Pavilion at Glacier Valley

Based on staff interview and record review, the facility did not designate a person to serve as the food and nutrition services director who was a certified dietary manager, had a national certification for food service management and safety from a national accrediting body, or had an associates or higher level degree in food service management or hospitality. This had the potential to affect all 72 residents residing in the facility. Dietary Manager (DM)-N did not have an approved dietary manager or food service manager certification course or other related education. Findings include: During an initial kitchen tour on 11/10/24 at 10:33 AM, Surveyor interviewed DM-N who indicated DM-N had been at the facility for a short time and did not have a dietary manager certification. DM-N indicated DM-N had a ServSafe certification, but was not yet enrolled in an approved course. DM-N also indicated the facility used a part-time Dietitian. On 11/12/24 at 1:41 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who confirmed DM-N did not have an approved certification course for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 4. From 11/10/24 to 11/12/24, Surveyor reviewed R12's medical record. R12 was admitted to the facility on [DATE] and had diagnoses including obesity, overactive bladder, chronic kidney disease (CKD), and chronic peripheral venous insufficiency. R12's MDS assessment, dated 8/23/24, had a BIMS score of 15 out of 15 which indicated R12 was not cognitively impaired. On 11/10/24 at 12:17 PM, Surveyor interviewed R12 about care at the facility. R12 stated call light response times ranged from ten minutes to one hour. R12 indicated R12 asked for a bedpan which an unnamed CNA would not provide. R12 stated R12 thought the refusal was cruel and inhuman treatment. R12 also indicated R12 asked staff to hold down a bed pan while R12 turned to get off the bed pan. R12 said the CNAs didn't do it which caused the bed pan to spill. R12 indicated sometimes staff didn't change R12's bedding and R12 had to lay on wet bedding for a half hour until night shift staff arrived. On 11/11/24 at 11:39 AM, Surveyor interviewed NHA-A who 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.

Based on observation, staff and resident interview, and record review, the facility did not ensure sufficient staffing was provided to meet the needs of 5 residents (R) (R30, R11, R17, R50, and R26) of 25 sampled residents with the potential to affect additional residents. The facility had low staffing on 4/14/24, 5/11/24, 5/12/24, and 6/23/24. On 11/10/24, R30 activated R30's call light for assistance with toileting on multiple occasions. Staff turned off R30's call light without providing assistance. On 11/10/24, R11 activated R11's call light for assistance to bed. Certified Nursing Assistant (CNA)-Y turned off R11's call light and left the room without assisting R11. On 11/10/24, R17 activated R17's call light for assistance to bed. CNA-Z turned off R17's call light and left the room without assisting R17. On 11/10/24, R50 activated R50's call light for an evening snack. Licensed Practical Nurse (LPN)-F turned off R50's call light and left the room without providing a snack. R26 did not consistently receive scheduled showers. Findings include: The facility's Staffing 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 observation, staff interview, and record review, the facility did not ensure all drugs and biologicals were stored in accordance with the facility's policy. One of five medication carts was observed unlocked and unattended in a resident hallway. One of two medication storage rooms contained expired medication and medical supplies. A prescription label on a medication card was not labeled according to the provider's order for 1 resident (R) (R33) observed during medication administration. This practice had the potential to affect more than 4 of the 72 residents residing in the facility. On [DATE], a medication cart on the 600 wing was unlocked and unattended. In addition, a cup that contained medication was on top of the cart and a computer screen that contained residents' personal information was open. The medication storage room on the long-term care unit contained expired medication and medical supplies. A medication card for R33 was not labeled according to the physician's order. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review, the facility did not ensure a call light was within reach for 1 resident (R) (R1) of 25 sampled residents. R1 was dependent on staff for mobility and other cares. During an observation on 11/10/24, R1's call light was not within reach. Findings include: From 11/10/24 to 11/12/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including traumatic brain injury (TBI), non-pressure chronic ulcer of skin of other sites limited to breakdown of skin, pain, and dysphagia (difficulty swallowing). R1's Minimum Data Set (MDS) assessment, dated 10/18/24, had a Brief Interview for Mental Status (BIMs) score of 15 out of 15 which indicated R1 was not cognitively impaired. The MDS indicated R1 was dependent on staff for mobility and transfers. R1 had alteration in vision due to a TBI. R1 was legally blind and relied on staff to help with items R1 needed. R1's plan of care indicated staff should to explain…

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 grievance was thoroughly investigated and resolution was provided for 1 resident (R) (R7) of 25 sampled residents. R7 told staff that R7 was missing items from laundry. Staff did not follow the facility's grievance process or follow-up with R7. Findings include: The facility's Missing Items policy, with a review date of 6/9/23, indicates: .5. When personal items are missing, the resident/responsible party is responsible to inform staff immediately and will complete a complaint/grievance form. From 11/10/24 to 11/12/24, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side and muscle weakness (generalized). R7's Minimum Data Set (MDS) assessment, dated 9/11/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R7 was not cognitively impaired. On 11/10/24 at 12:05 PM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff, resident and family interview, and record review, the facility did not ensure 3 residents (R) (R67, R17 and R1) of 5 sampled residents reviewed for pressure injuries received the necessary care and services to promote healing and/or prevent pressure injuries from developing. R67 had a pressure injury on the right heel. R67 did not have interventions in place that were recommended by the wound care provider. In addition, R67's care plan did not contain the wound care provider's recommendations. R17 developed a pressure injury from oxygen tubing that was not padded. R1 had a self determination care plan that indicated R1 chose to have a urinal propped against R1's scrotal area. R1's care plan did not contain an intervention to monitor for or prevent potential skin injury to R1's scrotal area. Findings include: The facility's Wound care Policies and Procedures, with a revision date of 6/1/15, indicates: Evaluation is the formal process in which wound characteristics, underlying…

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 the appropriate care and services were provided to increase and/or prevent further decrease in range of motion for 3 residents (R) (R14, R6, and R7) of 3 sampled residents. R14 did not receive restorative therapy per therapy discharge recommendations. Staff did not correctly enter the recommendations in R14's medical record, therefore, R14's Minimum Data Set (MDS) assessment was not coded correctly. R6 did not consistently receive restorative therapy. R7 did not consistently receive range of motion (ROM) per R7's orders and care plan. Findings include: On 11/11/24, Surveyor requested the facility's policy for restorative services. The facility provided a training that was titled Restorative Nursing Program Quick Start from Fundamental Clinical and Operational Services, LLC 2024 which contained educational slides for the restorative nursing program (RNP). The training indicated: .Care planning: specific detail approaches, 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.

Based on observation, staff interview, and record review, the facility did not provide the necessary care and services to prevent a urinary tract infection (UTI) for 1 resident (R) (R17) of 4 residents reviewed for catheter care. On 11/10/24, R17's uncovered catheter drainage bag was observed on the floor. Findings include: The facility's Catheter-Urinary Catheter, Cleaning and Maintenance Policy and Procedure taken from the Lippincott Nursing Procedures 9th edition (Copyright 2023 with complete revision: May 5, 2023) indicates: Don't place the drainage bag on the floor to reduce the risk of contamination and subsequent catheter-associated urinary tract infection (CAUTI). From 11/10/24 to 11/12/24, Surveyor reviewed R17's medical record. R17 received Hospice services and had diagnoses including chronic kidney disease (CKD) stage 3 and recurrent and persistent hematuria (blood in the urine). R17 had a physician order for an indwelling Foley catheter for acute urine retention (dated 10/18/24) and an order for a privacy bag in place every shift (dated 10/18/24). On 11/10/24 at 10:28…

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 1 resident (R) (R17) of 25 sampled residents received the necessary care and treatment related for oxygen therapy. During an observation on 11/10/24, R17's oxygen tubing did not contain a date or initials to indicate when the tubing was last changed. Findings include: The facility's Oxygen Administration policy, with a revision date of 2/12/24, indicates: Nasal Cannula: Change weekly, when soiled, and on an as needed basis or per state regulations. From 11/10/24 to 11/12/24, Surveyor reviewed R17's medical record. R17 received Hospice services and had diagnoses including chronic obstructive pulmonary disorder (COPD), congestive heart failure (CHF), and chronic kidney disease (CKD) stage 3. R17 had a physician order for 1-6 liters per minute (LPM) of oxygen via nasal cannula. The facility's general nursing orders, dated 7/29/24, indicated: Equipment Oxygen: Change oxygen tubing/nasal cannula/mast/humidification system weekly once a day on Tuesday from 10:00 PM to 6:00 AM. On 11/10/24 at 10:38 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 staff and resident interview and record review, the facility did not ensure medications were administered within the ordered timeframe for 1 resident (R) (R1) of 6 sampled residents. R1's medications were administered late on 7/29/24, 8/2/24, 10/28/24, 10/30/24, and 11/7/24. Findings include: The facility's Medication Management Program policy, with a revision date of 5/5/23, indicates: .7. Medications are administered no more than one hour before to one hour after the designated medication pass time .11. Immediately after administering the medication to the resident, the authorized staff or licensed nurse will return to the medication cart and document medication administration with initials on the MAR (Medication Administration Record). From 11/10/24 to 11/12/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including traumatic brain injury (TBI), non-pressure chronic ulcer of skin of other sites limited to breakdown of skin, pain, and dysphagia…

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

Based on observation, staff and resident interview, and record review, the facility did not ensure preferences for dietary needs were met for 1 resident (R) (R276) of 25 sampled residents. R276 did not receive consistently receive the dietary preferences that R276 specified to dietary staff. Findings include: Surveyor requested the facility's policy on food preferences and received a Facility Module User Guide for Matrixcare Meal Tracker, dated October 2024. The User Guide indicated how to enter residents' preferences/special requests in the system. On 11/10/24, Surveyor reviewed R276's medical record. R276 had diagnoses including surgical aftercare on digestive system, hyperkalemia, protein calorie malnutrition, and colon cancer. R276's Minimum Data Set (MDS) assessment, dated 11/3/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R276 was not cognitively impaired. R276's plan of care contained interventions to honor food preferences as feasible. R276 disliked oatmeal, bacon, sausage, and meats not in deli slice form. R276 liked fruit,…

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

Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable disease and infection for 1 resident (R) (R275) of 25 sampled residents. R275 was on enhanced barrier precautions (EBP). R275 did not have EBP signage outside of R275's room to inform staff of infection prevention precautions needed during the provision of care. Findings include: The facility's Infection Prevention and Control Policies and Procedures, dated 5/15/23, indicates: Enhanced Barrier Precautions (EBP): 1. EBP expand the use of personal protective equipment (PPE) (gowns and gloves) during high-contact resident care activities that provide opportunities for transfer of multidrug-resistant organisms (MDROs) to staff hands and clothing. A. EBP will be implemented for all residents with the following: .2) Wounds and/or indwelling medical devices (central lines, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization…

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 the accurate administration of medication for 3 residents (R) (R2, R6, and R7) of 5 residents observed during medication administration. In addition, the facility did not provide pharmaceutical services to ensure the safe handling of drugs and biologicals for 2 (R4 and R7) of 5 residents observed during medication administration. On 7/10/24, R2, R6 and R7's AM medications were administered late. During medication pass on 7/10/24, Surveyor observed Registered Nurse (RN)-E drop R4's aspirin on the floor and dispose of the tablet in the garbage. RN-E also did not administer R4's carvedilol (used to treat high blood pressure). During medication pass on 7/10/24, Surveyor observed Medication Technician (MT)-J dispose of R7's sertraline (used to treat depression) tablet in a Sharps container. Findings include: The facility's Medication Management Program policy, revised 5/5/23, indicates: Discontinuation and Destruction of Medications…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure a physician was notified of a change in condition for 1 resident (R) (R3) of 10 sampled residents. R3's physician was not notified when R3 had a nearly 12 pound weight loss in one week. Findings include: The facility's Weighing the Resident policy, with a revision date of 5/5/23, indicates: .4. If there is an actual 5% or more gain or loss in one month, notify the patient/resident/family, physician, and the Nutrition/Culinary Services Director. Document this notification per facility protocol .8. Percent body weight change is calculated using the following formula: % body weight change = usual weight - actual weight x 100 divided by usual weight. 9. Unplanned and undesired weight variance will be evaluated for significance utilizing the following guidelines: 3% in one week, 5% in 30 days, 7.5% in 90 days, and 10% in 180 days. On 7/10/24, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and had diagnoses…

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 grievances were documented, investigated, and thoroughly resolved for 1 resident (R) (R5) of 10 sampled residents. R5's representative submitted grievances to the facility via email or phone on the following dates: 4/7/24, 4/27/24, 5/23/24, 5/29/24, 5/30/24, 5/31/24, 6/19/24, and 6/24/24. The facility did not ensure the grievances were documented, thoroughly investigated, or resolved. Findings include: The facility's Social Services Policies and Procedures, with a revision date of 11/6/23, indicates: Facility leadership acts promptly to understand and resolve complaints and grievances completed in a reasonable expected time frame .Responsibility of Grievance Official .7. Ensure that all written grievance decisions include a summary statement of: The date the grievance was received, the resident's grievance, steps taken to investigate the grievance, pertinent findings or conclusions, decision if the grievance was confirmed or not confirmed, corrective action taken or to be taken, the date the decision was issued…

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, staff did not immediately report a resident-to-resident physical altercation to Nursing Home Administrator (NHA)-A per the facility's policy for 2 residents (R) (R7 and R8) of 2 sampled residents. Staff did not report a resident-to-resident altercation between R7 and R8 to NHA-A which delayed a report to the State Agency (SA). Findings include: The facility's undated Leadership Policies and Procedures indicates: .E. Resident-to-resident abuse: Bullying and threats of violence that cause mental anguish .Willful physical touching that leads to harm, mental anguish, or pain .V: Reporting/Response: .w. All alleged violations concerning abuse .are reported immediately to the facility's Abuse Coordinator, the Administrator, and to other officials in accordance with State law including the State Survey and Certification Agency. On 7/10/24, Surveyor reviewed R7's medical record. R7 had a diagnosis of vascular dementia without behavioral disturbance. R7's Minimum Data Set (MDS) assessment, dated 5/16/24, had a Brief Interview for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review, the facility did not ensure a hand splint and passive range of motion (PROM) was provided for 1 resident (R) (R2) of 1 sampled resident . R2's hand splint was not included on R2's care plan. In addition, PROM was not completed as ordered and was not included on R2's care plan. Findings include: On 7/10/24, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (commonly referred to as stroke), hemiplegia (weakness on one side of the body), hemiparesis (paralysis on one side of the body), congestive heart failure (CHF), and chronic kidney disease (CKD). R2's Minimum Data Set (MDS) assessment, dated 6/12/24, had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R2 had moderate cognitive impairment. R2's medical record contained the following physician orders: ~ Compression sleeve left upper extremity (LUE) on in AM and off at hour of sleep -…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interview, and record review, the facility did not ensure 2 Residents (R) (R6 and R2) of 3 residents received appropriate care and services to increase and/or prevent further decrease in range of motion (ROM). R6's therapy screen contained recommendations for staff to assist R6 with restorative exercises. R6's restorative program was not consistently followed. R2's therapy screen contained recommendations for staff to assist R2 with restorative exercises. R2's restorative program was not consistently followed. Findings include: The facility's Restorative Nursing Policies and Procedures, revised 5/1/22, indicated: ROM exercises: 1. Review care plan, determine the following: active or passive ROM exercises, body parts to be exercised, number of repetitions and special instructions; 4. Perform appropriate exercises as directed in the care plan. See techniques for passive range of motion exercises for specific instructions for each body part; 5. After the exercise sessions, report any…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review, the facility did not ensure medications were administered timely for 3 Residents (R) (R6, R2, and R1) of 5 residents reviewed. R6, R2, and R1's scheduled medications were not administered timely. Findings include: The facility's Medication Management Program, revised 5/5/23, indicated: Authorized staff must understand the 8 rights for administering medication .4. The right time .Medications are administered no more than one hour before to one hour after the designated medication pass time . 1. On 1/16/24, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] with diagnosis including chronic pain syndrome, multiple sclerosis, and ataxia unspecified. R6's Minimum Data Set (MDS) assessment, dated 10/23/23, documented R6's Brief Interview for Mental Status (BIMS) score was 15 out of 15 which indicated R6 was not cognitively impaired. On 1/16/24 at 9:34 AM, Surveyor observed Registered Nurse (RN)-F administer 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 observation, staff interview, and record review, the facility did not establish and maintain an infection control program designed to provide a safe and sanitary environment to help prevent the development and transmission of disease and infection. The facility did not ensure the proper handling and storage of linens to prevent the spread of infection. This has the potential to affect multiple residents (R) in the facility. In addition, staff did not complete appropriate hand hygiene during the provision of care for R330. The top and side of a storage rack used for clean resident linens contained dust and debris. In addition, Surveyor observed clean linens touch the floor during the folding process. Staff did not complete appropriate hand hygiene during the provision of care for R330. Findings include: The facility's Laundry policy, dated 3/2006, contained the following: ~All Linens: 1. Linens are to be handled in a safe manner to prevent contamination of the linen, the personnel, and the environment. Clean Linen: 5. Covers used to protect clean linen are clean and in good…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure protective placement was obtained for 1 Resident (R) (R25) of 1 sampled resident. R25 had a legal guardian. The facility did not file a petition for protective placement when R25's stay at the facility exceeded 60 days from admission on [DATE]. Findings include: WI state statute chapter 55.055(1)(b) contains the following information: The guardian of an individual who has been adjudicated incompetent may consent to the individual's admission to a nursing home or other facility not specified in par. (a) for which protective placement is otherwise required for a period not to exceed 60 days. In order to be admitted under this paragraph, the individual must be in need of recuperative care or be unable to provide for his or her own care or safety so as to create a serious risk of substantial harm to himself or herself or others. Prior to providing that consent, the guardian shall review the ward's right to the least restrictive residential…

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 an injury of unknown origin was thoroughly investigated for 1 Resident (R) (R40) of 2 sampled residents. On 9/25/23, R40 was found on the floor and initially refused an injury assessment. Later in the day, staff noted R40 had a laceration on the left arm that required 19 sutures. The facility did not conduct a thorough investigation related to R40's injury of unknown origin. Findings include: Facility policy titled Abuse, Neglect, Exploitation, or Mistreatment with no noted revision dated indicated: 1. The facility's Leadership prohibits neglect, mental, physical and/or verbal abuse, use of a physical and/or chemical restraint not required to treat a medical condition, involuntary seclusion, corporal punishment, and misappropriation of a patient's/resident's property and/or funds and ensures that alleged violation involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure the required Minimum Data Set (MDS) assessment data was completed, encoded, and transmitted timely for 1 Resident (R) (R6) of 3 residents reviewed. R6's MDS assessment, dated 10/25/23, did not have a completed transmission as of 12/12/23. Findings include: Chapter 5 of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, dated October 2023, indicates: .Nursing homes are required to submit Omnibus Budget Reconciliation Act (OBRA) required Minimum Data Set (MDS) records for all residents in Medicare- or Medicaid-certified beds regardless of the payer source .When the transmission file is received by iQIES, the system performs a series of validation edits to evaluate whether or not the data submitted meet the required standards. MDS records are edited to verify that clinical responses are within valid ranges and are consistent, dates are reasonable, and records are in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure Minimum Data Set (MDS) assessments were accurate for 2 Residents (R) (R50 and R3) of 3 residents reviewed for MDS completion. R50's medical record contained a Preadmission Screen and Resident Review (PASRR) Level II, dated 5/12/22, that indicated R50 met the federal definition of a serious mental illness. R50's MDS assessment, dated 5/12/23, was incorrectly coded for the question, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or related condition? R3's medical record contained a PASRR Level II, dated 2/8/22, that indicated R3 met the federal definition of a serious mental illness. R3's MDS assessment, dated 4/19/23, was incorrectly coded for the question, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or related condition? Findings include: The Centers for Medicare…

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 1 Resident (R) (R330) of 3 sampled residents received the appropriate treatment and services to prevent urinary tract infections (UTIs). R330 had a suprapubic catheter (a catheter inserted in the bladder through a small hole in the abdomen) and a history UTIs. R330's plan of care indicated R330's catheter drainage bag should be emptied every 2 hours which was not consistently completed. Findings include: According to the Centers for Disease Control and Prevention (CDC): A urinary tract infection (UTI) is an infection involving any part of the urinary system, including urethra, bladder, ureters, and kidney. UTIs are the most common type of healthcare-associated infection reported to the National Healthcare Safety Network (NHSN). On 12/12/23, Surveyor reviewed R330's medical record. R330 was admitted to the facility on [DATE] and had diagnoses including Multiple Sclerosis, UTIs, resistance to multiple…

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 Physician visits were timely for 1 Resident (R) (R27) of 1 resident reviewed. R27 was admitted to the facility on [DATE]. R27 not seen by a Physician or Nurse Practitioner every 60 days as required. Findings include: The facility's Leadership Policies and Procedures indicates in Section VI: Medical Services 2. The physician visits the patient/resident according to the following guidelines: Every months for three months and every 60 days thereafter, or more often as clinically driven. On 12/11/23, Surveyor reviewed R27's medical record. R27 was admitted to the facility with diagnoses including congestive heart failure (CHF), chronic obstructive pulmonary disorder (COPD), chronic kidney disease stage 4, depression, anxiety, diabetes mellitus type 2, respiratory failure with hypoxia, ischemic cardiomyopathy, and pulmonary hypertension. R27 also had a pacemaker. R27's medical record contained fax and telephone communication between 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 staff interview and record review, the facility did not ensure monitoring for adverse consequences of high-risk medications for 2 Residents (R) (R52 and R3) of 5 residents reviewed for unnecessary medications. R52 was prescribed tramadol and hydrocodone-acetaminophen (both high-risk medications in the opioid class used to treat moderate to severe pain). R52's care plan did not contain monitoring for adverse consequences of tramadol or hydrocodone-acetaminophen. R3 was prescribed tramadol. R3's care plan did not contain monitoring for adverse consequences of tramadol. Findings include: 1. On 12/11/23, Surveyor reviewed R52's medical record. R52 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (also known as stroke; a brain lesion in which a cluster of brain cells die when they don't get enough blood). R52's medical record contained the following physician orders: ~Hydrocodone-acetaminophen - Schedule II tablet; 5-325 mg (milligrams); 1 tablet; oral every 6 hours - PRN…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interview, and record review, the facility did not ensure 1 Resident (R) (R58) of 5 sampled residents was free from a significant medication error. R58 was readmitted to the facility on [DATE] with a hospital discharge order to take one 125 milligram (mg) capsule of vancomycin (an antibiotic) every 12 hours for 7 days. The order was transcribed without an end date and R58 received vancomycin through 12/12/23. Findings include: Center for Disease Control (CDC) web page Core Elements of Antibiotic Stewardship, updated of [DATE], indicates: Improving antibiotic prescribing and use is critical to effectively treat infections, protect patients from harms caused by unnecessary antibiotic use, and combat antibiotic resistance. The facility's Physician Orders policy, with a revision date of 5/5/23, contained the following information: The qualified licensed nurse completes an admission medication regimen review from the transfer record from an acute care hospital, home, or other entity. 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 interview and record review the facility did not provide the opportunity for 1 (R1) of 2 Residents reviewed to participate in the development and implementation of their person-centered plan of care by not facilitating the inclusion of R1 in the care planning process. Findings Include: Surveyor requested a facility policy and procedure on the care planning process for Residents and was not provided a policy during the survey process. R1 was admitted to the facility on [DATE] with diagnoses of Unspecified Focal Traumatic Brain Injury with Loss of Consciousness, Primary Carnitine Deficiency, Muscle Weakness, Overactive Bladder, Morbid Obesity, Lymphedema, Anxiety, Delusional Disorders, Major Depressive Disorder, Schizoaffective Disorder of Bipolar Type, and Other Schizophrenia. R1 is currently R1's own person. R1's Quarterly Minimum Data Set (MDS) dated [DATE] documents R1's Brief Interview for Mental Status (BIMS) score to be a 15, indicating R1 is cognitively intact for daily decision making. R1's MDS…

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 comprehensive person- centered care plan for 1 (R2) of 5 residents reviewed. R2 did not have a comprehensive care plan addressing impaired skin integrity, pressure injuries, or risk for falls when admitted to the facility. Findings include: The facility policy, entitled Nursing Policy and Procedures: Care Plan Process, Person-Centered Care, revised on 5/5/2023, states: The facility will develop and implement a baseline and comprehensive 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. Person- centered care means the facility focuses on the resident as the center of control and supports each resident in making his or her own choices. Person-centered care includes trying to understand what each resident is communicating, verbally and nonverbally, identifying what is important to each resident with regard 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, interview, and record review the Facility did not ensure quality of care was provided for 1 (R1) of 5 Residents. R1 was not wearing a compression glove on his right hand according to physician orders on 10/3/23 & 10/4/23. Findings include: R1's diagnoses includes traumatic brain injury, muscle weakness, abnormal posture, legally blind, and lymphedema. The quarterly MDS (Minimum Data Set) with an assessment reference date of 7/19/23 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. R1 is assessed as not have any behaviors including refusal of cares. R1 is assessed as requiring extensive assistance with one person physical assist for dressing. The physician order's dated 7/26/23 documents To RUE (right upper extremity) Compression glove to help with finger swelling. Double the tetra grip of the hand. If uncomfortable use 2 layer tetra grip, layer tetra grip with glove, or 2 layer tetra grip with glove twice daily. On 10/3/23 at 9:06 a.m. Surveyor observed R1 sitting in a broda chair at a table being fed breakfast by CNA…

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 were free from accident hazards and were provided supervision and assistive devices to prevent avoidable accidents for 3 (R2, R4, and R5) of 4 residents reviewed for accidents. * R2 did not have fall interventions in place for falls that occurred on 1/4/2023, 1/6/2023, and 1/7/2023. R2 did not have an investigation or root cause analysis done for a fall on 4/18/2023. * R4 did not have an investigation or root cause analysis done for a fall on 6/29/2023. * R5's bed was observed not at the lowest level as identified as a fall prevention in R5's care plan. Findings include: The facility policy, entitled Nursing Policies and Procedures: Fall Management, revised on 5/5/2023, states: 1. The facility will identify each patient/resident who is at risk for falls and will plan care and implement interventions to manage falls. 2. Qualified staff will complete the Fall Risk Evaluation to determine if patient/resident is a fall risk. 3.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure residents received routine drugs or obtain them as ordered for 1 (R1) of 5 residents. On 02/13/23, R1 was prescribed Levocarnitine three times per day (8:00 AM, 12:00 noon, and 8:00 PM), by their Medical Doctor (MD). R1 did not receive Levocarnitine as ordered on 6/6/23, 6/7/23, 6/8/23 and 6/9/23 before the Nurse Practitioner (NP) was notified and the Levocarnitine put on hold. Findings Include: The facility policy, entitled, Pharmacy Services Policies and Procedures, dated 04/01/22, states: Section 3 0 General Information Subject: 3.1 Provision of Pharmacy Services Policy: 1. The Facility will ensure that the provision of pharmaceutical services meets the needs of the residents for prescription and non-prescription medications, infusion therapy and equipment, supplies and services as they relate to pharmacy. Procedures: 1. The facility maintains current up-to-date facility and provide pharmacy policy and procedures pertaining 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 in interview, and record review the facility did not ensure and as needed (PRN) psychotropic medication was not utilized more than 14 days unless an alternate duration with rationale was provided for 1 (R2) of 3 residents reviewed for psychotropic medication use. R2's PRN Lorazepam (anti-anxiety medication) order was not discontinued after 14 days or obtained an alternate duration with rationale. Findings include: The facility policy, entitled Pharmacy Services Policy and Procedures: Medication Management- Use of Psychotropic Drugs, revised on 5/24/2022, states: 1. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. 2 D. PRN orders for psychotropic drugs are limited to 14 days. Except . if the attending physician or prescribing practitioner believes that is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for PRN order. E. PRN orders for…

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