Heritage Lakeside

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure care plans met medical needs and included preferences for 1 of 3 residents (R) reviewed.R1 had a fall out of wheelchair and there was no intervention added.R1 was sitting on multiple items in the wheelchair per preference that was not noted in the care plan.CAM boot was ordered from the doctor on 09/26/25 and was not added to the care plan.Findings:The facility policy titled, Fall Protocol, states, All licensed personnel are responsible for the initiation and completion of the Risk Management when a fall occurs and the Post Fall Evaluation. Licensed Personnel will implement interventions to prevent further falls. 10. The fall and interventions should be addressed in the care plan. 17. All falls will be addressed and interventions applied. Fall Assessment: . 11. Reassess resident's environment and risk of falling. 13. Implement Immediate Intervention to prevent another fall and add Risk Management report.R1 was admitted to 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 Based on observation, interview and record review, the facility did not ensure resident's environment was free from accidental hazards to prevent accidents for 1 of 3 residents reviewed.R1 was sitting on multiple items in a wheelchair, which contributed to R1 falling off the wheelchair seat during transport.Findings:According to Nemt Insurance article, dated 05/01/21, It is perfectly acceptable that additional cushioning may be an integral component to a wheelchair user's level of comfort. However, the cushion should be specifically designed by the manufacturer and integrated into the original design of the wheelchair by that manufacturer. If it isn't, then it should be removed from the wheelchair prior to transport in an effort to reduce the likelihood of severe injury if an accident were to occur. While a passenger's personal comfort is important; ultimately their safety, and the safety of those around them is more important.R1 was admitted to the facility on [DATE], with diagnoses that include a stroke…

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 The facility did not ensure licensed nurses had the specific competencies and skill sets necessary to care for residents' needs, which had the potential to affect all 42 residents. -Licensed Practical Nurse (LPN) G performed a venous blood draw from R1's foot without evidence of training. -The facility did not have a system in place to evaluate licensed nurse competencies. Findings: R1, an [AGE] year-old male, admitted to the facility on [DATE] for rehab following complications from exploratory abdominal surgery. On 04/29/25, progress notes read in part, Nurse unable to obtain IV access or blood draw for labs. 2 sticks have been attempted. Nurse will pass off to oncoming shift to attempt for stat labs. On 04/30/25, progress notes read in part, Labs drawn from right foot X1 attempt. Resident tolerated well .and given to lab at 0805 am. On 04/30/25 at 9:59 AM, order entered, NP [Nurse Practitioner]-ok to obtain blood sample from foot if able. On 07/01/25 at 1:42 PM, Surveyor requested training and competency…

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 and implement a person-centered care plan for each resident consistent with resident rights including services to attain or maintain the resident's highest or practicable physical, mental or psychosocial needs for 2 of 4 residents reviewed (R3 and R4). R3 and R4 did not have a care plan for an anticoagulant or risk for bleeding. Findings include: Facility policy titled, Care Plans-Comprehensive, last reviewed 06/2022, states in part . The comprehensive care plan is based on a thorough assessment Each resident's comprehensive care plan is designed to incorporate identified problem areas .Incorporate risk factors. Facility policy titled, Anticoagulation-Clinical Protocol, last reviewed 06/2022, states in part . The staff and physician will monitor for possible complications in individuals who are being anticoagulated signs of excessive bruising, hematuria, hemoptysis, or other evidence of bleeding . Example 1 R3, a [AGE] year-old-female, 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 observations, interviews and record review, the facility failed to protect the residents' right to be free from sexual abuse. The facility did not implement interventions to protect other residents (R) from exposure of R3's genital area. This affected 2 of 3 residents reviewed for sexual abuse. (R1 and R2) On 03/21/25, R3 exposed his penis in proximity to R1 and R2 in the west dining room. No new interventions were implemented and the previous intervention of placing a blanket on R3's lap was not effective. Findings include: The facility's Abuse policy, with a revision date of 10/2023, indicates: It is the policy of our facility to maintain a work and living environment that is professional and free from threat and/or occurrences of harassment, abuse (verbal, physical, mental, or sexual), neglect corporal punishment, involuntary seclusion, physical or chemical restrains not required to treat the residents' medical symptoms, exploitation and misappropriate of resident property. Immediate interventions…

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 policy review, the facility did not ensure they stored, prepared, distributed, and served food in accordance with professional standards for food policy safety. The facility failed to label and date perishable items found in the refrigerator. This has the potential to affect all 33 of 33 residents residing in the facility. Findings include: The facility policy, titled Food Storage, dated 09/23/24, states, 12. Leftover food will be stored in covered containers or wrapped carefully and securely. Each item will be clearly labeled and stated before being refrigerated. Leftover food is sued within 7 days or discarded as per the 2022 Federal food code. On 01/12/25 at 8:53 AM, during initial brief tour of the kitchen, Surveyor observed food items in the refrigerator were not labeled correctly. Surveyor observed an open bag of cherry jam dated December 2nd as the open date. Surveyor observed chopped onions in the refrigerator that were in a container not labeled. Surveyor observed an open milk jug that was half empty not labeled with an open date.…

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 and record review, the facility did not ensure drugs and biologicals were stored in accordance with currently accepted professional practice. This had the potential to affect 7 out of 7 residents (R) (R2, R14, R17, R20, R32, R33, R136) for proper storage and 1 of 1 resident (R) (R18) for proper labeling. 16 new unopened insulin pens and one bottle of Humalog were found in an out of temperature range refrigerator. R18 did not have an accurate label for insulin. Findings include: Example 1 The facility policy, titled Storage of Medications, dated November 2020, states: . The facility stores all drugs and biologicals in a safe, secure, and orderly manner. 3. The nursing staff is responsible for maintaining medication storage and preparations areas in a clean, safe, and sanitary manner. 7. Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured locations . The facility policy, titled Refrigerators and Freezers, dated…

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 resident (R) of 12 sampled residents (R21) was reasonably accommodated for personal needs. R21's room is set up so that he cannot access or use his sink. This is evidenced by: R21 was admitted to the facility on [DATE] and has diagnoses that include but are not limited to: Parkinson's disease with dyskinesia, with fluctuations; difficulty in walking, not elsewhere classified. R21's Minimum Data Set (MDS) assessment, dated 11/19/24, indicated that R21 uses a wheelchair and a 4 wheel walker for mobility. R21's care plan, dated 11/26/24, states: ADL: The resident has an ADL self-care performance deficit r/t Parkinson's disease, weakness, encephalopathy. Ambulation: Ambulate assist of two 250', follow with w/c and use personal 4ww (leave walker in hallway after use so resident does not attempt to use on is own) or distance as tolerate by resident and safe gait pattern. On 01/12/2025 at 1:01 PM, Surveyor interviewed R21 and his Family…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure that a resident who is unable to carry out Activities of Daily Living (ADLs) receive the necessary services to maintain safety and personal hygiene (hand hygiene) for 1 out 4 residents (R). R21 does not receive hand hygiene services after toileting or when in his room. This is evidenced by: The policy, titled Handwashing/Hand Hygiene, dated August 2019, states, This facility considers hand hygiene the primary means to prevent the spread of infections. R21 was admitted to the facility on [DATE] and has diagnoses that include but are not limited to: Parkinson's disease with dyskinesia, with fluctuations; non-Alzheimer's dementia; needs assistance with personal care; weakness; difficulty in walking, not elsewhere classified. R21's Minimum Data Set (MDS) assessment, dated 11/19/24, indicated that R21 needs assist with his personal hygiene and activities of daily living. For example, he has been assessed as needing substantial/maximum…

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 receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. The facility did not implement orders received for a resident with a foot wound upon reception of the order. Resident (R) 137 did not see a decline with the wound. This has the potential to effect 1 of 3 residents investigated for wound care. Findings include: The facility policy, titled Prevention of Skin Breakdown dated 07/02/2018, states, It is the policy to properly identify and assess residents whose clinical conditions increase the risk for impaired skin integrity, and pressure ulcers: to implement preventative measures; and to provide appropriate treatment modalities for ulcers according to industry standards . A . 4. implement interventions according to the resident Braden Score and/or individual risk factors identified. R137 was admitted to the facility 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 observation, interview and record review, the facility did not ensure the residents' safety through adequate supervision or use of safety devices in 2 of 4 residents, (R)21 and R30. Staff did not use a gait belt when transferring R21, and R21 was left unsupervised during cares. R30 had a recent fall with the new intervention to prevent falls not updated on the care plan. This is evidenced by: Example 1 The policy, titled Policy NO: 007-004 Subject: Gait Belts, dated April 2023, states, It is the policy to require the use of transfer belts for resident transfer and walks as indicated in the resident's plan of care or as needed to ensure resident's safety. R21 was admitted to the facility on [DATE] and has diagnoses that include but are not limited to: Parkinson's disease with dyskinesia, with fluctuations; encephalopathy, unspecified; non-Alzheimer's dementia; needs assistance with personal care; weakness, difficulty in walking, not elsewhere classified. R21's Minimum Data Set (MDS) assessment, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. The facility was not able to produce a reason to have Resident (R) 24's catheter changed on a monthly basis. This had the potential to affect 1 of 1 resident observed for catheter care (R24). Findings include: The Centers for Disease Control and Prevention (CDC) suggests changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. The facility policy that was received from the facility titled Foley Catheter Insertion, Male Resident which was not given a review data, did not have any standards regarding the standards of practice for frequency of catheter removal. R24 was admitted…

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 ensure that services for a resident who needs respiratory care, is provided such care, consistent with professional standards of practice, for 1 of 1 residents (R) R18 reviewed for respiratory assessment related to medication administration. R18 was administered a nebulizer treatment without a lung assessment completed prior to and after treatment. Findings include: According to the National Library of Medicine (2021), the standard of nursing care expected with small volume nebulizer treatment includes: .respiratory assessment pre/post treatment, respiratory rate, heart rate, and oxygen saturation. After treatment, the patient should be encouraged to cough and perform oral care. The patient's respiratory system should be reevaluated after the administration of inhaled medications to document therapeutic effects, as well as to monitor for adverse effects. R18 was admitted to the facility on [DATE] with a pertinent diagnosis of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not ensure 1 of 1 resident ((R)27) who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. This is evidenced by: R27 was admitted to the facility on [DATE] with current diagnoses of protein-calorie malnutrition, difficulty walking, attention deficit hyperactivity disorder (ADHD), post-traumatic stress disorder (PTSD), and major depression. Minimum Data Set (MDS) dated [DATE] a quarterly assessment documented R27's Brief Interview of Mental Status score of 11, indicating moderate cognitive impairment. R27's depression screen PHQ -9 score of 12, indicating moderate depression severity. The MDS documented R27 would often socially isolate. The facility did not comprehensively assess history of trauma, triggers which may 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 observation, interview and record review, the facility failed to have a policy identifying those circumstances when loss or damage of dentures is the facility's responsibility. This has the potential to affect all 33 residents residing in the facility. The facility failed to promptly, within 3 days, refer residents with lost or damaged dentures for dental services for 1 of 1 (R5) resident reviewed for missing dentures. R5's partial upper denture was lost on 11/01/24. They were not replaced and dental services were not provided after dentures were missing. Findings include: The facility was unable to provide Surveyor with a policy specific to missing dentures. R5 was admitted to the facility on [DATE] with pertinent diagnoses of diabetes mellitus II, anemia, anxiety, and cognitive communication deficit. R5's most recent Minimum Data Set (MDS) assessment dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 15 indicating cognition is intact, makes self understood, and able to understand…

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 maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections for 2 out of 4 residents (R18, R22) during care observations. Staff did not complete hand hygiene during personal cares for 1 of 4 residents (R18) during personal cares. Staff did not disinfect reusable medical equipment after use with R18. R22 did not have enhanced barrier precautions (EBP) in place. Findings include: Example 1 Facility policy titled, Handwashing/Hand Hygiene, with a revised date of 08/2019, stated in part: This facility considers hand hygiene the primary means to prevent the spread of infections. 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other…

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 report to the State Agency, an allegation of abuse immediately but not later than 2 hours after the allegation was made. This occurred for 1 of 1 resident (R1). R1's family member reported an allegation of staff bending R1's fingers back to cause pain to try and get R1 to stand up. The facility did not report this allegation of abuse to the State Agency. Findings: The facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating reads, in part . All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the…

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

Based on record review and interviews, the facility did not ensure 2 out of 5 Certified Nursing Assistants (CNA), (CNA BB, CNA DD), employed at the facility for more than one year received a minimum of 12 hours of in-service training each year. This has the potential to affect all 43 residents in the facility. This is evidenced by: On 09/23/24, Surveyor requested in-service training hours for CNA BB and CNA DD for review. CNA BB's date of hire is 09/16/22, and the facility did not provide 12 hours of in-service training, which included communication, behavioral health, and dementia care. CNA DD's date of hire is 12/22/15, and the facility did not provide 12 hours of in-service training, including communication, behavioral health, and dementia care. CNA BB and CNA DD have the potential to work with all residents in the facility. Surveyor requested in-service training completion for CNA BB and CNA DD from both the Director of Nursing (DON) B and the Nursing Home Administrator (NHA) A three different times during the survey. The facility did not provide Surveyor with the requested…

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

Based on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. The facility did not ensure staff used proper hand hygiene when distributing food. This has the ability to affect 5 of 43 residents (R11, R14, R15, R16, R17) residing in the facility. Findings Include: The facility policy, entitled, Food Preparation and Service, dated April 2019, states, Bare hand contact with food is prohibited. Gloves are worn when handling food directly and changed between tasks. Disposable gloves are single use items and are discarded after each use. On 09/16/24 at 11:52 AM, Surveyor observed the serving of food by Dietary Aide (DA) S. DA S was touching the meal tickets which were not a cleanable surface and then touching ready to eat foods. DA S grabbed R14's bun with gloved hands after touching tickets and then placed the bun on R14's plate for distribution. With the same gloved hands, DA S did the following: DA S touched the pizza and peas on R15's plate then distributed the food. DA S touched…

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 to help prevent the development and transmission of communicable diseases and infections. Staff did not sanitize the mechanical lift after use in another resident room, prior to using it for resident (R)11. Staff did not perform hand hygiene with glove changes during incontinent cares for R11 and R1 Staff did not wear proper personal protective equipment (PPE) when entering a resident room (R9) labeled Droplet Precautions. Staff did not wear gloves when obtaining a blood sample for blood glucose monitoring for R11. Staff did not wear proper personal protective equipment for enhanced barrier precautions when providing care for R18 and R3. Findings include: According to CDC Guidelines for Environmental Infection Control in Health-Care Facilities, multi-use patient care equipment should be properly cleaned and disinfected between patients. Facility policy and procedure entitled, Handwashing/Hand…

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 promptly notify and consult with a resident's physician when there was deterioration in a resident's clinical condition. R12 presented with symptoms of low blood pressure. R12's physician was not notified for all low blood pressure occurrences as was instructed by orders. This occurred for 1 of 4 residents (R12), reviewed for change in condition. Findings include: The facility policy, entitled Blood Pressure, Measuring revision date September 2010, states: 6. Hypotension is defined as blood pressure less than 100/60 mm/hg . 9. Hypotension should be reported to the physician. Staff should record several readings throughout the day, including before and after meals. R12 was admitted to the facility on [DATE] with diagnoses that included in part, cellulitis of right lower limb, morbid obesity, muscle weakness, (primary) hypertension, persistent atrial fibrillation, acute on chronic systolic (congestive) heart failure, type 2 diabetes mellitus with diabetic…

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 (R1) of 13 residents was provided privacy during personal cares. *Surveyor observed staff leave the window drapes and privacy curtain open while providing cares to R1. *Surveyor observed R1's breasts exposed from hallway. Findings include: R1 was readmitted to the facility on [DATE] with diagnoses which included in part: Alzheimer's disease, atrial fibrillation, nonrheumatic mitral valve insufficiency, and atherosclerotic heart disease. R1's Minimum Data Set (MDS) assessment, dated 07/23/24, identified R1 scored 3 during a Brief Interview for Mental Status (BIMS), indicating impaired cognition. R1 had no impairment to upper or lower extremities. R1 was independent with eating, supervision for oral hygiene, partial assistance rolling from left to right in bed, and dependent on toileting, upper/lower body dressing, and personal hygiene. MDS dated [DATE] indicated significant change in status, and MDS was not completed to show R1'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, record review and interviews, the facility did not ensure that 1 of 7 sampled residents (R) who are unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene. (R1) Findings include: R1 was readmitted to the facility on [DATE] with diagnoses which included in part: Alzheimer's disease, atrial fibrillation, nonrheumatic mitral valve insufficiency, and atherosclerotic heart disease. R1's Minimum Data Set (MDS) assessment, dated 07/23/24, identified R1 scored 3 during a Brief Interview for Mental Status (BIMS), indicating impaired cognition. R1 had no impairment to upper or lower extremities. R1 was independent with eating, supervision for oral hygiene, partial assistance rolling from left to right in bed, and dependent on toileting, upper/lower body dressing, and personal hygiene. MDS dated [DATE] indicated significant change in status, and MDS was not completed to show R1's current physical funcationality.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure the resident was assessed for removal of the catheter and had no orders in place for a foley catheter. For 1 of 1 residents (R) R1 reviewed with urinary catheters. R1 has an indwelling foley catheter without a physician order to direct the care and treatment for the catheter. Staff did not assess and prevent complications of catheter during R1's care. Findings include: Facility policy titled, Catheter Care, Urinary, dated 08/22, states in part, - .Input/output: 1. Observe the residents urine level for noticeable increases or decreases. -Maintain unobstructed urine flow: 1. Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks. 4. If the catheter material contributes to obstruction, notify the physician, and change the catheter if instructed to do so. 5. Catheter irrigation may be ordered to prevent obstruction in residents at risk for obstruction. -Complications 1. 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.

Based on observation and interview, the facility did not ensure staff followed procedures for the accurate administration of insulin. Staff did not complete a safety check by priming the needle on two insulin pens to ensure the injectable pens were dispensing insulin before administration for 2 of 3 residents (R), (R8 and R11). Findings include: Manufacturer's instructions for insulin pens state in part.Priming your pen: Priming means removing the air from the Needle and Cartridge that may collect during normal use. It is important to prime your Pen before each injection so that it will work correctly. If you do not prime before each injection, you may get too much or too little insulin . Step 6: To prime your Pen, turn the Dose Knob to select 2 units. Step 7: Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Step 8: Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip 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 and interview, the facility did not ensure all drugs and biologicals were stored and labeled in accordance with currently accepted professional. Staff did not ensure that medications that could be potentially harmful were secured. This occurred for 1 of 1 resident's (R13) rooms observed. Findings include: Facility policy, entitled, Medication Labeling and Storage, dated February 2023 states, If the facility has discontinued, outdated or deteriorated medication or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these issues . Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each residents' medications and biologicals are locked when not in use . On [DATE] at 1:38 PM, Surveyor observed insulin pens sitting on the bedside table in R13's room unattended. R13 was not in the building and was receiving dialysis. R13's door was open and insulin pens could be seen from the doorway. One…

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 report an incident of potential misconduct to the state agency immediately upon learning of the incident and did not submit the 5 day investigation within 5 days as required. The facility practice had the potential to affect 1 of 12 residents reviewed for abuse (R7). The facility administration learned of the incident when Certified Nursing Assistant (CNA) E flushed R7's feeding tube on 06/28/24. The facility did not report the incident to the state agency until 07/10/24 via a Misconduct Incident Report (5-day Investigation). No immediate initial reporting was submitted. Findings include: Surveyor requested and reviewed the facility policy titled Resident Safety Abuse Policy dated as last reviewed 10/23. The policy in part read: Purpose: It is the policy of our facility to maintain a work and living environment that is professional and free from .neglect . Federal Definitions: Neglect means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid…

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 conduct a thorough investigation and complete appropriate actions to correct an alleged violation affecting 1 of 12 residents (R) reviewed for potential abuse (R7). Certified Nursing Assistant (CNA) E flushed R7's feeding tube with warm water to make sure it was patent when she found R7's feeding tube not attached. The facility investigation included limited staff interviews, no resident interviews, and no post incident education to staff as a corrective action in attempts to prevent further incidents. Findings include: Surveyor requested and reviewed the facility policy titled Resident Safety Abuse Policy dated as last reviewed 10/23. The policy in part read: Purpose: It is the policy of our facility to maintain a work and living environment that is professional and free from .neglect . Federal Definitions: Neglect means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Procedure…

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 services were provided by a qualified person in accordance with resident's written plan of care. The facility practice had the potential to affect 1 of 12 sampled residents (R7). Certified Nursing Assistant (CNA) E flushed R7's feeding tube with warm water to make sure it was patent when she found R7's feeding tube not attached to R7. Findings include: Surveyor reviewed R7's care plan and noted: Focus: Resident requires tube feeding r/t (related to) swallowing problem. Date Initiated: 11/30/24. Goal: Resident will be free of side effects or complications related to feeding through review date: 10/08/24. Interventions: Resident is dependent with tube feeding and water flushes. See MD orders for orders. R7's orders were reviewed with the following noted: 12/28/23: four times a day Flush PEG tube with 250 ml four times daily Surveyor reviewed the misconduct incident report (5-day investigation) submitted to OCQ. The incident report noted as submitted 7/10/24 notes: Date discovered: 6/28/24. Time occurred: 11:15 AM.…

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 residents received the necessary treatment and services consistent with professional standards of practice for 2 of 2 residents (R2 and R4) reviewed with non-pressure injuries. -On 07/07/24, R4 developed a facility acquired non-pressure injury to his left heel. Documentation indicated staff was checking R4's heels and feet twice daily for skin issues. Weekly wound assessment on 07/08/24 is not accurate and indicated R4 had no skin concerns. On 07/16/24, R4 had developed two additional facility acquired non-pressure injuries to left and right foot and his previous non-pressure injury had worsened, this was not documented in a weekly wound assessment. Findings: Example 1 R4 was admitted to the facility on [DATE]. Diagnoses included diabetes mellitus, end stage renal disease, renal dialysis, failure to thrive, weakness, and difficulty walking. Minimum data set (MDS) assessment, completed on 06/16/24, confirmed R4 scored 15/15 during…

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 provide the needed supervision to prevent accidents for 2 of 3 residents reviewed for accidents (R6 and R11). Facility staff did not provide supervision while R6 was eating breakfast. Speech Therapy caregiver instructions and care plan indicated R6 requires supervision to eat. Facility staff did not provide supervision while R11 was eating breakfast. R11's caregiver instructions and care plan indicated she requires supervision to eat. This is evidenced by: Example 1 R6's most recent Minimum Data Set (MDS) completed 06/30/24 notes R6 eats independently. Follow-Up Caregiver Instructions: Referred by: Speech therapy (ST) dated 09/09/23 indicated: Issue: Swallowing Strategies: .Soft bite sized foods, thin liquids Activities to be performed with Resident: 1. Patient needs to be upright and alert for all meals, snacks, and meds. 2. Small bites-chew food well. 3. Small sips. 4. Alternate food and drink. Add butter or gravy, sauces etc. to foods that are dry. 5. Remain upright for 30 minutes after meal. Supervision at…

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 adequately assess and provide necessary care and services to attain or maintain the highest practicable physical wellbeing for 1 of 2 residents (R1) reviewed for pain management. R1 expressed increased pain utilizing a pain scale. The facility did not administer as needed medications when R1's pain was elevated. The facility did not document the effectiveness of as needed pain medications, when used. The facility did not follow R1's care plan to provide maximum comfort related to hospice care and terminal diagnosis. Findings: R1 was admitted to the facility on [DATE] at approximately 9:30 AM, after hospitalization. Diagnoses included vertebral osteomyelitis (bone infection), lumbar fractures, inferior vena cava (IVC) thrombus (a blood clot in a large abdominal vein), blood clots in bilateral femoral veins, abdominal cavity bleed, pulmonary blood clot, recurring urinary tract infections, heart failure, muscle pain and stiffness due to inflammatory…

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 licensed nurses had the specific competencies and skill set necessary to care for a resident's needs, as identified through resident assessment, and described in the plan of care, for 1 of 1 resident (R2) reviewed for negative pressure wound therapy (NPWT). R2's NPWT malfunctioned, and staff were unable to continue R2's NPWT. Findings: R2 was admitted to the facility on [DATE] after hospitalization for occlusion of right popliteal artery (the main artery supplying blood to the lower leg). A surgical procedure was performed to reduce pressure in R2's right lower leg, by making two incisions to the inner and outer right calf. R2's admission orders included NPWT to right outer calf and follow up with vascular surgery in 7-10 days. R2's hospital discharge summary stated, NPWT was indicated to promote tissue formation and increase healing time. Consequences of not using NPWT include delayed wound healing, infection, and sepsis. R2's care plan dated…

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 did not ensure staff performed proper handwashing during personal cares for 1 (R3) of 8 sampled residents. This is evidenced by: The facility policy titled Hand Washing/Hand Hygiene, dated 04/2024, states: Indications for Hand Hygiene: 1. Hand hygiene is indicated: a. Immediately before touching a resident; b. Before performing an aseptic task (for example, placing an indwelling device or handling an invasive medical device); c. After contact with blood, body fluids, or contaminated surfaces; d. After touching a resident; e. After touching the resident's environment; f. Before moving from work on a soiled body site to a clean body site on the same resident and g. Immediately after glove removal. 3. Wash hands with soap and water: a. When hands are visibly soiled; b. After contact with infectious diarrhea, including, but not limited to, infections caused by norovirus, salmonella, shigella, and C. difficile. 5. The use of gloves does not replace hand washing/hand hygiene. Applying and Removing Gloves: 1. Perform hand hygiene before…

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 have sufficient nursing staff to ensure the highest practicable physical, mental, and psychosocial well-being for five residents (R6, R7, R10, R11, and R12). R6, R7, R10, and R11 were not out of bed or prepared to eat meal when trays were delivered. R6, R7, R10, R11, and R12 waited over 40 minutes to eat after meal trays were delivered to floor. R6 and R7 were not provided adequate assistance with meal. R12 did not receive a meal tray. Findings: R6 was admitted to the facility on [DATE], after hospitalization from 01/15/24-02/06/24. R6 was previously living at home with family member providing care. Diagnoses included history of stroke with left sided paralysis, wounds to buttocks and heels present on admission, chronic pain syndrome, type 2 diabetes, anxiety, weakness, and assistance with personal cares. R6 has had a 21# weight loss since admission. R6's care plan indicated nutritional risk status, and resident to be up…

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 care plans were updated for 1 of 3 residents reviewed (R6). R6's care plan did not include areas for skin/wounds, pain, and refusal of cares. Findings include: R6 was admitted to the facility on [DATE], after hospitalization from 01/15/24-02/06/24. R6 was previously living at home with family member providing care. Diagnoses included history of stroke with left sided paralysis, wounds to buttocks and heels present on admission, chronic pain syndrome, type 2 diabetes, anxiety, weakness, and assistance with personal cares. Hospital history and physical briefly reported multiple skin wounds to hips and abdomen on 01/15/24, reporting R6's refusals of examination multiple times. Hospital discharge plan reported diagnosis of incontinence associated dermatitis, no orders. R6's minimum data set (MDS) assessment completed on 02/12/24 confirmed R6 scored 10/15 during Brief Interview for Mental Status (BIMS) indicating moderately impaired cognition.…

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

Based on observation, interview and record review, the facility did not ensure that medications ere administered in a manner to prevent a medication error in technique Medication technique errors were identified for residents (R4 and R9). R4 was not instructed to rinse and spit after receiving an inhalation medication. R9 was not instructed to or assisted with applying pressure to the inner corner of the eye after receiving medicated eye drops. Findings: Example 1 R4's physician orders included budesonide-formoterol fumarate aerosol (Brand name Symbicort), two puffs inhale two times daily for chronic obstructive pulmonary disease, rinse mouth and expectorate after use. Important safety information for Symbicort indicates localized infections of the mouth and throat have occurred, and patients should rinse the mouth after administration. On 03/06/24 at 10:10 AM, Surveyor observed Registered Nurse (RN) C administer R4's medications. Surveyor observed RN C administer R4's inhaler without instructing or encouraging R4 to rinse and spit after. Surveyor interviewed RN C. RN C stated she…

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 interview, the facility did not use the services of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week. This has the potential to affect all 34 residents that reside in the facility. This is evidenced by: On 12/13/23 at 9:30 AM, Surveyor completed an interview with Corporate Administrator (CA) F about PBJ submissions. CA F stated during that time period there was a change in the Business Office Manager and that he himself would have been responsible to submit the PBJ for the 3rd quarter. Surveyor then requested and reviewed the staff schedules for that time period (April 1 - June 30, 2023) and compared the data with time punches. There were no concerns uncovered related to licensed staff coverage or certified nursing assistant coverage. There were shortages of registered nurse coverage of at least 8 consecutive hours in a 24-hour time period for three dates. These were: - Sunday, 04/2/23 - Saturday, 04/22/23 - Sunday, 04/23/23 On 12/13/23 at 10:25 AM, Surveyor interviewed CA F regarding registered nurse coverage. CA F confirmed…

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 interviews and record review, the facility failed to submit Centers for Medicare and Medicaid Services (CMS) mandatory Payroll Based Journal (PBJ) data for the third quarter of 2023 (April 1-June 30). This has the potential to affect all 34 residents. This is evidenced by: Surveyor noted the facility failed to submit PBJ data for Fiscal Year Quarter 3. On 12/13/23 at 9:30 AM, Surveyor completed an interview with the Corporate Administrator (CA) F about the PBJ submissions. CA F stated during that time period there was a change in the Business Office Manager and that he himself would have been responsible to submit the PBJ for the 3rd quarter. CA F stated that he missed it and did not submit the data for the third quarter. CA F stated that the facility was staffed adequately and there was no shortage of staffing during that time period. Surveyor then reviewed the staff schedules for that time period (April 1 - June 30, 2023) and compared the data with time punches. There were no concerns uncovered related to licensed staff coverage or certified nursing assistant coverage.…

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

Based on interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. This had the potential to affect 34 of 34 residents (R) residing in the facility. -Legionella Water Management plan did not include a team that meets regularly, a flow diagram indicating potential areas of opportunity, control measures, or monitoring. -Infection control line listing of infections was not completed accurately or thoroughly. Findings include: Water Management Plan: The facility policy titled, Infection Prevention - Water Management Program (Legionella) dated 10/2023, reads in part: .This policy addresses our facility's water management program elements in line with accepted American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) Standard 188, state and local regulations. 1. Water Management Program Team: a. The Facility's Water Management Program is overseen by the Water…

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 practices were not used to restrict a resident's freedom of movement when staff were observed locking resident's wheelchair brakes. The facility practices affected 1 of 1 resident (R139). This is evidenced by: Surveyor requested and reviewed the facility policy titled Use of Restraints dated as revised on April 2017. The policy indicates: Policy Statement: Restraints shall only be used for the safety and well-being of the residents . Restraints shall only be used to treat resident's medical symptoms and never for discipline or staff convenience . Policy Interpretation: Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot easily remove, which restricts freedom of movement . On 12/11/23 at 12:19 PM, Surveyor observed R139 seated at dining room table across from the rehabilitation nurse's station. 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.

Based on observations, interviews and record reviews, the facility did not ensure 1 of 4 residents reviewed (R18) for pressure injuries (PI) received necessary treatment and services, consistent with professional standards of practice to prevent new ulcers from developing. This is evidenced by: According to the National Pressure Injury Advisory Panel (NPIAP) 2019, page 115, . Repositioning and mobilizing individuals is an important component in the prevention of pressure injuries. The underlying cause and formation of pressure injuries is multifaceted; however, by definition, pressure injuries cannot form without loading, or pressure, on tissue. Extended periods of lying or sitting on a particular part of the body and failure to redistribute the pressure on the body surface can result in sustained deformation of soft tissues and, ultimately, in tissue damage . According to Wound Care Education Institute (WCEI) 2018, for immobile or bed bound individuals, a full change in position should be conducted a minimum of every two hours. Some individuals require more frequent repositioning…

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 provide the needed supervision to prevent accidents for 1 of 5 residents reviewed for accidents (R17). This is evidenced by: On 12/11/23 at 12:04 PM, Surveyor observed R17 sitting at a table in the small lounge/dining area on the rehabilitation wing. Staff brought R17's meal tray over to the table. Surveyor observed staff exit the dining room. Certified Nursing Assistant (CNA) D was observed at the nurse's station with her back to the dining room where R17 was eating. There were no other staff present in the dining room. R17 consumed most of the chicken alfredo and beverages. At 12:21 PM, R17 stood from table, used her walker, and exited the dining room. There were no staff present in the lounge/dining room to cue or prompt R17 while she ate. Surveyor reviewed R17's record and noted a physician order that read: 09/06/23: FEEDING INSTRUCTIONS; supervision, monitoring recommended to cue: small bites, small sips, slow rate of intake. Alternate solid/liquid/solid/liquid. Increase moisture with foods that are dry…

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, interviews and record reviews, the facility did not ensure 1 of 4 residents reviewed (R18) for pain control, received necessary treatment and services consistent with professional standards of practice to manage pain. This is evidenced by: R18 has medical diagnoses that include but are not limited to, cerebral vascular accident (CVA) due to unspecified occlusion or stenosis of the left carotid arteries, cerebral infarction with hemiparesis and hemiplegia affecting the right dominant side, aphasia, metabolic encephalopathy, primary osteoarthritis, a current stage II PI of the right medial ankle, recent fracture of the left hip (08/06/23), muscle weakness, rhabdomyolysis and severe right leg contracture at the knee. On 12/11/23 at 10:30 AM, Surveyor interviewed R18 asking about her pain control. R18 stated that she . has pain in the arms, legs and back, it hurts all the time. They don't treat the pain, it hurts all the time. According to the most recent Minimum Data Set Assessment (MDSA), which was a quarterly assessment with the assessment reference date 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 did not identify specific targeted behaviors with individual behavioral goals and approaches or have a system in place to monitor the effectiveness of medications for 1 of 5 residents reviewed for unnecessary medications (R26). This is evidenced by: Surveyor reviewed the facility policy titled Antipsychotic Medication Use dated as revised on December 2016 which indicates the following: Policy Statement: Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-re-review. Policy Interpretation and Implementation: ~Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. ~The attending physician and other staff will gather and document information to clarify a residents behavior, mood, function, medical condition, specific symptoms and risk to resident and others. ~Staff will 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 interview and record review, the facility did not ensure 1 resident (R) (R1) out of 1 sampled resident who was reviewed for behaviors, received adequate supervision, or had interventions implemented to prevent behaviors of exposing genitals to female residents. *R1 displayed sexually inappropriate behavior by exposing self to R2 in the facility library. *R1 displayed sexually inappropriate behavior by exposing self to R3 upon entering R3's room. Findings: Example 1: R1 was admitted to the facility on [DATE] with diagnoses including but not limited to other toxic encephalopathy, unspecified mood (affective) disorder, major depressive disorder, cognitive communication deficit, disorientation-unspecified, and personal history of traumatic brain injury. R1's Minimum Data Set (MDS) assessment dated [DATE] documents R1 has a Brief Interview for Mental Status (BIMS) score of 8 out of 15, which indicates moderate cognitive impairment. R1 requires limited assist with mobility, transfer eating, dressing, toilet…

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 interview, the facility did not ensure 1 of 3 staff reviewed had the proper licensure or certification in accordance with Wisconsin state law licensure requirements. This had the potential to affect all 35 residents in the facility. Licensed Practical Nurse (LPN) C, who was an agency staff LPN, worked in the facility from 06/17/23 to 08/01/23 without a Wisconsin nursing license. Findings: On 08/15/23 at 1:35 p.m., Surveyor asked Director of Nursing (DON) B for proof of Wisconsin nursing licenses for 2 staff, and 1 certified nurse's aide (CNA) Wisconsin state registry certification. On 08/16/23, the Clinical Nurse Consultant (CNC) J provided documents on the licensure of the requested staff. LPN C's documentation showed a Wisconsin driver's license, and a Minnesota nursing license. (Minnesota is not a compact licensure state with Wisconsin). LPN C did not have a Wisconsin nursing license. LPN C worked at the facility from 06/07/23 to 08/01/23 without a Wisconsin nursing license. On 08/16/23 at 11:45 a.m., Surveyor interviewed DON B and CNC J and asked about…

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 interview, the facility did not ensure their abuse, neglect, and misappropriation policy was implemented for 1 of 3 staff reviewed for background checks. Licensed Practical Nurse (LPN) C did not have a criminal background check completed. Findings: The facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention program, dated 2001 MED-Pass, revised April 2021 states, in part: .Policy Interpretation and Implementation 4. Conduct employee background checks and not knowingly employ or otherwise engage any individual who has: a. been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law . On 08/15/23 at 1:35 p.m., Surveyor asked Director of Nursing (DON) B for background checks on LPN C, LPN D and Certified Nursing Assistant (CNA) E. On 08/16/23, Clinical Nurse Consultant (CNC) J provided Surveyor with facility documentation. Surveyor reviewed the documentation provided on the background checks. LPN C did not have a criminal background check completed prior to working in the…

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

Based on record review and staff interview, the facility did not ensure an allegation of abuse was reported to law enforcement. This occurred with 1 of 2 facility self-reported investigations reviewed (Resident R2.) The facility did not ensure the conclusion of the investigation was reported to the state agency (SA) no later than 5 working days of an incident. This occurred with 1 of 2 facility self-reported investigations (Resident R1.) R2 exposed R2's penis in front of R3. The facility did not report the incident to law enforcement. The facility did not submit the conclusion of the investigation of Certified Nursing Assistant (CNA) verbal abuse towards R1 to the SA no later than 5 working days of the incident. Findings: Example 1 The facility policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated 2001 MED-PASS, revised April 2021 states, in part: .Reporting Allegations to the Administrator and Authorities 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons 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.