Lincoln Square Post Acute Care

Based on observation, interview, and record review, the facility failed to accommodate the needs of 1 of 30 sampled residents (Resident 18) when, Resident 18 had a call light (device used to contact staff for assistance) that was not within Resident 18's reach.This deficient practice placed Resident 18 at increased risk for unmet care needs, delayed staff response, falls, and potential injury.Findings:Review of Resident 18's admission RECORD indicated Resident 18 was admitted to the facility with diagnoses including gram-negative sepsis (a serious infection caused by bacteria in the blood), urinary tract infection, obstructive and reflux uropathy (urine flow blockage or backward flow), dementia (memory loss and confusion), abnormalities of gait and balance (difficulty walking and maintaining balance), muscle weakness, need for assistance with personal care, and personal history of venous thrombosis and embolism (blood clots in veins or lungs).During a concurrent observation and interview on 3/24/26 at 11:29 AM, with Resident 18 in Resident 18's room, Resident 18 was sitting in a…

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

Based on observation, interview, and record review, the facility failed to ensure a homelike environment for 1 of 30 sampled residents (Resident 17) when, Resident 17 was provided a bathroom toilet that did not function.This failure negatively impacted Resident 17's homelike environment.Findings:During a concurrent observation and interview on 3/24/26, at 4:05 p.m., with Resident 17's family member (FM 1),Resident 17's bathroom door had a sign indicating, do not use. The toilet in Resident 17's bathroom did not have any water and a red and black build up in the toilet bowl was observed. FM 1 stated Resident 17 did not like that he had to go to another resident bathroom to use a toilet and instead of taking him to his own bathroom the facility had to assist Resident 17 to another resident bathroom.During a concurrent observation and interview in Resident 17's room on 3/24/26, at 4:30 p.m., with Licensed Nurse (LN) 4, LN 4 verified Resident 17's bathroom was not working and stated it had not been working for weeks.During an interview on 3/24/26, at 4:40 p.m., with the Director 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.

Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan (written plan that guides staff on daily care, safety, and interventions based on the resident's needs) for 1 of 30 sampled residents (Resident 63) when, Resident 63 refused to receive the COVID-19 (a contagious viral illness that affects the respiratory system) vaccine in April of 2025 and a care plan was not developed to help prevent Resident 63 from acquiring a COVID-19 infection.This failure resulted in Resident 63 acquiring a COVID-19 infection in the facility in September of 2025 and placed Resident 63 at risk of serious illness and complications related to COVID-19.Findings:Review of Resident 63's admission RECORD indicated Resident 63 was admitted to the facility with diagnoses including schizoaffective disorder (a mental health condition with mood problems and symptoms such as hallucinations or confusion), epilepsy (a condition that causes seizures), glaucoma (an eye disease that can damage vision due to increased pressure in the eye), visual loss, anxiety disorder,…

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 failed to provide necessary care and treatment for 1 of 30 sampled residents (Resident 47) when, Resident 47 complained of shortness of breath and the facility staff failed to obtain oxygen saturation as ordered and failed to implement available interventions, including administration of oxygen or an albuterol treatment ( a quick-relief or rescue medication used to treat or prevent breathing difficulties), prior to Resident 47 being transferred to the hospital.This failure had the potential to delay timely assessment and intervention for respiratory compromise, placing residents at risk for decreased oxygen levels and worsening condition.Findings:Review of Resident 47's admission RECORD indicated Resident 47 was admitted to the facility with multiple diagnoses, including chronic obstructive pulmonary disease (a long-term lung disease that makes it difficult to breathe due to airflow limitation), chronic respiratory failure with hypoxia (a condition in which the lungs do not adequately oxygenate the blood), and a history of lung…

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 failed to ensure 1 of 30 sampled residents (Resident 63) ) was free from unnecessary medication administration when, Resident 63 received an antihypertensive medication (used to manage high blood pressure; BP) outside of the hold parameters (when a medication is not to given based on blood pressure readings) four times between February and March of 2026.This failure increased the potential for Resident 63 to experience side effects such as low BP, leading to further heart related complication.Findings:A review of Resident 63's admission Record indicated Resident 63 was admitted to the facility with diagnoses that included but not limited to orthostatic hypotension (a sudden drop in blood pressure that occurs when standing up from a sitting or lying position), hypertension (a chronic condition where the force of blood pushing against artery walls is consistently too high), and repeated falls.A review of Resident 63's Order Summary Report dated 3/27/26, indicated, .Propranolol HCl [hydrochloride] Tablet [used to treat high blood…

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 failed to ensure antibiotic use was supported by ongoing reassessment and documented justification to determine if the antibiotic should be continued for 1 of 30 sampled residents (Resident 57) when, Resident 57 was prescribed an antibiotic for extended or long-term use.This failure placed Resident 57 at risk for unnecessary prolonged antibiotic exposure, adverse effects (harmful or unwanted side effects), antibiotic resistance (when bacteria no longer respond to the medication), and development and spread of MDROs (Multidrug-resistant organisms - germs that do not respond to multiple antibiotics) to other residents and staff in the facility.Findings:Review of Resident 57's admission RECORD, indicated Resident 57 was admitted with diagnoses including, palliative care (medical care for people with serious illnesses, focusing on relieving symptoms, pain, and stress to improve quality of life), anxiety, Atrial Fibrillation (or A.Fib, heart rhythm disease), and chronic nonhealing left knee and thigh wound with abscess (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 interview, and record review, the facility failed to report an allegation of verbal abuse (harsh and insulting language directed at a person; also known as verbal attack, verbal aggression, verbal assault) for one of three sampled residents (Resident 1) when Resident 1 reported that a Licensed Nurse (LN) was rude to him and called him a thief on 1/10/26.This failure had the potential to a delayed investigation by the Department and the risk of negatively affecting Resident 1's psychosocial well-being.Findings:A review of Resident 1's admission RECORD, indicated that Resident 1 was admitted to the facility in 2025.During a phone interview on 2/5/26, at 11:52 a.m., with Resident 1, Resident 1 stated on 1/10/26 in the early morning hours, he went to the snack room at the facility to get hot water for coffee, and a licensed nurse (LN) stated to him that he could not go into the snack room to get hot water. Resident 1 further stated the LN accused him of being a thief, and told him that if anything came up missing he would be the number one suspect. Resident 1 stated that the…

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

Based on interview, and record review, the facility failed to ensure an environment free of accidents or hazards for one of two sampled residents (Resident 1) when Resident 1 exited the facility through an unlocked door on 3/22/25 and was missing from the facility for one and one-half hours before staff became aware. This failure resulted in Resident 1 falling out of her wheelchair sustaining injuries that included bruises (contusion, ecchymosis; skin discoloration from damaged, leaking blood vessels under the skin) and a facial laceration (cut) that required sutures (stitches). This failure had the potential to result in Resident 1 sustaining life-threatening injuries. Findings: A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility in 2022 with diagnoses which included diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), chronic kidney disease (progressive damage and loss of function in the kidneys), and spinal stenosis (spinal stenosis happens when the space inside the backbone is too small, this can…

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 failed to maintain a resident's rights to privacy of personal and medical records when residents' meal tickets were discarded in the facility kitchen garbage bin for the 57 residents who ate facility prepared meals. This failure had the potential for unauthorized access of residents' personal and medical records. Findings: During an observation on 12/15/24, at 9:45 AM, with the Dietary Aide (DA) 1 in the dishwashing area, DA 1 was observed throwing uneaten food, used napkins, and residents' meal tickets left on the meal trays into the garbage bin. DA 1 confirmed the observation. During a concurrent observation and interview on 12/16/24, at 8:52 AM, with the Dietary Service Supervisor (DSS) in the dishwashing area, the DSS confirmed that DA 1 threw the residents' meal tickets into the garbage bin. The DSS also confirmed that multiple residents' meal tickets were returned with their meal trays to the kitchen. The DSS stated although this did not meet the facility's expectations, they currently did not have a process 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.

Based on observation, interview, and record review, the facility failed to provide food storage and preparation, as well as maintain kitchen equipment and food contact surfaces in accordance with professional standards for food safety for the 57 residents who ate facility prepared meals when: 1. Expired food was not thrown away; 2. Food was not labeled/dated properly; 3. Non food items were found in the dry food storage room; 4. A coffee water filter was expired; 5. A fan located in the food prep area was not clean; 6. Various tray line pans were stacked and stored wet; 7. The food processor bowel was ready to use wet; and 8. The ice machine was dirty. These failures had the potential to put residents eating facility prepared meals at risk for foodborne illnesses. Findings: 1. During the initial kitchen tour on 12/15/24, at 8:10 AM, in the reach in refrigerator and dry storage the following items were found ready to serve. The findings were confirmed by the Dietary Service Supervisor (DSS): a. Four out of twelve cases of strawberries (approximately 20 strawberries in each case) were…

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 failed to maintain trash in a closed dumpster for a census of 57 residents. This failure had the potential to lead to insect and rodent infestation. Findings: During a concurrent interview and observation on 12/15/24, at 9:18 AM, with the [NAME] (CK) 1, the trash bin for the facility was overflowing with trash bags and the lid was placed completely behind the bin. When asked why the bins were opened CK 1 stated the trash service placed them that way. During an interview on 12/16/24, at 10:58 AM, with the Dietary Services Supervisor (DSS), when interviewed about the trash bin lids being opened, the DSS stated the trash dumpster lids being opened was not the facility's normal process and it was important for the dumpster lids to be closed to avoid any pests. During an interview on 12/18/24 at 12:55 PM, with the Registered Dietician (RD), the RD stated the expectation was for the dumpster lids to be closed and there should be no garabage overflowing out of the dumpster to ensure no pests gets into the dumpster. The RD…

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 consistently implement an antibiotic stewardship program (to ensure medications used to treat infections are used only when necessary and appropriate) for a census of 57 residents when, Loeb (a set of minimum signs and symptoms that indicate a resident in long-term care likely has an infection and may need antibiotic) and/or McGeer criteria (a set of definitions used to identify infection after an antibiotic is started) were not consistently used to assess the initiation and/or the appropriateness of continued use of an antibiotic, including accurate documentation of the correct indication for use. This failure had the potential to result in antibiotics being prescribed when not indicated and the development of multi- drug resistant organisms (MDRO; germs that have developed the ability to survive antibiotics that were previously used to kill them; decreasing antimicrobial resistance (when antibiotics become ineffective against infection) requires antimicrobial stewardship and infection prevention efforts). Findings: 1.…

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 failed to ensure Resident 119 was treated with dignity for a census of 57 when staff did not cover resident's genital area with a sheet while he was sleeping in bed. These failures had the potential to negatively impact Resident 119's psychosocial well-being. Findings: During a concurrent observation and interview on 12/16/24, at 10:02 a.m., in Resident 119's room, with Certified Nursing Assistant (CNA) 2, CNA 2 confirmed Resident 119 was not covered with a sheet and Resident 119's genitals were exposed while he was in bed sleeping. CNA 2 stated we have to cover it .his private part. CNA 2 further stated the expectation was for residents' private parts to be covered. CNA 2 explained the risk included a loss of dignity and feelings of shame. During an interview on 12/16/24, at 11:52 a.m., the Assistant Director of Nursing (ADON) stated residents should be covered with a sheet when they were in bed for dignity. The ADON further stated, To prevent having residents exposed like that, staff should make rounds to make sure…

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 failed to submit a new Level I PASRR (Preadmission Screening and Resident Review- a screening for mental illness and treatment to ensure the facility coordinates with the appropriate State-designated authority to ensure that individuals with a mental disorder, intellectual disability or a related condition receives care and services appropriate to their needs) for 1 of 18 sampled residents (Resident 2) when, a level II Mental Health Evaluation was not completed for Resident 2 due to Resident 2 being on isolation as a health or safety precaution which required the facility to submit a new Level I screening for Resident 2. This failure had the potential to place Resident 2 at risk for not receiving the necessary care or services. Findings: During a review of Resident 2's admission RECORD, indicated that Resident 2 was admitted to the facility in 2022 with a diagnosis of schizophrenia (a mental disorder characterized by disruptions in thought process, perceptions, emotional responsiveness, and social interactions). A review 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.

Based on interview, and record review, the facility failed to ensure 1 of 18 sampled residents (Resident 269) received quality care when staff administered rapid-acting insulin to Resident 269 (Lispro-medication which starts to lower blood sugar within 10-15 minutes) on 12/17/24 based on a medication order that did not include parameters (a fixed limit that establishes how something must be done) defining when to hold/not administer the insulin; and staff did not notify the physician when Resident 269 did not eat her scheduled meal after the rapid-acting insulin was administered. These failures led to Resident 269 experiencing a hypoglycemic event (when the body's blood sugar level drops too low for the body to function properly) with a blood glucose (BG) of 36 (a BG below 70 is considered low BG; hypoglycemic) and needing emergent medical treatment. Findings: Review of Resident 269's admission RECORD, indicated Resident 269 was initially admitted to the facility with diagnoses including but not limited to type 2 diabetes mellitus (DM- inability for the body to regulate blood…

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 failed to ensure safe pharmaceutical services for a census of 57 residents when, narcotic medications (used for pain) were not accurately documented in the Medication Administration Record (MAR, a document listing medications and monitoring parameters) when removed from the Controlled Drug Record (CDR, a paper record that kept track of opioid medication use for accountability) for Resident 55. This failure resulted in the inaccurate documentation of Resident 55's pain medication dosages and had the potential to result in decreased well-being for Resident 55. Findings: A review of Resident 55's admission RECORD, indicated Resident 55 was admitted with diagnoses which included but were not limited to chronic kidney disease (progressive damage and loss of function in the kidneys), and non-pressure chronic ulcer of right midfoot and heel (an open wound that develops on the skin). A review of Resident 55's Physician Order Summary, indicated that Resident 55 was treated under Hospice Care (also considered as palliative care,…

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

Based on interview, and record review, the facility failed to ensure 1 of 18 sampled residents (Resident 56) was free from unnecessary medications when, Resident 56 received an antibiotic (medication used to treat infection) even though Resident 56 did not meet the criteria established for use of an antibiotic medication through the facility's antibiotic stewardship program (a set of efforts to ensure that antibiotics are used appropriately and only when necessary). This failure had the potential to result in unnecessary medication side effects for Resident 56 and had the potential to result in the development of multi-drug resistant organisms (MDRO; germs that have developed the ability to survive antibiotics that were previously used to kill them; decreasing antimicrobial resistance (when antibiotics become ineffective against infection) requires antimicrobial stewardship and infection prevention efforts). Findings: Review of Resident 56's SBAR [Situation Background Assessment Recommendation] Communication Form and progress note . dated 12/7/24, indicated, .[Resident 56] noted…

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 residents were free from significant medication errors when Resident 55 received more than the prescribed dose of a narcotic pain medication (a controlled medication that is used for pain that is severe) for more than one month. This failure had the potential for a decreased quality of life and well-being for Resident 55. Findings: A review of Resident 55's admission RECORD, indicated that Resident 55 was admitted with diagnoses which included but were not limited to chronic kidney disease (progressive damage and loss of function in the kidneys), and non-pressure chronic ulcer of right midfoot and heel (an open wound that develops on the skin). Review of Resident 55's Physician Order Summary, dated 7/16/24, indicated, .Morphine Sulfate [a medication used for severe pain] 20 mg/ml [milligram per milliliter; units of measurement] give 0.25ml by mouth every one hour as needed for moderate pain or difficulty breathing and give 0.5ml by mouth every one hour as needed for severe pain or difficulty breathing,…

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 failed to ensure medications were labeled, stored, and disposed of according to standards of practice for a census of 57 residents when: 1. An opened, unlabeled container of a psyllium fiber supplement (helps to bulk and soften poop, making it easier to pass) was stored in the medication cart; 2. An opened, unlabeled bottle of cough medicine was stored in the medication cart; and, 3. Medications for a discharged resident were stored in the medication cart. These unsafe medication storage practices could contribute to medication errors and unsafe medication use. Findings: During a concurrent observation and interview on 12/17/24, at 10:35 a.m., with Licensed Nurse (LN) 3, the [NAME] Unit Medication Cart Number 2 was observed. Medications for a discharged resident were observed in the medication cart lower left drawer. LN 3 stated the medications for a discharged resident should not be in the medication cart. LN 3 then removed the medications. A large container of psyllium fiber supplement was found in the medication…

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 failed to ensure safe infection prevention practices were used for a census of 57 when: 1. Resident 171 was placed in a room with another resident who tested positive for RSV (Respiratory Syncytial Virus, a virus (germ) that causes infection (invasion and growth of germs in the body) of the lung and the respiratory tract) with no Droplet Isolation Precautions (hand hygiene, wearing a surgical mask, eye protection, and a gown and gloves (if contact with blood/bloody fluids is possible) are used when in contact with a person who has an infection with germs that can be spread to others by coughing, talking, or sneezing) in place on 12/15/24; and, 2. Resident 9 tested positive for RSV on 12/11/24 but was not in Droplet Isolation Precautions on 12/15/24. These failures had the potential to decrease Resident 171's health and well-being and put other residents, staff, and visitors at increased risk for infection. Findings: 1. A review of Resident 171's admission RECORD indicated that Resident 171 was admitted with diagnoses…

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 failed to provide the influenza vaccine (also known as a flu shot, a safe and effective way to protect against the influenza virus) to 1 of 5 sampled residents (Resident 11) when, there was no documented evidence in Resident 11's medical record that the vaccine had been offered, given, and/or refused. This failure had the potential to result in Resident 11 acquiring, transmitting, or experiencing complications from influenza. Findings: Review of Resident 11's admission RECORD, indicated Resident 11 was admitted to the facility in 2022 with diagnoses including chronic obstructive pulmonary disease (a disease of the lungs that blocks airflow and makes it difficult to breath) and dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). Resident 11's admission record listed a conservator (a person appointed to make decisions on behalf of another person who is incapable of fully managing their own affairs due to age or physical or mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to accurately complete a medication reconciliation (the process of identifying the most accurate list of all medications that the patient is taking, including name, dosage, frequency, and route) on post- discharge medications for one of three residents (Resident 1) when Resident 1 was discharged home with a discontinued (no longer provided) medication. This failure had the potential for Resident 1 to take an unprescribed medication in error which could negatively affect his health and well-being. Findings: A review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility in 2024 with diagnoses that included depression (a mental health condition that involves a persistent feeling of sadness and loss of interest that interferes with daily life) and muscle weakness. A review of Resident 1's Order Summary Report, (list of physician orders) dated 6/27/24, indicated Resident 1 was prescribed Mirtazapine (medication to treat…

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 failed to maintain a kitchen free of potential hazards for food borne illnesses (nausea, vomiting, and diarrhea) for 55 residents who received and ate food from the kitchen when: 1. Perishable food items in the kitchen were not properly labeled; and, 2. The inside of the ice machine contained a black like substance. These failures had the potential to result in food borne illnesses for 55 of the residents who ate food from the kitchen. Findings: 1. During a concurrent observation and interview on 11/27/23, at 8:30 AM, with the Dietary Supervisor (DS), the large freezer was observed to have the following items without a use by date labeled on the food packages: cheese omelets (24 count), donuts (24 count), hamburger patties (6 count), and garlic (1/4 bag). The DS verified the listed food items were not labeled with a use by date. The DS stated there should have been an open date and a use by date on all opened food packages to ensure expired food items were not eaten, which could lead to the residents contracting a food…

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 failed to ensure accurate documentation of a mental health diagnosis for 2 of 18 sampled residents (Resident 3 and Resident 17) based on standards of practice when: 1. Resident 3's medical record was marked with schizoaffective disorder (a mental health disorder marked by a combination symptom, such as hallucinations or delusions, and mood disorder symptoms) as a diagnosis for use of quetiapine (or Seroquel, an antipsychotic [mind altering] medication used to treat mental disease) with no prior history of such diagnosis; and, 2. Resident 17's medical record was marked with schizophrenia (a serious mental condition involving a breakdown between thought, emotion, and behavior, leading to faulty perception and withdrawal from reality) as a diagnosis for use of quetiapine and perphenazine (a mind-altering medication used to treat mental disease) with no prior history of such diagnosis. These failures may result in unsafe treatment and care of the residents. Findings: 1. During a record review of Resident 3's medical record titled,…

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 failed to maintain an accurate and complete medical record for 3 of 18 sampled residents (Resident 11, Resident 19, and Resident 165) when: 1. Resident 11 and Resident 19's COVID immunization records was not readily available in their medical record, 2. Resident 165's Interdisciplinary (IDT- a care team consisting of different disciplines) care conference record was inaccurate and incomplete; and, 3. Resident 165's speech screening evaluation was not available in his record. This failures resulted in an incomplete and inaccurate medical documentation for Resident 11, Resident 19, and Resident 165. Findings: 1. A review of Resident 11's admission Record indicated Resident 11 was admitted to the facility in June 2023. A review of Resident 19's admission Record indicated Resident 19 was admitted to the facility the beginning of November 2023. Further review of Resident 11's medical records indicated Resident 11 had no immunization for COVID on file. Further review of Resident 19's medical record indicated Resident 19 had no…

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 failed to accurately assess 2 of 18 sampled residents (Resident 3, and Resident 17) when Resident 3 and Resident 17's documentation of a mental health diagnosis in the medical record was not accurately assessed. This failure resulted in Resident 3, and Resident 17's medical record with an inaccurate mental health diagnosis which could affect the care provided. Findings: 1a. During a record review of Resident 3's medical record, titled Medication Administration Record, (or MAR- a document that listed the medication use and doctor's orders) dated 11/2023, the record indicated Resident 3 was receiving a mind-altering medication called quetiapine (or Seroquel, a mind altering drug) for a diagnosis of schizoaffective disorder (a mental disorder marked by a combination symptoms, such as hallucinations or delusions, and mood disorder symptoms). Further review of the Resident 3's medical record titled, History and Physical, (or H&P, a summary of medical condition upon admission to the facility) dated 10/19/22, the record written by 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 interview, and record review, the facility failed to ensure 1 of 18 sampled residents (Resident 26) received proper vision treatment when Resident 26 was not seen by an ophthalmologist (a medical doctor who specializes in eye and vision care) as referred. This failure had the potential to delay care and treatment for Resident 26. Findings: During an interview on 11/28/23, at 12:15 p.m., Resident 26 stated he had an eye problem and he wanted to see a doctor. Resident 26 stated he could not see anything, and he wanted to tell the doctor that his eyes were not the same. Resident 26 stated he did not know what had happened to his eyes and he needed a doctor to help him. Resident 26 further stated the facility staff told him that there was no doctor. Review of Resident 26's nurses progress note, dated 7/9/23, indicated, Resident seen by NP [Nurse Practitioner] [Provider Name] for routine monthly routine visit. Received orders for referral to ophthalmologist. Orders noted and carried out. Review of Social…

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 failed to provide a safe environment and supervision for one of two residents (Resident 2) at risk of elopement (resident leaves the premises without the facility's knowledge and supervision) when: 1. Resident 2 eloped from the facility, falling out of her wheelchair and sustaining a fractured left ankle; and, 2. Resident 2's Elopement/Wandering Risk Assessment was not assessed accurately. These failures resulted in Resident 2 not receiving additional monitoring which allowed Resident 2 to exit the facility unnoticed and sustain an accidental injury while outside the facility's premises without supervision from staff. 1. During a review of Resident 2's clinical record titled, admission RECORD, (a document that contains the resident's demographics) indicated, Resident 2's diagnosis included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), depression (a medical illness that negatively affects how one feels or acts), and a history of falling. During 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 failed to ensure the necessary services and assistance were provided to maintain bowel and bladder continence (the ability to control movements of the bowels and bladder) for 1 of 18 sampled residents (Resident 4), when: 1. A bowel and bladder training program (a schedule of urinating and defecating to improve continence) was not developed and initiated for Resident 4 as indicated by her bowel and bladder assessment; and, 2. Resident 4's bowel and bladder assessments were not completed accurately. These failures resulted in Resident 4 using briefs (adult diapers) for urination, had the potential to not provide adequate care and a risk for further decline to Resident 4's bowel and bladder control. Findings: 1. Review of Resident 4's admission record indicated Resident 4 was admitted to the facility in September 2023 with multiple diagnoses including fracture of right femur (leg bone), chronic kidney disease, pain in right hip. Review of Resident 4'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 interview, and record review, the facility failed to provide the services of a full time (working 40 or more hours a week) Director of Nursing (DON) onsite to fulfill the job duties of the DON. This failure had the potential to result in the needs of the residents not being adequately assessed and met in a timely manner and could potentially impact the quality of care delivered by licensed and non-licensed nursing staff for a census of 57 residents. Findings: A review of the undated facility's job description titled, JOB DESCRIPTION JOB TITLE: Director of Nursing Services, the job description indicated, .The primary purpose of .[the DON] is to plan, organize, develop and direct the overall operation of .Nursing Service Department .to ensure that the highest degree of quality care is maintained at all times .The Director of Nursing Services reports to the Administrator .DUTIES AND RESPONSIBILITIES .Develop, implement, and maintain an ongoing Quality Assurance and Performance Improvement [QAPI; a data driven and proactive approach to quality improvement] Program for the…

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

Based on observation, interview, and record review, the facility failed to ensure safe and accountable medication use, documentation, and the timely availability of medication with a census of 57 when: 1. There was a discrepancy between the Controlled Drug Record (or CDR, an accountability record for opioid use) removal and the respective Medication Administration Record (or MAR referred to as a drug chart that serves as a legal record of the drugs administered to a resident) documentation for two residents (Resident 163 and Resident 999); and, 2. Diabetic medication (medication to lower blood sugar) was not available for Resident 113. These failures had the potential risk for diversion (transfer of a medication from a legal to an illegal use from the individual for whom it was prescribed, to another person for illicit use) and could negatively impact Resident 113's blood sugar control. Findings: 1a. During a review of the facility's document titled, Controlled Drug Record, dated 11/17/23, the record indicated Resident 163's narcotic medication called Oxycodone (a pain medication)…

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 failed to ensure insulin (a medicine to control blood sugar levels) use was documented and blood sugar monitoring was performed as ordered for 1 of 5 residents (Resident 45). These failures had the potential to negatively impact Resident 45's blood sugar control and monitoring. Findings: During a review of Resident 45's electronic medical record titled, Medication Administration Record, (or MAR, a legal drug chart where nurse documented medications administration), dated 11/2023, the MAR indicated a doctor's medication order for blood sugar monitoring and to give insulin when indicated per parameters three times a day. Further review of Resident 45's MAR indicated the insulin was not documented with corresponding blood sugar measurements on 11/4/23 at 6:30 a.m., 11/10/23 at 6:30 a.m., and 11/14/23 at 6:30 a.m. During a review of Resident 45's medical record titled, Weights & Vitals, (a document where blood sugar monitoring is documented) dated 11/2023, the record indicated, blood sugar measurement was not documented on 11/4/23 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure a psychotropic (mind-altering drug) medication called lorazepam (or Ativan, an [NAME]-anxiety medication) ordered for PRN (means as needed) use had a duration and clear direction for use in 1 out of 18 sampled residents (Resident 2). This failure could result in unsafe medication use and contribute to medication error. Findings: During a review of Resident 2's medical record titled, Medication Administration Record, (or MAR, a document that listed orders for medication and nursing care), dated 11/2023, the MAR indicated the following orders: Lorazepam Oral Tablet 0.5 MG .(or Ativan, an anxiety treatment medication; MG is milligram, a unit of measure); Give 1 tablet by mouth every 6 hours as needed for moderate anxiety and restlessness .-Start Date- 10/27/23. Lorazepam Oral Tablet 0.5 MG .; Give 1 tablet by mouth every 2 hours as needed for Severe Terminal agitation Titrate (means increase dosage) tabs 25% -100% (% is fraction of 100) every 2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure safe medication storage practices in one out of two medication rooms (a locked room for storage of prescription, non-prescription and controlled medications) and two out of four medication carts (mobile cart that stores resident's medication and supplies) with a census of 57 when: 1. One emergency kit (or Ekit- a box that stored medication for emergency use) was opened and unsealed with no documentation of its use, 2. The medication refrigerator was frosted when medications sensitive to freezing were stored in proximity, 3. Extra supplies were placed under the sink-based cabinet in the medication storage room, 4. Staff's personal belongings were stored in the active medication storage room; and, 5. Expired (outdated) supplies and medications were stored in medication carts and hazardous liquid (medication that may pose health risk upon direct exposure to the skin and body during handling) medication was not safely labeled as…

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's quality assessment and assurance (QAA) committee failed to meet quarterly with all the required members, when the Interim Director of Nursing (IDON) did not attend the second and third quarter meetings for the year of 2023. This failure had the potential for quality care improvement activities not to be evaluated and revised as needed with a possible decline in residents' quality of care. Findings: During a concurrent interview and record review on 11/30/23, at 3:49 p.m., the Administrator (ADM) stated the facility's QAA committee met monthly for Quality Assurance and Performance Improvement (QAPI: a data driven and proactive approach to quality improvement) meetings rather than required quarterly to have closure view of areas needed improvement. The ADM stated the facility's QAA committee members included Medical Director (MD), ADM, IDON, Infection Preventionist (IP), Director of Staff Development (DSD), Minimum Data Set (MDS) nurse, Rehabilitation Department, Dietary Department. Facility's QAPI meetings sign-in sheets were…

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 failed to ensure infection prevention measures were followed for a census of 57 when: 1. The shared glucometer (a device used to measure blood sugar) and blood pressure devices (or BP, Blood Pressure, measures the pressure of blood pushing against the walls of arteries) were not cleaned and sanitized in-between resident care based on manufacturer recommendation and standards of practice; and, 2. Hand hygiene was not performed in-between resident care during the medication administration task. These failures could pose health safety risks and spread of infection in the facility. Findings: 1a. During an observation with Licensed Nurse (LN) 1, in West-2 hallway, on 11/27/23, at 11:26 AM, LN 1 gathered the blood sugar supplies including a glucometer with a lancet device (spike needle) and entered Resident 43's room. LN 1 spiked Resident 43's right thumb finger to get blood and then soaked the test strip (a disposable testing strip that helped with blood sugar measurement) attached to glucometer with blood to get the blood…

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.