Serenity Spring Senior Living at Scandia Village

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 2 residents (R) (R21 and R15) of 7 sampled residents. R21 was on contact precautions which required staff to don a gown and gloves prior to room entry. Registered Nurse (RN)-L did not don a gown and gloves prior to entering R21's room to provide medication. RN-L did not complete hand hygiene in accordance with the facility's policy during wound care for R15. Findings include: The facility's Handwashing/Hand Hygiene policy, indicates: .This facility considers hand hygiene the primary means to prevent the spread of infections .2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections .Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap .and water for the following situations: .Before and after direct…

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 vaccines were offered for 2 residents (R) (R2 and R7) of 5 sampled residents.R2 was not offered the influenza vaccine in accordance with the facility's policy.R7 was not offered the PCV20 vaccine in accordance with the facility's policy.Findings include: The facility's Influenza Vaccine policy, revised January 2026, indicates: All residents .who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza .between October 1st and March 31st each year, the influenza vaccine shall be offered to residents. The facility's Pneumococcal Vaccine policy, revised Janauary 2026, indicates: All residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections .upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series and when indicated, are offered the vaccine…

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 residents with orders for a consistent carbohydrate (CCHO) diet received their prescribed diet. This practice had the potential to affect 12 residents (R) (R1, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, and R14) of 12 sampled residents. R1's hospital discharge orders indicated R1 should have a low carb diet (60 grams of carbohydrates per meal). The order in R1's medical record indicated R1 should have 90 grams of carbohydrates per meal.R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, and R14 had orders for a CCHO diet and did not receive what was on the CCHO diet lunch menu on 2/10/26.Findings include:The facility's undated Controlled Carbohydrates policy indicates: .Carbohydrates balanced consistently at each meal providing a range of 70-80 grams of carbohydrates. These diets can be used for the diabetic resident with glucose control concerns following regular and low-concentrated sweets are not omitted but planned…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident representative interview and record review, the facility did not notify a physician when blood sugars were outside the ordered parameters for 3 residents (R) (R4, R3, and R1) of 3 sampled residents. R4 had an order to notify the physician of blood sugars above 450 milligrams/deciliter (mg/dL). The physician was not notified when R4's blood sugars exceeded 450 mg/dL on 1/3/26, 1/11/26, 1/15/26, 1/16/26, 1/19/26, 1/20/26, and 1/31/26.R3 had an order to notify the physician of blood sugars above 350 mg/dL. The physician was not notified when R3's blood sugars exceeded 350 mg/dL on 1/5/26 and 2/6/26. R1 had an order to notify the physician of blood sugars above 400 mg/dL. The physician was not notified when R1's blood sugar exceeded 400 mg/dL on 1/31/26. Findings include:The facility's Diabetes Policy, revised November 2020, indicates the physician will order desired parameters for monitoring and reporting information related to blood sugar management. Staff will incorporate such…

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 40 residents residing in the facility. The deep fryer was stored uncovered and had food debris along the sides and in the oil. In addition, there was no cleaning schedule for the deep fryer. Butter was observed in an uncovered container in the prep area. Equipment in the kitchen was not in clean condition. The hood vent above the deep fryer and oven contained a greasy black substance. The stove top had dried food debris. The microwave in the kitchen contained dried food on the inside. Fifteen boxes were observed on the floor in the freezer. Findings include: On 5/5/25 at 9:54 AM, Surveyor interviewed [NAME] (CK)-D who indicated the facility follows the Wisconsin Food Code. Deep Fryer/Uncovered Food Items: The Wisconsin Food Code documents at 3-305.11 Food Storage: Food shall be protected from contamination by storing the food: .(2) Where it is not exposed to splash, dust, or 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.

Based staff interview and record review, the facility did not ensure their abuse policy was implemented for 5 (Certified Nursing Assistant (CNA)-F, CNA-H, Dietary Aide (DA)-J, CNA-G, and Registered Nurse (RN)-I) of 8 employees reviewed for background checks. CNA-F was hired and started work on 2/24/25. CNA-F's Background Information Disclosure (BID) form was completed on 3/1/25 and Department of Justice (DOJ) report was run on 3/28/25. CNA-F did not have an Integrated Background Information System (IBIS) report. CNA-H and DA-J's background checks did not contain IBIS reports. CNA-G did not have a background check completed within the last 4 years. RN-I's DOJ and IBIS reports were completed before RN-I signed a BID form. Findings include: The facility's undated Employee Screening policy indicates: Employee screening will be respected in terms of state law and facility policy. Background screening: It is a condition of employment that every employee successfully completes a background screening. Program eligibility checks: We are required by law to do pre-employment and then ongoing…

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) (R25, R7, and R22) of 5 sampled residents or their legal representatives were thoroughly informed in advance of the risks and benefits of prescribed psychotropic medication. R25 was prescribed lorazepam (an anti-anxiety medication), duloxetine (an antidepressant medication), trazodone (an antidepressant medication), and quetiapine (an antipsychotic medication). The facility did not ensure written consents were thoroughly reviewed and completed with R25's Power of Attorney for Healthcare (POAHC). R7 was prescribed venlafaxine (an antidepressant medication) and bupropion (an antidepressant medication). The facility did not ensure written consents were thoroughly reviewed and completed with R7's POAHC. R22 was prescribed citalopram (an antidepressant medication). The facility did not ensure a written consent was thoroughly reviewed and completed with R22's POAHC. Findings include: The facility's Psychotropic Medication policy,…

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 grievances were thoroughly investigated and resolved for 1 resident (R) (R28) of 13 sampled residents. The facility did not document, investigate, and follow-up with R28 after R28 reported seven missing articles of clothing. Findings include: The facility's resident grievance policy was not provided during the survey. From 5/5/25 to 5/7/25, Surveyor reviewed R28's medical record. R28 was admitted to the facility on [DATE]. R28's Minimum Data Set (MDS) assessment, dated 2/13/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R28 was not cognitively impaired. R28 made R28's own healthcare decisions. On 5/5/25 at 11:08 AM, Surveyor interviewed R28 who indicated R28 had informed several staff members, including housekeeping/laundry staff, about seven missing articles of clothing. R28 stated R28 was missing a yellow and tan t-shirt, a striped over-shirt, a matching top and bottom (missing since…

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 the effectiveness of psychotropic medication for 1 resident (R) (R25) of 5 sampled residents. R25 had an order for lorazepam (an anti-anxiety medication) 0.5 milligrams (mg) as needed (PRN) every 6 hours for anxiety disorder/irritability and anger with a start date of 2/25/25. The medication was not discontinued or reviewed after 14 days. Findings include: The facility's Psychotropic Medication Use policy, revised July 2022, indicates: .Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: .c. Anti-anxiety medications .12. Psychotropic medications are not prescribed or given on an as needed (PRN) basis unless the medication is necessary to treat a diagnosed specific condition .a. PRN orders for psychotropic medications are limited to 14 days. 1. For psychotropic medications .If the prescriber or attending physician…

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

Based on staff and resident interview and record review, the facility did not ensure 1 resident (R) (R11) of 1 resident reviewed for hospitalization received the proper notice of transfer, reason for transfer, location of transfer, appeal rights, and name and address (mailing and email) with telephone number of the Office of the State Long-Term Care Ombudsman. In addition, the facility did not ensure R11 received written information on the duration of the bed hold policy, the reserve bed payment policy, and the right to return to the facility. R11 was transferred to the Emergency Department (ED) on 5/1/25. R11 was not provided with a written transfer or bed hold notice. Findings include: The facility's Bed-Holds and Returns policy, revised October 2022, indicates: .Residents and/or representatives are informed (in writing) of the facility and state (if applicable) bed-hold policies .1. All residents .are provided written information regarding the .bed-hold policies, which address holding or reserving a resident's bed during periods of absence. Residents, regardless of payer source,…

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 Pre-admission Screening and Resident Review (PASRR) Level I Screen was updated to initiate a PASRR Level II Screen when a newly evident mental disorder and/or change in medication was identified for 1 resident (R) (R22) of 5 sampled residents. R22 received new diagnoses and orders for psychotropic medication, including an antipsychotic medication. The facility did not update R22's PASRR Level I Screen and submit for PASRR Level II reevaluation. Findings include: R22 was admitted to the facility on [DATE] and had diagnoses including fracture, anemia, hypertension, depression, and mood disorder. R22's most recent Minimum Data Set (MDS) assessment, dated 4/19/25, had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R22 had intact cognition. R22's PASRR Level I Screen was completed by the facility on 1/11/24. The Level I Screen indicated R22 did not have any diagnoses or medications prescribed that would…

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 revise a care plan in accordance with current care needs for 1 resident (R) (R34) of 4 sampled residents. R34 fell on 3/20/25 and fractured R34's left wrist. R34's care plan was not updated after the fall and did not include interventions to prevent future falls. Findings include: The facility's Falls-Clinical Protocol policy, revised March 2018, indicates: .Treatment/Management: 1. Based on the preceding assessment, the staff .will identify pertinent interventions to try to prevent subsequent falls and address the risks of clinically significant consequences of falling .2. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation .Monitoring and Follow-up: 1. The staff .will follow-up on any fall with associated injury until the resident is stable and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure 1 resident (R) (R18) of 4 sampled residents received care and treatment based on the resident's needs and hospital discharge instructions. R18 had a fall with a head laceration on 1/5/25. R18 was transferred to the emergency room (ER) and received staples to repair the laceration. R18's hospital discharge instructions stated to apply Neosporin or bacitracin ointment to the wound. The order was not implemented until two days after R18 returned to the facility. Findings include: From 5/5/25 to 5/7/25, Surveyor reviewed R18's medical record. R18 was admitted to the facility on [DATE] and had diagnoses including adult failure to thrive, chronic low back pain, peripheral neuropathy, and depression. R18's Minimum Data Set (MDS) assessment, dated 3/5/25, had a Brief Interview for Mental Status (BIMS) score of 7 out of 15 which indicated R18 had severe cognitive impairment. R18 had an activated Power of Attorney for Healthcare (POAHC) to assist with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. From 5/5/25 to 5/7/25, Surveyor reviewed R33's medical record. R33 was admitted to the facility on [DATE] and had diagnoses including congestive heart failure, renal insufficiency, diabetes, and malnutrition. R33's most recent MDS assessment, dated 2/10/25, had a BIMS score of 13 out of 15 which indicated R33 had intact cognition. On 5/6/25 at 9:17 AM, Surveyor observed medication administration for R33 with LPN-O. While in R33's room, Surveyor observed a bottle of lubricating eye drops on R33's bedside table. Surveyor noted the eye drops were not labeled or dated. LPN-O removed the eye drops from R33's room. On 5/6/25 at 9:22 AM, Surveyor interviewed LPN-O who indicated LPN-O was not sure where the eye drops came from and was not sure if R33 had a self-administration of medication assessment. On 5/6/25 at 2:24 PM, Surveyor interviewed DON-B regarding the eye drops at R33's bedside. DON-B indicated a box of Systane eye wipes and a tube of triple antibiotic ointment were also found in R33's beside drawer.…

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 monthly medication reviews were completed for 2 residents (R) (R7 and R25) of 5 sampled residents. R7 did not have a monthly medication review (MMR) documented for November 2024, January 2025, or March 2025. R25 did not have a monthly medication review (MMR) documented for April 2025. Findings include: 1. From 5/5/25 to 5/7/25, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including hypertension, depression, and history of a stroke. R7's Minimum Data Set (MDS) assessment, dated 4/18/25, had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 which indicated R7 had moderate cognitive impairment. R7 had an activated Power of Attorney for Healthcare (POAHC). On 5/7/25 at 12:28 PM, Surveyor reviewed R7's MMRs from November 2024 through April 2025. R7's medical record did not contain an MMR for November 2024, January 2025, or March 2025. 2. From 5/5/25 to 5/7/25, Surveyor reviewed…

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 allegations of potential neglect were thoroughly investigated for 2 residents (R) (R2 and R1) of 3 sampled residents. R2 passed away on [DATE] following a fall on [DATE]. The facility did not thoroughly investigate the incident of potential neglect. R1 fell on [DATE]. R1 went to the hospital on [DATE] due to increased pain and a change in condition and was diagnosed with a clavicle fracture. The facility did not thoroughly investigate the fall or the potential for abuse or neglect. Findings include: The facility was unable to provide a policy related to abuse and neglect investigations. 1. On [DATE], Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses including cerebral infarction affecting right dominant side, familial dysautonomia (a rare inherited condition that affects the nervous system), congestive heart failure, sick sinus syndrome (a group of abnormal heart rhythms resulting from…

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 thorough neurological checks were completed per the facility's policy for 2 residents (R) (R2 and R1) of 3 sampled residents. Staff did not consistently complete vital signs during neuro checks following R2's fall on 8/24/24. Staff did not complete neuro checks per the facility's policy after R1 fell and hit R1's head on 8/17/24. Findings include: The facility's Neurological Assessment 2001 Med-Pass policy, revised October 2010, indicates: Neurological Assessment are indicated: Upon physician order; Following an unwitnessed fall; Following a fall or other accident/injury involving head trauma; or when indicated by the resident's condition. 2. When assessing neurological status, always include frequent vital signs. Particular attention should be paid to widening pulse pressure (difference between systolic and diastolic pressures). This may be indicative of increasing intracranial pressure (ICP). Steps in the Procedure: .6. Take temperature,…

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 adequate assistive devices and interventions were in place to prevent falls for 1 resident (R) (R1) of 3 sampled residents. R1's care plan contained an intervention for a tab alarm. The intervention was not consistently implemented. Findings include: The facility's Safety and Supervision of Residents policy (from 2001 Med-Pass, Inc.), revised July 2017, indicates: Individualized, Resident-Centered Approach to Safety: .4. Implementing interventions to reduce accident risks and hazards shall include the following: .d. Ensuring that interventions are implemented. On 9/17/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including clavicle fracture and muscle weakness. R1's Minimum Data Set (MDS) assessment, dated 9/5/24, stated R1 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R1 had moderate cognitive impairment. R1 did not have an…

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

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect 27 of 27 residents residing in the facility. Staff did not ensure time/temperature control foods were labeled with open or use-by dates. Staff did not wear hair or beard restraints consistently throughout the kitchen. Kitchen equipment and food services areas were not in a clean and sanitary condition. Findings include: On 4/22/24 at 9:23 AM, Dietary Director (DD)-K indicated the facility follows the Food and Drug Administration (FDA) Food Code. Open/Unlabeled/Undated/Expired Food: The FDA Food Code 2022 documents at 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking: (A) Except when packaging food using a reduced oxygen packaging method as specified under § 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked 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 establish and maintain infection control and water management programs designed to help prevent the development and transmission of disease and infection. In addition, the facility did not ensure enhanced barrier precautions were implemented for 4 residents (R) (R2, R18, R4, and R79) of 4 residents to reduce the transmission of multidrug-resistant organisms (MDROs) and did not ensure staff performed appropriate hand hygiene for 5 (R1, R9, R16, R129 and R19) of 5 residents observed during medication administration. These practices had the potential to affect all 27 residents residing in the facility. The facility did not maintain surveillance logs to assist with the recognition of trends and patterns of infection to help prevent the spread of communicable disease. In addition, the facility did not monitor residents for signs and symptoms of infection. The facility did not have a water management program that identified areas in the water system where Legionella could grow and spread and to reduce the risk…

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 the designated Infection Preventionist (IP) completed infection prevention and control training and was employed at least part-time in the facility. This practice had the potential to affect all 27 residents residing in the facility. The facility's designated IP worked remotely and did not work in the facility at least part-time. In addition, the IP's certificate of completion for infection prevention and control training was not provided to Surveyor. Findings include: The Centers for Medicare & Medicaid Services (CMS) memo QSO-22-19-NH, last revised 6/29/22, indicates: In 2016, CMS overhauled the Requirements for Participation for Long-Term Care (LTC) facilities (i.e., nursing homes) which was implemented in three phases: .Phase 3 (11/28/19) regulations require nursing homes to have an Infection Preventionist who has specialized training onsite at least part-time to effectively oversee the facility's infection prevention and control program. During the entrance conference on 4/22/24 at 10:09 AM, Nursing Home…

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 the comprehensive plan of care was reviewed and revised in a timely manner for 6 residents (R) (R2, R16, R18, R20, R21, and R22) of 13 sampled residents. R2, R16, R18, R20, R21 and R22's care plans were not reviewed prior to or on the due dates listed on the care plans. Findings include: The facility's Care Planning-Interdisciplinary Team policy, revised March 2022, indicates: Resident care plans are developed according to the timeframes and criteria established in §483.21. §483.21(b) Comprehensive Care Plans indicates a comprehensive care plan must be .Developed seven days after completion of the comprehensive assessment .(iii) Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments .Facility staff must develop the comprehensive care plan within seven days of the completion of the comprehensive assessment (Admission, Annual or Significant Change in Status) and review and revise the care plan after each assessment. The Long-Term…

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, record review, the facility did not ensure weights were obtained per physician orders for 4 residents (R) (R13, R20, R16 and R128) of 4 sampled residents. Staff did not obtain and document weekly weights for R13, R20, and R16 per physician orders. R128 was admitted to the facility on [DATE]. R128's medical record did not contain weight information. Findings include: On 4/23/24, Surveyor reviewed R13's medical record. R13 had an activated Power of Attorney for Healthcare (POAHC) and diagnoses including dementia-severe with mood disturbance, edema, hypothyroidism, and anxiety. R13's Minimum Data Set (MDS) assessment, dated 3/13/24, contained a Brief Interview for Mental Status (BIMS) score of 0 out of 15 which indicated R13 had severely impaired cognition. R13's medical record contained a signed order from Medical Director (MD)-J, dated 2/1/24, for weekly weights on Tuesdays. R13's medical record did not contain weekly weights. Surveyor noted since October 2023, R13's weights…

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

Based on staff interview and record review, the facility did not ensure a resident or their representative was informed and consented to the risks and benefits of care and the treatment for 2 residents (R) (R16 and R20) of 5 sampled residents. R16 was prescribed Seroquel (an antipsychotic medication), Lexapro (an antidepressant medication), Depakote (an anticonvulsant/mood stabilizing medication), Paxil (an antidepressant medication), Buspar (an anti-anxiety medication), and Namenda (a cognition-enhancing medication). R16's medical record did not contain current consents for the medications. R20 was prescribed Seroquel, Depakote, Paxil, Namenda, and Exelon (a cognition-enhancing medication). R20's medical record did not contain current consents for the medications. Findings include: On 4/24/24 at 11:00 AM, Surveyor requested the facility's Resident Rights policy from Regional Consultant (RC)-C who indicated the facility followed state and federal laws regarding resident rights. The facility's Psychotropic Medication Use policy indicates: Residents, families and/or their…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure 2 residents (R) (R12 and R22) of 2 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 notify the Ombudsman of the transfers. R12 was transferred to the hospital on 6/3/23. R12 was not provided with a written transfer notice and the Ombudsman was not notified of the transfer. R22 was transferred to the hospital on [DATE]. R22 was not provided with a written transfer notice and the Ombudsman was not notified of the transfer. Findings include: The facility's Transfer Agreement policy, with an effective date of 8/1/17, indicates: Whenever the attending physician of a patient implements an order that a transfer of a patient from the facility to the hospital is medically necessary and appropriate, the facility shall transfer the patient .as promptly as possible .The facility shall…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure 2 residents (R) (R12 and R22) of 2 residents reviewed for hospitalization received written information of the duration of the facility's bed-hold policy, the reserve bed payment policy, and the right to return to the facility. R12 was transferred to the hospital on 6/3/23 and was not provided a copy of the facility's bed-hold policy. R22 was transferred to the hospital on [DATE] and was not provided a copy of the facility's bed-hold policy. Findings include: The facility's Bed-Holds and Returns policy, revised 3/2022, indicates: Residents and/or representatives are informed (in writing) of the facility and state (if applicable) bed-hold policies .1. All residents/representatives are provided written information regarding the facility's bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalizations or therapeutic leave). Residents are provided written information about these policies 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 staff interview and record review, the facility did not accurately code Minimum Data Set (MDS) 3.0 assessments for 2 residents (R) (R4 and R21) of 13 sampled residents. R4's MDS assessment, dated 2/21/24, did not contain a Brief Interview for Mental Status (BIMS) score or indicate R4's cognition was assessed. R21's MDS assessment, dated 3/28/24, did not contain a BIMS score or indicate R21's cognition was assessed. Findings include: The facility's MDS Completion and Submission Timeframes policy, revised July 2017, indicates: Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. 1. The Assessment Coordinator or designee is responsible for ensuring that resident assessments are submitted to the Centers for Medicare & Medicaid Services (CMS') Quality Improvement & Evaluation System (QIES) Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines. 2. Timeframes for completion and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure a Level I Pre-admission Screening and Resident Review (PASRR) Screen was completed prior to admission for 1 resident (R) (R22) of 5 residents. The facility did not ensure R22's Level I PASRR Screen was completed prior to admission. Findings include: On 4/22/24, Surveyor reviewed R22's medical record. R22 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), anxiety, and post-traumatic stress disorder (PTSD). R22's Minimum Data Set (MDS) assessment, dated 8/28/23, contained a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R22 had intact cognition. Surveyor noted R22's medical record did not contain a Level I PASRR Screen. On 4/24/24 at 2:31 PM, Surveyor interviewed Regional Consultant (RC)-C who could not locate R22's Level I PASRR Screen but agreed a Level I PASRR Screen should be completed for a resident with a diagnosis of anxiety. On 4/24/24 at 2:35…

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 baseline care plan was developed or provided within 48 hours of admission for 1 resident (R) (R178) of 13 sampled residents. A baseline care plan was not completed or provided to R178 within 48 hours of admission. Findings include: The facility's Care Planning-Interdisciplinary Team policy, revised March 2022, indicates: Resident Care plans are developed according to the timeframes and criteria established by state statute (§) 483.21. According to §483.21 Comprehensive person-centered care planning: (a) Baseline care plans: (1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must: (i) Be developed within 48 hours of a resident's admission; (ii) Include the minimum healthcare information necessary to properly care for a resident including,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not develop or implement an individualized comprehensive care plan for 1 resident (R) (R21) of 13 sampled residents. R21 required assistance with activities of daily living (ADL). The facility did not develop a comprehensive care plan that included ADL interventions related to toileting and incontinence care. Findings include: The facility's Care Planning-Interdisciplinary Team policy, revised March 2022, indicates: Resident care plans are developed according to the timeframes and criteria established by state statute (§) 483.21. §483.21(b) Comprehensive Care Plans indicates a comprehensive care plan must be .Developed seven days after completion of the comprehensive assessment .(iii) Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments .Facility staff must develop the comprehensive care plan within seven days of the completion of the comprehensive assessment…

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 provide assistance with activities of daily living (ADLs) for 1 resident (R) (R21) of 13 sampled residents. R21 required assistance with toileting and incontinence care which was not consistently provided. Findings include: On 4/23/24, Surveyor reviewed R21's medical record. R21 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, dementia, cerebral infarction (stroke), type two diabetes, anxiety, urinary tract infection (UTI), and sepsis. R21's Quarterly Minimum Data Set (MDS) assessment, dated 3/28/24, indicated a Brief Interview for Mental Status (BIMS) assessment was not completed. The MDS assessment also indicated R21 was occasionally incontinent of bladder and required partial/moderate assist for toileting hygiene. R21's previous MDS assessment, dated 12/28/23, indicated R21 was frequently incontinent of bladder and occasionally incontinent of bowel and required partial/moderate…

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 the provision of care and treatment in accordance with professional standards of practice for 1 resident (R) (R13) of 1 sampled resident with edema. R13 had a diagnosis of edema. R13's plan of care did not contain interventions to treat, monitor, or provide edema relief. In addition, the facility did not update R13's physician on the effectiveness of a short-term medication order for edema. Findings include: The facility's undated Goals and Objectives, Care Plans policy indicates: Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence .Care plan goals and objectives are defined as the desired outcome for a specific problem .When goals and objectives are not achieved, the resident's clinical record will be documented as to why the results were not achieved and what new goals and objectives have been established. Care plans will be modified accordingly .Care plan goals and objectives are derived from information contained 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. On 4/23/24, Surveyor reviewed R16's medical record. R16 had an activated Power of Attorney for Healthcare (POAHC) and diagnoses including dementia with delusional disorder, cognitive communication disorder, dysthymic disorder, acquired absence of other specified parts of digestive system, and anxiety. R16's MDS assessment, dated 3/6/24, contained a BIMS score of 0 out of 15 which indicated R16 had severely impaired cognition. A progress note, dated 4/22/24, indicated: Certified Nursing Assistant (CNA) indicated R16 lost footing when walking and fell to buttocks on the floor. Bruising noted to R16's right mid back and right hip. R16 transferred with assist and reported no pain. The progress note indicated R16 did not have footwear on during the fall. Surveyor reviewed R16's care plan, with a revision date of 10/15/23, and noted R16 had falls due to confusion and advanced dementia, running down hallways, poor safety, and spatial awareness. The care plan contained an intervention to ensure R16 wore appropriate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure monitoring of a high-risk medication was provided for 1 resident (R) (R22) of 5 residents reviewed for unnecessary medications. The facility did not monitor R22 for potential side effects or adverse reactions of anticoagulant (blood thinner) medication. Findings include: On 4/22/24, Surveyor reviewed R22's medical record. R22 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), anxiety, muscle weakness, difficulty walking, and long-term anticoagulant use. R22's Minimum Data Set (MDS) assessment, dated 8/28/23, contained a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R22 had intact cognition. R22 had a physician order for Eliquis (an anticoagulant mediation) 2.5 mg (milligrams), give 1 tablet by mouth two times daily for atrial fibrillation (abnormal heart rhythm). Surveyor noted R22's plan of care did not contain interventions that alerted staff to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure monitoring for adverse effects of psychotropic medication was provided for 3 residents (R) (R16, R128, and R178) of 5 residents reviewed for unnecessary medications. R16 was prescribed antipsychotic, antidepressant, and anti-anxiety medication. R16's medical record did not indicate a gradual dose reduction was attempted within the last year or that a GDR was contraindicated. R128 was prescribed antipsychotic, antidepressant, and anti-anxiety medication. R128's plan of care did not contain monitoring for signs and symptoms of adverse effects or the effectiveness of the medication. In addition, R128's medical record did not contain an Abnormal Involuntary Movement Scale (AIMS) assessment. R178 was prescribed antipsychotic and anti-anxiety medication. R178's plan of care did not contain monitoring for adverse effects or the effectiveness of the medication. In addition, R178's medical record did not contain an AIMS assessment. Findings include:…

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.