Alden Estates Of Barrington

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to discard expired house stock medications and label multi-dose medications with open date for three of four medication carts and one of one medication room observed for medication storage and labeling. This deficiency can affect all 126 residents residing in the facility. Findings include: On [DATE] at 1:20PM during observation with V33 (Registered Nurse/RN), Cart 4 in C-wing was observed with the following: 1. Opened house stock Lactobacillus acidophilus bottle with expiration date 7/23 2. R67's budesonide 0.5 milligrams (mg)/2 milliliters (ml) nebules in an open foil pouch with no open date 3. R9's budesonide 0.5 milligrams (mg)/2 milliliters (ml) nebules in an open foil pouch with no open date At 2:05PM during observation with V14 (Licensed Practical Nurse/LPN), Cart 2 in B-wing was observed with the following: 1. R22's opened 10ml vial of Heparin sodium 5000 units/ml with no open date 2. R12's opened 10ml vial of Heparin sodium 5000…

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 label the enteral tube feeding bags with the date and time it was initiated for four of thirteen residents (R24, R32, R52, R323) reviewed for tube feeding in a sample of 25. Findings include: On 08/15/2023 at 10:32AM during observation, R52 was observed with enteral tube feeding attached to her gastrostomy tube labeled with initiation date of 8/14/2023 with no time indicated. At 11:06 AM during observation, R32 was observed with enteral tube feeding attached to her gastrostomy tube labeled with initiation date of 8/14/2023 with no time indicated. At 11:10 AM during observation, R323 was observed with enteral tube feeding attached to her gastrostomy tube without label indicating the resident's name, and date and time it was initiated. At 12:13 PM during observation, R24 was observed with enteral tube feeding attached to her gastrostomy tube labeled with initiation date of 8/14/2023 with no time indicated. On 08/15/2023 at 12:02PM, V33 (Registered Nurse/RN) stated that they only write the date the feeding 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.

Based on observation, interviews and record review, the facility failed to follow their call light policy. The facility failed to place call light within reach. This deficient practice affects three residents (R15, R41 and R71) of three residents reviewed for call light placement in a total sample of 25 residents. Findings Include: On 8/15/23 at 10:30AM, Observed R71 in bed, observed call light placement not within reach. Call light was on the floor on the right side of R71's bed. R71 stated that she does not know where her call light is. Also stated that when her call light is not within reach, R71 will yell or call for help. On 8/15/23 at 10:35AM, V13 (RN) confirmed that the call light of R71 is on the floor and not within R71's reach. V13 also stated that she will inform the maintenance that the call light needs a clip. On 8/15/23 at 10:45AM, R15 in bed, observed call light wrapped in left upper side rail, No clip. R15 said she don't know where her call light is at that moment. Pointed at the left side rail, and R15 said I cannot see or reach it. On 8/15/23 at 10:50AM, V13 also…

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 follow their prevention and treatment of pressure injury policy and failed to implement preventative measure appropriately by not following the operation manual for a pressure injury preventative mattress. This deficient practice affected one resident (R38) of three residents reviewed for skin alterations in a total sample of 25 residents. Findings Include: On 8/15/23 at 11:00AM, observed R38 in bed, using a low air loss mattress (pressure injury preventative mattress). Machine checked and it is set on 230lbs (pound in weight). On 8/15/23 at 11:10AM, V14 (LPN) confirmed that the machine is set for 230 lbs. Stated that the low air loss mattress is supposed to be set to the weight of R38 and that she will check the weight of the resident and change the setting as necessary. On 8/16/23 at 10:00AM, observed R38 in bed, using a low air loss mattress (pressure injury preventative mattress). Machine checked and it is set on 280lbs (pound in weight). Machine for the low air loss mattress had six lights for weight by…

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 an extra tracheostomy (trach) cannula at the bed side and failed to have enough water in the aerosol bottle at the bed for two residents (R58 and R322) of nine residents reviewed for Trach care in a total sample of 25 residents. Findings Include: 1. On 8/15/23 at 11:30 am during screening R58's humidifier was observed with approximately 2 milliliters of water in the bottle, no bubbles were seen in the aerosol bottle or in the large bore corrugated tubing while still connected to R58's tracheostomy (trach) collar. There was no extra emergency tracheostomy cannula at the bedside. V23 (LPN) was observed going out to request an extra cannula from the respiratory therapist, V23 was informed by V24 (Respiratory Therapist) that there was an extra piece of cannula in R58's cupboard. V23 did not know where to find the extra emergency tracheostomy cannula. On 8/15/23 at 11:35 am, V23 and V24 both stated that there should be an extra…

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 and interview, the facility failed to properly store Bi-pap masks and Nebulizer mask and left masks open to air on bedside table. This failure affected 2 residents (R8 and R88) of 3 reviewed for oxygen equipment in a total sample of 25. Findings include: On 08/15/23 at 10:30 AM, observed R88's Bi-pap mask on the bedside table exposed to the air (not stored in plastic bag) as observed by V14 (LPN). On 08/15/23 at 10:49 AM, observed R8's nebulizer mask on the bedside table open to air (not stored in a plastic bag) as verified by V29 (CNA) and V29 immediately placed nebulizer mask in plastic bag in front of surveyor. On 8/17/23 at 11:48 AM, V2 (DON) said Bi-pap masks and nebulizer masks are stored in plastic bags. The masks are kept in a bag to keep masks clean after being cleaned per policy. On 08/15/23 at 10:30 AM, V14 (LPN) said the CNA is to inform the nurse and the nurse will place the Bi-pap mask in the bag. V14 said she will place the Bi-pap mask in a bag to keep it clean. On 08/15/23 at 10:49 AM, V29 (CNA) said it is the nurse's job to store nebulizer masks…

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

Based on interview and record review, the facility failed to ensure a resident's call light was in working condition. This failure affected 1 resident (R80) of 4 reviewed for call lights in a total sample of 25. Findings include: On 08-15-23 at 11:26 AM, asked R80 to push the call light and the resident was unable to activate the call light. The call light button and was unable to activate the call light. V30(CNA) asked to verify that the call light was working. V30 was observed pushing the the call light button several times and noted the light outside the room was not activated. V30 pulled the call light cord from the wall and replaced the cord. V30 pushed the call light button and the call light worked. On 08-15-23 at 11:26 AM, R80 said she is pushing the call light however the hallway light is not activated and there was no sound noted. On 8-18-23 at 12:55 PM, V1 (Administrator) said all staff are responsible for ensuring call lights are working. On 08-15-23 at 11:26 AM, V30 (CNA) said it is staff responsibility to ensure the call lights are working and in reach of the residents.

Based on interview and record review, the facility failed to provide and distribute nourishing snacks at bedtime to all residents in the facility. This failure affects all 89 residents receiving food from the facility. Findings include: On 9/12/22 V1 (administrator) presented the survey team with the number of residents currently in the facility. Facility census provided showed 121 total residents. Of these residents V7 (dietary manager) indicated there were 89 residents receiving food from the kitchen. On 9/12/22 at 11:45 am during the initial tour of the facility, R13 was observed in bed and spoke with the surveyor about her some concerns. R13 stated, I am concerned about the food as sometimes I get cold food given to me. I cannot walk or put myself on the wheelchair because I need a lot of help to do that so I rely on staff to do this for me. I sometimes go to bed hungry and I can't get a snack at night or anything. I have to wait until the next morning for breakfast before I eat and I am so hungry. Surveyor asked if she is ever offered any snacks during bed time or whether…

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 properly cover and label food items stored in the refrigerator and failed to follow their food storage policy and food storage guideline policy for the use of and discarding of foods. This failure has affected all 89 residents that receives meals from the kitchen. Findings include: On 09/12/2022 V1 (administrator) presented the survey team with the number of residents currently in the facility. Facility census provided showed 121 residents. Of these residents V7 (dietary Manger) indicated there were 89 residents receiving food from the kitchen. 09/12/22 at 9:59am During the observation of the refrigerator the surveyor noted two pans of Jell-O in the refrigerator not covered or dated, In the freezer there 4 packs of hot dog buns one noted with an expiration date of 09/06/2022 the other three packs of buns did not have dates . The buns have freezer burn on all 4 packs of bread. Observation of the dry storage room surveyor noted one can of dented sliced apples on the shelf mixed in with the non-dented cans, two…

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 follow federal regulations and their infection prevention and control program regarding donning personal protective equipment (PPE) prior to entry into a resident's room who is under contact isolation precautions, failed to practice proper PPE use and/or perform hand hygiene during food preparation to minimize the spread of infection. This failure has the potential to affect all 121 residents that reside in the facility. Findings include: On 09/12/2022 at 11:50 AM, observed standard precaution and contact isolation signs both posted on the outside of R73's room door which both indicated to don gloves and gown prior to entering. Also observed a three-drawer bin next to the doorway of R73's room that contained personal protective equipment and supplies. Reviewed resident isolation list provided by the facility for September 2022 that showed R73 is under contact isolation precautions for CRAB/ESBL in sputum/urine. Reviewed R73's active physician's orders which showed contact precautions for extended spectrum…

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, interviews, and record reviews, the facility failed to follow the plan of care for a resident with a pressure ulcer by not turning and repositioning the resident every two hours to aid in the prevention and healing of a sacral pressure ulcer. This failure applied to one (R70) of four residents reviewed for pressure ulcers in the sample of 53. Findings include: R70 is a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Chronic Respiratory Failure, Chronic Embolism and Thrombosis of unspecified Deep Veins of Lower Extremities, Hyperlipidemia, Encounter for Attention to Tracheostomy, and Encounter for Attention to Gastrostomy. According to MDS (Minimum Data Set) dated 08/04/2022 under Section C, R70 has a BIMS (Brief Interview of Mental Status) score of 15 indicating a high level of cognitive functioning; under section G, R70 requires extensive assistance in bed mobility with two+ person physical assist; under section M, R70 has one stage IV pressure ulcer that was 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.

Based on observation, interview, and record review, the facility failed to administer medications as ordered (at ordered times). There were 30 opportunities with 2 errors resulting in a 6.67% error rate. This applies to one (R53) of five residents reviewed during the medication pass task. Findings include: On 09/13/2022 at 11:40 AM Surveyor observed V5 (Licensed Practical Nurse) administer the following medications to R53: 1. Gabapentin Capsule 300 MG 1 capsule by mouth with apple sauce 2. Eliquis Tablet 5 MG 1 tablet by mouth with apple sauce On 09/13/2022 R53's Order Summary Report state in part; 1. Gabapentin Capsule 300 MG 1cap by mouth three times a day 2. Eliquis 5 mg 1 tablet by mouth every 12 hours On 09/13/2022 at 11:50 am, review of R53's Medication Administration Audit for 09/13/2022. Gabapentin Capsule 300 MG has a Schedule Date of 09/13/2022, with scheduled administration times of 0800, 1400, and 2000. Eliquis 5 mg 1 tablet has a Schedule Date of 09/13/2022, with scheduled administration times of 0900 and 2100. On 09/13/2022 at 11:57 AM V5 stated, I administered R53's…

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

Based on observation, interview, and record review, the facility failed to serve food in a manner that maintained proper holding temperatures. This failure affected all 89 residents that receive meals from the kitchen. Findings include: On 09/12/2022 V1 (administrator) presented the survey team with the number of residents currently in the facility. Facility census provided showed 121 residents. Of these residents V7 (dietary Manger) indicated there were 89 residents receiving food from the kitchen. On 09/12/2022 at 11:54am during an interview with Resident # 25 said when they bring my food in its cold and dried out so I don't eat it I send it back. Sometimes I do ask for something else and sometimes I don't be as hungry. On 09/12/2022 at 12:32pm during an interview with Resident # 75 said The food here is sometimes a hit or miss. It does be cool sometimes depending on what it is. Yes i have mention this to the dietary they supposed to be working on it. Hall trays are place on a hot heated food cart. On 09/13/2022 at 12:18pm Test tray temperatures was completed with (V10 Dietary…

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.