Lindengrove Waukesha

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure the drug regimen of each resident was reviewed at least once a month by a licensed pharmacist, and that irregularities identified by the pharmacist were reviewed, and action was taken to address them, for 3 (R1, R2, R43) of 5 residents reviewed. *R1 had pharmacist reviews dated 7/3/25, 8/7/25, and 9/3/25 with recommendations for a tardive dyskinesia assessment to be completed as R1 is on antipsychotic medication. The pharmacy recommendations were not followed up on. *R2's pharmacy reviews for 6/25, 7/25, 8/25, and 9/25 indicated that a screening for tardive dyskinesia assessment was needed to be completed due to Seroquel administration. The pharmacy recommendations were not followed up on. *The Pharmacist monthly review for R43 recommended the facility conduct an AIMS Assessment. The facility did not act upon this recommendation although R43 continued to take Antipsychotic medication. On 8/7/25, the Pharmacy Review again questioned why the AIMS…

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 its medication error rate is not 5 percent or greater. The medication error rate was 11.54%.Findings include:The facility policy titled Medication Administration General Guidelines dated May 2018 documents (in part):Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions.7). Tablet crushing/capsule opening: Crushing tablets may require a physician's order, per facility policy. If it is safe to do so, medication tablets may be crushed or capsules emptied out when a resident has difficulty swallowing or is tube-fed, using the following guidelines:c. Orders to crush medications should not be applied to medications which, if crushed, present a risk to the resident. For example:1. Long-acting or enteric-coated dosage forms should not be crushed; an alternative should 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 Based on observations, interviews and record review, the facility failed to ensure hospice collaboration and communication was established to ensure continuity of care between hospice provider and the facility for 1 (R13) of 2 residents reviewed for hospice services. *R13 started receiving hospice care and treatment on 7/29/25. R13's hospice plan of care initiated on 7/29/25, included Lorazepam (an anti-anxiety medication) and Hydromorphone (a narcotic pain medication) to be ordered and implemented by facility staff. Facility staff did not enter the physician order for Lorazepam until 9/6/25 and Hydromorphone until 9/15/25. R13 sustained falls on 8/2/25, 8/9/25, 8/18/25 and 9/2/25. Facility staff did not inform hospice staff of these falls on the day the falls happened. According to hospice and facility staff, R13 is to have a hospice binder at the nurse's station to aid in communication between the facility and the hospice provider. R13 was observed to not have a hospice binder.Findings include:The facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review, the facility failed to accurately transcribe medication orders to ensure correct administration of prednisone (oral steroid) and failed to notify the provider of elevated blood glucose levels for one of three residents (Resident (R) 2) reviewed for blood sugars out of 10 sampled residents. This failure had the potential to result in withdrawal symptoms from not tapering the prednisone and in adverse health effects from not managing elevated blood glucose levels. Findings include: Review of the facility's policy titled, Medication Administration-General Guidelines, revised 12/19, revealed Medications are administered as prescribed . Review of the facility's undated policy titled, Standard Diabetes Mellitus Protocol revealed . 2) blood sugars to be within parameters as determined by the physician orders 3) exhibit no hypo/hyperglycemic episodes . update physician and responsible party as needed . Review of R2's admission Record located in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to obtain wound treatment orders timely when a pressure injury was identified for two of three residents (Resident (R) 4 and R1) reviewed for pressure injury out of 10 sample residents. This had the potential for residents' pressure injuries to decline. Findings include: Review of the facility's policy titled, Pressure Injury Prevention and Managing Skin Integrity, dated 02/08/17, revealed: The care and intervention for any skin breakdown or wound is intended to prevent any further advancement of the wound or additional skin breakdown. 1. There will be collaboration with the interdisciplinary team [IDT] regarding the presence of breakdown and the intervention plan . Upon identification of abnormal skin findings, a licensed nurse will complete a skin assessment. Individual with abnormal skin concern(s) will be added to weekly wound rounds. Registered Nurse [RN] or designee will: i. conduct weekly skin evaluation, ii.…

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, record review, and facility policy review, the facility failed to have medications available to administer as ordered for two of four residents (Resident (R) 9 and R2) reviewed for medication availability out of 10 sample residents. This had the potential to result in adverse health outcomes. Findings include: Review of the facility's policy titled, Medication Administration - General Guidelines, revised 12/19, revealed: If a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than the scheduled time (e.g., the resident is not in the facility at scheduled dose time, or a starter dose of antibiotic is needed), .If electronic MAR [Medication Administration Record] is used, documentation of the unadministered dose is done as instructed by the procedures for use of the eMAR [electronic MAR] system . If [XX consecutive doses] of a vital medication are withheld, refused, or not available, the physician is notified. Nursing 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.

Based on observation, interview and record review the facility did not follow proper sanitation and food handling practices in accordance with professional standards for food service safety in the kitchen and 1 of 2 serving areas with the potential to affect 44 residents. * Garbage cans in the kitchen were observed to be very soiled and a lid was not on a garbage can next to a food preparation area. * Multiple items in the kitchen were found to be undated and several were uncovered. * The handwashing sink in the kitchen was very dirty. * The serving area on the second floor was found to have a mop and bucket with dirty water next to a cart for food trays. * Several food storage bins were observed to have the scoop stored inside the bin in direct contact with the product. Findings Include: On 5/28/24 at 8:48 AM the following was observed in the kitchen: * In a refrigerator in the food preparation area was a chef salad and 3 packs of partially used cold cuts without a date. * In the walk in Refrigerator was a large container of partially used fruit salad with no date, a pan of red 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 and interview, the facility did not ensure that residents have reasonable access to the use of telephone, in a place where calls can be made without being overheard. The facility provided telephones in resident's rooms on the first floor while resident's living on the second floor of the facility did not have reasonable access to the use of telephone. This deficient practice has the potential to affect 28 of 28 residents residing on the second floor of the facility who could request the use of telephone. Findings include: During Resident Council held on 5/29/24 at 2:00 PM, R14 stated, I am upset that there are not phones in the rooms on the second floor. R14 stated that they were told by the facility that the budget would be reviewed in July and a plan for phones would be addressed at that time. R14 stated that there was a phone at the end of the hallway on the second floor that residents could use but that it did not provide privacy. On 5/30/24 at 10:22 AM, Surveyor interviewed NHA (Nursing Home Administrator)-A regarding the phone system at the facility.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure information was provided and consent was obtained for a resident who was prescribed psychotropic medications for 1 (R37) of 5 residents reviewed for unnecessary medications. R37 was prescribed Mirtazapine and Trazadone which are antidepressant medications. The facility did not obtain written consent from R37's Power of Attorney (POA) for these medications. Findings include: The undated facility policy, entitled Standard Psychoactive Medication Protocol, documents, in part: Nursing: . Review and obtain signature for informed consents with individual or responsible party . R37 was admitted to the facility on [DATE] and has pertinent diagnoses that include: Stroke, Aphasia (loss of ability to speak), Lung cancer, and Adjustment disorder with mixed anxiety and depressed mood. R37's Quarterly Minimum Data Set (MDS) assessment, dated 3/22/2024 indicates that R37 is rarely/never understood and R37 is severely cognitively impaired. Surveyor reviewed R37'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 observation, interview, and record review, the facility did not ensure the accurate and safe administration of medication for 1 (R34) of 5 Residents observed for medication pass. R34 did not have a self-administration of medication assessment or a physician's order to self-administer medication. Findings include: The Facility Policy and Procedure titled, Self-Administration of Medications Effective Date: May 2018, states in part: Policy In order to maintain the residents' highest level of independence, residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer. Procedures A. If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive (including orientation to time), physical, and visual ability to carry out this responsibility during the care planning process . C. For those residents 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the Facility did not notify a resident's representative or attending physician when there was a change of condition involving 1 (R45) of 14 residents in the sample. R45 had a fall with injury and was transported to the hospital. There was no documentation R45's representative or attending physician were updated when the change of condition occurred. Findings include: R45 was admitted to the facility on [DATE] with diagnoses that include, in part, displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing, muscle weakness (generalized), dysphagia, oropharyngeal phase, difficulty in walking, not elsewhere classified, unsteadiness on feet, cognitive communication deficit. R45 has an activated power of attorney. The Medicare 5 day MDS (Minimum Data Set) dated 3/19/2024 indicates R45 has a BIMS (Brief Interview for Mental Status) of 06, indicating severe cognitive impairment. R45 is frequently incontinent of urine and bowel.…

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 a safe, home-like environment that provided reasonable care for the protection of a resident's property from loss for 1 (R33) of 1 residents reviewed. Two of R33's shirts were lost after R33 sent them to be cleaned by the facilities laundry department. R33 informed the facility. The facility started the process of locating the missing the shirts but did not follow through with locating them in a timely manner. Findings include: R33 was admitted to the facility on [DATE] and has pertinent diagnoses that include Depression, Anxiety, Chronic Kidney disease, and Muscle weakness. R33's Quarterly Minimum Data Set (MDS) assessment, dated 3/8/2024, indicated that R33 has a Brief Interview for Mental Status (BIMS) score of 15, indicating that R33 is cognitively intact for daily decision making. On 5/28/24, at 1:59 PM, Surveyor interviewed R33. R33 stated that the facility does her laundry. R33 stated that about 4 months ago, 2 of her shirts went missing…

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 information from the baseline care plan was reviewed with resident and a copy or summary of the plan was provided to the resident for one (R10) of one residents reviewed. Findings include: The facility policy, entitled Comprehensive Person-Centered Care Plan, with a review date of 8/10/2023, documents, in part: . Within 48 hours after admission: a Baseline Care Plan will be completed and reviewed with Individual and/or Individual Representative. R10 was admitted to the facility on [DATE] and has pertinent diagnoses that include Chronic heart failure, Weakness, Unsteadiness on feet and Chronic kidney disease. R10's admission Minimum Data Set (MDS) assessment, dated 4/16/2024 indicated that R10 has a Brief Interview for Mental Status (BIMS) score of 15, indicating that R10 is cognitively intact for daily decision making. On 5/28/24, at 10:41 AM, Surveyor interviewed R10, who stated that R10 had not participated in the baseline care planning process.…

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 develop and implement a comprehensive person-centered care plan for 1 (R100) of 12 residents to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment. Findings include: R100 was admitted to the facility on [DATE] with diagnoses that included diabetes, muscle weakness and urinary incontinence. On 5/30/24 R100's admission Minimum Data Set (MDS) dated [DATE] was reviewed and indicated R100 was at risk for pressure injuries and a Care Area Assessment (CAA) for Pressure Injury was triggered and documented: Will pressure injury be addressed on the care plan and yes is checked. R100's narrative for this CAA documented: CAA triggered for potential pressure injury due to need for assistance with bed mobility. Further complicated by sometimes incontinent of bowel and bladder and utilizes brief daily to manage. (R100) is at risk for skin breakdown. On 5/30/24 R100's Braden Scale for Predicting…

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 provide the necessary ADL (Activity of Daily Living) services for 2 (R8 and R31) of 14 residents that were dependent on staff to assist with ADL care. * R8 was observed to have long, dirty fingernails on both hands and was itching an open wound. * R31 was observed to have right and left hand contractures, R31's nails on both hands were long and dirty and had the potential of cutting into R31's palms. Findings include: The facility policy, entitled Standard ADL Protocol, that is not dated states: ADLs: . personal hygiene (oral care, face, hands) . PROBLEM: Individual requires assistance with ADLs . CNA (certified nursing assistant) . Trim finger and toenails on bath/shower day and as needed unless diabetic. RN (registered nurse) . Complete diabetic nail care. LPN (licensed practical nurse) . Complete diabetic nail care. 1.) R8 was admitted to the facility on [DATE] and has diagnoses that include (idiopathic) normal pressure hydrocephalus,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not provide an ongoing, individualized and meaningful activities program designed to meet the residents interest and support their physical, mental and psychosocial well-being for 2 (R247 and R33) of 2 residents reviewed for activities. R247 and R33 reported that they would like to participate in organized group activities on the weekend but activities are not offered on the weekends. Findings include: R247 was admitted to the facility on [DATE] after surgery to repair a broken femur. R247's admission Minimum Data Set (MDS) assessment, dated 5/22/2024 indicated that R247 has a Brief Interview for Mental Status (BIMS) score of 15, indicating that R33 is cognitively intact for daily decision making. Section F of the MDS documented that it is very important to R247 to do things with groups of people. On 5/28/2024, at 12/14 PM, Surveyor interviewed R247 about the facility's activity program. R47 stated that he enjoys joining the activities that the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not ensure that 1 (R6) of 3 residents reviewed for accidents had adequate assistance devices and interventions in place to prevent accidents. * R6 did not have a falls care plan initiated until 12/4/2023 even though R6 was admitted to the facility because of a fall at R6's previous residence and assessed at a high risk for falls. Findings include: R6 was admitted to the facility on [DATE] and has diagnoses that include age related osteoporosis, neuropathy, low back pain, spinal stenosis, cervical and lumbar region, glaucoma, atherosclerotic heart disease, bradycardia, and abnormalities of gait and mobility. R6's admission minimum data set (MDS) dated [DATE] indicated R6 had intact cognition with a Brief Interview of Mental Status (BIMS) score of 13 and the facility assessed R6 needing supervision with all activities of daily living (ADLs) and when walking 50 feet and performing turns. R6's fall risk evaluation assessed on 10/17/2023 indicated R6 was at risk…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility did not ensure 1 (R31) of 2 reviewed for an indwelling catheter had a valid medical justification for continued use of the indwelling catheter, received necessary services for monitoring of the indwelling catheter and provide dignity for resident who had an indwelling catheter. R31 was admitted to the facility with a foley catheter. There was no diagnosis or justification for the catheter, no size indicated, and no orders for monitoring or cares for the indwelling catheter. Observations were made of catheter bag not being in a privacy bag. Findings include: The facility policy, entitled STANDARD INDWELLING CATHETER PROTOCOL, no date indicated, states: Problem: Individual has Indwelling Catheter, . RN/LPN (registered nurse/ licensed practical nurse): Obtain order for indwelling catheter, Document type, size, balloon inflation size and indication for use . , Urinary assessment and documentation as indicated and directed by the RN, Change catheter/ bag…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility did not ensure the necessary care and services to provide respiratory care were consistent with professional standards of practice for 1 (R31) of 1 resident reviewed for respiratory care. R31's oxygen tubing was not labeled, there was no care plan for respiratory/ oxygen use, and no orders in place for care of oxygen supplies. Findings include: The Facility policy, entitled STANDARD RESPIRATORY PROTOCOL, no date indicated, states: Problem: Impaired or potential impairment of gas exchange r/t (related to) chronic respiratory disease. RN (registered nurse): Assess for signs of ineffective breathing pattern PRN (as needed), Monitor/Document respiratory status PRN, ., Protective covering to oxygen tubing, around ears, Replace DME (durable medical equipment) as ordered. MAA (medication administration assistant): . Replace DME as ordered, All: . Involve individual and/or responsible party in care plan process. R31 was admitted to the facility on [DATE]…

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

Based on observation, interview, and record review, the facility did not ensure the accurate and safe administration of medication for 2 (R7 and R34) of 5 Residents observed for medication pass. R7 and R34 were not provided medications that were on the physician orders due to not having on medication cart yet were signed out as given on the Medication Administration Record (MAR). Findings include: The Facility Policy and Procedure titled, Medication Administration-General Guidelines Effective Date: May 2018, states in part: Procedures A. Preparation . 11) If a medication with a current, active order cannot be located in the medication cart/drawer, other areas of the medication cart, medication room, and facility (e.g., other units) are searched, if possible. If the medication cannot be located after further investigation, the pharmacy is contacted, or medication removed from the night box/emergency kit . D. Documentation . 6) If a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than the scheduled time .if electronic MAR…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2.) R6 was admitted to the facility on [DATE] and has diagnoses that include age-related osteoporosis, neuropathy, low back pain, spinal stenosis- cervical region and lumbar region, glaucoma, bradycardia, and abnormalities of gait and mobility. R6's quarterly minimum data set (MDS) dated [DATE] indicated R6 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 15, PHQ-9 (patient health questionnaire-9- screening/diagnosing/monitoring/and measuring the severity of depression) score of 0 indicating no depressive symptoms, and R6 did not have any behaviors. Surveyor reviewed R6's medical record and noted an order for: 1. Duloxetine HCl oral capsule, Delayed release particles 40 MG (Duloxetine HCl)- Give 40 mg by mouth in the morning for depression (Start: 3/27/2024) 2. Anti-depressant medication use- observe resident closely for significant side effects: sedation, drowsiness, dry mouth, blurred vision, urinary retention, tachycardia, muscle tremor, agitation, headache, skin rash,…

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 the medication error rate was below 5% for 3 residents (R7, R35 and R100) of 5 residents observed receiving medications. The facility medication error rate was 11.11%. *R7 did not have Voltaren Gel applied per order and the gel was signed out on the Medication Administration Record (MAR). *R34 did not receive Hydrochlorothiazide 12.5 mg tablet which was signed out on the MAR. *R100 did not receive Amlodipine 10mg tablet which was signed out on the MAR. Findings include: The Facility Policy and Procedure titled, Medication Administration-General Guidelines Effective Date: May 2018, states in part: Procedures A. Preparation . 11) If a medication with a current, active order cannot be located in the medication cart/drawer, other areas of the medication cart, medication room, and facility (e.g., other units) are searched, if possible. If the medication cannot be located after further investigation, the pharmacy is contacted, or medication removed from the night box/emergency kit . D. Documentation . 6) If 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 1 of 3 residents reviewed (R100) was free of significant medication errors. * R100 had an order for Vancomycin every 3 days transcribed twice so she received double the ordered dose from 4/12/24 to 5/28/24 when it was brought to the facility's attention. Findings include: R100 was admitted to the facility on [DATE] with diagnoses that included status post right knee surgery for a right knee tear. On 5/28/24 R100's current Physician's orders were reviewed and included Vancomycin 125 milligrams (MG) for infection (right knee) every 3 days started on admission with the first dose on 3/12/24. R100 also had another order for Vancomycin 125 MG for right knee effusion every 3 days started on admission which was 4/12/24 and discontinued 5/28/24. On 5/28/24 R100's Medication Administration Record (MAR) for April and May 2024 were reviewed and documented that R100 received 16 extra doses of Vancomycin 125 MG in the timeframe from 4/12/24 to 5/27/24. On…

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

Based on observation, interview, and record review the facility did not ensure all drugs and biologicals were stored and labeled in accordance with currently accepted professional principles and did not ensure expired medications were removed from medication carts. This occurred for 3 of 5 medication carts/storage rooms observed. The refrigerators in the 1st and 2nd floor medication storage rooms did not have monitoring of temperatures recorded R9's Insulin Glargine was stored in the medication cart beyond use by date Findings include: 1.) The Facility Policy and Procedure titled, Medication Storage in the Facility Effective Date: May 2018, states in part: Procedures . K. Refrigerated medications are kept in closed and labeled containers, with internal and external medications separated . L. All medications are maintained within the temperature ranges noted in the United States Pharmacopeia . 3) Refrigerated 36 degrees to 46 degrees Fahrenheit with a thermometer to allow temperature monitoring . Temperature . C. Medications requiring refrigeration are kept in a refrigerator at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure one (Resident (R)8) of 11 residents reviewed for code status was accurately documented throughout the medical record. This had the potential for the resident and/or responsible party's wishes not to be honored. Findings include: Review of R8's Face Sheet located in the electronic medical record (EMR) revealed R8 was admitted to the facility on [DATE] under hospice care. R8 was noted to be a Full Code status. Review of R8's Plan of Care (POC) located in the Plan of Care tab in the EMR revealed R8 had a terminal prognosis and was under hospice care. R8's living will was to be reviewed and ensured it was followed, family is to be involved in the discussion. Review of the hospice form provided by the Administrator revealed R8 had been a Do not Resuscitate (DNR) since 10/02/22. During an interview on 03/25/24 at 1:38 PM with Family Member (FM) of R8 revealed they were walking into R8's room and found him nonresponsive, without a pulse 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 record review, staff interview, and review of facility policy, the facility failed to ensure that a resident who was admitted without a pressure injury was properly assessed and monitored to prevent the development of a pressure injury for one resident (Resident (R) 5) out of three residents reviewed for pressure injuries. This resulted in the development of a facility acquired, stage 3 pressure injury. Findings include: Review of the facility's policy titled, Pressure Injury-Prevention and Managing Skin Integrity dated 08/10/2023 indicated, 3. Skin Checks: a. Skin checks will be done upon admission, readmission or as clinically indicated. b. While providing routine care, a licensed nurse is to monitor the skin condition of each individual weekly and document the Skin Check in the medical record. Review of the R5's admission Record located in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease,…

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, staff interview, and facility policy review, the facility failed to complete a thorough investigation of a fall for one (Resident (R) 5) of three sampled residents reviewed for falls. This had the potential for additional falls and potential injuries to the resident. Findings include: Review of the facility's policy titled, Falls dated 06/13/23, indicated 2. Procedure of Fall Event and Implementation of Intervention: a. Licensed nurse completes electronic documentation of the Fall Incident Report. B. The Care Plan will be updated with an identified intervention .3. Administrative Review a. The Interdisciplinary Team (IDT) will review Fall Incident report and utilize root cause analysis to make further recommendations. Review of the R5's admission Record located in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, unsteadiness on feet, and muscle weakness. Review of R5's admission…

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, observation, interview, and policy review, the facility failed to provide incontinence care in a timely manner for one of three sampled residents (Resident (R) 3) reviewed for incontinence care. The failure of the facility to check and change the resident after an incontinent episode put the resident at risk for developing skin issues and potentially an urinary tract infection (UTI). Findings include: Review of the facility's undated policy titled, Standard ADL (Activities of Daily Living) Protocol revealed, ADL's: Dressing, grooming, eating, toileting, bathing and personal hygiene. Problem: Individual requires assistance with Activities of Daily Living (ADL's), Certified Nursing Assistant (CNA): Toileting every 2 to 3 hours or per individual preference .Provide incontinence care as needed. Review of R3's admission Record located in the electronic medical record (EMR) under the Profile tab revealed he was admitted to the facility on [DATE] with diagnoses of right hemiplegia (paralysis),…

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 interviews, and review of the facility's policy, the facility failed to ensure staff performed hand hygiene during incontinence care for one resident (Resident (R) 3) of one observed during from a sample of 11 residents. This had the potential for infection control not being maintained. Findings include: Review of the facility's policy titled, Hand Hygiene dated 09/20/23, revealed, The organization will promote clean hands as the single most important factor in preventing the spread of pathogens, antibiotic resistance, and incidence of infections. Specific indications for hand hygiene .3. Before moving from work on a soiled body site to a clean body site on the same patient . 6. Immediately after glove removal. Review of R3's admission Record located in the electronic medical record (EMR) under the Profile tab revealed he was admitted to the facility on [DATE] with diagnoses of right hemiplegia (paralysis), Alzheimer's disease, and dementia. Review of R3's quarterly Minimum Data Set…

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

Based on observation and interview, the facility did not ensure staff followed transmission- based precautions for 1 (R2) of 1 residents who tested positive for SARS-CoV-2. This practice has the possibility to affect 19 residents residing on in the facility. Surveyor observed CNA (Certified Nursing Assistant) G assist a SARS-CoV-2 positive resident (R2) in their room without donning an N95 mask. Findings include: The Centers for Disease Control's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated on September 23 2022, documents: HCP (HealthCare Personnel) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). On 02/09/23 at 7:47 AM, NHA (Nursing Home Administrator) A informed Surveyor an employee tested positive for SARS-CoV-2 yesterday. NHA…

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 immediately inform the resident's physician and Power of Attorney for Healthcare (POAH) of a significant change in the resident's status for 1 (R4) of 8 residents reviewed for a change in condition notification. * R4 had a documented 17 pound weight gain in 7 days which could indicate an underlying health concern and R4's physician and his POAH were not notified. Findings include: On 2/9/23 the facility policy and procedure titled Weighing Individuals dated 6/24/22 was reviewed and read: Weights are reviewed with previous weights for any changes. The provider is updated with weights as indicated. On 2/9/23 the facility policy and procedure titled Change of Condition and Provider Notification dated 7/13/21 was reviewed and read: Change of condition is a deviation from and individuals baseline in physical, cognitive, behavioral or functional status. Clinically important means a deviation that, without intervention, may result in complications or death.…

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

Based on interview and record review, the Facility did not ensure that a comprehensive care plan was developed for 1 (R12) of 8 Residents. R12 did not have problem areas of psychotropic medication and nutritional status identified on R12's care plans. Findings include: On 12/5/22, R12 admitted to the Facility with diagnoses that include Alzheimer's disease, Unspecified; Dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance; Adult Failure to Thrive and Diabetes Mellitus, Type II. R12's admission Minimum Data Set (MDS) assessment, dated 12/12/22, documents a Brief Interview of Mental Status (BIMS) score of 6, indicating R12 has severe cognitive impairment. The MDS also indicates R12 requires extensive assistance of one (1) staff member for dressing, toileting, transferring, ambulating and hygiene tasks. The MDS also documents R12 weighs 173 pounds and has had a 5% weight loss in the last month or has had a 10% or more weight loss in the last 6 months while not being on a physician prescribed weight-loss regime. The MDS also documents…

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 2 (R4, R12) of 2 Residents with significant weight changes received the necessary care and treatment. * On 1/30/23 R4 weighed 166 pounds and on 2/6/23 R4 weighed 183 (a 17 pound weight gain in 7 days) no intervention was taken by the facility after the weight gain. R4 was not weighed per the facility policy which indicated R4 should have been weighed on admission and every week for 4 weeks. R4's admission assessment did not include a weight and the section was left blank. *On 1/9/23, R12 weighed 177.4 pounds and on 1/16/23, R12 weighed 147.2 pounds (a 30.2 pound weight loss in 7 days); no intervention was taken by the facility after the weight loss. Findings include: On 2/9/23 the facility policy and procedure titled Weighing Individuals dated 6/24/22 was reviewed and read: Weights are obtained per order or on admission, weekly for the first 4 weeks after admission or readmission. Weights are reviewed with previous weights for any changes. 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, interview, and record review, the Facility did not ensure psychotropic medications were adequately monitored for indications for use. This was observed with 1 (R12) of 2 residents reviewed on psychotropic medications. R12 was admitted to the facility on antipsychotic and antidepressant medication without behavioral indications for use nor behavioral monitoring. Findings include: The Facility's Standard Psychoactive Medication Protocol, with no date: PROBLEM: Individual is prescribed a psychotropic medication. GOAL: Individual will have minimized side effects of psychotropic drug use. MAA: -document target behaviors and report changes to Licensed Nurse. Nursing: - . Document target behaviors, interventions and effectiveness. R12 is over [AGE] years of age and admitted to the facility on [DATE] with diagnoses that include Alzheimer's disease, Unspecified; Dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance; Adult Failure to Thrive 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.