Goldwater Care Bloomington

Based on interview and record review the facility failed to complete a discharge summary for one resident (R75) out of one resident reviewed for discharge in a sample list of 41 residents. Findings include: The facility was not able to provide a policy in regards to documentation upon a resident being discharge to home or to another facility. V1 stated at 11:18 AM on 2/26/25 was We only have this policy about transferring or discharging a resident. No information about what needs to be documented in the discharge summary or recapitulation of stay. R75 Electronic Medical Record (EMR) documents R75 admitted to facility on 11/6/24 and discharged on 11/27/24. R75's Electronic Medical Record does not include a discharge summary or recapitulation of stay while here at the facility. R75's Care Plan initiated 11/16/24 documents R75 wishes to return to her home in (Local CIty) and son whom she lives with. The careplan continues to document: to establish a pre-discharge plan with me/family/caregivers and evaluate progress and revise plan as needed. On 2/25/25 V2 at 11:30 AM V2, Director of…

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 services to address a decline in walking and transfer ability for one (R42) of 24 residents in the sample of 41. Findings include: On 2/23/25 between 10:30 AM and 4:00 PM and on 2/24/25 between 8:32 AM and 4:00 PM intermittent random observations were conducted of R42 who was sitting in a wheelchair near the nurses' station on R42's unit. On 2/25/25 at 10:33 AM V14 Certified Nursing Assistant (CNA) and V3 Licensed Practical Nurse (LPN) transferred R42 out of bed into a wheelchair and propelled R42 out into the hallway. On 2/25/25 at 3:12 PM R42 walked approximately 50 feet with wheeled walker and extensive assistance from V13 and V14 CNAs and V3 LPN. V3 had hold of the front of R42's walker to apply resistance pressure while walking backwards. V13 used a gait belt and assisted R42 with walking while V14 followed with the wheelchair. R42's gait was unsteady and R42 leaned forward with feet outstretched trailing behind R42. V3 stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide showers as scheduled for one (R35) of two residents reviewed for showers in the sample list of 41. Findings include: On 2/24/25 at 10:33 AM during the resident council meeting, R35 stated R35 is suppose to have showers twice per week, but has only been getting showers five or six times per month. R35's MDS dated [DATE] documents R35 is cognitively intact and requires substantial/maximal assistance from staff for bathing. R35's shower task documents R35 is scheduled for showers on Mondays and Thursdays and does not document that R35 was offered a shower after 2/17/25. On 2/25/25 at 2:36 PM V27 Certified Nursing Assistant (CNA) stated We work with four CNAs on the [NAME] Hall, which is not enough because we don't always get showers done. It would be nice to have a shower aide. On 2/24/25 R35's February 2025 shower documentation was requested. V2 provided R35's shower sheets dated 2/2/25, 2/11/25 and 2/14/25. On 2/24/25 at 12:43 PM V2 confirmed all…

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 and implement activities of interest for one (R42) of 24 residents reviewed for activities in the sample list of 41. Findings include: On 2/23/25 between 10:30 AM and 4:00 PM and on 2/24/25 between 8:32 AM and 4:00 PM intermittent random observations were conducted of R42 who was sitting in a wheelchair near the nurses' station on R42's unit. There was an overbed table in front of R42 with snacks and drinks. Staff provided feeding assistance for meals. R42 did not participate in any individual or group activities. R42's Minimum Data Set (MDS) dated [DATE] documents R42 has cognitive impairment. R42's MDS dated [DATE] documents reading books/magazines/newspapers, listening to music, doing things with groups of people, and spending time outdoors are R42's preferred activities. R42's Care Plan (current) documents R42 has a diagnoses of Huntington's Disease and R42 enjoys spending time in R42's room, time with family/friends, going…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide supervision to prevent falls and thoroughly investigate falls for one (R42) of one resident reviewed for falls in the sample list of 41. Findings include: R42's Minimum Data Set (MDS) dated [DATE] documents R42 has severe cognitive impairment, requires substantial/maximal staff assistance for toileting and supervision/touch assistance for transfers and walking, and R42 had had two ore more falls without injuries since the last assessment. R42's MDS dated [DATE] documents R42 uses a walker for mobility, is dependent on staff for toileting and supervision/touch staff assistance for eating, transfers and walking, and R42 had two or more falls without injury and two or more falls with minor injury since the last assessment. R42's Nursing Notes document the following: On 6/9/24 at 10:00 AM R42 had an unwitnessed fall outside in the gated patio and R42 was transferred to the emergency room for evaluation. On 6/10/2024 the interdisciplinary team (IDT)…

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 prevent cross contamination during incontinence care and urinary catheter care, failed to have physician's orders for catheters and catheter care, and failed to provide appropriate catheter care for three (R66, R28, R63) of four residents reviewed for urinary care in the sample list of 41. Findings include: The facility's Urinary Catheter Care policy dated 2/14/19 documents hand hygiene should be performed prior to handling urinary catheters, position the catheter below the level of the bladder to prevent back flow of urine into the bladder or tubing, and to use a bag or similar device to prevent the catheter bag from touching the floor and other surfaces. This policy documents to record catheter insertion in the nursing notes and treatment record. The facility's Incontinence Care policy dated 4/20/21 documents use a clean part of a soapy cloth when wiping genitalia and move in downward strokes between the labia for female residents. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to assess pain for one (R66) of two residents reviewed for pain in the sample list of 41. Findings include: The facility's Pain assessment dated [DATE] documents a pain assessment tool will be utilized to determine a resident's pain level and pain will be assessed upon admission, as indicated by diagnoses, and when as needed (PRN) pain medications are administered. Pain assessments will be documented in the nursing notes or on the Medication Administration Record (MAR). On 2/23/25 at 8:46 AM R66 stated R66 takes muscle relaxers that don't really help R66's pain. R66 stated R66 has quadriplegia and muscle spasms throughout R66's body. R66 stated R66 rates R66's pain on a 0 to 10 scale as a 10 even after medications are administered, but R66 stated R66 does not want to be drowsy for therapy. At this time R66's legs spasmed and R66's legs drew up toward R66's waist. On 2/23/25 at 1:04 PM V15 and V16 Certified Nursing Assistants dressed R66 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 notify the physician of the deterioration of a wound and failed to provide wound care as ordered by the physician for one (R1) of three residents reviewed for wounds on the sample list of three. Findings include: The facility's Skin Condition Assessment & Monitoring Pressure and Non Pressure policy revised on 6/8/18 documents, Physician ordered treatments shall be initialed by the staff on the electronic Treatment Administration Record after each dressing change. This policy documents that the physician will be notified of any changes to the wound. R1's Minimum Data Set, dated [DATE] documents R1 is cognitively intact. On 12/31/24 at 9:00 AM, R1 stated she had a doctor's appointment on 12/19/24. R1 stated while in her doctor's appointment R1 transferred from her wheelchair to an exam table with assistance of office staff. R1 stated during the transfer R1 sustained a laceration from a piece of metal sticking out on the exam table. R1 stated…

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 have an operational Legionella water management plan. This failure has the potential to affect all 72 residents residing in the facility. Findings include: The Water Management Program for Prevention of Legionella Growth documents that this procedure policy was last reviewed on 6/27/23. This policy documents additional monitoring or action may need implemented for the following risk factors, hot water temperature dropping where Legionella can grow, areas in pipes with stagnation. In areas where water is not used or is off the facility will do routine flushing of water lines (i.e. Running water for 15 minutes weekly in sinks or showers not in use, etc.). The Facility Assessment last reviewed 12/2024, does not contain a procedure to conduct a facility risk assessment to identify potential Legionella growth and other waterborne pathogens in the facility water system or specific testing protocols and acceptable ranges for control measures. On 12/26/24 at 5:30 AM, V15 Maintenance Director stated the out of order room which has a…

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

Based on observation, interview and record review the facility failed to ensure water temperatures were at comfortable levels. This failure has the potential to affect all 72 residents in the facility. Findings include: The Shower and Tub policy last revised 1/31/18 documents for staff to turn on water and ensure that water is a comfortable and safe temperature. Temperature should be 100-110 degrees Fahrenheit. The Room Water Temperature log dated 11/22/24 through 12/23/24 documents resident room temperatures are obtained twice weekly in Main Room, East Room, Main Building Temperature and East Building Temperature. The Resident Council Meeting Minutes for 7/2/24 document a concern with no hot water in the beauty shop and the showers are getting cold. The Maintenance Department documents that the water tank is still being reviewed to be replaced. Resident Council Meeting Minutes dated 9/5/24 document the temperature of the water on the west side of the building is colder than normal. The Maintenance Department documents they will turn off shower room water when not in use, so it does…

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 showers/bathing assistance for two of six residents (R8, R9) reviewed for showers in the sample list of 11 residents. Findings include: The Bathing-Shower and Tub Bath policy revised 1/31/18 documents a shower, tub bath or bed/sponge bath will be offered according to resident preference two times per week or as needed or requested. The 10/1/24 Resident Council Meeting Minutes document residents are not consistently getting showers or teeth brushed. The 11/1/24 Resident Council Meeting Minutes document residents are having to ask for showers. On 12/26/24 at 6:53 AM, R8 stated last week I never got my shower, and I'm not sure why. R8 stated R8 asked about a shower, but never received one. R8 stated R8's normal shower days are Monday, Wednesday and Friday. R8 stated R8 does not always receive R8's showers. On 12/24/24 at 8:00 AM, R9 stated he has not received a shower since he was admitted to the facility. R9 stated he has asked staff…

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 fingernail care for one (R1) of five residents reviewed for hygiene in the sample list of five. Findings include: The facility's Nail Care policy dated 1/25/18 documents to monitor fingernail and toenail condition and provide cleaning and trimming during bathing assistance. On 11/6/24 at 9:19 AM R1's fingernails were long, approximately 1/4 inch past R1's fingertips, and jagged. There was a black substance underneath R1's fingernails. R1's Minimum Data Set date 10/28/24 documents R1 has moderate cognitive impairment and requires supervision/touching assistance from staff for personal hygiene. R1's care plan dated 11/1/24 does not document R1 refuses cares. On 11/6/24 at 1:43 PM V10 Certified Nursing Assistant (CNA) stated R1 is cooperative with cares. V9 CNA stated R1 is scheduled for showers on Tuesdays and Fridays. V9 and V10 stated fingernail care is done by the CNAs. V10 stated the CNAs should be providing fingernail care as part of morning cares. At this time R1 self propelled his wheelchair to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to have physician orders for urinary catheters and document and report changes in urinary condition for two (R1, R5) of three residents reviewed for urinary catheters in the sample list of five. Findings include: The facility's Urinary Catheter Care policy dated 2/14/19 documents the nurse will insert the smallest sized urinary catheter as ordered by the physician and record catheter insertion in the nursing notes and treatment record. The facility's Physician-Family Notification-Change in Condition policy dated 11/13/18 documents to notify the resident's representative/family and physician when there is a significant change in the resident's physical, mental or psychosocial status. 1.) On 11/6/24 at 9:19 AM R1 stated R1 no longer has a urinary catheter since it was removed last night/early this morning. R1 stated R1 did not like the urinary catheter and R1 had tried to pull it out. R1 stated R1's urine had been dark and bloody. R1's Minimum…

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 physician orders and care plans for oxygen, and monitor oxygen saturation levels for three (R1, R2, R4) of three residents reviewed for oxygen in the sample list of five. Findings include: The facility's undated Oxygen Therapy General Standard policy documents oxygen is administered according to physician's orders and there will be ongoing resident assessments for oxygen administration, including assessing oxygen saturation levels. This policy documents oxygen flow rate will be increased or decreased based on the physician's orders or protocol. 1.) On 11/6/24 at 9:19 AM There was an oxygen concentrator in R1's room. R1 was in R1's room and was not wearing oxygen. R1 stated R1 has been in the facility for a few weeks and has been using oxygen prior to today. R1 stated the facility has been trying to wean R1 off of oxygen. R1's Nursing Note dated 10/23/2024 at 4:00 PM documents R1 admitted to the facility using oxygen at 4 liters per…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide timely toileting for one (R4) resident resulting in an incontinence episode out of four residents reviewed for timeliness of cares in a sample list of four residents. Findings include: R4's undated Face Sheet documents R4's medical diagnoses as Muscle Wasting and Atrophy, Diabetes Mellitus Type II, Morbid Obesity, Chronic Obstructive Pulmonary Disease (COPD), Weakness, Dependence on Wheelchair, Left Above the Knee Amputation and Spinal Stenosis. R4's Minimum Data Set (MDS) dated [DATE] documents R4 as cognitively intact. This same MDS documents R4 requires maximum assistance with toileting, bathing, dressing and personal hygiene. R4's Careplan intervention dated 3/11/24 documents R4 requires the assistance of two staff to transfer with a total body mechanical lift. Resident Council Minutes dated 7/2/24 document New business: Certified Nurse Aide (CNA)/Nursing Concerns Answer call buttons quicker (two residents said they waited two hours). CNA…

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 interventions for a resident with a known history of falling, complete thorough fall investigations, complete accurate fall risk assessments and obtain complete neurological checks for residents with head injury post fall. These multiple failures affect two (R1, R2) residents reviewed for accidents on a sample list of three residents. Findings Include: 1. R2's Facility Census documents R2 was admitted to the facility on [DATE] and includes the following medical diagnoses; Cerebellar Stroke Syndrome, Aphasia, Asthma, Lack of Coordination, Abnormal Posture, Repeated Falls, Need for Assistance with Personal Care, Ataxic and Abnormalities of Gait and Mobility. R2's Minimum Data Set (MDS) dated [DATE] documents R2's Brief Interview for Mental Status (BIMS) score 99, unable to participate in the interview, moderate cognitive impairment. R2's Care Plan dated 9/10/24 documents admission date of 7/2/24 states R2 has a diagnosis of…

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 sufficiently staff nurses and Certified Nursing Assistants for 10 (R1, R2, R3, R4, R5, R6, R7, R9, R10, R11) of 11 residents reviewed for staffing in the sample list of 11. This failure has the potential to affect all 72 residents residing in the facility. Findings include: The Facility's Facility assessment dated [DATE]-[DATE] documents an average daily census of 68 residents and staffs based on resident population and their needs for care/support. This assessment includes a staffing plan for 10 nurses per day and 21 nurse aides per day. The facility's Midnight Census Report dated 7/1/24 documents 72 residents reside in the facility, R1-R6 and R11 reside on the East wing and R7-R10 reside on the [NAME] wing. The facility's Daily Assignment Sheet dated 6/18/24-7/2/24 document two Certified Nursing Assistants (CNAs) were assigned to East Wing on two days for dayshift and four days for evening shift, and one nurse was assigned daily 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 ensure a severely cognitively impaired resident (R6) did not exit the facility unnoticed (elopement). The facility failed to ensure staff were trained on exit door alarms and identifying residents at risk for elopement, supervise R6, assess elopement/wandering risk, develop and implement a care plan and interventions for wandering/exit seeking behaviors, identify triggers for exit seeking behaviors, and monitor departure alert device placement for three (R6, R7, R8) of three residents reviewed for elopement in the sample list of 11. Findings include: 1.) R6's Nursing Note dated 7/2/2024 at 10:03 PM documents the following: At 8:10 PM the nurse (V14 Agency Licensed Practical Nurse (LPN)) received a call from an unidentified pedestrian reporting a resident (identified as R6) was walking in socks outside of the facility near the street, and R6 attempted to step onto the curb and tripped, causing R6 to fall and hit R5's head on the pavement.…

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 medications were administered timely as ordered resulting in repeated significant medication errors for two (R2, and R5) of five residents reviewed for medications in the sample list of 11. Findings include: On 7/2/24 between 9:15 AM and 11:45 AM V5 Licensed Practical Nurse (LPN) was the only nurse working on the East wing of the facility. On 7/3/24 at 9:36 AM V11 LPN was the only nurse working on the East wing. On 7/2/24 at 10:35 AM V5 was administering medications on R1's, R2's, and R5's hallway. V5 stated V5 is assigned to 25 residents, there is an hour window to give medications before/after the scheduled time, and V5 is behind with medication administration today. On 7/2/24 at 11:45 AM V5 stated V5 did not complete the East wing 8:00 AM medication pass until 10:00 AM-10:30 AM. V5 stated V5 has been having difficulty getting the medications administered timely since the facility changed to having only one nurse on the East wing,…

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 notify a resident's Power of Attorney (POA) of a fall with injury for one of three residents (R1) reviewed for notifications on the sample list of three. Findings include: R1's undated Face Sheet documents R1's medical diagnoses includes a history of Left Femur Fracture, Muscle Weakness, Abnormalities of Gait and Mobility, Hemiplegia and Hemiparesis following Cerebral Infarction, Dislocation of Left Shoulder Joint, Homonymous Bilateral Field Defects on Left Side, Optic Neuritis and Trochanteric Bursitis. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as moderately cognitively impaired. R1's Electronic Medical Record (EMR) documents V4 as R1's Power of Attorney (POA). R1's Nurse Progress Note dated 6/7/24 at 9:05 PM documents (R1) assisted to bathroom before bedtime tonight by (V5) Certified Nurse Aide (CNA). (R1) stood up to sit on toilet and his legs became unstable. (V5) CNA assisted (R1) to a sitting position on the ground and called 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 interview and record review the facility failed to implement fall prevention interventions and complete a thorough fall investigation for one (R1) resident out of three residents reviewed for falls in a sample list of three residents. Findings include: R1's undated Face Sheet documents R1's medical diagnoses as a history of Left Femur Fracture, Muscle Weakness, Abnormalities of Gait and Mobility, Hemiplegia and Hemiparesis following Cerebral Infarction, Dislocation of Left Shoulder Joint, Homonymous Bilateral Field Defects on Left Side, Optic Neuritis and Trochanteric Bursitis. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as moderately cognitively impaired. This same MDS documents R1 as requiring maximum assistance for toileting, dressing and moderate assistance with personal hygiene and transferring on and off the toilet. R1's Physician Order Sheet (POS) dated June 2024 documents a physician order dated 1/30/24 for R1 to wear Left Arm immobilizer at all times except for dressing and showering.…

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 store and maintain caustic cleaning chemicals in a manner to prevent access by an ambulatory resident diagnosed with dementia. This failure has the potential to affect one resident (R1) out of five reviewed for safety on the sample of five. Findings include: R1's Census Detail documents R1 was admitted to the facility 9/1/22. This same Census Detail documents R1 was discharged to the hospital 4/21/24. R1's Nurses Notes dated 4/21/24 document R1 was sent to the hospital for unwitnessed possible ingestion of unknown substance. R1's Diagnoses List documents R1's medical diagnoses includes Anxiety, Major Depression, Dementia with Behavioral Disturbance, Gastro-Esophageal Reflux Disease, Disorder of Phosphorus Metabolism, Adrenocortical Insufficiency, Hyponatremia/ Hypo-Osmolality, and a history of Gastro-Intestinal Hemorrhage. R1's Minimum Data Set, dated [DATE] documents R1 could not provide any comprehensible answers during a Brief…

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 notify a resident and resident representative in writing of an involuntary facility-initiated discharge. This failure affects one of five residents (R1) reviewed for involuntary discharge in a sample list of five residents. Findings Include: The facility's policy Bed Hold and Return to the Facility reviewed 9/16/17 states: Medicaid-eligible residents who are on therapeutic leave or are hospitalized beyond the State's bed-hold policy must be readmitted to the first available bed even if the residents have outstanding Medicaid balances. Once readmitted , however, these residents may be transferred if the facility can demonstrate that non- payment of charges exists and documentation and notice requirements are followed. R1's Care Plan updated 3/7/24 includes the following diagnoses: Alcoholic Cirrhosis of the Liver, Chronic Atrial Fibrillation, Long Term Use of Anticoagulant, Anemia, Depression, Aseptic Necrosis of Bilateral Femurs, Dysphagia, [NAME]…

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 allow a hospitalized resident to return to the facility. This failure affects one of five residents (R1) reviewed for involuntary discharge in a sample list of five. Findings Include: R1's Care Plan updated 3/7/24 includes the following diagnoses: Alcoholic Cirrhosis of the Liver, Chronic Atrial Fibrillation, Long Term Use of Anticoagulant, Anemia, Depression, Aseptic Necrosis of Bilateral Femurs, Dysphagia, [NAME] Matter Disease,and Amyotropic Lateral Sclerosis. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is cognitively intact, but unable to complete Brief Inventory of Mental Status (BIMS). R1's Progress notes from 1/2/24 to 4/2/24 document R1 refused offers to go to the dining room to be fed at least 94 times. R1's Progress notes from 1/2/24 to 4/2/24 document R1 refused offers of fall mats and bed in lowest position at least 15 times. There is no documentation to support R1 experienced a fall during this period. There is no documentation to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide assistance for oral care for one of three residents (R2) reviewed for oral care on the sample of three. Findings Include: R2's March 2024 Medical Diagnoses List documents R2 is diagnosed with Amyotrophic Lateral Sclerosis, Alcoholic Necrosis of Liver, [NAME] Matter Disease, Depression, Anemia, and Difficulty Walking. R2's Minimum Data Set, dated [DATE], documents R2 is cognitively intact. R2's Care Plan, dated 1/14/24, documents R2 is at risk for Activities of Daily Living Deficit and requires the assistance of one staff member for oral care. R2's February 2024- 3/6/24 Task Documentation for Oral Care documents eight days with no oral care and multiple days where oral care was only provided once per day. On 3/6/24 ay 12:20 PM, R2 stated facility staff have not offered to help him brush his teeth in two months or more. R2 stated the last time he brushed his teeth was when his sister assisted him. R2's teeth appear dark with a lot…

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 implement a wound intervention and complete wound treatments for one of three residents (R2) reviewed for wounds on the sample of three. Findings Include: The facility's Pressure Ulcer Prevention Policy, dated 1/15/18, documents specialty mattresses such as low air loss or alternating pressure may be used as determined clinically appropriate. The facility's Skin Condition Assessment and Monitoring: Pressure and Non-Pressure policy, dated 6/8/18, documents the purpose of the policy is to establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure injuries, and other non-pressure skin conditions and assuring interventions are implemented. The resident's Care Plan will be revised as appropriate to reflect alteration of skin integrity, approaches, and goal for care. Physician ordered treatments will be initialed by staff on the electronic Treatment Administration Record after each administration. R2's March 2024…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide showers to a dependent resident. This failure affected one of three residents (R56) reviewed for showers on the sample list of 31. Findings Include: The facility's Bathing Policy, dated 11/28/12, documents showers must be offered per resident preference at least twice per week and documented in the resident's Electronic Medical Record (EMR) when completed. R56's Medical Diagnoses, dated February 2024, documents R56 is diagnosed with Diabetes, Spinal Stenosis, Asthma, and Arthropathy. R56's Minimum Data Set, dated [DATE], documents R56 is completely cognitively intact and requires substantial maximum assistance for showering. The undated [NAME] Wing Shower Schedule documents R56 is to receive showers on Sundays and Wednesdays. R56's Electronic Medical Record (EMR) Bathing Task for February 2024 documents R56 received showers on 2/11/24, 2/14/24, and 2/16/24. Written shower sheets for R56 documented showers were also given on 2/4/24 and 2/7/24.…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain safe handrails. This failure has the potential to affect all 69 residents in the facility. Findings include: On 1/31/2024 at 2:54 PM, the handrail located between rooms [ROOM NUMBERS] was loose and the end portion approximately four feet in length was completely detached from the wall. On 1/31/2024 at 2:57 PM, V8 (Maintenance Director) observed the loose handrail and reported the handrail needed some bolts replaced to properly secure the rail to the wall surface. The Long-Term Care Facility Application for Medicare and Medicaid (2/2/2024) documents 69 residents reside in the facility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure dignity was maintained by speaking to a resident in a derogatory manner (R29), and failing to provide timely incontinence care and meet resident hygiene needs (R25, R41 and R40). (R25, R29, R41 and R40) are four of four residents reviewed for dignity in the sample of 32. Findings include: 1. R29's Diagnosis list, updated 01/08/24, documents the following: Anxiety Disorder, Depression, Legal Blindness, Immunodeficiency Unspecified Localized Swelling, Mass and Lump Lower Limb Bilateral, and Pressure Ulcer Sacral Region, Stage IV. R29's Minimum Data Set (MDS), dated [DATE], documents R29's Brief Interview of Mental status score of 12 out of a possible 15, indicating moderate cognitive impairment. R29's Care Plan, updated 02/01/24, documents the following: I am receiving (Private Company) Hospice services. I will be made comfortable. I am at risk for abuse/neglect related to: blindness, impaired mobility, anxiety/depression. 02/01/24: I…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to properly store medications by leaving medication cart unlocked and by leaving medications at the bedside for three (R22, R43 and R56) residents out of three residents reviewed for medication storage in a sample list of 32 residents. Findings include: 1. R56's Care Plan, initiated on 11/13/2023, documents R56's medical diagnosis of Hypertension, Pulmonary Embolism, Anemia, Embolism, Spinal Stenosis, and Diabetes Mellitus Type II. R56's Physician Order Sheet (POS), dated February 2024, does not document Physician orders for Nasa [NAME] 55 micrograms (mcg) per spray nor Timolol Maleate 0.5% eye drops. On 2/1/24 at 10:50 AM, R56 was sitting in a wheelchair in R56;s room. R56's Nasa [NAME] 55 micrograms (mcg) per spray nasal spray and opened bottle of Timolol Maleate 0.5% eye drops were sitting on R56's bedside table. Neither of these medications were labeled. There were no licensed nursing staff present in R56's room. R56's room was adjacent…

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 record review and interview, the facility failed to offer and/or document refusals of Pneumococcal Polysaccharide Vaccination (PPSV) 23 and/or Pneumococcal Conjugate Vaccine (PCV) 13, 15 or 20 to four residents (R25, R41, R43, R48) out of five residents reviewed for immunizations in a sample list of 32 residents. Findings include: 1. R25's undated Face Sheet documents R25's date of birth as 3/15/1941, and was admitted to facility on 2/10/2022. This same Face Sheet documents R25's medical diagnoses of Chronic Obstructive Pulmonary Disease, Acute and Chronic Respiratory Failure with Hypoxia, Diabetes Mellitus Type II, Severe Protein Calorie Nutrition, Altered Mental Status, Dementia, Cognitive Communication Deficit, Urine Retention, and History of Pneumonia. R25's Minimum Data Set (MDS), dated [DATE], documents R25 as severely cognitively impaired. This same MDS documents R25 requires moderate assistance with bathing, dressing, and personal hygiene. R25's Electronic Medical Record (EMR) documents R25…

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 record review and interview, the facility failed to invite residents and/or resident representatives to care plan meetings for two of two residents (R22, R48) reviewed for care plans in a sample list of 32 residents. Findings include: 1. R48's Minimum Data Set (MDS), dated [DATE], documents R48 as moderately cognitively impaired. R48's Electronic Medical Record (EMR) does not document a careplan meeting. On 1/30/24 at 3:30 PM, V10 (R48's) Power of Attorney (POA) stated, We like it there. The staff are pretty good. They miss things sometimes, but all in all they are good. I can't take care of (R48) at home anymore. I have never been asked to go to a careplan meeting. I didn't know they had those. That seems like a good idea to get together to talk about (R48) and how we can help him the best ways we can. 2. R22's undated Face Sheet documents R22 admitted to facility on 12/18/23 and discharged on 1/15/24. R22's Minimum Data Set (MDS), dated [DATE], documents R22 as moderately cognitively impaired. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to notify the Physician and resident/resident representative of changes and monitoring issues with residents weights. This failure affects two (R10, R22) residents out of three residents reviewed for notification of changes in a sample list of 32 residents. Findings include: The facility policy titled 'Weights', revised 10/17/2019, documents each resident shall be weighed on admission or at least monthly thereafter or in accordance with the Physician orders. 1. R10's undated Face Sheet documents R10 admitted to the facility on [DATE]. This same Face Sheet documents R10's medical diagnoses of Diabetes Mellitus Type II, Pulmonary Edema, Dementia, Chronic Kidney Disease Stage 3, Heart Failure, Abnormalities of Gait and Mobility, Schizophrenia, and Anxiety. R10's Minimum Data Set (MDS), dated [DATE], documents R10 as severely cognitively impaired. This same MDS documents R10 requires maximum assistance for eating, dressing, toileting, bed mobility 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 record review and interview, the facility failed to include a nutritional plan of care in the comprehensive care plan for a resident with significant weight loss for one of three residents (R10) reviewed for care plans in a sample list of 32 residents. Findings include: 1. R10's undated Face Sheet documents R10 admitted to facility on 9/22/23. This same Face Sheet documents R10's medical diagnoses of Diabetes Mellitus Type II, Pulmonary Edema, Dementia, Chronic Kidney Disease Stage 3, Heart Failure, Abnormalities of Gait and Mobility, Schizophrenia, and Anxiety. R10's Electronic Medical Record (EMR) documents R10's weight on 10/9/23 as 177.0 pounds (lbs), 10/17/23 as 176.0 pounds (lbs), 1/5/24 as 134.0 lbs and weight on 1/31/24 as 131.5 lbs. R10's Minimum Data Set (MDS), dated [DATE], documents R10 as severely cognitively impaired. This same MDS documents R10 required maximum assistance for eating, dressing, toileting, bed mobility and transfers. R10's Physician Order Sheet (POS), dated January 2024,…

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 complete a recapitulation of stay post discharge for one of (R79) of two residents reviewed for discharge summaries in a sample list of 32 residents. Findings include: 1. R79's undated Face Sheet documents R79 admitted to facility on 12/8/23, and discharged on 12/19/23 to home. R79's Physician Order Sheet (POS), dated December 2024, documents a physician order, dated 12/19/23, of OK to discharge to home on [DATE] with Home Health, Physical Therapy (PT), Occupational Therapy (OT) and Home Care Aide (HCA). R79's Discharge Instructions for Medication, dated 12/19/23, documents, OK to discharge home on [DATE] with Home Health, Physical Therapy (PT), Occupational Therapy (OT) and Home Care Aide (HCA). R79's Recapitulation of Stay Summary, dated 12/19/23, documents R79 was discharged to home on [DATE] in stable condition. R79's Nurse Progress Note, dated 12/19/23 at 10:50 AM, documents, Patient discharged home on [DATE]. On 2/1/24 at 2:00 PM, V2, Director of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide timely showers for one (R22) resident out of three residents reviewed for bathing in a sample list of 32 residents. Findings include: R22's undated Face Sheet documents R22 admitted to facility on 12/18/23 and discharged on 1/18/24. R22's Minimum Data Set (MDS), dated [DATE], documents R22 as moderately cognitively impaired. This same MDS documents R22 as dependent on staff for assistance with toileting, personal hygiene, bathing, bed mobility and supervision with eating. R22's Electronic Medical Record (EMR) documents one shower given on 12/19/23 for the entire length of stay. On 2/1/24 at 8:05 AM, V2 Director of Nurses (DON), stated the facility is unable to provide any further documentation than what is already in the EMR. V2 stated, We have looked and cannot find any paper shower sheets completed for (R22). I would like to say we (facility) gave (R22) more than one shower, but I have no documentation to prove it. V2, DON, stated 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 maintain a dressing to a stage four pressure sore for one of three residents (R29) reviewed for pressure sores in a sample list of 32 residents. Findings include: R29's Physician Order Set (POS), dated 02/02/24, documents: Coccyx Wound care: Normal saline Dressing care: Calcium Alginate, Silver Impregnated (medicated wound debridement gauze), Gauze Cut to size, Silver Alginate to the base of the coccygeal wound bed, apply lightly moist (gauze) (squeeze out), ( name brand thick layered cotton pad), and tape daily and PRN (as needed) if soiled or loose. R29's Care Plan, updated 2/1/24, documents the following: I have Stage IV Pressure Ulcer on Coccyx, that is managed by (Private Hospital) Wound Center and blister/vascular wound on right distal extremity. My Pressure ulcer will show signs of healing and remain free from infection through review date. Administer medications as ordered. Monitor/document for side effects and effectiveness. Administer treatments as ordered and monitor for effectiveness. Date…

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 safe mechanical lift transfers, failed to thoroughly investigate mechanical lift transfer incidents, and failed to implement fall interventions for three of six residents (R45, R51, and R48) reviewed for accident/falls on the sample list of 32. Findings include: The facility policy Fall Prevention Program, dated 01/21/2017, documents the following: Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Programs will monitor the program to assure ongoing effectiveness. The facility policy Accidents and Incidents, reviewed 04/07/2019, documents: 5. All incident/accident reports are reviewed, signed, and investigated by: a.The Administrator; and b.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure residents indwelling urinary catheter tubing was secured to prevent pain or discomfort. This failure affects two (R43, R29) residents out of three residents reviewed for incontinence care in a sample list of 32 residents. Findings include: The facility policy titled 'Urinary Catheter Care', revised 2/14/19, documents resident urinary indwelling catheter tubing will be secured to prevent trauma and tension. 1. R43's undated Face Sheet documents R43's date of birth as 7/5/1942. This same Face Sheet documents medical diagnoses of Alzheimer's Disease, Rheumatoid Arthritis, Spinal Stenosis, Pulmonary Embolism, Weakness, and Chronic Pain. R43's Minimum Data Set (MDS), dated [DATE], documents R43 as moderately cognitively intact. This same MDS documents R43 requires maximum assistance for eating, bed mobility, transfers, dressing and personal hygiene. On 2/1/24 at 9:25 AM, V22 and V37, Certified Nurse Aides (CNAs), provided perineal 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 provide oxygen humidifier bottle once depleted, and change oxygen nasal cannula, oxygen tubing, and humidifier bottle according to physician order and facility policy. This failure affected one of one resident ( R29) reviewed for respiratory on the sample list of 32. Findings include: R29's Physician Order Sheet (POS), dated 02/02/24, documents the following: Admit to (private company) hospice with primary diagnosis of Congestive Heart Failure (build up of fluids causes shortness of breath). The same POS documents: 02 (oxygen) at (administer) 2-3L/NC ( two to three liters per minute via nasal cannula) to keep sats ( blood oxygen saturation) above 90 %. Change change o2 tubing weekly night shift. 01/31/24 11:15 AM, R29 was lying in bed. R29's had a bedside oxygen concentrator next to her bed. The oxygen bedside concentrator had a totally empty humidifier bottle, dated 1/22/24. R29 had an undated nasal cannula actively delivering three liters of oxygen per minute into R29's nose. R29 stated R29's nares were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to complete hand hygiene during incontinence care for one (R41) out of four residents reviewed for Infection Control in a sample list of 32 residents. Findings include: R41's undated Face Sheet documents medical diagnoses of Alzheimer's Disease, Dementia, Lymphadema, Malignant Neoplasm of Prostrate, History of Falling, Spondylosis and Hypertension. R41's Minimum Data Set (MDS), dated [DATE], documents R41 as severely cognitively impaired. This same MDS documents R41 requires moderate staff assistance for bathing, dressing, toileting, and personal hygiene. On 2/1/24 at 9:00 AM, V33, Certified Nurse Aide (CNA), completed incontinence care for R41. V33, CNA, did not perform hand hygiene after touching R41's urine soaked incontinence brief, and cleansing R41's front and back perineal areas before applying new incontinence brief. V33, CNA, wore the same pair of disposable gloves throughout entire procedure. On 2/1/24 at 9:15 AM, V33, Certified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to address a residents malfunctioning call light. This failure affects one (R64) out of two residents reviewed for call lights in a sample list of 32 residents. Findings include: R64's Minimum Data Set (MDS), dated [DATE], documents R64 as cognitively intact. R64's Call Light Report, dated 2/1/24, documents R64's call light was activated from 10:12 AM-11:59 AM on 2/1/24. On 2/1/24 at 10:12 AM, R64's call light lit up on ceiling outside R64's room. On 2/1/24 at 10:28 AM, V20, Licensed Practical Nurse (LPN), entered R64's room to answer activated call light. On 2/1/24 at 10:35 AM, V34, Housekeeper, mopped R64's floor. On 2/1/24 at 10:40 AM, R64 was sitting in stationary chair next to bed. R64 was attempting to get up independently. R64's floor was very wet and slick. On 2/1/24 at 10:40 AM, R64 stated, I don't know where everybody is but I have to get up. Come help me get up. I turned on my call light a long time ago and no one has helped me. I…

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 protect a resident after an allegation of resident to resident abuse, failed to thoroughly investigate abuse allegations, and failed to maintain thorough documentation of abuse allegations for six residents (R8, R9, R18, R19, R20, R23) out of six residents reviewed for abuse in a sample list of 23 residents. Findings include: 1. R8's undated Face Sheet documents medical diagnoses of Cerebral Infarction, Dysarthria, Heart Failure, and Slurred Speech. R8's Minimum Data Set (MDS), dated [DATE], documents R8 as cognitively intact. On 1/9/24 at 12:30 PM, R8's allegation of mental and verbal abuse by R18 was reported to V1, Administrator. V1, Administrator, was also informed of R8's statement of not wanting R18 in R8's room, and that R8 claimed R8 was scared of R18. On 1/9/24 at 2:08 PM, R8 was laying in bed in R8's room. R18 was sitting in the wheelchair in R18 and R8's shared room with R8. On 1/11/24 at 2:00 PM, V1, Administrator, stated 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 interview and record review, the facility failed to document/monitor/track resident behaviors, report behaviors to the physician, and develop/implement behavioral care plans. This failure affects five (R9, R20, R22, R23, R18) of six residents reviewed for abuse in the sample list of 23. Findings include: The facility's Abuse Prevention and Reporting - Illinois policy, dated as revised 4/14/22, documents, Resident Assessment: As part of the resident social history evaluation and MDS (Minimum Data Set) assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment or misappropriation of resident property, or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches, which would reduce the chances of abuse, neglect, exploitation, mistreatment or misappropriation of resident property for these residents. Staff will continue to monitor the goals and approaches 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 timely report allegations of abuse to the State Survey Agency and Administrator for three (R20, R9, R23) of six residents reviewed for abuse in the sample list of 23. Findings include: 1. R9's Nursing Note, dated 12/19/2023 at 3:11 AM, recorded by V40, LPN, documents at 2:15 AM, a Certified Nursing Assistant (CNA) reported R9 was hitting R20 with the call light and bed control. R9 and R20 had been arguing over the tv volume and R20 had turned off the tv. V40 turned around to tell the CNA to bring R9 out of the room, and R9 slapped R20 on the left forearm. This note documents R9 was transferred into a wheelchair and while R9 was removed from the room, R9 reached over and squeezed/pinched R20's foot causing pain. This note documents R9 was sent to the emergency room for a psychiatric evaluation, the local police came to the facility and obtained statements, and V40 notified R9's Power of Attorney, the Nurse Practitioner, and the on-call nurse manager. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide weekly showers for two (R3, R4) residents out of eight residents reviewed for Activities of Daily Living in a sample list of 23 residents. Findings include: 1. R3's undated Face Sheet documents an admission date of 11/14/23. This same Face Sheet documents R3's medical diagnoses of Spondylosis of Lumbar Region without Myelopathy or Radiculopathy, Syndrome of Inappropriate secretion of Antidiuretic Hormone, Anxiety, Depression, Disorders of the eyelids, Exposure Keratoconjunctivitis, Legal Blindness, Seizure Disorder, Waldenstrom Macroglobulinemia, Methicillin Resistant Staphylococcus Aureas (MRSA), Pressure Ulcer of Sacrum Stage IV, Right Femur Fracture, and Obstructive and Reflex Uropathy. R3's Minimum Data Set (MDS), dated [DATE], documents R3 as cognitively intact. This same MDS documents R3 as legally blind and requiring maximum one person assist for toileting, bathing, and upper and lower body dressing, and moderate assistance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide timely incontinence care and/or urinary catheter care for three residents (R3, R5, R19) out of three residents reviewed for incontinence care in a sample list of 23 residents. Findings include: 1. R3's undated Face Sheet documents an admission date of 11/14/23. This same Face Sheet documents R3's medical diagnoses of Spondylosis of Lumbar Region without Myelopathy or Radiculopathy, Syndrome of Inappropriate secretion of Antidiuretic Hormone, Anxiety, Depression, Disorders of the eyelids, Exposure Keratoconjunctivitis, Legal Blindness, Seizure Disorder, Waldenstrom Macroglobulinemia, Methicillin Resistant Staphylococcus Aureas MRSA), Pressure Ulcer of Sacrum Stage IV, Right Femur Fracture, and Obstructive and Reflex Uropathy. R3's Minimum Data Set (MDS,) dated 12/27/23, documents R3 as cognitively intact. This same MDS documents R3 as legally blind and requiring maximum one person assist for toileting, bathing, upper and lower body…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide timely Physician visits for two (R7, R20) residents out of four residents reviewed for Physician Visits in a sample list of 23 residents. Findings include: 1.) R7's undated census documents R7 admitted to the facility on [DATE]. R7's medical record only contained physician progress notes, dated 8/28/23, 10/23/23, and 12/18/23, recorded by V39, Physician, and 9/1/23, recorded by V30, Nurse Practitioner. 2.) R20's undated census documents R20 admitted to the facility on [DATE]. R20's medical record only contained physician progress notes, dated 11/27/23 and 1/8/24, recorded by V39, Physician. On 1/18/24 at 1:09 PM, V6, Assistant Director of Nursing, stated V6 verified there are no other physician or nurse practitioner visits besides what is uploaded in R7's and R20's electronic medical record. V6 stated V6 checked the residents' paper charts as well, and the physician progress notes are sent to the facility and uploaded into the resident'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prevent cross contamination during wound care of Pressure Ulcers for two (R3, R14) residents out of three residents reviewed for Infection Control in a sample list of 23 residents. Findings include: 1. R3's undated Face Sheet documents an admission date of 11/14/23. This same Face Sheet documents R3's medical diagnoses of Spondylosis of Lumbar Region without Myelopathy or Radiculopathy, Syndrome of Inappropriate secretion of Antidiuretic Hormone, Anxiety, Depression, Disorders of the eyelids, Exposure Keratoconjunctivitis, Legal Blindness, Seizure Disorder, Waldenstrom Macroglobulinemia, Methicillin Resistant Staphylococcus Aureas MRSA), Pressure Ulcer of Sacrum Stage IV, Right Femur Fracture, and Obstructive and Reflex Uropathy. R3's Minimum Data Set (MDS), dated [DATE], documents R3 as cognitively intact. This same MDS documents R3 as legally blind and requiring maximum one person assist for toileting, upper and lower body dressing 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 interview and record review, the facility failed to protect the residents (R2, R3) rights to be free from verbal and physical abuse from a staff member for two (R2, R3) residents out of three residents reviewed for abuse in a sample list of five residents. Findings include: The facility policy titled 'Abuse Prevention and Reporting', reviewed 12/17/21, documents residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or mental anguish. 1.) R3's Minimum Data Set (MDS), dated [DATE], documents R3 as severely cognitively impaired. This same MDS documents R3 as requiring assistance of one person for transfers, bed mobility, personal hygiene, toileting and dressing. R2's Minimum Data Set (MDS), dated [DATE], documents R2 as cognitively intact. R3's Electronic Medical Record (EMR) documents R3 shares a room with R2. R3's Care…

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 their abuse prevention policy by failing to report allegations of staff to resident verbal and physical abuse to the Abuse Coordinator. This failure affects two (R2, R3) of three residents reviewed for abuse in a sample list of five residents. Findings include: The facility policy titled 'Abuse Prevention and Reporting', reviewed 12/17/21, documents residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or mental anguish. Facility staff are to report any allegation of abuse immediately to the Abuse Coordinator. R3's Minimum Data Set (MDS), dated [DATE], documents R3 as severely cognitively impaired. R2's Minimum Data Set (MDS), dated [DATE], documents R2 as cognitively intact. The Initial Incident Report to the State Agency, dated 10/11/23, documents R2'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 ensure a resident was provided incontinence care and provided clean pants for one of three residents (R1) reviewed for assistance with ADL's (Activities of Daily Living) in the sample of three. Findings include: The Facility's Bowel and Bladder Assessment and Toileting Programs policy, dated 12-3-18, documents, Purpose: Based on the resident's comprehensive assessment the facility will ensure that each resident with bowel and bladder incontinence will receive appropriate treatment and services. The goal is to keep the resident dry by telling them to void at regular intervals. R1's current Electronic Diagnoses Listing documents R1 has diagnoses of Cognitive Communication Deficit, Unspecified Dementia, Mixed Incontinence, and Angioedema. R1's MDS (Minimum Data Set) Assessment, dated 7-28-23, documents R1 is severely cognitively impaired, requires assistance of one staff for transfers and toileting, requires extensive assistance of one staff for dressing, and is frequently incontinent of bowel and bladder. R1'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 ensure a resident was toileted as directed by the resident's plan of care for one of three residents (R1) reviewed for toileting in the sample of three. Findings include: The Facility's Bowel and Bladder Assessment and Toileting Programs policy, dated 12-3-18, documents, Purpose: Based on the resident's comprehensive assessment the facility will ensure that each resident with bowel and bladder incontinence will receive appropriate treatment and services to restore as much normal bowel or bladder functioning as possible. If the resident is identified as being incontinent: The resident's plan of care will be developed to address the issues, goals, and appropriate interventions for elimination program, using an interdisciplinary approach. Toileting Programs: To reduce resident incontinence episodes and restore as much bowel and bladder incontinence as possible by trying to identify a voiding pattern and implement a toileting program. Scheduled toileting: A behavioral technique that calls for scheduled toileting…

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 report an injury of unknown origin immediately to the Administrator and to the State Agency for one (R1) of three residents reviewed for injury of unknown origin on the sample list of five. Findings include: On 8/3/23 at 10:00 AM, V4, Certified Nurse's Aide, lifted R1's shirt. [NAME] and yellow discoloration covered R1's chest. A purple black bruise was on R1's right side, extending from the right underarm to the top of the right hip. On 8/7/23 at 10:15 AM, V2, Director of Nursing, stated V9 Licensed Practical Nurse) called V2 late Sunday night ,July 23, 2023, and asked if she was aware of the bruising on R1. V2 stated V2 was not aware of the bruises. V9 stated there was no documentation about the bruises. V2 stated V9 told her the Certified Nurse's Assistant were saying they heard it may have happened during a transfer. V2 stated she can not say if it occurred during a transfer, and is unsure which staff were reporting the bruise. V2 stated V2 did not notify the Administrator until the next day. V2 stated…

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 safe transfers for one (R1) of three residents reviewed for injury on the sample list of 5. Findings include: On 8/3/23 at 10:00 AM, V4, Certified Nurse's Aide, lifted R1's shirt. [NAME] and yellow discoloration covered R1's chest. A purple black bruise was on R1's right side extending from the right underarm to the top of the right hip. R1's care plan contains an intervention, dated 5/21/23, to transfer R1 with a full mechanical lift. On 8/7/23 at 12:30 PM, V5, Certified Nurse's Assistant (CNA), stated, The bruising on (R1) was caused from the sit to stand lift. We had been using the sit to stand to transfer him since he admitted to the facility. We started using the full mechanical lift after (R1) was seen to have bruising. (R1) has been leaning to the left and fighting when we have him in the sit to stand. V5 stated V5 didn't know they had changed his transfer status in May. On 8/3/23 at 1:50 PM, V12, CNA, stated V12 worked 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 observation, interview, and record review, the facility failed to deliver meals to residents in a timely manner and at a palatable temperature. This failure has the potential to affect all 60 residents residing in the facility. Findings include: On 1/22/23 at 10:00 AM, V11, R9's Power of Attorney, said, (R9's) breakfast is over an hour late today, usually they are only a half hour late. V11 said V11 visits R9 every morning, and R9's breakfast is always late, and usually cold. On 1/22/23 at 10:05 AM, V6, Registered Nurse (RN), said, The residents were not served breakfast yet on the East wing; the kitchen is running late.They are late today, they are not usually this late. On 1/22/23 at 10:15 AM, 16 trays were delivered to the East Hall and passed by nursing staff, and all were delivered to the residents by 10:30 AM. On 1/23/23 at 9:00 AM, 20 trays were delivered to the [NAME] Hall and passed out by nursing staff. On 1/23/23 at 10:00 AM, R275 said, The food is always several minutes late, and usually warm enough to eat. Sometimes the food is not very hot, but I just eat 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 change and label oxygen tubing and humidification bottles (R9, R2, R35, R38), failed to clean CPAP (Continuous Positive Airway Pressure) mask, tubing, and humidifier (R275), and failed to obtain physician orders for changing oxygen tubing, changing humidification bottles and cleaning of the CPAP mask, tubing and humidifier for five of five residents (R275, R9, R2, R35, R38) reviewed for oxygen in the sample list of 40. Findings include: 1). On 1/22/23 at 9:22 AM, R275 was lying in bed wearing a CPAP (Continuous Positive Airway Pressure Device). R275 said, No one cleans the mask, but it should be cleaned. R275 is not able to clean the parts of the device. On 1/22/23 at 11:04 AM, R275's airway pressure device mask was lying on R275's bed. R275's Order Summary Report, dated 1/9/23, documents diagnoses including Emphysema, Acute Respiratory Failure with Hypoxia, Obstructive Sleep Apnea and Abnormalities of Breathing. R275's Care Plan, updated on 1/9/23, does not document R275's use of a positive airway pressure…

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 complete Quarterly Psychotropic Medication Assessments for four of six residents (R8, R28, R36, R44) reviewed for Psychotropic Medications on the sample list of 40. Findings include: 1.) R8's Physician Order Sheet (POS), dated January 2023, documents R8 is diagnosed with Dementia, Psychotic Disturbance, Mood Disturbance, Delusional Disorder, Anxiety Disorder, and Major Depressive Disorder. R8 is prescribed Sertraline (Antidepressant) 37.5 milligrams at bedtime, Seroquel (Antipsychotic) 25 milligrams by mouth two times per day, and Buspirone (Antianxiety) medication 7.5 milligrams two times per day. R8's Psychoactive Medication Quarterly Evaluation, dated 2/10/22, only includes the medication Sertraline. R8's Psychoactive Medication Quarterly Evaluation, dated 1/22/23, is the only other psychotropic medication assessment the facility completed within the last year. On 1/24/23 at 11:11 AM, V1, Administrator, confirmed the facility could not provide any other assessments for R8's Psychotropic medications, and should have…

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 informed consent to increase the dosage of a prescribed psychotropic anti-anxiety medication for one of six residents (R8) reviewed for psychotropic medications on the sample list of 40. Findings include: R8's Physician Order Sheet (POS), dated January 2023, documents R8 is prescribed Buspirone (anti-anxiety) medication 7.5 milligrams two times per day. This order was started on 8/30/22. R8's Antianxiety Medication Consent, dated 2/9/22, documents a consent for Buspirone 2.5 milligrams per day. On 1/24/23 at 3:45 PM, V1, Administrator, confirmed R8's Buspirone dose was increased to 7.5 milligrams two times per day on 8/30/22, and the facility should have obtained informed consent for this increase.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to initiate a Care Plan including resident centered interventions for three residents (R28, R36, R2) of 21 residents reviewed for Care Plans in a sample list of 40 residents. Findings Include: 1. R28's progress notes, printed [DATE], includes the following diagnoses: Dementia, Psychotic Disturbance, and Anxiety. R28's Care Plan, with a review date of [DATE], documents R28 experiences wandering and delusions, in which R28 believes R28's deceased (spouse) is coming to get R28 and their children. There are no Dementia specific resident centered interventions included in R28's Care plan to address R28's Dementia care. 2. R36's electronic medical record documents a current Physician's Order, dated [DATE], Please call Hospice with any concerns regarding (R28) including change of condition, falls, and death. R36's Care Plan, revised [DATE], does not include any hospice related interventions. On [DATE] at 1:08 PM, V4, Minimum Data Set Coordinator, stated V4 is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide an ongoing program for group activities in order to support psychosocial well-being for one of one resident (R61) reviewed for Activities on the sample list of 40. Findings include: During the survey, 1/22/23 through 1/24/23, the facility did not provide any communal dining or group activities for residents. R61's Minimum Data Set, dated [DATE], documents R61 is cognitively intact, and R61 feels it is very important to R61 to do R61's favorite activities and to do things with groups of people. R61's Comprehensive Care Plan, dated 12/1/22, documents R61 enjoys playing Bingo and will participate in group activities when desired. Staff are to invite and encourage R61 to participate in activities of interest, and assist R61 to and from those activities. R61's Care Plan also documents R61 may experience loneliness when in isolation due to Covid-19. On 1/22/23 at 9:00 AM, R61 stated the facility had been restricting residents from…

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 identify the root cause for a fall or initiate resident centered interventions to prevent a fall for one resident (R28) of five residents reviewed for accidents in a sample list of 40 residents. Findings Include: R28's progress notes, printed 1/28/23, includes the following diagnoses: Diabetes with Neuropathy, Chronic Obstructive Pulmonary Disease, Macular Degeneration, Congestive Heart Failure, Difficulty Walking, Muscle Atrophy, Weakness, History of Falling, Dementia, Psychotic Disturbance, and Anxiety. R28's Care Plan includes a problem, initiated 3/1/22, documenting, (R28) is at risk for falling due to dementia; macular degeneration; and weakness. R28's Minimum Data Set (MDS), dated [DATE], documents R28 requires extensive assistance of two or more staff to transfer. R28's Progress note, dated 9/12/22 at 4:23 PM, documents, (R28) has a diagnoses of dementia, and major depressive disorder and (Physician's) orders for Zoloft (antidepressant) 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 administer medications in accordance with Physician's Orders and manufacturer's recommendations for one of three residents (R18) reviewed for medication administration in the sample list of 40. The facility had 2 medication errors out of 32 opportunities resulting in a 6.25% medication error rate. Findings include: R18's electronic diagnosis list documents diagnoses including Gastrointestinal Hemorrhage, Gastro Esophageal Reflux Disease and Age Related Osteoporosis. R18's Physician's Orders document an order for Sucralfate (antiulcer medication) tablet 1 Gram by mouth dated 7/1/22 and an order for Calcium Carbonate-Vitamin D tablet chewable 1200-1000 mg (milligram) give one tablet by mouth dated 7/2/22. On 1/23/23 at 9:05 AM, V7, Registered Nurse, prepared R18's medications. V7 removed one Sucralfate 1 Gram tablet from the medication card. R18's Sucralfate medication card had warning labels on the card documenting, do not take with antacids, take at least two hours before or two hours after your other…

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

Based on observation and interview, the facility failed to maintain visual control of medications, and failed to prepare only one residents medication at a time for two of two residents (R21, R61) reviewed for medication storage in the sample list of 40. Findings include: On 1/24/23 at 9:12 AM, there was a medication cart parked in the hallway just inside the nurses station up against a wall. The medication cart was completely accessible to passersby in the hall way. There was no nurse or any other employee in visual control of the medication cart. A nurse could be heard on the telephone around the corner from the medication cart. There were two medication cups with medication inside the cups. Both cups had initials of two residents on them. One cup had R61's initials, and the other cup had R21's initials on it. There were several water cups with initials on them sitting on the medication cart also. At 9:15 AM, V7, Registered Nurse, returned to the medication cart. V7 confirmed the medications were prepared for R61 and R21, and stated V7 was heading that way to give them medications…

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 observe appropriate Contact Droplet Precautions for one known COVID (Human Coronavirus) positive resident. In addition, the facility failed to utilize staff Personal Protective Equipment correctly during one observation. This failure affects one (R43) of five residents reviewed for COVID in a sample list of 40 residents. Findings include: On 1/22/23 at 9:00AM, R43 was observed sitting outside the door to (R43's) room in a wheelchair. R43 was not wearing a mask. The door to R43's room was open to the hall. R43's roommate (also COVID positive) could be seen in bed in the room. Isolation signs were observed on the door. When staff observed surveyor, R43 was wheeled back into R43's room. R43 was not observed to be in close proximity to other residents. R43's Progress note, dated 1/23/23 at 10:19AM, documents, Resident COVID Positive-however has a dry cough. Remains in good spirits and vital signs Within Normal Limits. Will continue to monitor. On 1/24/23 at 9:00AM, V2, Director of Nursing, confirmed R43 tested…

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 full visual privacy for one of 20 residents (R32) reviewed for privacy in the sample list of 40. Findings include: R32's Care Plan, dated 1/10/23, documents diagnoses including Anxiety, Major Depressive Disorder, Insomnia and Personal History of Transient Ischemic Attack. R32's Minimum Data Set (MDS), dated [DATE], documents R32 is cognitively intact. On 1/22/23 at 8:30 AM, R32 was in a room with a roommate, and there was no privacy curtain hanging from the ceiling to go around R32's bed. There were hooks hanging on the track, but no curtain. R32 stated R32 does not have a privacy curtain, and R32's roommate has lots of family that visits. R32 stated R32 cannot have privacy during personal cares when the roommates family is present because R32 does not have a privacy curtain to close around R32's bed. On 1/24/23 at 11:13 AM, R32 still did not have a privacy curtain hanging from the ceiling to go around R32's bed. At this time, R32…

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.