Oakpark Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to document the presence or absence of seizure (a sudden, uncontrolled burst of electrical activity in the brain that disrupts normal brain function) activity and failed to monitor for complications associated with anti-seizure medications for one of one sampled resident (Resident 40). These deficient practices had the potential to delay the timely identification of changes in Resident 40's condition, which could result in delayed interventions and adverse outcomes. Findings: During a review of Resident 40's admission Record, the admission Record indicated the facility admitted Resident 40 to the facility on 2/21/2026 and readmitted on [DATE] with diagnoses that included epilepsy (chronic neurological condition characterized by recurrent, unprovoked seizures (a sudden, uncontrolled electrical disturbance in the brain, causing changes in behavior, consciousness, movements, or feelings), type 2 diabetes mellitus (a chronic condition that affects the way the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record, the facility failed to provide an environment that is free from accident hazards for one of one sampled resident (Resident 40) by failing to provide a padded side rail to Resident 40, who has a diagnosis of epilepsy (chronic neurological condition characterized by recurrent, unprovoked seizures [a sudden, uncontrolled electrical disturbance in the brain, causing changes in behavior, consciousness, movements, or feelings])This deficient practice placed the resident at increased risk for injury and harm. Findings:During a review of Resident 40's admission Record, the admission Record indicated the facility admitted Resident 40 to the facility on 2/21/2026 and readmitted on [DATE] with diagnoses that included epilepsy (chronic neurological condition characterized by recurrent, unprovoked seizures (a sudden, uncontrolled electrical disturbance in the brain, causing changes in behavior, consciousness, movements, or feelings), type 2 diabetes mellitus (a chronic condition…

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 a window screen did not have a gap that may be a potential entry point of insects into a shared resident room affecting two of four residents (Residents 19 and 38) investigated under the Environment task. This deficient practice created an entry point and access for insects to get inside the building which can potentially transmit insect borne illnesses and negatively affect the residents' quality of life. Findings: During a review of Resident 19's admission Record, the admission Record indicated the facility originally admitted the resident on 5/5/2023 and most recently readmitted the resident on 6/20/2025 with diagnoses including, but not limited to, Parkinsonism (neurological conditions causing slowed movement, rigidity, tremors, and postural instability), acute (a medical issue with a sudden onset and short duration) respiratory failure (a condition where the lungs cannot release enough oxygen into the blood), and dementia (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 c. During a review of Resident 37's admission Record (face sheet), the admission Record indicated that the facility originally admitted the resident on 6/7/2024 and readmitted on [DATE], with diagnoses including unspecified dementia (a progressive state of decline in mental abilities), difficulty in walking, dysphagia (difficulty swallowing), and epilepsy (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). During a review of Resident 37's Minimum Data Set (MDS- a resident assessment tool) dated 3/29/2025, the MDS indicated the resident`s cognitive skills (the brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated that Resident 37 required staff partial/moderate assistance (helper does less than half the effort) for toileting hygiene, showering/bathing, upper and lower body dressing, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Ensure a resident who was at high risk for falls had floor mats (a cushioning pad placed by a resident's bed to absorb the force of a resident falling) as ordered by the physician for one out of four sampled residents (Resident 36) investigated for accidents and hazards. 2. Implement accident risks and hazard intervention by failing to place a personal alarm (a device with sensors that will alarm when a resident stands up unassisted to help prevent falls by alerting staff) on a resident`s wheelchair as ordered by the physician for one of four (Resident 21) reviewed under accidents care area. This deficient practice had the potential to place Resident 21 at risk for recurrent falls and injuries. 3. Provide a resident with a bed alarm (a device designed to alert caregivers when a patient attempts to get out of bed) as ordered by the physician for one (Resident 17) out of four sampled residents investigated under the care area 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 2.c. During a review of Resident 16's admission Record, the admission Record indicated the facility admitted the resident on 1/22/2021 and readmitted the resident on 7/17/2023 with diagnoses including compression fracture of second lumbar vertebra (condition when second bone [one of the vertebrae] has collapsed or broken, making it shorter than normal), paroxysmal atrial fibrillation (a heart condition that causes an irregular and often abnormally fast heart rate), and chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems). During a review of Resident 16's Minimum Data Set (MDS - a resident assessment tool), dated 1/30/2025, the MDS indicated the resident had intact cognition (undamaged mental abilities, including remembering things, making decisions, concentrating, or learning) and required moderate- to -maximal assistance from staff for most activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs…

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 that its medication error rate was less than five (5) percent (%), due to 10 medication errors observed out of 41 total opportunities (error rate of 24.39 %) affecting two of five randomly selected residents (Resident 151 and Resident 25). The medication errors were as follows: 1. Licensed Vocational 3 (LVN 3) administered Resident 151 carvedilol (a medication used to treat hypertension [HTN-high blood pressure]) and pancrelipase (a medication to improve digestion of foods in adults who cannot digest food normally) at the time specified by the physician's order 2. Licensed Vocational Nurse 1 (LVN 1) mixed together eight crushed medications and administered them all at once via gastrostomy tube (g-tube - a feeding tube that is surgically inserted directly into the stomach through the abdominal wall) to Resident 25. These failures had the potential for Residents 25 and 151 to experience adverse medication effects (unwanted, uncomfortable, or dangerous effects that medication may have) and the potential to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure residents were free of any significant medication errors by failing to: 1. Rotate (a method to ensure repeated injections are not administered in the same area) insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) injection sites for Resident 4. This deficient practice had the potential for adverse effect (unwanted, unintended results) of same site subcutaneous (SQ- injecting in the fatty layer of the skin) administration of insulin such as bruising, pain, and lipodystrophy (lump or accumulation of fatty tissue under skin). 2. Ensure Resident 151 received carvedilol (a medication used to treat hypertension [HTN-high blood pressure]) and pancrelipase (a medication to improve digestion of foods in adults who cannot digest food normally) at a prescribed time as ordered by the physician. This deficient practice had the potential for Resident 151 to experience medication adverse…

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 store food in accordance with professional standards for food service safety by not labeling: a. two boxes (24 count) of ice cream open on 4/17/2025 with use by date and expiration date. b. one gallon of sweet relish with use by date c. one gallon of creamy Italian Dressing with use by date d.one gallon of whole egg mayonnaise with use by date e. 1 pound of unsalted margarine with use by date and expiration date. These deficient practices had the potential for 45 out of 46 residents in the facility to be at risk for food borne illness (illness caused by food contamination with bacteria, viruses, parasites, or toxins). Findings: During a concurrent observation and interview on 4/21/25 at 8:00 a.m., with the Dietary Supervisor (DS) observed in the freezer two boxes (24 count) of ice cream opened on 4/17/2025 without a use by date and expiration date label. During a concurrent observation and interview on 4/21/25 at 8:05 a.m., with the Dietary Supervisor (DS), observed in the walk-in refrigerator one gallon 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: 1. Ensure Certified Nursing Assistant (CNA 3) was wearing an isolation gown (type of personal protective equipment [PPE- specialized clothing or equipment worn by an employee for protection against infectious materials] used in healthcare settings to protect healthcare personnel from the spread of infection or illness, particularly from contact with blood and body fluids) while dressing a resident in the resident's room for one of five sampled residents (Resident 36) who were on enhanced barrier precautions (EBP -a set of infection control practices that use PPE to reduce exposure to reduce the spread of multidrug-resistant organisms [MDROs -microorganisms that are resistant to multiple classes of antibiotics and antifungals] in nursing homes). This deficient practice had the potential for transmission of bacteria that can lead to infection to other residents in the facility. 2. Ensure Licensed Vocational Nurse 1 (LVN 1) donned a gown before administering medications via a gastrostomy tube (g-tube - a thin…

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 Licensed Vocational Nurse 1 (LVN 1) knocked on a resident's door before entering the room for one (Resident 25) out of one sampled resident investigated under the care area of dignity. This deficient practice violated the resident's right to be treated with respect and dignity, which had the potential to affect the resident's sense of self-worth and self-esteem. Findings: During a review of Resident 25's admission Record, the admission Record indicated the facility originally admitted the resident on 3/28/2024 and readmitted the resident on 12/3/2024 with diagnoses including Parkinsonism (a term used to describe a group of movement disorders that share similar symptoms to Parkinson's disease [a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements]). During a review of Resident 25's Minimum Data Set (MDS - a resident assessment tool), dated 4/1/2025, the MDS indicated the resident had severely impaired cognitive (thought processes) skills for daily…

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 develop a comprehensive person-centered care plan (a document that summarizes a resident's needs, goals, and care/treatment) for one of five sampled residents (Resident 36) addressing Resident 36 being positive for extended spectrum beta-lactamase (ESBL- enzymes [proteins that help speed up metabolism] produced by bacteria that make them resistant to antibiotic) producing Escherichia coli (E. coli- type of bacteria that can cause food-borne illness [food poisoning]). This deficient practice had the potential to result in failure to deliver the necessary care and services. Findings: During a review of Resident 36's admission Record, the admission Record indicated the facility admitted the resident on 6/3/2022 and readmitted the resident on 3/22/2023 with diagnoses that included chronic obstructive pulmonary disease (a lung diseases that block airflow and make it difficult to breathe), urinary tract infection (UTI- an infection in any part of the urinary system), and atrial fibrillation (a heart condition that causes an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to update and revise a resident`s care plan (a document outlining a detailed approach to care customized to an individual resident's need) after a change of condition (COC-an improvement or worsening of a patient`s condition which was not anticipated) on 3/4/2025, for one of three sampled residents (Resident 21) reviewed under the Accidents care area. This deficient practice had the potential to result in Resident 21 receiving inadequate care and supervision at the facility. Findings: During a review of Resident 21's admission Record (face sheet), the admission Rrecord indicated that the facility originally admitted the resident on 8/18/2021 and readmitted on [DATE], with diagnoses including Parkinsonism (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), ataxic gait (when a person is walking in an abnormal, uncoordinated, or unsteady manner), and unspecified dementia (a progressive state 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 2. During a review of Resident 16's admission Record, the admission Record indicated the facility admitted the resident on 1/22/2021 and readmitted the resident on 7/17/2023, with diagnoses including compression fracture of second lumbar vertebra (condition when second bone [one of the vertebrae] has collapsed or broken, making it shorter than normal), paroxysmal atrial fibrillation (a heart condition that causes an irregular and often abnormally fast heart rate), and chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems). During a review of Resident 16's Minimum Data Set (MDS - a resident assessment tool), dated 1/30/2025, the MDS indicated the resident had intact cognition (undamaged mental abilities, including remembering things, making decisions, concentrating, or learning) and required moderate- to -maximal assistance from staff for most activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs…

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 call light (a device used by a resident to signal his/her need for assistance from staff) was within a resident's reach while in bed for one of three sampled residents (Resident 2). This deficient practice had the potential to delay the provision of services and resident's needs not being met. Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted the resident on 8/24/2024 with diagnoses including encephalopathy (brain disorder that affect brain function), cerebrovascular disease (condition that affect blood flow to your brain), and hemiplegia (one-sided paralysis [complete or partial loss of muscle function]) and hemiparesis (one-sided muscle weakness) following cerebral infarction (disrupted blood flow to the brain) affecting the left dominant side. During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool) dated 12/29/2024, the MDS indicated that Resident 2 was cognitively (the mental action or process of acquiring…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained a resident's dignity and respect in full recognition of their individuality by staff members by failing to knock prior to entering a resident's room for three of three sampled residents (Resident 29, 30, and 33). This deficient practice had the potential to affect Resident 29, Resident 30, and Resident 33's self-esteem and self-worth. a. A review of Resident 29's admission Record indicated the facility admitted the resident on 9/22/2023 with diagnoses that included heart failure (a condition in which the heart doesn't pump blood as well as it should), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) without behavioral disturbance. A review of Resident 29's Minimum Data Set (MDS- an assessment and screening tool) dated…

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 to implement their policy and procedure for resident council (a group of nursing home residents who meet regularly to discuss their rights, quality of care, and quality of life) by failing to ensure residents had a private space to conduct resident council meetings for five of five sampled residents (Resident 11, 12, 39, 38, and 4). This deficient practice had the potential of violating residents' rights of holding a resident council meeting privately. Findings: During an interview on 6/15/2024 at 10:15 a.m., with the Activity Director (AD), the AD stated that resident council meetings are arranged monthly, on the second Wednesday of the month, and are held in the activity room. When asked if the resident council has a private space to meet, the AD stated the resident council does not have a private space to meet. The AD stated that a table is placed in the middle of the activity room and the residents attending the resident council meetings sit around that table. The AD continued to state that during the resident council meeting,…

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 licensed nurses attempted non-pharmacological interventions (any type of healthcare intervention which is not primarily based on medication) prior to administering as needed (prn) opioid pain medication (a class of drugs that are used to treat moderate to severe pain) for one of 14 sampled residents (Resident 43). This deficient practice had the potential to place the resident at increased risk of experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention). Findings: A review of Resident 43's admission Record indicated the facility originally admitted the resident on 8/14/2023 and readmitted the resident on 4/30/2024 with diagnoses including malignant neoplasm of prostate (a cancerous tumor [solid mass of tissue that forms when abnormal cells group together] that forms in the tissues of the prostate gland [gland in the male reproductive system]). A review of Resident 43's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/7/2024,…

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: 1. Ensure licensed nurses administered blood pressure (the force of blood pushing against the walls of the arteries) medications within prescribed parameters (a set of defined limits) for one of 14 sampled residents (Resident 16). This deficient practice had the potential to place the resident at increased risk of experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention) from the medication. 2. Ensure the Medication Count Sheet (MCS- accountability record of medications that are considered to have a strong potential for abuse) coincided with the Medication Administration Record (MAR, a report detailing the drugs administered to a patient by the licensed nurses) for one of 14 sampled residents (Resident 5). These deficient practices had the potential to result in medication error and/or drug diversion (illegal distribution or abuse of prescription drug). Findings: 1. A review of Resident 16's…

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

Based on observation, interview, and record review, the facility failed to ensure a resident's call light (a device used by a resident to signal his/her need for assistance from staff) was within reach for one of 14 sampled residents (Resident 16). This deficient practice had the potential to cause a delay in resident care and for the resident's needs to remain unmet. Findings: A review of Resident 16's admission Record indicated the facility admitted the resident on 9/16/2021 with diagnoses including breast cancer (a disease that occurs when breast cells mutate and grow out of control, forming tumors [solid mass of tissue that forms when abnormal cells group together]) and bone cancer (growth of cells that start in a bone). A review of Resident 16's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/18/2024, indicated the resident had intact cognition (thought processes) and required moderate assistance from staff for some activities of daily living (ADLs - activities related to personal care). A review of Resident 16's care plan (a document that…

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

Based on interview and record review, the facility failed to implement the facility's policy on changes of condition (COC- a sudden clinically important deviation from a resident's baseline in physical, cognitive [the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses], behavioral, or functional domains) by failing to notify a resident's responsible party (RP) and the resident's physician after a fall incident for one of three sampled residents (Resident 30). This deficient practice had the potential outcome to have had a negative effect on Resident 30's treatment if any decisions were needed at the time of the change of condition. Findings: A review of Resident 30's admission Record indicated the facility admitted the resident on 9/12/2022 and readmitted the resident on 5/10/2023 with diagnoses that included Parkinsonism (a disorder of the central nervous system [makes up of the brain and spinal cord] that affects movement, often including tremors [involuntary shaking or movement]), neurocognitive disorder with Lewy bodies…

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 the window screen was affixed to the frame and did not have any gaps or openings from top to bottom for one of 18 resident rooms (Room A). This deficient practice had the potential to result in insect infestation (a large number of animals or insects that carry disease) that could pose harm to the residents. Findings: During the initial facility tour and room observation on 5/28/2024 at 11:37 a.m., observed Room A occupied by three residents. Upon observation of the room environment, observed one panel of the window screen was not affixed on the window frame creating a gap or opening from top to bottom measuring half an inch. During a concurrent observation and interview on 5/29/2024 at 11:46 a.m., with the Assistant Director of Nursing (ADON), observed the gap on the window screen of Room A. The ADON stated staff frequently conduct room inspections to ensure the environment is safe for the residents. The ADON stated that they make sure rooms are clutter free and free from insect infestations. The ADON…

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 develop and implement a person-centered care plan (a written document that summarizes a resident's needs, goals, and care/treatment) for antibiotic (medicines that fight infections caused by bacteria) use for one of two sampled residents (Resident 6). This deficient practice had the potential to result in failure to deliver the necessary care and services. Findings: A review of Resident 6's admission Record indicated the facility initially admitted the resident on 9/7/2022 and readmitted the resident on 9/14/2023 with diagnoses that included muscle weakness, urinary tract infection (an infection in any part of the urinary system), and gastro-esophageal reflux disease (a common condition in which the stomach contents move up into the esophagus [muscular tube through which food passes from the throat to the stomach]). A review of Resident 6's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 3/17/2024, indicated the resident had the capacity to make self-understood and the capacity to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY b. A review of Resident 33's admission Record indicated the facility admitted the resident on 6/23/2020 and readmitted the resident on 6/12/2024 with diagnoses that included heart failure (a condition in which the heart doesn't pump blood as well as it should), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), difficulty in walking, and history of falling. A review of Resident 33's MDS dated [DATE], indicated that Resident 33's cognitive skills for daily decision making were moderately impaired. The MDS indicated that Resident 33 required partial/moderate assistance with oral hygiene, upper body dressing, and personal hygiene. The MDS also indicated Resident 33 required substantial/maximal assistance with toileting hygiene and shower. During a concurrent observation and interview on 6/15/2024, at 10:30 a.m., with Resident 33, observed Resident 33 have long and untrimmed fingernails. Resident 33 stated that his nails were long and stated that he would like his nails…

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 During an interview and record review, the facility failed to implement the facility's fall policy, by failing to ensure a post-fall evaluation was conducted for two of two sampled residents (Resident 29 and Resident 30). This deficient practice placed the residents at risk of not receiving appropriate care and services after a fall incident. Findings: a. A review of Resident 29's admission Record indicated the facility admitted the resident on 9/22/2023 with diagnoses that included heart failure (a condition in which the heart doesn't pump blood as well as it should), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) without behavioral disturbance. A review of Resident 29's Minimum Data Set (MDS- an assessment and screening tool) dated 3/31/2024, indicated that Resident 29's cognitive (the mental action or process of acquiring knowledge…

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 complete a post-dialysis (the removing of waste and excess fluid to prevent build up in the body for residents who have loss of kidney [organs that remove waste products from the blood and produce urine] function) assessment for one of two sampled residents (Resident 5). This deficient practice placed Resident 5 at risk for complications of dialysis such as redness at the dialysis access site (way to reach the blood for hemodialysis), edema (too much fluid trapped in the body's tissues), excessive bleeding, and a change in vital signs (clinical measurements that indicate the state of a patient's essential body functions). Findings: A review of Resident 5's admission Record indicated the facility admitted the resident on 6/27/2020 and readmitted the resident on 9/19/2023 with diagnoses that included end stage renal disease (chronic irreversible kidney failure), dependence on renal (kidney) dialysis, and diabetes mellitus (a chronic condition that affects the way the body processes blood glucose [sugar]). 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain infection control practices by failing to: 1. Ensure Certified Nursing Assistant 4 (CNA 4) donned (put on) gloves, gown, and goggles prior to entering a droplet isolation room (used to prevent the spread of pathogens that are passed through respiratory secretions) for one of three sampled residents (Resident 33). This deficient practice had the potential for the spread of infection and cross contamination among residents. 2. Ensure a resident's nasal cannula (a medical device that provides supplemental oxygen or increased airflow to people who need respiratory help) was not touching the floor for one of 14 sampled residents (Resident 25). This deficient practice had the potential to place the resident at increased risk of contracting an infection. Findings: 1. A review of Resident 33's admission Record indicated the facility admitted the resident on 6/23/2020 and readmitted the resident on 6/12/2024 with diagnoses that included…

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 follow their policy and procedure by failing to monitor one of two sampled residents (Resident 2) after a fall incident. This deficient practice placed the resident at risk of not receiving appropriate care and services and the potential to result in undetected pain or injury after a fall incident. Findings: A review of Resident 2's admission Record indicated the facility admitted the resident on 4/23/2020 with diagnoses that included polyosteoarthritis (five or more of your joints have arthritis [inflammation or swelling of one or more joints] at the same time), difficulty walking, and unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A review of Resident 2's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 1/7/2024, indicated Resident 2 had severely impaired cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making. The 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.