Meadowbrook Manor

Based on observation, interview, and record review, the facility failed to follow physician order with regards to dosage of a resident's nasal spray and failed to follow medication administration policy and procedures during medications pass. There were 26 medication opportunities with 6 errors resulting to 23.07% error rate. This applies to 2 of 5 residents (R6, R95) reviewed for medication pass in the sample of 35. The findings include: 1. On July 28, 2025, at 5:49 PM, V30 administered medications (Allopurinol, Hydralazine, Torsemide) to R6. V30 placed these medications in a small plastic bag and crushed it all together. V30 then mixed it with pudding and gave it to R6. Facility's Medication Administration Policy and Procedure dated April 2025 shows:General: Facility will ensure that medications are administered in a safe and timely manner and as prescribed. Procedure: 23. Medications may be crushed with MD/NP order. Each medication should be crushed separately and administering each with food.2. On July 29 at 9:24 AM, V31 (Nurse) administered medications to R95 which include…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident received dental care for teeth that were painful and decaying.This applies to 1 of 1 resident (R236) reviewed for dental care in the sample of 35.The findings include:R236's face sheet showed that R236 was admitted to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary disease, unspecified, unspecified dementia, unspecified severity, with agitation, aphasia following cerebral infarction edema, cerebral infarction without residual deficits, chronic systolic heart failure, and type 2 diabetes mellitus.On July 28, 2025 at 10:22 AM, R236 stated he needs to see a dentist. R236 stated he has been telling the staff for a while that he has tooth pain and needs to see a dentist and they have not done anything about it. R236 stated they wrote it on a piece of paper, but nothing else has happened. R236 stated this is important because it hurts when he chews. R236 stated he told the staff last 3 days…

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 education and offer a resident the COVID-19 immunization.This apples to 1 of 5 residents (R126) reviewed for immunization in the sample of 35. The findings include:The EMR (Electronic Medical Record) showed R126 was a [AGE] year-old resident admitted to the facility on [DATE], with multiple diagnoses including dementia, malignant neoplasm of breast, acute embolism and thrombosis of right femoral vein, and heart disease.R126's Immunization Report dated July 30, 2025, showed R126 had not received any previous COVID-19 immunizations.As of July 30, 2025, at 11:30 AM, the facility does not have documentation to show R126 or R126's resident representative was provided education and offered the COVID-19 immunization. On July 30, 2025, at 10:09 AM, V29 (Educator) said he is responsible for resident immunizations. V29 said he assumed the responsibility of resident immunizations within the last couple of weeks, and prior to V29, resident immunizations…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident did not receive unnecessary medications. This applies to 1 of 3 residents (R2) reviewed for pharmacy services in the sample of 8. The findings include: The EMR (Electronic Medical Record) shows R2 was admitted to the facility on [DATE] for a hospice respite stay and was discharged to her home on April 19, 2025. R2 had multiple diagnoses including heart failure, Type 2 diabetes, hypertension, repeated falls, hallucinations, stress incontinence, and the presence of an automatic implantable cardiac defibrillator. R2's MDS (Minimum Data Set) dated April 19, 2025 shows R2 had severe cognitive impairment, required supervision with eating, partial/moderate assistance with oral hygiene, was dependent on facility staff for toilet hygiene, and required substantial/maximal assistance with all other ADLs (Activities of Daily Living). R2 was frequently incontinent of bowel and bladder. On April 10, 2025 at 4:05 PM, V20 (RN-Registered Nurse)…

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 residents receive showers as shown on the facility's shower schedule, and failed to ensure residents receive assistance with shaving and fingernail care. This applies to 4 of 4 residents (R1, R2, R3, and R4) reviewed for ADL (Activities of Daily Living) assistance in the sample of 4. The findings include: 1. On April 10, 2025 at 9:17 AM, R1 was lying in bed in his room. No sign was present to show R1 was in isolation. R1 had beard growth approximately 1/4 inch to 1/2 inch long, and long fingernails. R1's scalp hair had copious amounts of white flakes present. R1's hands were severely contracted and R1 said he is unable to perform personal care due to his contracted hands and paralysis. R1 said he does not like having long facial hair or fingernails. R1 also said he does not like receiving bed baths and he prefers to receive showers. R1 continued to say that since the facility moved him to a different room in March 2025, the level…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to thoroughly investigate the allegation of sexual abuse made by R1 and R2. R1 and R2 had consistently expressed being sexually assaulted by a housekeeper (V4) and the facility failed to investigate allegations after obtaining additional information, initially not substantiating R1 and R2's allegations of sexual abuse on January 25, 2025. These failures have the potential to affect all 237 residents who reside at the facility. The findings include: The facility's daily census on January 30, 2025, showed that there were 237 residents in the facility. R2 had multiple diagnoses including chronic obstructive pulmonary disease, paroxysmal atrial fibrillation, thrombocytopenia and need for assistance with personal care, based on the face sheet. R2's admission MDS (minimum data set) dated November 21, 2024, showed that the resident was cognitively intact (BIMS (Brief Interview for Mental Status) of 15) and required maximum to total assistance from the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide assistance to residents who required staff assistance for ADL (Activities of Daily Living) care. This applies to 4 of 6 residents (R2, R11, R12 and R13) reviewed for ADL care in a sample of 13. The findings include: 1. Face sheet, dated 1/7/25, shows R11's diagnoses included ideopathic progressive neuropathy, weakness, low back pain, reduced mobility, lack of coordination, open wounds of the toes, and chronic kidney disease. MDS (Minimum Data Set), dated 10/4/24, shows R11 was cognitively intact, R11 was always incontinent of bowel/bladder, and R11 was dependent on staff for toileting hygiene, bathing/showering, dressing, hygiene, tub/shower transfers, and chair/bed transfers. Care plan, dated 2/27/23, shows R11 had decreased balance, mobility, and strength, and R11 was dependent on two staff for using a full body mechanical lift machine for transfers. On 1/7/25 at 10:19 AM, R11 was lying in his bed and expressed frustration that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide sufficient staffing to meet the care needs of facility residents. This applies to 4 of 6 residents (R2, R11, R12 and R13) reviewed for staffing in a sample of 13. The findings include: 1. MDS (Minimum Data Set), dated 10/4/24, shows R11 was cognitively intact, R11 was always incontinent of bowel/bladder, and R11 was dependent on staff for toileting hygiene, bathing/showering, dressing, hygiene, tub/shower transfers, and chair/bed transfers. On 1/7/25 at 10:19 AM, R11 was lying in his bed and expressed frustration that the staff were not assisting him to get him out of bed. R11 stated he requested to be gotten out of bed at approximately 9:00 AM earlier that morning. R11 stated when he puts his call light on, staff respond, turn off the light and tell him they will return but do not. R11 stated he lived at the facility for 2 years and prefers to get up out of bed after breakfast. On 1/7/25, R11 remained in bed until 10:50 AM. On…

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

Based on interview and record review, the facility failed to change a resident's rectal tube collection bag according to manufacturer guidelines. This failure effects 1 of 1 residents (R1) reviewed for quality of care in a sample of 3. The findings include: On December 17, 2024 at 8:07 AM, V3 (Family Member) said R1 had a tube inserted into his rectum and the waste was collected into a bag. V3 said the facility staff had not changed the bag and it had been on for three days. V3 said the bag was leaking and so the staff wrapped a plastic bag around the collection bag and hung it on the bed. V3 said the staff would remove the bag, empty out the waste into the toilet, and reattach the bag to the tubing. V3 said she believed they were supposed to put a new bag on every day. V3 said V4 (ADON/Assistant Director Of Nursing) met up with her on December 13, 2024 and was told they would order new bags. V3 said she asked V4 how often the bags were supposed to be changed, to which V4 said the bags should be changed daily. V3 said on December 14, 2024, V8 (RN/Registered Nurse) came to look at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide treatments to pressure ulcers as ordered by the physician for 2 (R1, R5) of 3 residents reviewed for pressure ulcer treatments in the sample of 21. The findings include: 1. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. R1 was transferred to the local hospital on October 6, 2024 and diagnosed with Covid-19 and altered mental status. R1 returned to the facility on October 11, 2024. On October 21, 2024, R1 was transferred to the local hospital and diagnosed with encephalopathy. R1 was readmitted to the facility on [DATE]. On November 3, 2024, R1 experienced labored breathing at the facility and was transferred to the local hospital where he was diagnosed with acute hypoxic respiratory failure. R1 returned to the facility on November 15, 2024. R1 has multiple diagnoses including, traumatic subdural and subarachnoid hemorrhage, craniotomy, hepatic encephalopathy, gastrostomy tube, cirrhosis of the liver, acute…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their policy to fully investigate a grievance/concern and ensure grievances by family members are resolved. This applies to 1 of 3 residents (R7) reviewed for grievances in the sample of 7. The findings include: On October 7, 2024 at 10:22 AM, V14 (Family of R7) said, Someone from our family goes to the facility every single day to be with (R7). Of course, we love him and want to be with him, but our main concern is that we frequently find him soiled with urine or stool, and our main concern is we want to make sure he is dry. He has wounds on his scrotum from being wet all the time. When they heal, they come back. I frequently spoke to V7 (Former Administrator) about our concerns regarding timely incontinence care, but he no longer works there. He was very aware of everything and would always say he would get back to me. The other day I came in and (R7's) pants and sleeve were wet with urine. How would you feel going to visit your…

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 a resident's right to be free from physical abuse. This applies to 2 of 3 residents (R4, R5) reviewed for abuse in the sample of 7. The findings include: The facility's initial report to IDPH (Illinois Department of Public Health) dated September 23, 2024 shows: [R5] involved in physical altercation with [R4]. Staff responded and immediately separated residents. Placed on 1:1 supervision. Both residents assessed. [R5] has discoloration to back of right hand with superficial skin tear to right wrist. [R4] observed with minimal bump to top of left forehead and skin tear to lip. Provided with first aide . The facility's final report to IDPH dated September 27, 2024 shows, Original allegation: [R5] resident involved in physical altercation with [R4]. Both residents assessed and family and MD notified. Facts determined: .3. Both residents have severe impairment. Summary and analysis of the evidence: [R5] and [R4] have a BIMS (Brief Interview for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policy to conduct a thorough abuse investigation following a resident-to-resident physical altercation. This applies to 2 of 3 residents (R4, R5) reviewed for abuse in the sample of 7. The findings include: On October 7, 2024 at 9:40 AM, R5 was sitting in a chair in the dining room. R5 could not be interviewed due to her cognitive status. V16 (Nurse) said, [R5] wanders, but is doing better since she got to the dementia unit. She did get in an altercation with another resident but has not had any further altercations since she came to the dementia unit. She cannot answer questions due to her dementia. On October 7, 2024 at 9:46 AM, R4 was sitting in a chair in the dining room. R4 was not able to be interviewed due to her cognitive status. The EMR (Electronic Medical Record) shows R4 was admitted to the facility on [DATE]. R4 has multiple diagnoses including, dementia with behaviors, hypertension, major depressive disorder, anxiety disorder,…

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 to a resident who is dependent on facility staff for all ADLs (Activities of Daily Living), including toilet hygiene. This applies to 1 of 3 residents (R7) reviewed for timely incontinence care in the sample of 7. The findings include: On October 8, 2024, continuous observations of R7 were done from 8:47 AM to 11:15 AM. R7 was not able to answer questions due to his cognitive status. R7 was asleep for most of the observation period. During the continuous observation period, R7 remained sitting in a high back wheelchair in the dining room. No staff approached R7 to check his incontinence brief or take him from the room to provide incontinence care during the continuous observation period. On October 8, 2024, at 11:15 AM, V10 (Nursing Assistant Supervisor) and V11 (CNA-Certified Nursing Assistant) were approached by this surveyor to request a skin and incontinence check for R7. V10 said incontinent residents…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their policy to assess a resident for elopement risk within the first 24 hours and implement interventions to prevent elopement and exit seeking. This applies to 1 of 5 residents (R1) reviewed for supervision and elopement in the sample of 7. The findings include: The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. R1 has multiple diagnoses including, Parkinson's disease, chronic kidney disease, heart failure, atrial fibrillation, aortic aneurysm, thrombocytopenia, adult failure to thrive, dementia, anxiety, and bilateral hearing loss. R1's MDS (Minimum Data Set) dated September 30, 2024 shows R1 has moderate cognitive impairment, requires supervision with eating, substantial/maximal assistance with showering, and partial/moderate assistance with all other ADLs (Activities of Daily Living). R1 is always continent of bowel and bladder. The facility does not have documentation to show an elopement…

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

Based on observation, interview, and record review, the facility failed to ensure that the dishwashing machine was maintained at temperatures to properly sanitize the dishes. This applies to all 245 residents that receive foods prepared in the facility kitchen. The findings include: Facility provided information that on June 24, 2024 the residents census was 250 residents which included 5 residents on NPO (Nothing by Mouth) status. On June 24, 2024 at 9:40 AM, during initial tour of the facility kitchen, V6 (Dietary Aide) was seen putting soiled dishes on dish racks and running it through the conveyor belt of the dishwashing machine. During continuous observation between 9:41-9:49 AM, the dishwashing machine showed temperatures fluctuating at the following temperatures : Wash 160-165 degrees Fahrenheit, Rinse 160-163 degrees Fahrenheit, and Final Rinse 150-170 degrees Fahrenheit. A test strip was tested twice during the same time period and showed dark brown and tan color. V4 (Food Service Director) and V5 (Director of Culinary Services) who were in the vicinity, stated that the…

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

Based on interview and record review, the facility failed to hold quarterly and as needed QAPI (Quality Assurance Performance Improvement) committee meetings and failed to have the required members in attendance. This applies to all 250 residents who reside in the facility. The findings include: Form 671, dated June 25, 2024, showed the facility census was 250. The facility's last annual survey was September 14, 2023. The facility provided attendance records for their QAPI committee meetings. According to the QAPI meeting attendance records, the QAPI meetings held since the last annual survey, were dated January 18, 2024, and April 15, 2024. The previous QAPI meeting attendance record was dated July 26, 2023. There was no QAPI quarterly meeting held between July 26, 2023, and January 18, 2024. On June 26, 2024, at 2:10 PM, V1 (Administrator) stated there should have been a quarterly meeting in October 2023, but it was not scheduled. V1 also stated the meeting was not rescheduled to either November 2023 or December 2023, because during those months the facility was going through a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to offer the Covid-19 vaccine to residents and/or staff members. This applies to all 250 residents residing in the facility. The findings included: On June 25, 2024, at 2:10 PM, V1 (Administrator) said the facility had been in Covid-19 outbreak status in November and December 2023. They had 37 staff members and 62 residents test positive for Covid-19. On June 25, 2024, 4 of 5 (R2, R61, R116, R159) reviewed for Covid-19 vaccine status. R2's EMR (Electronic Medical Record) showed R2 was admitted to the facility on [DATE]. R2's immunization record showed R2's last Covid-19 vaccine was given October 24, 2022. There was no documentation that any further Covid-19 vaccines had been offered or refused. R61's EMR showed R61 was admitted to the facility on [DATE]. R61's immunization record showed R61's last Covid-19 vaccine was given on October 27, 2022. There was no documentation that any further Covid-19 vaccines had been offered or refused. R116's EMR showed…

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 in writing the resident/resident's representatives that their Medicare Part A services were ending. This applies to 4 of 4 residents (R18, R103, R142, R231) reviewed for SNF ABN (Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage) in the sample of 35. The findings include: 1. R18's face sheet showed R18 was admitted to the facility on [DATE], and continues to reside in the facility. R18's MDS (Minimum Data Set) dated April 30, 2024, showed R18 had moderately impaired cognition. R18's SNF (Skilled Nursing Facility) Beneficiary Notification Review showed R18's Medicare Part A services episode start date was March 13, 2024, and last covered day of services was April 30, 2024. The SNF ABN CMS (Central Management Services) form 10055 showed V38 (Social Services) filled out the form showing verbal notice was provided to R18's guardian. R18's progress notes were reviewed from April 28, 2024, to May 1, 2024, and there was no…

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 label and date medications after being opened to determine expiration dates, failed to remove medications that were expired based on the date that it was opened, failed to remove the used medications of residents that no longer reside in the facility, and failed to ensure that unused insulin was stored in the refrigerator as recommended by the pharmacy. This applies to 8 of 10 (R44, R75, R95, R114, R132, R140, R153, R217) residents reviewed for medication storage and labeling. The findings include: On [DATE], at 10:47 AM, the 4A medication cart was checked with V40 (Nurse), and the following were observed. 1. R153 has 2 bottles of Dorzolamide Timolol 0.2% eye drops which were opened on [DATE]. The pharmacy medication guidelines show to discard this medication 42 days after it was opened. 2. R44's Lumigan 0.01% eye drops was opened and not dated. The pharmacy medication guidelines show to discard this medication 42 days after it was…

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

Based on observation, interview, and record review, the facility failed to use serving scoop sizes as shown on facility menu spread sheet for mechanical soft and pureed consistency beef cubed steak. This applies to 10 of 10 residents (R23, R54, R76, R84, R123, R147, R156, R188, R216 and R241) reviewed for dining in the sample of 35. The findings include: Facility Spring/Summer menu spread sheet for week 3 Monday showed to use #6 scoop to serve ground cubed steak with mushroom and gravy for mechanical soft diets and pureed beef cubed steak with broth for pureed diets respectively. Recipe for 'Ground Cube Steak with Mushroom Gravy' included serving size: #6 scoop. The recipe also included to serve 3 oz (ounce) ground protein portion with #6 scoop, may add additional gravy if necessary to keep moist. Recipe for 'Pureed Beef Cubed Steak with Mushroom Gravy' included serving size: #6 scoop. The recipe also showed to portion with #6 scoop. On June 24, 2024 at 11:45 AM, the meal service was observed at the facility kitchen with V7 (Cook) plating the main meal entree items at the tray line…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow standard infection control practices with regards to hand hygiene and use of personal protective equipment (PPE) during provisions of care. In addition, the facility also failed to handle soiled linens in a sanitary manner, and failed to ensure that an indwelling urinary catheter bag is not touching the floor. This applies to 4 of 35 (R1, R21, R67, R214) reviewed for infection control in the sample of 35. The findings include: 1. On June 24, 2024, at 2:38 PM, V30 (Certified Nursing Assistant/CNA) rendered incontinence care to R67 who was wet with urine and had a bowel movement. V30 cleaned R67's perineum, changed incontinence brief, pulled R67's pants back in place, and helped reposition R67. V30 changed her gloves in between tasks, however, V30 did not perform hand hygiene all throughout the care. 2. On June 26, 2024, at 10:02 AM, V29 (Housekeeper) was observed walking in the 400-hallway carrying soiled linens with her gloved…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure a residents health care information was protected from view by unauthorized individuals. This applies to 1 of 35 residents (R123) reviewed for privacy in the sample of 35. The findings include: On June 26, 2024, at 9:29 AM, R123's MAR (Medication Administration Record) laptop screen, including identifying information, picture, and medication orders, was opened in view of the 200 hallway. The laptop computer screen was unlocked and there was no Nurse working at the cart. At the same time, R40 was sitting in her room doorway and was able to view the computer screen that was on top of the medication cart, that was parked across from R40's doorway. R40 asked for the nurse requesting medication. There was no nurse near the medication cart. V20 (Laundry Aide) was passing clothing to the rooms around the medication cart. R123's screen was in view of V20 as she passed by the medication cart numerous times on June 26, 2024, at 9:30 AM. On June 26, 2024, at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide assistance in grooming for residents that need assistance with personal hygiene. This apples to 3 of 3 residents (R127, R183, R12) reviewed for ADL (activities of daily living) in the sample of 35. The findings include: 1. R183's face sheet included diagnoses of unspecified dementia, unspecified severity, with other behavioral disturbance, spinal stenosis, site unspecified. R183's quarterly MDS (minimum data set) dated April 10, 2024 showed that R183 was moderately impaired in cognition and requires supervision with touching assistance for personal hygiene. On June 24, 2024 at 10:47 AM, R183 is seated in wheelchair in dining room in activities and noted to have multiple facial hair covering her chin. When asked, R183 stated that she would like them removed. R183's care plan revised April 14, 2024 included that R183 has an ADL self-care performance deficit related to impaired balance, limited mobility, functional limitations,…

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 wound care as needed for a resident who has a stage 4 ulcer with heavy drainage. This applies to 1 of 8 residents (R181) reviewed for pressure ulcers in the sample of 35. The findings include: On June 25, 2024, at 12:31 PM, V11 and V34 (Both Wound Care Nurse) provided wound care to R181. R181's wound dressing was heavily saturated with discharge and was noted with brown discoloration on the outside of the dressing. V11 and V34 both stated that R181 has multiple wounds/pressure ulcers on her body which include a stage 4 pressure ulcer on the sacrum and right buttock. V34 stated that R181's wound care is to be done daily and as needed. When the dressing is changed as needed, the nurse usually signs it on the TAR (Treatment Administration Record), or they document it in the progress notes. The dressing from the sacrum was observed to be almost detached from R181 related to the heaviness of the discharge. On June 26, 2024, at 10:17 AM, V32 and V33 (Both Certified Nursing Assistants/CNA) provided…

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 timely address recommendations from the pharmacist. This applies to 2 of 4 residents (R1, R2) reviewed for monthly medication reviews. Findings include: 1. R1 was admitted to the facility on [DATE] with diagnoses that include urinary tract infection, edema, altered mental status, dementia, depression, unspecified psychosis, constipation, difficulty walking, and weakness. R1's care plan dated 4/17/24 includes R1 uses psychotropic medications and has potential for complications/adverse reactions/side effects. Interventions include to consult with pharmacy, MD (Medical Doctor) / Psych to consider dosage reduction when clinically appropriate. R1 is at risk for adverse reaction related to polypharmacy. Interventions include request physician to review and evaluate medications. Review pharmacy consult recommendations and follow up as indicated. On 4/18/24 V8's (Pharmacist) consultation report states R1 was admitted with an order for an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to implement care plan interventions for transfers to prevent falls. This applies to 1 of 3 (R1) residents reviewed for falls. Findings include the following: R1 was admitted to the facility on [DATE], after an episode of nausea, diarrhea and treatment at a local hospital. R1 has been previously treated at the same hospital for post fall and fracture of the left tibia and right fibular fracture. During the first hospital stay, R1 was recommended rehab but she declined. Upon the second admission to the hospital, R1 was then transferred to the facility. R1 was admitted to the facility with the following diagnosis: hypertension, diabetes, history of falls, displaced fracture of the medial malleolus of left tibia, nondisplaced fracture of the lateral malleolus of right fibula, neuropathy, and protein calorie malnutrition. R1 received surgical treatment of the left ankle in Mexico after a fall. R1's medications included Insulin, Eliquis, Norco as needed,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow fall precaution interventions for residents who were at high risk for falls. The facility also failed to create safe environments to decrease the risk of falls and failed to supervise and reassess a resident who smoked. This applies to 5 of 5 residents (R3, R4, R5, R8, R9) reviewed for accidents and supervision. The findings include: 1. On February 21, 2024, at 11:24 AM, R3's bed alarm was alarming. R3's room was across from the dining room. R3 was laying in bed and had her legs on the fall mat next to her bed. R3 attempted to move, and the bed alarm continued to alarm. Four staff were observed in the dining hall. At 11:52 AM, a CNA (Certified Nurse Assistant) walks past R3's room. At 11:54 AM, an activity aide walks past R3's room. At 11:56 AM, a housekeeping staff is standing outside R3's room and a CNA walks into the room next door to R3. At 11:57 AM, the housekeeping staff enters R3's room to clean the room. At 11:58 AM,…

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

Based on observation, interview, and record review, the facility failed to provide incontinence care to a resident dependent on staff for toileting hygiene. This applies to 1 of 3 residents (R1) reviewed for incontinence care. The findings include: On February 20, 2024, at 10:37 AM, R1 told V17 (CNA/Certified Nurse Assistant) she was very wet. V17 uncovered R1 and R1's incontinence pad and fitted sheet were wet. R1 said she had requested to be changed twice since 10 PM the night before and she was not changed. R1 said the staff would get called away before providing incontinence care. R1 said she could feel wetness under her back and on her legs. V17 rolled R1 and there was a foul odor and yellow, dried areas as well as wet stains on the fitted sheet. R1 had redness on the perineal and perianal area, as well as the top of her thighs. V17 said she needed to change the entire bedding. V17 removed the fitted sheet and wet marks were visible on the mattress. R1's face sheet showed R1 was admitted with diagnoses including osteomyelitis of the left hand, chronic obstructive pulmonary…

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 an alleged allegation of verbal abuse was investigated. This applies to 1 of 5 residents (R2) reviewed for abuse in the sample of 5. The findings include: R2's face sheet shows she is an [AGE] year-old female with diagnoses including hypertension, major depressive disorder, chronic kidney disease stage 3, weakness, osteoporosis, and spinal stenosis. R2's Minimum Data Set assessment dated [DATE] shows she has no behaviors of psychosis including no delusions or hallucinations and requires moderate assistance with toileting, personal hygiene, transfers and frequently incontinent of urine. On 11/6/23 at 10:00 AM, R2 was observed sitting in her wheelchair. She said a few weeks ago in the evening hours about 10:00 PM, she was in her room sitting in her wheelchair. She heard a noise and pulled the privacy curtain back and a female staff member said, There you go again you nosey little B. I was crying so hard; I went to the nurse'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 wash dishes in a sanitary manner. This applies to 228 residents receiving oral diet at the facility. The findings include: Facility Resident Census and Conditions of Residents form (Form 672) dated September 11, 2023, showed that the facility census was 234. Facility gave additional information that 6 residents received nothing by mouth. On September 11, 2023, at 9:52 AM, V18 (Dietary Aide) was loading dishes into the dishwasher that showed 160 degrees Fahrenheit on the final rinse gauge. V19 (Dietary Aide) who was in the vicinity, stated that the booster for the dish machine is new, and the temperature will increase to 180 degrees Fahrenheit as the dishes are being washed. As V18 continued to load the dishes for the next ten minutes the gauge was noted to fluctuate between 160-162 degrees Fahrenheit. On September 11, 2023, at 10:06 AM, V19 ran a test strip through the dish machine and stated that the black line on the test strip should…

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 assist residents identified as needing assistance with personal hygiene and incontinence care. This applies to 6 of 6 residents (R16, R33, R62, R136, R159 and R173) reviewed for ADLs (activities of daily living) in the sample of 35. The findings include: 1. R62 had multiple diagnoses which included down syndrome, alzheimer's disease, dementia with other behavioral disturbance and need for assistance with personal care, based on the face sheet. R62's quarterly MDS (minimum data set) dated July 27, 2023, showed that the resident was severely impaired with cognition and was totally dependent on the staff for all his ADLs including personal hygiene. On September 11, 2023, at 11:41 AM, R62 was in bed alert but non-verbal. R62's fingernails were long, and he had accumulation of long facial hair. V21 (CNA/Certified Nursing Assistant) and V22 (CNA) were present during the observation. V21 stated that R62 needed his fingernails trimmed and facial…

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 incontinence and indwelling urinary catheter care in a manner that would prevent infection. In addition, the facility also failed to ensure that a urinary bag was not touching the floor. This applies to 4 of 7 residents (R106, R185, R191, R343), reviewed for incontinence and urinary catheter care in the sample of 35. The findings include: 1. The electronic medical record (EMR) showed that R343 is 76 years-old, with multiple medical diagnoses which include benign prostatic hyperplasia (BPH), bacteremia, and need assistance for personal care. On September 12, 2023, at 11:16 AM, V28 (Certified Nursing Assistant/CNA) rendered incontinence care to R343 who was wet with urine. R343 was uncircumcised, V28 cleaned R343 from front to back, however, V28 did not retract R343's foreskin during peri-care. 2. R191 is 80 years-old who has multiple medical diagnoses which include urinary tract infection (UTI). R191s Minimum Data Set (MDS) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 5. R92 was admitted to the facility on [DATE], according to his face sheet. R92's diagnoses included left femur fracture, diabetes, and the need for assistance with personal care, according to his physician's order summary report. R92 was noted cognitively intact and cooperative during care. R92's most recent minimum data set assessment (dated August 8, 2023) noted R92 was always incontinent of bowels. R92's care plan documented multiple current focus problems including, a high risk of infection due to his suprapubic (abdominally inserted) urinary catheter, a potential for infection due to his peripheral intravenous site (noted at his left hand), and pressure injuries of his skin with open areas to his buttocks. On September 13, 2023, at 11:45 AM, V33 (Certified Nursing Assistant/CNA) rendered incontinence care to R92 when loose stool was noted by V5 (Wound Care Nurse) during wound care to buttocks. V3 (Assistant Director of Nursing/Infection Preventionist) and V5 were present at R92's bedside during…

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 assess and provide supportive device/splint to a resident, to prevent further reduction in ROM (range of motion). This applies to 1 of 3 residents (R62) reviewed for range of motion in the sample of 35. The findings include: R62 had multiple diagnoses which included down syndrome, alzheimer's disease and dementia with other behavioral disturbance, based on the face sheet. R62's quarterly MDS (minimum data set) dated July 27, 2023, showed that the resident was severely impaired with cognition and was totally dependent from the staff with all his ADLs (activities of daily living). The same MDS showed that R62 had functional limitation in range of motion on both upper and lower extremities. On September 11, 2023, at 11:41 AM, R62 was in bed alert but non-verbal. R62 had contracture of his left hand. V21 (CNA/Certified Nursing Assistant) stated that R62 does not use any splint or device on the left hand. On September 12, 2023, at 1:58 PM, R62 was sitting in his reclining wheelchair. R62 was alert and was able 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 ensure that the port of entry of the PICC (Peripherally Inserted Central) line was visible for assessment. This applies to 2 of 4 residents (R191, R343) reviewed for PICC lines in the sample of 35. The findings include: 1. On September 11, 2023, at 11:11 AM, R191 was resting in bed. R191 had a PICC line to her right arm which was covered with a transparent dressing dated 9/7/23. However, the port of entry of the PICC line was not visible for assessment. 2. Face sheet showed that R343 was admitted to the facility on [DATE], from the hospital. On September 11, 2023, at 12:41 PM, and on September 12 at 11:16 AM, R343 was resting in bed. R343 had a PICC line in the left upper arm which was covered with a dressing dated September 5, 2023. The port of entry was not visible for assessment. On September 13, 2023, 3:21 PM, V4 (Assistant Director of Nursing/ADON) stated that staff should change the central line/PICC line dressing once a week and as…

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

Based on observation, interview, and record review, the facility failed to follow the physician's order to administer medication and failed to follow the pharmacy recommendation of not crushing a delayed release medication. There were 2 errors out of 26 opportunities resulting to 7.69% medication error rate. This applies to 2 of 4 residents (R74, R141) reviewed for medication pass in the sample of 35. The findings include: 1. On September 12, 2023, at 9:05 AM, V26 (Nurse) administered multiple medications to R74. The medications included Aspirin, Clonazepam, Cardizem ER, Furosemide, Escitalopram, Glipizide, Memantine, and Quetiapine. R74's MAR (Medication Administration Record) (MAR) showed all the above-mentioned medications were scheduled to be given in the morning along with Incruise Ellipta inhaler. However, the Incruise Ellipta was not given during the medication administration but V26 signed the MAR to show that Incruise Ellipta was given at 9:05 AM. On September 13, 2023, at 9:33 AM, V26 stated that the Incruise Ellipta was not available on September 12, 2023, and she called…

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 serve diets as ordered by the Physician. This applies to 3 of 3 residents (R11, R166, R183) reviewed for diet orders in the sample of 35. The findings include: 1. On September 11, 2023, at 12:14 PM, during lunch meal service in the 3rd floor dining room, R183 received a mechanical soft consistency chicken, mashed potatoes, broccoli, and a glass of yellow colored thin consistency juice. R183's diet ticket on tray showed nectar thick liquids. V30 (Restorative Aide) who was in the area, stated that the juice was lemonade and was not thickened. V30 looked through the drinks placed on the service counter and showed a thickened juice prepackaged container and stated that it should have been served instead. On September 12, 2023, at 12:35 PM, R183 was seen seated upright in his bed and did not adequately respond to queries. R183 had a bottle (16.9 fluid ounces) of regular consistency lemon flavored tea at bedside with about a 1/4 of the container…

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.