West Suburban Nursing & Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to assist a resident in discharge planning. This applies to 1 of 3 residents (R1) reviewed for discharge planning in the sample of 9. The findings include: On April 28, 2025 at 11:28 AM, R1 was sitting up in his wheelchair in his room. R1 stated he wants to move to a different facility to be closer to his family. R1 has talked with V11 Ombudsman and V4 Social Services (SS) about it, and nothing has been done. On April 28, 2025 at 8:51 AM, V11 Ombudsman stated, R1 wants to go to a different facility to be closer to his family. R1 has provided a list to the facility of facilities that are closer, and they still haven't done anything. R1 has asked about the progress and V4 SS told R1 that V4 has sent the referral packet but V4's not actually reaching out to the facilities. On April 28, 2025 at 10:06 AM, V4 SS stated, he did not have anyone actively discharging at the moment. V4 had sent a referral to another local skilled nursing facility (SNF)…

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 residents were supervised in the dining area to prevent a resident to resident incident resulting in a fall for 2 of 4 residents (R3, R4) reviewed for supervision in the sample of 9. The findings include: The facility provided roster shows R3 and R4 reside in the memory care unit of the facility. R3's Care Plan shows she has a diagnosis of dementia and has a cognitive deficit with periods of disorientation. R3's 4/17/25 Minimum Data Set (MDS) assessment shows she has a cognitive impairment and has periods of confusion and forgetfulness. R4's Care Plan shows she has a diagnosis of dementia and has a cognitive deficit with periods of disorientation. R4's 2/6/25 MDS assessment shows she has a cognitive impairment and has periods of confusion and forgetfulness. A facility Resident to Resident Altercation reported completed by V7 (Registered Nurse/ RN) on 4/19/25, shows during the noon meal on 4/19/25, R3 was found lying on the floor of the dining room. The report shows when V7 spoke with R3, R3 indicated that another…

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 protect residents from facility abuse. This applies to 2 of 7 residents (R5 and R7) reviewed for abuse in a sample of 11. The findings include: 1. Review of R7's care plan showed R7's diagnoses include anxiety disorder, dementia, depression, psychosis, cognitive communication disorder, bipolar disorder, toxic encephalopathy, and insomnia. Care plan, initiated [DATE] and revised [DATE], shows R7 hoards items related to his diagnoses of dementia including entering other resident rooms in search of items to hoard, rummaging through drawers/closets, and becoming angry and defensive when asked to remove items. The care plan also shows R7 had a history of abuse/neglect/exploitation/past trauma that may increase his susceptibility to abuse and neglect. MDS (Minimum Data Set), dated [DATE], shows R7's cognition was moderately impaired. Review of R6's care plan show R6's diagnoses include depression, anxiety, alcohol use, cannabis use, suicidal ideation, 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 interviews and record reviews, the facility failed to provide timely assistance with transfers to bed and showers as scheduled for residents who require staff assistance for transfers and bathing. This applies to 3 of 3 residents (R2, R3 and R8) reviewed for staffing in a sample of 11. The findings include: 1. Face sheet, dated 1/10/25, shows R2's diagnoses included multiple sclerosis, neuromuscular dysfunction of bladder, congestive heart failure, osteoarthritis, and muscle wasting. MDS (Minimum Data Set), dated 1/1/25, shows R2's cognition was intact and R2 was dependent on staff for bathing. Care plan, dated 5/27/22, shows R2 required extensive assistance and one person support from staff for bathing. On 1/9/25 at 11:58 AM, R2 stated, It's not fair! I deserve my shower! It's all I have. I don't get my shower if there isn't enough staff. I didn't have a shower last week. I don't know the last time I had a shower. I am a very clean person. Shower sheets, dated 11/1/24 to 1/10/25, showed R2 was only…

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 provide timely assistance with transfers to bed and showers as scheduled for residents who require staff assistance for transfers and bathing. This applies to 3 of 3 residents (R2, R3 and R8) reviewed for staffing in a sample of 11. The findings include: 1. Face sheet, dated 1/10/25, shows R2's diagnoses included multiple sclerosis, neuromuscular dysfunction of bladder, congestive heart failure, osteoarthritis, and muscle wasting. MDS (Minimum Data Set), dated 1/1/25, shows R2's cognition was intact and R2 was dependent on staff for bathing. On 1/9/25 at 11:58 AM, R2 stated, It's not fair! I deserve my shower! It's all I have. I don't get my shower if there isn't enough staff. I didn't have a shower last week. I don't know the last time I had a shower. I am a very clean person. Shower sheets, dated 11/1/24 to 1/10/25, showed R2 was only offered 9 showers (11/8/24, 11/12/24 refused, 11/19/24, 11/22/24 refused, 11/26/24, 12/10/24 refused, 12/17/24…

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

Based on observation, interview, and record review the facility failed to ensure food service pans, trays, and utensils were handled in a way to prevent cross-contamination. This applies to all 183 residents receiving food from the kitchen. The findings include: The Centers for Medicare and Medicaid form 671 dated 10/28/24 shows there are 188 residents residing in the facility. Facility provided list of residents who receive nutrition strictly via tube feedings dated 10/29/24 shows there are 5 residents that do not receive food from the kitchen. On 10/28/24 at 9:33 AM, V5 (Dietary Aide) said V10 (Food Service Director) was on vacation this week and would not be on site. On 10/28/24 at 9:35 AM, V4 (Dietary Aide) was wearing teal rubber gloves that extended up to his elbows. V4 was draining the water from the three-compartment sink. V4 was clearing food debris from the first sink which was a yellowish color from being soiled. As V4 removed food debris from the sink, V4 would transfer the food debris to the garbage can located next to the three-compartment sink. V4 continued to drain…

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 expired medications and failed to ensure the medication was refrigerated at the correct temperature for 9 of 35 residents (R175, R105, R152, R169, R46, R167, R156, R37 and R29) reviewed for medication storage in the sample of 35. The findings include: On 10/29/24 at 9:24 AM, while checking the medication cart on the second floor of the facility with V14, Licensed Practical Nurse, a glucagon injection labeled for R105 with an expiration date of 5/2024, eye drops labeled for R167 with 8/11/24 written on it, artificial tears labeled for R156 with 7/22/24 written on it, artificial tears labeled for R37 with 5/28/24 written on it, and eye drops labeled for R29 with 8/1/24 written on it were found. V14 said the nurse writes the date eye drops are opened on the box and they are good for 30 days after being opened. On 10/29/24 at 09:31 AM, the medication refrigerator in the second-floor medication room was checked with V14. The temperature was confirmed with V14 to be 50 degrees Fahrenheit (F). The…

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

Based on observation, interview, and record review the facility failed to ensure pureed broccoli and pureed ham were free of particles and at a smooth consistency. This applies to 4 of 4 residents (R172, R179, R155, R129) reviewed for pureed diets in the sample of 35. The findings include: Facility provided list of residents on a pureed diet shows that R172, R179, R155, and R129 received a pureed diet. On 10/28/24 at 10:01 AM, V7 (Cook) was pureeing the broccoli for the noon meal. At 10:08 AM, V7 finished the pureed broccoli and it appeared to have some small chunks when finished. V7 did not test the pureed broccoli before placing it into a steam table pan to use at service. V7 was already finished pureeing the ham before this surveyor watched. On 10/28/24 at 1:12 PM, the facility provided test tray of pureed ham, pureed broccoli, and pureed stuffing was reviewed. The pureed ham had small chunks in it, prompting and requiring chewing. The pureed broccoli also had small chunks in it, prompting and requiring chewing. On 10/28/24 at 1:21 PM, V9 (Cook) said the ham could be a little…

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 was free from abuse for one of 35 residents (R146) reviewed for abuse in the sample of 35. The findings include: R146's admission Record dated October 28, 2024 shows she was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia, adult failure to thrive, history of falling, weakness, difficulty in walking, and depression. On October 28, 2024 at 9:23 AM, R146 was observed in bed. R146 had a large lemon sized bump to her right forehead. The right side of R146's face was discolored from bruising. R146 was not able to reposition herself in bed and was nonverbal. R146's Care Plan initiated on July 4, 2024 shows R146 has poor sitting balance can cannot maintain and upright position when she is in a wheel chair. R146's Care Plan initiated on August 24, 2022 shows R146 requires an extensive assist of one person for bed mobility and is non ambulatory. R146's Fall Incident Report dated October 14, 2024 entered…

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 clarify orders following a missed appointment for a residents treatment of rheumatoid arthritis. This applies to 1 of 35 residents (R58) reviewed for quality of care in the sample of 35. The findings include: R58's face sheet shows she is a [AGE] year old female admitted on [DATE] with diagnosis including rheumatoid arthritis, COPD, anxiety, major depressive disorder and low back pain. On 10/28/24 at 9:30 AM, R58 was observed lying in bed. R58 said she was not doing well. R58 has Rheumatoid Arthritis (RA) and has pain in her hands, shoulder, and arms and she is not receiving treatment for her RA. R58 was taking injections and steroids for her RA. R58 missed her appointment in September due to transportation not showing up and she is supposed to have another appointment in November. R58 is receiving hydrocodone (pain medication) but still having pain. On 10/29/24 at 11:21 AM, V15 (RN-Registered Nurse) said R58 is alert and oriented, she…

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 1 of 35 residents (R118) reviewed for vision aids received a pair of corrective eyeglasses, as prescribed, in the sample of 35. The findings include: On 10/28/24 at 10:39 AM, R118 said she saw the eye doctor and needs glasses, but she has not gotten them. R118 was not wearing eyeglasses. On 10/29/24 at 12:51 PM, V20, Social Services, said R118 saw the eye doctor on 6/17/24 and she has a prescription for eyeglasses. V20 said he has not given R118 a pair of glasses; they probably have not come in yet. V20 said they should follow up with the eye doctor to check on the status. On 10/30/24 at 10:53 AM, R118 said she still wants her eyeglasses, but she was never given the option to order glasses and she had an eye exam in June. R118 said no one has ever followed up with her, so she is not sure if her glasses were ordered. R118's Patient Encounter with the Doctor of Optometry dated 6/10/24 shows R118 received a prescription for eyeglasses. R118's current care plan provided by the facility shows, The resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a protective dressing was in place for a resident with stage 3 sacral pressure ulcer. This applies to 1 of 9 residents (R152) reviewed for pressure ulcers in the sample of 35. The findings include: R152's face sheet shows he is a [AGE] year old male with diagnoses including orthopedic aftercare following surgical amputation, acquired absence of right leg above knee amputee, type 2 diabetes, PVD (peripheral vascular disease), end stage renal disease, dependence on renal dialysis, and hypertensive heart disease. On 10/28/24 at 9:49 AM, R152 was observed lying in bed, his oatmeal spilled over his bedsheets. R152 has a right leg amputation and a gauze dressing to his left foot. V17 (Certified Nursing Assistant-CNA) came in to the room to provide assistance. V17 pulled down R152 incontinent brief, an open area was observed to R152's sacrum without a dressing in place. R152's Braden Scale for Predicting Pressure Sore Risk shows he is 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 2. R152's face sheet shows he is a [AGE] year-old male with diagnoses including orthopedic aftercare following surgical amputation, acquired absence of right leg above knee amputee, type 2 diabetes, PVD (peripheral vascular disease), end stage renal disease, dependence on renal dialysis, hypertensive heart disease. On 10/28/24 at 9:49 AM, R152 was observed lying in bed, his oatmeal spilled over his bed sheets. R152 pressed his call light for assistance. R152 said it takes a while for staff to answer his call light. At 9:58 AM, this surveyor looked outside of R152's room, his call light was not alarming. R152 pressed his call light again and the light did not alarm outside of his room. This surveyor pressed the call light from bed 1, it alarmed outside. V17 (Certified Nursing Assistant-CNA) entered the room and was notified R152's call light was not working. She said she will put in the book about his call light is not working. On 10/29/24 at 12:28 PM, R152 was lying in bed, he said no one has come to fix his…

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

Based on observation, interview, and record review the facility failed to ensure a urinary catheter collection bag and tubing was positioned in a manner to prevent infection for 2 of 5 residents (R30 and R49) reviewed for urinary catheters in the sample of 35. The findings include: 1. On 10/28/24 at 09:58 AM, R30 was up in her electric wheelchair by the nurses station. R30's urinary catheter collection bag was hung on back of chair even with bladder. The catheter tubing went down from the resident and then back up into the collection bag. There was yellow cloudy urine in downward area of the tubing, unable to go up into the collection bag. R30 said she has had a perpetual urinary tract infection for years. R30's Care Plan shows R30 is at risk for complications related to suprapubic catheter use related to urogenic bladder with intervention of monitor position of drainage bag and keep below waist to ensure proper drainage. 2. On 10/28/24 at 11:52 AM, R49 was propelling himself in his wheelchair down the hallway towards his room. R49's urinary catheter tubing was dragging on the…

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

Based on interview and record review the facility failed to ensure the Health Care Worker Registry was checked prior to hire to determine work eligibility for Certified Nursing Assistants (CNAs). This failure has the potential to affect all 183 residents residing in the facility. The findings include: The Center for Medicaid and Medicare Services (CMS-671) form completed by the facility on 12/4/23 shows the facility census was 183. On 12/6/23 at 8:32 AM, V19 (HR Director) said she was off work for a couple weeks recently and was not able to do the background checks which included the Healthcare worker registry check prior to hire for V21 and V22. V19 said the registry check for CNAs should be completed prior to hire as this determines work eligibility. Facility provided background checks for new hires show: V22 (CNA) was hired on 11/13/23 and the Healthcare Worker Registry was not checked until 11/21/23. V21 (CNA) was hired on 11/16/23 and the Healthcare Worker Registry was not checked until 11/21/23. On 12/6/23 at 10:30 AM, V19 checked in the computer system and verified that V22…

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 code status was assessed and accurately documented in the medical record upon readmission to the facility. This applies to 1 of 35 residents (R37) reviewed for advanced directives in the sample of 35. The findings include: R37's Face Sheet shows R37 was last admitted to the facility after hospitalization on 11/11/23 (original admission date 12/5/19) with diagnoses including Dementia, Sepsis and Metabolic Encephalopathy. This same document shows R37 has a code status of Full Code. R37's Physician's Order Sheet printed on 12/5/23 shows an order dated 11/11/23 states, Full Code. R37's EMR (Electronic Medical Record) shows a copy of R37's Do Not Resuscitate (DNR)/ POLST (Practitioner's Orders for Life Sustaining Treatment) dated 11/26/2019, this form shows a marked box of Do Not Resuscitate. R37's undated care plan showing her last admission date of 11/11/23 states, I have requested to be a DNR with selective measures. On 12/6/23 at 9:05 AM V10 (Social Worker) stated, I know her DNR is in her chart- I don't…

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 wound treatments were completed and wound interventions were in place for residents with non-pressure wounds and failed to schedule transportation for a residents physician appointments for 3 of 35 (R24) (102) (R116) reviewed for quality of care. Findings include: 1. R24's electronic face sheet printed on 12/6/23 showed R24 was admitted to the facility on [DATE] with diagnoses to include but not limited to non-pressure chronic ulcer of skin of other sites with necrosis of muscle, unspecified open wound, left hip, infection following a procedure, other surgical site, Sequela. R24's physicians order sheet (POS) printed on 12/6/23 showed left hip lateral /distal cleanse with Hibiclens loose packing, iodoform calcium alginate foam dressing BID (twice daily) and prn (as needed) two times a day for wound care. Left hip distal cleanse with Hibiclens irrigate/ calcium alginate over wound, cover with super absorbent pad dressing daily BID 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 a resident with dysphagia was supervised during meals. The facility also failed to ensure a resident's call light was placed within his reach. This applies to 2 of 35 residents (R57, R28) reviewed for safety and supervision in the sample of 35. 1. On 12/5/23 at 8:48 AM R57 was sitting up in bed in his room at the end of the hall, feeding himself breakfast. R57 had food particles all over his face, chest, and bedding. R57 stated he did not need any help and confirmed he was able to feed himself. No staff was present in R57's room or in the hallway. On 12/6/23 at 9:00 AM R57 was again seen feeding himself breakfast. R57 had scrambled eggs on his chest and chin and some on the floor next to his bed. V12 (CNA) was in another resident's room in the middle of the hall assisting that resident to eat. No other staff were present in the hallway. On 12/6/23 at 8:40 AM V12 stated, (R57) can feed himself , he needs a little set up but he feeds…

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 monitor and record weights for a resident at risk for weight loss for 1 of 9 residents (R146) reviewed for weight loss in the sample of 35. The findings include: R146's current care plan showed R146 was at risk for weight loss due to her diagnoses of dementia and depression. The plan showed R146's weight loss care plan/focus area was initiated on 8/12/22. The plan showed, Weigh the resident monthly or per facility protocol. The care plan showed no documentation of R146 refusing monthly weights prior to 11/17/23. R146's Weights and Vitals Summary record printed 12/5/23 showed R146 weighed 114 pounds (lbs.) on 7/2/23 and 101 lbs. on 8/26/23. The record showed no weight for R146 in August 2023 prior, to the weight documented on 8/26/23. This record showed R146 sustained a significant weight loss of 11.4% in 7 weeks. R146's discharge hospital record dated 8/21/23 showed R146 weighed 47.6 kilograms (104.7 lbs.). The record showed R146 was admitted to a local hospital, on 8/20/23, with diagnoses of diarrhea, syncope, and low…

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 unqualified staff did not operate a resident's enteral (tube) feeding pump for 1 of 6 residents (R154) reviewed for tube feeding management in the sample of 35. The findings include: R154's current care plan showed R154 had a gastrostomy tube in place and required enteral (tube) feedings for adequate nutrition and hydration. The care plan showed a nurse was responsible for turning the feeding pump off prior to resuming the infusion once cares were completed. The plan showed, The feeding tube will be utilized in compliance with current clinical standards of practice and services provided to prevent complications to the extent possible for the resident. On 12/4/23 at 9:46 AM, R154 was in bed. An enteral feeding pump was noted on a pole next to her bed. The pump was on, infusing enteral feeding via R154's gastrostomy tube, at 60 ml (milliliters) per hour. On 12/4/23 at 10:26 AM, V5 and V6 Certified Nursing Assistants (CNA) entered R154's room to provide cares. V5 CNA walked over to R154's feeding pump 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.

Based on observation, interview, and record review, the facility failed to perform hand hygiene and change gloves during incontinence care to prevent cross contamination for 1 of 35 residents (R163) reviewed for infection control in the sample of 35. The findings include: On 12/04/23 at 10:31 AM, V15, Certified Nursing Assistant (CNA), was providing incontinence care to R163. V15 used gloved hands to wipe stool from R163's frontal peri area then V15 rolled R163 to his right side and wiped his backside. V15 took the bottle of peri wash and sprayed R163's behind, removed his gloves and left the room (presumably to get more wipes). V15 did not perform hand hygiene before leaving or reentering R163's room. When V15 returned, he applied clean gloves and finished wiping the stool from R163's back side. Then using the same gloves, V15 rolled a clean pad and brief under R163. V15 removed the soiled pad and set it on the floor. V15 took the sheet and put it in a plastic bag with the pad then put a clean sheet over R163, adjusted his pillow and pulled him up in bed all with the same gloved…

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 the interview and record review, the facility failed to follow its change in condition policy by not reporting the psychotropic medication adverse effect (drowsiness) to the provider. This applies to 1 of 6 residents reviewed (R1) for psychotropic medications/overdose/adverse effects in a sample of 6. The findings include: R1 was an [AGE] year-old female admitted on [DATE] with severe cognitive impairment per the Minimum Data Set (MDS) dated [DATE]. Record review on Physician Order sheet (POS) and Medication Administration Record (MAR) for 09/2023 document R1 was receiving Lasix 20 milligram (mg) daily, Mirtazapine 7.5 mg at bedtime, Sertraline 100 mg daily at 0900, Depakote 125 mg two times per day (0600 and 1800), Risperidone 2 mg two times per day (0800 and 2000, started on 5/18/23 and discontinued on 9/26/23), and Vistaril 25 mg two times per day (0900 and 1700). A review of the nursing Progress note dated 9/26/23, documented R1 was noted with a decline in condition, having episodes of lethargy. The…

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

Based on observation, interview, and record review the facility failed to treat residents in a dignified manner by not sitting down to feed residents for two of 34 residents (R45, R105) reviewed for dignity in the sample of 34. The findings include: On 6/12/23 at 12:02 PM, V7 (Escort) was standing in between R45 and R105. R45 and R105 were sitting in their chairs. V7 was feeding R45 and R105 while standing between them. On 6/14/23 at 9:45 AM, V8 CNA (Certified Nursing Assistant) said staff should always sit down while feeding a resident so it makes the resident comfortable and so the resident feels like they are getting the care they deserve. The facility's Dignity policy not dated shows, Staff will not stand to feed a resident. Residents are to have all aspects of their dignity maintained by staff regardless of the resident's cognitive level or ability to realize or understand what is being said or done by others.

Based on observation, interview, and record review the facility failed to ensure the call light system was within reach for a resident when needing assist of staff for 1 resident (R42) reviewed for call lights within reach in a sample of 34. Findings include: R42's Face sheet printed on 6/12/23 showed R43's diagnoses which include: proximal atrial fibrillation, hypertension, chronic pain, weakness, difficulty in walking and unsteadiness on feet. R42's MDS (Minimum Data Set) dated 5/15/23 showed R42 is cognitively impaired, requires extensive two-person assistance for bed mobility and toileting, and is totally dependence needing two-person physical assist with transfers. On 06/12/23 at 10:44 AM, R42s's call light was not within her reach. It was instead tied on the left side bed rail. R42 lifted her left arm, bent it upward to reach the call cord but was unable to reach it. R42 said, Where is it? I can't reach it. 06/12/23 at 10:55 AM, V11 (Certified Nursing Assistant) CNA said if the call light is not in reach, she might need something and we can't help her if her call light is 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 observation, interview, and record review the facility failed to provide ADL (Activities of Daily Living) assistance for two of nine residents (R106, R21) who require extensive assistance with ADL care in the sample of 34. The findings include: 1. R106's admission Record shows he was admitted to the facility on [DATE] with diagnoses including dysphagia, history of falling, traumatic brain injury, muscle weakness, need for assistance with personal care, and dementia. R106's MDS (Minimum Data Set) dated 4/4/23 shows he is not cognitively intact, requires extensive assistance with bed mobility, toilet use and personal hygiene, and is frequently incontinent of bowel and bladder. On 6/12/23 R106 was observed in the same spot in the dining room/activity room at various times from 10:23 AM-12:15 PM. At 12:15 PM, R106 was moved to the table for lunch. At 12:28 PM, R106 was done being fed lunch. R106 remained in the dining room/activity room until 1:40 PM. At 1:42 PM, V3 and V6 CNA (Certified Nursing Assistants)…

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 safely transfer and reposition a resident for two of six residents (R144, R21) reviewed for safety in the sample of 34. The findings include: 1. R144's admission Record shows she was admitted to the facility on [DATE] with diagnoses including dementia, schizoaffective disorder, cognitive communication deficit, history of falling, unsteadiness on feet, weakness, and need for assistance with personal care. R144 MDS (Minimum Data Set) dated 4/20/23 shows she is not cognitively intact and requires extensive assistance with bed mobility and transferring. R144's Fall Risk Review dated 4/18/23 shows she is a high risk for falls. R144's Care Plan initiated 7/31/22 shows, I may have fluctuations in my normal day to day ADL assistance and staff support needs due to my chronic disease process and/or any acute exacerbations. I may occasionally receive a two person assist with bed mobility, transfers, and toileting. I am at risk for falls. Gait belt 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.

Based on observation, interview, and record review the facility failed to ensure a resident at risk for weight loss received double portions as ordered for 1 of 34 residents (R373) reviewed for therapeutic diets in the sample of 34. The findings include: On 06/12/23 (Monday) at 12:20 PM, R373 was sitting at the dining room table. R373's dietary card showed double portions for breakfast, lunch, and dinner. R373's plate contained two separate portions of rice (about 1 cup) on the plate, one regular serving of pork (about 1/2 cup) with gravy, and a single portion size of vegetables (about 1/2 cup). R373 stated What's this? (Pointing to the pork) I'm not eating it. R373 ate all the rice, vegetables, and bread on the plate, but did not eat the pork. On 06/13/23 (Tuesday) at 12:16 PM, R373 was at lunch in the dining room. R373's dietary card showed double portions. R373 was served 2 chicken fried steaks, about 1/2 cup of cabbage, 3 small slices of potatoes, 2 pieces of bread, and one container of applesauce. R373's portions of cabbage and potatoes were noted to be same size as residents…

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 and change gloves in a manner to prevent cross contamination for three of 34 residents (R21, R32, R106) reviewed for infection control in the sample of 34. The findings include: 1. R21's admission Record shows she was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, anorexia, Alzheimer's disease, history of falling, urinary tract infection, dementia, and need for assistance with personal care. R21's MDS dated [DATE] shows R21 is not cognitively intact, requires extensive assistance with bed mobility, transferring, toilet use, and personal hygiene. R21 is always incontinent of urine and frequently incontinent of stool. On 6/12/23 at 1:24 PM, V3 and V4 CNAs (Certified Nursing Assistants) provided incontinence care to R21. There was urine in R21's incontinence brief. V3 wiped R21's front peri area, touched R21's body to turn her, placed a clean brief on, touched the bed control 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.