La Bella Of Alton

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the resident's responsible party prior to a transfer to an acute care facility for evaluation and treatment of a change in condition for 2 of 3 residents (R3, R4)) reviewed for hospitalization in the sample of 12. The Findings Include: 1. R3's Face Sheet, undated, documents R3 was originally admitted to the facility on [DATE] and was discharged to the hospital on 8/16/24 with diagnosis of Chronic Obstructive Pulmonary Disease (COPD), Respiratory Failure, Panlobular Emphysema, Type 2 Diabetes Mellitus (DM), Malnutrition, Schizophrenia, Hypertension (HTN), Dependence on Supplemental Oxygen, COVID-19, and Deep Vein Thrombosis (DVT). R3's Care Plan, dated 7/25/24, documents R3 has a behavior problem related to threatening and cursing staff. R3 refuses labs, and wearing oxygen, R3 is a smoker/tobacco user and refuses to give cigarettes to staff for safe keeping. It continues 8/16/24: R3 is at Risk for rehospitalization and or unsuccessful discharge…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to administer medications as ordered for one of 5 residents (R8) reviewed for medication administration in the sample of 12. Finding include: On 8/21/24 at 8:15 AM R8 stated there is one certain agency nurse who does not come in and give her the 3 little thyroid pills she is supposed to have at 4:30 AM . She stated she did not know who the nurse was and she did not report it to anyone because she couldn't remember when it happened. R8's Minimum Data Set (MDS) dated [DATE] documents R8 is alert and oriented. R8's active Physician Order dated 11/30/23 documents she is to receive Levothyroxine 25 micrograms (mcg) Give 75 mcg by mouth one time a day for hypothyroidism. R8's Medication Administration Record (MAR) dated 8/1/24 to 8/31/24 does not document R8 received her scheduled dose of Levothryroxine on 8/12/24. On 8/22/24 at 10:25 AM V2, Director of Nursing (DON) , stated R8 was in the facility on the morning of 8/12/24 and should have received her…

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 communication and continuity of care between the facility and dialysis center for 1 of 3 residents (R2) reviewed for dialysis in the sample of 6. Findings include: R2's Physician Order Sheet (POS) for [DATE] documents diagnoses of end stage renal disease, atherosclerotic heart disease of native coronary artery without angina pectoris, type 2 diabetes mellites with hyperglycemia, cardiomyopathy, peripheral vascular disease, chronic systolic (congestive) heart failure, unspecified essential (primary) hypertension, need for assistance with personal care, difficulty in walking, gout, primary pulmonary hypertension, paroxysmal atrial fibrillation, systemic inflammatory response syndrome of non-infectious origin without acute organ dysfunction. R2's POS also documents she is to receive dialysis one time a day every Monday, Wednesday, and Friday for kidney disease. R2's Care Plan dated [DATE] documents problems: ESRD (end stage renal disease), Short…

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 operationalize their policy and procedures for testing and tracking COVID-19; wear appropriate PPE (Personal Protective Equipment), clean multi-use equipment, and perform hand hygiene after resident encounter of a COVID-19 resident, and post signage indicating the Facility is in COVID-19 outbreak. This failure has the potential to affect all 126 residents living in the Facility. Findings include: 1-The Facility's Line List for COVID-19 Outbreaks in Long Term Care Facilities documents the Facility's COVID-19 Outbreak began on 7/1/24. R6's Progress Notes document R6 was sent to the hospital for cough on 7/5/24 and returned on 7/10/24. R6's COVID Monitoring Assessment documents COVID-19 testing was not completed following hospitalization until four days later on 7/14/24. R6's Medical Records fail to document R6 was tested for COVID-19 upon 7/10/24 return to the Facility. 2-The Facility's Census Lists from 7/10/24 through 7/13/24 document R6…

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 employ a qualified Infection Preventionist (IP) with specialized training needed to track Facility infections and prevent the spread of infectious diseases, including COVID-19. This has the potential to affect all 126 residents living in the Facility. Findings include: The Facility's Line List for COVID-19 Outbreaks in Long Term Care Facilities documents the Facility has been in COVID-19 Outbreak Status since 7/1/24. On 7/23/24 at 12:15 PM, V3, Assistant Director of Nursing/Infection Preventionist (ADON/IP), stated she does not have the IP certification, but is currently working on the training. On 7/25/24 at 8:30 AM, V1, Administrator, stated V2, Director of Nursing (DON) and V7, Minimum Data Set (MDS) Coordinator, oversee infection control since V3, ADON/IP is not yet certified. She stated V2 and V7 both have full time roles, in addition to overseeing infection control. On 7/25/24 at 8:55 AM, V1, Administrator, stated she expects the Facility to follow policies regarding infection control. The Facility's Infection…

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, observation, and record review, the facility failed to provide the physician prescribed medication. There were 25 opportunities with 2 errors resulting in a 8% medication error rate. The errors involved R13 in the sample of 22. Findings include: On 7/23/24 at 5:21 AM V12, Licensed Practical Nurse (LPN), went to her medication cart to prepare R13's 5:00 AM medications. V12 was unable to locate the Levoxyl or the Omeprozole that was prescribed for R13. V12 stated that these medications have been ordered but have not came in yet. R13's July 2024 Physician Orders, documents, Levoxyl Tablet 88 MCG (micrograms) (Levothyroxine Sodium) Give 1 tablet by mouth one time a day for low thyroid hormone. This medication is scheduled for 5:00 AM. R13's July 2024 Physician Orders documents Omeprazole Oral Tablet Delayed Release 20 MG (milligrams) (Omeprazole). Give 1 tablet by mouth one time a day for GI (gastrointestinal). This medication is scheduled for 5:00 AM. R13's July 2024 Medication Administration Record documents that the Levoxyl and the Omeprozole were not available 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 accommodate and inform 1 of 5 residents (R5) of change in shower schedule. Findings include: R5's Face sheet documents an admission date of 10/10/2022. Diagnosis include Congestive Heart Failure, Atherosclerotic Heart Disease, Protein Calorie Malnutrition, Gastrointestinal Hemorrhage. R5's Minimum Data Set, MDS, dated [DATE] documents R5 has no cognitive deficits and requires partial/moderate assist with showering. R5's Care Plan with a revision date of 10/24/2022 documents R5 has an activity of daily living, ADL's, self-care performance deficit related to ADL needs and participation vary, Fatigue, Impaired balance, Limited Mobility, Weakness. Resident is currently receiving skilled therapy services with goal of returning home upon completion of rehab. Interventions include Bathing: Physical Limited - assist/1 staff. R5's progress notes dated 7/6/2024 at 11:04AM documents R5 very upset about many things going on. R5 is upset about the shower change…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review, the facility failed to provide showers for 4 of 4 residents (R2, R5, R6 and R17) in the sample of 21 reviewed for showers. Findings include: 1.R2's face sheet, dated 6/27/24, documented that R2 was admitted to the facility on [DATE]. R2's medical diagnosis sheet, dated 6/27/24, documented that R2 has the following diagnoses: cerebral ischemia, hypertension, history of cerebral infarction, depression, anxiety, muscle weakness, schizoaffective disorder, and need for assistance with personal care. R2's MDS (Minimum Data Set), dated 3/15/24, documented R2 is cognitively intact, R2 requires partial moderate assistance with hygiene and is dependent on staff for all mobility. On 6/25/24 R2's bath and skin report sheet, dated June 2024, documented that R2 had 2 showers in June on 6/8/24 and 6/15/24. On 6/25/24 at 9:20 am R2 was lying in bed with dried food stuck to her left arm and chest. R2's hair appeared greasy, and she appeared unkempt. R2 stated that she had not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure residents were seen by a physician for 4 of 7 residents (R2, R5, R18 and R21) reviewed for physician visits in the sample of 21. 1.R2's face sheet, dated 6/27/24, documented that R2 was admitted to the facility on [DATE]. R2's medical diagnosis sheet, dated 6/27/24, documented that R2 has the following diagnoses: cerebral ischemia, hypertension, history of cerebral infarction, depression, anxiety, muscle weakness, schizoaffective disorder, and need for assistance with personal care. R2's MDS (Minimum Data Set), dated 3/15/24, documented R2 is cognitively intact. On 6/26/24 at 9:15 am R2 stated that she has only seen her Medical Doctor (V18) one time and that was when she was admitted about two years ago. R2 stated that the Physician Assistant comes to see her but that her doctor never does. R2's EMR (Electronic Medical Record) does not document any Medical Doctor progress notes for 2024. 2.R5's face sheet, dated 6/27/24, documented that R5 was…

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, observation, and record review, the facility failed to sufficiently staff the facility to care for the resident needs, including Activities of Daily Living (ADLs), and answering call lights for 5 of 5 residents (R1, R2, R3, R4, R5) reviewed for sufficient staffing in the sample of 7. This deficiency has the potential to affect all 131 residents living in the facility. Findings include: 1. R1's Face Sheet, undated, documents, R1 was admitted to the facility on [DATE]. R1's Minimum Data Set, (MDS), dated [DATE], documents, R1 is cognitively intact. On 5/6/24 at 11:35 AM, R1 stated, They could use more help on the evenings and nights because, they always seem to be busier. I had an incontinent episode one night, and I put my call light on, and it took three hours to get someone to come clean me up. 2. R2's Face Sheet, undated, documents, R2 was admitted to the facility on [DATE] and was discharged on 4/24/25. R2's MDS, dated [DATE], documents, R2 had a moderate cognitive impairment. On 5/6/24 at…

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

Based on interview and record review, the facility failed to follow through on a recommendation for a medication change for 1 of 11 residents (R2) reviewed for medications in the sample of 11. Findings include: On 4/23/24 at 2:00PM, V15, R2's Guardian, stated, in January, after R2 was seen by the surgeon, the surgeon called her and told her R2 is cancer free and he will be starting back on his Levothyroxine 137 micrograms, (mcg). V15 stated, that never happened and then some Doctor with the facility, started him on a different dose and his Endocrinologist is upset. V15 stated, she doesn't want anyone changing any of R2's medications without consulting V17, his Endocrinologist. R2's Face Sheet, printed on 4/18/24, documents, his diagnoses to include Vascular Dementia, Unspecified Cirrhosis of Liver, Cerebral Infarction, Hypertension and Postprocedural Hypothyroidism. R2's Order Audit Report dated 4/18/24 documents, an order dated 2/01/24 by V7, Physician Assistant, for R2 to start taking Levothyroxine 112 mcg one time a day for hypothyroidism. Per the Order Audit Summary this order…

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 Administer Medications as ordered by the Physician for 1 of 11 residents (R11) reviewed for medications in the sample of 11. Findings include: On 4/24/24 at 8:25AM, a medication pass was observed with V19, Licensed Practical Nurse, (LPN), when she administered medications to R11. R11's Order Summary Report dated 4/24/24, documents, the order: 1/02/24: Folic Acid Oral Tablet 1 milligram, (mg), Give 3 tablets by mouth one time a day for supplement. During the observed medication pass, V19 only administered one Folic Acid 1 mg tablet, instead of the 3 tablets that were ordered. R11's Order Summary Report, also documented, the order: 3/28/24: Lamotrigine Oral Tablet 25 mg Give 2 tablets by mouth in the morning for seizures. During the observed medication pass, V19 only administered one tablet of Lamotrigine 25 mg, instead of the two tablets ordered by the Physician. R11's Order Summary Report, also documented, the order dated 1/05/24: Sertraline HCI Tablet 100 mg, Give 2 tablets by mouth one time a day 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, record review, and interview the facility failed to provide Therapeutic Diets as ordered by the Physician for two of three residents (R2 and R4) reviewed for Therapeutic Diets in a sample of 11. Findings Include: 1. On 4/23/2024 at 12:00PM, R4 received his lunch tray in his room. Observed his lunch to be a single serving of pasta and meat, (protein), and double portion of salad. R4's meal ticket documented, no specific diet order. On 4/18/2024 at 2:55PM, R4 face sheet revealed a diagnosis of sepsis, malignant neoplasm of rectum, history of antineoplastic chemotherapy; severe, protein calorie malnutrition, colostomy, human immunodeficiency virus disease, gastroesophageal reflux disease without esophagitis, iron deficiency anemia, hypokalemia, osteomyelitis of vertebrae, sacral and sacrococcygeal region, encounter for surgical aftercare following surgery on the digestive system. R4's Physician Order, dated, 4/16/24, documents, the order: Regular diet, Regular texture, Regular liquids…

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, observation and record review, the facility failed to store food at appropriate temperatures and failed to perform hand hygiene and change gloves while plating food to prevent potential food-borne illnesses. This has the potential to affect all 126 residents in the facility. Findings include: 1. On 3/18/24 at 7:30 AM, the kitchen was entered and toured. V15 Dietary Manager was present for the tour. The walk-in refrigerator thermometer read 44 degrees Fahrenheit (F) during the initial tour. On 3/18/24 at 12:15 PM the walk-in refrigerator thermometer was observed to be at 43 degrees F. On 3/18/24 at 12:40 PM the walk-in refrigerator thermometer was observed to be at 45 degrees F. On 3/19/24 at 12:15 PM the walk-in refrigerator temperature thermometer was observed, and it read 48 degrees F. On 3/18/24 at 7:30 AM there was a Daily Cooler Temperature Log, dated March 2024, posted on the wall by the walk-in refrigerator. V15 stated it was the temperature log for the walk-in refrigerator. The Daily Cooler Temperature Log documented AM and PM temperatures. This document…

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

Based on interview and record review, the facility failed to provide Dementia, Abuse, and other training to ensure competency of nurse's aides. This failure had the potential to affect all 126 residents residing in the facility. Findings include: 1.On 3/21/24 at 11:50 AM, V42, Human Resource (HR) Director stated All staff are hired with their license or certification prior to starting. They spend time with me to do all the HR paperwork and things like that. I don't know anything about other staff training. I do know when they start, they are on the floor doing hands-on training for at least three days. On 3/21/24 at 11:56 AM, V2, Director of Nursing (DON), stated CNAs (Certified Nursing Assistants) start with on-the -floor training for three to five days, usually one day per unit, and more if they need it. There is no other training done for new hires. I did have a company who was supposed to come in and train for Dementia, but they cancelled last week. (V1, Administrator) has told me that we will be getting (Online Education) training started again, but for now, and since 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 review the facility failed to provide complete incontinent care and proper catheter care to prevent urinary tract infections (UTIs) for 4 of 4 residents (R76, R85, R107, R108) reviewed for incontinence care in the sample of 59. Findings include: 1. R107's admission Record, undated, documented R107 was admitted to the facility on [DATE] with diagnoses of cerebral infarction, hemiplegia, dysarthria, dysphagia, essential hypertension, hyperlipidemia and type two diabetes mellitus (DM). R107's Minimum Data Set, MDS, dated [DATE], documented R107 is cognitively intact. R107's Care Plan, undated, documented R107 is incontinent of bladder and bowel and requires facility staff to provide perineal care after each incontinent episode. On 3/19/24 at 9:50 AM V18, Certified Nurse Assistant, CNA, and V19 CNA entered R107's room, donned gloves without the benefit of hand hygiene and removed R107's disposable brief. R107 was incontinent of urine and stool. V18 cleansed R107's inner…

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 document a date accessed/opened for multi-dose insulin injection pens for 4 of 4 residents (R12, R27, R122, R229) reviewed for medication labeling in the sample of 59. Findings include: 1. On 3/18/24, at 7: 31AM, V7, Licensed Practical Nurse, (LPN), stated that R27's, NovoLog FlexPen solution (pen-insulin) has been used. On 3/18/24 at 7:34AM, R27's insulin pen, not enclosed in a bag, was located inside the medication cart and did not have a date marked for when it was first accessed/opened. R27's Physician Order Sheet (POS), dated 3/2024, documented R27's is to receive Humulin 70/30, Kwik pen suspension subcutaneous injection of 100units/milliliters, give 20 units subcutaneous at 5:00AM and 30 units at 7:00PM. 2. On 3/18/24, at 7:40 AM, V7 stated R229's Humulin 70/30, Kwik Pen has been used. On 3/18/24 at 7:40 AM, R229's Humulin insulin pen, out of a sealed bag with a label on the injection pen, was not dated when it was accessed/opened. R229's POS documented R229 is to receive Humulin 70/30 to be started on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to perform hand hygiene to prevent the spread of infection for 4 of 5 residents (R76, R85, R107, R108) reviewed for infection control in the sample of 59. Findings include: 1. R76's admission Record, undated, documented R76 was admitted to the facility on [DATE] with diagnoses of inflammatory polyneuropathy, chronic obstructive pulmonary disease, essential hypertension, hyperlipidemia, chronic pain syndrome, dementia, atherosclerotic heart disease and polyosteoarthritis. R76's Minimum Data Set, MDS, dated [DATE], documented R76 is cognitively intact. R76's Care Plan, undated, documented R76 has occasional urinary incontinence and staff are to provide incontinence care as needed. On 3/19/24 at 10:30 AM V19, Certified Nurse's Aide, CNA, entered R76's room and donned gloves without the benefit of hand hygiene. V19 CNA removed R76's urine saturated disposable brief. V19 then rolled R76 onto her left side and V19 cleansed R76's buttock. V19 then…

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 timely complete the quarterly Minimum Data Sets (MDSs) for 3 of 3 residents (R85, R87) reviewed for timely completion of MDS quarterly assessments in the sample of 59. Findings include: 1.R87's Quarterly Minimum Data Set, (MDS), was dated 11/18/23. R87's Quarterly MDS, dated [DATE], was not completed (no information was entered into the assessment) within the 90 days of the last Quarterly MDS which was conducted on 11/18/23. On 03/19/24 at 2:42 PM, V24, MDS Coordinator, stated, there are two MDS Coordinators. V24 stated V25, MDS Coordinator, went on medical leave the first of February 2024. V24 stated, she thought the residents MDS's assessments, quarterly and annuals were up to date, but the computer system revealed a past due closing date greater that 90 days which included R87's quarterly MDS. V24 stated currently she is completing the residents MDS that is triggered in the system that is overdue. 2. R85's most recent completed MDS was 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide timely turning and repositioning to prevent pressure ulcers for 3 of 6 residents (R85, R107, R279) reviewed for pressure ulcers in the sample of 59. Findings include: 1. R279's Face Sheet, undated, documents R279 was admitted to the facility on [DATE] with diagnoses of Sepsis, Urinary Tract Infections (UTI), Malnutrition, COVID-19, Atherosclerotic Heart Disease (ASHD), Congested Heart Failure (CHF), Dementia, Dysphagia, Hypertension (HTN). R279's Care Plan, dated 2/10/24, documents R279 is at risk for skin impairment/pressure injury. R279's Care Plan Interventions document the following: avoid prolonged periods of skin to skin contact, minimize pressure over boney prominences, assist with turning and positioning if resident is unable, provide pressure relieving mattress. It continues R279 has area(s) of skin impairment. Left upper back P4 resolved 3/5/24, Left lower back P4, Right heel Deep Tissue Injury (DTI). 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to secure cigarettes and lighters for 2 of 2 residents (R21, and R281) reviewed for supervision to prevent accidents in the sample of 59. Findings include: 1. On 3/19/2024 at 9:15 AM R21 was sitting outside her room on 4 wheeled scooter. R21 stated she can smoke whenever she wants to smoke. R21 stated she smokes without staff supervision. R21 stated she keeps cigarettes and lighter in her personal possession. R21 opened pocket of hoodie and showed surveyor cigarettes and lighter. R21's Care Plan, dated 6/2/2023, documents R21's cigarettes and lighter are to be stored in a secure place. On 3/21/2024 at 1:50 PM, V1, Administrator, stated if R21's Care Plan documents that R2's cigarettes and lighter are to be kept in a secure place, she would expect the Care Plan to be followed. 2. R281's Face Sheet, undated, documents R281 was admitted to the facility on [DATE] with diagnoses of Metabolic Encephalopathy, Atherosclerotic Heart Disease (ASHD),…

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 all medications were administered with an error rate less than 5%. There were 30 opportunities with 2 errors observed which calculated to a medication error rate of 6.67%. This deficient practice was identified for 1 of 3 nurses administering medications to one of 3 residents (R58) reviewed for medication administration in the sample of 59. Findings include: 1. On 03/18/24 at 7:56 AM during medication administration, V4, Licensed Practical Nurse (LPN) did not administer Empagliflozin 10 milligrams (mg) as ordered to R58. V4 stated it was not available in the medication cart to give. During medication administration V4 obtained R58's inhaler out of the mediation cart and laid on top of cart, V4 then had to leave cart to go get stock medication that was not in the cart. At that time V4 locked R58's inhaler up in the cart and upon return did not administer the inhaler to R58. R58's Physician Order (PO) dated 3/6/2024 documents Empagliflozin 10 mg oral tablet give one daily one time a day for Diabetes…

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 obtain resident blood glucose levels, failed to administer medications, and failed to contact the Physician as ordered for 4 of 6 residents (R1, R8, R12, R13) reviewed for medication administration, in the sample of 13. The findings include: 1. R1's Face Sheet, undated, documented that R1 was admitted to the facility on [DATE] with diagnosis of Congestive Heart Failure (CHF), Falls, Atrial-Fibrillation (A-Fib), Type 2 Diabetes Mellitus (DM), Occlusion/Stenosis of bilateral carotid arteries, Chronic Kidney Disease (CKD), Atherosclerotic Heart Disease (ASHD), Malignant neoplasm of colon, Depression, COVID, Seizures, and Obstructive/Reflux uropathy. R1's Care Plan, dated 12/27/23, documented, (R1) has an ADL (Activities of Daily Living) self-care performance deficit. Interventions: ADL Care: the resident may need assistance x one or x two staff members for ADL care, Transfer: the resident is limited to extensive assist and may need assistance x one or x…

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, observation and record review, the facility failed to provide flavorful and palatable food. This failure has the ability to affect all 139 residents residing at the facility. Findings include: 1. On 01/03/2023 at 9:15 am, R236 stated that she can't have eggs because they make her sick nor does she eat sausage, but she has been given it regardless and the food does not taste good. 2. On 01/03/2023 at 9:20 AM, R49 stated that the food was not good. 3. On 01/03/2023 at 09:26 AM, R1 stated food was always cold, does not taste good and they always run out. On 01/04/2023 at 12:00 PM, A test tray was given, the meatloaf had a mushy texture to it and was greasy. The mixed vegetables were mushy and the color of the green beans were faded to clear. The dinner roll was on top of the mixed vegetables and was soggy. The facility's menu, Week at a Glance Week 2 documented for Wednesday, Tomato Glazed Meatloaf, Mushroom Gravy, Whipped Potatoes, Capri Mixed Veg., Dinner roll and Peach Cobbler. What was being served for lunch during the observation period. Resident Council…

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 perform hand hygiene and cleanse soiled resident equipment 5 of 5 residents (R56, R63, R95, R127 and R235) reviewed for infection control in the sample of 57. Findings include: 1. On 01/04/2023 at 1200 PM V4, Certified Nurse Assistant (CNA) took hall trays down to residents who were in their room for lunch. V4, CNA, without benefit of hand hygiene entered R95's room with his meal tray, came out and retrieved dessert and drink off the hall cart and went back into R95's room. When she exited his room, she did not perform hand hygiene. She then donned gloves, without benefit of hand hygiene and entered R127's room, who is on isolation. V4 CNA stated he was on isolation for a foot wound. She then took his meal tray in set it down, came back out with the same gloves and took a dessert and drink off the cart and took it into R127's room. V4, CNA doffed gloves in room did not perform hand hygiene exited room. Then she took R235's meal tray off cart and entered his room. Set his tray down, came out of his room, took a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide complete incontinent care for 4 residents (R36, R56, R284, and R285) of 7 residents reviewed for incontinent care in the sample of 57. Findings include: 1. On 1/05/23 at 10:10AM during incontinent care V9, Certified Nursing Assistant (CNA) and V10 transferred R36 from chair with mechanical lift to the bed. R36 had strong odor of urine. V9, CNA with gloves on rolled R36 to left side and removed R36's adult diaper which was saturated with urine. V9, CNA handed V10 CNA cleansing wipes. V10 with cleansing wipe cleansed right groin and then left groin. V10 CNA swiped down front of R36's peri area and did not separate the labia. R36 started urinating V10 CNA doffed gloves sanitized hands and donned gloves. V10 cleansed left and right groin. V10 then swiped down R36's peri area with cleansing wipe. V10 did not separate the labia. V10 doffed gloves and sanitized hands. R36 turned to right side, R36 incontinent of stool. V10, cleaning R36…

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

Based on record review and interview the facility failed to maintain accountability of narcotic medication for 1 resident (R116) of 1 resident reviewed for misappropriation of property in the sample of 57. Findings include: 1. The facility reported dated 12/21/2022 at 4:00PM documents unable to locate 30 hydrocodone 7.5-325mg (card) of medication. The report document immediate action taken; facility obtained replacement card of medication to ensure patient did not miss any needed medication, nurses who have worked since medication delivery were interviewed. all medication carts have bed checked for misplacement of medication, Illinois State Police (ISP) Medicaid fraud control bureau notified. On 1/4/2023 at 3:10PM V2, Director of nursing stated it was not discovered there was medication missing until the nurse called to get a new card and pharmacy informed the facility, they had already sent out a card of 30 pills. V2 stated that she had interviewed all nurses with the exception of a nurse who worked for agency, and she did not return her call. V2 also stated that she had notified…

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 provide showers or bathing assist for 2 of 2 (R233 and R236) residents reviewed for Activities of Daily Living in a sample of 57. Findings include: 1. On 01/03/2023 at 08:30 AM, R233 stated that she was admitted last Friday and has not received a shower or bath yet. She continued to state that she doesn't know when her shower days are. R233's hair appeared greasy ad unkept. On 01/09/2023 at 01:50 PM R233 stated that she still has not had a bath or shower since she has been admitted , she would like a shower. She continued to state that there was 1 time that they offered, and she refused it because she wasn't feeling well but they haven't offered since or even on a different day, R233's hair appears greasy. R233's Baseline Care Plan, dated 12/5/2022, documented, BASELINE CARE PLAN: Resident needs assist with ADLs. Resident will have ADL needs met. Assist/provide ADL care and support as needed. The Facilities Shower list, dated 01/09/2023, documents 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations interview and record review the facility failed to implement interventions and transfer appropriately for 2 of 6 (R18, R283) residents reviewed for accidents and incidents in a sample of 57. This failure caused R283 to experience pain during transfer. 1. R283's Care Plan, dated 12/29/22, documents that Resident needs help transferring in and out of the bed or chair: It continues Transfer: the resident is not able to help with a transfer at all and will need the assistance of 2 staff and a (full body mechanical) lift to move from bed to chair and back. R283's MDS, dated [DATE], documents that R283 requires extensive assist of 2 people for transfers. On 1/3/2022 at 10:40 AM observed V17 transfer R283 into his wheelchair using the sit to stand mechanical lift. Once in chair V17 attempted to reposition R283. R283's right foot and lower leg was turned outward. R283's left leg was stretched out in front of him. V17 lifted R283 up and R283 yelled out how V17 instructed R283 to stand. V17 then…

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

Based on observation, interview and record review, the facility failed to provide appropriate water flushes and give medication as the physician had ordered for 1 of 1 (R107) resident reviewed for enteral feedings in a sample of 57. Findings include: 01/05/23 09:28 AM V16, License Practical Nurse (LPN) prepared R107's Polyethylene powder in 60 ml of water. performed hand hygiene donned gloves. V16 then auscultated gastrostomy tube (g-tube) with air bolus, listened to bowel sounds but did not check for residual. V16 then administered Polyethylene powder mixture as bolus then used plunger to administer rest of the medication. She then flushed the g-tube with 180 ml of water via bolus. R107's Physician Order, dated 10/27/2022, documented, Flush G-tube with 150ml water every 4 hours. R107's Physician Order, dated 11/04/2022, documented, Polyethylene Glycol Powder, Give 17 gram by mouth one time a day for Constipation. R107's Care plan, dated 11/18/2022, documents, Administer tube feeding formula and flushes as ordered (see current physician orders & MAR). Check residual per 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, interview and record review, the facility failed to maintain confidentiality/privacy of medical records for 4 of 4 residents (R20, R25, R53, and R183) reviewed for privacy in the sample of 46. Findings include: 1. On 12/15/21 at 7:35 AM, V11, Licensed Practical Nurse (LPN), was observed during medication administration. V11 obtained R25's medication, walked away from the computer leaving it open in the hallway and displaying R25's medical information. 2. On 12/15/21 at 8:00 AM, V11 was observed during medication administration. V11 obtained R53's medication, walked away from the computer leaving it open in the hallway and displaying R53's medical information. 3. On 12/15/21 at 8:05 AM, V11 was observed during medication administration. V11 obtained R20's medication, walked away from the computer leaving it open in the hallway and displaying R20's medical information. 4. On 12/15/21 at 8:20 AM, V11was observed during medication administration. V11 obtained R183's medication, walked away from the computer leaving it open in the hallway and displaying R183'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 store medications in a locked area to prevent access to resident medications and ensure insulin is labeled upon opening for for 6 of 6 residents (R16, R20, R25, R53, R54 and R183), reviewed for labeling/storage of medications in the sample of 46. Findings include: 1. On 12/15/21 at 7:35 AM, V11, Licensed Practical Nurse (LPN), was observed during medication administration. V11 obtained R25's medication and walked away from the medication cart into R25's room leaving the medication cart unlocked in the hallway, out of sight. 2. On 12/15/21 at 8:00 AM, V11 was observed during medication administration. V11 obtained R53's medication and walked away from the medication cart into R53's room leaving the medication cart unlocked in the hallway, out of sight. 3. On 12/15/21 at 8:05 AM, V11 was observed during medication administration. V11 obtained R20's medication and walked away from the medication cart into R20's room leaving the medication cart unlocked in the hallway, out of sight. 4. On 12/15/21 at 8:20 AM, V11…

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

Based on interview and record review the facility failed to provide adequate tracking for antibiotic stewardship surveillance to monitor for patterns and trends in infections and antibiotic use for 4 of 4 residents (R40, R47, R79 and R80) reviewed for antibiotic stewardship in the sample of 46. Findings include: 1. The facility infection control log documents R40 has a Urinary Tract Infection (UTI) with an onset date of 10/2/21. The log has no documentation that a urine culture identified an organism. R40's Physician Order Sheet (POS) documents an order, dated 10/2/21, for Nitrofurantoin 100 milligrams (mg) every 12 hours for a UTI. R40's Urinalysis/Urine Culture, dated 9/30/21, documents the urine culture was unable to be performed due to the specimen being too old and it was recommended to collect a new specimen. The urine culture, dated 10/22/21, documents no growth. 2. The facility infection control log documents R47 has a UTI with an onset date of 10/25/21. The log has no documentation that a urinalysis/urine culture was obtained or that an organism was identified. R47's POS…

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 call lights were within resident's reach for one of one residents (R25) reviewed for accommodation of need in the sample of 46. Finding includes: R25's Care Plan, dated 11/14/21 documents R25 is at risk for falls. R25's Care Plan Intervention documents be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. R25's quarterly Minimum Data Set (MDS), dated [DATE], documents she is cognitively intact. On 12/15/21 at 9:15 AM, R25 was in bed and did not have her call light within reach, it was on the floor. R25 stated she did not have her call light within reach from the evening on 12/14/21 into the morning of 12/15/21. R25 stated she needed staff assistance, but she did not have her call light to call for help. Review of the facility's standards and guidance call light policy, revised 3/27/21, documents It will be the standard of this facility to respond to the resident's requests…

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 administer pressure ulcer treatments as ordered for 1 of 8 residents (R81) reviewed for pressure ulcers in the sample of 46. Findings include: R81's Face Sheet documents his diagnoses to include Paraplegia, Unspecified Severe Protein-Calorie Malnutrition, Systemic Inflammation Response Syndrome of Non-Infectious Origin Without Acute Organ Dysfunction, and Pressure Ulcer of Sacrum. On 12/14/21 at 9:33 AM R81 stated sometimes they don't change his dressing to his pressure ulcer on his bottom after he has a BM (bowel movement). He stated the doctor does not want his wound to be soiled with BM and get infected. On 12/15/21 at 11:15 AM V13, Wound Nurse, performed dressing change to R81's coccyx pressure ulcer. V13 removed the old dressing, dated 12/14/21 from R81's coccyx pressure ulcer. The old dressing had brown drainage/fecal material on edges but not on the wound bed. While wound care being done, R81's skin was observed. R81's coccyx…

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, and interview, the facility failed to administer tube feeding as ordered for 1 of 2 residents (R77) reviewed for enteral feedings in a sample of 46. Finding includes: R77's quarterly Minimum Data Set (MDS), dated [DATE], documents R77 is moderately cognitively impaired and 51% or more proportion of total calories the resident received through parenteral or tube feeding. The MDS documents R77 was 65 inches tall and weighed 104 pounds. R77's Health Status Note, dated 12/1/21 at 9:55 PM documents Late entry for 4:00 PM, writer spoke to (proper name of nurse) nurse for the dialysis center that patient attends for tx (treatment.) She asked for a med (medication) list to be faxed specifically inquiring about enteral (tube) feeding schedule and the nutrition that is being administered. Fax was sent, awaiting further correspondence. R77's Nutritional Progress Note, dated 12/3/2021 at 12:01 PM documents Registered dietitian consult regarding dialysis labs and tube feed formula type.…

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 staff documented the narcotic medication counts correctly on the resident's narcotic medication count sheet for 3 of 3 residents (R21, R41, R46) reviewed for Pharmacy Procedures/Records in a sample of 46. Findings include: 1. R21's December 2021 Physician's Order Sheet (POS), documents R21 is to receive Oxycodone (narcotic) 5 milligram (mg) tablet give 1 tablet by mouth every 4 hours as needed (PRN) for pain. On 12/15/21 at 1:00 PM R21's medication card for Oxycodone 5 mg had 13 tablets. Review of R21's Oxycodone narcotic count sheet documents 14 tablets. 2. R41's December 2021 POS, documents R41 is to receive Tramadol (narcotic) 50 mg 1 tablet three times a day for pain. On 12/15/21 at 1:05 PM observation of 41's narcotic medication card for Tramadol 50 mg showed he had 6 tablets. Review of R41's Tramadol narcotic count sheet documents 7 tablets. 3. R46's POS, dated 12/2021, documents R46 is to receive Diazepam (scheduled 4 controlled substance) tablet 5 mg 1 tablet by mouth three times a day 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, interview, and record review, the facility failed to identify residents on isolation precautions, by failing to place signage outside resident's doors for 2 of 2 residents (R236, R237), reviewed for infections control precautions in the sample of 46. Findings include: 1.R236's Face Sheet documents she was admitted on [DATE] with diagnoses of kidney failure, COPD, and hypoxia. R236 is unvaccinated. R236's Care Plan dated 12/13/2021 documents R236 has the potential for contact or exposure to the novel Coronavirus (COVID-19). The Care Plan document to minimize the risk of resident exposure to the novel Coronavirus (COVID-19). The Care Plan documents Staff will wear required PPE (Personal Care Equipment) while providing care and in contact with resident and resident areas, as is appropriate, to include, but not limited to: Gloves, Masks, Goggles/Face Shields, Gowns. On 12/14/2021 at 9:30 AM R236 was in her room. There was no signage on door to advise visitors and staff that R236 is on contact…

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.