagnosis includes diabetes mellitus. R3's physician order dated 7/26/23 documents Metformin HCI tablet 500 mg (milligrams) Give 1 tablet by mouth two times a day for HTN (hypertension). Metformin is not prescribed for hypertension. Surveyor reviewed R3's February 2024, March 2024, & April 2024 MARs (medication administration record) and noted R3 received Metformin HCI 500 mg twice a day according to physician orders for hypertension. According to www.webmd.com under uses documents Metformin is used with a proper diet and exercise program and possibly with other medications to control high blood sugar. It is used in patients with type 2 diabetes. Controlling high…

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 there was a medication error rate below 5 percent. There were 5 medication errors in 33 opportunities which resulted in a medication error rate of 15.15%. Medication errors were identified for R12 & R3. Findings include: R12's Humalog insulin was administered late and the insulin pen was not labeled with any Resident's name & not dated when opened. R3 was administered Baclofen 10 mg (milligrams). The physician order is for Baclofen 15 mg. R3 received Lidocaine 4% patch. R3's orders are for Icy Hot External patch 5%. R3 did not receive Docusate Sodium 100 mg and Miralax 17 grams. Findings include: 1.) On [DATE] at 10:24 a.m. Surveyor observed Med Tech-M remove a Humalog insulin pen from the top drawer of the [NAME] medication cart, wiped the end with an alcohol pad and attach the needle. Med Tech-M primed the insulin pen and then showed Surveyor there are 2 units of insulin to be given to R12. Surveyor observed the Humalog insulin pen…

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 interviews, the facility did not ensure timely assistance with Activities of Daily Living (ADL) care for 2 residents (R10 and R9) of 10 sampled residents. On 8/29/23, R10 waited 44 minutes for assistance with perineal care following urine incontinence. R9 reported long wait times for assistance to the bathroom which included need for assistance with perineal care when R9 had urine incontinence related to long wait times. Findings Include: Example 1: R10 was admitted to the facility on [DATE] with diagnoses to include Osteoarthritis, and Chronic Obstructive Pulmonary Disease. R10's Minimum Data Set (MDS) assessment dated [DATE] stated R10's Brief Interview for Mental Status (BIMS) score was 12 out of 15 which indicated R10 had moderate cognitive impairment. R10's medical record indicated R10 was responsible for R10's own healthcare decisions. The MDS also indicated R10 required extensive assistance of one staff person for personal hygiene. R10's Care Plan indicated R10 required use 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 record review and interview, the facility failed to ensure accurate administration of medication for 3 residents (R8, R9 and R10) of 3 sampled residents reviewed for medication administration times. R8 did not consistently receive multiple medication doses timely as ordered by R8's physician. R9 did not consistently receive multiple medication doses timely as ordered by R9's physician. R10 did not consistently receive multiple medication doses timely as ordered by R10's physician. Findings Include: Facility provided policy titled Medication Pass Times with revision/reviewed date of 05/2023 stated, Medications are administered according to a standard schedule, resident needs and physician orders . The following is a list of scheduled medication times: .a. QD (every day) : 9am b. BID (twice daily) : 9am - 5pm c. TID (three times daily) : 9am - 1pm - 5pm .h. Q 12hr (every 12 hours) : 6am - 6pm . Example 1: R8 was admitted to the facility on [DATE] with diagnosis to include wedge compression fracture of…

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

Based on record review and staff interview, the facility failed to ensure that it did not employ individuals who were found guilty of abuse, neglect, exploitation or mistreatment by failure to conduct complete background checks, including the Background Information Disclosure (BID) form for 6 of 8 facility staff reviewed for pre-employment screening. This had the potential to affect all 95 residents who resided at the facility. Certified Nursing Assistant (CNA)-P was hired by the facility on 05/10/2022 and did not have a BID form completed. Licensed Practical Nurse (LPN)-Q was hired by the facility on 10/18/2022 and did not have a BID form completed. Certified Medication Technician (CMT)-R was hired by the facility on 06/21/2022 and did not have a BID form completed. CNA-T was hired by the facility on 02/07/2023 and did not have a BID form completed. Executive Chef (EC)-U was hired by the facility on 07/01/2022. EC-U did not have a BID form completed nor did EC-U have an Integrated Background Information System (IBIS) or Department of Justice (DOJ) criminal history record completed…

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 review of employee records, the facility did not ensure 2 out of 5 medication technicians were qualified to pass medications to residents residing in the Facility having the potential to affect an approximate average of 30 residents residing on the units where Med Tech (MT)-R and MT-S worked. MT-R was employed by the facility on 06/21/2022 as a med tech but lacked the proper qualifications to pass medications in a skilled nursing facility (SNF). MT-S was employed by the facility on 11/08/2022 as a med tech but lacked the proper qualifications to pass medications in a SNF. Findings include: The facility's Certified Medication Assistant Job Description, not dated, documented, Required Education and Experience: .3. State certified Medication Aide training with CNA (Certified Nursing Assistant) certification or currently enrolled in a nursing program with successful documented proof of passing pharmacology course . Surveyor reviewed five random CNA certifications. MT-R was listed on the facility staff roster as a med tech hired on 06/21/2022. Surveyor was given…

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

Based on observation, interview and record review the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This deficient practice had the potential to affect 31 residents residing in the facility. Findings include: The facility glucometer, which is shared between residents, was not cleaned according to manufacturer's instructions. The facility policy and procedure titled Blood Glucose Monitoring dated November 2020 documents (in part) . .To ensure blood glucose monitoring is completed per provider orders and in accordance with all state and federal regulations. All glucometers will be cleaned per manufacturer recommendations prior to performing a bedside test. Container holding glucometer supplies will be cleaned by staff daily with appropriate sanitization solution observing manufacturer recommended wet contact time. The glucometer will be cleaned prior to each use and after each use per manufacturer…

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 5 of 5 direct staff chosen at random received communication training. CMA (Certified Medication Aide)-II, CNA (Certified Nursing Assistant)-P, CNA-R, LPN (Licensed Practical Nurse)-QQ & RN (Registered Nurse)-CC did not receive communication training. This has the potential to affect 37 Residents who reside on the 200 unit where CMA-II, CNA-P, LPN-QQ & RN-CC typically are assigned. Findings include: The Staff Competency Training policy & procedure dated October 2018 under Policy/Procedure documents 1. Comprehensive staff training will be completed upon hire, annually and as needed in accordance with all state and federal requirements. The Facility Assessment with the latest date of assessment or update documents 4/5/23. The section Staff Education under topic documents Communication - effective communications for direct care staff. For staff type and timing documents All staff- upon hire, monthly, PRN (as needed) and on demand if issues are identified. On 7/27/23 at approximately 11:15 a.m. Surveyor provided…

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 6 of 6 staff chosen at random received QAPI (quality assurance performance improvement) training on the elements & goals of the Facility's QAPI program. CMA (Certified Medication Aide)-II, CNA (Certified Nursing Assistant)-P, CNA-R, LPN (Licensed Practical Nurse)-QQ, RN (Registered Nurse)-CC & Server-MM did not receive QAPI program training. This has the potential to affect 37 Residents who reside on the 200 unit where CMA-II, CNA-P, LPN-QQ & RN-CC typically are assigned. Server-MM works in the kitchen. Findings include: The Staff Competency Training policy & procedure dated October 2018 under Policy/Procedure documents 1. Comprehensive staff training will be completed upon hire, annually and as needed in accordance with all state and federal requirements. On 7/27/23 at approximately 11:15 a.m. Surveyor provided Administrator-A with six names highlighted on the staff list and requested their in-service training for the last year. On 7/27/23 at 12:17 p.m. DOC (Director of Culture)-W provided surveyor with in-services…

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

Based on interview and record review the Facility did not ensure 6 of 6 staff chosen at random received annual training on the Facility's compliance and ethics program. CMA (Certified Medication Aide)-II, CNA (Certified Nursing Assistant)-P, CNA-R, LPN (Licensed Practical Nurse)-QQ, RN (Registered Nurse)-CC & Server-MM did not receive training on the Facility's compliance and ethics program. This has the potential to affect 37 Residents who reside on the 200 unit where CMA-II, CNA-P, LPN-QQ & RN-CC typically are assigned. Server-MM works in the kitchen. Findings include: The Staff Competency Training policy & procedure dated October 2018 under Policy/Procedure documents 1. Comprehensive staff training will be completed upon hire, annually and as needed in accordance with all state and federal requirements. On 7/27/23 at approximately 11:15 a.m. Surveyor provided Administrator-A with six names highlighted on the staff list and requested their in-service training for the last year. On 7/27/23 at 12:17 p.m. DOC (Director of Culture)-W provided surveyor with in-services for the five…

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 5 of 5 direct staff chosen at random received behavioral health training. CMA (Certified Medication Aide)-II, CNA (Certified Nursing Assistant)-P, CNA-R, LPN (Licensed Practical Nurse)-QQ & RN (Registered Nurse)-CC did not receive behavioral health training. This has the potential to affect 37 Residents who reside on the 200 unit where CMA-II, CNA-P, LPN-QQ & RN-CC typically are assigned. Findings include: The Staff Competency Training policy & procedure dated October 2018 under Policy/Procedure documents 1. Comprehensive staff training will be completed upon hire, annually and as needed in accordance with all state and federal requirements. The Facility Assessment with the latest date of assessment or update documents 4/5/23. Under the section mental health for behavioral health needs documents for the number/average or range of residents 15-20. On 7/27/23 at approximately 11:15 a.m. Surveyor provided Administrator-A with six names highlighted on the staff list and requested their in-service training for the last…

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 (R38, R35) of 3 Resident's reviewed, signed and received copies of the Notice of Medicare Non Coverage (NOMNC) form and/or Skilled Nursing Facility-Advanced Beneficiary Notice (SNF-ABN) form. The SNF-ABN and NOMNC forms inform Residents of their final day of Medicare Part A insurance coverage, potential liability for payment (daily cost of care and services at the facility) and standard claim appeal rights and instructions. * On 2/8/23, Care Transitions Assistant (CTA)-O informed R38's Legal Guardian of the facility's decision to end R38's Medicare Part A coverage at the facility. CTA-O documented the notification on R38's Notice of Medicare Non Coverage (NOMNC) form. However, R38's Legal Guardian did not sign the form acknowledging receipt and understanding of the notice nor did she receive a copy of the form with the phone number and instructions on the process to appeal the facility's decision to end Medicare Part A coverage for R38. R38…

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 allegations of mistreatment or abuse were reported to the State Agency for 1 (Resident R12) of 2 allegations reviewed for abuse, neglect, exploitation, or mistreatment. R12 reported to Surveyor an aide hurt her shoulder and night staff holler at her to go to sleep. R12 informed Surveyor these allegations had been reported previously to staff. Findings include: The Abuse, Neglect, Exploitation Prevention policy dated April 2020 documents, All facility employees, contracted individuals, family members and volunteers are educated that all alleged or suspected violations involving mistreatment, neglect, abuse or exploitation including injuries of unknown origin and involuntary seclusion and misappropriation of resident property are reported IMMEDIATELY to the Administrator but not later than two (2) hours after the alleged incident without fear of retribution, retaliation or reprisal. The Chief Executive Officer and/or Administrator ensure that all alleged or suspected violations involving mistreatment, neglect, or 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 allegations of mistreatment or abuse were investigated for 1 (R12) of 2 allegations reviewed for abuse, neglect, exploitation or mistreatment. R12 reported to Surveyor an aide hurt her shoulder and night staff holler at her to go to sleep. R12 informed Surveyor these allegations had been reported previously to staff. The Facility did not investigate these allegations until after Surveyor spoke with Administrator-A. Findings include: The Abuse, Neglect, Exploitation Prevention policy dated April 2020 documents The Chief Executive Officer and/or Administrator ensure that all alleged or suspected violations involving mistreatment, neglect, or abuse, including injuries of unknown origin and misappropriation of resident property are investigated and reported immediately to the Wisconsin Department of Health, Division of Quality Assurance. R12's quarterly MDS (minimum data set) with an assessment reference date of 6/11/23 has a BIMS (brief interview…

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, clinical record documentation and EMR (electronic medical record review), the facility did not ensure that the PASARR (Pre-admission Screen and Resident Review) for 2 of 5 Residents (R) (R40 and R68) were completed as indicated by resident characteristics. * R40 had a Level 1 PASARR (Preadmission Screen and Resident Review) dated 4/22/21 indicating R40 has a serious mental illness with medications and a diagnosis which would trigger a Level 2 screen to be completed, in order to determine the need for specialized services. A hospital discharge exemption of 30 day maximum is documented, however there is no documentation provided by the facility that R40's PASARR Level 1 screen was completed after the 30 days and sent for further review. R40 has remained in the facility. * R68 admitted to the facility on [DATE], and did not have a PASARR completed at time of admission. Findings Include: Surveyor reviewed the facility's Preadmission Screening and Annual Resident Review (PASARR) policy 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 there was evidence of physician orders for how often neuro checks were to be completed or if neuro checks were no longer required after the initial neuro check for 3 (R88, R22, & R36) of 3 Residents reviewed for falls. Findings include: The Neurological Assessment policy & procedure last revised/reviewed 5/2023 under procedure documents: 1. Neurological assessments are done upon physician order when indicated for a change of resident condition and with all head injuries. 10. Determinations of how often to check above are based on physician or nurse practitioner order or change of resident condition. 11. The neurological assessment should be documented on the neurological glow sic (flow) sheet or in the nurses notes. 1.) R88 was admitted to the facility on [DATE] with diagnoses which includes contusion of scalp, anemia, and coronary artery disease. The admission MDS (minimum data set) with an assessment reference date of 7/3/23 has a BIMS (brief…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the Facility did not ensure that Residents with a pressure injury or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 3 (R88, R144 & R28) of 6 Residents reviewed for pressure injuries. * R88 was admitted with a Stage 3 pressure injury on the left heel which has healed. R88's skin integrity care plan does not include interventions to offload R88's heels, R88's heels were observed not being offloaded and there is no documentation in R88's medical record regarding refusals. * R144 was admitted with Stage 1 pressure injuries on her heels and Stage 2 pressure injuries on her left and right buttocks. R144's heels were observed not being offloaded. On 7/18/23 R144's left and right buttock pressure injury wound bed was not cleansed prior to the application of the dressing during the treatment observation. * R28 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility did not ensure 1 (R36) of 2 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. *R36 was observed during the survey process to not be wearing R36's palm protectors to prevent further decrease in range of motion. Findings Include: R36 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease, Type 2 Diabetes Mellitus, Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side, Chronic Kidney Disease, Stage 3, Hyperlipidemia, Essential Hypertension, Bipolar Disorder, and Major Depressive Disorder. R36 has a legal guardian. R36's Quarterly Minimum Data Set (MDS) dated [DATE] documents R36 has a Brief Interview for Mental Status (BIMS) score of 3, indicating that R36 demonstrates severely impaired skills for daily decision making. R36 requires extensive assistance of 2 staff for bed…

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 staff interview, the facility did not ensure residents who presented with a weight change were assessed promptly. This affected 2 (R9 and R28) out of 4 residents reviewed for nutritional concerns. *R28 presented with a steady weight loss from admission on [DATE] to 06/28/23. The facility assessed documented weight loss on 06/09/23 and implemented interventions. R28 continued to lose weight without reevaluation of interventions or new interventions implemented. *R9 presented with weight gain which the facility did not assess promptly. Findings include: Facility policy titled, Weight policy, dated 11/2018, documented, .4. Residents will be weighed using the same scale at the same time of day and in the same way each time they are weighed .5. All weights, upon completion will be given to the DON (Director of Nursing) or designee to determine a list of reweight's. 6. Once the reweight's have occurred any resident with an unexplained significant to insidious weight loss will…

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 respiratory care was consistent with professional standards of practice for 2 (R13 & R49) of 2 Residents reviewed for oxygen administration and care. R13 & R49 were observed receiving oxygen throughout the survey with no labeling of the tubing or humidifier bottles as to when they were last changed. Findings include: The O2 (Oxygen) Hygiene policy dated November 2018 under General documents To ensure proper utilization of oxygen equipment to prevent infection. Under policy #3 documents Tubing will be changed and/or cleaned in accordance with physician order to prevention infection. 1,) R13's diagnosis includes congestive heart failure. The physician order dated 4/26/23 documents Change O2 tubing every day shift every Mon (Monday) and as needed. The physician order dated 5/25/23 documents Change O2 tubing every night shift every Fri (Friday) and as needed. The physician orders dated 7/6/23 documents Continuous O2 (oxygen) via NC…

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 have an attending physician review and document on an identified medication irregularity for 1 (R36) of 5 Residents identified in a pharmacy medication regime report. Findings Include: R36 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease, Type 2 Diabetes Mellitus, Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side, Chronic Kidney Disease, Stage 3, Hyperlipidemia, Essential Hypertension, Bipolar Disorder, and Major Depressive Disorder. R36 has a legal guardian. On 7/18/23 at 1:03 PM, Surveyor reviewed R36's pharmacy reviews. The pharmacy review on 1/26/23 documents that there is no documented medical diagnosis for R36's Seroquel and it is recommended that there should be a documented medical diagnosis to support continued use. There is no documentation of the attending physician reviewing this recommendation from the pharmacy. Surveyor reviewed R36's psychiatric consults from 1/12/23,…

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 upon interview and record review the facility did not ensure 1 (R343) of 5 residents reviewed for unnecessary medications had monitoring of behaviors and possible side effects. R343 had medication increases in Seroquel without clear monitoring of behaviors or side effects as ordered by the physician. Findings include: R343 was admitted on [DATE] with diagnoses including Metabolic encephalopathy, acute kidney failure, dependence on renal dialysis, other symptoms and signs involving cognitive functions and awareness unspecified dementia - unspecified severity, and without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R343's admission Minimum Data Set Assessment (MDS), dated [DATE] documented R343 had a Brief Interview for Mental Status (BIMs) of 99 indicating R343 was unable to complete the BIMs assessment due to cognitive issues; physical and verbal behaviors towards others 1-3 days exhibited; and behaviors not towards others exhibited 1-3 days; the behaviors interfere 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.

Based on observation, interview and record review the facility did not ensure its Medication error rates was not 5 percent or greater. The facility medication error rate was 6.25% affecting 2 of 2 (R61 and R67) residents. Findings include: The facility policy and procedure titled Administration of Medications dated revised 04/2023 documents (in part) . .Procedure: 3. Check medication administration record prior to administering medication for the right medication, dose, route, patient and time. 4. Read each order entirely. 5. Remove medication from drawer and read label three times; when removing from drawer, before pouring and after pouring. 13. Click confirm on the eMAR (Medication Administration Record) once the medication is removed from the package. 16. Remain with the resident to ensure that the resident swallows the medication. Once resident takes the medication, hit save on the eMAR. 17. If a medication is not administered, record reason on the eMAR and notify physician or nurse practitioner. 18. If the medication is given at a time different from the scheduled 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 (R143) of 26 Resident's records were complete and accurately documented. R143 ambulated into the bathroom with staff, sat abruptly onto the toilet sustaining a skin tear on R143's coccyx. There is no evidence of this incident in R143's medical record. Findings include: The Facility's Documentation by exception policy last revised/reviewed 4/2023 documents under general A resident is not generally documented on daily unless there is an unusual event or circumstance that requires frequent documentation. Under policy includes documentation of: 2. Documentation should include any unusual event or change of condition of the resident. 3. Any communication with the physician, nurse practitioner, consulting physician or family should also be documented. R143 was admitted to the facility on [DATE] and discharged on 6/25/23. Diagnoses includes left femur fracture, metabolic encephalopathy, chronic obstructive pulmonary disease, hypertension, depressive…

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.