Resolve at West Allis Respiratory and Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure 3 (R2, R3, and R4) of 3 residents and/or representative were notified of the reason for transfer/discharge in writing and the rate to reserve the residents' bed was not documented in the Bed Hold and Notice of Transfer. *R2 was discharged to the hospital on [DATE] and 12/28/25. The facility's transfer and discharge notice was not provided in writing and in a language understood to R2 and/or R2's representative. R2's bed hold notices did not document the facility per diem daily rate. *R3 was discharged to the hospital on [DATE], 12/2/25, 12/7/25 and 12/11/25. The facility's transfer and discharge notice was not provided in writing and in a language understood to R3 and/or R3's representative. R3's bed hold notices did not document the facility per diem daily rate. *R4 was discharged to the hospital on [DATE]. The facility's transfer and discharge notice was not provided in writing and in a language understood to R4 and/or R4's representative. R4'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 there was a medication error rate below 5 percent. There were 2 medication errors in 31 opportunities which resulted in a medication error rate of 6.45%. Medication errors were identified for R7 & R9.*R7's Prednisolone Acetate Ophthalmic Solution 1% was not shaken prior to administration.*R9 was administered two drops of Cromolyn Sodium 4% eye drops into each eye without waiting one minute between drops.Findings include:The facility's policy titled, Administration of Eye Drops or Ointments and not dated under Policy documents Eye medications are administered as ordered by the physician and in accordance with professional standards of practice to lubricate the eye or treat certain eye conditions.1.) On 1/14/26, at 12:16 p.m., Surveyor observed Licensed Practical Nurse (LPN)-C remove a glucometer and a clear bag containing R7's Prednisolone Acetate Ophthalmic Solution 1% from the medication cart. Surveyor observed the clear bag containing this eye drop is affixed with a blue sticker instructing to shake…

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 (R7) of 1 resident were free of significant medication errors.R7 was admitted to the facility on [DATE]. R7's has an order for Acetaminophen 1000 mg (milligrams) by mouth every 6 hours for pain/discomfort with a start date of 8/21/25. This order was not entered correctly, and Acetaminophen 1000 mg did not appear on R7's monthly medication administration records resulting in R7 not receiving Acetaminophen 1000 mg every six hours daily. R7 missed 48 doses in August 2025, 120 doses in September 2025, 124 doses in October 2025, 120 doses in November 2025, 124 doses in December 2025, and 53 doses in January 2026. R7 was not administered 589 doses of Acetaminophen 1000 mg.Findings include:The facility's policy titled, Medication Orders and not dated under Policy Explanation and Compliance Guidelines documents for 4. Documentation of Medication Orders: a. Each medication order should be documented with the date, time and signature of 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 observations, interviews, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for 1 (R11) of 3 residents reviewed for medication administration via Enteral Tube (ET) (a tube that is connected to the digestive system and is used to deliver hydration, nutrition, or medications.) R11 was on Enhanced Barrier Precautions (EBP), a staff member placed a graduated cylinder and syringe, from R11's room that's used for R11's ET cares, on the nurse's medication cart leaving residual fluid on the cart. The staff member did not sanitize the cart but then began preparing the next medication administration for another resident by placing cups on the contaminated cart/fluid. R11 is on EBP, a staff member did not maintain EBP after providing cares to R11. The staff member did not remove Personal Protective…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, observation, and policy review, the facility failed to determine one of five sampled residents (Resident (R) 5) was safe in the self-administration of physician ordered medications. This failure had the potential for R5 not to take his medication and experience adverse effects of not taking the physician ordered medications.Findings include:Review of R5's undated Face Sheet located under the Profile' tab in the electronic medical record (EMR) indicated R5 was originally admitted to the facility on [DATE] with the diagnosis which included type two diabetes mellitus, hypertension, and transient ischemic attack.Review of R5's quarterly Minimum Data Set (MDS) located under the MDS tab in the EMR, with an Assessment Reference Date (ARD) of 07/23/25 indicated R5 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R5 was cognitively intact.Review of R5's Physician Orders located under the Orders tab in the EMR indicated the following orders:-08/29/25…

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, interviews, and facility policy review, the facility failed to ensure medication administration was timely for two of three residents (Resident (R)1 and R5) reviewed for late medications out of five sampled residents. This failure had the potential to interfere with the medication effectiveness.Findings include:1.Review of R1's updated Face Sheet located under the Profile tab in the electronic medical record (EMR) indicated R1 was admitted to the facility on [DATE] with the diagnosis of quadriplegia, and pressure ulcer to left buttock.Review of R1's quarterly Minimum Data Set (MDS) located under the MDS tab in the EMR, with an Assessment Reference Date (ARD) of 08/13/25 indicated R1 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 was cognitively intact. R1 was also coded as having a stage three pressure ulcer that was unhealed.During an interview on 10/13/25 at 2:55 PM, R1 stated he either received his medications too early or late. R1 reported 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, record review, interview and document review, the facility failed 1. to prime an unused insulin pen prior to the injection of insulin as well as 2. failed to ensure the insulin was administered as ordered for one of five sampled residents (Resident (R)5). This failure had the potential for R5 not to receive the physician ordered amount of insulin to R5 and the potential to have uncontrolled blood sugars as a result of this action.Findings include:Review of R5's Review of R5's undated Face Sheet located under the Profile' tab in the electronic medical record (EMR) indicated R5 was originally admitted to the facility on [DATE] with the diagnosis which included type two diabetes mellitus, hypertension, and transient ischemic attack.Review of R5's quarterly Minimum Data Set (MDS) located under the MDS tab in the EMR, with an Assessment Reference Date (ARD) of 07/23/25 indicated R5 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R5 was cognitively…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview and document review, the facility failed to follow infection control guidelines during a wound care observation for two of three residents (Resident (R)1 and R4) observed out of five sampled residents. This failure had the potential for R1 and R4 to be exposed to infections.Findings include:1.Review of R1's updated Face Sheet located under the Profile tab in the electronic medical record (EMR) indicated R1 was admitted to the facility on [DATE] with the diagnosis of quadriplegia, and pressure ulcer to left buttock.Review of R1's quarterly Minimum Data Set (MDS) located under the MDS tab in the EMR, with an Assessment Reference Date (ARD) of 08/13/25 indicated R1 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 was cognitively intact. R1 was also coded as having a stage three pressure ulcer that was unhealed.Review of R1's Physician Orders located under the Orders tab in the EMR indicated an order dated 10/06/25 for Left buttock…

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 observations, interviews, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (R5) of 3 residents observed with Enhanced Barrier Precautions (EBP). *R5 has a facility acquired pressure injury to the sacral area. On 6/26/25 Surveyor observed R5's wound treatment. Facility staff did not wear the proper Personal Protective Equipment (PPE) while performing R5's wound treatment. Findings include: On 6/26/25 at 11:40 AM, Surveyor observed Centers for Disease Control (CDC) signage outside of R5's room. CDC signage documented the following: Enhanced Barrier Precautions-Everyone must clean their hands before entering and prior to leaving room. Providers and Staff must also: Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting 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 record review, document review and staff interviews, the facility failed to ensure one of one (Resident (R) 2) family member (F1) was provided with a timely refund for paying privately prior to the approval of R2's Medicaid application for long-term care services. Findings include: Review of an email that was provided by the facility dated 03/14/25 and written by the Clinical Liaison/admission Coordinator indicated she was notified by R2's representative that the resident was approved by long-term care Medicaid coverage. Review of a document provided by the facility referred to as a sample admission Packet undated indicated, . Facility may provide information needed in applying for coverage under Medicare, Medicaid or third-party insurance, but you are responsible for applying for and maintaining coverage. For example, the daily basic rate will apply, and payment will be due from the Resident's personal funds while a Medicaid application is pending . The estimated Resident Liability will continue until…

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, and facility policy review, the facility failed to ensure one (Resident (R)1) care plan out of a survey sample of 15, accurately reflected the resident's current status. This failure created an increased risk for the resident to receive care and services not appropriate for their current clinical condition. Findings include: Review of the facility's policy titled Care Plans, Comprehensive Person, Centered dated 03/22 indicated, . Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. Review of R1's electronic medical record (EMR) titled admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of R1's EMR titled Care Plan located under the Care Plan tab dated 01/08/24 indicated the resident's code status was a full code. Review of R1's EMR significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/26/25…

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, record review, facility policy review, and Centers for Disease Control (CDC) guidance, the facility failed to adhere to infection control practices and policies during wound care related to staff failing to perform hand hygiene during glove changes for one of two residents (Resident (R) 6) observed for wound care in the sample of 15 residents. In addition, the Respiratory Therapist (RP)1 failed to apply appropriate Personal Protective Equipment (PPE) prior to performing a respiratory treatment for one of one resident (R1) with a tracheostomy in the sample of 15 The deficient practice increased the risk for cross contamination and infections. Findings include: 1. Review of the facility's policy titled, Handwashing/Hand Hygiene revised October 2023 provided by the facility indicated, Hand hygiene is indicated: . before moving from work on a soiled body site to a clean body site on the same resident; and immediately after glove removal. Applying and Removing Gloves: Perform hand…

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, record review, and policy review, the facility failed to notify the representative of a hospital transfer for one of two residents (Resident (R) reviewed for hospital transfer out of a total sample of 17. Findings include: Review of the facility's policy titled, Determining Decision-Making Capacity, revised 09/2017, revealed, . Physicians and staff shall collaborate to define each resident/patient's decision-making capacity . Residents/patients who lack decision-making capacity will have decisions made by an appropriately authorized substitute decision-maker. 3. The facility's care will be consistent with related clinical standards of practice and will comply with applicable laws and regulations related to determining decision-making capacity . Procedures 4. Based on these assessments and related discussions, and consistent with applicable laws and regulations, the physician and staff will define an individual's decision-making capacity and will document the basis for such conclusions 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 review of facility policy, record review, and interviews, the facility failed to protect the resident's right to be free of staff to resident abuse for two of 17 residents (Resident (R ) 2 and R7) reviewed for abuse out of a total sample of 17. This failure created the potential for these and other residents to experience further abuse. Findings include: Review of the facility's undated Freedom from Abuse and Neglect Policy read, in pertinent part, Purpose: To prohibit abuse, neglect, exploitation of residents and misappropriation of property; and Definition: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. 1. Review of R2's admission Record, dated 03/13/25 and found in the electronic medical record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included quadriplegia. Review of R2's quarterly Minimum Data Set (MDS), with an Assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, record review, and interviews, the facility failed to ensure timely reporting of potential abuse for one out of 17 residents (Resident (R) R7) reviewed for abuse out of a total sample of 17. This failure created the potential for this and other residents to experience further abuse. Findings include: The facility's undated Freedom from Abuse and Neglect Policy read, in pertinent part, Staff will immediately report any suspicious event or injury that may constitute abuse, neglect, exploitation or misappropriation to the Executive Director (Administrator.) Review of R7's admission Record, dated 03/13/25 and found in the EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included type 2 diabetes and chronic obstructive pulmonary disease (COPD). Review of R7's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/14/25 and found in the EMR under the MDS tab, indicated a Brief Interview for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, record review, and interviews, the facility failed to ensure one out of 17 residents (Resident (R) R2 reviewed in the sample received his medication routinely as ordered by his physician. This failure caused multiple medication errors during the resident's medication administration, which created the potential for this resident to experience significant negative physical effects related to the errors. Findings include: The facility's Medication Administration - General Guidelines Policy, dated 12/2019, read, in pertinent part, FIVE Rights - Right resident, right drug, right dose, right route and right time, are applied for each medication being administered. Review of R2's admission Record, dated 03/13/25 and found in the electronic medical record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included quadriplegia and orthostatic hypotension. Review of R2's quarterly Minimum Data Set (MDS), with an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review., the facility did not ensure that 1 (R79) of 2 residents reviewed for discharge, had a discharge plan that was developed or implemented in an effective discharge planning process that focuses on the resident's discharge goals and resident safety. *R79 stated a desire to return home after being admitted to the facility. R79 was scheduled for discharge on [DATE] and 12/2/2024. R79's care plan was developed without including measurable objectives or defined interventions consistent with R79's needs and goals. Findings include: The facility policy, titled Discharge Planning Process, dated 1/10/2024, states: Procedure: 1. A Discharge plan of care will be developed for each resident and will be included as part of the Comprehensive Care Plan. 2. The discharge plan of care must: -Identify needs that must be addressed before the resident can be discharged , such as resident education, rehabilitation, and caregiver support and education. -Be re-evaluated regularly 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, interview, and record review the facility did not ensure residents who are unable to carry out activities of daily living receive the necessary services to maintain good grooming for 1 (R50) of 19 resident's reviewed for ADL's (Activities of Daily Living). *R50's request for nail trim and face shave was not completed. The explanation for why R50 did not receive a beard trim and nails trimmed is that R50 refuses baths. R50 did not have a plan of care to address R50's refusals. The facility did not assist in providing personal hygiene that did not require a full bath to complete. Findings include: The facility policy titled Activities of Daily Living (ADLs), Supporting revised March 2018 documents: Policy Statement: Residents will provided [sic] with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility did not ensure 1 (R57) of 1 residents reviewed for Dialysis received Dialysis care in accordance with professional standards of practice. *R57 did not have a MD (Medical Doctor) order for monitoring R57's Arterio-Venous (AV) Fistula for bruit (whooshing sound of blood flow) or thrill (palpable vibration of the blood flow) until 12/2/24, which was after the current Recertification Survey began. There is no evidence staff were monitoring R57's AV fistula site for bruit or thrill from the end of the last Recertification Survey (6/11/24) through 12/2/24. Findings include: Vascular Access Fact Sheet developed by the American Nephrology Nurses Association and copyrighted in 2023, documents, in part: . Measures can be taken to prevent clotting or infection to the access. Patency is assessed by feeling the 'thrill' or vibration of blood through the access or using a stethoscope to listen to the 'bruit' or 'whoosh' of blood through the access. The patient…

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 a sanitary environment was maintained to help prevent the potential development of infections for 1 (R71) of 7 residents observed during wound care. R71 was incontinent of liquid stool prior to Licensed Practical Nurse (LPN)-C doing a dressing change to R71's Stage 4 pressure injury to the coccyx. LPN-C did not provide incontinence care to clean the buttocks or intergluteal cleft prior to completing the dressing change potentially contaminating the dressing and introducing fecal matter into the Stage 4 pressure injury. Findings include: The facility policy and procedure titled Wound Care from Med-Pass ©2001 revised 2010 documents: Steps in the Procedure: . 11. Place one (1) gauze to cover all broken skin. Wash tissue around the wound that is usually covered by the dressing, tape or gauze with antiseptic or soap and water. 16. Discard disposable items into the designated container. Discard all soiled laundry, linen, towels, 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 interview and record review the facility did not ensure 1 (R4) of 1 Residents reviewed for grievances has the right to voice grievances in writing, in a manner they prefer, and receive written grievance decisions. On 4/29/24 the facility issued a letter to residents and/or their representatives informing them they would not accept grievances emailed to the facility. Resident's grievances do not include whether their issues were confirmed or not confirmed and the date written decisions were issued to the individual with the grievance/concern Findings include: The facility's policy titled, Grievance/Concern Process and not dated under procedure documents: 1. The facility must notify the residents individually or through posting in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance officer with whom a grievance can be filed, that is his or her name, business address and business phone number; a reasonable expected time frame for…

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

Based on interview and record review the facility did not report 1 (R6) of 3 incidents to the State survey agency and/or Nursing Home Administrator during the required timeframe. An allegation of verbal abuse and possible neglect on 7/10/24 was not reported to NHA (Nursing Home Administrator)-A or the State agency until 7/16/24 which was 6 days after the incident occurred. Findings include: The facility's policy titled, Freedom from Abuse and Neglect not dated under Reporting and Response documents: 1. Allegations will be reported to the Executive Director immediately. 2. The facility will report all alleged violations and substantiated incidents to the state agency and to all other agencies as required and will take all necessary corrective actions depending on the results of the investigation. R6's diagnoses includes epilepsy, anoxic brain injury, and depression. The quarterly MDS (minimum data set) with an assessment reference date of 8/8/24 has a BIMS (brief interview mental status score of 14 which indicates cognitively intact. The Facility's investigation for Resident Name…

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 1 (R2) of 2 Residents received prescribed medication as ordered by the physician. On 7/10/24 the medication cart and narcotics drawer were observed open & unlocked. RN (Registered Nurse) Supervisor-D removed 2 medication cards from the narcotics drawer of the unlocked medication cart for R2. R2 did not receive her Tramadol HCL 50 mg (milligrams) and Lorazepam 0.25 mg as ordered by the physician during the evening medication pass. Findings include: The facility's policy titled, Medication Administration -General Guidelines and dated March 2021 under procedures for B. Administration #2 documents Medications are administered in accordance with written orders of the prescriber. #16 documents During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. In…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility did not establish and maintain an infection prevention and control program based upon current standards of practice, designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections. This deficient practice has the potential to several of the 79 residents. The facility's Water Management Plan (WMP) was not based on current standards of practice and did not: ~Include water management team members who were knowledgeable about the facility's water system. ~Identify all locations where Legionella could grow and spread. ~Identify where control measures should be applied based on where Legionella could grow and spread and identify how to monitor the control measures and risks. ~Identify acceptable ranges of control limits (temperature ranges) and corrective actions to take when control limits are not met. ~Identify what actions should be taken to protect all residents when a resident is…

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 did not ensure that residents who entered the facility with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 1 (R47) residents reviewed for range of motion. R47 was not wearing her palm protectors during survey. Findings include: R47 admitted to the facility on [DATE] with diagnoses that include Bipolar Disorder, Idiopathic Peripheral Autonomic Neuropathy, Type 2 Diabetes Mellitus, Morbid Obesity, Hypertension, Cerebral Infarction and Disruptive Mood Dysregulation Disorder. The facility policy titled Resident Mobility and Range of Motion revised July 2017 documents (in part) . .2. Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM (range of motion). 5. The care plan will include specific interventions, exercises, and therapies to maintain, prevent avoidable…

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 it's medication error rate is not 5 percent or greater. The facility had a medication error rate of 6.45% affecting 1 of 4 (R76) residents observed during medication pass. R76 was administered medications crushed, which is contraindicated. Findings include: The facility policy titled Specific Medication Administration Procedures dated March 2021 documents (in part) . .Purpose: To administer oral medications in a safe, accurate and effective manner. Special Considerations: A. Refer to crushing guidelines (See Appendix 1: Medication Crushing Guidelines) prior to crushing any medication for assurance that it can be pulverized. B. Appendix 1: Medication crushing guidelines dated March 2021 documents (in part) . .Medications that should not be crushed or chewed: The solid dosage forms of many medications should not be crushed or chewed for a variety of reasons. When a resident's condition prohibits the administration of solid dosage forms (tablets, capsules, etc.), the nurse administering the medication should…

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 drugs and biological's used in the facility were labeled in accordance with currently accepted professional standards of practice, to include the expiration date when applicable for 2 of 2 (R50 and R84) residents' insulin observed. Open and used insulin belonging to R50 and R84 were not dated when opened. Findings include: The facility policy titled Preparation and General Guidelines dated March 2021 documents (in part) . .Policy: Vials and ampules of injectable medications are used in accordance with the manufacturer's recommendations or the provider pharmacy's directions for storage, use, and disposal. Procedures: B. Expiration dates: Opening a vial or not following storage requirements triggers a shortened expiration date that is unique for that product. The date opened and this triggered expiration date are both important to be recorded on multidose vials on the vial label or an accessory label affixed for that purpose. At a minimum, the date opened must be recorded. F. USP <797> guidelines…

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 2 allegations involving potential abuse, neglect, misappropriation, injuries of unknown origin or exploitation were reported to the State Survey Agency. On 3/16/24 an unknown Certified Nursing Assistant (CNA) informed R4 of rumors being spread in the facility. The rumors were that R4 was in a romantic relationship with Licensed Practical Nurse (LPN-D) and that R4 was buying gifts for LPN-D. These rumors caused R4 to call the police. On 3/18/24, R4 reported to the Director of Nursing (DON-B) that R4 had bought various gifts for LPN-D. The facility did not identify this as an allegation of exploitation and did not report this allegation to the State Survey Agency. Findings include: The facility policy, entitled: WI Abuse and Neglect Policy and Exploitation, dated 1/23/2017, states, in part: Definition: To prohibit and prevent abuse, neglect, exploitation of residents and misappropriation of property . Procedure: The facility staff will…

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 interviews, the facility did not ensure all allegations involving potential abuse, neglect, misappropriation, injuries of unknown origin and exploitation were thoroughly investigated for 1 (R4) of 2 allegations of abuse. R4 was told by a Certified Nursing Assistant (CNA) of rumors that R4 had a romantic relationship with and was buying gifts for Liscenced Practical Nurse (LPN)-D. R4 reported this to a staff member who did not report it to administration. After R4 heard that LPN-D was suspended because of these rumors, R4 called the police. At this time the admiistration became aware of all the rumors about R4 and LPN-D. The facilty did not investigate this as an allegation of abuse or exploitation. Findings include: The facility policy, entitled: WI Abuse and Neglect Policy and Exploitation, dated 1/23/2017, states, in part: Definition: To prohibit and prevent abuse, neglect, exploitation of residents and misappropriation of property . Procedure: The facility staff will conduct an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure that 4 ( R3, R4, R5, R2) of 4 Residents reviewed were provided medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being. * R3 is assessed to be severely cognitively impaired for daily decision making skills and has a court appointed legal guardian. R3's capacity to consent to engage in sexual relationships was not regularly evaluated and documented on R3's plan of care. On 1/28/24 an allegation was made of R3 having oral sex with R5 in her room. R3's care plan was not updated to reflect parameters of male visitation in her room after 8:30 pm. There was no psychological evaluation to establish and/or support the capacity for consent for engaging in intimate relationships. The last psych evaluation was dated 2/2/22 which documented R3's thought process was difficult to determine and R3's judgement/insight is fair. This psych evaluation did not address R3's ability to consent to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility did not ensure 1 of 1 resident's right (R8) to be treated with dignity and respect in an environment that enhances R8's quality of life. R8 is assessed to have severe cognitive impairment with daily decision-making skills and requires assistance for dressing. On 12/20/23 at approximately 2:15pm, R8 was in the common area wearing a T-shirt and sweater and just a towel covering R8's waist area. R8 had no pants or brief on and was naked from the waist down. An allegation was made that 2 Residents (R5 and an additional unknown Resident) were laughing and pointing at R8. CNA-P was notified of the situation and removed R8 from the common area. CNA-P brought R8 to R8's room. R5 followed where R5 entered through R8's closed door without permission, was yelling and pointing in a threatening manner. R8 was observed to be naked from the waist down. R5 continued to yell and scream in a violent manner and violently pushed CNA-P's shoulder into the room door. R8 was noted to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility did not ensure the right of a Resident to receive visitors at the time of their choosing for 1 (R2) of 1 Resident reviewed for visitation rights. The facility restricted R2's husband immediate access to R2 unless R2's husband was accompanied either by their daughter who lives in Minnesota or son who has his own business. Findings include: The Visitation Policy 2001 Med-Pass Inc (Revised May 2017) under Policy Statement documents, Our facility permits residents to receive visitors subject to the resident's wishes and the protection of the rights of other residents in the facility. Under Policy Interpretation and Implementation includes documentation of: 1. We recognize the resident's need to maintain contact with the community in which he or she has lived or is familiar. Therefore, the resident is permitted to have visitors as he/she wishes. 2. The facility provides 24-hour access to all individuals visiting with the consent of the resident. Some visitation may…

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 to provide a safe, clean, and homelike environment for 3 (R2, R10, & R11) of 5 Resident's reviewed for their environment. * The base of R2's tube feeding pole was splattered with dried tube feeding and there was dried feeding on the floor. This was observed on 2/19/24, 2/20/24, 2/21/24, & 2/22/24. * There is a piece of wall paper missing on the wall to the left of R10's bed measuring approximately two feet in length by 4 inches in width. The cove base is missing next to the bathroom door. * There are two wall tiles that have come off the wall and are laying on the floor on the right side in R11's bathroom. Findings include: 1. R2's physician orders with an order date of 2/14/24 includes Enteral Feeding order four times a day for TF (tube feeding) Enteral Nutrition via Bolus: Osmolite 1.2 300 ml (milliliter) at frequency: 4x (times) day. Total ml's (milliliters)/24 hours: 1200 ml . FWF (free water flush) 100 ml pre/post feeding., On 2/19/24 at 9:34 a.m. Surveyor observed there is dried tube feeding on the floor near R2'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the Facility did not promptly resolve a grievance for 1 (R1) of 1 grievance reviewed. On 1/20/24 R1's son filed a grievance that R1's echo show 8 (3rd generation) was missing. The date of resolution on the January grievance log is documented as 1/25/24. On 2/6/24 SSD (Social Service Director)-G indicated she was just informed the Facility needs a receipt for the item in order to submit for reimbursement. On 2/7/24 R1's son provided SSD-G with the order information from [Amazon] and this information was then provided to provided to Assistant Administrator-C on 2/7/24. As of 2/19/24 when Surveyor inquired about R1's son's grievance, R1's son was not provided with reimbursement for the missing echo show 8. R1's grievance was not resolved on 1/25/24. Findings include: The Grievance/Concern Process policy and procedure not dated under purpose documents To establish a process for responding to a resident or resident representative to resolve grievances a resident may have. Under…

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 interviews, the facility did not ensure that 3 of 3 allegations of abuse (R5, R3, and R4) reviewed was reported no later than 2 hours and 1 of 1 allegation of misappropriation of funds(R3) was reported no later than 24 hours to the State Survey Agency and other officials in accordance with State law through established procedures. The facility did not report results of the investigations to the State Survey Agency within 5 working days of the incident and if the alleged violation required corrective action. *On 12/20/23, it was reported to administration that R5 had a physical altercation with certified nursing assistant (CNA-P). CNA-P and CNA-I provided written statements of the altercation between R5 and CNA-P and in which CNA-P ended up calling the police. The facility determined the altercation was a result of miscommunication, however had no further information as to what the miscommunication entailed. The facility did not submit an Alleged Nursing Home Resident Mistreatment,…

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 interviews, the facility did not ensure all allegations involving potential abuse, neglect and misappropriation of Resident funds (R3) were thoroughly investigated for 3 Residents(R) (R5, R3, and R4,) of 3 Residents reviewed for all abuse, neglect, and misappropriation of Resident property investigations. The facility did not thoroughly investigate the allegations and the facility did not report the results of the investigations to the State Survey Agency within 5 working days of the incident and if the alleged violation required corrective action. * On 12/20/23, it was reported to administration that R5 had a physical altercation with certified nursing assistant (CNA-P). The facility did not complete a thorough investigation as evidenced by obtaining only 4 staff statements. The facility concluded this incident between R5 and CNA- P was as a result of miscommunication however the facility's investigation never identified what the miscommunication was about. The facility did 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 observation, interview, and record review, the Facility did not ensure that Residents at risk for pressure injuries received necessary treatment and services to prevent the development of pressure injuries for 1 (R2) of 2 Residents reviewed for pressure injuries. * On 2/20/24 and 2/21/24, R2 was observed in bed without the pressure relieving boot on R2's left foot per plan of care. Findings include: The Prevention of Pressure Injuries policy and procedure Revised January 2023 under Preparation documents Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. R2's diagnoses includes multiple sclerosis, peripheral vascular disease, right below knee amputation, and hypertension. The at risk for further impaired skin integrity care plan initiated 8/23/23 & revised 2/15/24 includes an intervention initiated 8/23/23 & revised on 2/15/24 of Turn and reposition to maintain skin integrity Q2 hrs (every two hours).…

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 for 3 (R2, R12, & R11) of 4 Residents receiving oxygen care. * R2 was readmitted to the facility on [DATE] and was receiving oxygen via nasal cannula. There was no physician's order for R2's oxygen until 2/20/24. * The filter on R12's oxygen concentrator had dust and white particles throughout. * R11's oxygen concentrator had a coating of dust on the back vent portion, there was dust on the front of the concentrator throughout and under the humidifier bottle there was a large accumulation of dust & dirt. Findings include: The Oxygen Administration Policy & Procedure 2001 Med Pass Inc, (Revised October 2010) under Purpose documents The purpose of this procedure is to provide guidelines for safe oxygen administration. Under Preparation documents 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen…

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 upon interview and record review, the facility did not ensure the facility wide assessment developed by the facility included all relevant details to ensure the facility provided care and services to residents to meet their individual needs within the facility's identified resources. This has the potential to affect all 99 residents residing in the facility. Findings include: On 12/5/23 at 4:15 pm, Surveyors met with the facility to discuss possible concerns regarding the facility Quality Assurance and Assessment (QAPI) process (Cross-reference F867). During this discussion Nursing Home Administrator (NHA)-A and [NAME] President of Operations (VPO)-AA shared they believe the facility has a vigorous and exceptional QAPI program and the facility tends to take residents that other facilities will not admit, and their resident population has a higher acuity than other facilities. Surveyors discussed the facility assessment at this time and requested an up-to-date copy of the facility assessment. VPO-AA indicated the facility had just updated this document and provided a copy to…

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

Based on interview and record review, the facility did not ensure that the mandatory staffing data that had been submitted from 4/1/23-6/30/23 was complete and accurate. This has the ability to affect all of the 99 residents residing in the facility at the time of the survey. Findings include: Surveyor reviewed staffing data from the third quarter (April-June) of 2023 related to the facility triggering for low weekend staffing on the Payroll Based Journal (PB&J). Surveyor noted one day in particular, Sunday, May 7th, 2023, where the facility had significantly lower staffing than required. According to time clock punches for that day, the facility had five Certified Nursing Assistants (CNAs) on dayshift, four CNAs on PM shift and 3 CNAs (plus one medication tech) on night shift. On 11/30/23 at 1:19 PM, Surveyor interviewed Staff Scheduler (SS)-H. SS-H informed Surveyor she was not the scheduler in May. Per SS-H the bare minimum CNAs needed for safety are 10 each on days and PMS and 8 on night shift. Surveyor reviewed the facility's grievance log and did not note a marked increase in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility did not ensure residents the right to a safe, clean, comfortable and homelike environment. This deficient practice has the potential to affect all 54 residents residing on the second floor. R63's room had multiple black half circle marks, missing paint and exposed dry wall next to bed. The South 2 hallway has two areas on floor tiles with large cracks/gaps. The second-floor dining room was observed to have a loveseat that was buckled down the middle and a metal screen frame on a window was bent. The corner of R2's nightstand is broken. Findings include: The facility policy, entitled, Quality of Life - Homelike Environment, dated 5/2017, states: Policy Statement: Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. #2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike…

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 9.) R15 was admitted to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary disease, vascular dementia, hemiplegia, sequelae following unspecified cerebrovascular disease, depressive disorder, heart failure, peripheral vascular disease and paralytic syndrome. R15's Quarterly Minimum Data Set (MDS) dated [DATE] indicates R15 is moderately cognitively impaired. R15 understands and is understood by others and is able to make their needs known. R15 is totally dependent on staff for transfers with a mechanical lift and requires extensive staff assistance with bed mobility, toileting and dressing. Review of R15's Care Plan documents R15 uses anti-anxiety medications (Lorazepam) due to anxiety, date initiated 7/8/22 and revised on 7/11/22. Switched from Buspirone to Lorazepam, date initiated 7/11/22. Interventions include, administer anti-anxiety medications as ordered by physician, educate (R15)/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of Lorazepam…

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 each resident is treated with dignity and ensured an environment that promotes enhancement of their quality of life. This occurred for 1 (R15) of 20 residents reviewed for dignity. R15 requested staff assistance to be changed and was told they would be changed later when it was time for their shower. R15 waited over two hours to be changed out of a urine-soaked brief. Just prior to receiving incontinence care, staff answered their personal cell phone while in the resident room and held a conversation for several minutes. R15 requested to have the bed linen changed as they were soiled and wet from laying in a urine-soaked brief for a prolonged period of time. Staff was observed telling R15 the bed linen was fine and proceeded to make the bed. Findings include: The facility policy, entitled Dignity, revised date February 2021, states: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being,…

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 interviews, the facility did not ensure residents had an individualized comprehensive plan of care. This was observed with 3 (R101, R95 and R55) of 20 resident comprehensive care plan reviews. -R101 was admitted to the facility with bowel and bladder incontinence and there was no comprehensive plan of care with individualized interventions to address bowel and bladder incontinence. -R95 was admitted to the facility with bowel and bladder incontinence and there was no comprehensive plan of care with individualized interventions to address bowel and bladder incontinence. - R55 was admitted with oxygen and there was no comprehensive plan of care with individualized interventions to address oxygen management. Findings include: Surveyor reviewed the facility's policy and procedures on Care Plans, Comprehensive Person-Centered revised March 2022. The Policy indicates the following: 2. The comprehensive, person-centered care plan is developed within 7 days of the completion of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure 1 (R34) of 5 residents reviewed for discharge received a thorough discharge summary in order to communicate necessary information to the resident, continuing care provider, and other authorized persons at the time of the anticipated discharge. *R34 discharged from the facility on 10/02/23. R34 had lab work drawn on 10/02/23 prior to discharge. R34's discharge summary did not include the results of the lab work and there was no documentation R34 or R34's representatives were aware of the lab results. Findings include: R34 was admitted to the facility on [DATE] and discharged home on [DATE]. R34 had diagnoses including type two Diabetes Mellitus with Diabetic Chronic Kidney Disease and Urinary Tract Infection. R34's quarterly Minimum Data Set (MDS) assessment, dated 09/28/23, documented R34 had a Brief Interview for Mental Status of 12 indicating R34 had mild cognitive impairments. Surveyor noted the following active physician's orders in R34'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 medication error rate was below 5%, with 4 errors of 29 opportunities, affecting 1 supplemental resident (R99) of 4 residents observed receiving medications. The facility medication error rate was 13.79%. *R99's placement of g-tube was not confirmed before medication administration, medications were combined and crushed together, and the doctor's order to flush with 30mL between each individual medication was not followed. *R99 did not have her Lidocaine patches applied per order and the patches were signed out on Medication Administration Record (MAR). *R99 did not receive her Pantoprazole Sodium Powder which was signed out on the MAR. *R99 was given Carvedilol 25mg after Surveyor observation completed and should have been held per doctor's order to hold for heart rate under 60. Findings include: The facility policy entitled Medication Administration dated 6/21/2017, states .8. Verify tube placement according to facility policy. 9. Flush with at least 30ml water prior to medication administration.…

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.