Chicago Ridge SNF

Based on interview and record review the facility failed to follow professional standards of care to transcribe and follow the physician orders for one of one resident (R1) to monitor the right foot for increased discoloration, to assess pedal pulse, and monitor for temperature changes. This affects one of three residents reviewed for professional standards. Findings include: R1 face sheet shows diagnosis of occlusion and stenosis of right carotid artery, essential hypertension, and anemia. On 4/23/25 at 11:50am V11 (Nurse Practitioner) said R1 complained of discoloration to her right foot, and she ordered a doppler ultrasound for R1's feet bilaterally. V11 said she assessed R1 foot, R1 denied pain. V11 said she observed R1 right foot to be cool to touch (cooler than the left foot) and R1 had edema bilaterally to the feet. V11 said the doppler results was negative for deep vein thrombus (DVT). V11 said she was not concerned for ischemia because the doppler was negative for DVT. V11 said although the doppler was negative, the plan of care was to monitor R1's foot due to the lateral…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to notify a physician of a resident refusing psychotropic medication for one (R7) of three residents reviewed for quality of care in a sample of 14. Findings include: R7 was admitted to the facility on [DATE] with diagnosis including but not limited to Schizoaffective Disorder, Unspecified; Hyperlipidemia, Unspecified; Paranoid Schizophrenia; Brief Psychotic Disorder; Restlessness And Agitation; Anemia, Unspecified; Body Dysmorphic Disorder; Gastro-Esophageal Reflux Disease Without Esophagitis; Other Specified Phobia; Obsessive-Compulsive Disorder, Unspecified; and Other Schizoaffective Disorders. According to R7's MDS (Minimum Data Set) assessment dated [DATE] under section C, R7 has BIMS (Brief Interview of Mental Status) score of 15 indicating, indicating intact cognition. According to R7's MDS (Minimum Data Set) assessment dated [DATE] under section E, R7 has a history of refusing of care, including refusing taking medications. R7's care plan (R7)…

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 keep a resident free from verbal abuse from a staff member. This failure applied to one (R1) of one resident reviewed for abuse. Findings include: R1 originally admitted to the facility on [DATE] and discharged AMA (Against Medical Advice) on 2/26/2025. R1 has multiple diagnoses including but not limited to the following: multiple puncture wounds, pain, mental and behavioral, anxiety, and depression. MDS (Minimum Data Set) dated 2/28/2025 shows R2 has a BIMS (Brief Interview for Mental Status) of a 15 meaning R2 is cognitively intact. MDS dated [DATE] shows R1 has a BIMS of 15 also meaning R1 is cognitively intact. Initial facility reported incident dated 2/23/2025 states in part but not limited to the following: R1 reported V3 (Former Social Service Aide/Smoking Monitor) was verbally inappropriate with residents. R1's witness statement dated 2/23/2025 states in part but not limited to the following: R1 requested a cigarette from V3 during smoking…

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 to effectively exterminate pests (cockroaches) in the Facility. This failure has the potential to affect all 205 Residents residing in the Facility. Findings include: Facility Midnight Census Report, dated 2/22/25, documents 205 Residents residing in the Facility. Facility Resident Rights for People Living in Long-Term Care Facilities Policy, revised 11/2018, documents your Facility must be safe, clean, comfortable and homelike. The Facility Pest Control Agreement, dated 12/1/2002, documents targeted pest control for roaches and twice a month service, with additional services at a cost. Facility Grievance Opportunity Resolution Form, dated 1/7/25, documents concerns of a pest problem and the action taken was to deep cleaning. Facility Grievance Opportunity Resolution Form, dated 2/4/25, documents concerns of a would like pest control to spray his room and the action taken was pest control 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 interview and record review the Facility failed to follow Care Plan interventions and implement appropriate fall prevention interventions to prevent repetitive falls for one of three Residents (R2) reviewed for falls in a sample of four. Findings include: Facility Fall Prevention Program Policy, dated 2/28/14, documents: it is the policy of the Facility to have a fall prevention program to assure the safety of the all residents in the facility; the program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary; and the fall prevention program includes methods to identify risk factors, identify residents at risk, use and implementation of professional standards of practice, changes in interventions that were unsuccessful, documentation requirements and Care Plan incorporates identification of all risk/issue and interventions…

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 call light policy and procedures by not promptly answering residents call lights. This failure applies to five (R6, R7, R13, R14, R15) of 15 residents reviewed for call light response. Findings include: R6 is a [AGE] year-old female with a diagnoses history of Schizoaffective Disorder, COPD, and Stage 3 Chronic Kidney Disease, who was admitted to the facility 11/20/2024. On 01/27/2025 at 9:35 AM, R6 stated during nights it has taken an hour for staff to respond to her call light. R6 stated as a result of this she has trouble getting water or being dried at night and has experienced some itchiness and burning in her peri area from being left wet for too long. R7 is a [AGE] year-old female with a diagnoses history of Polyneuropathy, Reduced Mobility, and Chronic Embolism and Thrombosis who was admitted to the facility 06/08/2023. R7 stated during nights it has taken an hour for staff to respond to her call light. R7 stated 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to follow their grievance policy and procedures by not ensuring that a concern reported to staff regarding assistance with activities of daily living was documented, investigated, followed up on, and resolved. This failure applies to one of fifteen residents (R7) reviewed for grievance procedures. Findings include: R7 is a [AGE] year-old female with a diagnoses history of Polyneuropathy, Reduced Mobility, and Chronic Embolism and Thrombosis who was admitted to the facility 06/08/2023. On 01/22/2025 at 10:09 AM, V10 (Assistant Director of Nursing) stated about a week ago there was an incident of one of the mechanical lifts not working because it needed to be charged. On 01/27/2025 at 9:35 AM, R7 stated V27 (Family Member) filed a grievance with the facility regarding her being left in the chair for 17 hours. R7 stated in response to V27's report about her being left in the chair the facility explained it takes at least two hours for the mechanical lift to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to have a system in place to ensure that a resident who was assessed to not be able to navigate safely and independently in the community, leave the facility unsupervised. This failure applied to one (R1) of one residents reviewed for supervision and resulted in R1 eloping from the facility on 01/10/25 with no access to ordered medical care and was subsequently found (at an undetermined date) intoxicated by local police and taken to local hospital. The Immediate Jeopardy began on 01/10/25 when R1 eloped from the facility. V1 (Administrator) was notified of the Immediate Jeopardy on 01/22/2025 at 3:39 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 01/28/25 but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R1 is a [AGE] year-old male who was admitted to 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 ensure sufficient nursing staff were available to ensure medications were administered as ordered to 34 residents (R1, R4, and R6-R37). This failure has the potential to affect 34 residents ordered to received medication from third floor front cart. Findings include: The 3rd floor (12/25/2024) census of 72 residents was provided to surveyor by V1 administrator. R1's face sheet dated 12/30/2024 documents that R1 is a [AGE] year-old resident with diagnoses including but not limited to: unspecified dementia, unspecified psychosis, seizures, depression, encephalopathy, essential hypertension, and chronic obstructive pulmonary disease. R1's Minimum Data Set (MDS) dated [DATE] documents R1 has a Brief Interview for Mental Status (BIMS) score of 12, which suggests that R1 is moderately cognitively impaired. Medication Administration Records (MAR) for December 2024 for (R1, R4, and R6- R37) all document that medications were not given 12/25/2024, day shift. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide medications to 34 residents (R1, R4, and R6-R37) as ordered by the prescriber to meet the needs of each resident. This failure has the potential to affect thirty-four residents receiving medication from third floor front cart. Findings include: R1's face sheet dated 12/30/2024 documents that R1 has a diagnoses including but not limited to: unspecified dementia, unspecified psychosis, seizures, depression, encephalopathy, essential hypertension, and chronic obstructive pulmonary disease. R1's Minimum Data Set (MDS) dated [DATE] documents that R1 has a Brief Interview for Mental Status (BIMS) score of 12, which suggests that R1 is moderately cognitively impaired. Medication Administration Records (MAR) for December 2024 for (R1, R4, and R6- R37) all document that medications were not given 12/25/2024, day shift. On 12/30/2024, at 10:06 am, R4 stated, we always have a nurse on shift to give medications except on Christmas Eve or Christmas Day 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 provide significant medications to five residents (R1, R16, R26, R33 and R37) on 12/25/2024 on day shift. This failure affected five of thirty-four residents reviewed for significant medication. Findings include: Complaint dated 12/25/2024 alleges R1 is missing medications, given wrong medications and at times not all the medications due to no nurse. R1's face sheet dated 12/30/2024 documents that R1 is a [AGE] year-old resident with diagnoses including but not limited to: unspecified dementia, unspecified psychosis, seizures, depression, encephalopathy, essential hypertension, and chronic obstructive pulmonary disease. R1's Minimum Data Set (MDS) dated [DATE] documents that R1 has a Brief Interview for Mental Status (BIMS) score of 12, which suggests that R1 is moderately cognitively impaired. Medication Administration Records (MAR) for December 2024 for (R1, R16, R26, R33 and R37) all document that seizure medication were not given on on 12/25/2024,…

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 prevent and protect a resident (R2) from resident-to-resident physical abuse. This failure affected one (R2) of four residents reviewed for abuse. Findings include: R2's face sheet dated 01/12/2023, initial admit date [DATE] documents that R2 is a [AGE] year-old male with diagnoses including but not limited to: unspecified focal traumatic brain injury with loss of consciousness of unspecified duration, anxiety disorder due to know physiological condition, bipolar disorder, major depressive disorder, unspecified dementia. R2's Minimum Data Set (MDS) dated [DATE] documents: Brief Interview for Mental Status (BIMS) score of 00/15, which suggests severe cognitive impairment. Minimum data set (MDS) section GG dated 10/22/2024, R2 is dependent for toileting, shower/bathe, lower body dressing, putting/taking off footwear, personal hygiene. R2 requires partial/moderate assistance for eating and oral hygiene. Walk 10 feet - Not attempted due to medical…

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

Based on observation, interview, and record review the facility failed to follow the menu and ensure residents received garlic Texas toast with the lunch meal on 12/18/24 and oatmeal and scrambled eggs with cheese with the breakfast meal on 12/20/24 for all 211 residents who receive meals in the facility. Findings include: The lunch menu for 12/18/24 lunch noted 1/2 slice of garlic Texas toast was to be served. On 12/18/24 at 12:45PM, lunch service on the first floor nursing unit was observed. All residents were served one slice of white bread with meal. On 12/18/24 at 1:10PM, lunch trays on the second floor nursing unit was observed. All residents were served one slice of white bread with meal. On 12/18/24 at 1:20PM, lunch trays on the third floor nursing unit was observed. All residents were served one slice of white bread with meal. On 12/20/24 at 8:55AM, breakfast meal service for the third floor nursing unit residents was observed. Residents that use a wheelchair were observed sitting at the dining room tables waiting for breakfast to be served. There were 8 plastic bowls…

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 observations, interviews, and record reviews, the facility failed to ensure that there were plates, cups, eating utensils, and napkins available for each resident during the lunch meal service. This failure has the potential to affect all 75 residents residing on the third floor nursing unit. Findings include: On 12/18/24 at 12:36PM, this surveyor observed the lunch meal service on the third floor nursing unit. There was one member from the kitchen plating the residents' food. There were two staff members handing the meal tray and drinks to residents. Residents were served canned fruit in a Styrofoam bowl. The first forty-five residents received lunch served on a plastic plate. On 12/18/24 at 12:50PM, the food server ran out of plates. The following thirty residents received lunch on a Styrofoam plate. At the same time, the servers ran out of plastic cups with handles for coffee. Ten residents that were offered coffee, received it in a Styrofoam cup without a handle. On 12/18/24 at 12:53PM, the food servers ran out of napkins, twenty-five residents were not given a napkin.…

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, interviews and record reviews, the facility failed to follow its care plan policy and initiate an individualized falls care plan with interventions, implement fall precautions immediately to prevent a fall, and adequately supervise a resident at moderate risk for falls. This failure affected one resident (R2) out of three reviewed for falls in a sample of 18. Findings include: On 12/17/24 at 11:15AM, R2 was observed laying in bed. R2's call light cord was observed on the floor under R2's bed and not within reach. R2's left eye was observed to have purple discoloration, left side of face swelling, and R2's left cheek had green-yellow discoloration. On 12/23/24 at 9:30AM, R2 was observed laying in bed. R2's call light cord was observed on the floor under R2's bed and not within reach. On 12/17/24 at 11:15AM, R2 stated that she was walking in her room and fell hitting left eye on her roommate's foot board of her bed. On 12/18/24, V6 (Restorative Nurse) stated that V6 is responsible for investigating resident falls and updating the residents' care plans. V6 stated…

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

Based on observations, interviews, and record reviews, the facility failed to follow its fall risk and post fall assessment policy and accurately assess the resident's fall risk upon admission, identify and implement fall prevention interventions immediately to prevent a fall. This failure affected one resident (R2) out of three reviewed for falls in a sample of 18. Findings include: On 12/17/24 at 11:15AM, R2 was observed lying in bed. R2's call light cord was observed on the floor under R2's bed and not within reach. R2's left eye was observed to have purple discoloration, left side of face swelling, and R2's left cheek had green-yellow discoloration. On 12/23/24 at 9:30AM, R2 was observed lying in bed. R2's call light cord was observed on the floor under R2's bed and not within reach. On 12/17/24 at 11:15AM, R2 stated that she was walking in her room and fell hitting left eye on her roommate's foot board of her bed. On 12/18/24, V6 (Restorative Nurse) stated that V6 is responsible for investigating resident falls and updating the residents' care plans. V6 stated that V6 did 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide an environment that was clean and free of pervasive odor of urine in residents' rooms, failed to ensure that residents rooms are cleaned, and that garbage is properly disposed, failed to properly dispose of wet, soiled, stained linens from resident's room, and failed to properly clean or replace soiled mattresses. This failure affected seven of seven residents (R1, R4, R5 R6, R7, R8, R10) reviewed for environment and has the potential to affect all 67 residents residing on the third floor of the facility. Findings include: 1. 10/21/2024 at 10:00am while conducting rounds on the third floor, surveyor noted several rooms to be dirty with garbage all over the floor. Some of the rooms have brownish stains on the floor that looks dark and sticky. There is also a strong urine like smell coming from some of the rooms on the A side of the third floor that can be perceived in the hallway. At 4:30PM, the hallway on the A side of the third…

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 observations, interviews, and record reviews, the facility failed to follow their policy and procedures for serving food under sanitary conditions and ensuring residents meals are served in a manner to maintain appropriate serving temperatures by not covering meal trays with lids during dining service. This failure applied to all (66) residents receiving meals on the 2nd floor of the facility. Findings include: On 10/22/2024 at 1:15 PM Observed several food trays on the 2nd floor sitting on skeleton carts with no lids with gnats flying on and around food. On 10/22/2024 at 1:18 PM Observed the dietary aides food service cart with several unused clean lids. On 10/22/2024 at 1:22 PM V15 (Certified Nursing Assistant) stated meal trays lids are normally not available V15 stated she didn't see lids on the food service cart which is why she didn't use them. On 10/22/2024 at 1:26 PM V14 (Certified Nursing Assistant) stated she didn't pay attention that the lids weren't on the meal trays when she was delivering them on the cart from the dining area. V14 stated she normally covers…

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 ensure documented alternate communication methods were used to maintain communication for a resident with a communication barrier. This failure applied to one (R2) of eleven residents reviewed for quality of life and care. Findings include: R2 is a [AGE] year-old male with a diagnoses history of Cerebral Palsy, Epilepsy, Other Specified Disorders of the Brain, and Urinary Incontinence who was admitted to the facility 10/10/2024. On 10/21/2024 at 11:59 AM Observed R2 difficult to understand and with extremely limited speech. Observed there was no communication board available to communicate with R2. On 10/21/2024 at 12:09 PM observed V16 (Licensed Practical Nurse) respond to R2's call light. V16 stated there is no communication board used for R2, and he understands R2 a little. Observed R2 with a muffled and difficult to understand response when asked by V16 what his needs were. Observed there was no communication board used by V16 when…

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 altercation between two residents (R1 and R4) was identified and investigated as abuse. This failure applied to two (R1, R4) of three residents reviewed for abuse. Findings include: R1 is a [AGE] year-old female who admitted to the facility on [DATE] and continues to reside in the facility. R1 has multiple diagnoses including but not limited to the following: anxiety, depression, COPD, PTSD, and psychoactive substance abuse. Per Minimum Data Set, dated [DATE] states residents has a Brief Interview of Mental Status (BIMS) of 15 meaning resident is cognitively intact. R4 is a [AGE] year-old female who originally admitted to the facility on [DATE] and continues to reside in the facility. R4 has multiple diagnoses including but not limited to the following: hypertension, panic disorder, psychoactive substance abuse, borderline personality disorder, bipolar disorder, and depression. On 10/7/2024 at 11:50AM, R1 was interviewed regarding incident…

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 transmission-based precaution (PPE, isolation signage and set-up, resident/employee/visitor screening) and infection surveillance were implemented during COVID 19 outbreak. These deficiencies affected 14 residents (R5, R7, R38, R64, R69, R90, R99, R114, R147, R148, R150, R155, R158, R142) and has the potential to affect the rest of 180 residents residing in the building. Findings include: On 9/24/2024 at 10:30AM V3 (Infection Control Nurse) provided surveyor with COVID 19 resident tracking with names and corresponding room number. During positive COVID 19 room rounds with V3, discrepancies were identified as room number assigned did not matched current residents in the room. One room was identified with positive residents along with previously positive resident whose isolation have ended were all in the same room. On 9/24/2024 at 10:45AM, V3 said residents identified as COVID positive and resident with discontinued COVID isolation…

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 follow their policy in alerting a resident's responsible party of a change in condition. This failure affects one (R3) of two residents reviewed for notification of responsible party of resident's change in condition in a sample of 35. Findings include: On 9/27/2024 at 12:30, surveyor reviewed the documentations for R3 hospitalization on 3/20/2023 and 5/29/2024. No indication that R3 responsible family member was notified of the hospitalizations. On 9/27/2024 at 12:43 PM, V2 (Director of Nursing) said that the family member should have been notified of the two hospitalizations. The Facility's Policy: Guideline: Change In Resident's Condition Review Date: 11/2023 General: It is the policy of the facility, except in a medical emergency, to alert the resident, resident's physician/NP and resident's responsible party of a change in condition. Policy: 4. Communication with the resident and their responsible party as well as the physician/NP will be documented in the residents in the resident's medical record or other…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to follow their policy and procedures for providing effective pest control interventions by not adequately assisting residents with maintaining a clean environment and not providing pest control treatments consistently. This failure applies to all 202 residents currently in the facility. Findings include: R1 is a [AGE] year-old male with a diagnoses history of Local Infection of the Skin, Rheumatoid Arthritis, Chest Pain, Cellulitis of Right Lower Limb, Non-Pressure Chronic Ulcer of Right Ankle, Pulmonary Nodule, and Pericarditis who was admitted to the facility 04/11/2024. On 09/10/2024 at 12:35 PM Observed gnats flying around R1's room. R1 stated he sees roaches and flying insects in his room. On 09/10/2024 at 1:54 PM V17 (Family Member) stated she has observed R1's tray to be full of flies and another visiting family member took a video of his tray being left in the room and it being full of flies. On 09/11/2024 at 11:55 AM Observed…

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 environmental policy and procedures by not ensuring resident living areas were kept free of mold or mold promoting conditions. This failure applied to three of three residents (R1, R13, and R14) reviewed for environment. Findings include: R1 is a [AGE] year-old male with a diagnoses history of Local Infection of the Skin, Rheumatoid Arthritis, Chest Pain, Cellulitis of Right Lower Limb, Non-Pressure Chronic Ulcer of Right Ankle, Pulmonary Nodule, and Pericarditis who was admitted to the facility 04/11/2024. R13 is a [AGE] year-old male with a diagnoses history of Schizoaffective Disorder, Anxiety Disorder, and Benign Prostatic Hyperplasia who was admitted to the facility 10/10/2023. R14 is a [AGE] year-old male with a diagnoses history of Type 2 Diabetes Mellitus with Hyperglycemia, Atherosclerotic Heart Disease, History of Pulmonary Embolism, and Metabolic Encephalopathy who was admitted to the facility 05/02/2022. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to follow their policy and procedure for wound treatments by not ensuring residents received wound treatments daily as ordered by the physician, with multiple missed wound treatments. This failure applied to two of three residents (R1 and R3) reviewed for wound care. Findings include: 1) R1 is a [AGE] year-old male with a diagnoses history of Local Infection of the Skin, Rheumatoid Arthritis, Chest Pain, Cellulitis of Right Lower Limb, Non-Pressure Chronic Ulcer of Right Ankle, Pulmonary Nodule, and Pericarditis who was admitted to the facility 04/11/2024. On 09/10/2024 at 12:35 PM R1 stated the bandage on his right leg is changed every few days or so and was last changed on Friday or Saturday. Observed R1's bandage on his right leg with some reddish brown stains. R1's current care plan documents he is at increased risk for alteration in skin integrity related to post surgical wound to his right heel, and right lateral ankle 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 interviews and record reviews, the facility failed to follow their policy and procedures for internal reporting requirements of abuse allegations by not reporting a family reported allegation of abuse to the abuse coordinator (Administrator). This failure applied to one of three residents (R2) reviewed for abuse. Findings include: R2 is a [AGE] year-old male with a diagnoses history of Schizoaffective Disorder, Adult Failure to Thrive, Dementia, Major Depressive Disorder, Bipolar Disorder, and History of Falling who was admitted to the facility 03/09/2021. On 09/10/2024 Abuse investigation reports from June - September 2024 were reviewed with no reports included regarding V18's abuse allegation regarding R2. On 09/11/2024 at 2:06 PM V18 (Family Member) stated on approximately 08/18/2024 or 08/19/2024 at approximately 2 or 3 PM on the second day after R2's admission, V19 (Certified Nursing Assistant) came in with V20 (Certified Nursing Assistant) to change R2's brief and sheets. V18 stated they would…

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 ensure bed linens were changed as needed for a resident who requires assistance with activities of daily living. This failure applied to one of three residents (R1) reviewed for activities of daily living. Findings include: R1 is a [AGE] year-old male with a diagnoses history of Local Infection of the Skin, Rheumatoid Arthritis, Chest Pain, Cellulitis of Right Lower Limb, Non-Pressure Chronic Ulcer of Right Ankle, Pulmonary Nodule, and Pericarditis who was admitted to the facility 04/11/2024. On 09/10/2024 at 12:35 PM Observed both of R1's hands with contractures. Observed R1's linens and pillowcases with stains that appeared old. On 09/18/2024 at 12:48 PM Fellow surveyor observed R1's bed linens with stains that appeared old. On 09/19/2024 at 1:24 PM V17 (Family Member) stated a couple of weeks ago when she and other family member's visited R1 she observed R1's bed linens stained. On 09/19/2024 at 2:35 PM V17 (Family Member) stated she…

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 policy and procedures for weight management by not ensuring specialized dietary orders were followed, not following a physician's supplemental recommendations from hospital records, not honoring a residents supplemental preference, not accurately documenting supplement administration, not obtaining dietary preferences, not providing feeding assistance as needed, and not accurately documenting meal consumption for a resident at high risk for and exhibiting signs of severe malnutrition. This failure applied to one of one resident (R1) reviewed for nutrition status. Findings include: R1 is a [AGE] year-old male with a diagnoses history of Local Infection of the Skin, Rheumatoid Arthritis, Chest Pain, Cellulitis of Right Lower Limb, Non-Pressure Chronic Ulcer of Right Ankle, Pulmonary Nodule, and Pericarditis who was admitted to the facility 04/11/2024. On 09/10/2024 at 12:35 PM Observed R1 with multiple missing teeth. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to follow their policy and procedures for providing specialized diets by not ensuring specialized dietary orders were followed and not providing feeding assistance as needed for a resident who receives a mechanical soft diet. This failure applied to one of one resident (R1) reviewed for specialized diet. Findings include: R1 is a [AGE] year-old male with a diagnoses history of Local Infection of the Skin, Rheumatoid Arthritis, Chest Pain, Cellulitis of Right Lower Limb, Non-Pressure Chronic Ulcer of Right Ankle, Pulmonary Nodule, and Pericarditis who was admitted to the facility 04/11/2024. On 09/10/2024 at 12:35 PM Observed R1 with multiple missing teeth. On 09/10/2024 at 1:31 PM Observed R1 both of R1's hands with contractures. Observed V15 (Licensed Practical Nurse) assisting R1 with eating his meal. R1 stated he can't eat everything because some foods are hard to chew or just completely hard. R1 showed surveyor that his chicken 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 follow the plan of care and provide Activity of Daily Living to a resident dependent on staff for incontinent care. This affects one of 3 residents (R4) reviewed for activities of daily living care. Findings include: R4 MDS (Minimum Data Set) dated 5/18/24 for functional abilities denotes R4 is dependent for toileting. Most recent discharge MDS dated [DATE] for functional abilities denotes R4 is dependent for toileting. R4 most recent care plan denotes R4 has a self care deficit (ADLs/Mobility) R/T (related /to) generalized weakness and shortness of breath. Resident will improve/maintain highest level of function with participation in therapies and/or restorative programs through next review. One assist with dressing / hygiene tasks; encourage as much self-performance as safely able. Resident is dependent with ADL care; provide total assistance in all aspects of hygiene/dressing. Toilet with two assists. On 7/30/24 at 10:49am V29 (LPN-Licensed Practical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by a resident. This failure applied to two of two (R5, R15) residents reviewed for abuse. Findings include: R5 [AGE] years old, was initially admitted to the facility 2/1/23 with diagnoses that include Major Depressive Disorder, Anxiety Disorder and Chronic Kidney Disease Stage III. R15 is [AGE] years old, admitted to the facility from the hospital on 3/11/24 with diagnoses that included Schizophrenia. The facility reported to IDPH an incident that occurred on 3/11/24 which indicated that R15 found R5 in the hallway and hit them unprovoked. R5 did not sustain any injuries and did not require hospitalization R15 discharged from the facility Against Medical Advice later that evening. On 5/29/24 at 11:02AM V15 PRSC (Psychiatric Rehabilitative Services Coordinator) said that R15 was in their office while conducting an admission assessment, when all of a sudden, R15 abruptly got up, went into 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 and interview the facility failed to provide one resident (R14) with clean and untorn socks at his request. This failure affected one of three residents reviewed for resident rights in the sample. The findings include: R14's diagnosis include but are not limited to Unspecified Dementia, Polyneuropathy, Right Leg Ulcerations, and Glaucoma. On 4/4/24 at 10:00AM R14 observed in his room. There is a strong foul odor in the room coming from R14. R14 is wearing torn clothing and is unkempt. R14 is wearing hospital issued socks with torn grips, feet exposed, soil covered, dirty, torn at heel and various areas on the soul. R14 said I've had these socks since October. I want new socks, but they won't give me socks, I asked them. On 4/4/24 at 10:12AM the surveyor asked V1, Licensed Practical Nurse, if she has seen the condition of R14's socks, with holes, torn, missing bottoms, and dirty. V1 said I was going to get him socks yesterday, but there weren't any. I did not get him any. On 4/4/24 at 11:46AM V3, Certified Nursing Assistant, said We need to find (R14) bigger…

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 prevent and contain the spread of Covid-19 and other infectious diseases by failing to ensure a posting at the entrance to the facility of active Covid-19 infection; failing to implement source control measures regarding the use of face masks when Covid-19 is present in the facility; failing to ensure alcohol based hand rub was available in the PPE (personal protection equipment) carts for transmission based precaution isolation rooms; failing to ensure dedicated or disposable non critical resident care equipment was available for transmission based precaution isolation rooms; and failing to ensure all residents, their representatives and families were notified following the occurrence of either a single confirmed infection of Covid-19 or three or more residents or staff with new onset of symptoms. This failure has the potential to affect all 187 residents in the facility. Findings include: On 1/2/24 at 10:25 AM, upon entrance to…

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

Based on interviews and record reviews the facility failed to follow their abuse policy and procedures by not ensuring a care plan was implemented for a resident when they were initially observed engaging in verbally and physically aggressive behaviors. This failure applies to two of four residents (R11 and R12) reviewed for abuse. Findings include: Final Abuse Investigation Report dated 11/05/2023 documents on 11/05/2023 R12 reported that she and her roommate R11 were involved in a verbal disagreement and R11 threw a cup of liquid on her. R11 denied throwing the liquid on R12 and both residents were hospitalized for psychiatric evaluation. R11's progress note dated 9/15/2023 documents she was observed presenting agitation with verbal aggression with obscene language. R11 was counseled on presenting social and verbal appropriate behavior. Resident was not receptive. Writer counseled the resident on presenting social and verbal appropriate behavior. R11's progress note dated 9/23/2023 documents she was observed hitting another resident in the face. Per R11 she was in hallway and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to prevent the misappropriation and/or diversion of medications for two (R2, R17) of three residents reviewed for medication administration; and failed to follow their facility's ordering and receiving of medications policy. This failure resulted in R2's pain medication (ibuprofen) being reordered in excess with minimal documentation of medication being administered to R2; and failed to have both resident's (R2, R17) personal medication supply readily available upon request for administration on numerous occasions. Findings include: 1. R2's electronic medical record indicated resident is a [AGE] year old male who admitted to facility on 11/07/2022 and has a past medical history not limited to: dementia with behavioral disturbance, hypertensive heart disease, anemia, polyneuropathy, cellulitis of bilateral lower extremities, peripheral vascular disease, glaucoma, and atherosclerosis. On 01/02/2024 at 2:11 PM, R2 stated that one to two…

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 monitor and assess a resident's (R13) condition who was receiving blood thinner medication and had previous laceration; and failed to have an active care plan for a resident (R14) for diabetes care and act promptly to provide an intervention for a resident with low blood sugars. These failures involved two residents, R13 and R14. As a result, on 11/10/23 R13 was found lying in a moderate amount of blood in bed and sent to the hospital via 911 emergency. On 11/11/23 R14 was found lying on the floor unresponsive and sent out via 911 after paramedics administered a blood glucose check and which the result of was a hypoglycemic reading. Findings include: 1. R13 is [AGE] years old and was originally admitted to the facility 6/1/22 and has diagnoses of dementia, history of falling and other mental health disorders. According to the electronic health record, and facility fall reports, R13 had a fall in the facility on 10/25/23. From the fall incident, R13…

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 sufficient nursing coverage on specific days and shifts, causing call lights not to be answered and not ensuring adequate resident care and assistance for three of three residents (R4, R8 and R13) reviewed for staffing. Findings Include: Per residents' census report dated 01/02/24, there are 186 residents currently residing in the facility. On 01/02/24 at 2:23 PM, R4 mentioned during an interview that call lights were not answered by staff in a timely manner. R8 and R13 verbalized concerns regarding staffing in the facility. R4, R8 and R13 stated call light responses, provision of care and necessary support from staff were issues due to lack of staff. V38 (Staffing Coordinator) was interviewed on 01/08/24 at 9:27 AM regarding staffing. V38 stated, The facility has three floors, first floor is both short term and long term; Second floor is long term. Residents on the second floor all need total care, are dependent on staff for ADLs (activities of daily living), and need constant supervision and monitoring. A lot of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide medications and/or biologicals, as ordered by the prescriber to meet the needs of each resident and failed to provide pharmaceutical services to meet each resident's needs which includes acquiring, receiving, dispensing, accurately administering, or disposing of medications. This failure affected one resident (R17) of four residents reviewed for medication administration, causing the resident to endure pain related to not having pain medication available when needed. Findings include: R17 is a [AGE] year-old female who have resided at the facility since 2021, past medical history includes, but not limited to Nondisplaced transcondylar fracture of right humerus, subsequent encounter for fracture with routine healing, dementia in other diseases classified elsewhere unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, type 2 diabetes, Epilepsy unspecified, etc. On 1/3/2024 at…

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

Based on observations, interviews, and records reviewed the facility failed to ensure to provide evidence to support sufficient nursing staff based on the facilities staffing numbers. This affected two of two residents (R138, R222) reviewed for staffing. This has the potential to affect all 191 residents. The findings include: According to the CMS 672 dated 10.16.23 there are currently 191 residents. On 10/15/23 at 11:39 AM V18, Certified Nursing Assistant (CNA), said yesterday (10/14/23) she was the only CNA on the floor. V18 said she is the only CNA on the floor today. On 10/15/23 at 11:00 AM, R138 said there is not enough staff, and it takes a long time for staff to respond. R138 said he can wait up to an hour for staff to respond to his call light. On 10/15/23 at 11:04 AM, R222 said there is not enough nurses and there should be 2 nurses on each side instead of 1 nurse. R222 said the nurses and CNA take too long to respond to the lights. On 10/16/23 11:25 AM V13, Staffing, said we should have 2 CNAs on the 1st floor, 6 CNAs on the 2nd floor and the 3rd floor has 2 CNAs at…

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

Based on observation, interview and record review, the facility failed to ensure the dessert cooler, three compartment sink and ventilation hood were in good working condition. This failure has the potential to affect all 191 residents at the facility. Findings include: According to the CMS 672 dated 10/16/23 there are 191 residents in the facility. On 10/15/23 at 9:52AM, a tour of kitchen observed dessert cooler temperature reading at 50 degrees Fahrenheit on the inside and outside temperature gauge. V37 (dietary aide) assisted with Food temperatures measurements of food contained within the dessert cooler and said the thermometer was calibrated and ok to measure food temperatures. The following temperatures were recorded: scrambled eggs at 55 degrees; pureed eggs dated 10/14 at 44 degrees Fahrenheit; chicken alfredo pasta dated 10/14/23 measuring 54 degrees Fahrenheit; pureed bread dated 10/14 measuring 42 degrees Fahrenheit and applesauce dated 10/14/23 measuring 51 degrees Fahrenheit. Temperature log on the dessert cooler for October 2023 documents: Coolers 40 degrees Fahrenheit…

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 their policy titled food safety and sanitation when handling food during meal service. Findings include: Food service observation on 10/15/23 from 12:44pm to 1:38pm. On 10/15/23 at 12:49pm V37 (Dietary Tech) was observed serving lunch meals. V37 approached the metal cart, scratched his left arm with his right hand and V37's arm turned ashy white from scratching and flakes of dead skin were observed. V37 walked back to the serving stove/cart and V37 resumed with meal service. V37 picked up a plate and plated the meal. That plate of food was served to the resident. V37 did not practice any hand washing or hand hygiene with alcohol based hand rub. On 10/15/23 at 01:39 PM, V37 said he didn't wash his hands after scratching his arms and touching his glasses throughout the meal service. V37 said he washed his hands before he came up the stairs. V37 said he should have practice hand hygiene after scratching his arm and touching his glasses. On 10/17/23 at 11:56am V38 (Dietary Manager) said hand hygiene and or…

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

Based on observation, interview, and record review, the facility failed to have an effective pest control program. This failure affected 5 of 5 (R90, R24, R102, R58, R272) in the sample reviewed for pest control. This has the potential to affect all 191 residents. Findings Include: According to the CMS 672 dated 10/16/23 there are 191 residents in the facility. On 10/15/23 at 10:17AM, a dead medium size dark brown elongated bug consistent with a roach was seen on its back in the kitchen's dry storage area behind the refrigerator. V26 (Dietary) said, he was not sure what type of bug was dead behind the refrigerator. On 10/15/23 at 10:28AM, multiple crawling small and medium size brown bugs consistent with roaches were observed in R90 and R24's room and bathroom. R24 said, we have roaches. The roaches are all under our items. Just move anything and they will come out. They live in the walls and in our bathroom. R90 said, we have roaches in our room. V12 (Nurse) said, those bugs are roaches. We have a problem with roaches. On 10/15/23 at 1:12PM, small brown elongated bugs consistent…

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 residents are aware of where the ombudsmen contact information is posted in the facility. This affects eight of eight residents (R5, R26, R45, R79, R80, R135, R152, and R274) in the sample of 36 reviewed for residents rights for ombudsmen postings. Findings include: On 10.16.23 at 10:27am during the residents council meeting R5, R26, R45, R79, R80, R135, R152, and R274 all asked, what is the ombudsmen. They all asked who is the ombudsmen and said they do not know where the ombudsmen contact information is posted in the facility. They all said they don't know who the ombudsmen is. On 10.16.23 at 12:36pm there was an 8x10 posting noted on the glass wall near the door exiting into the front lobby. There was not a name listed for the ombudsmen. The posting was posted high on the wall greater than 5 feet 5 inches high. Surveyor had to look up to see the sign.

Based on observation, interview and record review the facility failed to ensure that the state inspection is available for the residents to read without having to ask the staff for them. This affected eight of eight (R5, R26, R45, R79, R80, R135, R152, and R274) residents in the sample of 36 resident reviewed for residents rights. Findings include: On 10.16.23 at 10:27am R5, R26, R45, R79, R80, R135, R152, and R274 all asked what is the state inspection. They all said they don't know where to go to read the state inspection. On 10.17.23 at 4:04pm V1 (Administrator) was asked where is the state inspection? V1 went through the door behind the front desk and pointed to a white binder. V1 was asked if the resident had access behind the front desk. V1 then stated that the inspection report is at each nurse station and pointed to a sign. On 10.18.23 at 9:05am surveyor stopped at the first floor nursing station and requested to review the state inspection. V12(Nurse) asked what's that. The state inspection was not present at the first floor nurse station. On 10.18.23 at 9:06am surveyor…

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 their Oxygen Equipment Policy. The facility failed to date oxygen tubing and prefilled humidifier. This affected five of five residents (R46, R62, R140, R425 and R427) reviewed for oxygen administration in a total sample. Findings Include: On 10/15/23 at 10:45AM, R62 observed to have an oxygen concentrator at bedside, oxygen tubing dated 9/10/23, and empty prefilled humidifier dated 4/9/23. On 10/15/23 at 10:50AM, R46 observed to have oxygen concentrator at bedside, oxygen tubing and prefilled humidifier not dated, and humidifier bottle is empty. On 10/15/23 at 11:10AM, R140 observed to have oxygen concentrator at bedside and prefilled humidifier bottle not dated. On 10/15/23 at 11:15AM, R425 observed to have oxygen concentrator at bedside, oxygen tubing and prefilled humidifier bottle not dated. On 10/15/23 at 11:20AM, R427 observed to have oxygen concentrator at bedside, oxygen tubing not dated and prefilled humidifier bottle not dated and bottle empty. On 10/15/23 at 11:05AM, confirmed and verified…

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 observations, interviews, and records reviewed the facility failed to provide clean assistive devices and assistive devices in good working order for one (R102) of three residents reviewed in the sample. The findings include: On 10/15/23 at 10:07AM R102 observed sitting in his wheelchair during interview. The surveyor observed the back support of R102's wheelchair is not fully attached and all the way up on the back bars. R102's wheelchair has no foot pedals, is dirty with dried on unidentifiable particles, and both the front rubber wheels are thin and almost not present. R102's wheelchair has a seat and metal frame but without no back support. On 10/15/23 at 12:44 PM R102 said I would take a new wheelchair if they gave it to me. R102 said I use the wheelchair to get around the facility. On 10/15/23 at 1:20 PM V5, Nurse, was asked about R102's wheelchair. V5 said he won't let me take his wheelchair, I have tried, he refuses. The surveyor requested documentation specific to R102 wheelchair refusals. On 10/15/23 at 2:18PM V5, Nurse, said R102 was given a new wheelchair. He 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.

Based on interview and record review, the facility failed to clearly document an advance directive status. This affected one of three residents (R89) reviewed for advance directives in the electronic medical record. Findings include: On 10/17/23 at 12:55pm, V3(DON) said code status should be on the physician order sheets and located in electronic health record. V3 did not see any code status for R89 when checking the medical record. R89's practitioner order for life sustaining treatment POLST form documents: Do not attempt Resuscitation dated 9/22/23. R89's physician order sheet does not document any code status.

Based on interviews and records reviewed the facility failed to notify the physician when medications were not available for greater than 72 hours. This affected one of three residents (R373) reviewed for notification of missed medications in the sample. The findings include: On 10/15/23 at 10:04AM R373 said I have not received my methadone in 2 days. On 10/15/23 at 2:55 PM V5, Nurse, checked the medication cart. V5 said no, R373's medications have not been delivered yet. On 10/16/23 at 9:51 AM R373 said I'm feeling sick and sweaty. They haven't given me my Methadone. R373 said I need my medications. The nurse gave me Tylenol this morning, but it's not working. On 10/16/23 at 1:05PM V15, Transportation Scheduler, said R373 has been scheduled to go to the Methadone Clinic for treatment on 10/19/23 (6 days since admission). On 10/16/23 at 09:53 AM V7, Licensed Practical Nurse said R373 did not get her Methadone. On 10/18/23 at 12:07PM V28, Nurse Practitioner, said I was not notified of any concerns related to R373. V28 said if I had been notified that R373 was not scheduled to receive…

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 prevent the misappropriation and/or diversion of medications for two (R2, R17) of three residents reviewed for medication administration; and failed to follow their facility's ordering and receiving of medications policy. This failure resulted in R2's pain medication (ibuprofen) being reordered in excess with minimal documentation of medication being administered to R2; and failed to have both resident's (R2, R17) personal medication supply readily available upon request for administration on numerous occasions. Findings include: 1. R2's electronic medical record indicated resident is a [AGE] year old male who admitted to facility on 11/07/2022 and has a past medical history not limited to: dementia with behavioral disturbance, hypertensive heart disease, anemia, polyneuropathy, cellulitis of bilateral lower extremities, peripheral vascular disease, glaucoma, and atherosclerosis. On 01/02/2024 at 2:11 PM, R2 stated that one to two…

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 follow their abuse policy by not reporting allegations of abuse for two of three residents (R69, R66) reviewed for abuse reporting. Findings Include: On 10/15/23 at 10:57am, R69 who was delusional said in 2016, she was raped while she slept. R69 said, when she awoke, she saw R7 walking out of her room in the middle of the night. R69 said, R7 raped her that night. R69 did not recall the act of being raped or when R7 was on top of her but she knew she was raped when she saw R7 walking out of her room. R69 said, she had semen in her vaginal area at that time. R69 also said, the semen is currently still in her vaginal area. On 10/16/23 at 4:38pm, V2 (regional consultant) said, R69's allegation of sexual abuse should have been reported after her hospitalization. I expect the nurse to review the hospital paperwork for continuity of care. Nursing note dated 8/27/23 documents: R69 had hallucinations and delusions. R69's petition form completed. Hospital paperwork dated 8/28/23 documents: R69 admitted to ED due to acute psychosis.…

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 observations, interviews, and record review the facility failed to follow care plan interventions by not utilizing the communication book for communication for a resident unable to voice their needs. This affected one of three residents (R147) reviewed for communication in the sample. The findings include: R147's diagnosis include but not limited to Altered Mental Status. R147's speech, hearing, and vision assessment notes unclear speech and is sometimes understood and understands others sometimes. R147's cognition notes he is severely cognitively impaired. On 10/15/23 at 11:25AM the surveyor met R147 in the hallway and attempted to speak to him. R147 only made low grunting sounds and was not able to pronounce his name or identify which bed in the room is his. On 10/15/23 at 11:39 AM V18, Certified Nursing Assistant (CNA), said reguarding R147, he don't have no communication board he just say yes or no. V18 said R147 can't have a conversation, but he can understand you. On 10/16/23 at 9:07 AM V6, Assistant Social Service Director said the social service department does 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 provide feeding assistance for one resident identified as needing feeding assistance. This affected one of three residents (R160) reviewed for feeding assistance in the sample. Findings Include: R160's diagnosis includes unqualified visual loss, both eyes and autistic disorder. Minimal data set section G (functional status) dated 9/7/23 documents: R160 requires supervision with one person physical assist with eating. Physician order sheet dated 8/16/23 documents: for diet need assistance with feeding. On 10/15/23 at 12:51PM, R160 was assisted by co-peer/another resident who was sitting at R160's table to remove the plastic wrap from a peanut butter sandwich. R160 fed self without any staff assistance. R160's co-peer offered R160 his juice and placed it in R160's hand. On 10/16/23 at 12:39pm, R160 was given a double cheeseburger from a co-peer. The restaurant sandwich was dropped out of a paper bag on the table in front of R160. Another resident unwrapped the cheeseburger and placed it in R160's hand. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to follow their pressure ulcer prevention interventions which include inappropriate Low Air Loss Mattress pressure setting for residents identified to be at risk for skin breakdown. This affected two of three residents (R62 and R 86) reviewed for pressure ulcer prevention and interventions in a total sample of 36 residents. Findings Include: On 10/15/23 at 10:45AM, observed R62 in bed using low air loss mattress. Machine setting is at 350 lbs. On 10/15/23 at 11:30AM, observed R86 in bed, using low air loss mattress. Machine setting is at 320 lbs. On 10/15/23 at 11:05 AM, showed V3 (DON) and confirmed that the mattress setting is set on 350 lbs. On 10/15/23 at 11:30AM, showed V11 (nurse) and confirmed that the mattress setting is set on 320 lbs. On 10/17/23 at 10:30AM, V3 stated that Low Air Loss Mattress settings need to be set close to the resident's weight. We use Low Air loss Mattress to prevent skin alteration and maintain the integrity 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 ensure one resident with history of mental illness had been assessed by a mental health professional since admission. This affected one of one resident (R167) reviewed for mental health services in the sample. Findings include: R167 admitted to the facility on [DATE] with a diagnosis of major depressive disorder severe without psychotic features and psychoactive substance abuse. R167 Preadmission screening and resident review (PASRR) dated 6/29/23 documents: You have a Level II PASRR condition of Major Depressive Disorder and Anxiety Disorder, which needs routine follow up with a mental health professional and a medication regimen. PASRR dated 9/20/23 under rehabilitative services: A psychiatrist will watch how your respond to your medicine and make changes if needed. R167's medical record reviewed with no notes from any mental health professionals. On 10/18/23 at 11:16AM, R167 who was alert and oriented at time of interview, said she has never seen…

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 their medication labeling and storage policy. This affected three of three residents (R472, R473, and R136) reviewed for medication storage in the sample. Findings Include: On 10/16/23 at 10:02am, two prescription bottles were observed in a box with old empty pill cards and paper under the 3rd floor nursing station. R472 had a prescribed bottle of amlodipine 5mg dated 7/24/23 (documents: take one tablet by mouth every day) with 22 pills inside the bottle and chlorthalidone 25mg dated 7/24/23 (documents: take one tablet by mouth every day) with 21 pills inside. V16 (ADON) said, there should not be any medication under the nursing station. All medication should be locked in the medication room until disposed of or returned. R472's physician order sheet dated 10/14/23 documents: Amlodipine 10mg give one tablet by mouth one time a day. Chlorthalidone was not documented as a prescribed medication. On 10/16/23 at 10:07am, R473 had a Haldol dec medication bottle in the medication room which was dispensed…

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 maintain an effective abuse prevention training policy/practice for reporting allegations of abuse for 1 resident (R66) in sample of 36 reviewed for reporting. Findings include: On 10/15/23 at 10:28am, R66 said the devil rapes her stomach by taking her fingers and hands and scratching my stomach. On 10/15/23 at 10:38am this allegation was reported to V19 (Nurse). Follow up with V19 at 11:13am, V19 said she reported this allegation to V36 (Social Services). On 10/16/23 at 2:31pm V1 (Administrator) said no one reported any allegations to him. V1 made aware of the allegation reported by R66. Facility abuse prevention program policy and procedures dated 1/4/18 denotes in-part internal reporting requirements and identifications of allegations, employees are required to report any incident, allegations, or suspicious of potential abuse, neglect, exploration, mistreatment or misappropriation of resident's policy.

Based on interview and record review, the facility failed to follow their abuse policy by not investigating an allegation of abuse for one of three residents (R69) reviewed for abuse reporting. Findings Include: On 10/15/23 at 10:57am R69, who was delusional, said in 2016 she was raped while she slept. R69 said, when she awoke she saw R7 walking out of her room in the middle of the night. R69 said, R7 raped her that night. R69 did not recall the act of being raped or when R7 was on top of her but she knew she was raped when she saw R7 walking out of her room. R69 said, she had semen in her vaginal area at that time. R69 also said, the semen is currently still in her vaginal area. On 10/16/23 at 4:38pm, V2 (regional consultant) said, R69's allegation of sexual abuse should have been investigated after her hospitalization. I expect the nurse to review the hospital paperwork for continuity of care. Nursing note dated 8/27/23 documents: R69 had hallucinations and delusion. R69's petition form completed. Hospital paper work dated 8/28/23 documents: R69 admitted to ED due to acute…

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

Based on observation, interview and record review, the facility failed to ensure the Daily Nurse Schedule was posted in a prominent place readily accessible to residents and visitors; and failed to ensure the Daily Nurse Schedule was complete. This failure affected all 185 residents residing in the facility. Findings include: The (12/12/2022) facility census was 185. On 12/12/2022 at 9:10am, by the receptionist area, there was no daily nursing staffing posted. On 12/12/2022 at 10:58am, this surveyor inquired about the posting of daily nursing staffing. V4 ADON (Assistant Director of Nursing) stated, We (facility) keep it in the 2nd floor nurse's station. This surveyor inquired if the daily nursing staffing was visible to visitors who come into the facility. V4 stated, No. It should be visible. V4 and this surveyor went to the second floor. On the second floor, V4 pulled out the Facility Daily Nurse Schedule from the binder called Nursing Staffing Informational Binder and showed the daily nursing staffing to this surveyor. Upon review of the Daily Nurse Schedule, no resident census…

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 clean a kitchen fan; failed to ensure food items were discarded before the expiration date; and failed to practice safe use of glove practices to prevent food borne illness. These deficient food sanitation practices have the potential to affect all 183 residents receiving oral diets from the facility's kitchen. Findings include: On 12/12/22 during the facility entrance, V1 (Administrator) reported the facility census as 185. The NPO (Nothing by mouth) list provided by V1 indicated 2 residents are not receiving an oral diet from the kitchen. On 12/12/22 at 10:20am during the initial inspection of the kitchen with V20 (Dietary Manager), the following observations were observed: A metal fan was in use sitting near the dishwasher. The fan had visible accumulated dust on the front of the fan. In the walk-in cooler, a box of 19 four-ounce containers of yogurt with the expiration date: 12/4/2022. V20 stated, the yogurt was delivered to the facility on the previous Friday when he was not at the facility and that the…

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

Based on observation, interview and record review the facility failed to ensure that the outside dumpster lid was closed to prevent pest and rodents from entering into the garbage bin. This failure has the potential to affect all 185 residents residing in the facility. Findings include: The (12/12/22) facility census was 185 as reported by V1 (administrator). On 12/12/22 at 1:55 pm, four outside dumpsters were observed without lids. Each dumpster had a black lid attached which were all flipped to the back of the dumpster. On 12/13/22 at 1:30 pm, three outside dumpsters were observed without lids. Each dumpster had a black lid attached which were all flipped to the back of the dumpster. On 12/13/22 at 1:30 pm, V26 (Director of Housekeeping) observed the open dumpster's and stated, the lids are often left open after the garbage is picked up by disposal service. V26 further stated, the wind often prevents the lids from staying down and they do not have locks or latches on the lids. Facility policy received by V26 on 12/13/22 titled, Waste Management (dated 5/2014), reads in part:…

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 develop policies and procedures that include the processes for ensuring documentation for religious exemptions for Covid-19 vaccination; process for tracking and securely documenting staff Covid-19 vaccination status; a process for contingency plans for staff who are not fully vaccinated with Covid-19 vaccine; and failed to track and ensure 100% of staff were vaccinated as required by CDC (Centers for Disease Control and Prevention). These failures have the potential to affect all 185 residents in the facility. Findings include: On 12/12/22 at 10:11 AM, V1 (Administrator) stated that the official facility census is 185 residents. On 12/13/22 at 12:00 PM, the surveyor requested a policy on staff vaccinations for Covid-19. V3 (Infection Preventionist) provided the surveyor with a policy dated 11/8/2022 titled Policy and Procedure Vaccinations with the procedure comprised of only 3 steps: 1. Educate residents, staff, and families on the importance of vaccination. 2. Facilitate vaccination administration. 3. Report SARS-CoV-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.

Based on observation, interview and record review, the facility failed to ensure a homelike environment for six residents (R13, R19, R84, R88, R124 and R160) in the sample of 69 residents. Findings include: On 12\12\2022 at 10:48am observed a blue trash can in R84's room with no trash can liner in the trash can. On 12\12\2022 at 10:50am R84 stated housekeeping has been in my room this morning but did not put a bag in my trash can. On 12\12\2022 at 1:02pm V11(Housekeeper) stated, there should be a trash bag in the trash can of R84. V11 stated, the floor care staff is responsible for putting the trash liner in the garbage can. On 12\12\2022 at 1:07pm V12 (Housekeeper\Floor Care) stated, I changed the trash bags in the resident's rooms at about seven in the morning. V12 stated, I (V12) am responsible for putting a liner in the resident's garbage can. On 12\13\2022 at 12:13pm V30 (Housekeeper\Floor Care) stated, the floor tech is responsible for placing the bag in the resident's trash can. V30 stated, the reason for placing the trash bag in the can is to make sure no trash damages 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 ensure that two nurses document together on the shift-to-shift controlled substances count sheet and failed to sign out controlled substances on narcotics accountability sheet for two residents (R109 and R165). This has the potential to affect two (R109 and R165) residents on the second floor. Findings include: On 12/12/2022 V1 (Administrator) presented facility census report that documented the residents census on the second floor was 63. On 12/12/22 at 3:15 pm, Surveyor and V24 (Registered Nurse, RN) performed a controlled substance audit of the second floor Team B medication cart. Surveyor observed the controlled substance binder containing the controlled drug receipt/record/disposition form that V24 did not sign for the following residents: R109's Tramadol HCL tablet 50 mg, take 1 tablet by mouth every 6 hours as needed for pain. Surveyor observed R109's medication card with 7 pills and R109's-controlled drug receipt/record/disposition form observed with 8 pills indicated for dispense. R165's Lacosamide…

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 two medication carts out of the three medication carts reviewed were free of loose tablets and failed to ensure Insulin vials were labeled with an open date after opening the vials. This failure has the potential to affect 68 residents on the third floor, 58 residents on the first floor who receive medications from the medication carts and four resident's (R85, R159, R171, and R332) who receive insulin on the first floor. Findings include: On [DATE] at 1:23 pm, Surveyor and V4 (Assistant Director of Nursing, ADON, Registered Nurse, RN) inspected the second-floor medication room and observed the following insulin medications inside of the second-floor medication room refrigerator, open in use without an open date: R85's Levemir Solution 100 unit per ml vial open in use with no open date labeled. R159's Novolog 70/30 suspension 100 unit per ml vial open in use with no open date labeled. R171's Insulin Glargine Solution 100 unit per 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.

Based on observation, interview and record review, the facility failed to ensure oxygen tubing was changed per facility policy for one resident (R79); failed to ensure staff donned proper PPE (Personal Protective Equipment) when entering an isolation room for two residents (R24 and R54) to prevent the spread of Covid 19; failed to ensure proper hand hygiene was performed during resident dining for four residents (R20, R50, R84, R166) with the potential to affect all 34 residents eating lunch in 3rd floor dining room; and failed to ensure that the indwelling catheter for one resident (R17) was not lying on the floor. These failures affected R17, R20, R24, R50, R54, R79, R84 and R166 in the total sample of 69 residents reviewed for infection control. Findings include: On 12/12/22 at 10:50 AM, the surveyor observed R79's oxygen concentrator with tubing dated 12/1/22. R79 stated, I wear it whenever I need it. The surveyor inquired how often the oxygen tubing is changed. R79 replied, It varies how often, and added that prior to the date of 12/1/22, the tubing hadn't been changed for 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 track the vaccination status, failed to offer, and failed to educate 4 eligible residents (R54, R178, R432 and R433) out of 5 residents reviewed for influenza and pneumococcal vaccinations in the total sample of 69 residents. Findings include: On 12/13/22 at 1:39 PM, the surveyor could not find any influenza or pneumococcal immunizations documented in the electronic medical record for R433. This was brought to the attention of V3 (Infection Preventionist/LPN, Licensed Practical Nurse) who stated, That's our new guy. I have not seen anything in his (R433) hospital records. I was researching. I was going to reach out to the liaison who sends us our admission to see if she has anything on him (R433). The surveyor inquired if there is a timeframe in which vaccination status has to be entered or vaccinations offered for new admissions. V3 replied, Not from my knowledge. They have not given me a time-frame. V3 added, New admissions are considered 30 days.…

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

Based on interview and record review, the facility failed to track the vaccination status, failed to offer, and failed to educate 4 eligible residents (R54, R178, R432, R433) out of 5 residents reviewed for Covid-19 vaccinations in the total sample of 69 residents. Findings include: On 12/13/22 at 1:39 PM, the surveyor could not find any Covid-19 immunizations documented in the electronic medical record for R433. This was brought to the attention of V3 (Infection Preventionist/LPN, Licensed Practical Nurse) who stated, That's our new guy. I have not seen anything in his (R433) hospital records. I was researching. I was going to reach out to the liaison who sends us our admissions to see if she has anything on him (R433). The surveyor inquired if there is a timeframe in which vaccination status has to be entered or vaccinations offered for new admissions. V3 replied, Not from my knowledge. They have not given me a time-frame. V3 added, New admissions are considered 30 days. After that, all assessments should be complete. R433's admission Record documents and admission date 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 ensure protected health information remained confidential for one resident (R66) reviewed for confidentiality of record in the sample of 69 residents. This failure has the potential to affect all 63 residents residing on the second floor. Findings Include: On 12/12/2022 V1 (Administrator) presented facility census report that documented the resident census on the second floor was 63. On 12/12/22 at 10:47 am, Surveyor observed the facility's second floor Team B medication cart unattended with an empty medication dispensing card labeled visible with R66's, name, medication, dose, and frequency for (Levetiracetam 750 mg, give 2 tablets two times a daily) on top of Team B's medication cart. At 10:49 am, Surveyor observed V23's (Licensed Practical Nurse, LPN) walked to Team B's cart. When V23 was asked regarding the importance of not leaving the patients empty medication card visible on top of the medication cart, V23 stated, For HIPAA (Health Insurance Portability and Accountability Act). I (V23) was going to…

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

Based on observation, interview, and record review, the facility failed to ensure that residents who depend on staff's assistance for their ADL (Activities of Daily Living) care and grooming receive nail care and skin care. This affects two residents (R81 and R165) in the total sample of 69 residents, reviewed for ADL care and grooming. Findings include: On 12/12/22 at 11:35am, R81 was observed awake in bed with dry peeling skin on the lower legs and long fingernails that had accumulated brownish black substances on the nail beds. On 12/12/22 at 11:32am, R165 was observed awake in bed with dry peeling skin on the legs and feet. Resident's wife complained that resident was not getting assistance with foot care and nail care. R165's fingernails are long and dirty with the left-hand middle fingernail digging into resident's palm. The care plans for both residents as dated below show that both R81 and R165 have self-care deficit, and they require assistance with ADL care and grooming: R81's care plan dated 5/5/21 R165's care plan dated 5/12/22. MDS (Minimal Data Status) Section G 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 provide foot care to residents, to prevent complications from medical conditions. This failure affected three residents (R74, R111, and R165) of five residents, reviewed for foot care and treatment, in a total sample of 69 residents. Findings include: On 12/12/22 between 11am and 1pm during observation of residents on the second floor, R74, R111, and R165 were observed awake in bed with dry peeling feet and discoloration on the long toenails. R74 has no record that the foot doctor saw the resident. R74's right foot second toenail has brownish black dot mark underneath the toe. Other toenails are long and thickened, with blackish brownish color. On 12/12/22 at 10:50am, R111 stated I need help with my toes. Toenails were long, thickened, and blackish brown. Left foot toes #3 and #4 have brownish black dot marks underneath the toes. V28 (RN/Registered Nurse) was notified. On 12/12/22 at 12:02pm, R165 was observed awake in bed. R165 complained that staff was not helping with foot care and nail care. Again, on…

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

Based on observation, interview, and record review, the facility failed to ensure that a resident receives restorative care as indicated in the assessment and care plan, to prevent further contractures of the left hand. This affects one resident (R165) of three residents, reviewed for restorative care, in a total sample of 69 residents. Findings include: On 12/12/22 at 11:45am during resident observation on the second floor of the facility, R165 was observed in bed with contracture of the left hand. R165 was asked if he (R165) was able to move his left-hand fingers that were contracted. R105 (R165's wife and roommate) stated that no one has come to help R165 with range of motion exercises for a long time. On 12/13/22 at 1:45pm, the surveyor observed resident's left hand contracted with no device in place and resident's wife again complained that no staff came to help her husband with range of motion exercises. On 12/12/23 at 2:50pm, V21(Restorative Aide) was interviewed regarding this. V21 stated that she (V21) is assigned to care for Rooms 101-117, and that the Restorative Nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement individualized fall prevention interventions for residents who were identified to be at risk for falls. This failure affected 2 residents (R113 and R129) out of 4 residents reviewed for fall injury prevention interventions, in a total sample of 69 residents. Findings include: On 12/12/22 at 11:00am, R129 was observed in bed, the bed was in a high position. Again at 12:05pm, R129 was still in bed, the bed was in a high position . R129 was not able to use the bed control to lower the bed due to cognitive status. R129's BIMS (Basic Interview for Mental Status) score was 4 out of 15 according to MDS (Minimum Data Status dated 12/6/22. V28 (RN/Registered Nurse) was notified of this. On 12/12/22 between 11am and 12:22pm, R113 was observed in bed, the bed was in a high position. At 12:25pm, R113 was not able to use the bed control to lower the bed due to cognitive status. R113's BIMS score is 0 out of 15, according to MDS dated [DATE].…

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

Based on observation, interviews, and record review the facility failed to follow dietary orders and monitor for weight loss for one resident (R173) reviewed for nutrition in a total sample of 69 residents. Findings include: R173 is 68 yr. old male admitted to facility on 9/21/22 with diagnosis including but not limited to: Major depressive disorder, Type 2 diabetes mellitus and irritable bowel syndrome. R173 has a BIMS (Brief Interview for Mental Status) score of 10/15. R173's documented admission weight was 175.2 lbs. (pounds). On 12/12/2022 at 12:25 PM, R173 was observed in dining room having a general regular single portion size lunch meal. After lunch, R173 was interviewed in his room and he (R173) stated in part, I eat fast because I have to catch the steam table before it leaves the dining room so that I can get seconds . I won't eat again until dinner, then I will starve from 5 PM to 8AM, because I don't get anything else to eat after dinner The food is not sufficient enough for me. On 12/13/2022 at 12:20pm a second lunch observation for R173 was observed by surveyor. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that residents' call light system is maintained, functional and adequately equipped to allow residents to call for staff assistance. This failure affected three residents (R109, R105 and R165) of four residents, reviewed for functional resident call system, in a total sample of 69 residents. Findings include: On 12/12/22 between 10:55am and 12:20pm during resident observation on the second floor, the call lights for R109, R105 and R165 were observed to be non-functional, and the residents could not call staff for assistance. On 12/12/22 at 11:59am, R105 complained that she (R105) and R165 (her roommate and husband) were not getting help. Surveyor asked R105 to pull the call light for help. Call light was not answered for about 15 minutes. Surveyor went to the nursing station and asked V28 (RN/Registered Nurse) about how residents' call lights function to show up at the nursing station to alert staff that residents need help. V28…

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.