Avina of Pewaukee

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each resident this affected 4 of 23 Residents (R57, R46, R67, and R56) reviewed for activities. Surveyor observed R57, who needs assistance to/from structured leisure activities, not being provided activities. The facility failed to ensure R46's activity care plan is meaningful, personalized, and had measurable goals. R56's Comprehensive Care Plan does not contain an activities care plan. R67's Comprehensive Care Plan does not actually list any Resident specific preferred activities. Evidenced by: The facility policy, Activities, dated 2/1/25, states, in part; .It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility sponsored group, individual, and independent activities will be…

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 Example 2 R26 was admitted to the facility on [DATE] with diagnoses that include in part: Cerebral Palsy (a group of neurodevelopmental disorders that affect body movement and muscle coordination), Type II Diabetes, Spinal Stenosis, lumbar region with neurogenic claudication (A condition where the spinal canal narrows, compressing spinal nerves and causing leg pain, particularly when walking), Gastro-Esophageal Reflux, and other fatigue. R26's Most recent MDS (Minimum Data Set), with a target date of 3/20/25, indicates a BIMS (Brief Interview for Mental Status) score of 15, meaning R26 is cognitively intact. On 6/3/25 at 1:03 PM, during the record review portion of the initial pool process, surveyor was unable to locate all weights for trending weight loss or gain. On 6/4/25 at 7:30AM the facility provided the following list of weights for R26 from 1/1/25 to present: 1/1/25: 263 Lbs (Hoyer Scale) 3/21/25: 255 Lbs (Wheelchair) 4/9/25: 255 Lbs (Last weight obtained - refusal) R26's Comprehensive Care Plan,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure appropriate staffing to maintain residents highest practicable, physical, mental and psychosocial well-being. This affected 2 of 2 sampled residents (R47 and R24) and 1 of 1 supplemental residents (R29) reviewed for staffing. This has the potential to affect more than a limited number of residents residing in the home. Resident's voiced concerns regarding long call light wait times. Observations were made of no staff on the 200 hall for 45 minutes. Surveyor observed 45-minute call light wait time. Evidenced by: The facility policy, Call Lights: Accessibility and Timely Response, dated 2/1/25, states, in part; .The purpose of this policy is to assure the facility is adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response .10. All staff members who…

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

Based on observation, interview, and record review, the facility did not ensure that all drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles for 4 of 5 supplemental residents (R14, R15, R25,and R35 ), 3 of 6 medication carts, and 1 of 2 medication storage rooms. R14's eye drops were not dated with an open date. R15's eye drops were not dated with an open date and were not stored in the refrigerator. R25's Anbesol has no expiration date. R35's eye drops were past the discard date. The facility's 200-hallway medication cart had a loose pill in the top drawer and unlabeled medication. The facility's 300-hallway medication cart had loose pills in the top drawer and expired stock medication. The facility's 600-hallway medication cart had unlabeled insulin in the top drawer. The facility's medication room had undated tuberculin (TB) testing solution open and undated and missing refrigerator temperatures in the vaccine storage refrigerator. This is evidenced by: The facility's policy titled Medication Storage in 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 Example 4 On 6/3/25 at 8:25AM Surveyor interviewed R53 as part of the initial screening process. R53 indicated the hot food is not always hot. R53 indicated the french fries are usually cool, sometimes potato dishes and wedges are almost raw, and noodles are not hot enough. R53 indicated this happens 1 to 2 times a week. Based on observation, interview, and record review, the facility did not ensure that food was palatable and at a safe and appetizing temperature for 4 of 15 residents (R46, R24, R53 and R12) who had specific complaints about food quality and serving temperature and 1 of 1 test trays were unpalatable. Residents voiced concerns about hot foods being served cold. Surveyor observed hot foods not hot and cold foods not cold on 1 of 1 test trays. Evidenced by: The facility policy, Food Temperature, no date, states, in part; .1. All hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135F .2. All cold food items must be stored and served at 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 interview and record review, the facility did not ensure the right to request, refuse and/or discontinue treatment and to formulate an advanced directive for 2 of 25 Residents (R34 and R53). R34 and R53's charts did not contain current copies of their advanced directive and/or did not contain evidence of advanced care planning, other than code status, for a time when they are not able to make their own healthcare decisions. Evidenced by: The facility policy titled, Residents' Rights Regarding Treatment and Advanced Directives, with an implementation date of 2/1/25, indicates, in part: Policy: It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate advance directives . Policy Explanation and Compliance Guidelines: 1. On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive. 2.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that each resident is free from physical restraints that are not required to treat the resident's medical symptoms for 1 of 1 residents reviewed (R67). R67 was placed in a low Broda chair (a specialty wheelchair that assists with positioning) that has brakes located on the back of the wheels at the bottom of the chair. R67's brakes were engaged while R67's was at the dining table, not allowing R67 to move the chair. Evidenced by: The facility's policy titled Restraint Free Environment dated 2/1/2025 states in part .Physical Restraint refers to any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Physical restraints may include, but are not limited to: .Using devices in conjunction with a chair, such as trays, tables, cushions, bars or belts, that 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 observation, interview, and record review, facility staff did not provide care and treatment in accordance with professional standards of practice for 3 of 3 supplemental residents (R11, R381, & R52). R11 experienced a fall with a change of condition in which there was a delay of assessment of R11's right hip fracture. R381 had a change of condition and did not have documented assessments through the course of antibiotic treatment. R52 had a change of condition and did not have documented assessments through the course of antibiotic treatment. This is evidenced by: Surveyor requested facility's Change of Condition Policy. DON B states the facility does not have a Change of Condition policy but does follow AMDA (American Medical Directors Association) guidelines. According to the AMDA Change of Condition guidelines, the resident should be assessed further for an acute change of condition for pain worsening in severity, duration, or occurring in a new location, new onset of pain associated with trauma, or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility did not ensure that a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility for 1 of 3 (R33) residents reviewed for mobility/restorative programs. R33 was on a walking program this program this program was discontinued. R33 voiced frustration with not being in the walking program and wanting to walk. This is evidenced by: The facility's Screening and Restorative Policy, dated 3/4/24, states, in part: 1. Most new and readmissions will admit with therapy evaluation orders; however, for those that don't all new and readmissions should be screened to determine therapy needs.3. Restorative Program/Therapy to Nursing Communication form should be completed and dated.c. Give a copy of the Restorative Program/Therapy to Nursing Communication form to MDS (Minimum Data Set), DON (Director of Nursing) and/or Restorative Nurse. R33 was admitted to the facility on [DATE] and has diagnoses that 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.

Based on interview and record review that facility did not ensure that residents acknowledge the understanding of an arbitration agreement and that they have just 30 days to rescind the arbitration agreement if they so choose after it is signed, this affected 1 of 1 sampled resident's (R73) and 1 of 2 supplemental residents (R430) reviewed for arbitration. R430 signed an arbitration agreement 5/29/25, R430 was not able to articulate understanding of the arbitration agreement and did not understand she had 30 days to change her mind. R73 signed an arbitration agreement 3/12/25, she did not know she only had 30 days to change her mind. This is evidenced by: The Facilities Policy and Procedure entitled Binding Arbitration Agreements dated 2/1/25, does not speak to the process of signing the document or the 30-day window to rescind. Example 1 R430 signed arbitration agreement on 5/29/25, the day following her admission to the facility. On 6/4/25 at 12:40 PM, Surveyor asked R430 (and her daughter who was present in room) if she could explain what a binding arbitration agreement is, R430…

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 report 1 (R5) of 2 allegations of abuse or neglect to the State Survey Agency during the required timeframe. An allegation of neglect involving R5 was not reported to the State Survey Agency within 24 hours of the allegation being made. Findings include: The Facility Policy titled Abuse Prevention Policy revised 9/28/23, documents (in part) . This will be done by: . -Immediately protecting residents involved in identified reports of possible abuse, neglect, exploitation, mistreatment, and misappropriation of property; -Implementing systems to promptly and aggressively investigate all reports and allegations of abuse, neglect, exploitation, misappropriation of property and mistreatment, and making the necessary changes to prevent future occurrences; . -Filing accurate and timely investigation reports . IV. Internal Reporting Requirements and Identification of Allegations . Any incident that does not involve abuse and does not result in serious bodily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were thoroughly investigated for 1 (R5) of 2 allegations of abuse or neglect reviewed. R5 made an accusation of neglect on 4/29/2024 that was not thoroughly investigated. Findings include: The Facility Policy titled Abuse Prevention Policy revised 9/28/23, documents (in part) . This will be done by: . -Immediately protecting residents involved in identified reports of possible abuse, neglect, exploitation, mistreatment, and misappropriation of property; -Implementing systems to promptly and aggressively investigate all reports and allegations of abuse, neglect, exploitation, misappropriation of property and mistreatment, and making the necessary changes to prevent future occurrences; . -Filing accurate and timely investigation reports . V. Protection of Residents The facility will take steps to prevent potential abuse while the investigation is underway .…

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 revise the resident plan of care with person centered interventions for 1 (R4) of 5 residents who's plan of care were reviewed. R4 had three orders on the Medication and Treatment Administration Record that were not carried through to the plan of care and/or [NAME] (a summary of patient information used frequently by certified nursing assistants). Findings include: The Facility Policy titled Comprehensive Care Plan Policy revised 8/10/2022, documents (in part) . Purpose: To develop a comprehensive care plan that directs the care team and incorporates the resident's goals, preferences, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Guidelines: . The comprehensive care plan must describe the following: -The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . A comprehensive care…

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 2 (R3 & R4) of 2 residents with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. R3 & R4 were observed not wearing their palm protectors during the survey. Findings include: 1.) R3's diagnoses includes hemiplegia and hemiparesis following cerebral infarction affecting right dominate side and vascular dementia. The physician order with an order date of 7/15/22 documents Palm protector to RUE (right upper extremity) daily, off at night. Monitor skin for breakdown. Every morning and bedtime related to Hemiplegia and Hemiparesis following cerebral infarction affecting right dominate side. The ADL (activities daily living) self-care performance deficit care plan initiated 3/26/22 & revised 4/25/23 includes an intervention dated 7/15/22 of Palm protector to RUE daily, off at night. Monitor skin for breakdown. The quarterly MDS (minimum data…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility did not ensure 1 (R3) of 1 residents who is fed by enteral means receives the appropriate treatment and services to prevent complication of enteral feeding. During personal care observations on 8/19/24 & 8/20/24, R3's head of the bed lowered flat while the tube feeding continued to be running. R3's Osmolite 1.5 was not running according to physician orders on 8/19/24 & 8/20/24. On 8/19/24, R3's water bag, Osmolite 1.5 container, and syringe were not labeled & dated. There is no assessment or order for R3's GT's (gastrostomy tube) secure device. Findings include: The facility's policy titled, Gastrostomy Tube Feeding and Care and dated 5/17/22 under Purpose documents: To provide nutrients, fluids and medications, as per physician orders, to residents requiring feeding through an artificial opening into the stomach. Under Procedure documents: 1. Licensed nurse will review physician's order for type of formula, concentration, rate of flow, and method…

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 interview, the facility did not ensure 1 resident (R2) of 5 sampled residents had a medical record that contained complete and accurate information. The facility did not have R2's initial psychiatric consult and R2's talk therapy consult readily accessible for Surveyor to review. Findings Include: The facility's policy Health Information Management-Retention of Medical Records effective [DATE] documents: . Policy Statement: Protection and retention of medical records-The facility is responsible for protecting the Residents' medical records from loss, destruction or unauthorized use. The records must be retained for the period required by applicable state law and/or according to HIPPA guidelines. If there is no state law, then the information must be retained for five years from the date of discharge (or for three years after a minor reaches the state's legal age if the Resident was a minor. Guidelines: Nursing Home Records The administrator is responsible for providing 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, record review and interview, the facility did not have a process in place to ensure the high temperature dish machine was effectively washing and sanitizing the dishes for 1 of 1 dish machines in the kitchen which has the potential to affect all 84 residents within the facility. *The facility did not have a process in place to verify the temperature of the high temperature dish machine. Findings include: The facility police, entitled Cleaning Dishes/Dish Machine, with no date, states: All flatware, serving dishes, and cookware will be cleaned, rinsed, and sanitized after each use. The dish machines will be checked prior to meals to assure proper functioning and appropriate temperature for cleaning and sanitizing. Procedure #1. Prior to use, verify proper temperatures and machine function. Confirm that soap and rinse dispensers are filled and have enough cleaning products for the shift. NOTE: Staff should check the dish machine gauges throughout the cycle to assure proper temperatures for sanitization. Thermal strips may be used as verification that 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, interview, and record review, many of the facility nursing staff were not fit tested for N95 masks to be worn in Covid-19 positive rooms. Laundry staff were not provided a hand washing station or personal protective equipment (PPE) of gowns or gloves in the dirty laundry sorting area. This has the potential to affect 84 of 84 residents the facility. -The facility last fit tested staff for N95 masks on 9/27/2023, staff hired after that date were not fitted to wear N95 masks in droplet precaution rooms. On 2/24/24 R76 returned from the hospital where R76 tested positive for COVID-19. R76 was placed in isolation and facility staff were required to wear Personal Protective Equipment (PPE) related to contact/droplet precautions while caring for R76. 16 of 20 staff who cared for R76 upon R76's return to the facility were not fit tested for their N95. This causes concern of droplets not being filtered out and the individual becoming infected with Covid-19 and carrying throughout facility. -Appropriate PPE/hand washing was not in place for staff sorting potentially…

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

Based on interview and record review, the facility did not make a prompt effort to resolve grievances for 6 (R70, R45, R40, R67, R28 & R73) of 6 residents who had voiced a grievance/concern to the facility. *On 2/27/24 during the resident council task, R70, R45, R40, R67 & R28 voiced that there have been multiple concerns brought forward related to facility food that have not been addressed. *On 2/27/24, R73 was observed to not be receiving their full general diet meal on their breakfast meal tray. Findings Include: On 2/27/24 at 11:35 AM, Surveyor completed the resident council meeting. Attendees of the resident council meeting conducted on 2/27/24 with Surveyor included R70, R45, R40, R67 & R28. During the resident council meeting, residents voiced that there have been multiple concerns brought forward related to facility food that have not been addressed. R70 voiced concerns that The food totally sucks .especially breakfast! The fake butter won't even melt on the pancakes and the scrambled eggs are cold too. I can reheat my own food but what about the residents who are in 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 interview, and record review the facility did not ensure quality of care was provided for 4 (R15, R64, R66, and R75) of 7 residents reviewed for neurological checks. * R15's neurological checks were not completed per facility policy after an unwitnessed fall on 10/7/2023. * R64's neurological checks were not completed per facility policy after an unwitnessed fall on 12/20/2023. * R66's neurological checks were not completed per facility policy after unwitnessed fall on 12/22/23. * R75's neurological checks were not completed per policy after two unwitnessed falls. Findings include: The facility policy entitled Accidents / Fall Prevention Program dated 1/30/2023 states: . 5. If a fall or other incident/accident should occur, nursing/emergency care is to be provided to the resident per nursing assessment. Neurological (neuros) observations will be conducted following any observation of a resident hitting their head during a fall/ incident/ accident or if it is unknown/ not observed whether 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 5. R15 was admitted to the facility on [DATE] and has diagnoses that include vascular dementia, epilepsy, anxiety, arthritis, and type 2 diabetes mellitus. R15's admission minimum data set (MDS) dated [DATE] indicated R15 has moderately impaired cognition with a brief interview for mental status (BIMS) score of 9 and the facility assessed R15 needing maximal assist with one staff member using a gait belt and a two wheeled walker for ambulation and transfers. R15 was assessed on 10/27/2023 to be a high risk for falls with a fall risk score of 12. R15's risk for falls care plan was initiated on 10/16/2023 with the following interventions: - Be sure the resident's (R15) call light is within reach and encourage R15 to use it for assistance as needed. - Ensure that R15 is wearing appropriate footwear. (Initiated 10/19/2023) - Follow facility fall protocol. - Offer R15 to lay down afternoon for nap. On 12/20/2023 at 16:02 (4:02 PM) in the progress notes nursing charted resident (R15) was found next to R15's bed 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 observations, record review and staff interviews, the facility did not always ensure that they provided the necessary care and treatment to 2 out of 6 residents (R53, R5) reviewed with the necessary services to promote the healing of a pressure ulcer and to prevent new pressure ulcers from developing. * R53 has an unstageable pressure ulcer to her left heel which has been slowly healing since September, 2023. R53 was observed to not be offered the pressure relieving boots or pillow when she was assisted to bed. * R5 has a history of pressure ulcers and was assessed to be at high risk for redeveloping a pressure ulcer. R5 was observed laying in bed, on the special air mattress which was not powered on. This is evidenced by: Policy Review: AA Healthcare Management of Wounds, revised 7/25/16 Handout A- Pressure Ulcer Prevention Positioning devices: positioning devices should be used to keep bony prominences from direct contact with each other. These devices may be in the form of pillows or foam wedges.…

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 consistent communication with a dialysis facility for 1 (R385) of 1 resident who received dialysis care and services. * R385 received dialysis three times a week. There are no communication forms between the facility and dialysis center on dialysis days resulting in inconsistent communication between the facility and the dialysis center. Findings include: The facility policy entitled Dialysis Monitoring and Observation dated 5/17/2022 states: To ensure residents receiving hemodialysis are monitored for complications. Monitoring: . 8. Communication system will be established with treating dialysis center. Pre and post vital signs and pre and post weights are done at the dialysis center to ensure consistency unless otherwise ordered. Documentation: . 4. Dialysis vital sign and weight logs will be uploaded in the EMR (electronic medical record) on a routine basis. The facility and dialysis center agreement for outpatient dialysis…

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 comprehensively assess or develop a plan of care to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 (R78) of 5 residents reviewed for behavior management. R78 made statements regarding suicidal idealization and the facility did not update the plan of care or comprehensively assess the psychosocial needs of the resident to address suicidal statements. Findings include: R78 was admitted to the facility on [DATE] with diagnoses that include cognitive communication deficit, chronic obstructive pulmonary disease, chronic kidney disease, muscle weakness and dysphagia. R78's admission Minimum Data Set (MDS) dated [DATE] indicated R78 was assessed to have a Brief Interview of Mental Status score of 14 indicating cognitively intact. R78's patient depression questionnaire score was 8 indicating mild depression. The MDS assessment showed that…

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 obtain and provide medications to meet the needs of each resident for 3 (R29, R12, and R41) of 6 residents observed during medication administration. * R29 did not have a probiotic available during medication administration observation. * R12 did not have a vitamin available during medication administration observation. * R41 did not have two inhalers available during medication administration observation. Findings include: The facility policy entitled MEDICATION ORDERING AND RECEIVING FROM PHARMACY- IC3: ORDERING AND RECEIVING NON-CONTROLLED MEDICATIONS FROM THE DISPENSING PHARMACY revised January 2018 states: Medications and related products are received from the dispensing pharmacy on a timely basis. The facility maintains accurate records of medication order and receipt. 20 a. Reorder medications [three to four] days in advance of need as directed by the pharmacy order and delivery schedule, to assure an adequate supply is on hand. When reordering medication that requires special processing . order at least…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure the physician acted upon recommendations by the pharmacist for 1 (R64) of 5 residents reviewed for unnecessary medications. * Pharmacy recommendations were noted on 9/29/2023 for R64 to DC (discontinue) Melatonin 5mg QHS (every hour of sleep/ bedtime) and start Melatonin 3mg by mouth once daily with supper for insomnia. These pharmacy recommendations were not followed up on. Findings include: The facility policy entitled CONSULTANT PHARMACIST REPORTS- IIIA2: DOCUMENTATION AND COMMUNICATION OF CONSULTANT PHARMACIST RECOMMENDATIONS revised January 2018 states: The consultant pharmacist works with the facility to establish a system whereby the consultant pharmacist observations and recommendations regarding residents' medication therapies are communicated to those with authority and /or responsibility to implement the recommendations, and are responded to in an appropriate and timely fashion. Procedures: . C. Recommendations are acted upon 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 interview and record review the facility did not ensure 1 (R64) of 5 residents drug regime was free from unnecessary medications. * R64 receives an anticoagulant (Eliquis) in which the facility is not adequately monitoring and there is no care plan in place to address the use of the anticoagulant. Findings include: R64 was admitted to the facility on [DATE] and has diagnoses that include acute embolism and thrombosis of other specified deep vein (DVT) of left lower extremity, polyneuropathy, dementia, type 2 diabetes, osteoarthritis, peripheral vascular disease, anxiety, abnormalities of gait and balance, muscle weakness, and cognitive communication deficit. R64 has severely impaired cognition with a BIMS (Brief Interview for Mental Status) score of 3 and the facility assessed R64 needing moderate assist with one staff member with toileting, personal hygiene, and dressing. R64 requires moderate assistance of 1 staff member, a gait belt, and pivot transfer from wheelchair for transfers. R64 was assessed…

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 assure drugs and biological's used in the facility were stored and labeled in accordance with currently accepted professional practices and include the expiration date when applicable and medications were not labeled when opened or include a resident's name in 2 of 3 medication carts reviewed for compliance. Surveyor observed undated, opened inhalers and eye drops, expired medications, and unlabeled medications in medication carts located on the 300 unit and 100 unit. Findings include: The facility policy entitled MEDICATION STORAGE IN THE FACILITY revised January 2018 states: Medications and biological's are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff member lawfully authorized to administer medications. Procedures: . H. Outdated . medications are immediately removed from inventory, disposed of according to procedures for medication disposal 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, interview and record review the facility did not prepare mechanically altered food appropriately for 2 of 2 residents who receive puree texture food. * Cook-I did not use a recipe to prepare puree ham and broccoli. Findings include: The facility policy, entitled Puree Food Preparation, with no date, states: Puree food is mechanically altered into a smooth, mashed potato like consistency to meet the individual needs of the resident. Procedure #2. Follow the recipe for puree food. #3. Place measured food item to be pureed in the robot coupe. DO not overfill. Pulse the food until ground fine. Then begin to add fluid to thin the food into a puree consistency. #4. When adding liquid to the mixture add milk, broth, juice, or other fluids with nutritional or flavor profile. Do not use water unless specified in the recipe. The lunch menu for 2/28/24 was au gratin ham and potatoes and seasoned broccoli. On 02/28/24, at 09:27 AM, Surveyor observed Cook-I prepare a puree meal for the same days lunch. Cook-I identified the items he was pureeing separately was diced ham 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 observation and interview the facility did not provide a safe, clean, comfortable home-like environment which had the potential to affect all 18 residents on the 200 pod and those residents that use the community conference/meeting room. On the 200-pod multiple resident rooms had dirt build up on the floors around the doorway to each room, floors were observed with dark stains, cracked tile. Liquid spills observed on lower half of the walls around the center of the pod area, shadow boxes outside of each resident room some were without protective glass or broken glass; overhead light fixtures with multiple dark spots on each overhead fixture and numerous bugs crawling on the walls and dead bugs on the floor of the facility conference/meeting room. Findings include: 200 Pod On 12/18/23, at 12:44 PM, Surveyor began and environmental tour of the 200 Pod. Surveyor observed the pod lounge/dining area had overhead lighting. The overhead lighting continues around the pod. Surveyor observed in the lighting…

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 review, the facility did not ensure 1 of 2 residents (R1) reviewed for allegations of sexual abuse were provided a thorough investigation after the alleged violation. The facility's self-report dated 12/11/23 indicates R1 woke up with her brief open and alleged she was raped. The facility did not investigate possible medical concerns causing R1's vulvar pain. The facility did not conduct a thorough investigation into R1's allegation of rape to determine if there was a physical condition contributing to R1's allegation. In addition, on the same date as R1's allegation of rape, on 12/4/23, the facility became aware of an allegation of sexual abuse between two additional residents (R2 and R4). There is no evidence the facility considered if there was any correlation between the two allegations, both alleging sexual abuse. Findings include: Surveyor reviewed the facility's Policy and Procedure, Abuse Policy dated 10/18/22 and noted the following as applicable; Immediately protecting…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure 1 (R1) of 1 resident reviewed received the necessary care and treatment for vulvar pain and vaginal bleeding. The facility did not follow up with recommendations for R1 to schedule a Gynecological follow up appointment for uterine bleeding and vulvar pain. Findings include: Surveyor reviewed R1's medical record which indicated in part; R1 was admitted to the facility on [DATE] with diagnoses of schizophrenia, severe morbid obesity, panic disorder, delirium, borderline personality disorder, dysphagia, abnormalities of gait and mobility, and cognitive communication deficit. R1 has an activated POA (Power of Attorney). R1's quarterly MDS (minimum data set) dated 11/16/23, documents a BIMS (brief interview for mental status) score of 13 which indicates cognitively intact. It also indicates R1 has impairment on both sides of lower extremities, requires a walker or wheelchair for mobility, and requires substantial/maximal assistance with toileting,…

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, interviews, and record review, the facility did not ensure 1 of 5 residents (R2) reviewed for abuse was provided medically related social services to assist R2 in attaining or maintaining their mental and psychosocial health. * On 12/4/23, R2 was sexually abused by R4 who attempted to kiss and stick his tongue in her mouth, while grabbing R2's groin. The facility did not provide R2 with medically related social services for R2 to attain or maintain her highest practicable psychosocial well-being. R2 expressed to Surveyors being afraid of R4. In addition, R2 informed the police that the sexual abuse occurring on 12/4/23 was not consensual. There was no facility follow up with R2 to discuss her comfort with present room arrangements, there was no care plan updates to ensure R2 was free from potential further abuse from R4. Additionally, R2 was not provided with psychological support services until after surveyors discussed this with the facility. (Cross Reference F600) 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 interviews and record review, the facility did not ensure 1 (R4) of 1 residents reviewed had adequate indications for use of an antidepressant medication (Paxil). R4 was prescribed an antidepressant medication without adequate indications for use. Findings include: R4 was admitted to the facility on [DATE] with diagnoses of Parkinson's disease, alcohol dependence, impulsiveness, cognitive communication deficit, psychosis, and opioid abuse. R4's quarterly Minimum Data Set (MDS) dated [DATE], documents: A Brief Interview of Mental Status (BIMS) score of 15, indicating R4 is cognitively intact; a Patient Health Questionnaire (PHQ-9) score of 5, indicating R4 has mild depressive symptoms; no behavior symptoms documented; requires assistance of 1 staff for bathing and dressing. R4 uses a wheelchair independently and has range of motion impairment of one upper extremity and both lower extremities. Antianxiety medication taken 7 of the last 7 days. R4's comprehensive care plan contains the following…

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, record review, facility document and policy review, the facility failed to implement new interventions after an elopement for 1 (R15) of 2 sampled residents reviewed for elopement. Findings included: A review of a facility policy titled Elopement Prevention, revised on 03/29/23, revealed, It is the policy of this facility that all residents are afforded adequate supervision to meet each resident's nursing and personal care needs. All residents will be assessed for behaviors or conditions that could potentially place them at risk for elopement. All residents so identified will have these issues addressed in their plan of care. Continued review revealed, Should an elopement occur, the facility's Quality Improvement Committee or Safety Committee shall review the facility's systems, policies and procedures, and responses to elopements to evaluate if all systems are functioning properly, or whether there are any gaps that should be addressed or areas that could be improved. Should a 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 interviews, record reviews, and facility document and policy review, the facility failed to provide social services assistance for 1 (R6) of 3 residents reviewed for social services. Findings included: A review of a facility policy titled AA Healthcare Abuse Prevention Program, dated 02/07/17, revealed, As part of the resident's life history on the admission assessment, comprehensive care plan, and MDS [Minimum Data Set] assessments, staff will identify resident with increased vulnerability for abuse, neglect, exploitation, mistreatment or misappropriation of resident property, or who have needs and behaviors that might lead to conflict. A review of the Director of Social Services job description provided by the facility dated 2003 revealed Duties and Responsibilities that included Participate in community planning related to the interests of the facility and the services and needs of the resident and family and Refer resident/families to appropriate social service agencies when the facility does not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure 7 (R74, R15, R12, R244, R47, R90, and R49) of 7 residents reviewed that required hospitalization were provided with a written transfer notice which included the date of the transfer, location of transfer, and the reasons for the transfer with appeal rights. The facility did not ensure the resident/representatives received a completed transfer notice. *R74 was transferred to the hospital on 7/30/22 and R74 and her representative did not receive written notification of transfer or appeal rights. *R15 was transferred to the hospital on 9/5/22, 10/5/22, and 10/15/22 and R15 and his representative did not receive written notification of transfers to the hospital and appeal rights. *R12 was transferred to the hospital on 8/11/22 and R12 and his representative did not receive written notification of transfer to the hospital and appeal rights. *R244 was transferred to the hospital on [DATE] and R244 and his representative did not receive written…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not ensure 4 (R49, R42, R47 and R84) out of 5 residents reviewed, were given psychotropic medications for valid reasons, with appropriate behavioral interventions and adequate monitoring. * R49 was administered scheduled risperidone, sertraline, and as needed ativan with no indications for use identified or behavior monitoring completed. * R42 was administered scheduled buspirone and aripiprazole with no indications for use identified or behavior monitoring completed. * R47 was administered scheduled risperidone and sertraline with no indications for use identified or behavior monitoring completed. * R84 was administered scheduled buspirone, zyprexia and sertraline with no indications for use identified or behavior monitoring completed. R84 did not have a screening/assessment for tardive dyskinesia completed with the use of Zyprexia. Findings include: On 11/30/22 the facility policy titled: Psychotropic Drug Use, undated, was reviewed and documents: 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 interview and record review, the facility failed to provide the needed care and services to meet the resident's physical needs for 1 (R47) of 6 residents reviewed for change of condition. R47 presented with respiratory disease-like symptoms, R47's physician was updated and ordered a CBC (Complete Blood Count) and a BMP (Basic Metabolic Panel) lab work which was not completed as ordered. R47's condition deteriorated and R47 was subsequently sent to the hospital. Findings include: R47 was admitted to the facility on [DATE] following a fall that resulted in multiple fractures. R47 has current diagnoses that include, unspecified atrial fibrillation; pneumonia, unspecified organism; unspecified severe protein-calorie malnutrition; and dementia in other diseases classified elsewhere. R47's Annual MDS (Minimum Data Set) Assessment with an ARD (Assessment Reference Date) of 08/26/2022, documents R47 has a BIMS (Brief Interview of Mental Status) assessment score of 01, indicating R47 has severe cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide adequate supervision and assistance devices to prevent accidents for 1 (R84) of 2 residents reviewed for accidents. R84 sustained a fall that resulted in R84 being transferred to the hospital due to a head laceration and need for sutures. The facility did not identify the root cause of the fall and did not implement person centered fall prevention interventions to addressed the root cause and prevent future falls. Findings include: Facility policy entitled, Fall Prevention Program, dated [DATE], includes: * .Care Plan incorporates: . Addresses each fall and interventions are changed with each fall, as appropriate; * .Fall Incident reports will be studied to determine any significant factors that may have caused the fall and to identify additional fall prevention strategies that may be indicated. *The DON (Director of Nursing) or designee will be responsible for implementing and communicating resident-specific recommendations 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 ensure that residents who require dialysis received such services, consistent with professional standards of practice and the comprehensive person centered care plan for 1 (R51) of 2 Resident reviewed who receive dialysis care and services. The facility did not complete dialysis center communication forms to allow for ongoing communication and collaboration with the dialysis facility regarding R51's dialysis care and services. Findings include: Surveyor reviewed the undated facility policy and procedure for Hemodialysis and notes the following: .1. Purpose To implement processes to promote the comfort, safety and management of hemodialysis Residents. 2. Contractual agreement will include but may not be limited to the following . b. Development and implementation of a Resident's plan of care. c. Interchange of information useful/necessary for the care of the Residents d. Identifying roles and responsibilities between the facility and the dialysis center.…

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 1 (R37) of 1 residents receiving insulin medication had the insulin identified with a pharmacy label and date of when the insulin was opened. On 12/1/22, during medication pass observation, Registered Nurse (RN)-F prepared R37's insulins. RN-F attempted to give R37 lispro insulin pen with R142's labeled insulin pen. Prior to administering the insulin, Surveyor pointed out the label to RN-F. RN-F then went back to the medication cart to look for R37's insulin pen. RN-F identified and pulled out 2 other insulin pens that did not have a pharmacy label with the resident's name on it. Findings include: On 12/1/22, at 8:16 a.m., Surveyor observed RN-F prepare R37's insulin to be administered. RN-F primed Lispro insulin pen then dialed up 4 units. Surveyor observed the lispro pen label and it is labeled for R142 and did not include the date it was opened. Surveyor observed the lispro pen dialed up to 4 units. RN-F then drew up Levemir 58 units from a insulin vial. Surveyor observed the syringe to have 58 units…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility did not maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (R74 and R37) of 18 residents reviewed for infection control. *R74's catheter bag was observed lying directly on the floor. *RN (Registered Nurse)-F was observed attempting to give R37 insulin from an insulin pen labeled for a different resident. Findings Include: 1.) The Facility Policy and Procedure titled: Urinary Catheter Care, dated 05/3/2022, documents (in part) . Purpose: To establish guidelines to reduce the risk of or prevent infections in residents with an indwelling catheter. Guidelines: . 7. Urinary drainage bags and tubing shall be positioned to prevent either from touching the floor directly. May place drainage bag and excess tubing in secondary vinyl bag or other similar device to prevent primary contact with floor or…

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