Avina of Weyauwega

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and Ombudsman interview and record review, the facility did not ensure 2 residents (R) (R11 and R18) of 5 sampled residents received a written transfer notice that included the date of the transfer, the reason for the transfer, the location of the transfer, and appeal rights. In addition, the facility did not notify Ombudsman (OMB)-PP of hospital transfers and an involuntary 30-day discharge notice for 5 residents (R11, R18, R19, R24, and R49) of 5 sampled residents. R11 was transferred to the hospital on [DATE] and 1/3/25. R11 was not provided with a written transfer notice for either transfer. In addition, OMB-PP was not notified of the transfers. R18 was transferred to the hospital on 2/17/25. R18 was not provided with a written transfer notice. In addition, OMB-PP was not notified of the transfer. R19 was transferred to the hospital on 1/23/25. OMB-PP was not notified of the transfer. In addition, R19 was provided an involuntary 30-day discharge notice on 3/18/25. A copy of the discharge…

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

Based on observation, staff and resident interview, and record review, the facility did not ensure the provision of sufficient nursing staff to meet residents' needs. This practice had the potential to affect more than 4 of the 49 residents residing in the facility. R24, R29, R44, R3, and R53 expressed concerns with staffing and call light response times. In addition, R24's call light was activated for 1 hour and 19 minutes on 4/9/25. Two other residents' call lights were activated for 35 minutes and 55 minutes. On 4/8/25, Certified Nursing Assistant (CNA)-DD was the only staff present in the dining room. R23 and R402 require feeding assistance and had to wait until all other residents were served. R41 asked for water twice but was not provided water. The facility did not ensure sufficient staffing levels were maintained to meet residents' needs in accordance with the Facility Assessment and resident acuity. Findings include: 1. On 4/7/25 at 10:30 AM, Surveyor interviewed R24 who indicated R24 had waited up to 3 hours for staff to respond to R24's call light. R24 indicated staff are…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not ensure drugs and biologicals were stored in accordance with the facility's policy in 1 of 1 medication storage room and 2 of 3 medication carts. In addition, unsecured narcotic medication was stored at the nursing station. This practice had the potential to affect more than 4 of the 49 residents residing in the facility. Medication carts on the B wing and near the nurses' station were left unlocked and unattended. In addition, seven medication cards, including schedule two narcotic medications, were observed in an unlocked desk drawer at the nurses' station. The E wing medication cart contained improperly labeled, undated, and/or expired medications. The D wing medication storage room contained expired medication and medical supplies and unlabeled medication. Findings include: The facility's Equipment and Supplies for Administering Medications policy, revised 1/2018, indicates: .A. The following equipment and supplies are acquired and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident representative interview and record review, the facility did not ensure an Advance Directive was followed for 1 resident (R) (R37) of 20 sampled residents. R37 had an activated Power of Attorney for Healthcare (POAHC) when R37 returned from the hospital and signed multiple consent forms on [DATE]. The facility did not request and obtain a capacity evaluation when R37's cognition improved after recovering from sepsis. In addition, R37's POAHC was not notified until [DATE] that R37 was deemed to b incapacitated on [DATE]. Findings include: From [DATE] to [DATE], Surveyor reviewed R37's medical record. R37 was admitted to the facility on [DATE] and had diagnoses including depression, malnutrition, type two diabetes, and obstructive uropathy. R37's most recent Minimum Data Set (MDS) assessment, dated [DATE], indicated R37 was not cognitively impaired. R37 was hospitalized on [DATE] for urinary sepsis and returned to the facility on [DATE]. R37's care plan, with a target date of [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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure Preadmission Screening and Resident Review (PASRR) requirements were met for 2 residents (R) (R9 and R19) of 6 sampled residents. R9's PASRR Level I Screen indicated R9 had a mental illness (MI) and a 30-day hospital discharge exemption. The facility did not obtain form F-20822 for R9's 30-day exemption and did not submit for a PASRR Level II Screen in a timely manner. R19's PASRR Level I Screen indicated R19 had an MI and a 30-day hospital discharge exemption. The facility did not obtain form F-20822 for R19's 30-day exemption and R19's medical record did not include a PASRR Level II Screen. Findings include: According to the State of Wisconsin Department of Health Services, PASRR is a federal requirement that all applicants to Medicaid-certified nursing facilities be assessed to determine whether they might have an intellectual disability (ID)/developmental disability (DD) and/or MI. This is called a Level I Screen. The purpose of a Level…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review, the facility did not ensure the appropriate care and treatment was provided for 2 residents (R) (R53 and R44) of 5 residents reviewed for wound care. R53 was admitted to the facility with multiple wounds. The facility did not complete timely skin assessments or wound care for R53. The facility did not ensure R44 had a treatment order for an open area on R44's left lower shin and received timely wound care. Findings include: The facility's Wound Management-Clean Dressing Change policy, dated 4/11/11, indicates: It is the facility's policy to ensure dressing changes in accordance with state and federal regulations and national guidelines .1) Verify and review the physician's order for the procedure .26) Document the completion of the dressing change on the treatment record. 1. From 4/7/25 to 4/10/25, Surveyor reviewed R53's medical record. R53 was admitted to the facility on [DATE] and had diagnoses including sepsis and type 2 diabetes. R53'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 staff interview and record review, the facility did not ensure physician visits were completed timely for 1 resident (R) (R36) of 5 sampled residents. Regulation allows for a physician to delegate alternating visits to a physician extender, such as a Nurse Practitioner (NP). R36 was not seen by a physician in February 2025 based on an alternating schedule. Findings include: The facility's Physician Services policy, dated 1/1/21, indicates: It is the policy of the facility to provide physician services in accordance with state and federal regulations .12. Residents must be seen by a physician at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter. 13. A physician visit is considered timely if it occurs not later than 10 days after the date the visit was required. 14. All required physician visits will be made by the physician personally. 15. At the option of the physician, required visits in skilled nursing facilities (SNFs) after the initial visit…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not provide pharmaceutical services to meet the needs of 3 residents (R) (R300, R24 and R29) of 5 sampled residents. On 4/7/25, Surveyor observed a bottle of 60 milligram (mg) melatonin gummies on R300's bedside table. R300 did not have a physician order to keep medication at the bedside and did not have a self-administration of medication assessment that indicated R300 could self-administer medication. In addition, R300 did not receive bedtime (HS) medications on 4/3/25. On 4/7/25, Surveyor observed a bottle of bovine collagen pills, a bottle of liquid Imodium, and two albuterol inhalers on a table in R24's room. R24 did not have a physician order to keep Imodium at the bedside or a self-administration of medication assessment that indicated R24 could self-administer Imodium. On 4/7/25, Surveyor observed a plastic bag on R29's bed that contained triamcinolone cream and lidocaine ointment. Surveyor also observed a bottle of Elderberry…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure sleep assessments or sleep monitoring was completed for 1 resident (R) (R29) of 5 sampled residents. R29 had an order for trazodone 25 milligrams (mg) at bedtime to promote sleep. The facility did not ensure sleep assessments or sleep monitoring logs were completed for R29 per the facility's policy. Findings include: The facility's Psychotropic Drug Use policy, dated 1/11/21, indicates: .Based on a comprehensive assessment of a resident, the facility will ensure residents are not given psychotropic medications unless psychotropic drug therapy is necessary to treat specific conditions and residents who use psychotropic drugs receive gradual dose reductions and behavioral interventions unless clinically contraindicated .E. Residents who use antipsychotic medications will be reviewed a minimum of quarterly . From 4/7/25 to 4/10/25, Surveyor reviewed R29's medical record. R29 was admitted to the facility on [DATE] and had diagnoses including…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure 2 residents (R) (R27 and R36) of 5 sampled residents were provided influenza or pneumococcal vaccines as indicated. R27's Power of Attorney for Healthcare (POAHC) gave consent for R27 to receive the influenza vaccine. The facility did not administer the vaccine. R36 was eligible for and signed consent to receive a pneumococcal vaccine. The facility did not administer the vaccine. Findings Include: The facility's Influenza, COVID, and Pneumococcal Immunizations for Residents policy, dated 2/4/21, indicates: The facility's policy ensures that the resident receives influenza and pneumococcal immunizations per state and federal regulations and national guidelines .5. Influenza immunization will be offered in accordance with the Centers for Disease Control and Prevention (CDC) .5. Pneumococcal immunization will be offered in accordance with the CDC. 1. On 4/7/25, Surveyor reviewed R27's medical record. R27 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure 1 resident (R) (R9) of 5 sampled residents was offered a COVID-19 vaccine as indicated. R9's Power of Attorney for Healthcare (POAHC) gave consent for R9 to receive a COVID-19 vaccine. The facility did not administer the vaccine. Findings include: The facility's Influenza, COVID and Pneumococcal Immunizations for Residents policy, dated 2/4/21, indicates: The facility's policy ensures the resident receives influenza and pneumococcal immunizations per state and federal regulations and national guidelines .5. COVID immunization will be offered in accordance with the Centers for Disease Control and Prevention (CDC) . On 4/7/25, Surveyor reviewed R9's medical record. R9 was admitted to the facility on [DATE] and had a diagnosis of chronic obstructive pulmonary disease (COPD). R9's Minimum Data Set (MDS) assessment, dated 2/18/25, stated R9's Brief Interview for Mental Status (BIMS) score was 10 out of 15 which indicated R9 had moderate cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interview and record review, the facility did not provide the necessary care and services to promote healing and/or prevent pressure injuries from developing for 1 resident (R) (R53) of 5 sampled residents. R53 was admitted to the facility with a pressure injury on the right buttock. The facility did not ensure thorough, accurate, and timely skin assessments were completed and did not ensure a treatment was provided. Findings include: The facility's Wound Management-Clean Dressing Change policy, dated 4/11/11, indicates: It is the facility's policy to ensure dressing changes in accordance with state and federal regulations and national guidelines .1) Verify and review the physician's order for the procedure .26) Document the completion of the dressing change on the treatment record. From 4/7/25 to 4/10/25, Surveyor reviewed R53 medical record. R53 was admitted to the facility on [DATE] and had diagnoses including sepsis and type 2 diabetes. R53's Minimum Data Set (MDS) 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 staff interview and record review, the facility did not provide timely access to a medical record for 1 resident (R) (R2) of 1 sampled resident. R2 requested a copy of R2's medical record in writing on 1/3/25. R2's medical record was mailed on 1/28/25 (25 days later) which was not in accordance with the facility's policy that indicated the facility would provide a copy within 7 days. Findings include: The facility's Medical Records policy, dated 1/11/21, indicates: It is the policy of the facility to maintain medical records in accordance with state and federal regulations .8. Unless expressly prohibited by a legally competent resident, the facility will furnish to the spouse, guardian, surrogate, proxy, or attorney of a current resident, within 7 working days after receipt of a written request, or a former resident, within 10 working days after receipt of a written request, a copy of that resident's records which are in the possession of the facility. On 2/18/25, Surveyor reviewed R2's medical record.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 2 residents (R) (R5 and R6) of 3 sampled residents. R5 had a suprapubic catheter and was on enhanced barrier precautions (EBP). On 2/18/25, Certified Nursing Assistant (CNA)-D did not wear a gown during personal hygiene and catheter care for R5. On 2/18/25, CNA-E did not complete hand hygiene or change gloves appropriately during an observation of care for R6. Findings include: The facility's Bathing Policy, revised 12/12/24, indicates: .9. Wash back, buttocks and genitalia. 10. Change water during bath if necessary. 11. Remove gloves, complete hand hygiene, and apply new gloves . The facility's Infection Control-Hand Hygiene policy, revised 7/7/23, indicates: .Alcohol-based hand sanitizer is appropriate for decontaminating hands .e. When moving from a contaminated body site to a clean body site during…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review, the facility did not ensure they had sufficient nursing staff to provide care and services to meet the needs of 6 residents (R) (R1, R13, R11, R10, R2, and R12) of 13 sampled residents. R1, R13, R11, R10, and R2 reported cares were not completed timely due to staffing shortages. Multiple staff stated resident cares (including for R12) were not provided timely due to staffing shortages. Findings include: The Facility Assessment, dated 8/8/24, states under subsection Staff Type that the facility provides care and services based upon the needs of the resident population .Staffing Plan indicates the designated position and total number needed on average or range: Licensed nursing providing direct care is 5-9. Nurse aides are listed as 8-15 with other nursing personnel listed as 2-3 (Director of Nursing (DON), Unit manager, Minimum Data Set (MDS) Coordinator). Individual Staff Assignment: Staffing patterns are reviewed to evaluate the needs 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 staff interview and record review, the facility did not ensure a Neurologist was notified when medication was not administered for 1 resident (R) (R7) of 4 sampled residents. R7 had an order for clozapine (an antipsychotic medication used to treat psychosis) twice daily. R7 did not receive clozapine from 11/23/24 through 11/26/24. R7's Neurologist was not informed that clozapine was not administered. R7 was hospitalized on [DATE] for psychosis symptoms, including attempting to ingest lotion. Findings include: The facility's undated Notification of Change policy indicates the facility will consult a resident's physician within 24 to 48 hours based upon nursing assessment when there is a significant alteration to a resident's treatment. From 1/13/25 to 1/14/25, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including Parkinson's disease, anxiety, hallucinations, and malnutrition. R7's most recent Minimum Data Set (MDS) assessment, dated 12/22/24, had a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not provide care and treatment to ensure the highest practicable well being for 3 residents (R) (R7, R3, and R5) of 13 sampled residents. R7 was admitted to the facility with a deep brain stimulator (DBS) for Parkinson's disease. Staff did not appropriately apply or charge the DBS as ordered. R3's care plan indicated R3 had an intimate relationship with R2. When R3 had a change of condition, including a decreased level of cognition, staff did not complete an updated assessment. R5 had a diagnosis of fungal candidiasis (a type of yeast infection). Oral care was not provided per R5's care plan. Findings include: The facility's Comprehensive Care Plan policy, revised 5/1/21, indicates it is the policy of the facility to promote seamless interdisciplinary care for residents based on assessment, planning, treatment, service, and intervention. It is used to plan for and manage resident care as evidenced by documentation from admission through…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for 1 resident (R) (R6) of 13 sampled residents. On 1/3/25, R6 fell when staff transferred R6 incorrectly and did not follow R6's care plan. In addition, the facility did not provide staff education in a timely manner. Batteries used for motorized wheelchairs were charged in a vacant resident room which did not have appropriate ventilation. The room was used for storage and did not have a door closure in place. Findings include: The facility's Fall Policy, dated 7/17/24, indicates all residents will receive adequate supervision, assistance, and assistive devices to prevent falls. Each resident will be evaluated for safety risks, including falls and accidents. Care plans will be created and implemented based on individual risk factors to aid in preventing falls. All falls are to be investigated and monitored . 1. On 1/13/25, Surveyor reviewed R6's medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interview and record review, the facility did not ensure accurate administration of medication for 2 residents (R) (R4 and R10) of 13 sampled residents. R4 was administered multiple scheduled medications late in December 2024 and January 2025. R10's scheduled pain medication was not administered on the 1/13/25 night (NOC) shift. In addition, R10's medications were left with R10 to take without staff supervision. R10 did not have a self-administration of medication assessment that indicated R10 could safely and accurately self-administer medication. Findings include: The facility's Administration Procedures for All Medications policy, revised January 2018, indicates: To administer medications in a safe and effective manner .C. Review 5 rights (3) times .a) Check Medication Administration Record (MAR)/Treatment Administration Record (TAR) for order .c) If unfamiliar with the medication, consult a drug reference .or pharmacist for more information .P. Notification of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 1 resident (R) (R3) of 6 sampled residents. On 8/11/24, Certified Nursing Assistant (CNA)-C reported an allegation of verbal abuse involving CNA-D and R3. The facility did not report the allegation of abuse to local law enforcement. Findings include: The facility's undated Abuse policy indicates: External Reporting: Informing Local Law Enforcement: The facility shall also contact local law enforcement authorities .in the following situations: When there is a reasonable suspicion that a crime has been committed in the facility by a person other than a resident. If there is reasonable suspicion that a crime has been committed that is not listed above and does not involve serious bodily injury, then report to local law enforcement as soon as possible but within 24 hours of when the suspicion was formed. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure competent staff completed nail care for 1 resident (R) (R3) of 9 sampled residents. In addition, the facility did not ensure competent staff completed vital signs which had the potential to affect multiple residents residing in the facility. Hospitality Aide (HA)-E was asked to complete nail care for R3 under the direction of Registered Nurse (RN)-C. HA-E and HA-L were asked to complete vital signs for multiple residents by RN-C. HA-E and HA-L were not enrolled in a Certified Nursing Assistant (CNA) course. Findings include: The Department of Health Services (DHS) memo P-01559 titled Role of Non-Certified Staff in Provision of Care, dated November 2021, states in 2000, the Department approved the following list of tasks that an individual can perform without being listed on the Wisconsin Nurse Aide Registry as a nurse aide to assist long-term care facilities with the implementation of helpersor hospitality aides and to ensure the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure protective placement was obtained for 2 Residents (R) (R21 and R35) of 4 sampled residents. R21 had a legal guardian at the time of admission on [DATE]. The facility did not obtain court-ordered protective placement for R21. R35 had a legal guardian at the time of admission on [DATE]. The facility did not obtain court-ordered protective placement for R35. Findings include: State Statute Chapter 55.03 (4) indicates: The law requires a court ordered protective placement for any resident admitted to a nursing home who has a legal guardian and whose nursing home stay exceeds 90 days. Protective placement is reviewed annually (State Statute Chapter 55.18) to determine if placement continues to be least restrictive and in the best interest of the individual. 1. On 2/12/24, Surveyor reviewed R21's medical record. R21 was admitted to the facility on [DATE]. R21 had a court-ordered guardian and paperwork from County (CTY)-L, dated 6/15/17. R21's…

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

Based on staff interview and record review, the facility did not ensure written notification of Medicare Non-Coverage appeal rights were provided to 2 Residents (R) (R20 and R202) of 3 residents. In addition, the facility did not ensure written notification of financial liability was provided for 1 (R20) of 3 residents who remained in the facility when their Medicare Part A benefits ended. The facility did not provide an Advanced Beneficiary Notice (ABN) or Notice of Medicare Non-Coverage (NOMNC) form to R20 when R20's Medicare Part A benefits ended on 10/27/23 and R20 remained in the facility. The facility did not provide an ABN to R202 when R202's Medicare Part A benefits ended on 12/8/23 and R202 discharged home. Findings include: 1. On 2/14/24, Surveyor reviewed R20's Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review Form. The facility indicated an ABN and NOMNC form were not provided to R20 because R20 had exhausted one hundred Medicare benefit days. R20's stay at the facility was covered by Managed Care until 12/14/23 when R20 switched to private pay.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure timely transmittal of Resident Assessment Information (RAI)/Minimum Data Set (MDS) assessments for 2 Residents (R) (R28 and R41) of 72 sampled residents. R28's Comprehensive Assessment was completed 17 days late. In addition, R28's Death in Facility Tracking Record was completed 24 days late and transmitted 10 days late. R41's Quarterly Assessment was completed 32 days late. In addition, R41's Discharge Assessment was completed 4 days late. Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.18.1, dated October 2023, indicates: All Medicare and/or Medicaid-certified nursing homes must complete and transmit required Minimum Data Set (MDS) records to the Centers for Medicare and Medicaid Services' (CMS') Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system. Required MDS records include: Admission, Quarterly, Annual, Discharge Assessments,…

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

Based on observation, staff interview, and record review, the facility did not ensure 1 Resident (R) (R21) of 16 sampled residents received the necessary care and services to maintain personal hygiene. R21 was dependent on staff for oral care. During an observation on 2/13/24, staff did not offer or provide oral care. Findings include: On 2/13/24, Surveyor reviewed R21's medical record. R21 had diagnoses including spastic quadriplegia after anoxic brain injury, severe protein calorie malnutrition, and chronic pressure injury stage 4 coccygeal region. R21's Minimum Data Set (MDS) assessment, dated 12/13/23, indicated R21 was rarely or never understood and required staff assistance for activities of daily living (ADLs). On 2/13/24 at 9:37 AM, Surveyor observed Certified Nursing Assistant (CNA)-E and CNA-F provide morning care for R21. During the observation, Surveyor noted CNA-E and CNA-F did not provide oral care. Surveyor was unable to observe R21's teeth because R21's mouth was firmly closed. On 2/14/24 at 11:55 AM, CNA-E stated oral hygiene for R21 is not usually provided with a…

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

Based on observation, staff interview, and record review, the facility did not ensure a resident who was fed via enteral feeding (a way of sending nutrition right to the stomach or small intestine via tube) received care and services to avoid complications for 1 Resident (R) (R21) of 1 sampled resident. On 2/13/24, the head of R21's bed was lowered to less than 30 degrees while R21's tube feeding was being administered. Findings include: On 2/13/24, Surveyor reviewed R21's medical record. R21's had diagnoses including spastic quadriplegia after anoxic brain injury, severe protein calorie malnutrition, chronic pressure injury stage 4 coccygeal region, and COVID-19. R21's Minimum Data Set (MDS) assessment, dated 12/13/23, indicated R21 was rarely or never understood and required staff assistance for activities of daily living (ADLs). Surveyor reviewed R21's alteration in ability to consume food and/or fluids care plan which indicated R21 required enteral feeding due to dysphagia and inadequate oral nutrient intakes. The care plan contained the following intervention: Hold feeding when…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review, the facility did not provide appropriate care and services for 2 Residents (R) (R31 and R153) of 2 residents reviewed for respiratory care. R31's respiratory equipment was not sanitized and stored in a manner to maintain infection control standards. R153's respiratory equipment was not sanitized and stored in a manner to maintain infection control standards. In addition, R153 did not have a physician order for tracheostomy suctioning. Findings include: The facility's Oxygen & Respiratory Equipment-Changing/Cleaning policy, dated 5/19/22, indicated the purpose of the policy was to minimize the risk of infection transmission. 1. On 2/13/24, Surveyor reviewed R31's medical record. R31 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure and had a tracheostomy. R31 was non-verbal and was dependent on staff for activities of daily living (ADLs). On 2/13/24, Surveyor observed R31 in R31's room. R31 had 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 staff interview and record review, the facility did not ensure vaccinations were reviewed, offered, or administered for 3 Residents (R) (R30, R23 and R153) of 5 residents reviewed for vaccines. The facility did not review R30's vaccination history or offer R30 the PCV20 (Prevnar 20®) vaccine. The facility did not review R23's vaccination history or offer R23 the PPSV23 (Pneumovax23®) or PCV20 vaccine. The facility did not review R153's vaccination history or offer R153 the PCV20 vaccine. Findings include: Abbreviations (www.cdc.gov): PCV13: 13-valent pneumococcal conjugate vaccine (Prevnar13®) PCV15: 15-valent pneumococcal conjugate vaccine (Vaxneuvance®) PCV20: 20-valent pneumococcal conjugate vaccine (Prevnar 20®) PPSV23: 23-valent pneumococcal polysaccharide vaccine (Pneumovax23®) The most recent Centers for Disease Control and Prevention (CDC) recommendations for pneumococcal vaccinations indicate: For adults 65 years or older who have only received PPSV23, the CDC recommends: Give 1 dose of PCV15…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not develop and/or implement an individualized comprehensive care plan for 2 Residents (R) (R21 and R43) of 16 sampled residents. R21 needed assistance with activities of daily living (ADLs). The facility did not develop a comprehensive care plan that included interventions related to grooming and oral hygiene. In addition, R21's self-care performance deficit care plan contained an intervention that indicated R21 preferred to wear a gown and R21's potential for pressure ulcer care plan contained an intervention for a foot cradle to bed. The interventions were not consistently implemented. R43 incurred falls on 1/26/24 and 1/30/24. Following R43's fall on 1/26/24, interventions were to place R43's bed against the wall and use a Broda chair. Following R43's fall on 1/30/24, an intervention was to lower the seat in R43's Broda chair. R43's care plan was not updated to reflect the interventions. Findings include: The facility's Comprehensive…

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 resident and staff interview, and record review, the facility did not ensure the necessary care and services were provided to prevent pressure injuries from developing or worsening and/or promote healing for 1 Resident (R) (R2) of 3 sampled residents. R2 was admitted to the facility on [DATE] with a pressure injury to right ischium, full thickness stage four. The facility did not follow wound consultation recommendations for an antibiotic on 9/20/23 and 9/27/23. R2 was hospitalized on [DATE] due to a change of condition with diagnoses including osteomyelitis and sepsis. Findings include: The facility's Physician Orders-Entering and Processing policy, revised 1/31/18, contained the following information: Purpose: To provide guidelines when receiving, entering, and confirming physician or prescriber's orders. Guidelines: Notify the resident's physician (if not the prescribing physician), for verification if applicable. On 11/1/23, Surveyor reviewed R2's medical record. R2 was admitted to the facility 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility did not ensure staff who cared for 2 Residents (R) (R40 and R346) (and potentially other residents) of 15 sampled residents had the competencies and skills to provide nursing-related services to assure resident safety. This had the potential to affect multiple residents in the facility who required assistance, including transfers, toileting, personal care, wound care and ostomy care. Former Social Services (SS)-C (who did not have a Nurse Aide Certification or Nursing License) and Civilian (CIV)-D (who was SS-C's spouse and was not employed by the facility) provided care to R40 (and potentially other residents) on [DATE]. In addition, SS-C provided care to residents on [DATE], including wound care for R346. Findings include: R40 admitted to the facility on [DATE] and had diagnoses to include abnormalities of gait and mobility, weakness, anxiety disorder, breakdown of skin, low back pain, morbid obesity and repeated falls. R40's Minimum Data Set (MDS)…

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

Based on observation, record review and staff interview, the facility did not ensure safe food handling practices were implemented. This had the potential to affect 51 residents residing in the facility. Dish machine water temperature gauges indicated water did not rise to required temperatures for rinse and/or wash cycles and surface temperature monitoring of dishes used to serve residents' food was not routinely conducted during dishwashing. Kitchen walls, ceilings, shelving, cooking surfaces, vents, air exchange units and a microwave were dirty with debris, food splatters, dust and/or a mildew-like substance. In addition, ceiling vents contained rusty areas. Ceiling vents and areas around the walk-in freezer also contained peeling paint. Drinking glasses and bowls were stored upright which made them vulnerable to contamination from dust and other substances noted on the kitchen walls, ceilings and vents. Drinking glasses were stacked while still wet. Drinking glasses were noted to have a lime-like build-up on the inside. Food items were not dated when opened. A can that contained…

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

Based on record review and staff interview, the facility did not establish and maintain an infection surveillance program designed to help prevent the development and transmission of disease and infection which had the potential to affect all 51 Residents in the facility. The facility did not consistently maintain Infection Surveillance/Tracking Logs designed to assist with the detection of disease transmission patterns. Findings include: On 1/10/23 at 3:48 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated Human Resources Director (HRD)-F was responsible for tracking employee illnesses. On 1/10/23 at 4:04 PM, Surveyor interviewed HRD-F who indicated HRD-F kept employee call in slips. When asked how employee illnesses were tracked for infection surveillance, HRD-F stated, To be quite honest, we don't have a tracking system (for employee illnesses). HRD-F stated employees were directed to speak to nursing to discuss symptoms and their ability to return to work. On 1/11/23, Surveyor reviewed Employee Absence Forms for the previous three months. Surveyor randomly choose…

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

Based on staff interview, the facility did not ensure a staff person designated as the Infection Preventionist completed specialized training in infection prevention and control which had the potential to affect all 51 residents in the facility. Director of Nursing (DON)-B was the facility's designated Infection Preventionist (IP) in addition to performing full-time DON duties. DON-B did not complete specialized training for infection prevention and control before assuming the role of IP. Findings include: On 1/10/23 at 9:11 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated DON-B was the facility's designated IP. On 1/11/23 at 3:42 PM, Surveyor interviewed NHA-A who verified DON-B did not complete certification for Infection Surveillance and Prevention. NHA-A stated, We have instructed (DON-B) to complete it several times. On 1/12/23 at 10:51 AM, Surveyor interviewed DON-B who stated DON-B was working on the Center for Disease Control and Prevention (CDC) Infection Prevention Training for Long Term Care Facilities, a course made up of 23 modules 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 record review and staff interview, the facility did not ensure COVID-19 testing was completed in accordance with the Centers for Disease Control and Prevention's (CDC's) recommendations for staff. This had the potential to affect all 51 residents in the facility. The facility did not consistently implement their process to track staff compliance with COVID-19 testing. Findings include: The facility's Mandatory COVID-19 Vaccine Policy and Procedure Guidance, dated 12/4/21 contained the following information: . Accommodations for Exempted Staff. A. Staff members who are exempt from the COVID-19 vaccine, are still required to follow all other Facility COVID-19 related policies. B. Staff members who are exempt and therefore not vaccinated are required to follow additional precautions to mitigate the transmission of COVID-19. These precautions include, but are not limited to: a. Bi-Weekly COVID-19 testing . The facility's COVID-19 Resident, Staff and Visitation Guidelines policy, with a revision date of 9/29/22, contained the following information: . Routine testing 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 record review and staff interview, the facility did not ensure all allegations of abuse and neglect were reported to Nursing Home Administrator (NHA)-A and the State Agency (SA) for 4 Residents (R) (R40, R346, R38 and R45) of 15 sampled residents. Former Social Services (SS)-C and Civilian (CIV)-D (SS-C's spouse who was not an employee of the facility) provided care to R40 despite the fact neither SS-C or CIV-D held a Nursing Assistant Certification or a Nursing License. The facility did not report the allegation to the SA. In addition, it was alleged SS-C provided care to R346's wound vac (a machine which assists in healing complex wounds) and assisted an unknown resident with ostomy (a surgical opening in the abdomen which alters the way stool is passed) care. NHA-A was not made aware of the allegation of colostomy care. An investigation form indicated R38 was inappropriately touched by R45. The facility did not report the allegation of abuse to the SA. Findings include: The facility's Abuse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility did not ensure all allegations of abuse and neglect were thoroughly investigated for 4 Residents (R) (R40, R346, R38 and R45) of 15 sampled residents. Former Social Services (SS)-C and Civilian (CIV)-D (SS-C's spouse who was not an employee of the facility) provided care to R40. Neither SS-C or CIV-D held a Nursing Assistant Certification or a Nursing License. In addition, it was alleged SS-C provided care to R346's wound vac (a machine which assists in healing complex wounds) and assisted an unknown resident with ostomy (a surgical opening in the abdomen which alters the way stool is passed) care. The facility did not conduct a thorough investigation. The facility did not thoroughly investigate an allegation that R38 was inappropriately touched by R45. Findings include: The facility's Abuse Prevention Program policy, revised on 4/28/21, reads as follows: Investigation Procedures: Regardless of the specific nature of the allegation (physical, sexual,…

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 resident and staff interview, and record review, the facility did not notify a medical provider when 1 Resident (R) (R305) of 15 sampled residents experienced a significant change in physical status. Staff did not obtain a baseline weight when R305 was admitted to the facility on [DATE]. R305's weight was last obtained in the hospital and documented as 171.11 pounds on 1/5/23. On 1/11/23, staff weighed R305 and documented a weight of 148.4 pounds which was a 13.27 % weight loss since admission. The facility did not notify R305's Provider of the significant weight change. Findings include: R305 was admitted to the facility on [DATE] with diagnoses to include malignant neoplasm of rectosigmoid junction (a cancerous tumor involving the rectum and sigmoid colon) status post low anterior mass resection, anasarca (an accumulation of fluid in various tissues and cavities in the body causing swelling) and pleural effusion (a buildup of fluid between the tissues that line the lungs and the chest). R305 also had…

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

Based on staff interview and record review, the facility did not ensure written notification of financial liability via an Advanced Beneficiary Notice (ABN) was provided for 2 Residents (R) (R4 and R19) of 2 residents who remained in the facility at the end of their Medicare Part A benefit period. The facility did not provide an ABN to R4 when R4's Medicare Part A benefits ended on 1/5/23 or R19 when R19's Medicare Part A benefits ended on 10/13/22. Both R4 and R19 remained in the facility. Findings include: On 1/10/23 at 10:52 AM, Surveyor selected three residents from a list provided by the facility that contained names of residents whose Medicare A stay or benefit period ended. On 1/10/23 at 1:08 PM, Surveyor reviewed the Beneficiary Protection Notification Review documents. R4's review indicated R4's last covered Medicare Part A service date was 1/5/23. R4 remained at the facility. The document indicated an ABN was not provided to R4. R19's review indicated R19's last covered Medicare Part A service date was 10/13/22. R19 remained at the facility. The document indicted an ABN…

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 Resident (R) (R6) of 15 sampled residents was free from falls. R6 had a history of falls. R6's current care plan interventions were not consistently implemented by the facility. Findings include: R6 had diagnoses of metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood)and dementia. R6's Minimum Data Set (MDS), dated [DATE], indicated R6 had severely impaired cognition. R6's plan of care indicated R6 was at risk for falls due to confusion, deconditioning and psychoactive drug use and was unaware of safety needs. The goal for R6 was to be free of injury. R6's care plan interventions included: Dycem (a non-slip mat) in chair, Broda (a specialized wheelchair that aids in preventing skin breakdown) chair, appropriate footwear and keep in line of sight in common areas. Surveyor reviewed R6's medical record. On 1/4/23 at 9:30 AM, R6 had an unwitnessed fall and was found lying on the left side 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.

Based on resident and staff interview and record review, the facility did not ensure 1 Resident (R) (R305) of 15 sampled residents received a comprehensive assessment to address weight loss. Upon admission to the facility on 1/6/23, R305's weight was documented as 171.11 pounds which was obtained in the hospital on 1/5/23. The facility did not obtain a baseline weight for R305 upon admission. On 1/11/23, a weight of 148.4 pounds was obtained after Surveyor asked to have R305 weighed. Surveyor noted R305 incurred a 13.27% weight loss since admission. Findings include: The facility's Weight Monitoring Program policy read as follows: Each resident's weight will be monitored consistently and closely by the Interdisciplinary Team. All residents with patterned or significant weight changes will be assessed by the facility's Interdisciplinary Team as indicated .Upon admission/readmission to the facility, the nursing staff will weigh each resident, establish an accurate weight, and document the weight weekly .If a patterned or significant weight loss or gain is noted, the resident is to 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.