Nexus at Berwyn

Based on observation, interview and record review, the facility failed to ensure that staff administer ordered pain medications to residents according to resident's needs and as outlined in their care plan and failed to ensure that resident's medications readily available. These failures affected two residents (R1 and R2) of four residents reviewed for pain management and have the potential to affect all 45 residents on the first floor of the facility. This failure resulted in R1 and R2 missed multiple doses of about 9 different pain medications while at the facility. Findings include: 1.R1's diagnosis includes, but are not limited to Malignant neoplasm of bone and articular cartilage, secondary malignant neoplasm of other parts of nervous system, anemia, benign prostatic hyperplasia without lower urinary tract symptom, wedge compression fracture of first lumbar vertebrae, osteomyelitis unspecified, etc. On 6/23/2025 at12:20PM, R1 was interviewed, and he said that his pain is not being managed because of how staff give his medications, he would like to have something in between…

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 that resident personal washroom was equipped with toilet tissue/rolls in a timely manner in the resident's bathroom for personal hygiene. This failure affected 4 of 4 residents (R4, R6, R7 and R12) reviewed for personal hygiene equipment toilet rolls. Findings include: On 06/04/25 from 10:13am to 11:30am, the following observations were made: At 10:23am, R7's clothing noted on the bare floor R7 stated they are dirty clothes and stated he has no plastic bag to put the clothes Complain of not having toilet paper in the toilet for days at a time. At 10:42am, on the 1st floor, 1 south room [ROOM NUMBER], room floor noted with yellowish dry colored particles and orange peels. At 10:47am, V15 CNA stated the resident must have spill something, its dry possibly from previous shift. I am the CNA for this morning and the floor has been like that. On the 3floor at 10:54am, room [ROOM NUMBER] noted with no toilet paper in the toilet. No 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, interview and record review the facility failed to ensure that emergency cart, treatment cart was locked when not in proximity of the nurse and individual medications were locked up safely in the medication cart to prevent tampering and accidental hazard. This failure affected 2 of 2 residents (R3 and R1) in the sample reviewed for medication administration. Findings include: On 06/04/25 at 10:13am, the treatment cart noted in the hallway unlocked and unattended to by Room105. V7 LPN (Wound Care Nurse) confirm that it was the treatment cart stating that it is the treatment cart with treatment medications. V7 stated that the facility policy is to have it locked when not at eyesight level and not in use. At 10:40am, V2 (DON) stated that the treatment cart should be locked when not in visual contact of the nurse. V2 stated that V7 (treatment nurse) has told me about it (not locking the cart). I told her lock to the cart always when not in the eye contact with the cart. On 06/04/25 at 11:24am, crash cart noted in the hallway in front of the elevator unlocked 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.

Based on observation, interview and record review, the facility failed to maintain an available manual resuscitator and failed to provide timely suctioning care for two (R1 and R6) out of three residents with a tracheostomy. Findings include: According to the electronic health record, R1 has diagnosis including s/p tracheostomy, g-tube placement, hypertension, hyponatremia, anemia, sacral decubitus ulcer, chronic respiratory failure, and gastroparesis. R1 is nonverbal. On 3/21/2025 at 9:40 AM, R1 was observed asleep, tracheostomy attached to oxygen concentrator; tracheostomy collar appears clean and dry, no secretions present at the entrance of the tracheostomy tube observed. Manual resuscitator was not available at the bedside. V2, Director of Nursing (DON) confirmed that a manual resuscitator (a handheld medical device used to manually ventilate a patient who is not breathing or is breathing inadequately, often used in emergency situations like cardiac arrest or respiratory failure) was not available at the bedside. V2 further stated that there should be a manual resuscitator…

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 appropriate infection control practices to resident on tracheostomy tube and during medication administration. This deficiency affects all five (R19, R66, R93, R108 and R110) residents in the sample of 25 reviewed for Infection Control. Findings include: On 2/25/25 at 9:58AM, Observed R108 with V3 DON (Director of Nursing) lying in bed with Tracheostomy tube connected to oxygen at 8 LPM (liters per minute). R108 is awake, non-verbal and needs total assistance with ADLs (Activity of Daily Living) and transfers. The tracheostomy corrugated tubing and drainage collection bag touching floor. V3 DON said that it should not be touching the floor for infection control. On 2/25/25 at 12:21PM, Observed R110 with V4 ADON (Assistant Director of Nursing) lying in bed with tracheostomy tube connected to oxygen at 8LPM. R110, non-verbal and needs total assistance with ADLs (Activity of Daily Living) and transfers. The tracheostomy corrugated tubing and drainage collection bag touching the floor. V4 ADON said that 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure resident call light is within reach. This deficiency affects two (R68, R78) of three residents in the sample for 25 reviewed for accommodation of needs. Findings include: On 02/25/25 at 11:23 AM, R78 observed in bed, with call light behind curtain on top of dresser. On 02/25/25 at 11:24 AM, R68 observed in room with call light behind curtain on top of dresser, R68 said she could not reach it, said it is usually next to her. On 02/25/25 at 11:27 AM, V25 (Restorative aide) made aware of above findings and said that call lights should be within reach, not sure why they were on top of dresser. On 02/26/25 at 1:25 PM, V3 (Director of Nursing) said her expectations for residents call lights are to be within reach at all times and answered promptly. R68 admitted on [DATE] with diagnosis in part but not limited to encounter for surgical aftercare following surgery on the digestive system, bacteremia, hyperlipidemia, diabetes type 2 mellitus…

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 nail and foot care to dependent resident. The facility also failed to incontinence care to dependent and incontinent resident in a timely manner. This deficiency affects one (R108) of three residents in the sample of 25 reviewed for Activity of daily living (ADL) Program. Findings include: On 2/25/25 at 9:39AM, V18 Family member said that R108 has stroke and one side of the body is partially functioning. He cannot walk, talk nor eat on his own. He has been bed bound since July 2024. V18 said that every time he comes to visit R108 he has to advocate for his needs. On 2/25/25 at 10:14AM, Observed R108 with V15 CNA (Certified Nurse Assistant) and V14 WCN (Wound Care Nurse) lying in bed. V15 and V14 preparing R108 for wound care treatment. Observed bilateral hands with long and dirty fingernails, bilateral toenails are long thickened and discolored. Both said that CNAs are responsible for nails care and for foot care they usually…

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 implement measures to prevent resident from acquiring pressure ulcer in the facility and updated wound care plan intervention. This deficiency affects one (R108) of three residents in the sample of 25 reviewed for Wound/Pressure Ulcer Prevention and management. Findings include: On 2/25/25 at 9:39AM, V18 Family member said that R108 has stroke and one side of the body is partially functioning. He cannot walk, talk nor eat on his own. He has been bed bound since July 2024. V18 said that R108 developed pressure ulcer on sacral area since last year and still not healing. V18 said that every time he comes to visit R108 he has to advocate for his needs. On 2/25/25 at 10:14AM, Observed R108 with V15 CNA (Certified Nurse Assistant) and V14 WCN (Wound Care Nurse) lying in bed. V15 and V14 preparing R108 for wound care treatment. V15 CNA then opened disposable brief of R108 soaked with feces. V15 turned him to his left side, observed disposable…

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 ongoing assessment was in place for a totally dependent resident who has limited range of motion (ROM) to prevent contractures. This deficiency affects one (R108) of three residents in the sample of 25 reviewed for Restorative Nursing Program. Findings include: On 2/25/25 at 9:39AM, V18 Family member said that R108 has stroke and one side of the body is partially functioning. He cannot walk, talk nor eat on his own. He has been bed bound since July 2024. V18 said that every time he comes to visit R108 he has to advocate for his needs. On 2/25/25 at 9:58AM, Observed R108 with V3 DON (Director of Nursing) lying in bed. Observed right hand wrist with extension contraction. V16 LPN (Licensed Practical Nurse) said that R108 does not have splint. On 2/25/25 at 1:51AM, Informed V11 Restorative Nurse of above observation made. She said that she just started and have to check her notes. On 2/26/25 at 12:20PM V11 Restorative Nurse said 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 observation, interview, and record review the facility failed to ensure adequate supervision is rendered to dependent resident who is at high risk and had several unwitnessed falls in his room. This deficiency affects one (R108) of three residents in the sample of 25 reviewed for Fall prevention program. Findings include: On 2/25/25 at 9:39AM, V18 Family member said that R108 has stroke and one side of the body is partially functioning. He cannot walk, talk nor eat on his own. He has been bed bound since July 2024. Facility reported unwitnessed fall out from bed twice. He was placed in the far end of the facility as if being ignored away from the nursing station in case an emergency was to occur. V18 said that every time he comes to visit R108 he has to advocate for his needs. On 2/25/25 at 9:58AM, Observed R108 lying in low air loss mattress. He has tracheostomy tube connected to oxygen at 8LPM (liters per minute). He is awake and nonverbal; he needs total care with ADLs (Activity of Daily Living) and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that Medication error rates are not 5 percent or greater. This deficiency affects one (R66) of four residents in a sample of 25 reviewed for medication administration. Findings include: On 2/26/25 at 8:40AM, V19 (Licensed Practical Nurse) during medication administration observation with R66 administered Aspirin 81mg chewable 1 tablet and Senna 8.6mg 1 tablet. On 2/26/25 at 8:45AM, V19 said she follows physician orders from medication administration record. On 2/27/25 at 10:33 AM, V3 (Director of Nursing) made aware of above findings and said nurses should follow physician orders when administering medications. R66 admitted on [DATE] with diagnosis in part of but not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, type 2 diabetes mellitus without complications, other seizures, gastrostomy status, muscle weakness. R66 Physician order report 2/26/25 Order Summary: Aspirin oral capsule…

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 interviews and record review, the facility failed to follow their Laboratory Specimens policy. Facility failed to send urine specimen labeled and with requisition, resulting in laboratory unable to process Urinalysis and Culture/Sensitivity test. This deficiency practice affects one resident (R1) of three residents reviewed for quality of care. Findings Include: R1 admitted in the facility on 8/10/23. BIMS of 15 (Intact Cognition) On 1/14/25 at 11AM, R1 stated that her urine sample was taken twice in the facility, does not recall exactly when in December. The urine sample was taken the same day R1 reported an odor in her urine. First urine sample, R1 was informed that the urine sample was not labeled. And then the second sample was taken, and R1 was informed by the NP, saying that the urine sample says the lab received it, however no result can be found. Stated that NP suggested for a third specimen, R1 refused and decided to go to this primary physician in the community. Stated January 2nd R1went to doctor's appointment. Specimen taken on this appointment and days later…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident has the right to receive unopened personal mail in a timely manner. This failure affected one (R3) resident in a sample of 6 residents reviewed for privacy and resident rights. Findings include, R3 is [AGE] years old with BIMS (Cognition test) score of 15, meaning R3 is cognitively intact. On 12/21/24 at 9:56 am R3 said, he received a letter from IDPH and when he got his letter it was opened and also there was no envelope to send appeal. R3 was not sure if it came with the letter. R3 said, the letter was mailed on 12/4/24 and it was handed to him by the facility on 12/13/24. R3 said, activity brought the letter and it was V14 who handed the letter to him. R3 said, V14 told him when she picked up the letter from downstairs, it was already open like that. R3 provided the letter, and it was opened neatly and looked like it was opened with a letter opener or scissors. R3 said, he does not have scissors or letter opener in his room. 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.

Based on interview and record review the facility failed to provide the necessary transportation for a resident to attend a doctor's appointment outside of the facility for 1 of 3 residents (R1) reviewed for necessary care and services in the sample 5. The findings include: R1's appointment note dated 6/28/24 showed R1 had a scheduled appointment to see a dermatologist, on 8/27/24, at a local outpatient clinic. On 9/13/24 at 9:28 AM, R1 stated, I missed my derm (dermatologist) appointment on August 27, 2024. I was supposed to go by the facility van but that van was broken so they couldn't take me. (V12 Facility Van Driver) told me it was because there was something broken in the van. On 9/13/24 at 9:42 AM, V13 Facility Scheduler stated, I was aware of (R1's) appointment on 8/27/24. I wrote it down in the appointment book. I arranged to have our van take her to it. I don't know exactly why she didn't go to the appointment. I think it had something to do with the van. On 9/13/24 at 9:50 AM, V12 Facility Van Driver stated on 8/27/24, There was an issue with the van so I couldn't take…

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 obtain medication from the pharmacy for 1 of 3 residents (R2) reviewed for pharmacy services in the sample of 5. The findings include: R2's face sheet shows he has diagnoses including: anxiety disorder, major depressive disorder recurrent, bipolar disorder, and mood disorder. R2's active Physician Order Summary (POS) shows he has an acitve order for Alprazolam 1 MG (milligram). One time a day for anxiety. R2's 8/1-8/31/24 Medication Administration Record (MAR) shows he should receive Alprazolam (xanax) tablet 1 MG. at 5:00 AM for anxiety. This dose of medication is documented in the MAR using a code 9 which indicates (see notes). A eMAR- Medication Administration Note completed on 8/21/24 at 5:10 AM by V6 (Licensed Practical Nurse/LPN) states, out of stock, f/up with pharmacy. insurance order for tomorrow. A Nurse Practitioner progress note completed on 8/21/24 at 9:35 AM states, {R2} was seen today at the request of the nursing staff for a medication refill. He takes xanax 1 mg and 2 mg for anxiety and needs refill. 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 interview and record review, the facility failed to initiate discharge for a resident upon request and failed to update the discharge care plan to include a desire for transfer or discharge which affected one (R2) of two residents reviewed for discharge planning. Findings include: R2 is [AGE] years old and was transferred to the facility on 4/9/24. Diagnoses listed for R2 include dementia, osteitis (inflammation of bone), convulsions and violent behavior. According to the Minimum Data Assessment of 4/19/24, R2 was assessed to have mild cognitive impairment. On 7/7/24 at 2:19PM V10 and V14, Family Members of R2 said, we have been directly involved in R2's care since transfer into the facility. V10 said, at first the facility primarily contacted (V14), but after a verbal altercation with staff, V6 Director of Nursing asked if V10 could be the primary contact. V14 said the altercation was due to the frustration and lack of help from the staff. V10 and V14 expressed concerns regarding discharge planning,…

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 follow physician orders for two of two (R2, R3) residents reviewed for medication administration by inaccurately transcribing a medication for R2 and by not ensuring timely ordering of medications for R3. Findings include: R2 is [AGE] years old and was transferred to the facility on 4/9/24. Diagnoses listed for R2 include dementia, osteitis (inflammation of bone), convulsions and violent behavior. According to the Minimum Data Assessment of 4/19/24, R2 was assessed to have mild cognitive impairment. The Physician order sheet active during this survey and the Medication Administration Record (July 2024), include Olanzapine 15mg oral daily which was ordered 6/24/24. On 7/8/24 at 3:47PM V13 Psychiatric PA (Physician's Assistant) said that they manage psychotropic medications for R2. On 6/6/24, V13 assessed R2 and made a recommendation to increase a medication Aripiprazole (antipsychotic) from 10mg to 15mg. When seeing R2 again on 6/20/24, V13 noted 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 observation, interview and record review, the facility failed to ensure stock medications, eye drops and insulins were labeled with open and expiration date, failed to label multidose vials and multidose liquid medications and failed to dispose expired medications. These failures affected 8 (R2, R7, R8, R16, R23, R42, R69 and R100,) residents reviewed for medication storage and labeling and have the potential to affect 126 residents receiving medications on all floors. Three out of six medication carts and three out of three medication rooms reviewed for medication storage and labeling. Findings include: On 04/23/24 at 11:00am, medication storage and labeling observation completed with V10 (Licensed Practical Nurse) on the second-floor south medication cart, 1-Humalog insulin vial opened and not dated for R2. 2-Cromolyn Sodium Ophthalmic Solution 4% opened and undated for R69 3- Levetiracetam 100mg/ml for R8 opened and undated. Floor stock Medication observed to be open and undated as follows: 1 Bottle…

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 document medication administration in the Electronic Medical Record in accordance with acceptable clinical practice for seven (R29, R109, R17, R64, R28, R86, R25) residents reviewed for medication administration. Findings include: On 04/23/24 at 08:47 AM V8 (License Practical nurse) stated, I finished passing all my medications for all my patients. The electronic medical record screen displays a yellow color over all residents' names. V8 stated, I did not sign the medications after I passed them. I normally pass the medication first for each resident, then I will sit down and sign them out, even though the facility policy is to sign each medication after the patient takes them, I did not do it today. R29 was admitted on [DATE] with diagnosis that include and are not limited to diabetes and sacral pressure ulcer, per current physician orders dated: 4-2024 reads: 12 medications are due at 9:00am R109 was admitted on [DATE] with diagnosis 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 observation, interview and record review, the facility failed to ensure staff provide shower/bed bath and grooming for residents who are dependent on staff for Activities of Daily Living (ADL). This failure affected 6 residents (R3, R7, R21, R47, R78, R99) of 11 residents reviewed for ADL care. Findings include: R21 is [AGE] years old and have resided at the facility since 2021, past medical history includes multiple sclerosis, hyperlipidemia, acquired absence of left leg below the knee, history of falling, etc. On 04/22/24 at 10:55AM, R21 was observed in bed, awake and alert and stated that she is doing okay, R21 told surveyor to come closer, because she had something to show surveyor. R21 raised up her head from the pillow and showed surveyor her long hair that was clumped together and matted in the back, with a lump of hair in the middle all tangled up. R21 stated, the facility does not give her showers or bed bath, no one has ever washed or combed her hair since admission, she does not want 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, interview, and record review, the facility failed to ensure sufficient nursing coverage to adequately meet the residents care needs. This failure has the potential to affect all 45 residents who are currently residing on the third floor. Findings Include: Per daily census report dated 4/22/24 shows that 45 total residents reside on the third floor. On 4/22/24 at 11:36AM, R3 stated, she is usually changed after lunch but she has not been changed at all today. R3 stated, the last time she was changed was last night (4/21/24). R3 stated, the staff get upset when I use my call light. V22 (CNA) stated, R3 has not been changed today because they are short staffed. V22 stated, they need to have four CNA's but they only have three CNA's. V22 stated, a lot of the resident's on the third floor need two person assistance and assistance with meals. This requires a lot of care and takes a while to get all the resident's up out of bed. On 4/23/23 at 10:10AM, V1 (Administrator) was interviewed regarding new facility interventions put into place to help prevent abuse. V1…

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 have a five percent (5%) or lower medication error rate. There were nine (9) medication errors out of 29 medication opportunities, resulting in a 31.03% medication error rate. This applies to 6 residents (R1, R15, R19, R22, R37, R92) of 10 residents observed during medication administration. Findings included: 1. On 04/23/24 at 09:40 AM Medication observation with V10 (license Practical Nurse) completed for R22. R22 has a diagnosis of cerebral vascular disease, Atrial Fibrillation and Congestive Heart failure. V10 gave the following medications crushed and in apple sauce to R22: Isosorbide mononitrate 30mg 1 tab, Aspirin 81mg 1 tab- Per Physician order sheet dated: April 2024 reads: Aspirin Oral Tablet 325 MG (Aspirin) Give 1 tablet by mouth one time a day, identified wrong dose was given. Isosorbide Mononitrate ER Tablet Extended Release 24 Hour 30 MG Give 1 tablet by mouth one time a day. 2. On 04/23/24 10:00 AM Medication observation…

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 follow its enhanced barrier precaution policy by failing to place any signage with informational material on one (R47) resident door or making personal protective equipment (PPE) available inside or outside resident's room perform hand hygiene between glove changes during wound care observation, failed to clean blood pressure machine and glucose monitor device after used between patients. and failed to keep linen in a closed hamper with the lids closed. These failures affect six (R15, R19, R22, R29, R38, R47) residents reviewed for infection control practices Findings Include: On 04/23/24 at 09:15 am, surveyor observed V10 (License Practical Nurse) taking blood pressure on R15, then on R22 without cleaning the blood pressure cuff. R15 was admitted on [DATE] with diagnosis that include and are not limited to hypertension and heart failure. R22 was admitted on [DATE] with diagnosis of hypertension and cerebral infarction. On 04/23/24 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to refer a resident with a new mental health diagnosis for a level II PASARR assessment. This failure applies to one of three residents (R102) reviewed for PASARR assessments. Findings include: R102 is a [AGE] year-old male with a diagnoses history of Recurrent Major Depressive Disorder (as of 08/17/2023), Adjustment Disorder with Mixed Anxiety and Depressed Mood (as of 07/13/2023), who was admitted to the facility 02/19/2023. R102's medical records did not include a PASARR Level II Assessment On 04/24/24 at 01:27 PM V11 (Psychotropic/Falls Nurse) stated, she believes R102 had a stroke at a young age [AGE]. V11 stated she has always been able to sit and talk with R102 and has not had to send him out, but at times he cannot be calmed down or deescalated. V11 stated, she gave R102 a supervised pass but that does not seem to be sufficient. V11 stated she believes R102 does not belong at the facility and maybe belongs in a different type of facility. 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 interviews and record reviews the facility failed to follow their policy and procedures for comprehensive care planning by not developing and implementing person centered care plan interventions for a resident who refused ADL (Activities of Daily Living) care, a resident with a history of substance use who was observed to be under the suspicion of substance use, and a resident with a history of aggressive and maladaptive behaviors. This failure applies to three of three residents (R78, R85, and R102) reviewed for care planning. Findings include: 1. R78 is a [AGE] year-old male with a diagnoses history of Cerebral Infarction, Unspecified Symptoms and Signs Involving the Nervous System, and Aphasia following Cerebrovascular Disease who was admitted to the facility 11/10/2022. On 4/23/24 at 11:19 AM surveyor observed R78's gown, linens and body with a strong odor of urine. R78 shook his head no when asked by surveyor if he needed to be changed. R78 shook his head up and down to confirm he wanted to be…

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 interviews and record reviews the facility failed to follow their policy and procedure for ensuring residents are provided necessary behavioral health care and services to maintain their highest practicable mental and psychosocial wellbeing consistent with a comprehensive assessment and plan of care and for the prevention and treatment of substance use disorders by not developing comprehensive person-centered care plans, and not reporting signs of resident substance use to social services,. This failure applies to two of three residents (R85, and R102) reviewed for behaviors. Findings include: 1. R85 is a [AGE] year-old male with a diagnoses history of End Stage Renal Disease and Nicotine Dependence who was admitted to the facility 09/17/2022. On 04/22/24 from 10:55 - 12:13 PM surveyor observed a strong odor of Marijuana outside of and in R85's room. Observed R85 with strong Marijuana odor near him. Observed R85 walking through the facility with his eyes appearing red and droopy. On 04/23/24 at 9:12 AM…

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 interviews and record reviews, the facility failed to follow its abuse prevention policy to prevent incidents of resident-to-resident abuse. This affected six of eight residents reviewed (R3 - R8) reviewed for resident-to-resident abuse. This failure resulted in R4 stabbing R3 with a butter knife after a verbal disagreement, R8 throwing a walker at and hitting R7 causing a bruise, and R6 slapping R5 in the face with a open hand. Findings include: 1. R3: On 3/29/24 at 1:10pm, R3 was assessed to be alert and oriented x 3. R3 stated that his previous roommate, R4, and he got into a verbal altercation over the volume of the television. R3 stated that R4 then picked up a butter knife and was swinging it at R3. R3 stated that R4 cut him on his head with the butter knife. R3 stated that he informed V24 (former administrator) of this incident. R3 stated that he and R4 were separated. R3 stated that he went to the dining area and R4 remained in R3 and R4's room until R4 was transported to the hospital for psychiatric evaluation. R3 stated that he informed his case manager of this…

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 interviews and record reviews, the facility failed to follow its abuse policy and immediately report an incident of resident-to-resident abuse to the regulatory agency. This affected two of six residents (R3, R4) reviewed for abuse policy and reporting. This failure resulted in a delay in reporting for over 2 months. Findings include: On 3/29/24 at 1:10pm, R3 was assessed to be alert and oriented x 3. R3 stated that his previous roommate, R4, and he got into a verbal altercation over the volume of the television. R3 stated that R4 then picked up a butter knife and was swinging it at R3. R3 stated that R4 cut him on his head with the butter knife. R3 stated that he informed V24 (former administrator) of this incident. R3 stated that he and R4 were separated. R3 stated that he went to the dining area and R4 remained in R3 and R4's room until R4 was transported to the hospital for psychiatric evaluation. R3 stated that he informed his case manager of this incident on 7/26/23 and she reported it to facility. R3's BIMS (brief interview of mental status) score, dated 3/5/24,…

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 observation, interview, and record review the facility failed to provide privacy for gastric tube medication administration for one resident (R28) of five residents reviewed for medication administration in the sample of 26. Findings include On 11/30/22 at 12:22 PM R7 (RN-Registered Nurse) administered oxcarbazepine 300 mg via gastric tube to R28. V7 exposed R28's abdomen to administer the medication. V7 did not close R28's privacy curtain. R28 was in the line of sight of R33 (her roommate) and V14 (family member of R33). V7 said, I should have pulled the privacy curtain. On 12/1/22 at 10:48 AM V3 (Director of Nursing) said, the nurses should use the privacy curtain if needed to provide privacy for procedures. Policy: Privacy and Dignity 1/17/2016 Policy Statement: It is the facility's policy to ensure that resident's privacy and dignity is respected by the staff at all times. Procedures: 1. During care that requires privacy such as incontinence care, the resident will be placed in bed and the privacy curtain will be drawn to provide full visual privacy. If the privacy…

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 develop and implement care plans for residents with specialized needs for two (R80, R366) of 12 residents reviewed for care plans in a sample of 26. Findings include: 1. R366's order summary report dated 11/29/2022 indicated orders for Heparin sodium 5000 unit/mL (milliliters) to inject 5000 units subcutaneously every 12 hours for clotting prevention and clopidogrel bisulfate 75mg 1 tablet by mouth one time daily for blood clot prevention with order date of 11/17/2022. Baseline care plan and comprehensive care plan were reviewed and did not indicate R366 is on anticoagulation therapy. On 12/01/2022 at 10:20AM, V6 (Minimum Data Set (MDS) Coordinator) stated that anticoagulants should be included on the baseline care plan and comprehensive care plan. On 12/01/2022 at 10:52AM, V3 (Director of Nursing) said that if a resident is on anticoagulation therapy, there should be a care plan addressing it, including the baseline care plan. R366'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 apply compression stockings for one (R72) of one resident reviewed for edema in a sample of 26. Findings include: On 11/29/2022 at 10:48AM during observation, R72 was observed walking in the hallway with left leg larger than the right leg, and no compression stockings were observed. On 11/30/2022 at 9:10AM, R72 was observed standing at bedside with left leg larger than the right leg, and no compression stockings were observed. On 12/01/2022 at 11:05AM, R72 was observed sitting at bedside left leg larger than the right leg, and no compression stockings were observed. On 11/29/2022 at 11:41AM, R72 was observed with V7 (Registered Nurse) and said that R72 has an order for compression stockings, and it should be on at this time. On 12/1/2022 at 12:00PM, V3 (Director of Nursing) observed R72 and stated that if the resident has order for stockings, nurses apply it since it usually appears on their electronic administration record. R72's Order Summary Report dated 11/29/2022 indicated admission date of 09/05/2020,…

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 verify placement of a gastric tube before administering medication to one resident (R28) of five residents reviewed for medication administration in the sample of 26. Findings include: On 11/30/22 at 12:22 PM V7 (RN-Registered Nurse) administered Oxcarbazepine 300 mg (milligrams) to R28 via gastric tube. V7 did not check placement of the gastric tube. V7 did not check for a placement mark on the gastric tube or aspirate the contents and check the pH (power of hydrogen) or inject air into the tube while listening over the stomach. V7 said, I confirmed the placement of her g-tube (gastric tube) when I did her medications this morning at 9:30. We aspirate to check for gastric contents. When asked if the placement should have been verified before administering medication three hours later V7 did not answer. On 12/1/22 at 10:48 AM V3 (Director of Nursing) said, the nurses should check for placement of the g-tube prior to administering medications, water, or anything in the g-tube. If there is no marking for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to obtain physician orders for a CPAP (Continuous Positive Airway Pressure) machine for one resident (R80) of four residents reviewed for respiratory care in the sample of 26. Findings include On 11/30/22 at 1:01 PM R80 was observed in bed using a CPAP (Continuous Positive Airway Pressure) machine. R80 said, this is my machine, I brought it with me when I came here and I've been using it every night. They just give me the distilled water for it. A review of R80's medical record revealed that there is no physician's order or care plan for the CPAP machine use. The face sheet indicates that R80 was admitted on [DATE]. On 12/1/22 at 10:15 AM V6 (Minimum Data Set Coordinator) said, you need an order to proceed with the care plan. The order should have been obtained when he started using the CPAP. I will put the respiratory care plan in if there is an order. On 12/1/22 at 10:48 AM V3 (Director of Nursing) said, we should contact the physician 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.

Based on observation, interview and record review the facility failed to dispose of medications after the use by date in two of three medication carts reviewed for medication and storage. Findings include: On 11/30/22 at 3:50 PM the 1 North medication cart contained glargine insulin for R56 with an opened date of 10/11/22 and a use by date of 11/11/22. The cart contained insulin aspart for R57 with an opened date of 10/22/22 and a use by date of 11/22/22. V3 (Director of Nursing) said, these should have been removed from the cart. On 11/30/22 at 4:15 PM the 2 South medication cart contained timolol 0.25% eyedrops for R2 with an opened date of 10/28/22 and a use by date of 11/28/22. The cart contained dorzolamide 2% eyedrops for R2 with an opened date of 10/27/22 and a use by date of 11/27/22. V13 (RN-Registered Nurse) said, these shouldn't have been put back in the cart. Policy: Medication Pass 1/5/2016 Medication Labeling: 1. All opened medication vials in the refrigerator should be labeled with the date when it was opened and discarded within 28 days of opening except for (insulin…

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.