Bria Of Cahokia

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to discontinue use of a resident's insulin after it was expired for 1 of 5 residents (R28) reviewed for labeling and storage of medications in the sample of 42. Findings include: On [DATE] at 1:45 PM the South Hall medication cart was reviewed with V4, Licensed Practical Nurse (LPN) and R28's Humalog Kwikpen was labeled as opened on [DATE] and expired on [DATE], indicating it had been expired for 8 days. V4 confirmed this is the only Humalog Kwikpen in the medication cart for R28 and would have been used to administer R28's sliding scale insulin. V4 stated this insulin should have been discarded on [DATE] and replaced with a new Humalog Kwikpen. R28 stated V4's blood glucose levels are checked three times a day and sometimes R4 gets Humalog insulin and sometimes she doesn't, depending on the blood glucose results. R28's Order Summary Report dated [DATE] documents an order dated [DATE], Insulin Lispro (Humalog) Inject as per sliding scale: if…

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 to justify the use of antibiotics for 3 of 4 residents (R10, R72, R306) reviewed for antibiotic stewardship in the sample of 42. Findings include: 1.R10's Face Sheet, undated, documents her admittance date as and documents R10's medical diagnoses as Benign Prostatic Hyperplasia without Lower Urinary Tract Symptoms, Unspecified Intestinal Obstruction Unspecified as Partial versus complete, Unspecialized Conjunctivitis bilateral and allergic rhinitis. R10's Physician Order Summary (POS) dated March 2025 documents medications as Amoxicillin 500 Milligrams with a start date 4/1/25. R10's urine sample collected 3/26/25 documents no organism. The urine sample documents the urine sample indicated mixed flora. Further testing dated 3/27/25 documented no growth. R10's Electronic Medication Administration (eMAR) dated April 2025 documents R10 was administered 21 doses of the antibiotic Amoxicillin. On 4/17/25 at 4:00 PM R10 stated he did take antibiotics but did not know what kind and what for. 2. R72's Face Sheet undated documents R72'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 maintain an effective pest control program for 6 of 6 residents (R1, R2, R3, R4, R5, R6) reviewed for pest control in Facility in the sample of 6. Findings include: 1.On 4/8/2025 at 9:00AM, there were many gnats in R2's room. 2.On 4/8/2025 at 3:00PM, there were many gnats in R5's room flying into surveyor's face and landing on clothes. Many gnats in conference room and staff restrooms. R5 stated she sees gnats and flies. R5's Minimum Data Set (MDS) dated [DATE] documents R5 has no cognitive deficits. 3.On 4/8/2025 at 1:40 PM R3 stated she has seen gnats in the hallways and in the kitchen/dining area. R3 stated seeing the gnats around her in the hallways makes her feel nasty, and the facility needs to do something about them. R3's Minimum Data Set (MDS) dated [DATE], documents R3 is cognitively intact. 4.On 4/8/2025 at 1:55 PM R1 stated he has seen bugs and gnats in the facility and there are gnats in his room. R1 stated the gnats will be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, the facility failed to provide incontinence care to 2 of 3 residents (R1, R4) reviewed for incontinent care in the sample of 6. Findings include: 1.R4's Face sheet documents an admission date of 9/23/2015 with diagnoses of Cerebral Palsy, Intellectual Disabilities, Neuralgia and Neuritis Contracture of Left and Right Knee, Schizoaffective Disorder, Bipolar type, Contracture Right Elbow. R4's Minimum Data Set, MDS, updated 3/27/2025 documents R4 has no cognitive impairments and is dependent for mobility and transfers. MDS dated [DATE] documents R4 is always incontinent of bladder and bowel. R4's Care Plan updated 3/3/2025 documents Activities of Daily Living, ADL: R4 is alert with a diagnosis of Cerebral Palsy, Mental Retardation, Schizoaffective disorder, and Depression. R4 requires extensive to total assistance of one with his daily care tasks He has functional incontinence of both bowel and bladder and is noted to demand to wear multiple depends at one time.…

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, Observation, and Record Review, the facility failed to maintain a clean and sanitary environment during wound care, and to wear Personal Protective Equipment (PPE) for residents who are on Enhanced Barrier Precautions (EBP) for 3 of 3 residents (R3, R5, R37) reviewed for wound care in the sample of 19. The findings include: 1. R3's admission Record, dated 5/12/25, documents R3 was admitted to the facility on [DATE] with diagnosis of Cerebral Infarction, Paraplegia, Flaccid Neuropathic Bladder, Moderate Protein-Calorie Malnutrition, and Osteomyelitis. R3's Care Plan, dated 3/5/25, documents R3 requires assist with daily care. Interventions: Monitor skin integrity during routine care and report abnormal findings. It continues R3 requires Enhanced Barrier Precautions (EBP) related to wound and indwelling medical device (urinary catheter). Interventions: Enhanced Barrier Precautions as per facility protocol, staff to wear gown and gloves when performing ADL's (activities of daily living):…

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 all alleged violations were thoroughly investigated for 4 of 13 residents (R1, R5, R12, R29) reviewed for abuse investigations in the sample of 51. Findings include: 1. R12's Physician Order Sheet (POS) dated January 2025 document diagnoses of schizoaffective disorder, bipolar type, insomnia due to other mental disorder, mild intellectual disabilities, and bipolar disorder. R12's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) score of 15 indicating cognitively intact for decision making for activities of daily living. R12's Care Plan with a date initiated of 1/10/2025 documents Abuse: (R12) is at risk for abuse and neglect related to DM (diabetes mellitus), type 2, schizoaffective disorder, bipolar disorder, asthma and mild intellectual disability. On 1/29/2025 at 3:14 PM, R12 was unable to recall the incident between her and R5. R12's Initial Report dated 12/7/2024 at 11:03 AM, documents, Resident 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 interview and record review the Facility failed to implement progressive interventions to prevent falls, failed to implement safe mechanical lift transfer techniques, and ensure equipment is in good repair to prevent injury for 4 of 7 residents (R6, R7, R25, R30) reviewed for supervision to prevent falls/accidents in the sample of 51. Findings include: 1.R6's Physician Order Sheet (POS) for January 2025 documents a diagnosis of hemiplegia, unspecified affecting right dominant side, hemiplegia, unspecified affecting left dominant side, type 2 diabetes mellitus without complications, difficulty in walking, abnormal posture, need for assistance with personal care, weakness, other abnormalities of gait and mobility, repeated falls, unspecified dementia, unspecified severity with other behavioral disturbances, and schizoaffective disorder. R6's Minimum Data Set, (MDS), dated [DATE] documents R6 has moderate cognitive impairment. R6 needs substantial/ maximal, helper does more than half the effort. Helper…

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 properly store medications for 6 of 6 residents (R4, R11, R34, R36, R37, R38) observed for proper medication storage in the sample of 51. The Findings Include: 1. R11's admission Record, dated 2/3/25, documents R11 was admitted to the facility on [DATE] and discharged on 1/29/25 with diagnosis of Compartment Syndrome of right lower extremity, Type 2 Diabetes Mellitus (DM), Accidental discharge from firearms, Deep Vein Thrombosis, Malignant neoplasm of colon, Vascular implants and grafts, Hypertension (HTN), and Peripheral Vascular Disease (PVD). R11's Care Plan, dated 1/22/25, documents R11 is at risk for bleeding/bruising related to anticoagulation medication use. He takes Lovenox as ordered. He has a history embolism. R11's Minimum Data Set (MDS), dated [DATE], documents R11 was cognitively intact. R11's Physician Order, dated 12/31/24, documents Enoxaparin Sodium (Lovenox) Injection Solution Prefilled Syringe 120 MG/0.8ML Inject 0.8 ml…

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 treat pressure ulcers per physician's orders for 1 of 4 residents (R35) reviewed for pressure ulcers in the sample of 51. Findings include: 1. R35's undated Face Sheet documents R35's medical diagnoses include Encephalopathy, Chronic Obstructive Pulmonary Disease, Benign Prostatic Hyperplasia, Parkinsonism, Paranoid Schizophrenia, and Need for assistance with personal care. R35's Care Plan, dated 1/22/25, documents R35 is at risk for skin complications related to needing assistance with activities of daily living. R35 refuses to lay down at times and is non-compliant with footwear. Interventions include skin assessment weekly. R35's Minimum Data Set (MDS), dated [DATE], documents R35 has memory problems and is rarely/never understood, needs partial/moderate assistance with toileting hygiene, and is always incontinent of bowel and bladder. R35's Braden Skin assessment dated [DATE] documents R35 is at moderate risk for pressure ulcers.…

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, Observation, and Record Review, the facility failed to maintain a clean and sanitary environment during wound care, and to wear Personal Protective Equipment (PPE) for residents who are on Enhanced Barrier Precautions (EBP) for 3 of 3 residents (R3, R5, R37) reviewed for wound care in the sample of 19. The findings include: 1. R3's admission Record, dated 5/12/25, documents R3 was admitted to the facility on [DATE] with diagnosis of Cerebral Infarction, Paraplegia, Flaccid Neuropathic Bladder, Moderate Protein-Calorie Malnutrition, and Osteomyelitis. R3's Care Plan, dated 3/5/25, documents R3 requires assist with daily care. Interventions: Monitor skin integrity during routine care and report abnormal findings. It continues R3 requires Enhanced Barrier Precautions (EBP) related to wound and indwelling medical device (urinary catheter). Interventions: Enhanced Barrier Precautions as per facility protocol, staff to wear gown and gloves when performing ADL's (activities of daily living):…

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 maintain an effective pest control program related to roaches and mice in the facility. This failure has the potential to affect all 110 residents residing in the facility. Finding includes: The facility's Pest Control Provider's Product usage report, dated 11/22/2024, documents (Water Soluble Granular Insecticide), Application method: spot treatment. Target areas: living areas, target issues: roaches. (Product name) Cockroach Gel Bait applied to crack and crevices in living areas for roaches. 12/16/2024 (WSG), target areas entry ways, hallways, interior baseboards, kitchen, lobby, mechanical room, office, storage room, wall voids. target issues: General pests and roaches. (Product name) cockroach bait applied in kitchen. Glue Board multi-catch station applied. On 1/13/2025 at 10:49 AM observed roaches on floor behind bedroom door, crawling across floor in room and dead roaches on the floor. On 1/13/2025 at 11:24 AM observed multiple bugs on the ceiling…

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 coffee and condiments per menu for 8 of 9 residents (R1, R2, R4, R5, R6, R7, R8, and R9) reviewed for following the menu in the sample of 9. Findings Include: The menu provided for Week 1 documented that for breakfast, lunch and dinner coffee and condiments should be served. Milk should be served for breakfast and dinner. On 11/14/2024 at 8:30 AM R4 stated that they always receive coffee first before the breakfast tray. R4 added that the facility runs out of cream, sugar and milk. On 11/14/2024 at 8:30 am R5 was sitting in the dining room. R5 stated that two days ago, he didn't receive milk with his cereal. On 11/14/2024 at 8:15 am, R6 stated that his breakfast should have been served by now. He stated that sometimes they run out of sugar and cream. R6 stated they run out of milk all of the time. On 11/14/2024 at 8:20 am, R7 stated that they may have sugar for one meal and no sugar for the next meal. Sometimes staff will say they have no milk.…

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 an alleged abuse allegation was thoroughly investigated for 1 of 3 residents (R2) reviewed for verbal abuse in the sample of 6. Findings include: R2's Physician Order Sheets for October 2024 documents a diagnosis of cognitive communication deficit; anxiety disorder, personal history of other drug therapy, hypertension, hyperlipidemia, UTI, low back pain, need for assistance with personal care, weakness, pain in left foot, cannabis abuse, paranoid schizophrenia, abnormal gait and mobility, multiple fractures of ribs, right side, type 2 diabetes mellitus without complications, cirrhosis of liver, morbid obesity, and unsteadiness on feet. R2's Minimum Data Set (MDS) dated [DATE] documents R2 was cognitively intact for decision making of activities of daily living. R2 uses a walker and has no impairments. R2's Care Plan for Abuse with a date initiated of 10/3/2023 documents, (R2) is at risk for abuse and neglect r/t (related to) COPD, anxiety,…

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 administer medication as prescribed for 1 of 3 (R3) residents reviewed for medication administration in a sample of 11. Findings include: R3's admission Record, not dated, documents Unspecified Fracture of upper end of right humerus, subsequent encounter for fracture with routine healing, Acute hematogenous osteomyelitis, left ankle foot, liver transplant failure, type 2 diabetes mellitus without complications. R3's Baseline Care Plan, dated 10/11/2024, documents PAIN: 1.FOCUS: B. Potential for pain 2. GOAL B. Resident will verbalize or acknowledge pain when questioned by staff 3. INTERVENTIONS: A. Administer pain medications as ordered by MD B. Monitor for non verbal indicators of pain daily with care tasks and activities C. Monitor for side effects D. Provide non pharmacological interventions (i.e. back rub, aroma therapy, ice or cold packs, etc.) FRACTURE 1. FOCUS: A. Resident has limited mobility related to fracture 3. INTERVENTIONS: A. Assist with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to adequately monitor meal intakes to identify concerns with nutrition in 1 of 5 residents (R5), reviewed for nutrition/hydration status maintenance in the sample of 13. Findings include: R5's Face Sheet, undated, documents R5 has a diagnosis of Dementia, Dysphagia and Moderate Protein-Calorie Malnutrition. R5's Minimum Data Set, dated [DATE], documents R5 has severe cognitive impairment, requires set up with meals and has not had a weight loss. R5's Care Plan, dated 10/28/22, document R5 is at risk for complications with weight and nutrition with an intervention to monitor and document resident's food intake and notify the Physician, Dietician and Director of Nurses of any significant weight changes. R5's Physician Order Sheet, documents an order dated 8/15/24 to monitor resident's intakes and outputs. R5's Progress Note, dated 5/7/24 at 10:48 AM, documents R5 has had an unintended significant weight loss in 30 days (6.8%) with a recommendation by the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to administer medications as ordered in 3 of 7 residents (R3, R4, R10) reviewed for pharmacy services in the sample of 13. Findings include: 1. On 8/2/24 at 11:15 AM, R3 stated his medications are still a problem, not getting them on time and sometimes not at all, unless he asks about them. R3's Face Sheet, undated, documents R3 has a diagnosis of MDD (Major Depressive Disorder) R3's MDS (Minimum Data Set), dated 7/10/23, documents R3 has a BIMS (Brief Interview for Mental Status) score of 15, indicating he is cognitively intact. R3's Care Plan, dated 1/31/23, documents R3 is at risk of alteration of mood due to a diagnosis of MDD. R3's Progress note, dated 7/22/24 at 9:03 AM, documents Duloxetine HCL 60 mg (milligrams) for MDD was not administered due to the medication not available. Medication has been reordered. R3's Progress Note, dated 7/23/24 at 9:11 AM, documents Duloxetine HCL 60 mg was not administered due to medication not available. Medication…

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 supervision to prevent elopement for 1 of 3 residents (R2) reviewed for elopement in the sample of 36. Findings include: R2's July 2024 Physician Order Sheets (POS) documents a diagnosis of Alzheimer disease with early onset, type 2 diabetes mellitus without complications, need for assistance with personal care, schizoaffective disorder, bipolar type, and unspecified dementia. R2's Minimum Data Set (MDS) dated [DATE] documents R2 is severely impaired for cognition, he has no impairments, does not use a wheelchair, and does not have any elopement alarms. R2's Elopement Evaluation dated 7/10/2024 documents, (R2) recently climbed out of the dining room window. He is high risk for elopement. R2's Care Plan documents, Diagnosis: (R2) has a diagnosis of Dementia and/or Alzheimer's and may display moods/behaviors related to diagnosis such as: Agitation/Aggression, Isolative Behaviors/May prefer to stay in room and not socialize. Refusal…

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 administer medications as ordered by the physician. The facility also failed to have a working system in place to ensure required prescriptions for renewal of medication are timely signed by a medical provider to ensure medications are requested from the pharmacy in a timely manner and are consistently available for administration for 4 of 4 residents (R6, R7, R8 and R9) reviewed for medications in the sample of 36. Findings include: 1.) R7's Physician Order Sheet (POS) for July 2024 documents a diagnosis of liver cell carcinoma (cancer), liver cirrhosis, human immunodeficiency virus (HIV) and migraines. R7's Minimum Data Set (MDS) dated [DATE] documents R7 was cognitively intact for decision making of activities of daily living. R7's care plan dated 7/8/24 documents, (R7) has a problem with pain and the goal that (R7) will not experience a decline in overall function. R7's interventions for pain documents, to include to administer pain medicine and…

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

Based on observation, interview, and record review the Facility failed to follow CDC Infection Control Guidelines during an COVID outbreak and staff failed to wear the proper PPE (Personal Protective Equipment) during patient care for 4 of 18 residents (R33, R34, R35 and R36) reviewed for COVID in the sample of 36. Findings include: On 7/16/2024 at 2:55 PM, V1 (Administrator) stated, We do have COVID in the building and I am not sure of the exact number now, but it was 12 residents, but you will need to check with our ICP (Infection Control Preventionist) just to make sure. On 7/16/2024 at 9:35 AM, R33, R34 and R35's room has PPE (Protective Personal Equipment) outside in the hallway in a plastic bin that was sitting on the floor. V5 (Registered Nurse/RN) was providing care to the R33 and was only wearing a surgical mask which was pulled down under her chin and her mouth and nose was exposed while she was providing care. V5 was touching the tubing of R33's tube feeding and was touching the resident. V5 was not wearing any googles and/or face shield. On 7/16/2024 at 9:38 V5 (RN) then…

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 correct medication was administered to the right resident for 1 of 12 residents (R2) reviewed for medications in a sample of 13. R2 was given R3's blood pressure medication and anti-psychotic medication. R2 was sent to the emergency room for evaluation. Findings include: R2's Face Sheet, print date of 06/17/24, documents R2 has diagnoses of but not limited to Chronic Obstructive Pulmonary Disease (COPD), Mild intermittent asthma, emphysema, hypertension (HTN), depression, and gastroesophageal reflux disease (GERD). R2's Minimum Data Set (MDS), dated [DATE], documents R2 is cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 out of 15 and she requires supervision/touching assistance with eating, oral hygiene, toileting hygiene, shower/bathe, upper and lower body dressing, putting on/taking off footwear, personal hygiene, bed mobility, transfer, and she is always continent of bowel and bladder. R2's Progress notes, 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.

Based on observation, interview, and record review the facility failed to ensure food is stored and prepared in a manner which prevents potential contamination and potential food borne illness. This has the potential to affect all 88 residents living in the facility. Findings include: 06/04/24 at 8:35 AM, in the stand-up refrigerator in the kitchen there were two trays with 24 (4 ounce) cups filled with a pink liquid covered, but no date or label. Next to it was a tray with two (four ounce) cups of clear liquid with no date and/or label. On 6/4/2024 at 8:37 AM, the vent above the stove hood was shiny and greasy in appearance. There were small particles in the cracks of the vent, and it needed cleaned. On 6/5/2024 at 8:42 AM, during the breakfast service, V30 (Cook) was on the tray line. During the breakfast meal service V30 was wearing only one glove, then she went over to the stove and took her ungloved hand, reached into the pot on the stove and grabbed a hard-boiled egg with her bare hand. V30 did not rinse or wash or hands or apply disinfectant before or after touching the egg…

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 assure residents were receiving diet as ordered to maintain normal body weight and acceptable nutritional values and menus/recipes were followed for 4 of 5 residents (R12, R53, R75, R76) reviewed for nutritional needs in the sample of 52. Findings include: 1.On 6/4/2024 at 8:35 AM during the breakfast service there was a large metal pan full of oatmeal and another large pan full of grits. On 6/4/2024 at 9:01 AM, V30 (Cook) stated there was no fortified oatmeal for breakfast and she just adds butter and brown sugar to the regular oatmeal in place of fortified oatmeal, and that is what everyone gets who wants oatmeal. There is no fortified oatmeal. On 6/4/2024 at 9:09 AM, R75 was served the regular oatmeal, no fortified oatmeal was served. 2.R75's Physician Order Sheet (POS) for June 2024 documents and order for regular diet, Mech (mechanical)/soft texture, regular liquids consistency, divided plates, Health Shakes TID (Three times a day) with meals and fortified foods all meals. R75's Dietary Card for June 2024…

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

Based on interview and record review the facility failed to provide residents with working toilets for 5 of 5 residents (R16, R29, R50, R86, and R99) reviewed for safe, functional, sanitary, comfortable, environment in the sample of 52. Findings include: A Local Plumbers Invoice dated 2/24/24 documents on 01/26/2024 low water pressure. Returned and checked water pressure, still showing 25-30PSI (pounds per square inch). Waited onsite for city to show up per (V4 Assistant Administrator and V31 Maintenance Man) request. Met with city employee. He called his boss (V32) (City) Sewer Department. Spoke with (V32), he told me that the city has (9) underground leaks that they cannot locate. Working 24-7 to locate, pressure will be low until city repairs water leaks. 01/25/2024 - emergency: low water pressure checked for underground water leak (not leaking). Checked pressure (average pressure 25-30 PSI (on fire main). Old test reports Show 45-65 PSI (on fire main) for the last 3 years. This shows pressure drop. Discussed w (with)/ customer that we are currently dealing with (2) customer 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 interview and record review the Facility failed to prevent resident to resident abuse for 2 of 5 residents (R31 and R87) reviewed for abuse in the sample of 52. Findings include: R87's Physician Order Sheet (POS), dated June 2024, documents diagnoses of unspecified dementia, adult failure to thrive, unspecified severity, without behavioral disturbances, mood disturbance and anxiety. R87's Care Plan undated documents, Abuse: (R87) is at risk for abuse and neglect related weakness, mood disorder and cholecystitis. R87's Care Plan Target Date 7/4/2024 documents, Staff will monitor well-being of others. Resident will have zero episodes of abuse and neglect through next review. R87's Progress Note dated 5/18/2024 4:47 PM, documents Resident was hit in the face by his roommate. Resident has a laceration on the left side of his eye. Laceration was cleaned and band-aid was applied, Resident is now sitting at the nurse's station. Administrator made aware of incident. R87's Initial Report dated 5/18/2024…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to investigate an allegation of physical abuse for one of 5 residents (R66) reviewed for abuse in the sample of 52. Findings include: R66's Minimum Data Set (MDS) dated [DATE] documents he is alert and oriented to person, place, and time. On 6/6/2024 at 1:11 PM, R66 stated, A housekeeper smacked me a couple of times. This happened a while ago. Maybe a month ago. The Psych-social staff saw her smack me and the housekeeper. The staff is still working here. On 6/7/24 at 9:00 AM V12 (Certified Nursing Assistant/CNA) stated she heard R66 state a housekeeper hit him but did not witness anyone hit him or hear a sound of a slap. She stated she thought it might have happened back in April. She stated she heard him say, She slapped me. and then another CNA (unknown) asked him, Who slapped you? and R66 stated the housekeeper. V12 stated V21 (Housekeeper) told her R66 was lying, and the housekeeper reported it to the administrator. On 6/7/24 at 9:35 AM V21…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide supervision to prevent a resident from eloping from the facility for 1 of 2 residents (R208) reviewed for elopement in the sample of 52. Findings include: R208's Face Sheet printed on 5/24/24 documents he was admitted to the facility on [DATE] with the diagnoses of Schizophrenia, Hypertension, Cocaine Abuse, Bipolar Disorder and Major Depressive Disorder, Recurrent, Mild. R208's Progress Note dated 5/17/24 at 11:58 PM documents, Resident was reported missing from facility around 10:15 last time resident was seen was around 8:45 PM in his room. Staff searched the facility and perimeter for resident. Resident was not found. Attempted to call mother x2 no answer at this time. DON (Director of Nursing) and police contacted and made aware. R208's Progress Note dated 5/18/24 at 12:09 PM documents, Pt (Patient) discharged AMA (Against Medical Advice) from this facility. Pt is aware of the facility policies and procedures when a pt (patient) signs out…

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 the facility to provide timely refills of narcotic pain medication for one of one resident (R97) reviewed for pharmacy services in the sample of 52. Findings include: R97's Electronic Medication Administration (EMAR) Note dated 2/18/24 documents new admit. R97's EMAR Medication Administration Note dated 2/19/24 documents awaiting arrival from Pharmacy. R97's Medication Administration Record (MAR) documents R97 did not receive his Oxycodone (narcotic pain medication) 5 milligrams (mg) three times a day on 2/18/24 on day shift, 2/27/24 on day shift, 2/25/24 at 1:00PM, 2/28/24 at 1:00PM and 2/26/24 through 2/27/24 at 9:00PM. R97's EMAR Medication Administration Note dated 2/25/24 documents Note Oxycodone oral capsule 5 MG Give 1 capsule by mouth three times a day for pain Medication not available, pharmacy stated pt (patient) is in need of a new script. R97's EMAR Medication Administration Note dated 2/26/24 documents Oxycodone oral capsule 5 MG Give 1 capsule by mouth three times a day for pain not available. R97's EMAR Medication Administration Note…

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 residents with limited range of motion receive appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 3 residents (R4) reviewed for range of motion/mobility, in the sample of 7. Findings include: On 4/26/24 at 1:00 PM, R4 was lying in bed in his room with grab bars on the sides of his bed watching television. He stated that he has not received any Restorative Therapy since he returned to the facility after hospitalization in March 2024. R4's Face Sheet documented that R4 was admitted to the facility on [DATE] with diagnoses including paraplegia, type 2 diabetes mellitus without complications, need for assistance with personal care, stage 4 pressure ulcer of sacrum, and abnormal findings on diagnostic imaging of abdominal regions. R4's Minimum Data Set (MDS), dated [DATE], documented that R4 was cognitively intact, required substantial/maximal assistance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an allegation of abuse to the state surveying agency in 1 of 6 residents (R3), reviewed for abuse in the sample of 11. Findings include: R3's Abuse Investigation was reviewed with the following noted: 4/8/24 - The morning of 4/8/24, R3 reported abuse. He stated that he felt the staff didn't want him in the facility. When questioned why he felt this way, he stated the staff believes he is faking his seizures. He also stated that a staff member had kicked him. R3 mentioned that the individual who had kicked him was in the building doing 1:1 (one on one observation). R3 was admitted on [DATE], and that employee only works Saturdays & Sundays as a Psychosocial Aide and wouldn't have had any contact with him. When I (V1 Administrator) advised R3 that it couldn't have been the employee doing the 1:1, he then stated it was one of the managers, who also doesn't work weekends and typically wouldn't have any contact with him. He then stated he doesn't…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to properly investigate and prevent abuse for 1 of 3 (R7) residents reviewed for abuse, in a sample of 12. This failure resulted in R7 being fearful, feeling trapped, unprotected, and feeling less than a man. Findings include: R7's Care Plan, dated 12/11/23, documented, ABUSE: (R7) is at risk for abuse and neglect r/t (related to) his impaired mobility. He is noted to make false allegations toward staff. 8/15/2023 Resident reported that CNA (Certified Nursing Assistant) was rough while providing care. 11/27/2023 Resident reported that a CNA was rough while providing care. It continues, Assure resident that he/she is in a safe and secure environment with caring professionals. Explain that psychosocial adjustment is often facilitated by developing a trusting relationship with another person (i.e., social worker, nurse, CNA, peer) and by verbalizing thoughts, needs and feelings. Immediately report any episodes of unknown injury, abuse or change in resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to administer medications as ordered for 4 of 4 residents (R1, R2, R4, and R8) reviewed for Pharmacy Services in the sample of 18. Findings include: 1. On 2/6/24 at 11:40 AM R8 stated sometimes she doesn't get her medications and she is diabetic, so it is important that she gets her blood checked and gets her insulin. R8's Medication Administration Records (MARs) were reviewed for January and February 2024 with multiple missed doses of medications as noted by lack of documentation in R8's Electronic Medication Administration Record (eMAR). February 2024 MAR has no documentation of 9:00 PM medications being administered to R8 on 2/3/24 which included Atorvastatin 80 milligrams (mg), Insulin Glargine 14 units, and Trazadone 50 mg. There was no documentation on R8's 5:00 PM medications being given on 2/3/24 which included Haloperidol 3 mg, Benztropine 0.5 mg, Fluticasone Salmeterol 250/25 mcg/ACT one puff, Hydralazine 25 mg, and Pepcid 20 mg. 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.

Based on observation, interview and record review, the facility failed to provide treatments to a diabetic ulcer as ordered by the physician for one of three residents (R9) reviewed for wounds in the sample of 18. Findings include: On 2/8/24 at 8:35 AM V14 (Registered Nurse) performed treatment to wound on R9's right outer heel. After soaking the dressing off, the old dressing was noted to have moderate amount of serosanguinous drainage on it. The wound was about the size of a quarter with a black necrotic base. R9 voiced discomfort when V14 cleansed the wound, so he stopped and had her nurse, V11 (Licensed Practical Nurse) come and administer some pain medication (Oxycontin 5 mg). R9 allowed V14 to continue to cleanse the wound with wound cleanser, apply betadine and dry dressing and then wrap it with gauze. After the treatment was completed, R9 stated the nurses do her treatments on most days but not every day. R9's Physician Order dated 2/8/24 documents Cleanse right lateral heel with wound cleanser/normal saline, apply betadine and cover with dry dressing and wrap with stretch…

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 Director of Nursing was working full time in the facility. This has the potential to affect all 105 residents living in the facility. Findings include: On 1/16/2024 at 5:51 PM, V16 (Receptionist) stated, (V17) is no longer the Administrator. (V1) is the administrator now. We do not have a DON (Director of Nursing) or a ADON (Assistant Director of Nursing) at this time. On 1/16/2024 at 5:59 PM, during a tour of the facility there was no Registered Nurse (RN) or a (DON) observed working in the facility. On 1/16/2024 at 6:00 PM, R5 stated, Girl, things are a mess here. We just got a new Administrator who use to do medical records. We do not have a DON or even a ADON anymore. I am not sure what is happening, but it is not good. Things are a mess now because there is nobody in charge to answer to. On 1/16/2024 at 6:04 PM, R6 stated, We have a new Administrator (V1), but we do not have a DON or ADON. They both quit and nobody else has been hired. It has been a few months now since the DON left. On 1/16/2024…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and observation the facility failed to provide a safe, clean, comfortable, and homelike environment due to toilets not working appropriately for 8 of 8 residents (R4, R5, R9, R10, R11, R12, R13 and R14) reviewed for plumbing issues in the sample of 14. Findings Include: R4's Minimum Data Set (MDS), dated [DATE] documents, R4 is cognitively intact. R5's MDS dated [DATE] documents, R5 is cognitively intact. R9's MDS dated [DATE] documents, R9 is cognitively intact. R10's MDS dated [DATE] documents, R10 is moderately cognitively impaired. R11's MDS dated [DATE] documents, R11 is cognitively intact. R12's MDS dated [DATE] documents, R12 is moderately cognitively impaired. R13's MDS dated [DATE] documents, R13 is moderately Cognitively impaired. R14's MDS dated [DATE] documents, R14 is cognitively intact. On 01/23/24 at 9:25 AM R4 stated, my toilet has been plugged for 4 days, and they just came to fix it today. On 01/23/24 at 3:11 PM V27 (Certified Nursing Assistant/CNA) 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to answer call lights in a timely manner for 3 of 3 residents (R2, R4, R8) reviewed for call lights in the sample of 14. Findings Include: 1. R2's MDS (Minimum Data Set) dated 12/31/23 documents R2 is cognitively intact. R2's MDS also documents, he is always incontinent of bowels. R2 has an indwelling catheter. R2's Care Plan dated 01/24/24 documents, R2 requires assist with daily care needs r/t (related to), his dx (diagnosis) of Paraplegia. He requires extensive to total assist to complete ADL's (Activity of Daily Living) at this time. On 01/23/24 at 9:00 AM R2 stated, yes depending on who is working you might get help or not. This past weekend I didn't have a CNA (Certified Nursing Assistant). They will ignore the call light or come in and shut it off and never come back. On the night shift you may have to wait 2 to 3 hours or better. 2. R4's MDS dated [DATE] documents, R4 is cognitively intact. For toileting he is a substantial maximal assistance. R4…

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 adhere to their Medication Administration Policy, administer medications as prescribed by a physician, and ensure medications were administered safely for 3 of 4 residents (R1, R5 and R6) reviewed for medication administration in the sample of 7. Findings include: 1. R1's admission record form, dated 12/27/23, documented R1 was admitted to the facility on [DATE]. R1 was admitted with diagnosis of chronic obstructive pulmonary disease, schizoaffective disorder, bipolar disorder, encephalopathy, paranoid schizoaffective disorder, absolute glaucoma, parkinsonism, benign prostatic hyperplasia, hyperosmolality, hypernatremia, hypomagnesemia, parkinsonism, and obesity. R1's MDS (Minimum Data Set), dated 12/5/23, documented R1 as moderately cognitively impaired. R1's psychotropic medications care plan, dated 4/22/16, documented R1 receives psychotropic medications due to his diagnosis of paranoid schizophrenia. It continues, R1 expresses…

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 Fall Prevention Policy by not providing proper notification for 1 of 3 residents (R1) reviewed for Policy and Procedure, in the sample of 7. Findings include: R1's admission record form, dated 12/27/23, documented R1 was admitted to the facility on [DATE]. R1 was admitted with diagnosis of chronic obstructive pulmonary disease, schizoaffective disorder, bipolar disorder, encephalopathy, paranoid schizoaffective disorder, absolute glaucoma, parkinsonism, benign prostatic hyperplasia, hyperosmolality, hypernatremia, hypomagnesemia, parkinsonism, and obesity. R1's MDS (Minimum Data Set), dated 12/5/23, documented R1 as moderately cognitively impaired. R1's care plan, dated 12/11/23, documented R1 is at high risk for falls. R1's care plan documented interventions are to remind resident that staff will clear trays after every meal, encourage him to wear appropriate shoes, staff to encourage resident to accept assist during transfers, clock 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 interview and record review, the facility failed to follow their Fall Prevention Policy, investigate the root cause of a fall, as well as implement effective interventions for 1 of 3 residents (R1) reviewed for falls, in the sample of 7. Findings include: R1's admission record form, dated 12/27/23, documented R1 was admitted to the facility on [DATE]. R1 was admitted with diagnosis of chronic obstructive pulmonary disease, schizoaffective disorder, bipolar disorder, encephalopathy, paranoid schizoaffective disorder, absolute glaucoma, parkinsonism, benign prostatic hyperplasia, hyperosmolality, hypernatremia, hypomagnesemia, parkinsonism, and obesity. The facility's incidents by incident type log, dated 9/26/23 to 12/26/23, documented R1 fell on [DATE]. R1's MDS (Minimum Data Set), dated 12/5/23, documented R1 as moderately cognitively impaired. R1's care plan, dated 12/11/23, documented R1 is at high risk for falls. R1's care plan documented interventions are to remind resident that staff will clear…

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 prevent resident to resident abuse for 1 of 4 residents (R2) reviewed for abuse in the sample of 16. Findings include: 1. The facility's document, Facility-Reported Incident Form/ Follow-up Investigation Report dated 9/19/23 identified the allegedly abused resident as R2 and the alleged perpetrator as R12. The report's conclusion documents, On September 12, 2023 (R2) was ambulating towards the patio, upon ambulating in front of (R12), (R12) raised her pocketbook and made contact with (R2's) right lower arm. Residents were immediately separated. Enhanced monitoring initiated with (R12). (Local police) notified. Physician notified for both residents. Skin assessment completed on (R2) with discoloration noted to right lower arm. Resident denies pain. Medication review completed with (R2), noted to take Aspirin daily which increases risk for bruising. ROM (Range of Motion) within normal limits. (R12) was interviewed and stated, when she walked in front of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to offer Influenza, COVID and Pneumococcal Vaccines to 4 of 5 residents (R1, R14, R15 and R16) reviewed for vaccinations in the sample of 16. Findings include: On 12/21/23 at 1:30 PM R14 stated he has been hollering about getting vaccinated for whatever vaccinations he is able to have. He stated he wants COVID vaccines and Pneumonia vaccines because he has had COVID three times now and wants whatever he can have to keep from getting it again. He stated he was in the hospital two weeks ago and they did give him the Influenza vaccine then, but he still needs his COVID and pneumonia vaccines. He stated he has told the nurses that he wants the vaccine, and they told him they will put him on the list and as soon as there are enough residents who want it, they will set up a clinic. R14 stated he does not want to wait any longer because he doesn't want to get sick again. R14's Immunizations are documented in his Electronic Medical Record (EMR) as: Influenza…

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 it's abuse policy by failing to immediately report an allegation of abuse after becoming aware for 1 of 4 residents (R2) reviewed for abuse in the sample of 16. Findings include: R2's Progress Note documented by V18 (Nurse Practitioner) on 11/20/23 at 2:00 PM documents, Ordered right knee x-rays. She reported one of the residents told her she has bad breath and then while she is about to sit in her chair, resident kicked this, and she accidentally slide. Denies hit her head. She reported her right knee. Her buttock (upper thoracic area). muscle contusion? Observation. Ordered right knee X-ray. Swollen more prominent than left. skin no scratched back, both knees no skin laceration. INCIDENT happened Saturday 18, 2023. Lumbar spine history (hx) of mild deg changes/arthritic hx (history) of heroin abuse, asking more pain meds. (There were no progress notes dated 11/18/23 when R2 fell, and the last progress note before this note was documented 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, observation and record review, the facility failed to provide adequate pest control. This failure has the potential to affect all 99 residents residing in the facility. Findings include: On 10/26/23 at 9:05 AM, Lavender Lane was observed with gnats noted in the shower room around the shower drain and flies noted in the hallway. On 10/26/23 at 9:10 AM, [NAME] Boulevard was observed with gnats noted in the shower room. On 10/26/23 at 9:15 AM, Marigold Lane was observed with flies in the hallway. On 10/26/23 at 9:30 AM, the East Hallway was observed with flies in the hallway. On 10/26/23 at 2:05 PM, V7 (Licensed Practical Nurse/LPN) stated the flies are so bad, they go in her mouth while she's talking. V7 stated the flies are everywhere. During the interview with V7 flies were observed at the Marigold/Iris Nursing Station and flies were flying around with one landing on V7's face. On 10/27/23 at 8:10 AM, V10 (Maintenance Assistant) stated (contracted pest control) comes monthly and puts traps down for roaches in high traffic and suspected areas of infestation. V10…

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, observation and record review, the facility failed to provide incontinent care in 1 of 3 residents (R8) reviewed for Activities of Daily Living Care (ADL) in the sample of 10. Findings include: On 10/26/23 at 9:20 AM and 12:35 PM, R8 was observed at the nurse's station in his reclining wheelchair. On 10/26/23 at 1:55 PM, V8 (Certified Nurse Assistant/CNA) was observed lying R8 in bed. V8 removed R8's incontinence brief, which was soiled with urine, covered R8 up and did not perform incontinent care. R8's buttocks had deep creases and red areas to his coccyx, with a stage 1 pressure ulcer noted to R8's right coccyx area. V8 stated, that she got R8 out of bed at 8:00 AM and has not laid him down, repositioned him or provided incontinence care since he was gotten up that morning. R8's Face Sheet, undated, documents, R8 has a diagnosis of Alzheimer's Disease and Traumatic Brain Injury. R8's Minimum Data Set, dated [DATE], documents, R8 requires an extensive assist with toileting and is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review, the facility failed to provide timely turning/repositioning in 1 (R8) of 3 residents reviewed for pressure ulcer prevention in the sample of 10. Findings include: On 10/26/23 at 9:20 AM and 12:35 PM, R8 was observed sitting at the nurses' station in his reclining wheelchair. On 10/26/23 at 1:55 PM, R8's buttocks were observed with V8 (Certified Nurse Assistant/CNA). V8 removed R8's incontinence brief, which was soiled with urine. R8's buttocks had deep creases and there were red areas noted to R8's coccyx area. R8's right coccyx area was red with approximately a 5 cm (centimeter) x 5 cm stage 1 pressure ulcer noted. V8 stated that she got R8 out of bed around 8 AM that morning and has not changed or repositioned R8 until now. V8 stated R8 does not have any pressure ulcers. After observing R8's buttocks, V8 covered R8 up and did not provide incontinence care. On 10/26/23 at 2:05 PM, V7 (Licensed Practical Nurse/LPN), stated she is unaware of R8 having any red…

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 recipes and ensure palatable food and temperatures in 5 of 5 residents (R3, R5, R6, R7, and R9) reviewed for food palatability in the sample of 29. Findings include: On 8/24/23 at 8:10 AM, there was pan on the steam table that appeared to contain eggs, meat, and cheese. V9 (Cook) stated the breakfast entrée today was sausage, egg, and cheese casserole. The Facility Menu for Breakfast on 8/24/23 documented, Choice of Vit C (Vitamin C) Juice, Choice of Hot or Cold Cereal, Scrambled Eggs with Cheese, Biscuit, Jelly, Margarine, Whole Milk, Coffee/Hot Tea, and Condiments. On 8/24/23 at 8:25 AM, V9 (Cook) presented the recipe for the Scrambled Eggs with Cheese and stated, I added sausage. I added a little cheese in there too. The Scrambled Eggs with Cheese Recipe contains the following ingredients: Frozen scrambled eggs, shredded cheddar cheese, salt, and black pepper. (The recipe does not contain sausage). On 8/24/23 at 8:31 AM, V9 (Cook) stated the only people who get regular scrambled eggs without sausage…

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

Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was working in the facility for 8 consecutive hours, 7 days a week. This failure has the potential to affect all 115 residents living in the facility. Findings include: Staffing schedules were reviewed for the past 14 days from 3/8/2023 to 3/21/2023. No Registered Nurse (RN) was documented as working on Saturday, 3/18/2023 and Saturday, 3/11/2023. On 3/23/2023 at 9:12 AM, no other information was provided documenting there was any additional RN coverage for 3/18/2023 and 3/11/2023. The Facility Assessment, updated on 11/4/2022 documents, Facility Resources and Staff Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies staff type includes, but is not limited to: Nursing Services (e.g., DON [Director of Nursing], ADON [Assistant Director of Nursing], QA [Quality Assurance] Nurse/Infection Preventionist, Restorative Nurse, Certified Wound Nurse, MDS (Minimum Data Set) nurse, RN, LPN [Licensed Practical Nurse], CNA [Certified Nursing…

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

Based on observation, interview, and record review the facility failed to ensure food is stored and prepared in a manner which prevents potential contamination. This has the potential to affect all 115 residents living in the facility. Findings include: On 03/21/23 at 8:27 AM, the surveyor entered the kitchen in the dry storage area there was a large 18-gallon black storage tub with no label or date sitting on the shelf. Upon removing the lid of the tub there were crumbs inside of the container, nothing was wrapped, the crumbs were just emptied in the container. On 03/21/23 at 8:31 AM, V5 (Dietary Manager) stated, Those are breadcrumbs in that bin. I am not sure why they are being stored in that bin as it is not food grade. It was like that when I got here. I have only been here for a few days. On 03/23/23 at 8:39 AM, on the metal shelf was a plastic milk carton container sitting on the shelf and it contained 5 heads of cabbage. The cabbage was not refrigerated. The outer leaves of the cabbage were dry and brown in color. On 03/23/23 at 8:42 AM, V5 stated, I am not sure why the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its assessment and was not current and up to date. This has the potential to affect all 115 residents living in the facility. Findings include: On 03/21/2023 at 10:03 AM, the Facility Assessment was requested from the facility. On 03/21/2023 at 10:35 AM, V33 (Former Administrator) provided a Facility Assessment Tool to the surveyor. On 03/24/2023 at 10:49 AM, V33 stated, I was the former administrator at the facility for 3 years. The Facility Assessment Tool updated 01/01/2017 was not an actual assessment and did not document a facility wide assessment to determine what resources are necessary to care for its residents. The Facility Assessment Tool, provided by the facility, documents there were 131 beds. Of the 131 beds certified, the category that had the greatest number documented was (47), (Behavioral Symptoms and cognitive performance). Nothing…

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 with facility failed to prioritize, develop, and implement, QAA (quality assessment and assurance) Improvement Activities with an action plan to address abuse concerns. This failure has the potential to affect all 115 residents residing in the facility. Findings include: R21's Face Sheet, undated, documents R21 has a diagnosis of Paranoid Schizophrenia, Major Depressive Disorder (Recurrent) and Alcohol Abuse. R21's Minimum Data Set, (MDS), dated [DATE], documents R21 has severe cognitive impairment. R21's Care Plan, dated 04/11/22, documents R21 is at risk for abuse/neglect, R21 is verbally aggressive and difficult to redirect at times and has a history of peer-to-peer altercations. R21 has a history of aggressive behavior and has a history of verbal and physical altercations and becomes easily irritated with peers. R21 has a history of criminal behavior and has been charged with aggravated battery, resisting a peace officer, criminal damage to property and assault with 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 ensure care plans were updated, current, and interventions were implemented for 4 of 27 residents (R21, R43, R77, R93) reviewed for care plans in the sample of 47. Findings include: 1. R93's Physician Order Sheet (POS) for March 2023 documents a diagnosis of alcohol dependence with withdrawal, opioid abuse, and chronic viral hepatitis C. R93's Minimum Data Set (MDS) dated [DATE] documents R93 is cognitively intact for decision making. R93's care plan does not address or document his diagnosis of viral hepatitis C. R93's care plan does not address interventions and/or goals for addressing R93's viral hepatitis. 2. R43's March 2023 POS documents a diagnosis of unspecified dementia, and acute delta-(super) infection of hepatitis B Carrier. R42's care plan does not document or address acute delta (Super) infection of Hepatitis B Carrier. On 3/24/2023 at 10:24 AM, V2 (Director of Nursing/DON), stated, If a resident is positive for hepatitis, I would expect…

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 failed to monitor to ensure the gastrostomy tube water flush was infused for 1 of 2 residents (R22) reviewed for tube feeding in the sample of 47. Findings include: R22's Physician's Order Sheet (POS), dated 12/15/2022, documents 2-gram Na (sodium) diet, pureed texture, regular liquids consistency diet. Order dated 12/15/2022 to flush G-tube (gastrostomy tube) with 30 cc (cubic centimeter) of water before and after each medication administration, flush with 5cc of water between medications every shift for prophylaxis. Enteral Feed Order every 4 hours flush 150ml q (every) 4 hours for total 1200ml and (Name brand of tube feeding) 60ml/hr (milliliter per hour) cont. (continuous) for total 1440ml ordered on 2/3/2023. On 3/21/2023 at 10:36 AM, observation of R22 was lying in bed with the head of bed (HOB) elevated 30 degrees. R22's water flush showed 800 milliters (ml) in the bag. The pump machine read 150 ml water flush every 4 hours. At this same time, R22 stated, I want a drink of water, water, water. I'm thirsty so thirsty.…

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

Based on interview and record review the facility failed to ensure medications were administered as ordered for 1 of 3 residents (R84) reviewed for medications in the sample of 47. Findings include: R84's March 2023 Physician Order Sheet (POS) document a diagnosis to include Type 2 Diabetes mellitus without complications. R84's Physician Order Sheet (POS) also documents, Lantus Solution 100 UNIT/ML (Insulin Glargine); Inject 30 unit subcutaneously at bedtime for elevated blood sugar. Humalog Solution 100 UNIT/ML (Insulin Lispro); Humalog OG Solution 100 Unit/ML (insulin Lispro) inject 10 units subcutaneously three times a day for elevated blood sugar related to type 2 diabetes mellitus without complications. R84's Medication Administration Record (MAR) dated January 2023 documents R84 did not receive his 10 units of Humalog OG solution 10 units on 1/5/2023 and on 1/15/2023 R84 did not receive his three doses of insulin (order for three times day). R84's MAR for March 2023 documents 1 dose of Humalog Solution 100 units/ml (milliliters) 10 units subcutaneously was not given 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.