Plymouth Health Services

Based on observation, staff and resident interview, and record review, the facility did not ensure 1 Resident (R) (R5) of 2 sampled residents received appropriate care and services to prevent urinary tract infections (UTIs). Staff did not ensure R5 was provided catheter care in a manner that decreased the risk of infection. Findings include: The facility's Catheter Care policy, revised 3/15/23, 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 .Privacy/dignity bags will be available and catheter drainage bags should be covered or shielded at all times while in use . On 8/26/24, Surveyor reviewed R5's medical record. R5 had diagnoses including type 2 diabetes with chronic kidney disease, retention of urine, and benign prostatic hyperplasia (BPH) with lower urinary tract symptoms. R5's Minimum Data Set (MDS) assessment, dated 6/11/24, had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R5 had…

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

Based on observation, staff and resident interview, and record review, the facility did not ensure 3 Residents (R) (R1, R2, and R5) of 5 sampled residents received the necessary care and services to prevent dehydration. The facility did not provide consistent hydration for R1, R2, and R5. Findings include: The facility's Hydration policy, dated 7/26/22, indicates: The facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health .4. b. Interventions will be individualized to address the specific needs of the resident. Examples include, but are not limited to: .i. Offer the resident a variety of fluids during and between meals . 1. On 8/26/24, Surveyor reviewed R1's medical record. R1 had diagnoses including type 2 diabetes, severe constipation due to opioid use with current complications involving impaction, history of pressure and diabetic wounds with recent amputation of partial toe, and gout. R1's Minimum Data Set (MDS) assessment, dated 8/8/24, had a Brief Interview 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 staff and resident interview and record review, the facility did not ensure accurate administration of medication for 1 Resident (R) (R1) of 5 sampled residents. R1 did not consistently receive scheduled medications timely as ordered by R1's physician. Findings include: The facility's Medication Administration policy, dated 1/2024, indicates: Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices .Medications are administered within 60 minutes of the scheduled time, except before or after meal orders, which are administered based on mealtimes. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the nursing care center . On 8/26/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, anxiety disorder, and history of urinary tract infections (UTIs). R1'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 and resident interview, and record review, the facility did not ensure adequate supervision was provided for 1 Resident (R) (R2) of 11 sampled residents. On 6/19/24, facility staff discontinued R2's increased supervision after an allegation of sexual assault. The facility did not ensure adequate supervision was provided to prevent R2 from wandering and/or disrobing in front of other residents. Findings include: On 7/31/24, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses including cognitive communication deficit, hypertension, and congestive heart failure. R2's most recent Minimum Data Set (MDS) assessment, dated 7/6/24, stated R2's Brief Interview for Mental Status (BIMS) score was 11 out of 15 which indicated R2 had moderate cognitive impairment. R2's wandering care plan, revised on 6/19/24, had a focus area of wandering related to cognitive impairment and a history of disrobing in public. The care plan contained interventions to…

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

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect all 26 residents residing in the facility. Staff did not perform proper hand hygiene prior to donning gloves, while passing silverware, prior to touching ready to eat food, and while doing dishes. Staff did not wear a beard net while plating food. The handwashing sink in the nourishment room on a resident unit was not in clean condition and appeared to be used for things other than handwashing. Kitchen equipment, refrigerators, an ice machine, and dishes were not stored clean, in a down facing position, covered appropriately, and/or stored 6 inches off the floor. Food items in unit refrigerators were not labeled or dated and/or were expired. Findings include: On 6/24/24 at 10:16 AM, Surveyor began an initial kitchen tour of the kitchen with Dietary Manager (DM)-D who stated the facility follows the Federal and State food codes (whichever is stricter). Hand Hygiene: The Wisconsin Food Code documents…

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 court-ordered documents for guardianship and protective placement were obtained and/or on file for 1 resident (R) (R14) of 14 sampled residents. R14 had a court-ordered guardian. The facility did not have court documents for determination of permanent guardianship on file. In addition, the facility did not ensure court-ordered protective placement was completed for R14. Findings include: WI State Statute Chapter 55.03(4). The law 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. WI State Statue Chapter 54 indicates Standby guardian means an individual designated by the court under s. 54.52 (2) whose appointment as guardian becomes effective immediately upon the death, resignation, or court's removal of the initially appointed guardian, or if the initially appointed guardian is temporarily or permanently unable, unavailable, or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure 3 residents (R) (R7, R12 and R23) of 3 residents reviewed for hospitalization received a transfer notice that included the date of the transfer, the reason for the transfer, the location of the transfer, and appeal rights. In addition, the facility did not inform the State Long-Term Care Ombudsman for 2 (R7 and R23) of 3 residents reviewed for transfer/discharge. R7 was transferred to the hospital on 2/24/24. R7 was not provided with a written transfer notice. In addition, the Ombudsman was not notified of R7's transfer. R12 was transferred to the hospital on [DATE], 1/1/24, and 2/27/24. R12 was not provided with written transfer notices. R23 was transferred to the hospital on 6/11/24. R23 was not provided with a written transfer notice. In addition, the Ombudsman was not notified of R23's transfer. Findings include: The facility's Transfer and Discharge (including Against Medical Advice (AMA)) policy, with a revision date of 7/15/22, states…

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 3 residents (R) (R7, R12 and R23) of 3 residents reviewed for hospitalization received the proper bed hold notice when transferred to the hospital. R7 was transferred to the hospital on 2/24/24. The facility did not provide R7 with a bed hold notification. R12 was transferred to the hospital on [DATE], 1/1/24 and 2/27/24. The facility did not provide R12 with a bed hold notifications. R23 was transferred to the hospital on 6/11/24. The facility did not provide R23 with a bed hold notification Findings include: The facility's Transfer and Discharge (including Against Medical Advice (AMA)) policy, with a revision date of 7/15/22, states it is the policy of the facility to permit each resident to remain in the facility, and not to transfer or discharge the resident from the facility except as initiated by the resident, necessary for the health and safety of residents or other individuals are endangered, or as otherwise permitted by law. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure the state mental health authority was promptly notified following a significant change in mental illness for 1 resident (R) (R12) of 6 sampled residents. R12 was admitted to the facility on [DATE] with a diagnosed mental illness (MI) with corresponding medication. The facility did not submit R12's Preadmission Screen and Resident Review (PASRR) Level I for a Level II Screen following R12's acute psychiatric hospital stay from 10/25/23 through 10/30/23. Findings include: According to Centers for Medicare and Medicaid Services' (CMS), Long-Term Care Facility Resident Assessment Instrument 3.0 User Manual, dated October 2023, if a significant change in status (SCSA) occurs for an individual known or suspected to have a mental illness, intellectual disability, or related condition (as defined by 42 CFR 483.102), a referral to the State Mental Health or Intellectual Disability/Developmental Disabilities Administration authority (SMH/ID/DDA) for 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 monitor for adverse reactions or side effects of high risk medications for 1 resident (R) (R3) of 5 residents reviewed for unnecessary medications. R3 was prescribed anti-convulsant medications for seizures. R3 did not have a care plan that addressed seizures or contained monitoring interventions for adverse reactions and side effects of the anti-convulsant medication. Findings include: The facility did not provide a policy related to non-psychotropic high-risk medications. Between 6/24/24 and 6/26/24, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] with a diagnosis of epilepsy. R3's Minimum Data Set (MDS) assessment, dated 6/20/24, had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated R3 had severely impaired cognition. R3's medical record indicated R3 was prescribed the following anti-convulsant medications since admission on [DATE]. ~ Gabapentin 300 mg (milligrams) by mouth three…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not ensure meal preferences were followed for 2 residents (R21 and R8) of 16 sampled residents. R21 stated the facility often lost R21's meal ticket which had R21's preferences for lunch on 6/24/24. During an observation of lunch service on 6/24/24, R21 did not receive R21's documented preferences. R8's care plan indicated R8 was legally blind and contained an intervention that staff should explain what was on R8's plate and where the food was located. The intervention was not consistently followed. Findings include: Between 6/24/24 and 6/25/24, Surveyor reviewed R21's medical record. R21 was admitted to the facility on [DATE] with a diagnosis of schizoaffective disorder. R21's Minimum Data Set (MDS) assessment, dated 6/7/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R21 had intact cognition. R21 had an order for a regular diet. During lunch service in the dining room on 6/24/24 at 12:56 PM,…

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

Based on observation, staff interview, and record review, the facility did not maintain an infection control program designed to prevent the development and transmission of disease and infection during the provision of care for 1 resident (R) (R23) of 2 sampled residents. CNA (Certified Nursing Assistant)-I did not appropriately change gloves during the provision of care for R23. Findings include: The facility's Hand Hygiene Policy, dated 11/2/22, indicates: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility .1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice .a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. On 6/26/24, Surveyor reviewed R23's medical record. R23 was admitted to facility on 2/2/24 with diagnoses including neurogenic bladder,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interview and record review, the facility did not provide routine drugs and biologicals for 1 resident (R) (R1) of 3 residents reviewed for medication administration. R1 had an order for insulin lispro (a fast-acting medication to lower blood sugar) to be given three times a day. R1 did not receive one dose of insulin on 5/17/24 and received one dose outside of the scheduled administration time on 5/18/24. Findings include: The facility's Medication Administration policy, dated 1/2024, states that medications to be given with meals are to be scheduled for administration at the resident's meal times and medications to given before meals are to be scheduled 30 minutes to 2 hours prior to meals. Medications to be given at bedtime are to be scheduled for administration up to 1 hour prior to the resident's scheduled bedtime. On 6/10/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes, morbid obesity, anxiety, 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 and resident interview and record review, the facility did not ensure 1 Resident (R1) of 1 resident was treated with respect and dignity regarding their preference for care. On 3/4/24, R1 told staff that R1 did not want to be woken up at night and checked for incontinence. R1's care plan was not updated and staff continued to check R1 at night. Findings include: Between 3/18/24 and 3/19/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] following a hospitalization from 1/18/24 to 2/16/24. R1 had diagnoses including necrotizing fasciitis, schizophrenia, anxiety disorder, and insomnia. R1's Minimum Data Set (MDS) assessment, dated 2/27/24, contained a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 had intact cognition. On 3/19/24 at 12:32 PM, Surveyor interviewed R1 who indicated R1 did not want to be woken up between 11:00 PM and 7:00 AM and is aware when R1 needs to be changed. R1 stated R1 takes multiple medications for sleep…

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 a provider was notified when 1 Resident (R) (R1) of 3 residents experienced a change in condition. R1 experienced bladder spasms with increased pain on 2/23/24. Staff stated R1 needed to wait until 2/26/24 before something could be done. R1 was sent to the hospital on 2/24/24 and diagnosed with a urinary tract infection (UTI). Findings include: R1 was admitted to the facility on [DATE] after a hospitalization from 1/18/24 to 2/21/24. R1 had diagnoses including urinary retention, insomnia, necrotizing fasciitis, schizophrenia, and anxiety disorder and had an indwelling catheter. R1's Minimum Data Set (MDS) assessment, dated 2/27/24, contained a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 had intact cognition. A medication administration note written by Registered Nurse (RN)-I on 2/23/24 at 8:26 PM indicated: R1 received 15 mg (milligram) of oxycodone which was ineffective. R1 rated R1's pain at a level 5…

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 document, investigate, or thoroughly resolve grievances for 2 Residents (R) (R1 and R2) of 8 residents. R1 expressed grievances on multiple occasions. The facility did not appropriately document, investigate, or thoroughly resolve the grievances. R2 expressed medication-related grievances on multiple occasions. The grievances were not investigated or resolved. Findings include: The facility's Grievance Policy, with review date of 7/2022, indicates: The facility will seek to resolve concerns, complaints or grievances and provide residents, responsible parties, staff and others feedback and resolution in a timely manner. When a Complaint/Grievance Report is initiated: A copy of the initiated concern form will be placed in the grievance notebook as a reminder that the grievance is still being investigated and resolved. The original form will then be forwarded to the department head for which the grievance pertains. The department head…

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

Based on staff interview and record review, the facility did not ensure their abuse policy was implemented for 2 of 8 employees reviewed for caregiver background checks. Certified Nursing Assistant (CNA)-D's last completed background check forms were dated 3/2/20. Cook (CK)-E's last completed background check forms were dated 3/17/20. Findings include: The facility's Abuse, Neglect, and Exploitation policy, dated 7/15/22, indicates: Background, reference, and credentials checks shall be conducted on potential employees, contracted temporary staff background checks, including re-checks, will be completed consistent with applicable state laws and regulation. On 3/19/24, Surveyor reviewed a sample of employee background checks and noted CNA-D's most recent Background Information Disclosure (BID) form, and Department of Justice (DOJ) and Integrated Background Information System (IBIS) letters were dated 3/2/20. CNA-D was hired by the facility on 12/1/19. On 3/19/24, Surveyor noted CK-E's most recent BID form was dated 11/20/19. CK-E's most recent DOJ and IBIS letters were dated 3/17/20.…

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 failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 1 Resident (R) (R1) of 8 residents. R1 informed staff that R1 felt violated when Certified Nursing Assistant (CNA)-G checked R1's peri-area after R1 told CNA-G that R1 did not want to be checked, was not wet, and did not have a bowel movement. The facility did not report the allegation of abuse to the State Agency (SA) or local law enforcement. Findings include: The facility's Abuse, Neglect, and Exploitation policy, with a review date of 7/15/22, indicates: VII. Reporting/Response: 1. Reporting of all alleged violations to the .State Agency .and to all other required agencies (e.g. law enforcement when applicable) within specified timeframes: b. Not later than 24 hours if the events that cause the allegation do not involved abuse and do not result in serious bodily injury.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interview and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 1 Resident (R) (R1) of 8 residents. R1 informed staff that R1 felt violated when Certified Nursing Assistant (CNA-G) checked R1's peri-area after R1 told CNA-G that R1 did not want to be checked, was not wet, and did not have a bowel movement. The facility did not thoroughly investigate the allegation of abuse. Findings include: The facility's Abuse, Neglect, and Exploitation policy, with a review date of 7/15/22, indicates: V. Investigation of Alleged Abuse, Neglect, and Exploitation. A. An immediate investigation is warranted when allegation or suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Identify and interview all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation. 6. Provide complete and thorough documentation of the investigation. On…

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 administration of medication for 1 Resident (R) (R2) of 8 sampled residents. R2 did not consistently receive medication doses as ordered by R2's physician. Findings include: The facility's Medication Administration policy, dated 1/24, indicates: Medications are administered as prescribed in accordance with manufacturer's specifications, good nursing principles and practices and only by persons legally authorized to do so .1. Medications are administered in accordance with written orders of the prescriber .4. Medications are to be administered at the time they are prepared. 5. The person who prepares the dose for administration is the person who administers the dose .14. Medications are administered within 60 minutes of scheduled time .Documentation: 1. The individual who administers the medication dose, records the administration on the resident's MAR (Medication Administration Record) immediately following the medication being…

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

Based on observation, staff interview, and record review, the facility did not store, prepare, and serve food in accordance with professional standards for food service safety. This practice had the potential to affect multiple residents residing in the facility. Food items in a dry storage area and prep cooler were open and undated. Temperature monitoring logs for the prep cooler and freezer contained missing entries. Findings include: Per ServSafe Essentials: Fifth Edition (2008), under the section titled Monitoring: Check cooler temperatures at least once during each shift. Place hanging thermometers inside the cooler to make this task easy to do. Some coolers have a temperature readout on the outside. On 5/8/23 at 8:28 AM, Surveyor began an initial tour of the kitchen with Dietary Manager (DM)-E. During the initial tour, Surveyor observed the following: Dry storage area Two open and undated packages of noodles One package of open and undated cereal Food cooler #1 Open and undated lettuce Open and undated butter Open and undated provolone cheese Undated leftover lasagna Undated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review, the facility did not ensure a self-medication assessment was completed for 1 Resident (R) (R14) of 1 resident observed with medication at the bedside. On 5/8/23, Surveyor observed 8 pills in varying sizes and colors on R14's bedside table. R14 did not have a physician's order to self-administer medication or a self-administration of medication assessment that indicated R14 could safely self-administer medication. Findings include: The facility's Medication Administration Self-Administration by Resident policy, dated 1/23, contained the following information: Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe and medications are appropriate and safe for self-administration. R14 was admitted to the facility on [DATE] with diagnoses to include displaced intertrochanteric fracture of the right…

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 protective placement documentation was obtained for 1 Resident (R) (R3) of 3 residents reviewed. R3s medical record did not contain protective placement documentation. Findings include: From 5/8/23 through 5/10/23, Surveyor reviewed R3's medical record which documented R3 was admitted to the facility on [DATE]. R3's Minimum Data Set (MDS) assessment, dated 4/9/23, contained a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R3 was not cognitively impaired. R3's medical record contained a guardianship document, dated 3/1/07. Surveyor noted R3's medical record did not include a protective placement document. On 5/8/23 at 1:45 PM, Surveyor interviewed Social Worker (SW)-D who verified the facility did not have a protective placement document for R3 and stated SW-D attempted unsuccessfully to obtain the document. SW-D stated a protective placement document should have been obtained prior to R3's admission or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interview, and record review, the facility did not ensure all allegations of misappropriation were reported to the State Agency (SA) for 3 Residents (R) (R2, R3, and R11) of 3 sampled residents. On 4/1/23, R2's iPad was found in R3's possession. The facility did not report the allegation of misappropriation to the SA. On 4/23/23, an iPad, charger, and food were reported missing from R11's room and found in R3's room. The facility did not report the allegation of misappropriation to the SA. Findings include: The facility's Abuse, Neglect, and Exploitation policy, revised on 7/15/23, contained the following information: The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation .Reporting of all alleged violations to the Administrator, State Agency, Adult Protective Services and to all other required agencies within specified timeframes: .Not later than 24 hours if the events that cause…

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 all allegations of misappropriation were thoroughly investigated for 3 Residents (R) (R2, R3 and R11) of 10 sampled residents. On 4/1/23, R2's iPad was found in R3's possession. The facility did not thoroughly investigate the allegation of misappropriation. On 4/23/23, an iPad, charger, and food were reported missing from R11's room. The facility found R11's iPad and charger in R3's possession. The facility did not thoroughly investigate the allegation of misappropriation. Findings include: The facility's Abuse, Neglect and Exploitation policy, revised on 7/15/22, contained the following information: The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation .An immediate investigation is warranted when allegations of suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. 1. On 5/9/23,…

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 on staff interview and record review, the facility did not provide foot care per standards of practice for 1 Resident (R) (R8) of 2 residents reviewed. R8 had a podiatry exam on 5/4/23 and a subsequent order to paint scabs/dry abrasions L (left) 2nd, 3rd, 4th, 5th toes daily with betadine until healed. The order was not contained or transcribed in R8's medical record. Findings include: R8 was admitted to the facility on [DATE] with diagnoses to include paranoid schizophrenia, delusional disorder, diabetes mellitus type two, unspecified dementia, anxiety disorder, and moderate protein-calorie malnutrition. R8's most recent Minimum Data Set (MDS) assessment indicated R8 was severely cognitively impaired. On 5/9/23, Surveyor reviewed R8's medical record and noted the following: A podiatry report, dated 5/4/23, contained the following information: Recommended New Orders: paint scabs/dry abrasions L 2nd, 3rd, 4th, 5th toes daily with betadine until healed. A progress note contained the following 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.