Warren Barr Buffalo Grove

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident was screened prior to admission for 1 of 5 residents (R96) reviewed for preadmission screenings (PASARR) in the sample of 30. The findings include: On 01/27/25 at 10:03 AM, R96 was sitting up in a reclining chair in his room sleeping. On 01/28/25 at 12:00 PM, V1 Administrator said there was no PASARR done for R96. V1 said he has not left the facility since he was admitted . V1 said admissions is doing a screening now. R96's Face Sheet shows R96 was admitted to the facility on [DATE] with a diagnoses of unspecified dementia and schizophrenia. The facility's PASSAR Screening of Residents with Mental Disorder or Intellectual Disability dated 8/16/24 shows The facility will not allow admission form the hospital without a preadmission screening which includes PASSAR screening for those with mental or intellectual disorder.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide ADL (Activities of Daily Living) assistance for residents that are dependent on staff for two of 30 residents (R25, R1) reviewed for ADLs assistance in the sample of 30. The findings include: 1. R25's admission Record dated January 26, 2025 shows she was admitted to the facility on [DATE] with diagnoses including dysphagia, history of Covid-19, mid cognitive impairment, scoliosis, pain, and history of falling. R25's Care Plan initiated August 21, 2020 shows, [R25] is incontinent of bowel and bladder, check resident every two hours and assist in toileting as needed. Provide incontinence care after each incontinence episode. The resident requires extensive one staff participation with personal hygiene and oral care. On January 26, 2025 at 9:39 AM, V12 CNA (Certified Nursing Assistant) provided incontinence care for R25. R25's incontinence brief was saturated with dark urine and soft stool. There was creases in R25's buttocks. V12…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to obtain daily weights on a resident with a history of fluid overload and failed to ensure protective arm sleeves were applied as ordered for two of 39 residents (R37, R70) reviewed for quality of care in the sample of 30. The findings include: 1. R37's admission Record dated January 27, 2025 shows she was admitted to the facility on [DATE] with diagnoses including reduced mobility, need for assistance with personal care, prosthetic heart valve, pleural effusion, acute respiratory failure with hypoxia, pulmonary hypertension, chronic diastolic congestive heart failure, and stage four chronic kidney disease. R37's Order Review Report dated January 27, 2025 shows an order was entered on January 9, 2025 for daily weight due to diagnosis of congestive heart failure, notify doctor with patient gains three pounds in one day or five pounds in one week, in the morning. R37's Care Plan shows potential for fluid overload. Weight will be obtained 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 ensure fall interventions were in place for a resident that is at high risk for falls. This applies to 1 of 30 residents (R39) reviewed for safety in the sample of 30. The findings include: R39's Face Sheet shows diagnoses of: parkinson's disease with dyskinesia, lack of coordination, unstreadiness of feet and history of falling. On 1/26/25 at 11:22 AM, R39 was in the common area. R39 had a wheelchair pressure sensor alarm attached to his wheelchair. R39 lifted his buttocks off of the seat of the wheelchair multiple times and the alarm did not sound. The In Use light on the alarm box was not on. At 2:16 PM, V29 (Certified Nursing Assistant) had R39 stand from his wheelchair. R39's alarm did not sound when he stood up. V29 turned the alarm box on and it sounded and there was a green light on the alarm box that was blinking In Use. On 1/27/25 at 2:07 PM, V18 (CNA) said that R39 is at fall risk. V18 said that R39 will try and stand on his own but he is not stable and that is why he has an alarm. V18 said 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain a nephrostomy and urinary drainage bag below the level of the bladder for 2 of 7 residents (R67, R121) in the sample of 30. The findings include: 1. On 01/27/25 at 09:47 AM, R67 was in bed with her nephrostomy drainage bag containing urine laying on the bed. R67's foot of the bed was elevated making the urine pool at the opening of the nephrostomy drainage bag, and up into the nephrostomy tubing. The urine in the tubing unable to drain into the bag. On 01/27/25 at 12:26 PM, R67's nephrostomy drainage bag remained on the bed in the same position, with the urine unable to drain into the bag. On 01/27/25 at 3:00 PM. R67's nephrostomy drainage bag remained in the same position, with urine backing up into the nephrostomy tubing. On 01/29/25 at 09:31 AM, V2 Director of Nursing said you should position the nephrostomy drainage bag so the flow of urine can go into the bag to prevent infection. V2 said care is provided the same way as 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 observation, interview, and record review that facility failed to ensure placement of a gastrostomy tube was checked prior to administering medication for 1 of 4 residents (R39) reviewed for enteral nutrition in the sample of 30. The findings include: R39's Face Sheet shows that he re-admitted to the facility on [DATE] with a new diagnosis of gastrostomy. On 1/26/25 at 10:00 AM, V14 (Licensed Practical Nurse) went into R39's room to administer his medications. At that time, R39 said that it is sometimes painful when things are put into his tube. V14 assessed the area and told R39 that she would go slow and then administered his medications. V14 did not check the placement of R39's gastrostomy tube before administering his medications. On 1/28/25 at 1:53 PM, V16 (Registered Nurse) said that the type of gastrostomy tube that R39 had does not have a line to check for placement. V16 showed the gastrostomy tube insertion site and there was no line present. V16 said that placement is always checked before…

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's oxygen tubing and bubble humidifier bottle was changed as ordered and failed to ensure a resident's oxygen humidifier bottle was kept filled for 1 of 8 residents (R32) reviewed for oxygen administration in the sample of 30. The findings include: On 1/26/25 at 11:30 AM, R32 was laying in bed with oxygen being administered via nasal cannula. R32's oxygen tubing and bubble humidifier bottle was labeled 12/13/24. R32's bubble humidifier bottle was empty. On 1/27/25 (Monday) at 12:23 PM, the tubing and bottle were still labeled 12/13/24 and the humidifier bottle was still empty. On 1/126/25 at 11:30 AM, R32 said that she does frequently get sinus pain and a dry nose. On 1/27/25 at 1:37 PM, V28 (Licensed Practical Nurse) said that oxygen tubing and bubblers are changed weekly. V28 said that the bubbler humidifier bottle should be filled before it is empty. R32's Physician's Order Sheet printed on 1/27/25 shows an order dated 9/23/24 for, Change oxygen tubing/bubblers weekly and PRN (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.

Based on observation, interview, and record review, the facility failed to administer medications according to standard of practice for a resident receiving medications through a gastrostomy tube. There were 25 opportunities with 5 errors resulting in a 20% error rate. This applies to 1 of 7 residents (R39) observed in the medication pass. The findings include: R39's January Medication Administration Record shows that he receives aspirin 81 mg (milligrams) chewable, omeprazole 20 mg, multiple vitamin with minerals, tramadol 25 mg, vitamin D3 25 mcg (micrograms)-2 tablets and carbidopa-levodopa 25-100 mg-2 tablets via G-tube at 9:00 AM. R39's Physician's Order Sheet does not document that all medications can be given at the same time. On 1/26/25 at 10:00 AM, V14 (Licensed Practical Nurse) prepared R39's morning medications. V14 put R39's aspirin, multivitamin, vitamin D3 and carbidopa-levodopa into a pill crusher pouch, crushed the medications and place them into a medication cup. V14 then opened the omeprazole capsule and placed the contents into the same cup. V14 then went into…

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's medication was stored in a secure manner for 1 of 30 residents (R54) reviewed for medication storage in the sample of 30. The findings include: On 1/26/25 (Sunday) at 10:32 AM, there was a blue and white capsule in a medication cup on R54's bedside table. R54 said that she was not sure what it was but she thinks that it is something she was supposed to take at breakfast. At 11:11 AM, V14 (Licensed Practical Nurse) brought R54 her medications. V14 said that she was unsure what the medication on her bedside table was. On 1/26/25 at 11:20 AM, V14 verified that the blue and white capsule was PhosLo 667 mg (milligrams). V14 said that medications should never be left at the resident's bedside. V14 said that the resident could forget to take the medication or another resident could take it. R54's Physician's Order Sheet (POS) printed on 1/27/25 shows an order for, PhosLo Oral Capsule 667 MG-Give 3 capsules by mouth with meals for end stage renal disease give at 6 am on HD (Hemodialysis) days. R54'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 ensure 4 residents (R1,R2,R3,R7) had access to their call lights. This applies to 4 of 9 residents observed and reviewed for call light accessibility in the sample of 9. The findings include: 1) R1's electronic face sheet printed on 6/16/24 showed R1 has diagnoses including but not limited to cerebral infarction, weakness, osteoarthritis, complete traumatic amputation of right hand at wrist level, and dysphagia. R1's facility assessment dated [DATE] showed R1 has severe cognitive impairment. (During interview, R1 was oriented to person, place, and situation) R1's care plan dated 6/7/23 showed, (R1) is at low risk for falls related to cerebral infarction, complete traumatic amputation of right hand at wrist level .I prefer to keep the bed in low position for safety, I would like staff to provide me a safe environment: even floors, free from spills or clutter, adequate, glare-free light; a working and reachable call light, the bed in low…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement physician's orders for a resident (R1) at risk for bruising. This applies to 1 of 3 residents reviewed for skin conditions in the sample of 9. The findings include: R1's electronic face sheet printed on 6/16/24 showed R1 has diagnoses including but not limited to cerebral infarction, weakness, osteoarthritis, complete traumatic amputation of right hand at wrist level, and dysphagia. R1's facility assessment dated [DATE] showed R1 has severe cognitive impairment and is dependent on staff for bed mobility. R1's care plan dated 9/27/18 showed, Potential for skin bruising related to thin/fragile skin. Use caution during ADL (activities of daily living) care. Handle gently, observe for bruises. R1's progress notes dated 5/27/24 showed, Resident was noted to have a discoloration to right elbow measuring 9x5.5x0cm (centimeters). Skin remains intact with slight bogginess felt in the center. Periwound is intact with no swelling or…

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 notify the doctor and power of attorney/family when a change in condition occurred for 1 of 4 residents (R1) reviewed for change in condition. The findings include: The Change in Condition note dated 2/21/24 at 1:31 PM for R1 showed: 9:00 AM - RN (Registered Nurse) checked patient's (R1's) vital signs, blood pressure 98/50, heart rate 67, oxygen saturation 98%, and respiratory rate 18. Patient took all morning meds (medication) as scheduled including midodrine. 10:50 AM - PT (Physical Therapy) and OT (Occupational Therapy) started therapy session together. Patient appeared to be short of breath at room air, therefore therapist instructed on pursed lip breathing and oxygen saturation was checked. It was initially 96% and steadily decreased to 72%. Patient then started on oxygen at 3 liters via nasal cannula, and nurse on duty was called and assessed the resident further. Oxygen saturation increased to 96% on 3 liters per nasal cannula. Nurse instructed therapist to keep the oxygen at 3 liters while doing therapy, and upon…

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 the information available in the resident's chart was accurate for 1 of 3 residents (R1) reviewed for medical records. The findings include: The Face Sheet dated 4/28/24 for R1 showed she was admitted to the facility on [DATE] with medical diagnoses including type 2 diabetes mellitus, cardiomegaly, peripheral vascular disease, diverticulosis, pressure ulcer, spinal stenosis, cellulitis of abdominal wall, end stage renal disease, hyperkalemia, morbid obesity, chronic pain, hypotension, hypothyroidism, hyperlipidemia, essential hypertension, dependence on renal dialysis, and other sequelae following unspecified cerebrovascular disease. The facility's admission Packet Information for R1 was dated 1/15/24 and R1 was admitted on [DATE]. The Consent for the Use of side rails, Fall Prevention Education Material, Informed Consent for Influenza Vaccination, Informed Consent for Pneumonia Vaccination, and Informed consent for Vaccination (RSV - respiratory…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. On 2/28/24 at 12:07 PM, V9 CNA (Certified Nursing Assistant) was sitting at a table feeding R71 while R56 sat at the same table without a food tray in front of her. R96 was brought over to the same table as R71 and R56 and did not have a food tray in front of her. V9 stated they have early trays for the residents that need to be fed and they feed those residents before other residents are given their food trays. At 12:18 PM, R56 was given her food tray and was able to feed herself. The food trays were removed from the food cart and were delivered to residents at different tables. Some residents were eating at the same table while others waited for their food trays. R96 was sitting at the table with R71 who had finished eating and R56 who had just received her tray. R96 stated she wanted her food and that she was hungry. R96 stated she needed to be fed. V13 (Activity Aide) told R96 he would look for her tray of food but he could not feed her because he was an activity aide. R96 yelled, Help me, Help me! 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 oral care and failed to ensure a resident received a shower for 2 of 3 residents (R301, R1) reviewed for Activities of Daily Living (ADLs) in the sample of 18. The findings include: 1. On 2/27/24 at 10:55 AM, R301 was lying on her back, in bed. R301's lips were dry and cracked. There was a line of brown debris to the corners of her both, just below the lips. R301's tongue was dry and coated in white material. R301's teeth were coated in a white film. During the interview, R301's voice was rasping and her lips kept sticking to her teeth. R301 stated, Just a minute. It's so hard for me to talk. My mouth is so dry. R301 closed her mouth and swallow. R301's speech was difficult to understand at times, due to the dryness of her mouth, tongue, and lips. R301 said she had not received any oral care today. R301 said they are supposed to help me brush my teeth in the morning, but no one has been in here yet. R301 did not have any water 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 ensure heels were off-loaded for a resident with contractures and history of pressure injury to her heels for 1 of 10 residents (R67) reviewed for pressure in the sample of 18. The findings include: On 2/28/24 at 10:15 AM, R67 was in bed on her left side with splints in place to her hands. R67 had braces on her legs. The left side of R67's foot and heel was on the mattress of her bed not offloaded. R67 had a scarred area to her left heel with some red discoloration in the middle of the scarred area. On 2/28/24 at 1:15 PM, V7 (Wound Care Certified Nursing Assistant) and V8 LPN (Licensed Practical Nurse/Wound Nurse) went into R67's room to change the dressing to her stage 4 pressure ulcer on her sacrum. R67 was laying on her right side in bed with a thin pillow between her legs. The right side of R67's foot and heel were resting on the mattress. V8 stated R67's left heel looked red where she had a previous heel wound. V8 stated they are…

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 supervise a resident with dysphagia during meal time for 1 resident (R8) and failed to transfer a resident with a gait belt for 1 resident (R70). These failures apply to 2 of 10 residents reviewed for accidents in the sample of 18. The findings include: 1. R8's electronic face sheet printed on 2/29/24 showed R8 has diagnoses including but not limited to chronic obstructive pulmonary disease, dysphagia, chronic fatigue, dementia with behaviors, pseudobulbar affect, delusional disorder, bipolar disorder, type 2 diabetes, and major depressive disorder. R8's facility assessment dated [DATE] showed R8 has severe cognitive impairment and receives a mechanically altered diet. R8's physician's orders dated 10/9/23 showed, General diet, pureed texture, nectar thick liquids. R8's nursing care plan dated 10/10/23 showed, Swallowing problems: some risk to potentially choke or aspirate food or liquids. This problem is related to 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.

Based on observation, interview, and record review, the facility failed to perform safe medication administration for one residents (R7) of seven residents reviewed for medication administration on the total sample list of 18. The findings include: R7's February 2024 medication administration record showed R7 receives aspirin 81mg (milligrams), dutasteride 0.5mg, cranberry capsule 425mg, flomax 0.4mg, folic acid 800mg, isosorbide mononitrate ER (extended release) 30mg, nifedipine ER 60mg, methocarbamol 750mg, and sodium bicarbonate 650mg at 9:00AM. On 2/27/24 at 10:47 AM, V18 (Registered Nurse) took R7's medications into his room and set them on his overbed table. V18 assessed R7 and then told him to take his medications and left the room. V18 stated, I know he will take his medications, he's good about it. I have a few residents that I leave them in the room for them. I know it's not best practice but this is a busy unit so we have to keep moving. On 2/28/24 at 11:07 AM, V2 (Director of Nursing) stated, It is not our practice to leave medications at the bedside for residents to…

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

Based on observation, interview, and record review, the facility failed to administer medications at ordered times. There were 31 opportunities with 5 errors resulting in a 16.13% medication error rate. This applies to 2 of 7 residents (R7 and R84) reviewed in the medication pass on tthe total sample list of 18. The findings include: 1. R7's February 2024 medication administration record showed R7 receives ferrous sulfate 325mg (milligrams), methocarbamol 750mg, sodium bicarbonate 650mg, and adalat 60mg at 9:00 AM and 5:00 PM every day. On 2/27/24 at 10:47 AM, V18 (Registered Nurse) took R7's medications into his room and set them on his overbed table. V18 assessed R7 and then told him to take his medications and left the room. V18 stated, I know he will take his medications, he's good about it. I have a few residents that I leave them in the room for them. I know it's not best practice but this is a busy unit so we have to keep moving. (1 hour and 47 minutes past the ordered administration time). 2. R84's February 2024 medication administration record showed R84 receives Senna 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 refrigerate and label open insulin vials with open and use by dates. This applies to 1 of 1 resident (R14) reviewed for Medication Storage in a sample of 18. The findings include: 1. On 2/27/24 at 1:28 PM, the 300 hall medication cart had R14's open, multi dose vial of Novolog insulin with no open or use by date on it. The vial had 50 units left in it. R14's Levemir flexpen had no open or use by date and had 150 units left in it. R14's un-opened Tresiba pen was not refrigerated. The packaging for the Tresiba pen had a sticker on it that shows to Refrigerate. On 2/27/24 at 1:42 PM, V18 RN (Registered Nurse) said, We should have insulin dated so we know when it was opened and when to discard it, and to ensure it remains effective. V18 said, We should be discarding it after 28 days, but we wouldn't know the 28 days unless it was labeled with the opened date. On 2/28/24 at 11:07 AM, V2 DON (Director of Nursing) said, insulin vial dates should contain the open and use by dates, because without them you wouldn't know…

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 water/other liquids for a resident for one of five residents (R301) reviewed for hydration in the sample of 18. The findings include: On 2/27/24 at 10:55 AM, R301 was lying on her back, in bed. R301's lips were dry and cracked. There was a line of brown debris to the corners of her both, just below the lips. R301's tongue was dry and coated in white material. R301's teeth were coated in a white film. During the interview, R301's voice was rasping and her lips kept sticking to her teeth. R301 stated, Just a minute. It's so hard for me to talk. My mouth is so dry. R301 closed her mouth and swallow. R301's speech was difficult to understand at times, due to the dryness of her mouth, tongue, and lips. R301 said she had not received any oral care today. R301 did not have any water at the bedside. R301 said a drink of water would be nice. On 2/29/24 at 10:19 AM, R301 was sitting in a dialysis chair, outside the door to dialysis. V3 (Certified Nursing Assistant - CNA) pushed R301 back to her room. V3 and V4…

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 nursing staff to meet the needs of 5 residents (R1-R5) reviewed for sufficient staffing in the sample of 8. The findings include: On 11/1/23 at 6:14 PM, R1 said the facility is short-staffed. Mostly on the overnight shifts and the weekends. R1 said the weekend of 10/27/23-10/29/23, they had one CNA (Certified Nursing Assistant) for 68 residents. R1 said she told V3 (CNA) she had been waiting for over two and a half hours for assistance and V3 said she was sorry, but there was not enough staff, and she could not get to everyone who had their call light on. R1 said V3 told her that she had her light on earlier in the night and she tended to her needs, however, she was trying to get to the residents that she had not gone to yet. R1 said she has heart disease and is getting weaker. She needs staff to help her with getting up and walking with a gait belt and a walker. On 11/2/23 at 10:42 AM, R1 was in her motorized…

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 develop a resident centered plan of care, notify a physician timely of abnormal diagnostic test results and failed to ensure a resident was immediately transported to the emergency room for evaluation for 1 of 3 residents (R1) reviewed for quality of care in the sample of 3. The findings include: R1's Face Sheet shows that she was admitted to the facility on [DATE] with the diagnoses of: Hypertension, Anxiety and Heart Failure. R1's Change of Condition Note dated 8/5/23 at 6:09 PM shows, The patient was using bathroom for BM (bowel movement), was assisted by CNA (Certified Nursing Assistant), after sometime, the CNA came to attending nurse to notify that the patient was having difficulty breathing, the patient noted with SOB (Shortness of Breath), the patient was using her accessory muscle to breathe in and out. VS (vital signs) high BP (blood pressure), pulse high, and RR (respiration rate) was also high. The patient got weak .had given the patient…

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 the privacy of residents' personal health information for 4 of 4 residents (R71, R44, R111, R21) in the sample for privacy of the medical record and 16 residents outside the sample (R104, R122, R114, R91, R7, R123, R57, R42, R61, R64, R88, R98, R20, R115, R30, R117). The findings include: On 3/29/23 at 9:00 AM, V17 (Licensed Practical Nurse/LPN) walked past this surveyor near the nurses' station. The medication cart was sitting at the end of this hallway, unsupervised. The surveyor arrived at the medication cart. The computer mounted on the medication cart had R42's EMR (Electronic Medical Record) displayed on the screen (anyone passing the cart would have access to R42's personal information). On the top of the medication cart was a nurse report sheet with room numbers, resident names, how the residents take their medications, code status, and resident specific notes regarding their medical needs and care. V7 (Restorative Aide)…

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 pressure ulcer dressings were in place, failed to provide wound care as ordered, failed to assess and ensure the physician was aware of a wound, and failed to implement pressure reducing interventions for 3 of 8 resident (R186, R1, R73) reviewed for pressure ulcers in the sample of 27. The findings include: 1. R186's face sheet printed on 3/30/23 showed diagnoses including but not limited to heart disease, peripheral vascular disease, diabetes mellitus, end stage renal disease, fracture of pelvis, and orthopedic aftercare. R186's facility assessment dated [DATE] showed severe cognitive impairment and extensive staff assistance required for bed mobility, transfers, toilet use, and hygiene. The same assessment showed R186 is occasionally incontinent of urine and bowel. R186's wound assessment report dated 3/30/23 showed an unstageable pressure ulcer to the sacrum and a stage 3 pressure ulcer to the left buttock present on admit.…

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 keep smoking paraphernalia in a designated area for residents with a history of unsafe smoking for 1 of 2 residents (R71) reviewed for smoking in the sample of 27 and 1 resident (R38) outside the sample. The findings include: 1. On 3/28/23 at 10:27 AM, R71 was sitting in her wheelchair in the hallway. R71 was wearing a black shirt, with a burn hole on the stomach area of the shift, and a heavy jacket. R71 stated, I just came in from smoking and it was cold out there this morning. I'm freezing from my legs down. I go out 2-3 times a day. Basically the door is open from 8:00 AM to 8:00 PM and I can go whenever I want. I have my cigarettes and lighter in my purse. There was a small purse hanging from R71's wheelchair. R71 pointed to the purse and stated, They're in there. R71 smelled of cigarette smoke. R71 said she goes out by herself and is not supervised by facility staff. On 3/30/23 at 8:49 AM, R71 self-propelled her wheelchair from 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 indwelling urinary catheter care was provided in a manner to prevent potential infection and failed to ensure urinary drainage tubing was not in contact with the floor for 2 of 3 residents (R8, R73) reviewed for indwelling urinary catheters in the sample of 27. The findings include: 1. On 3/28/23 at 1:40 PM, V16 (Certified Nursing Assistant/CNA) emptied urine from the urine bag into a urinal. In the process of emptying the urine into the urinal, the spout of the urine bag touched the wall of the urinal. V16 did not clean the tip of the urine bag spout before replacing it in its holder. On 3/30/23 at 11:10 AM, V16 (CNA) stated that she touched the spout of the urine bag on the side of the urinal and that it was wrong. V16 stated that she did not wipe the spout before replacing it in the holder. V16 stated that this practice was wrong because it could cause potential infection to the resident. V16 stated that she has had in-service 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 implement interventions for a resident with unplanned significant weight loss for 1 of 2 residents (R6) reviewed for weight loss in the sample of 27. The findings include: R6's face sheet showed the resident resided on the memory care unit with diagnoses of Alzheimer's disease, cardiomyopathy, dementia, and anemia. On 3/28/23 at 12:35 PM, R6 was in bed with her eyes closed. R6 remained in bed through 2:20 PM when observations ceased. From 12:35 PM to 2:04 PM, R6's lunch tray sat on the counter of the third floor dining room. R6's lunch tray was never delivered to the resident in her room and was sent back to the kitchen. There was no ice cream or coffee on the tray. R6 did not exhibit any behaviors. On 3/29/23 at 9:16 AM, R6 was in bed on her left side with her eyes closed. R6's full untouched breakfast tray sat on her bedside table. The table was not within reach of R6. On 3/30/23 at 9:44 AM, R6 was dressed and ambulated to the dining/activity room. R6's breakfast tray was set in front of her as she sat 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 ensure residents received respiratory care and services that are in accordance with professional standards of practice for 2 of 2 (R36, R54) residents reviewed for oxygen therapy in the sample of 27. The findings include: 1. On 3/28/23 at 11:00 AM, R36's mask used for nebulizer treatment was left on the nightstand uncovered. The canister to pour the nebulization solution was wet and attached to the mask. The BiPap (positive airway pressure) machine mask was left on the nightstand uncovered. The oxygen tubing connected to R36's nasal cannula, the humidifier on the oxygen concentrator, the nebulization machine mask and tubing did not have a label with date on them. On 3/28/23 at 12:15 PM, V16 (Certified Nursing Assistant/CNA) propelled R36 in a high-back reclining chair towards the elevator for dialysis appointment. R36's nasal cannula was not connected to an oxygen source. There was no oxygen cylinder anywhere on the chair. On 3/28/23 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 ensure medications remained under direct supervision of a licensed nurse for 1 of 5 residents (R42) observed for medication administration in the sample of 27. The findings include: On 3/29/23 at 9:00 AM, V17 (Licensed Practical Nurse/LPN) walked past this surveyor near the nurses' station. The medication cart was sitting at the end of this hallway, unsupervised. The surveyor arrived at the medication cart. There was a short acting insulin pen and long-acting insulin pen lying on top of the medication cart unsupervised. V7 (Restorative Aide) exited R42's room and stated, I don't know where the nurse went. At 9:04 AM, V17 (LPN) returned to the medication cart with additional long-acting insulin pens. V17 placed the additional insulin pens on top of the medication cart and entered R42's room. At 9:06 AM, V17 exited R42's room and returned to the medication cart. At 1:50 PM, V17 said she ran out of a R42's long-acting insulin and 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 ensure PPE (personal protective equipment) was worn in a manner to prevent cross contamination for 3 of 8 residents (R186, R127, R8) reviewed for infection control in the sample of 27. The findings include: 1. On 3/29/23 at 11:40 AM, R186 had a PPE bin outside her door. There was a large sign on the door of her room that said, STOP Enhanced Barrier Precautions. The signage had illustrations to show gloves and gowns must be worn when inside the room. The sign clearly stated gowns to be worn when high-contact resident care activities were performed. The care activities included but were not limited to wound care and changing briefs. V10 (Wound Care Nurse) prepared supplies to perform wound care for R186 and entered the room. V10 said R186 gets daily dressing changes done by the wound care nurse. V10 went to the bedside and removed R186's incontinence brief. At 11:50 AM, V11 (second Wound Care Nurse) entered the room wearing a gown. V10 performed wound care to R186's buttocks while V11 held the resident on her…

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.