Northbrook Healthcare and Rehabilitation Center

Based on clinical record review, facility policy review, resident interview, and staff interview, the facility failed to ensure staff obtained and/or administered medications per physician order and professional standards of practice for 1 of 1 residents sampled (Resident #7) with a resident reported medication error by staff. The facility reported a census of 85 residents.Findings include: The Minimum Data Set (MDS) assessment for Resident #7, dated 6/5/25, revealed diagnoses of end stage renal disease and systemic Lupus (an autoimmune disease). The MDS identified the resident had a Brief Interview for Mental Status (BIMS) of 13 out of 15 (indicative of a mild cognitive impairment). The MDS identified the resident received renal dialysis. The Care Plan for Resident #7, last revised 8/1/25, revealed the resident took a sedative/hypnotic for insomnia. On 8/13/2025 at 8:09 AM, Resident #7 reported concerns with nursing staff medication administration for two different medications. Resident #7 explained that she had been taking Zolpidem (Ambien) to treat insomnia for the last 15 years.…

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 clinical record review, policy review, and resident and staff interviews, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities for 1 of 1 residents reviewed for activities(Resident #81). The facility reported a census of 85 residents. The admission Minimum Data Set (MDS) assessment tool, dated 4/23/25, listed diagnoses for Resident #81 which included anxiety, depression, and weakness. The MDS stated it was very important for the resident to go outside when the weather was good. The MDS listed the Brief Interview for Mental Status (BIMS) score as 14 out of 15, indicating intact cognition. The facility policy Activities, dated 3/27/25, stated the facility would provide an ongoing program to support the resident in their choice of activities based on their comprehensive assessment, care plan, and preferences. A 4/23/25 Resident Preferences Evaluation stated it was very important to the resident to go outside to get fresh air when 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 clincal record review, staff interview and policy review the facility failed to complete an assessment for 1 of 4 residents (Resident #96) reviewed for hospitalizations. The facility reported a census of 85 residents. Findings include: Progress Notes written on 6/3/25 at 4:28 PM document Resident #96 readmitted to the facility following cholecystitis (inflammation of the gallbladder), sepsis (sepsis happens when an infection you already have triggers a chain reaction throughout the body. It is a life threatening, medical emergency per the Center for Disease Control (CDC)), and septic shock (a severe form of sepsis characterized by dangerously low blood pressure and abnormalities in cellular and metabolic function). The clinical record lacked a physical assessment or vital signs on 6/3 and 6/4. The pre-dialysis assessment completed on 6/5 included vitals of Temperature 97.2 Fahrenheit (F), Pulse 88, Respirations 16, Blood Pressure (BP) 96/56 and oxygen saturation (O2 Sat) of 88%. The post-dialysis assessment completed on 6/5 included vitals of Temperature 98.7 F, Pulse 80,…

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, clinical record review, and staff interviews, the facility failed to utilize foot pedals during wheelchair transport in order to ensure safety and failed to ensure good working order of a walker to prevent falls for 3 of 5 residents reviewed for accidents (Residents #12, #49, and #101). The facility reported a census of 85 residents.Findings include: 1. The Minimum Data Set (MDS) assessment tool, dated 6/18/25, listed diagnoses for Resident #12 which included non-Alzheimer's dementia, anxiety disorder, and cancer. The MDS stated the resident was dependent on staff to propel her wheelchair and listed her Brief Interview for Mental Status (BIMS) score as 12 out of 15, indicating moderately impaired cognition. On 8/11/25 at approximately 11:00 a.m., Staff A Hospice Tech pushed Resident #12 in her wheelchair from the nursing station to her room, a distance of approximately 50 feet. The resident's feet were not placed on foot pedals and the bottoms of her feet lightly touched the ground while Staff A pushed her. On 8/13/25 at 4:38 p.m., the Director of Nursing(DON)…

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 clinical record review, review of facility policy/protocol, resident and staff interview, the facility failed to ensure that a resident with symptoms of a potential urinary tract infection (UTI) received prompt testing and ongoing assessment to prevent worsening of symptoms for 1 of 1 resident (Resident #17) with a complaint of a possible UTI. The facility reported a census of 85.Findings include:The Minimum Data Set (MDS) assessment for Resident #17, dated 5/22/25, identified diagnoses of atrial fibrillation, heart failure, and chronic kidney disease. The MDS identified a Brief Interview for Mental Status (BIMS) score of 14 out of 15 (indicative of mild cognitive impairment).The Care Plan for Resident #17, last revised 7/30/25, included a focus area of bladder incontinence and the following intervention: Monitor/document for s/sx (signs/symptoms) UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change 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 clinical record review, observation, facility policy review and staff interview, the facility failed to ensure nursing staff followed facility policy and physician orders regarding checking for enteral feeding tube placement, checking for residual gastric volume, and flushing with the correct amount of fluid prior to administering an enteral feeding to 1 of 1 sampled residents (Resident #4) with an gastric feeding tube. The facility reported a census of 85.Findings include: The Minimum Data Set (MDS) assessment, dated 7/14/25, identified Resident #4 had diagnoses of cerebral infarction (stroke) and dysphagia (difficulty swallowing). The MDS identified the resident received nutrition enterally (through a feeding tube) and had a severe cognitive impairment. The Care Plan for Resident #4, last revised 5/22/25, identified the resident had an order for nothing by mouth (NPO) and required feeding, medication, and hydration through a gastric feeding tube (G-Tube). The Care Plan included an intervention for staff to check for tube placement and gastric contents/residual volume. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on electronic health record (EHR) review, clinical record review, facility records, resident, physician and staff interviews, the facility failed to ensure a resident understood the Alternative Dispute Resolution before signing the agreement for 1 of 3 residents (Resident #104) reviewed. The facility reported a census of 89 residents. Findings include:During the Entrance Conference on 8/11/25, The Administrator revealed the facility offered Alternative Dispute Resolution agreements to residents. Staff X, Licensed Practical Nurse (LPN)/Admissions & Marketing Coordinator was responsible for explaining and reviewing the paperwork with the resident and/or the resident's legal representative. The History & Physical (H&P) dated 7/26/25 provided by the facility documented Resident #104 had dementia with major neurocognitive disorder.The Preadmission Screening and Resident Review (PASRR) screening dated 7/29/25 provided by the facility documented the Level I screen showed Resident #104 to have evidence of 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 clinical record review, observation, facility policy review and staff interview, the facility failed to ensure staff followed infection prevention policies including enhanced barrier precautions for 3 of 3 sampled residents (Resident #4, #6, and #58) who required the use of enhanced barrier precautions and for the staffs' lack of knowledge in the handling of soiled linens. The facility reported a census of 85. 1. The Minimum Data Set (MDS) assessment, dated 7/14/25, identified Resident #4 had diagnoses of cerebral infarction (stroke) and dysphagia (difficulty swallowing). The MDS identified the resident received nutrition enterally (through a feeding tube) and had a severe cognitive impairment. The Care Plan for Resident #4, last revised 5/22/25, identified the resident had an order for nothing by mouth (NPO) and required feeding, medication and hydration through a gastric feeding tube (G-Tube). The Care Plan included a focus on enhanced barrier precautions (EBP) which included interventions of wearing a gown and gloves for all high contact activities. The Care Plan…

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 clinical record review, staff and resident interviews, policy review, and observations the facility failed to keep the facility in a clean, homelike manner. The facility reported a census of 73 residents. Findings include: Observation on 3/11/25 at 1:00 pm revealed the following: a. 5 of 9 resident rooms on Hall A noted to have window curtains that are falling down, not attached to the curtain rods. b. 3 of 7 resident rooms on Hall C noted to have window curtains that are falling down, not attached to the curtain rods. c. 2 of 11 residents rooms on Hall D do not have window curtains or rods but have a white sheet covering the entire window. 6 of 11 resident rooms noted to have window curtains that are falling down, not attached to the curtain rod. Room D-12 does not have any window covering. Observation on 3/11/25 at 1:00 pm revealed the following: a. 9 of 9 resident rooms on Hall A exterior windows are dirty, noted to have dust and grime covering the exterior window. b. 4 of 7 resident rooms on Hall C exterior windows are dirty, noted to have dust and grime covering 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 staff interview, resident record review, and facility policy review the facility failed to treat 1 out of 3 residents reviewed with respect and dignity (Resident #7). The facility reported a census of 73 residents. Finding include: The Minimum Data Set(MDS) assessment tool dated 1/23/25, listed diagnoses for Resident #7 which included history of traumatic brain injury and non Alzheimer's dementia. The MDS stated the resident required extensive to total assist of staff for toileting, hygiene, showering, and personal hygiene. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 5 out of 15, indicating severe cognitive impairment. Review of the Progress Note dated 1/21/2025 at 2:25 PM revealed a follow up with Resident #7 about physical abuse incident. He denies feeling unsafe or scared for his safety. Review of the summary of Allegation of Abuse document revealed on 1/15/25 at 9:55 AM Staff C, CNA struck Resident #7 on the back of the head. The swat to the head had enough force that it caused his chin to go forward towards his chest. On 3/10/25 2:41…

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, clinical record review, staff interview, and policy review, the facility failed to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections during dining and during wound care for 2 of 2 residents reviewed for wound care (Resident #16 and #52). The facility reported a census of 72 residents. Findings include: 1. During an observation 9/17/24, from 12:11 PM to 12:45 PM, in the main dining hall, Staff I, Certified Nursing Assistant (CNA), assisted three residents with cutting up food on their plates, two residents at one table, one at another table, assisted two with their first bites, touched their dessert cup with fingers on the inside of the cup. Staff I did not sanitize hands in between residents. Staff I continued to move back and forth between two residents at one table with giving them bites of their food without sanitizing hands in between residents. Staff I then went to another table and assisted another resident with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, family interview, staff interview, and clinical record review the facility failed to ensure resident dignity for 2 of 3 residents reviewed (Residents #16 & #52). The facility reported a census of 72 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #52 dated 6/27/24 documented diagnoses that included dementia, anxiety, and depression. A Brief Interview for Mental Status (BIMS) assessment was coded, not completed resident rarely/never understood. The Care Plan focus and intervention initiated 1/11/23 documented self-care performance deficits related to activity intolerance, aggressive behavior, confusion, dementia, fatigue, limited mobility. Resident #52 was totally dependent on two staff for dressing. In an interview on 9/18/24 at 10:30 AM Resident #52's responsible party relayed they had reported on two occasions staff brought Resident #52 into the main dining room without pants and only a blanket, Resident would be mortified to know he was exposed. They…

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

Based on resident interview, family interview, staff interview, clinical record and documents review the facility failed to include resident in decision making, denied resident right to be informed and choose options affecting care for 1 of 6 resident reviewed for choices (Resident #19). The facility reported a census of 72 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #19 dated 6/26/24 revealed diagnoses, End stage renal disease (ESRD), anxiety and depression. A Brief Interview for Mental Status (BIMS) assessment scored 15 out of 15 indicating no cognitive impairment. The care plan focus initiated 5/1/24 for Resident #19 directed staff to discuss with resident any concerns related to loss of independence, decline in function. Interventions also included resident teaching should include disease progression. Additional focus area initiated 3/8/24 revealed resident is independent for meeting emotional, intellectual, physical and social needs. A Durable Power of Healthcare document dated 7/31/12 for Resident #19 documented allows family member…

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 clinical record review, staff interview, and policy review, the facility failed to fully review and revise the comprehensive Care Plan for 1 of 5 residents who were sampled for Care Plan review (Resident #5). The facility reported a census of 72 residents. Findings include: The Minimum Data Set (MDS) for Resident #5, dated 8/29/24, documented a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. The MDS further documented diagnoses to include medically complex conditions, cancer, non-Alzheimer's dementia, anxiety disorder, and depression. The MDS further revealed the resident was taking an antidepressant medication. A review of the electronic health record (EHR) for Resident #5 revealed an order for Remeron Oral Tablet 15 milligram (MG) (Mirtazapine) to be given by mouth at bedtime for depression, ordered on 4/11/24. The EHR for Resident #5 revealed diagnoses of Major Depressive Disorder, Depression, unspecified, and Anxiety Disorder, unspecified. The Care Plan for Resident #5, with a revision date of 9/11/24, did not include a focus…

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

Based on observation, staff interview, resident interview, and policy review the facility failed to follow the diet order for 1 of 3 residents reviewed on therapeutic diet (Resident #19). The facility reported a census of 72 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #19 dated 6/26/24 revealed a therapeutic diet ordered. Diagnoses included End state Renal Disease (ESRD). A Brief Interview for Mental Status (BIMS) assessment scored 15 out of 15 indicating no cognitive impairment. The Care Plan focus initiated 3/5/24 documented nutrition risk related to ESRD on dialysis, food intolerances, and therapeutic diet. Direct staff to serve diet as ordered. Documented double servings eggs, cereal at breakfast that was added on 4/3/24. In an interview and observation on 9/17/24 at 12:59 PM Resident #19 revealed his lunch plate, over half the plate full of food. Resident relayed he could not eat this, the meat was terrible, couldn't eat the meal other than a few bites. Relayed sauerkraut was awful and having that on the plate made it all taste bad. Relayed…

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 clinical record review, resident interview, staff interview, and dialysis transfer agreement the facility failed to ensure pre and post dialysis assessments were completed for 1 of 1 resident reviewed for dialysis (Resident #19). The facility reported a census of 72 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #19 dated 6/26/24 revealed a diagnosis of End stage renal disease (ESRD). A Brief Interview for Mental Status (BIMS) assessment scored 15 out of 15 indicating no cognitive impairment. The Care Plan focus initiated 3/1/24 documented, Resident #19 needed hemodialysis related to renal failure, scheduled weekly on Monday, Wednesday, and Friday, documented the resident would have immediate intervention should any signs or symptoms of complications from dialysis occur. On 09/16/24 at 02:29 PM, Resident #19 confirmed long term dialysis and history of health complications resulted in nursing home placement this year, could not recall a pattern of assessments completed relating to dialysis appointments. A Clinical record review on 9/17/24…

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

Based on record review, staff interviews, and policy review the facility failed to complete a quarterly assessment in a timely manner for 1 of 3 residents reviewed (Resident #2). The facility reported a census of 74 residents. Findings include: The Minimum Data Set (MDS) for Resident #2 dated 4/25/24 documented a Brief Interview for Mental Status (BIMS) of 12/15 indicating moderate cognitive impairment, and included diagnoses of acute respiratory failure with hypoxia (not enough oxygen in tissue), sepsis, and congestive heart failure. Section GG documented the resident used a walker or wheelchair for mobility and required set up or clean up assistance with sit to stand, chair to bed/bed to chair transfers, and toilet transfers. The electronic health record (EHR) for Resident #2 documented MDS assessments completed for discharge with anticipated return on 7/10/24 and entry back to the facility 7/11/24. The EHR showed a quarterly assessment due date of 7/26/24 with a complete by date of 8/9/24. At the time of this review that assessment due date was highlighted red and indicated it…

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; clinical record review; a written grievance; and staff, resident, and family interviews the facility failed to provide consistent restorative cares to prevent decline in mobility and/or range of motion for 3 of 4 residents reviewed (Residents #1, #2, #3). The facility reported a census of 77 residents. Findings include: 1. The Minimum Data Set (MDS) for Resident #1 dated 5/31/24 documented diagnoses of hemiplegia following cerebral infarction (stroke) affecting the left side, weakness, and arthritis. MDS Section C documented a Brief Interview for Mental Status (BIMS) of 12/15, indicating moderate cognitive impairment. Section GG documented the resident required a walker or wheelchair for mobility, needed substantial to maximal assistance with bed mobility, and was dependent on 2 or more helpers for sit to stand and transfers. The resident did not have a history of using a mechanical lift. Resident #1 ' s care plan revealed a focus area dated 5/24/24 which documented an ADL self care deficit related to limited range of motion and limited mobility. Interventions…

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

Based on record review, policy review, and interviews the facility failed to ensure providers reviewed medications and associated diagnoses for 1 of 3 residents reviewed (Residents #2). During 3 visits in June 2024, including a medication review, the provider did not find the medication error The facility reported a census of 77. Findings include: The Minimum Data Set (MDS) for Resident #2 dated 4/25/24 documented a Brief Interview for Mental Status (BIMS) of 12/15 indicating moderate cognitive impairment, and included diagnoses of acute respiratory failure with hypoxia (not enough oxygen in tissue), sepsis, and congestive heart failure. It did not include a diagnosis of diabetes. The Medication Administration Record (MAR) documented Resident #2 received 77 doses of Glimepiride Tablet 2 MG for diabetes between 4/24/24 and 7/11/24. Progress notes dated from 3/17/24 through 7/15/24 labeled Order Note lacked orders for the Glimepiride entered into the MAR. A document titled Order Details from the EHR documented the order was entered and confirmed by Staff G, Licensed Practical Nurse,…

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

Based on record review, policy review, and interviews the facility failed to ensure pharmacy consultants reviewed medications and associated diagnoses for 1 of 3 residents reviewed (Residents #2). During 3 separate monthly drug regimen reviews the pharmacy consultant failed to find the diabetic medication error for the resident. The facility reported a census of 77. Findings include: The Minimum Data Set (MDS) for Resident #2 dated 4/25/24 documented a Brief Interview for Mental Status (BIMS) of 12/15 indicating moderate cognitive impairment, and included diagnoses of acute respiratory failure with hypoxia (not enough oxygen in tissue), sepsis, and congestive heart failure. It did not include a diagnosis of diabetes. The Medication Administration Record (MAR) documented Resident #2 received 77 doses of Glimepiride Tablet 2 MG for diabetes between 4/24/24 and 7/11/24. Progress notes dated from 3/17/24 through 7/15/24 labeled Order Note lacked orders for the glimepiride entered into the MAR. Progress notes labeled Pharmacy Note indicated the resident ' s medications were reviewed 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 clinical record review, policy review and staff interviews, the facility failed to provide 4 of 5 resident's reviewed with 2 baths weekly (Residents # 3, #4, #5, #6). The facility reported a census of 78 residents. Findings include: 1. According to the MDS (Minimum Data Set) dated 12/14/2023, Resident #3 had diagnoses which included dementia and cerebrovascular insufficiency, and had severely impaired cognitive ability. The resident's Care Plan indicated the resident transferred with the assistance of two staff and a mechanical lift. Staff were instructed to wash what the resident could not do for herself. Review of the December, 2023 bath record revealed the resident received two baths during the month from December 1 - December 31, 2023. 2. According to the MDS dated [DATE], Resident #4 had severely impaired cognitive ability, required staff assistance to transfer and ambulate, and had diagnoses including dementia, weakness, and depression. The resident's Care Plan directed staff to provide a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff and resident interviews, policy review, and observations, the facility failed to provide appropriate assessments and interventions for 4 of 6 residents reviewed with impaired skin and a change of condition (Residents #1, #6, #8, #9). The facility reported a census of 78 residents. Findings include: 1. According to the Minimum Data Set (MDS) dated [DATE], Resident #1 had diagnoses which included heart disease, Covid related weakness, and Alzheimer's. The MDS revealed the resident required assistance of 1 staff for transfers, dressing, bathing, and hygiene. The resident utilized a wheelchair and walker to move about the facility. The Resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognitive ability. Review of the initial Care Plan dated 1/31/24 indicated Resident #1 was at risk for skin breakdown related to bladder incontinence. The plan directed the staff to provide medications, treatments and dressings as ordered by the physician.…

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, clinical record review, and staff interviews, the facility failed to follow the resident's Care Plan for 1 of 11 residents reviewed (Resident #6). The facility reported a census of 78 residents. Findings include: The MDS (Minimum Data Set), an assessment tool, dated 1/4/2024, revealed Resident #6 had impaired cognitive abilities with long and short term memory impairment. The resident was dependent on staff to transfer from one surface to another, had one stage two pressure ulcer and incontinent of bowel and bladder. The resident had diagnoses including dementia and depressive disorder. The resident's Care Plan identified the resident had a risk for pressure sore development related to immobility initiated 7/13/2023. On 11/16/2023 the Care Plan indicated a stage II coccyx wound healed. The Care Plan directed staff to assist resident to shift weight in wheel chair every 15 minutes, educate resident/family/caregivers as to causes of skin breakdown including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition…

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 clinical record review, staff and resident interviews, policy review and observations, the facility failed to follow physician's orders for 3 of 3 residents reviewed (Resident #1, #6, #9). The facility reported a census of 78 residents. Findings include: 1. According to the Minimum Data Set (MDS) dated [DATE], Resident #1 had diagnoses which included heart disease, Covid related weakness, and Alzheimer's. The MDS revealed the resident required assistance of 1 staff for transfers, dressing, bathing, and hygiene. The resident utilized a wheelchair and walker to move about the facility. The Resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had intact cognitive ability. Review of the initial Care Plan dated 1/31/24 indicated Resident #1 was at risk for skin breakdown related to bladder incontinence. The plan directed the staff to provide medications, treatments, and dressings as ordered by the physician. Review of the unsigned Resident admission assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. Resident #46's MDS assessment dated [DATE] identified a BIMS score of 6, indicating severe cognitive impact. The MDS included diagnoses of medically complex conditions, renal insufficiency (inadequate kidney function), Alzheimer's disease and traumatic brain injury. The Care Plan Focus revised 9/20/23 indicated that Resident #46 had an activities of daily living (ADL) self-care performance deficit related to Alzheimer's, confusion, dementia, fatigue, shortness of breath, stroke, and traumatic brain injury. On 10/10/23 at 1:05 PM observed Resident #46 in the hallway outside of his room without pants or underwear on, sitting in his wheelchair. Resident #46's private area was visibly exposed. Resident #46 asked Staff E, Housekeeper, to get him assistance. Resident #46's roommate and two other residents noted in the hallway at the time. Resident #46 remained exposed in the hallway without pants or underwear on for approximately six minutes. On 10/10/23 at 1:10 PM, Staff E indicated Resident #46 yelled out for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, policy review, and staff interview the facility failed to store and prepare food under sanitary conditions for 2 of 2 kitchen observations that included sanitizer buckets, expired food items, and a dishwasher in disrepair. Observations of staff clothing touching the pureed food containers during the puree and reheat processes which impacted 3 of 3 residents. The facility reported a census of 61 residents. Findings include: 1. The initial kitchen observation and tour with the Food Services Supervisor (FSS) on 10/9/23 revealed the following: A. At 10:37 AM two red sanitizer buckets for food preparation surfaces were empty and dry while noodles, chicken, sauce, and vegetables were prepared. Observation included utensils for foods placed on multiple surfaces and one bucket moved from the dirty dish side of the kitchen to the clean side of the kitchen and set on the counter to be filled without being wiped down. B. At 10:42 AM the dishwasher wash cycle temperature read 162.6 degrees. The rinse…

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 clinical record review and staff interviews, the facility failed to notify the physician and family when a resident required the Heimlich maneuver for 1 of 4 residents reviewed (Resident #39). Findings include: A review of the clinical medical records on 10/10/23 at 3:40 PM, documented on 9/11/23 at 8:00 AM in the nurse's notes Resident #39 had the Heimlich maneuver done three times by the nurse. Resident #39's clinical record lacked notification to the physician and family regarding the Heimlich maneuver. On 10/11/23 at 8:15 AM the Director of Nursing (DON) reported that the physician and family did not get notified due to the nurse who did the Heimlich maneuver reported Resident #39 had been coughing. The DON educated the nurse on if a resident is coughing then the resident should not have the Heimlich done. When clarifying with the DON, she reported the facility should notify the physician and family when the Heimlich maneuver is done on a resident.

Based on observation and staff interviews the facility failed to provide a clean, safe and comfortable environment for the residents. The facility reported a census of 61 residents. Findings include: An observation on starting on 10/10/23 at 10:48 AM revealed a missing air vent grill on Room B4 and CR20 room air conditioners. Witnessed the shower rooms propped open with buckets. Missing and broken tile in hallway B shower room. The white caulk on the base of the shower appeared to have most of it covered in a black buildup of dirt and grim. During a walkthrough of the laundry room on 10/11/23 at 10:00 AM revealed an unattached baseboard next to the washing machine lying on the floor. Noted duct tape used to put the baseboard up, but the duct tape hung on the base of the wall. On 10/11/23 at 3:00 PM, the Director of Nursing (DON) reported that she did know about the air conditioner missing a part or the concerns in the Hallway B shower room, but, she would look into getting them fixed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy review, staff and resident interview, the facility failed to report a resident to resident altercation to the Iowa Department of Inspections and Appeals (DIA) for 1 of 1 residents sampled for a resident to resident altercation (Resident #41). Findings include: 1. Resident #41's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS indicated that Resident #41 did not have any behavioral symptoms during the look back period. The MDS included diagnoses of anxiety, depression, chronic pain syndrome. Resident #41's Care Plan initiated 2/3/21 documented that she had depression. The Goal indicated that Resident #41 would remain free of symptoms of depression, anxiety, or sad mood through the review date (12/20/23). The Intervention dated 2/3/21 directed the staff to monitor, document, and report fi she experiences a sense of hopelessness, helplessness, and/or safety…

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 clinical record review, facility policy review, staff and resident interview, the facility failed to complete a thorough investigation for 1 of 1 residents sampled for a resident to resident altercation (Resident #41). Findings include: 1. Resident #41's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS indicated that Resident #41 did not have any behavioral symptoms during the look back period. The MDS included diagnoses of anxiety, depression, chronic pain syndrome. Resident #41's Care Plan initiated 2/3/21 documented that she had depression. The Goal indicated that Resident #41 would remain free of symptoms of depression, anxiety, or sad mood through the review date (12/20/23). The Intervention dated 2/3/21 directed the staff to monitor, document, and report fi she experiences a sense of hopelessness, helplessness, and/or safety awareness. Then report to the Medical Director (MD) if Resident #41 felt…

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 clinical record review, family and staff interviews, the facility failed to accurately complete a comprehensive Care Plan for 1 of 15 residents reviewed (Resident #39). Findings include: On 10/9/23 at 5:09 PM, Resident #39's daughter reported that she had to remind the staff to put the continuous positive airway pressure machine (CPAP, machine to help treat sleep apnea) on her mother at night. The Care Plan lacked documentation of the use of a CPAP machine for Resident #39. On 10/11/23 at 8:10 AM the Director of Nursing (DON) reported Resident #39's Care Plan should include her use of a CPAP and did not know how it got was missed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, policy review, and interviews the facility failed to weigh a resident weekly as ordered by the physician for 1 of 3 residents reviewed for nutrition (Resident #14). Findings include: Resident #14's Minimum Data Set (MDS) assessment dated [DATE] included diagnoses of anemia (low iron in the blood), peripheral vascular disease (narrowing of blood vessels outside of the heart or brain), and gastro-esophageal reflux disease (GERD, stomach acid repeatedly flows into the esophagus). The assessment lacked a current weight and listed weight loss of 5% or more in the last month or a loss of 10% or more the last six months as no or unknown. The Physician's Orders sheet signed by the physician on 8/8/23 listed an order dated 5/18/23 to check weekly weights. The Care Plan failed to address weekly weights as ordered by the physician beginning 5/18/23 and alternate options for declined nutritional supplements. The Nutritional Risk Assessment in the electronic health record (EHR), effective…

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 4. Resident #37's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 3, indicating severely impaired cognition. The MDS included diagnoses of arthritis, traumatic brain injury, and anxiety. Resident #37 required extensive assistance from two persons for bed mobility, transfers, dressing, and toilet use, with an extensive assistance from one person for eating and personal hygiene. The Care Plan Focus revised 9/20/23 documented that Resident #37 required assistance meeting his emotional, intellectual, physical, and social needs related to cognitive deficits. The Intervention dated 11/21/22 indicated that Resident #37 needed assistance/escort to activity functions. The Care Plan Focus revised 9/20/23 documented that Resident #37 had impaired physical mobility related to Alzheimer's, contractures, disease process, rheumatoid arthritis, subdural hematoma (bleeding on a part of the brain), and weakness. Interventions included staff and resident propelled…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, policy review, and interviews the facility failed to a comprehensive assessment of a resident's nutritional needs for 1 of 3 residents reviewed (Resident #14) for nutrition. Findings include: Resident #14's Minimum Data Set (MDS) assessment dated [DATE] included diagnoses of anemia (low iron in the blood), peripheral vascular disease (narrowing of blood vessels outside of the heart or brain), and gastro-esophageal reflux disease (GERD, stomach acid repeatedly flows into the esophagus). The assessment lacked a current weight and listed weight loss of 5% or more in the last month or a loss of 10% or more the last six months as no or unknown. Resident #14's previous MDS assessment dated [DATE] documented a weight of 95 pounds. The assessment indicated that Resident #14 had a weight loss of 5% or more in the last month or a loss of 10% or more the last six months, not on physician prescribed weight loss regimen. On 10/10/23 at 8:15 AM Resident #14 reported that she is losing…

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, clinical record review, and staff interview the facility failed to secure a level 4 controlled drug, lorazepam concentrated liquid (anti-anxiety medication), that required refrigeration in a locked medication refrigerator for 2 of 2 mediation refrigerators in the facility. Schedule II-V controlled medications have a potential for abuse and may also lead to physical or psychological dependence. The facility reported a census of 61 residents. Findings include: On 10/9/23 at 2:44 PM, Staff A, Licensed Practical Nurse (LPN), opened the unlocked fridge in the medication room on the CR Unit (rehabilitation unit), revealing three bottles of liquid lorazepam in the refrigerator. The refrigerator was not locked. The medication room was locked. Staff A verified that the Lorazepam should be double locked. On 10/10/23 at 9:27 AM, Staff B, Registered Nurse (RN), opened the unlocked refrigerator in the front nurse's station medication room. The refrigerator had a padlock on the door of the refrigerator but the second part to the lock that should have been fastened to 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 clinical record review, observations, facility policy review, staff, and resident interviews, the facility failed to implement prevention practices to decrease the risk of infection for 2 of 8 the residents reviewed (Resident #39 and Resident #26). The facility failed to clean Resident #39's machine used to breathe at night. The nurse failed to wear gloves while giving Resident #26, his insulin. The facility reported a census of 61 residents. Finding included: 1. Resident #39's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. Resident #39 required extensive assistance from two persons with toilet use and limited assistance from one person with personal hygiene. On 10/9/23 at 5:09 PM Resident #39's daughter reported that the facility never cleaned her mother's continuous positive airway pressure machine (CPAP). Review of Resident #39's electronic and paper clinical health records lacked documentation of cleaning…

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.