Meadowbrook at Oconto Falls

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review, the facility did not ensure appropriate supervision was in place for 1 resident (R) (R2) of 3 residents who wandered and was physically and verbally aggressive. R2 wandered throughout the facility and was physically and verbally aggressive. The facility did not appropriately supervise R2 to protect R2 and other residents. In addition, the facility did not revise R2's plan of care to include behavioral and monitoring interventions. Findings include: The facility's Dementia Care policy, dated March 2020, indicates: Residents with dementia-related diagnoses will have individualized care plans developed by the Interdisciplinary Team which provide person-centered care that is supportive, promotes comfort, recognizes individual needs/preferences, and includes past life experiences and preferences when possible .The facility's behavior committee will monitor residents for new and worsening behaviors and will implement individualized care approaches…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interview and record review, the facility did not ensure care plans were updated for 4 residents (R) (R3, R4, R5, and R2) of 7 sampled residents. R3's care plan was not updated to indicate R3 frequently called out and did not include interventions to offer R3 when R3 called out. R4's care plan was not updated with interventions to offer R4 when R4 expressed concern about another resident frequently calling out. R5's care plan was not updated with interventions to offer R5 when R5 expressed concern about another resident frequently calling out. R2's care plan was not updated to indicate R2 no longer required 1:1 supervision. Findings include: The facility's Comprehensive Care Plan policy, with a revision date of February 2021, indicates: .5. The care plan is reviewed on an ongoing basis and revised as indicated by the resident's needs, wishes, or a change in condition. At a minimum, the care plan is updated with each comprehensive and quarterly assessment in accordance with Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interview and record review, the facility did not thoroughly investigate and resolve grievances for 2 residents (R) (R4 and R5) of 7 sampled residents. R4 and R5 expressed concerns to staff that R3 frequently called out. Grievance forms were not completed and the grievances were not thoroughly investigated or resolved. Findings include: The facility's Company Concerns Policy, with a revision date of October 2020, indicates: Concerns may be filed orally or in writing and may be anonymous if so desired. 1. At the time a concern is noted (either verbal or written), the resident or his/her representative may speak to any staff member and report the nature of the grievance or submit a written concern form. 2. The staff member will, at the time of the concern, attempt to resolve the issue or direct the resident/representative to the appropriate department head or staff member for further action and/or notify the Concern Officer. 3. Upon notification of a resident concern, information…

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

Based on staff interview and record review, the facility did not ensure a Registered Nurse (RN) was on duty at least 8 consecutive hours per day 7 days per week. This practice had the potential to affect all 51 residents residing in the facility. The facility did not have an RN on duty from 5/17/24 at 6:05 PM until 5/19/24 at 12:00 PM. Findings include: On 5/21/24, Surveyor reviewed the facility's assessment, revised 5/14/24, that indicated the facility will have an RN on duty at least 8 consecutive hours per day 7 days per week. On 5/21/24, Surveyor reviewed the facility's waivers. The facility did not have a waiver related to staffing or having an RN on duty. On 5/21/24, Surveyor reviewed the facility's schedules and time sheets from 5/17/24 through 5/20/24. Surveyor noted an RN was on duty until 6:05 PM on 5/17/24, but another RN did not punch in until 6:00 PM on 5/20/24. On 5/21/24 at 9:40 AM, Surveyor interviewed Director of Nursing (DON)-B regarding staffing for the weekend of 5/17/24 through 5/19/24. DON-B verified the RN who was scheduled that weekend did not come in. DON-B…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to provide a safe and sanitary environment to prevent the transmission of communicable disease and infection. The facility did not maintain an infection tracking and surveillance log which had the potential to affect all 50 residents residing in the facility. In addition, staff did not perform appropriate hand hygiene or sanitize equipment during the provision of cares for 2 residents (R) (R30 and R4) of 2 residents and did not don appropriate personal protective equipment (PPE) for 1 (R2) of 2 residents on transmission-based precautions. The facility did not consistently maintain infection surveillance logs designed to assist with the detection of disease transmission patterns. During an observation on 4/28/24, Laundry Aide (LA)-L entered R2's room and did not don the appropriate PPE. During an observation on 4/29/24, Licensed Practical Nurse (LPN)-J did not perform…

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 4. R1 was admitted to the facility on [DATE] and had diagnoses including quadriplegia, anxiety, depression, and insomnia. R1's MDS assessment, dated 4/3/24, stated R1 had a BIMS score of 15 out of 15 which indicated R1 had intact cognition. Between 4/28/24 and 4/30/24, Surveyor reviewed R1's medical record and noted R1 was prescribed the following medications with a black box warning: lorazepam 1 milligram (mg) every 12 hours for anxiety; escitalopram 5 mg for depression; duloxetine 90 mg for depression; Ambien 10 mg for insomnia; and Benadryl for anxiety. Surveyor reviewed R1's Informed Consent for Mediation documents for the above medications. Surveyor noted the consents for the medication were signed by R1 on 4/24/24, but pages one, two, and three were not initialed and dated by R1. On 4/30/24 at 1:29 PM, Surveyor interviewed DON-B who verified R1's Informed Consent for Medication documents were not completed as required. Based on staff interview and record review, the facility did not ensure 4 residents (R)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure vaccinations were reviewed, offered, and administered for 4 residents (R) (R17, R18, R20, and R23) of 5 residents reviewed for vaccines. The facility did not review R17's vaccination history or offer R17 the PCV20 (Prevnar 20®) vaccine. The facility did not review R18's vaccination history or offer R18 the Prevnar 20® vaccine. The facility did not review R20's vaccination history or offer R20 the Prevnar 20® vaccine. The facility did not review R23's vaccination history or offer R23 the Prevnar 20® vaccine. Findings include: Abbreviations (www.cdc.gov): PCV13: 13-valent pneumococcal conjugate vaccine (Prevnar13®) PCV20: 20-valent pneumococcal conjugate vaccine (Prevnar 20®) PPSV23: 23-valent pneumococcal polysaccharide vaccine (Pneumovax23®) The most recent Centers for Disease Control and Prevention (CDC) recommendations for pneumococcal vaccinations indicate: For adults 65 years or older who have only received PPSV23, the CDC recommends:…

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 staff and resident interview, the facility did not ensure mechanical lift equipment used to transfer residents was maintained in a safe operating condition. This had the potential to affect 17 residents who were transferred via lift. The facility's mechanical lift equipment showed signs of wear and tear. Residents and staff expressed concerns with the condition of the equipment and the length of time it took to transfer residents. In addition, the emergency pull was broken on one of the lifts. Findings include: The facility's Sling Safety Inspection and Care policy, dated April 2020, contains a Lift Inspection Checklist that indicates the following are to be inspected monthly: 1) [NAME] base; 2) Shifter handle; 3) Mast; 4) Boom; 5) Swivel bar; 6) Electric actuator assembly; 7) Emergency release. The checklist also indicates moving parts on the lifts are to be lubricated every 6 months. The manufacturer's recommendations for Invacare Reliant Lifts RPL450-1 and RPL600-1 state regular…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not provide the necessary care and services to prevent the development of or promote healing for 1 resident (R) (R4) of 3 residents reviewed for pressure injuries. R4 had a pressure injury on the left heel. During observations on 4/28/24 and 4/29/24, R4 was not wearing a left heel boot as ordered. Certified Nursing Assistant (CNA) staff was not aware R4 should wear a heel boot when out of bed and R4's care plan was not updated to reflect the intervention. Findings include: The facility's Skin Management policy, with a revision date of July 2020, indicates: 5. A care plan is developed upon admission, and reviewed upon readmission .and interventions implemented to promote healing and prevent further breakdown. The care plan should address, but is not limited to the following: .C. Preventive devices . R4 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, osteoarthritis, and history of falling. R4's Minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not provide appropriate care and services to prevent urinary tract infections (UTIs) for 2 residents (R) (R20 and R18) of 2 residents with indwelling catheters. R20 and R18's uncovered catheter drainage bags were observed in contact with the floor. Findings include: On 4/29/24 at 10:49 AM, Surveyor reviewed the facility's policy and procedure for catheter care and Relias training provided annually to nursing staff. The facility's undated Catheter Policy indicates: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use .2. Privacy bags will be available and catheter drainage bags will be covered at all times while in use . The facility's Catheter Policy did not address positioning/placement of tubing or drainage bags. The facility's Care of a Urinary Catheter Relias training indicates: .Many 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 observation, staff interview, and record review, the facility did not ensure 3 residents (R) (R7, R12 and R2) of 3 residents with respiratory needs were provided with the necessary care and treatment. R7 used oxygen therapy. R7 did not have a physician's order for oxygen therapy. In addition, R7's plan of care did not address the use oxygen therapy. R12 and R2 were on droplet and contact precautions. R12 and R2's medical records did not contain consistent monitoring or assessments. Findings include: The facility's Liquid Oxygen Use policy, dated October 2020, states that residents should be provided oxygen therapy whenever possible for the purpose of ensuring maximum mobility in alignment with safety regulations .It is the responsibility of the nurse to provide emergency oxygen administration when necessary and to contact the physician as soon as possible to obtain a physician's order .Oxygen tubing including nasal cannula tubing should be changed weekly or more frequently if necessary .Residents who…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure they had a signed and dated contract that contained the correct name of the dialysis center for 1 resident (R) (R46) of 1 resident who received dialysis services. R46 received treatment at a dialysis center three times weekly. The facility did not have an accurate signed and dated contract with the dialysis center to ensure agreed upon communication and services were in place to provide the necessary care and treatment. Findings include: The facility's Hemodialysis policy, dated March 2023, indicates it is the policy of the facility to ensure each resident receives care and services for hemodialysis .As appropriate, the administrator, nursing director, medical director, and pharmacist, and the quality assurance committee should review the facility's dialysis care and services on an ongoing basis, including communication, training, supervision, and care coordination between the facility and the dialysis facility .Whether policies and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure timely administration of all drugs and biologicals for 1 resident (R) (R30) of 23 sampled residents. R30 was prescribed Fiasp (a short-acting insulin used to treat high blood sugar) with dosing based on blood sugar levels. On 4/29/24, R30 did not receive R30's morning dose of Fiasp timely following a blood sugar check. Findings include: On 4/28/24, Surveyor reviewed R30's medical record. R30 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus. R30's Minimum Data Set (MDS) assessment, dated 2/25/24, stated R30's Brief Interview for Mental Status (BIMS) score was 15 out of 15 which indicated R30 had intact cognition. R30's medical record indicated R30 was responsible for R30's healthcare decisions. R30's medical record contained the following physician orders: ~Fiasp (insulin) 100 unit/ml (units per milliliter) Inject 18 units subcutaneously (under the skin) three times daily . Give with sliding scale ~ Fiasp 100…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure monitoring for adverse reactions or the effectiveness of psychotropic medication was initiated for 1 resident (R) (R48) of 5 residents reviewed for unnecessary medications. R48 was prescribed mirtazapine (an antidepressant medication). R48's plan of care did not contain interventions for staff to monitor R48 for adverse reactions or the effectiveness of mirtazapine. Findings include: On 4/28/24, Surveyor reviewed R48's medical record. R48 was admitted to the facility on [DATE] with diagnoses including multiple fractures and internal injuries following a motor vehicle accident. R48's Minimum Data Set (MDS) assessment, dated 4/10/24, stated R48 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R48 had intact cognition. R48's medical record indicated R48 was responsible for R48's healthcare decisions. R48's care plan indicated R48 was feeling bad about R48's current medical issues. R48's 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 observation, staff interview, and record review, the facility did not ensure it was free of a medication error rate of 5% or greater. During medication administration observations, 5 errors occurred during 25 opportunities which resulted in a 20% medication error rate that affected 3 residents (R) (R2, R23, and R30) of 3 residents observed during medication pass. On 4/29/24, R2 was administered an incorrect dose of Miralax (used to treat/prevent constipation). On 4/29/24, R23 was administered the wrong medication for vitamin B-complex with folic acid (used as a supplement), was administered the wrong dose of vitamin B-12 (used as a supplement), and was administered the wrong medication for a multivitamin (used as a supplement). On 4/29/24, Surveyor intervened before staff administered an incorrect dose of Fiasp (a fast-acting insulin used to treat high blood sugar). Findings include: The facility's Medication Administration policy, with a revision date of January 2023, indicates: Resident medications…

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 implement their abuse policy and complete timely background checks for 5 of 8 staff reviewed. Maintenance Staff (MS)-C had a conviction that required the facility to obtain further information prior to employment. The facility did not obtain further information regarding the conviction. Activity Aid (AA)-F, Social Worker (SW)-G, and Certified Nursing Assistant (CNA)-H did not have a background check completed within the past 4 years. CNA-E did not have a new background check completed after a more than 30 day lapse in employment with the facility. Findings include: The facility's undated Abuse Prevention Program Facility Procedures Training Program and Staff Materials policy indicated: Procedures: 1. Pre-Employment Screening of Potential Employees. Prior to a new employee starting a work schedule, this facility will: Obtain a Wisconsin Criminal History Record from the Wisconsin Department of Justice, Division of Law Enforcement Services for the individual being hired; and Obtain a Caregiver Background Check from 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, resident and staff interview, and record review, the facility did not meet state minimum staffing requirements, did not address resident council complaints and resident grievances regarding insufficient staffing, and did not ensure sufficient nursing staff to answer residents' call lights and provide care in a timely manner. This had the potential to affect all residents residing in the facility. Staffing levels were below the state minimum staffing requirement of 2.5 skilled nursing staff hours per Resident (R) per day on three (2/23/23, 2/25/23, and 3/4/23) of fourteen days reviewed. Staff did not answer call lights and meet needs for residents R27, R30, R20, R56, R51, and R54 in a timely manner. R20 had 3 documented showers between 1/11/23 and 3/15/23. R50 was not checked and changed and remained in a soiled brief from approximately 5:00 PM until 10:06 PM. The facility did not address resident council complaints of insufficient staffing documented as a concern in monthly meeting minutes…

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.

2. During record review on resident council meeting notes, Surveyor noted insufficient staffing documented as a concern on monthly meeting minutes for November 2022, December 2022, and January 2023. On 3/14/23 at 2:01 PM, R15, R17, R22, R29, R30, R43 and R44 participated in a group interview with Surveyors and all expressed concerns with staffing levels. R22, who was the resident council president, and R44, who attended resident council meetings regularly, stated staffing concerns were repeatedly brought up at resident council meetings, but were not addressed by the facility. In addition, most residents denied knowledge of the facility's grievance officer. When Surveyor inquired about communication with staff following concerns, R30 stated, We tell the aides and that's as far as it goes. R30 stated there is no follow-up by the facility after concerns are communicated to staff. R15 stated, The buck is passed on. Based on resident and staff interview and record review, the facility did not promptly resolve grievances for 8 Residents (R) (R15, R17, R22, R27, R29, R30, R43 and R44) 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, staff interview and record review, the facility did not ensure staff performed proper hand hygiene for 4 Residents (R) (R48, R19, R268 and R51) of 8 residents observed during medication administration. On 3/15/23, Licensed Practical Nurse (LPN)-M did not consistently perform appropriate hand hygiene when obtaining R48's blood sugar level. On 3/15/23, LPN-M did not consistently perform appropriate hand hygiene when obtaining R19's blood sugar level and administering R19's insulin injection. On 3/16/23, LPN-S did not consistently perform appropriate hand hygiene following administration of R268's insulin injection. On 3/16/23, LPN-S did not consistently perform appropriate hand hygiene prior to, during and after preparation of R51's oral medication. Findings include: 1. On 3/15/23, Surveyor reviewed R48's medical record. R48 was admitted to the facility on [DATE] with diagnoses to include diabetes mellitus (a disease in which blood sugar levels are too high). On 3/15/23 at 11:41 AM, Surveyor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure 1 resident (R) (R19) of 1 sampled resident with a guardian was provided services following State Statute Chapter 55.03(4) which requires a court-ordered protective placement for any resident admitted to a nursing home who has a legal guardian and whose nursing home stay exceeds ninety days. Protective placement is reviewed annually (State Statute Chapter 55.18) to determine if placement continues to be least restrictive and in the best interest of the resident. R19 was admitted to the facility on [DATE] and had a legal guardian. The most current protective placement (temporary or permanent) court documentation contained in R19's medical record was dated 6/9/21. The facility did not ensure R19's protective placement was reviewed annually. Findings include: On 3/15/23, Surveyor reviewed R19's medical record. R19 was admitted to the facility on [DATE] with diagnoses to include aphasia (a disorder that affects how one communicates) following 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 staff interview and record review, the facility did not ensure PASRR (Pre-admission Screen and Resident Review) requirements were met for 3 Residents (R) (R58, R167 and R3) of 16 sampled residents. R58 did not have a PASRR Level 2 Screen completed after R58's 30 day exemption expired. R167's Level 1 PASRR Screen was completed late. R3's Level 1 PASRR Screen was completed late. Findings include: The Department of Health Services Preadmission Screen and Resident Review (PASRR) Level 1 Screen (F-22191) document, revised in [DATE], contains the following information: .Federal law requires that all persons requesting admission to a nursing facility must be screened to determine the presence of a major mental illness and/or a developmental disability .All persons seeking admission to a nursing facility must receive a Level 1 Screen prior to admission .Section B. Short Term Exemptions: If, during the short-term stay, it is established that the person will be staying for a longer period of time than permitted…

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 2. R56 was admitted to the facility on [DATE] with diagnoses to include dependence on supplemental oxygen, chronic obstructive pulmonary disease (COPD), shortness of breath, major depressive disorder and had a recent bout of influenza A and pneumonia. R56's MDS assessment, dated 1/8/23, contained a BIMS score of 15 out of 15 which indicated R56 had intact cognition. On 3/13/23 at 6:32 PM, Surveyor interviewed R56 and noted R56 had difficulty speaking. Surveyor noted R56 became tired easily, was breathy and used partial words. Surveyor then asked R56 yes or no questions and R56 shook a fisted hand yes or no to answer the questions. R56 shook yes when asked if R56 could hear and understand the questions. R56 shook yes when asked if R56 had a difficult time getting words out. R56 did not indicate any distress at the time. Between 3/14/23 and 3/16/23, Surveyor reviewed R56's medical record and noted the following: ~On 1/2/23, R56 went to the emergency room (ER) and was diagnosed with influenza A. ~On 3/2/23, R56 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 resident and staff interview and record review, the facility did not ensure 1 Resident (R) (R20) of 16 residents received weekly showers as scheduled. R20 did not receive weekly showers as scheduled. In addition, R20s bed linens were not changed regularly. Findings include: R20 was admitted to the facility on [DATE] with diagnoses to include multiple sclerosis (MS), major depressive disorder, anxiety disorder, weakness and chronic pain. R20's Minimum Data Set (MDS) assessment, dated 1/7/23, contained a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R20 had intact cognition. R20 had a self-care performance deficit care plan related to MS which indicated R20 required assistance of one staff for bathing and preferred a shower. On 3/13/23 at 6:55 PM, Surveyor interviewed R20 who stated R20 only received three showers since admission, but was supposed to receive showers weekly. R20 stated staff provided bed baths; however, R20 wanted a weekly shower. R20 also stated R20s…

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, resident and staff interview and record review, the facility did not ensure treatment and care in accordance with professional standards of practice for 2 Residents (R) (R19 and R48) of 3 residents reviewed for insulin administration. On 3/15/23, R19 was administered a short-acting insulin dose based on a blood sugar level taken over an hour prior to the administration. In addition, on 3/16/23, the facility did not follow their policy in response to R19's hypoglycemia (low blood sugar) incident. From 3/1/23 through the breakfast dose on 3/16/23, ten of forty six insulin doses administered to R48 were incorrect based on R48's physician order. Findings include: The facility's Diabetic Management policy, dated May 2020, contained the following information: Diabetic Management involves both preventative measures and treatment of complications .Blood glucose (sugar) measurements are taken per the physician order. Results outside of ordered parameters are communicated to the physician…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and record review, the facility did not provide proper assistance in maintaining hearing ability for 1 Resident (R) (R55) of 16 residents reviewed. R55 had hearing aids that R55 did not wear. Staff documented R55's hearing aids were put in and taken out daily. In addition, R55's communication care plan was not updated and did not include approaches for successful communication with R55 when R55 did not wear hearing aids. Findings include: R55 was admitted to the facility on [DATE] with diagnoses including dementia without behavioral disturbance and bilateral hearing loss. R55's Minimum Data Set (MDS) assessment, dated 2/24/23, contained a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated R55 had severe cognitive impairment. R55 was admitted to the facility with both right and left hearing aids. R55 had a care plan, initiated 11/17/22, that indicated R55 had the potential for a communication problem related to dementia with approaches 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 staff interview and record review, the facility did not ensure accurate and safe administration of medication for 1 Resident (R) (R68) of 17 sampled and supplemental sampled residents. On or about 11/29/22, R68 reportedly self-administered a dose of ondansetron (an antiemetic medication used to prevent nausea and vomiting) which was left at R68's bedside. R68 was assessed as not safe to self-administer medication. Findings include: The facility's Medication Error policy, dated February 2022, contained the following information: All medication errors and drug reactions will be reported immediately to the Director of Nursing, the attending physician and will be documented according to established procedures .Medication error is defined as the preparation or administration of a medication or biological that is not in accordance with the Prescriber's order .and/or accepted professional standards for medication or biological administration. A detailed account of the error will be recorded in the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not ensure it was free of a medication error rate of 5% or greater. During medication administration observations, 2 errors occurred during 38 opportunities which resulted in a 5.26% medication error rate affecting 2 Residents (R) (R19 and R48) of 8 residents observed during medication pass. On 3/15/23, R19 was given a short-acting insulin dose based on a blood sugar taken over an hour prior which was not in accordance with acceptable standards of practice. On 3/15/23, R48 was given an insulin dose not in accordance with the math requirements of R48's physician order. Findings include: The facility's Medication Error policy, dated February 2021, contained the following information: . Medication error is defined as the preparation or administration of medications or biological that is not in accordance with the prescriber's orders, manufacturer specifications regarding the preparation and administration of the medication or biological…

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.