Avantara Chicago Ridge

Based on interview and record review the facility failed to refer a resident to the appropriate state-designated authority for a PASRR/Preadmission Screening and Resident Review level 2 screening for evaluation and determination of newly evident serious mental illness related condition, for one of one resident (R111) reviewed for a PASRR level 2 screening in a sample of 32. Findings include: On 1/9/2025 at 1:20pm V16 (Social Service Director-SSD) said that she is responsible for making sure resident's that have new mental illness diagnosis receive an updated PASRR level 2 screening but was not made aware that R111 had new diagnosis until now and that she had contacted the agency to have a PASRR level 2 screening completed so that R111 can receive the appropriate treatment and services. On 1/10/2025 at 10:30am V36 (Admissions Director) stated that R111 had an PASRR level 1 screening completed before admissions and did not need any further evaluation at that time if a resident has a new mental illness diagnosis, then social services will be responsible to obtain a PASSAR level 2…

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 safety interventions were in place for a resident who is at high risk and has history of falls. This deficiency affects two (R27 and R216) of three residents in the sample of 32 reviewed for fall prevention program. This failure resulted in R216 falling and sustaining a laceration to his right eyebrow that required a visit to the hospital for suturing. Findings include: On 1/7/25 at 10:30AM, V2 Director of Nursing (DON) stated that R216 was discharged home from the facility on 10/27/24. V2 stated that V29 Agency nurse who worked with R216 on the day of his unwitnessed fall was no longer working in the facility, she was terminated. Per R216's medical record R216 was admitted on [DATE] with diagnoses listed in part but not limited to Displaced fracture of shaft of humerus right arm, history of falling, Dementia with Anxiety, Cataract, Glaucoma, Abnormalities of gait and mobility, lack of coordination, Weakness, Malaise, Malignant neoplasm 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 supervise residents while taking medications during medication administration for two of four residents (R53, R100) observed for medication administration. The facility also failed to account for the usage, disposition, and reconciliation of controlled medications for one of five medication carts (2nd floor [NAME] medication cart) observed for medication storage affecting all seven residents (R3, R11, R29, R73, R76, R86, R149) on controlled medications on 2nd floor [NAME] medication cart. Findings include: 1. On 01/07/2025 at 10:47AM during unit rounds, medication cup with 3 big white pills was on the food tray of R53. On 01/07/2025 at 10:50AM, R53 was with V4 (Licensed Practical Nurse) taking the medications in the medication cup on the food tray. On 01/07/2025 at 10:47AM during interview with R53, R53 stated that the nurse usually leaves it with her because the nurse trusts that R53 will take it and R53 stated that she will take it. On 01/07/2025 at 10:50AM during interview, V4 stated that R53 was eating 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that coordinated care services was provided to a resident who had a fractured hip from a fall at the facility. The facility failed to provide skilled therapy services as ordered by physician in a timely manner. This deficiency affects one (R74) of three residents in the sample of 32 reviewed for Quality of care. Findings include: On 1/10/25 at 11:05 AM, R74 in bed, alert and verbal with some confusion and forgetfulness. R74 bed in the lowest position, floor mats on both sides of bed, and call light within reach. R74 room is close to the nurse ' s station. R74 stated he had a fall but does not remember when it happened. On 1/10/25 at 11:13 AM, V32 (Registered Nurse Agency) stated that R74 is alert and oriented to person, place and has some confusion. She knows R74 is a fall risk. She is not aware that R74 ' s fractured right hip was due to recent fall at the facility last 12/14/24. On 1/10/25 at 11:54 AM, V2 (Director of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to document incontinence care every shift per facility policy. This failure applied to two (R1 and R2) of three residents reviewed for incontinence care. Findings include: R1 is a [AGE] year-old female who admitted to the facility 8/6/24 with diagnoses that included hemiplegia and hemiparesis following a cerebral infarction and one pressure ulcer of the sacrum stage I. Minimum data set (MDS) assessed 8/8/24 indicates that R1 is dependent on staff for incontinence of bowel and bladder function. R2 admitted to the facility 8/30/24 with diagnoses that included femur fracture, cognitive communication deficit, and generalized weakness. MDS (9/2/24) notes that R2 is dependent on nursing staff for mobility and incontinence care. On 9/18/24 at 10:55am family member of R2 voiced concerns that R2 did not receive overnight incontinence care which led to R2 being soaked in urine when they arrived to visit in the morning. A 30-day lookback was reviewed for R1 and R2…

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 a new pressure ulcer from developing for a resident who was assessed to be at risk for developing pressure ulcers while in the facility. This failure applied to one (R1) of three residents reviewed for pressure ulcers. Findings include: R1 is a [AGE] year-old female who admitted to the facility 8/6/24 with diagnoses that included hemiplegia and hemiparesis following a cerebral infarction and one pressure ulcer of the sacrum stage I. Minimum data set (8/8/24) notes that R1 is dependent on staff for activities of daily living that include turning, repositioning and incontinence care. According to wound care nurse practitioner's progress notes on 8/9/24 R1 was assessed with a wound of the sacrum that measured in centimeters length x width x depth: 2 cm x 3 cm x 1 cm. On 9/11/24 the wound care nurses documented new skin alterations that included Gluteal Cleft tear and Right ischium (skin tear) which did not include measurements. On 9/13/24, the…

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

Based on observation, interview, and record review, the facility failed to replace a damaged call light cord in a resident's room. This failure applied to one (R2) of three residents reviewed for accidents and hazards. Findings include: R2 admitted to the facility 8/30/24 with diagnoses that included femur fracture, cognitive communication deficit, and generalized weakness. R2 discharged from the facility 9/7/24. On 9/18/24 at 10:55am family member of R2 informed the surveyor of a damaged call light with exposed wires in R2's former room. On 9/19/24 at 12:30pm, the call light in R2's former room was observed to be damaged and had been taped ineffectively covering the exposed wires. During the observation, V9 Guest Services entered the room as requested. When V9 saw the damaged cord, V9 removed it and said that they would replace it immediately. Later at 2:04pm, V1 Administrator stated, although the cord did appear to have some damage, it was functional, however it was replaced immediately after bringing it to our attention. Policy titled Hazards revised 7/24 states in part; Policy…

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 On 1/3/24 at 9:17 AM V19 (Registered Nurse) retrieved a gown from the PPE (Personal Protective Equipment) cart. V19 dropped a gown on the floor and picked it up and returned it to the cart on top of the clean gown and closed the drawer. Surveyor asked if that was acceptable, she said I don't know what I was thinking. She removed the dropped gown and the clean gown from the cart. V19 then measured the vital signs for R134. V19 cleaned the blood pressure cuff and the pulse oximeter with a bleach wipe and removed her gloves. She did not perform hand hygiene and proceeded to pour and administer medications to R134. Surveyor asked V19 why hand hygiene wasn't performed after removing her gloves. V19 stated I should have done that. On 1/3/24 at 1:20 PM V2 (Director of Nursing) stated it (gown) should be discarded. It is no longer clean. V2 stated hand hygiene should be done after cleaning equipment and removing gloves. R134 has a physician order that indicates isolation-enhanced barrier precautions. Reason for…

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

Based on observation interview and record the facility failed to ensure a dignity pouch was provided for a urine collection bag for one of three residents' (R94) reviewed for dignity in a sample of 28. Findings include: On 1/2/2024 at 12:40pm R94 was observed in bed with the urine collection bag facing the outside door with no dignity pouch covering. On 1/2/2024 at 12:45pm V25(Nurse-Agency) stated R94s urine collection bag should be covered with a dignity pouch. On 1/2/2024 at 1:00pm V2(Director of Nursing-DON) stated the urine collection bag should have a dignity pouch over the urine bag. An order summary report dated on 1/2/2024 indicates that R94 has a history of Neuromuscular dysfunction of bladder. An order on 9/6/2023 indicates R94 has an indwelling catheter 16 French with 10ml balloon for a (Neurogenic bladder). Facility Policy: Unable to provide a dignity Policy.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that the necessary follow up is done and that the pacemakers are in good working condition. This deficiency affects one (R97) of one resident in the sample of 28 reviewed for Professional Standards of Practice. Findings include: On 1/2/24 at 12:20PM, observed R97 sitting on bed in her room. She is alert and oriented, speaks limited English language. She showed and pointed her pacemaker on the left side of her chest. R97 was admitted on [DATE] with diagnoses listed in part but not limited to Presence of Cardiac Pacemaker, Chronic Atrial Fibrillation, Acute on Chronic Diastolic (Congestive) Heart Failure. Active Physician Order Sheet (POS) does not indicate order for pacemaker monitoring. On 1/3/24 at 11:14AM, V19 Agency Nurse said that she is not aware that R97 has pacemaker. She said, it was not endorsed to her, and it was not written in the 24 hours report/endorsement. Surveyor and V19 went to R97 and observed pacemaker chest on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide a means of communication for resident who has language barrier. This deficiency affects one (R97) of two residents in the sample of 28 reviewed for Communication. Findings include: On 1/2/24 at 12:20PM, observed R97 sitting on bed in her room. She is alert and oriented but speaks and understand limited English language. She will make hand/body gestures to communicate but still difficult to understand. No communication board found in the room. On 1/3/24 at 11:14AM, V19 Agency Nurse stated that she is the assigned nurse to R97. V19 stated that R97 speaks mainly Polish Language with limited English Language. V19 stated that she did not know that R97 has a communication barrier. V19 stated she did not assess her. V19 stated she just gave R97 her morning medications. V19 state there is no communication board in R97's room. V19 stated she does not know how to use the translation service line posted at R97's bedroom wall. V19 stated 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.

Based on observation, interview and record review the facility failed to ensure effective interventions were in place to reduce the risk of falls for one of three residents' (R91) reviewed for falls in a sample of 28. Findings Include: On 1/3/2024 at 12:10pm R91 was observed up in wheelchair in the dining room with chair alarm not turned on. On 1/3/2024 at 12:15pm V23(Licensed Practical Nurse-LPN) stated R91 is a fall risk and the chair alarm should be on whenever the resident is up in the chair. On 1/3/2024 at 12:17pm V24(Certified Nursing Assistant-CNA) state the alarm should be turned on and then proceeded to turn on the chair alarm. On 1/3/2024 at 12:30pm V2(Director of Nursing-DON) said R91 is a fall risk, and the chair alarm should be turned on if she is in the chair. An Order summary report dated 1/3/2024 indicated that R91 has a history of falling, an order that was placed on the order sheet on 1/3/2024 to check bed/chair alarm is working properly every shift. R91s care-plan dated 10/17/2023 indicates a bed/chair alarm. Facility Policy: Fall Occurrence Revised 7/17/2023.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to follow physician order of checking bladder scan every shift for resident who has urinary retention. This deficiency affects one (R72) of one resident in the sample of 28 reviewed Bladder Management program. Findings include: On 1/2/24 at 11:50AM, observed R72 sitting in wheelchair in her room. She is alert and oriented, able to verbalize her needs to staff. R72 stated that she has a problem urinating, she has problem letting the urine out. R72 stated that it has been going on for a while. R72 was admitted on [DATE] with diagnoses listed in part but not limited to Neuromuscular dysfunction of bladder, Chronic Kidney Disease Stage 3. R72s Active physician order indicates: Bladder scan every shift dated 12/7/23. On 1/3/24 at 11:48AM, observed R72 sitting in wheelchair in her room with V16 RN (Registered Nurse). R72 stated that she has a hard time urinating. R72 added, like yesterday, I did not urinate for the whole day not until the evening.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to follow physician order in providing enteral feeding and enteral stoma care. This deficiency affects two (R12 and R246) of three residents in the sample of 28 reviewed for Enteral Tube Feeding Management. Findings include: On 1/2/24 at 11:26AM, observed R246 lying in bed. Gastric tube (GT) feeding pump off with feeding bag of Jevity 1.2 empty and disconnected. On 1/2/24 at 1:30PM, observed R246 lying in bed. GT feeding pump off with feeding bag of Jevity 1.2 empty and disconnected. On 1/3/24 at 11:39AM, observed R246 lying in bed connected to GT feeding of Jevity 1.2 running at 90ml/hour and flushing of water at 30ml/hr. V19 Agency Nurse said that R246 receives 22 hours of tube feeding from 6AM to 4AM. V19 assessed GT site, observed no dry dressing in placed. V19 said that GT dressing is done by night shift. R246 was admitted on [DATE] with diagnoses listed in part but not limited to Gastrostomy, Disorder of Glossopharyngeal nerve. Active…

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 accompany a resident to an appointment for 1 of 3 residents (R2) reviewed for appointments in the sample of 8 The findings include: On 10/20/23 at 9:22 AM, R2 was sitting up in a wheelchair in the dining room. R2 had a brace on her left arm and her feet were resting on the footrests of the wheelchair. R2 responded to her name but did not answer any other questions. On 10/20/23 at 10:32 AM, V16 Medical Records/Scheduler said the Nurse Practitioner scheduled R2's appointment with the Gastrologist and she arranged the transport. V16 said she called V18 (R2's Power of Attorney) and V18 was not able to go to the appointment. V16 said she sent R2 to the appointment by herself. V16 said she didn't check with nursing to see if R2 could go by herself or would be able to answer questions. On 10/20/23 at 10:51 AM, V11 Registered Nurse said R2 is alert to self and place only, requires two persons assist for transfers, and is dependent on staff for…

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

Based on interview and record review the facility failed to ensure a resident was free of significant medication errors to 1 of 3 residents (R6) reviewed for medications in the sample of 8. The findings include: R6's Physician Order Sheet dated 10/23 show R6 has diagnoses of hypertension and coronary artery disease. On 10/20/23 at 11:19 AM, R6 was sitting in the dining room in her wheelchair. R6 said she was fine, and she depends on the nurses to administer her medications. A document entitled Medication Error Report dated 8/2/23 with a date of error of 7/21/23 show Medication Ordered as Documented in the POS (Amiloride 5 mg but it should have been Amlodipine 5 mg) Medication Error Summary dated 7/21/23 show Medications entered incorrectly in PCC. Resident received wrong medications. R6 received Amiloride-(water pill-diuretic) from 7/21/23 to 8/2/23 (approximately 12 days) instead of Amlodipine (R6's ordered anti-hypertensive meds). On 10/20/23 at 12:11 PM, V2 (Director of Nursing) said the medication error was discovered during one of V3's (Nurse Practitioner) visit that R6 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 repair 2 broken condensers on the air conditioning unit to ensure the facility temperatures did not rise above 81 degrees Fahrenheit, and the failed failed to have a thermometer gun with a humidity reading for taking temperatures in resident rooms. This failure affected all 141 residents in the facility. Findings Include: R1 - R11 were reviewed for inadequate cooling. On the initial tour, R1 - R11 reported the building being uncomfortably hot on 8/23/23 and 8/24/23. At 3:31 PM, room temperature checks were initiated on R1 - R11's room. V9 (Maintenance Director) and V1 (Asst. Administrator) were present for all room temperature checks. V9 used a hand held thermometer gun. V9 endorsed the thermometer was calibrated. The first floor rooms were checked first, then the second floor rooms, and finished on the third floor. All of the temperatures were taken in Fahrenheit. The following list is the order in which the temperatures were taken. R9's room was 85 degrees, R10's room was 85 degrees, R11's room was 80…

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 observation, interview, and record review the facility failed to maintain a comfortable temperature of 71-81 degrees Fahrenheit in resident rooms for 11 out of 11 (R1-R11) residents reviewed for inadequate cooling in a total sample of 11. Findings Include: The initial tour began on 8/23/23 around 10:50AM on the third floor down to the first floor. Four fans are noted on the third floor in the halls blowing on high. There are no fans in the hall way on the second of first floor. There are thermometers at each end of the hall (east and west side) on each floor. These thermometers have a humidity reading as well as a temperature reading. The first floor dining room was not cooler like the second and third floor dining rooms were. At 11:00 AM, R1 was lying in bed with a fan on high next to the bed. R1 was in a hospital gown. R1 stated the facility has been too hot since yesterday. R1 endorsed having difficulty sleeping the night before due to the temperature being too hot. The air conditioning unit in R1's room was lightly blowing out air that felt the same temperature as the…

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

Based on observation, interview and record review, the facility failed to 1.) ensure food items were properly labeled, dated, and stored; 2.) discard food products on or before the expiration date; 3.) practice appropriate hand hygiene; 4.) keep kitchen walk-in refrigerator clean 5.) allow equipment to air-dry before use. These failures have the potential to affect all 141 residents receiving oral diets from the facility kitchen. Findings include: On 10/25/22 at 9:22am, V6 (Food Service Director) conducted kitchen tour with surveyor. The following observations were made in the milk/meat walk-in refrigerator: 1. Opened 1 gallon cherries container labeled with an open date of 9/15/22 and use by date of 10/15/22. 2. Opened 1 gallon Mayo container labeled with delivery date 10/5/22 with no open or use by date. 3. Opened 1 gallon dill pickle chips container dated with delivery date 5/21/22 and opened date 6/17/22. There was no use by date documented. 4. Small package of sliced white American cheese wrapped in plastic wrapping with no label or date. 5. Sliced Ham package prepared 9/27/22…

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

Based on observation, interview, and record review the facility failed to maintain a medication error rate below 5% as evidenced by 4 medication errors out of 35 opportunities, resulting in a medication error rate of 11.43% for four (R30, R135, R62, R18) of seven residents observed during medication administration. Findings Include: On 10/26/22 at 08:14am V12 (Registered Nurse) prepared R30s' medications at the medication cart. V12 then entered R30s' room to administer the medication. R30 received: Aspirin chewable 81mg 1 tablet by mouth Apixaban 5mg 1 tablet by mouth Ferrous Sulfate Tablet 325mg 1 tablet by mouth Metoprolol Tartrate Tablet 12.5 mg 1 tab by mouth Amlodipine Besylate 5 mg 1 tablet by mouth Probiotic Capsule 250 mg 1 capsule by mouth R30's Physician order dated 08/12/2022 documents in part, Aspirin EC Low Dose Delayed Release 81mg- Give 1 tablet by mouth one time a day. V12 (Registered Nurse) was observed giving R30 Aspirin chewable 81mg 1 tablet. On 10/26/2022 at 8:37am V12 (Registered Nurse) prepared R135s' medications at the medication cart. V12 then entered R135s'…

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

Based on observation, interview, and record review the facility failed to ensure that medications and 1 of 6 medication carts were secure while not in use or in view. These deficient practices have the potential to affect 60 residents residing on the third floor of the facility. Findings include: On 10/25/2022 at 12:52pm, surveyor located on the 3rd floor of the facility observed a medication cart (identified as East cart) unlocked and unattended. Approximately 4 minutes elapsed, and surveyor observed V26 (Licensed Practical Nurse) walking towards surveyor and East cart medication cart located at nurses station. On 10/25/2022 at 12:56pm, V26 approached the East cart medication cart and locked the medication cart. V26 stated I didn't know I left the cart unlocked, I had to step away to get some oxygen tubing for another resident. I've been a nurse for 40 years and I usually don't do this, at first the medication cart was locked. I know, a resident could have gotten access to the medications by going in there and they could die by grabbing and taking all the medications. On 10/26/2022…

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

Based on observation and interview, the facility failed to provide care according to professional standards for two (R131, R135) residents out of a sample of 26 residents reviewed. Findings include: On 10/26/2022 at 8:37am V12 (Registered Nurse) prepared R135s' medications at the medication cart. V12 then entered R135s' room to administer the medication. R135 received: Memantine HCl Oral Tablet 10 MG 1 tablet by mouth Multivitamin w/minerals 1 tablet by mouth Vitamin D Tablet (Cholecalciferol) 2000 IU by mouth Allopurinol 100mg tab 1 tablet by mouth Record review of R135s' electronic medication administration record and physician order sheet document an order for: Quetiapine 25mg tab Give 0.5 (12.5mg) tablet by mouth one time a day every 2 day(s) to be administered at 9:00am. R135 did not receive Quetiapine 25mg tab 0.5 (12.5mg) tablet by mouth as ordered by physician during observed medication administration pass. On 10/26/2022 at 8:37am, V12 stated I will give R135 the rest of R135s' medication and I will check with pharmacy later regarding R135s' Seroquel (Quetiapine) 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.

Based on observation, interview and record review the facility failed to ensure air mattresses were at the appropriate settings for 2 (R12, R26) residents reviewed for pressure ulcer prevention in a sample of 29. Findings Include: R12 has diagnoses (Dx) not limited to senile degeneration of brain, peripheral vascular disease, dementia, quadriplegia, chronic kidney disease, uninhibited neuropathic bladder, major depressive disorder R12's Order Summary Report document in part: Pressure reduction mattress, order date 10/25/22. R12's Care Plan document in part: R12 has (stage 4 pressure ulcer present on sacrum) related to impaired mobility, incontinence, cognitive deficit, Dx: quadriplegia, history of CVA, dementia, depression, terminal illness, at risk for malnutrition, weight loss, date initiated 8/24/2021. R12's Braden Scale dated 09/30/22 document in part: Braden Risk Levels: Very High Risk - Total Score 0-9. R12 has a score of 9. On 10/25/22 at 11:05 AM R12 was observed reclining in the bed on a low air loss mattress. The low air loss mattress was set at 8 (firm). R26 has diagnoses…

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 properly label oxygen tubing for one (R55) resident reviewed for oxygen therapy in a sample of 29 residents. Findings include: On 10/25/2022 at 11:58am, R55 observed lying in R55s' bed in high-fowlers position without any signs or symptoms of respiratory distress. R55 observed receiving prescribed oxygen therapy via nasal cannula. R55's Oxygen concentrator observed turned on at R55s' bedside with nasal cannula tubing connected to the oxygen concentrator. Surveyor observed that R55s' nasal cannula oxygen tubing was not properly labeled with a date. On 10/25/2022 at 11:59am, R55 stated I don't know when the staff last changed my oxygen tubing; I guess they change it every now and then, I don't know. On 10/25/2022 at 12:44pm, surveyor and V26 (LPN) entered R55s' room and observed R55 sitting on R55s' bed in high-fowler's position while receiving oxygen therapy via nasal cannula with oxygen tubing connected to oxygen concentrator next to R55s' bed. V26 also observed that R55s' nasal cannula tubing was not…

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

Based on observation, interview, and record review, the facility failed to obtain medications from the pharmacy and administer medications as prescribed for one (R135) resident out of a sample of 26 residents reviewed. Findings include: On 10/26/2022 at 8:37am V12 (Registered Nurse) prepared R135s' medications at the medication cart. V12 then entered R135s' room to administer the medication. R135 received: Memantine HCl Oral Tablet 10 MG 1 tablet by mouth Multivitamin w/minerals 1 tablet by mouth Vitamin D Tablet (Cholecalciferol) 2000 iu by mouth Allopurinol 100mg tab 1 tablet by mouth Record review of R135s'electronic medication administration record and physician order sheet documents an order for: Quetiapine 25mg tab Give 0.5 (12.5mg) tablet by mouth one time a day every 2 day(s) to be administered at 9:00am. R135 did not receive Quetiapine 25mg tab 0.5 (12.5mg) tablet by mouth as ordered by physician during observed medication administration pass. On 10/26/2022 at 8:37am, V12 stated I will give R135 the rest of R135s' medication and I will check with pharmacy later regarding…

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 observations, interviews, and record reviews, the facility failed to follow their infection prevention and control policy when staff entered the rooms of 1 residents (R392) on transmission-based precautions without wearing the appropriate personal protective equipment (PPE). Findings Include: On 10/25/2022 at 12:03pm, R392's room observed with a droplet and contact precaution signage posted on the outside of the room door. Isolation signage instructs individuals entering R392's room, to put on a face mask, face shield or goggles, gloves, and isolation gown before entering the room. V39 (Certified Nursing Assistant) observed in R392's room not wearing gloves or an isolation gown. On 10/25/2022 at 12:03pm, V39 stated, I have been working here for 4 weeks, and I have never seen an isolation sign posted on R392's door. These signs are new, and I did not see them posted. I should be wearing an isolation gown and gloves when I'm in R392's room. On 10/26/2022 at 8:57am, V38 (Vendor) observed bringing an air…

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.