Stevens Point Health Services

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not ensure proper footwear was worn during a mechanical lift transfer for 1 resident (R) (R17) of 1 sampled resident. R17 had diabetes and was at risk for foot injury. Staff did not ensure R17 wore proper footwear when they transferred R17 with a sit-to-stand lift. Findings include: The facility's Safe Lifting and Movement of Residents policy, revised 11/28/22. indicates: In order to protect the safety and well being of staff and residents and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents. Procedure: 1. Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. WisTech Open under Nursing Assistant Section 8.4-Assisting Clients to Transfer indicates staff should check that the resident is wearing non-skid footwear before transferring.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not provide adaptive eating equipment for 1 resident (R) (R5) of 16 sampled residents. Staff did not provide R5 with lidded cups and a divided plate per R5's meal ticket. Findings include: The facility's Assistive Devices policy, revised 9/2017, indicates: .Assistive devices/utensils will be provided as identified in the individualized plan of care to maintain or improve a resident's ability to eat or drink independently On 6/13/25, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, cerebral ischemia (reduced blood flow to the brain) and dysphagia (difficulty swallowing). R5''s Minimum Data Set (MDS) assessment, dated 5/9/25, had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated R5 had severe cognitive impairment. R5 had a legal Guardian. On 6/13/25, Surveyor reviewed R5's meal ticket which indicated R5 should receive cups 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 Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 1 resident (R) (R17) of 2 residents observed during the provision of care. Staff did not ensure enhanced barrier precautions (EBP) were followed for R17 during high-contact cares. Findings include: The facility's Enhanced Barrier Precautions policy, revised 8/8/24, indicates: The facility will implement enhanced barrier precautions (EBP) for prevention of the transmission of multidrug-resistant organisms (MDROs) .EBP refers to an infection control intervention designed to reduce transmission of MDROs that employs targeted gown and glove use during high-contact resident care activities .4. High-contact resident care activities include: a. dressing .c. transferring . On 6/13/25, Surveyor reviewed R17's medical record. R17 was admitted to the facility on [DATE] and had diagnoses including presence of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interview and record review, the facility did not ensure an allegation of abuse/neglect was reported to the State Agency (SA) in a timely manner for 1 resident (R) (R2) of 11 sampled residents. R2 and R2's family member reported an allegation of abuse/neglect to staff. The facility did not report the allegation to the SA. Findings include: The facility's Abuse, Neglect, and Exploitation policy, revised 7/15/22, indicates: IV. Possible indicators of abuse include, but are not limited to: 1. Resident, staff or family report of abuse .VII. Reporting Response: 1. Reporting of all alleged violations to the Administrator, State Agency, Adult Protective Services and to all other required agencies (e.g., law enforcement when applicable) within specified time frames. On 4/8/25, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including obesity, muscle weakness, anxiety, and depression. R2's Minimum Data Set (MDS) assessment, dated 3/7/25, had a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interview and record review, the facility did not ensure all allegation of abuse/neglect was thoroughly investigated for 1 resident (R) (R2) of 11 sampled residents. The facility did not thoroughly investigate on allegation of abuse/neglect reported by R2 and R2's family member. Findings include: The facility's Abuse, Neglect, and Exploitation policy, revised 7/15/22, indicates: .IV. Possible indicators of abuse include, but are not limited to: 1. Resident, staff, or family report of abuse .V. Investigation of Alleged abuse, Neglect, and Exploitation: A. An immediate investigation is warranted when an allegation or suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. 1. Written procedures for investigations include: Identifying staff responsible for the investigation .4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation .6.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not provide the necessary care and services to promote healing and/or prevent pressure injuries from developing for 1 resident (R) (R1) of 2 sampled residents. R1 was admitted to the facility with a pressure injury (PI) on the left heel. The facility did not complete accurate assessments of R1's left heel PI. Findings include: The facility's Pressure Injuries and Non Pressure Injuries policy, revised 7/20/22, indicates: The center will complete a comprehensive assessment to identify risk factors for the development of pressure injuries and put in place measures intended to achieve the goal of prevention of pressure injuries in our residents. For those residents admitted with, or who subsequently develop a pressure injury or impaired skin integrity, they will receive care, treatment, and services that seek to promote healing, prevent infection, and prevent further development of pressure injuries/impaired skin integrity .The staging of a pressure injury…

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

Based on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 3 residents (R) (R9, R6, and R5) of 7 residents observed during medication administration and the provision of care. During observations of medication administration for R9, R6, and R5, Medication Technician (MT)-C and Licensed Practical Nurse (LPN)-D did not complete appropriate hand hygiene. MT-C and LPN-D did not adhere to contact precautions during medication administration for R6 and R5. Findings include: The facility's Transmission-Based (Isolation) Precautions policy, dated 9/24/24, indicates: .Contact precautions refer to measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment .c. Healthcare personnel caring for residents on contact precautions wear a gown and gloves for all interactions that may involve contact with the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident representative interview and record review, the facility did not ensure a resident representative was notified of a change in condition for 1 resident (R) (R1) of 4 sampled residents. R1 experienced an overall decline including changes in transfer ability and eating habits during November and December of 2024. The changes were not communicated to R1's court-appointed Guardian. Findings include: The facility's Change in Condition of the Resident policy, revised 9/20/22, indicates: A facility should immediately inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident representative(s) when there is .a significant change in the resident's physical, mental or psychosocial status (that is deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); or a need to alter treatment .4. Notify the resident's family/responsible party as applicable and in accordance 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 Based on observation, staff interview, and record review, the facility did not consistently monitor nutrition intake for 1 resident (R) (R1) of 4 sampled residents. R1 experienced a significant weight loss. Staff did not consistently monitor or document R1's meal intake to determine if nutritional interventions were effective. Findings include: The facility's Weight Monitoring policy, revised 12/21/22, indicates: The interdisciplinary team will strive to prevent, monitor, and intervene for undesirable weight change for our residents .8. The threshold for significant weight change will be based on the following criteria .a. 1 month - 5% weight change is significant; greater than 5% is severe . On 2/11/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including unspecified dementia (a group of symptoms associated with a decline in memory severe enough to reduce a person's ability to perform everyday activities). R1's Minimum Data Set (MDS) assessment, dated…

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

Based on observation, resident and staff interview, and record review, the facility did not ensure proper infection control practices were maintained related to the use of personal protective equipment (PPE) for 2 residents (R) (R2 and R3) of 2 residents who were on enhanced barrier precautions (EBP). R2 was on EBP due to urinary concerns. Staff did not don the appropriate PPE during the provision of high-contact care for R2 on 11/5/24. R3 was on EBP due to wounds and colonized bacteria in R3's urine. Staff did not don the appropriate PPE during the provision of high-contact care for R3 on 11/5/24. Findings include: The facility's Infection Prevention and Control Program, revised 7/23/2024, indicates: .4. Standard Precautions: a) All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care. b) Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. c) All staff shall use personal protective equipment (PPE) according to established…

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 bathing assistance was provided for 1 Resident (R) (R1) of 4 sampled residents. R1 did not receive 3 of 10 scheduled showers between the dates of 4/23/24 and 7/10/24. Findings include: On 8/13/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD) (a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and diabetes mellitus (a disease in which blood sugar levels are too high). R1's Minimum Data Set (MDS) assessment, dated 6/13/24, stated R1's Brief Interview for Mental Status (BIMS) score was 10 out of 15 which indicated R1 had moderate cognitive impairment. R1's MDS assessment indicated R1 required the assistance of staff for bathing. R1 was hospitalized on [DATE], returned to the facility on 6/27/24, was hospitalized on [DATE], returned to the facility on 7/7/24, and passed away at the facility on 7/10/24. R1 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure accurate administration of medication for 1 Resident (R) (R1) of 4 sampled residents. R1 did not consistently receive pain medication timely or accurately as ordered by R1's physician. Findings include: The facility's Medication Administration policy, dated 1/2024, indicates: Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices .Medications are administered in accordance with written orders of the prescriber .Medications are administered within 60 minutes of their scheduled time . On 8/13/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD) (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), lung cancer, and bone cancer. R1's Minimum Data Set (MDS) assessment, dated 6/13/24, stated R1's Brief Interview for Mental Status (BIMS) score…

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 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 practice had the potential to affect all 42 residents residing in the facility. Dietary Manager (DM)-H did not complete an approved dietary manager or food service manager certification course or other related education. Findings include: On 5/6/24 at 9:53 AM, Surveyor interviewed DM-H who indicated DM-H just started as a cook at the facility. DM-H indicated DM-H worked in maintenance and also worked as a cook in an assisted living facility. DM-H stated DM-H was enrolled in ServSafe (which is not an approved Dietary Manager certification course,) but had not yet completed the course. DM-H also indicated DM-H would enroll in a dietary manager course after DM-H finished the ServSafe course. DM-H stated the facility had a…

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

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 42 residents residing in the facility. Staff did not complete hand hygiene after washing dishes and prior to touching ready to eat food. The counter was not in clean condition when staff cut vegetables. The microwave was not in clean condition and the mixer was not covered. Staff did not maintain unit refrigerator and freezer temperature logs. Open items in the walk-in cooler and dry storage area did not contain open dates. Findings include: On 5/6/24 at 9:48 AM, Surveyor began an initial kitchen tour with Dietary Manager (DM)-H who stated the facility follows the Wisconsin Food Code. Hand Hygiene: The Wisconsin Food Code documents at Chapter 2 Personal Cleanliness 2-301.14 When to Wash: Food employees shall clean their hands and exposed portions of their arms as specified under 2-301.12 .(E) After handling soiled equipment or utensils; .(I) After engaging in other activities that contaminate…

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 42 residents residing in the facility. The facility's designated IP did not work in the facility at least part-time. 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 5/6/24 at 9:29 AM, Nursing Home Administrator (NHA)-A informed Surveyor that Director of Nursing Mentor (DONM)-E oversaw the IP role and mentored Assistant Director of Nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility did not ensure the right to personal privacy for 1 resident (R) (R21) of 19 sampled residents. During an observation on 5/6/24, staff did not ensure R21 had visual privacy and dignity during personal care. Findings include: On 5/6/24, Surveyor reviewed R21's medical record. R21 was admitted to the facility on [DATE] with a past medical history including Parkinson's disease and dementia. R21's Minimum Data Set (MDS) assessment, dated 4/8/24, indicated R21's Brief Interview for Mental Status (BIMS) score was 10 out of 15 which indicated R21 had moderately impaired cognition. R21's care plan, dated 4/29/24, with a target date of 5/30/24, indicated the following: ~ R21 had physical limitations, cognitive loss, and difficulty communicating. ~ R21 was dependent on staff for bathing, showing, dressing, and bed mobility. ~ R21's needs would be met with comfort and dignity. On 5/6/24 at 2:41 PM, Surveyor was standing in the lobby near the nurses' station and noted a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review, the facility did not ensure adequate fall prevention interventions were in place for 3 residents (R) (R36, R10, and R291) of 3 sampled residents. R36 fell on 3/14/24 and 3/18/24. The facility did not implement new fall interventions to prevent future falls. R36 fell again on 3/22/24. R10 was admitted to the facility following a fall with a fracture at home. R10 had a rug in R10's room with curled edges. The facility did not develop a comprehensive falls care plan, including R10's preference and risk for keeping the rug in R10's room. R291's smoking materials were to be stored securely by staff. During an observation on 5/7/24, smoking materials were observed in R291's room. Findings include: The facility's Fall Prevention and Management Guidelines policy, with review date of 11/8/22, indicates: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized plan of care to minimize the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review, the facility did not provide the necessary respiratory care and services for 2 residents (R) (R8 and R144) of 2 residents reviewed for oxygen therapy. R8 used humidified oxygen from a concentrator. R8 did not have a physician's order for oxygen use. In addition, R8's care plan did not address oxygen use and R8's oxygen tubing was not labeled to indicate the date the tubing was last changed. R144 used oxygen from a concentrator. R144 did not have a physician's order for oxygen use or a care plan that addressed the use of oxygen. Findings include: The facility's Oxygen Cylinder Compressed Gas policy, with a reviewed/revised date of 6/27/22, indicates oxygen is a drug which must be ordered by a physician .Oxygen devices: Nasal cannula - change out weekly and as needed (PRN) 1. Between 5/6/24 and 5/8/24, Surveyor reviewed R8's medical record. R8 was admitted to the facility on [DATE] and had diagnoses including chronic acute and chronic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not provide pharmacy services in accordance with the wishes of a resident/legal representative when the facility administered vaccines to 1 resident (R) (R11) of 5 sampled residents who declined the vaccines. The facility administered COVID 19 and influenza vaccines to R11 after R11 declined the vaccines. Findings include: 1. From 5/6/24 through 5/8/24, Surveyor reviewed R11's medical record. R11 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), multiple sclerosis, type 2 diabetes with neuropathy, and respiratory syncytial virus (RSV) pneumonia. R11 had a legal guardian for decision making. A progress note, dated 1/3/24 at 11:32 AM, indicated R11 declined the influenza and COVID-19 vaccines per a consent/declination sheet signed by R11's legal guardian on 1/3/24. A progress note, dated 1/3/24 at 13:37, indicated R11 received an influenza vaccine and a COVID-19 booster. R11's vaccination record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. On 5/8/24 at 11:02 AM, Surveyor observed CNA-P and CNA-Q provide care for R27. After performing hand hygiene and donning gloves, CNA-P and CNA-Q assisted R27 onto the commode via EZ stand. CNA-P removed R27's incontinence brief which was soiled with a small amount of stool. CNA-P performed hand hygiene, donned clean gloves, and washed R27's perineal area. Following perineal care, CNA-P did not remove gloves, cleanse hands, and don clean gloves before CNA-P touched R27's clean brief, clothing, wheelchair, and the EZ stand lift. On 5/8/24 at 11:10 AM, Surveyor interviewed CNA-P who verified CNA-P did not remove soiled gloves and perform hand hygiene after completing pericare and before touching the items mentioned above. On 5/8/24 at 12:57 PM, Surveyor interviewed DON-B who stated DON-B expects staff to complete hand hygiene prior to donning gloves for pericare and after cleansing the resident. DOB-B indicated moving from a dirty to clean task requires hand hygiene. Based on observation, staff interview, 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 vaccinations were reviewed, offered, or administered for 3 residents (R) (R7, R11, and R21) of 5 residents reviewed for vaccines. The facility did not offer R7 the PCV20 (Prevnar 20®) vaccine. The facility did not offer R11 the PCV20® vaccine. The facility did not offer R21 the PCV20® vaccine. Findings include: Abbreviations (www.cdc.gov): PCV13: 13-valent pneumococcal conjugate vaccine (Prevnar13®) PCV15: 15-valent pneumococcal conjugate vaccine (Vaxneuvance®) PCV20: 20-valent pneumococcal conjugate vaccine (Prevnar 20®) PPSV23: 23-valent pneumococcal polysaccharide vaccine (Pneumovax23®) The most recent Centers for Disease Control and Prevention (CDC) recommendations for pneumococcal vaccinations indicate: For adults 65 years or older who have only received PPSV23, the CDC recommends: Give 1 dose of PCV15 or PCV20. The PCV15 or PCV20 dose should be administered at least 1 year after the most recent PPSV23 vaccination. Regardless of if…

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 effective pain management was provided for 1 resident (R) (R91) of 1 resident reviewed for pain management. R91 was not provided effective pain management in a timely manner on 3/18/24. Findings include: The facility's Pain Management policy, with a review date of 8/9/22 indicates: The facility must ensure pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences .1. To help a resident attain or maintain his/her highest practicable level of physical, mental and psychosocial well-being and to prevent or manage pain, the facility will: a. Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated .c. Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's…

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

Based on staff interview and record review, the facility did not implement written policies and procedures that prohibit and prevent abuse for 5 of 8 facility and contracted staff reviewed for caregiver background checks. The facility did not ensure thorough and timely caregiver background checks were completed for Maintenance Director (MD)-C, Certified Nursing Assistant (CNA)-D, CNA-E, CNA-F, and Occupational Therapist (OT)-G. Findings include: The facility's Abuse, Neglect and Exploitation policy, with review date of 7/15/22, indicates: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference, and credentials checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic…

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 potential allegation of abuse was reported to the State Agency (SA) for 1 Resident (R) (R1) of 8 sampled residents. R1 expressed fear of the care provided by Certified Nursing Assistant (CNA)-E following an incident on 1/31/24. The potential allegation of abuse was not reported timely to Nursing Home Administrator (NHA)-A and was not reported to the SA. Findings include: The facility's Abuse, Neglect and Exploitation policy, with a review date of 7/15/22, indicates: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .Possible indicators of abuse include, but are not limited to: .10. Sudden or unexplained changes in behaviors and/or activities such as fear of a person .Reporting of all alleged violations to the Administrator,…

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 potential allegation of abuse was thoroughly investigated for 1 Resident (R) (R1) of 8 sampled residents. R1 expressed fear of the care provided by Certified Nursing Assistant (CNA)-E following an incident on 1/31/24. The potential allegation of abuse was not thoroughly investigated. Findings include: The facility's Abuse, Neglect and Exploitation policy, with a review date of 7/15/22, indicates: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .Possible indicators of abuse include, but are not limited to: .10. Sudden or unexplained changes in behaviors and/or activities such as fear of a person .An immediate investigation is warranted when an allegation or suspicion of abuse, neglect or exploitation, or reports of abuse,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure a provider or Power of Attorney for Healthcare (POAHC) were notified following falls for 2 Residents (R) (R3 and R14) of 2 sampled residents. The facility did not notify R3's provider following two of three falls on 9/1/23. The facility did not notify R3's POAHC following any of the falls. The facility did not notify R14's provider or POAHC following falls on 9/5/23, 9/17/23, and 11/27/23. Finding include: The facility's Fall Prevention and Management Guidelines policy, last reviewed on 11/8/22, included the following: When any resident experiences a fall, the facility will: .C. Notify physician and family/responsible party . 1. R3 was admitted to the facility on [DATE] with diagnoses including dementia, anxiety, depression, hypertension, and chronic kidney disease. R3 was nonverbal, had an activated POAHC, and discharged from the facility on 9/5/23. On 1/8/24, Surveyor reviewed R3's medical record which included a nursing note, dated 9/1/23…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff and resident interview, the facility did not make a prompt effort to thoroughly investigate and resolve a grievance for 1 Resident (R) (R2) of 14 sampled residents. On 8/6/23, R2's Power of Attorney for Healthcare (POAHC) sent an email to the facility that expressed multiple concerns regarding R2's care. The facility did not thoroughly investigate or provide resolution of the grievance. Findings include: The facility's Grievance Policy, with a review date of 7/2022, indicated: The facility will seek to resolve concerns, complaints or grievances and provide residents, responsible parties, staff and others feedback and resolution in a timely manner .The resident has a right to voice grievances without fear of retaliation .The Grievance Officer for the facility is the Administrator .During the investigation, the Grievance Officer will prevent any potential or further violation of resident rights .Once resolution of the grievance is achieved, the Grievance Officer will ensure follow…

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 fall assessments were completed and care plan interventions to prevent falls were added/updated for 2 Residents (R) (R3 and R14) of 2 sampled residents. The facility did not appropriately assess R3 following three falls on 9/1/23. In addition, the facility did not investigate the circumstances surrounding the falls or update R3's care plan with interventions to prevent future falls. The facility did not appropriately assess R14 following falls on 9/5/23, 9/17/23, and 11/27/23. In addition, the facility did not investigate the circumstances surrounding the falls or update R14's care plan with interventions to prevent future falls. Finding include: The facility's Fall Prevention and Management Guidelines policy, last reviewed on 11/8/22, included the following: When any resident experiences a fall, the facility will: a. Complete a post-fall assessment and review. 1. Physical assessment with vital signs. 2. Neurochecks for any unwitnessed fall…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not provide opportunities for residents and/or their legal representatives to participate in their care planning process when changes were made during the assessment and care planning process. This has the potential to affect 5 of 9 sampled residents. (R14, R2, R20, R19 and R22). Sampled residents R14, R2, R20, R19 and R22 were not provided the opportunity to participate in their care planning process when Minimum Data Set (MDS) assessments prompted changes to the plan of care. Findings include: Example 1 R14 was admitted to the facility on [DATE] from another skilled nursing facility. Diagnoses include, in part, dementia with behavioral disturbances, multiple sclerosis, diabetes, malnutrition, and heart disease. R14 has court appointed guardian and is protectively placed. R14's most recent quarterly MDS completed on 01/15/23 notes R14 has severe cognitive impairment, rarely understands and is rarely understood. On 04/16/23 at 1:20 p.m., Surveyor spoke 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 Based on interviews and record reviews, the facility did not ensure timely physician visits were being conducted for four residents (R9, R10, R2 and R16). - R9 was hospitalized [DATE]- 5/28/22. From 5/28/22 through next hospital stay of 1/13/23 - 1/1/7/23 there have been no face-to face visits from a physician with the exception of Dermatology. R9 was again sent to the Emergency Department 3/1/23 and returned that evening. - R10 was admitted [DATE] and to date, has not yet been seen by a medical physician. - R2 was not seen by a physician from 8/8/22 until present. - R16 was admitted [DATE]. There is no record that R16 has yet been seen by a physician. This is evidenced by: During the Covid-19 Pandemic, CMS (Centers for Medicare and Medicaid Services) issued a temporary emergency declaration blanket waiver for Physician visits, indicating that Physician visits may be conducted offsite through Telehealth services. On 4/7/22, CMS published Memo QSO-22-15-NH (Nursing Home) & NLTC (National Long-Term Care) & LSC…

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

Based on record review and interview, the facility did not obtain written consent explaining the risks and benefits of psychotropic medications for 1 of 5 residents reviewed for unnecessary medications (R19). R19 is prescribed risperdal, an antipsychotic medication for agitation related to dementia with lewy bodies, and buspirone, an antianxiety medication for general anxiety. The facility did not have a written, signed consent explaining the risks and benefits of to R19's power of attorney (POA). This is evidenced by: Surveyor reviewed R19's current physician orders and noted R19 is currently ordered the following: ~3/29/23: Buspirone 15 mg tid for general anxiety ~2/03/23: Risperdal 0.25 mg every day for agitation related to dementia with lewy bodies Surveyor noted although there were dose changes, the Buspirone was initiated on 2/16/23 and the Risperdal was initiated on 8/13/21. Surveyor noted R19 has an activated power of attorney for his health care decisions. Surveyor reviewed R19's record and could not locate a written consent explaining the reason for the medications, 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 interviews and record reviews, the facility did not complete and implement baseline or comprehensive care plans (CP) for 1 of 3 Residents (R 79), within 48 hours of admission, that included instructions on how to provide effective and person-centered care for the resident. Surveyor reviewed R79's medical record and was unable to locate a baseline or comprehensive CP that would have been dated within the first 48 hours of admission. The CP was first developed 4/11/23 or four days following admission. This is evidenced by: The facility policy titled Baseline Care Plan was dated 9/22/22 and included the following directives to staff: .1. The baseline care plan will be developed within 48 hours of a resident's admission and will include the minimum healthcare information necessary to properly care for a resident including, but not limited to: i. Initial goals based on admission orders ii. Physician orders iii. Dietary orders iv. Therapy services v. Social services . 2. The admitting nurse/designee shall gather information from the admission physical assessment, hospital…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews and record review, the facility did not ensure staff consistently provided necessary services to maintain good grooming and toileting needs for 2 of 4 residents (R25 and R79) sampled. - R79 indicated a long call light response, and as a result of the lengthy time in which to receive care, had a large incontinent bowel movement in her pants. - Random observations were conducted in which R25 had long whiskers on her chin, which were bothersome to her and she requested multiple times to have them tended to. This is evidenced by: Example 1 R79 was admitted to the facility 4/7/23, following hospitalization after a fall at home in which she sustained a Displaced Fracture of the Second Vertebra, multiple fractures of right sided ribs, a Left-Sided Cervical 2 fracture and a Traumatic Hemopneumothorax. Other medical diagnoses for R79 include, but are not limited to Muscle Weakness, Difficulty in Walking, Syncope and Collapse, Hypothyroidism, Chronic Combined Systolic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility did not ensure 2 of 15 (R9 and R19) residents reviewed, received treatment and care in accordance with professional standards of practice. - R9's physician orders were not followed related to labwork requested. - R19 has not gotten out of bed for several weeks due to his poor positioning in his wheelchair. Example 1 R9 had medical diagnoses that included, but were not limited to Acute Pancreatitis without Necrosis or infection, Muscle Weakness, Diabetes Mellitus Type II, Major Depressive Disorder, Generalized Anxiety Disorder and Post-Traumatic Stress Disorder. According to the most recent Minimum Data Set Assessment, which was a quarterly assessment dated [DATE], R9 required extensive assistance of two staff to meet her basic needs of personal hygiene and dressing and limited assistance of two staff for bathing. The Comprehensive Care Plan devised for R9 also addressed the need for staff assistance in the problem titled The resident has a self…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, 1 of 1 residents reviewed for limited range of motion did not receive the necessary care and service to prevent further decline in range of motion. R19 was admitted [DATE]. R19 has limitation of his lower extremity range of motion and has not received range of motion services since the program was initiated by therapy department. This is evidenced by: Surveyor reviewed R19's medical record and noted he was admitted [DATE] with a primary diagnosis of non Alzheimer's dementia R19's most recent minimum data set (MDS) which was a quarterly dated: 1/16/23 notes R19 rarely understands, is rarely understood and has severe cognitive impairment. R19 requires extensive assist of 2 staff for bed mobility, toilet use and hygiene. R19 is dependent on 2 staff for transfer. R19 has limited range of motion of both lower extremities. Surveyor reviewed R19's most recent comprehensive annual MDS dated [DATE]. The MDS notes R19 rarely understands and is rarely understood 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.

Based on observation, interviews and record reviews, the facility did not ensure staff performed proper hand hygiene for 3 of 6 residents (R) observed in the dining room. R11, R4 and R5. On 4/16/23 at 1200 PM, Certified Nursing Assistant (CNA) P did not perform appropriate hand hygiene when moving from resident to resident (R4, R5, R11) in the dining room. This is evidenced by: On 4/18/23, Surveyor reviewed the facility policy titled; Hand Hygiene. Under number 6 it states: Additional considerations; a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves and immediately after removing gloves. On the facility Hand Hygiene Table it notes that hands should be washed with soap and water or with hand sanitizer between resident contacts. On 4/16/23 at approximately 12:00 PM, Surveyor observed lunch being served in the 2nd floor dining area. There were 6 residents in the dining area at that time being served lunch on individual trays. Surveyor observed CNA P serve R5 their meal. R5 appeared to be blind and CNA P 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.