Alden Estates Of Northmoor

Based on observation, interview, and record review the facility failed to follow standardized pureed recipe during food preparation. This failure has the potential to affect 4 residents (R34, R71, R95, R160) receiving pureed diets prepared in the facility's kitchen based on Diet Type Report dated 10/31/24. Findings Include: On 10/29/24 at 12:30 PM, observed vegetable soup being served with lunch meal which contained pasta, fresh spinach, carrots, and celery. Residents on pureed diets received thin broth. The pureed broth was not blended with anything. V42 (Dietary Aide) stated that is the way the pureed soup usually looks (broth only). On 10/30/24 at 10:38 AM, V37 (Chef) stated when preparing soup for a meal first, the soup is made for the regular diets and then portions of the regular soup are placed in a large strainer to separate the liquid from the solids. V38 stated the strained off liquid is then used as soup for the pureed diets. V37 stated no solids from the regular soup are given to the pureed diets only the broth is given. V37 stated the soup for the pureed diets is 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 record review and interview the facility failed to follow Influenza and Pneumococcal Immunization policy related to determining, offering, and providing the vaccine for five [R93, R124, R145, R150, R158] residents reviewed in the sample of 33. Findings Include: On 10/31/24 at 9:22 AM, R145 stated, I would like my Influenza and pneumonia shot, but I was not offered. R145's minimum data set [MDS]section [C] brief interview dated 10/9/24, indicates R145 is alert, oriented and cognitively intact. R145's MDS section [O] dated 10/9/24 indicates R145 was not offered influenza vaccine, and R145 was not eligible to receive pneumococcal vaccine. R145 is a [AGE] year-old with the following medical diagnosis in part; Peripheral vascular disease, type II diabetes, essential hypertension, and long-term use of insulin. On 10/31/24 at 9:26 AM, R158 stated, I was admitted here in July. The nurse told me they did not give out the flu shots until October, but tomorrow is November, and I have not received my flu shot, I…

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 treat 1 (R17) resident with respect and dignity by standing over the resident while assisting to eat. This failure affected 1 (R17) resident reviewed for dignity during dining observation in a sample of 33. The findings include: R17's health record documented admission date on 1/26/2018 with diagnoses not limited to Multiple sclerosis, Pseudobulbar affect, Attention-deficit hyperactivity disorder, Dysphagia oropharyngeal phase, Flexion deformity right wrist, Peripheral vascular disease, Anemia, Anxiety disorder, Bipolar disorder. On 10/30/24 at 12:36 2nd floor dining observation conducted. Observed R17 sitting in wheelchair, alert with confusion. Lunch tray observed with bread, grounded meat, and green beans. Observed V26 (Certified Nursing Assistant/CNA) standing over R17 while feeding R17 in the dining room. 2 other residents (R115 and R5) were also seated at the same table with R17. On 10/30/24 at 4:03pm V3 (DON/DIRECTOR OF NURSING) stated when staff is feeding the resident, the staff should be sitting 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 record reviews, the facility failed to follow standards of practice during medication administration for one (R63) out of three residents reviewed during medication administration observations. Findings include: R63's admission Record documents in part medical diagnoses of Alzheimer's disease; dementia; muscle wasting and atrophy; weakness; age-related physical debility; and adult failure to thrive. R63's Order Summary Report documents in part orders for Aspirin, Ferrous Sulfate, Jardiance, and Sertraline. It also documents in part that staff may crush medications if manufacturer allows or give liquids if R63 is unable to take intact dosage form. On 10/30/2024 at 9:59 AM, Observed V10 (Nurse) prepare R63's morning medications which included one tablet of Aspirin 81 mg (milligram), one tablet of Ferrous Sulfate 325 mg, one tablet of Jardiance 10 mg, and one tablet of Sertraline Hydrochloride 50 mg. At 10:04 AM, V10 placed all four tablets in a clear, plastic packet and crushed them using a pill crusher. V10 poured the crushed contents into 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.

Based on observation, interview, and record review, the facility failed to ensure incontinence care was provided in a timely manner for 1 (R66) resident who is dependent in toileting reviewed for activities of daily living (ADL) in a total sample of 33. The findings include: R66's health record documented initial admission date on 4/1/2024 with diagnoses not limited to Chronic obstructive pulmonary disease, Hypertensive heart and chronic kidney disease with heart failure, Type 2 diabetes mellitus, Unspecified atrial fibrillation, Heart failure, Atherosclerotic heart disease of native coronary artery, Hyperlipidemia, Major depressive disorder, Insomnia, Post-traumatic stress disorder, Unspecified asthma, Other sequelae of cerebral infarction, Chronic kidney disease, Gastro-esophageal reflux disease, Gout, Dependence on supplemental oxygen, Anemia. On 10/29/24 at 11:14 AM R66 was observed lying in bed on moderate high back rest with oxygen inhalation via nasal cannula at 2L(liters)/min. Alert and oriented x 3, verbally responsive. R66 said she is using an incontinence brief and is…

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

Based on observation, interview and record review the facility failed to follow plan of care and apply splint to both hands as prescribed by doctor for 1 (R136) resident reviewed for limited range of motion in a sample of 33. The findings include: R136's health record showed initial admission date on 7/21/2023 with diagnoses not limited to Permanent atrial fibrillation, Encounter for attention to gastrostomy, Hypertensive heart disease with heart failure, Chronic systolic (congestive) heart failure, Anemia in chronic kidney disease, Rheumatoid arthritis, Pressure ulcer of sacral region stage 4, Pressure ulcer of right upper back stage 4, Hypothyroidism, Adult failure to thrive, Anxiety disorder, Dependence on supplemental oxygen, Chronic embolism and thrombosis of other specified veins, Gastro-esophageal reflux disease, Adjustment disorder with mixed anxiety and depressed mood. On 10/29/24 12:04pm R136 Observed lying in bed, alert and oriented x 4, and verbally responsive. R136's hands were both contracted, with no splint or device in place. R136 stated she has crippled rheumatoid…

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 have a spare tracheostomy (trach) tube at bedside for R14 for one of two residents reviewed for tracheostomies. Findings include: R14's admission Record documents in part medical diagnoses of chronic respiratory failure with hypoxia and encounter for attention to tracheostomy. R14's Order Summary Report documents in part the type and brand of trach tube for R14. Trach size of 7.5 mm (millimeter). It also documents in part an order for Trach Care: In case of emergency, trained nurse may reinsert outer cannula of tracheostomy as needed (active 07/01/2024). On 10/29/2024 at 12:05 PM, R14 was alert and oriented to person, place, and time. During interview, R14 did not know the type of trach [R14] had or the size of the trach tube. R14 gave permission for surveyors to search tracheostomy care supplies at bedside. Surveyors did not find a spare trach tube. At 12:16 PM, V6 (Nurse) entered the room. V6 stated V6 regularly cared for R14 but could not recall the type or size of R14's trach tube. Surveyor inquired…

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 recognize and offer pain medication to resident experiencing pain and failed to update or revise comprehensive care plan to reflect resident's pain status, goals and preferences. These failures affected 1 (R35) resident reviewed for pain management in a sample of 33. The findings include: R35's health record showed initial admission date on 5/26/2021 with diagnoses not limited to Chronic obstructive pulmonary disease, Hypertensive heart and chronic kidney disease with heart failure, Heart failure, Cervicalgia, Non-pressure chronic ulcer of left calf with fat layer exposed, Type 2 diabetes mellitus with diabetic polyneuropathy, Schizoaffective disorder, Gastro-esophageal reflux disease, Chronic venous hypertension (idiopathic) with ulcer of unspecified lower extremity, Other specified peripheral vascular diseases, Anxiety disorder, Hypothyroidism, Hyperlipidemia, Other specified arthritis, Anemia, Dependence on supplemental oxygen, Chronic kidney disease, Chronic respiratory failure. On 10/29/24 At 11:36AM R35…

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 account for and dispose of controlled medications in a manner that would decrease the possibility of loss or diversion. This failure affected two residents (R2, R115) during narcotic reconciliation for one out of four medication carts. Findings include: R2's admission Record documents in part a medical diagnosis of chronic pain syndrome and osteoarthritis. R2's Order Summary Report documents in part an order for Tramadol HCl (Hydrochloride) 50 mg (milligram) one tablet by mouth every eight hours as needed for pain. R115's admission Record documents in part a medical diagnosis of polyosteoarthritis, adjustment disorder with anxiety, and encounter for palliative care. R115's Order Summary Report documents in part an order for Lorazepam 1 mg one tablet by mouth every two hours as needed for anxiety and restlessness. It also contains an order for Oxycodone HCl 5 mg one tablet by mouth every four hours as needed for pain management. On 10/29/2024 at 10:20 AM, surveyor reviewed the Team Two medication cart with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to follow their policy to complete AIMS (Abnormal Involuntary Movement Scale) Assessment in a timely manner. These failures could potentially affect one (R26) of seven residents reviewed for Unnecessary Psychotic Medication Use in a sample of 33. The findings include: R26's electronic health record (EHR) documented admission date 04/11/22 with diagnosis includes but not limited to Unspecified Dementia, Unspecified Psychosis, Unspecified Mood Affective Disorder, Dysphagia, Atherosclerotic Heart Disease. R26's MDS (Minimum Data Set) from 10/22/24 documents in part, R26 is taking high risk drug class antipsychotic on a routine basis and on 08/19/24 GDR (Gradual Dose Reduction) has been documented by a physician as clinically contraindicated. R26's Order Summary Report dated 10/31/24 documents in part, Olanzapine 7.5 mg (milligram) give 0.5 tablet by mouth two times a day related to Unspecified Psychosis with start date of 06/26/23. Review of R26's EHR…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to investigate and report an injury of unknown origin for one (R1) of three residents in a sample of four. Findings include: R1's face sheet documents R1 is an [AGE] year-old admitted to the facility on [DATE], with diagnoses including but not limited to: Hypertensive Heart Disease with Heart Failure, Spinal Stenosis, Type 2 Diabetes Mellitus, History of Falling, and Generalized Anxiety Disorder. R1's MDS (Minimum Data Set-10/21/2024) documents a BIMS (Brief Interview for Mental Status) of 10 (moderate cognitive impairment). On 10/22/2024, at 10:36 AM, R1 was observed lying in bed. Two greenish bruises/bumps to right side of his forehead and abrasion to the right side of nose was noted. R1 denied falling. R1 said approximately one week ago, a female hit him in his face with a phone. R1 said it was dark out when this occurred. R1 did not provide any other details (time, who female is). R1 said he did not report the incident. On 10/22/2024, at 12:38 PM V2…

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 two residents (R3 and R4) were provided with incontinent care as needed. This failure resulted in R3 and R4 being wet and soiled with urine for an extended period during the day shift. Findings include: R4 is a [AGE] year old with diagnosis including but not limited to: polyneuropathy, age-related physical debility, morbid obesity and history of falling. R4's BIMS (Brief Interview of Mental Status) score is 15, which indicates cognitively intact. R4's MDS - Function Abilities dated 09/18/2024 documents, R4 is dependent on facility for hygiene; R4 does not have the ability to utilize a toilet due to medical condition. On 10/15/2024 at 11:50 AM, R4 was observed lying in bed. At that time, R4 said, I need to be changed. I've been wet since 6:00 AM. I'm so tired of this happening to me. It happens all of the time. I just want to be treated like a human. They tell me that I need to wait for my turn to be changed. On 10/15/2024 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review the facility failed to ensure that one resident (R1), who has a tracheostomy, was supervised while eating as recommended by Speech Therapy. This failure has the potential to affect thirteen other residents who require feeding assistance in the facility. Findings include: R1 is [AGE] year old with diagnosis including but not limited to: Encounter for attention to tracheostomy, age related physical debility, malignant neoplasm of thyroid gland, paralysis of vocal cord and larynx. R1 has a BIMS (Brief Interview of Mental Status) score of 15, which indicates cognitively intact. On 10/15/2024 at 12:50 PM, R1 was observed in bed having lunch. At that time, no staff member was monitoring R1 while eating. Surveyor asked R1 if any staff usually monitored R1 for choking during meals. R1 said No, no one monitors me while I eat. I can just pull my call light if I ever feel like I may choke. I'm not worried about it because I just eat small bites of food so that it's easier…

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 Fire Watch policy by failing to provide all staff with an in-service related to Fire Watch and fire safety procedures and failed to notify the Fire Department and State Health Agency after all systems have been restored. These failures have the potential to affect all 175 residents and facility staff safety related to fire safety emergencies. Findings include: On 9/24/2024 at 9:31 AM, V1 (Administrator) stated that the box for the water sprinkler has a problem. If the water sprinkler will turn on, it will be low pressure after 7 minutes. The fire department needs to come and connect a water hose to help water pressure in the sprinklers. We (the facility) were on fire watch. On 9/24/2024 at 1:42 PM, surveyor requested to meet with V3, listed as Building Manager on the facility directory provided by V1. V1 stated that V3 had not worked in the facility for quite some time and the best person to answer questions is either him (V1) or V4 (Corporate Maintenance). V1 stated that fire sprinklers were 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 interview and record review, the facility failed to provide appropriate adaptive equipment during transfer of a resident which resulted with the resident falling and sustaining a bruise and an abrasion on the resident's knees. This failure affected 1 (R1) resident reviewed for use of adaptive equipment in the total sample of 5 residents. Findings include: R1's (06/05/2024) Fall documented, in part Staff notified nurse that the resident is on the floor in the shower room. Immediate Action Taken. Description: Body assessment done(,) noted with small superficial abrasion to left knee, no bleeding and small bruise to right knee. Notes. 6/6/2024. (R1) is dependent on transfer with (mechanical lift). (R1) has history of falling. On 6/5/2024, CNA (certified nursing assistant). was going to give a shower to the resident, resident was standing up holding on to the side rails in the shower room and going to transfer to the shower chair, resident(')s legs gave in and was assisted to the floor by the CNA. Head 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 turn and reposition as identified in the care plan for one resident (R4) out of three residents reviewed who are identified as at risk for development of pressure injuries. Findings include: On 05/25/2024 between 9:23 AM to 11:34 AM, no observations of staff helping R4 to turn and reposition. On 5/25/24 9:23 AM observed R4 lying on her bed, on her back, sleeping. On 5/25/24 11:34 AM observed R4 laying on her bed, laying on her back, wearing a yellow gown. R4 states that she needs assistance with getting cleaned up and to turn to different positions because R4 states that she is unable to do it by herself. R4 states that her skin has kind of cleared up. R4 states that she used to have a lot of blisters. R4 states that the last time she was changed was during the night shift. R4 states that she has not been moved or repositioned since the last time they changed her in the night shift. R4 states that staff have not been in her room to ask…

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

Based on observation, interview and record review the facility failed to properly label and date food items stored in the refrigerator. This failure has the potential to affect all residents residing in the facility that receives meals from the kitchen. Findings include: On 10/22/2023 at 9:23am surveyor observed food items listed below with no use by date on any of the items. 1 Medium sized metal pan with salad mix-10/21/2023 2 large pans of beef with orange sticker-10/21/2023 2 large pans of lemon and 2 large pans of orange gelatin with no date and not covered. 2 stacks of yellow cheese slices, 2 stacks of ham slices wrapped in saran wrap with no date on it. 1 square pan of pudding (8 cups) with 10/11/2023; 1 round silver tray of 26 cups of pudding with 10/11/2023. 1 medium sized steel pan of Pureed fruit-10/21/2023 1 medium sized steel pans of Tomato Paste with a date of 10/15/2023 and a use by date of 10/21/2023 1 medium sized steel pans of Ketchup (10/18/2023), Jelly (10/19/2023), Oil/Garlic mixture (10/20/2023), Garlic mixture (10/20/2023), peas and carrots (10/21/2023). 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 secure lids on the external garbage dumpster. This failure has the potential to affect all residents residing in the facility. Findings include: On 10/22/2023 at 12:44pm surveyor observed the lid for the middle section of the dumper open. On 10/23/2023 at 11:03am surveyor observed the garbage dumpster with the two outer lids open. On 10/23/2023 at 11:37am V4 (Dietary Manager) stated, the lids should be closed on all dumpsters to prevent rodents from entering the dumpsters. Groundskeeping policy with a revised date of 1/23 documents, in part, the facility grounds will be kept free of trash and debris through regular inspection and maintenance and dumpster lids and corral doors will be kept closed at all times.

Based on observation, interview and record review, the facility failed to eliminate the hazard of unsecured medication being accessible to residents in the facility which has the potential to affect the 49 residents residing on the 4th floor. Findings include: On 10/22/23 at 12:45 pm, this surveyor observed a capsule pill, pale yellow in color with 215 marking on the pill in blue color (in no packaging) on the hallway floor (hardwood) outside the dining room in front of a seating bench and the communal bathrooms. This surveyor called over V11 (Admissions Director) to where this surveyor was standing in hallway, pointed to the unsecured pill, and asked V11 about the pill on the floor? V11 stated, It looks like a pill, but I (V11) am not clinical. V11 stated, V11 would get the nurse and called V6 (Licensed Practical Nurse, LPN) over to this surveyor in the 4th floor hallway outside the dining room. This surveyor pointed to the pill on the hallway floor asking about the pill on the floor. V6 stated, It's medication. When asked what medication it was, V6 stated, It looks like…

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 two licensed personnel conducted a physical inventory of controlled substances at each change of shift. This failure has the potential to affect all 24 residents receiving medications from the 3rd Floor side two medication cart. Findings include: On 10/24/2023 at 11:00 am review of the 3rd floor, side 2, medication cart with V27 (LPN/Licensed Practical Nurse) surveyor observed the controlled substance shift count documentation form for October 2023. The signature in the off duty box was left blank for October 1, 2023, first shift, indicating the controlled substance shift count documentation at the end and beginning of the shift was not completed. On 10/24/2023 at 1:25pm V3 (DON/Director of Nursing) stated, the outgoing and oncoming nurses are to count the controlled substance medications together. V3 stated, the on-coming and outgoing nurses are to sign the controlled substance shift count documentation form once the count of the controlled substances is correct. V3 stated, the nurses on duty are…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident's call light was accessible within reach to call for staff assistance which affected two (R53 and R149) in the sample of 59 reviewed for accommodation of needs. Findings include: 1) On 10/22/23 at 10:35 am, R53 observed awake lying in bed, and R53's call light is not visible. R53 asked if R53 needed help and if so, how does R53 call for help from staff. R53 stated, R53 cannot see the call light. This surveyor then activated the bathroom call light in R53 and R149's room. On 10/22/23 at 10:36 am, V5 (Assistant Director of Nursing, ADON) responded to R53 and R149's room. This surveyor asked V5 where R53's call light was located since it was not visible to this surveyor or R53. V5 then squatted down towards floor and traced R53's call light cord from the wall and pulled the cord from the floor through bed frame. After retrieving R53's call light, V5 placed the call light button next to R53 by pinning it on the bed sheet…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to label the use date for gastrostomy tube (G-tube) piston syringe bottle and failed to discard G-tube piston syringe bottle after one week per facility policy which affected two (R53 and R66) residents reviewed for tube feedings in the sample of 59 residents. Findings include: R53's admission Record, documents, in part, diagnoses of dementia, attention for gastrostomy, type 2 diabetes mellitus, atrial fibrillation, schizoaffective disorder, right eye nuclear cataract, dysphagia, right ear hearing loss, chronic kidney disease (stage 2), spondylosis, and osteoarthritis. R53's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview for Mental Status (BIMS) score of 3 indicating that R53 has severe cognitive impairment. R53's Nutritional Status for nutritional approaches includes a feeding tube. R53's Care Plan, dated 9/23/22, documents, in part, a focus of (R53) requires tube feeding with an intervention of check placement…

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

Based on observation, interview and record review, the facility failed to properly date oxygen tubing and failed to ensure the humidifier bottle was not empty. These failures affected two residents (R105 and R126) reviewed for oxygen equipment, in a total sample of 59 residents. Findings include: R105 has a history of respiratory failure with hypoxia, heart failure, cardiomyopathy, and dependence on supplemental oxygen. R105 BIMS (Brief Interview for Mental Status) dated 10/2/23 score is 13. R105 is cognitively intact. On 10/22/23 observed R105 lying in bed receiving oxygen thru an oxygen nasal tube at 3 ½ liters. R105's humidifier bottle was undated and empty. R105 stated, the humidifier bottle had been empty for a couple of days. R105 said had told the CNA to tell the nurse that he needed some water in the bottle. R105's Active Orders as of 10/24/23 documents in part, Respiratory: Oxygen per nasal cannula at 2-3 liters per minute continuous every shift. R105's care plan date 8/8/23 documents in part, R105 requires oxygen therapy related to diagnosis of acute respiratory failure.…

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 properly label multidose medication with discard date and failed to follow policy for discontinued medication for one (R90) resident. These failures affected R90 reviewed for medication storage and labeling in the total sample of 59 residents. Findings include: On [DATE] at 10:47am, during the medication cart observation task with V26 (Licensed Practice Nurse) of the medication cart labeled 1st floor, side 2, observed R90's Novolog pen with open date 10/11 and exp (Expire) 11/27. On [DATE] at 10:48am, V26 stated, I (V26) know insulin should be discarded after 28days upon opening. Whoever opened the insulin did not calculate the discard date right. On [DATE] at 11:15am, V3 (Director of Nursing - DON) stated for insulin, except Levemir, the expectation is to the label it with the date it was opened and to label with the discard date which is 28 days upon opening. The purpose of labeling the insulin is to know the expiration date of 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 the call light system was functioning which affected one (R76) resident in the sample of 59 residents. Findings include: R76's admission Record, documents, in part, diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, Alzheimer's disease, dementia, dysphagia, history of falling, type 2 diabetes mellitus, chronic kidney disease, dependence on supplemental oxygen, diastolic (congestive) heart failure and depression. R76's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview for Mental Status (BIMS) score of 5 indicating that R76 has severe cognitive impairment. R76's Functional Status for Activities of Daily Living (ADL) assistance for bed mobility is coded as extensive assistance for self-performance and coded as one-person physical assist for staff support. R76's Care Plan, dated 7/14/23, documents, in part, a focus of (R76) is at risk for falls with an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain parameters for antihypertensive medications for one of three residents (R1) reviewed for antihypertensive medications. Findings include: R2's medical record (Face Sheet) documents R2 is a [AGE] year-old admitted to the facility on 9.6.2023 with diagnoses including but not limited to: Hemorrhage affecting right dominant side, Dysarthria following nontraumatic intracerebral hemorrhage, Aphasia following nontraumatic intracerebral hemorrhage, and Encounter for attention to colostomy. R2's MDS (Minimum Data Set of 9.13.2023) documents R2 is cognitively intact, is totally dependent/2+persons physical assist for bed mobility, transfers, and toilet use, and is frequently incontinent of urine/has a colostomy. 10.18.2023 at 1:40 PM and 10.20.2023 at 9:50 AM, V2 (DON-Director of Nursing) said, They (R2's Family Members) are hyper fixated on her blood pressure because she had a stroke. They wanted an outside doctor to follow her blood pressure, we agreed.…

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 perform colostomy care consistent with professional standards for one of three residents (R2) reviewed for colostomy care. Findings include: R2's medical record (Face Sheet) documents R2 is a [AGE] year-old admitted to the facility on 9.6.2023 with diagnoses including but not limited to: Hemorrhage affecting right dominant side, Dysarthria following nontraumatic intracerebral hemorrhage, Aphasia following nontraumatic intracerebral hemorrhage, and Encounter for attention to colostomy. R2's MDS (Minimum Data Set of 9.13.2023) documents R2 is cognitively intact, is totally dependent/2+persons physical assist for bed mobility, transfers, and toilet use, and is frequently incontinent of urine/has a colostomy. 10.18.2023 at 3:35 PM, R2 was observed, awake, alert, neat and clean, sitting up in bed. V16 was noted to be oval and irregularly shaped. R2 (R2's Family Member) was sitting at R2's bedside and answered most questions for R2 as R2 has…

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

Based on interview and record review, the facility failed to ensure a resident (R1) was free from resident-to-resident physical abuse. This failure affected R1 reviewed for physical altercation with another resident, who sustained a redness on right side of face. Findings include: R1's (7/4/2023) # 1520 Physical (Risk Management) documented, in part: Nursing Description: while coming back from another resident's room I heard a scream in the hall way, and noted another resident struck (R1) on the right side of her (R1) eyes. Immediate Action Taken. Description: Resident immediately separated, assessed for any injury, a little bruising noted, ice pack was placed on it. Authored by V19 (Licensed Practice Nurse). On 09/21/2023 at 11:07am, V19 stated, I (V19) remember I (V19) was passing the medication, before or after dinner; between 4pm-6pm when I (V19) heard (R5) screaming. (R5) usually sits close to the nurse's station, and usually (R1) walks. The CNAs and other staff were seated by the nurse's station supervising the residents. (R5) screamed because (R1) was getting in her (R5)…

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 report an injury of unknown origin to IDPH (Illinois Department of Public Health) within regulatory requirements. This failure affected one resident (R3) reviewed for reporting of injury of unknown origin. Findings include: R3's admission Record documented that R3's diagnoses include but not limited to multiple sclerosis, paraplegia, fracture of left femur, disorder of bone density and structure, localized osteoporosis, and dementia. R3's (08/07/2023) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 02. Indicating R3's mental status as severely impaired. V2 (Director of Nursing)'s (08/02/2023) email correspondence with State Agency documented, in part Sent: Wednesday, August 2, 2023, 9:18 PM. Subject: Initial Report. Attachments: (R3) Initial 8-2-23. R3's (8/2/2023) Initial reportable documented, in part MD (medical doctor) ordered x-ray of L (left), L hip, and L rib. X-ray results showed a fracture of the distal shaft of L femur. R3's…

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

Based on observation, interview, and record review, the facility failed to ensure one resident (R2) was not layered properly while lying on a low air loss mattress; and failed to ensure the low air loss mattress was set at the recommended setting for one resident (R3). These failures affected two residents (R2 and R3) reviewed for prevention of pressure injury/ulcer in the total sample of 9 residents. Findings include: 1. On 09/18/2023 at 11:15am, R2 was lying on a low air loss mattress setting was at 130 lbs., alternating every 10-15 minutes. On 09/18/2023 at 11:20am, V9 (Licensed Practice Nurse) checked (R2's) incontinence brief. (R2) was wearing a blue incontinence brief and a yellow incontinence brief. The low air loss mattress was layered with a quad folded blanket and a flat sheet. V9 stated, our policy is to use just one incontinence brief to prevent sore. On 09/18/2023 at 11:38am, V11 (Wound Care Coordinator) stated, the purpose of the low air loss mattress is to alleviate pressure, minimize moisture and to prevent skin breakdown. Low air loss mattress should be layered 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.