Aliya On 87th

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, facility failed to follow their policy and did not notify resident's legal representative/guardian about a fall incident for one resident (R1) in the final sample of 8 residents reviewed for quality care/treatment.On 1/20/2026 during complaint investigation for allegation of quality care, record review, and interviews showed in part, that R1's legal guardian was not notified of R1's fall incident on 4/8/2025, and instead, R1's second emergency contact was left a phone message, and no other notification was documented.On 1/20/2025 at 10:05 AM, confirmed that R1 no longer resides in the facility.R1 was discharged [DATE].On 1/20/2026, R1's admission record sheet showed in part that R1 was admitted to the facility on [DATE] from acute care hospital and that R1's contacts information included, but not limited to a family member as a second emergency contact and V25 (Legal Guardian/Case Manager) as R1's state appointed legal guardian and a case manager.R1's admission record…

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, facility failed to follow their policy to ensure residents are free from physical and verbal abuse by not providing necessary care, resulting in a staff worker being physically rough during activities of daily living (ADL) care and being verbally abusive to one resident (R1) out of three residents reviewed for abuse in a sample of four.Findings include:On 12/09/2025, surveyor observed R1, R2 and R3 share a room. On 12/09/2025 at 10:00 AM, surveyor observed R1 in his room. R1 stated that this past Saturday night a CNA comes into my room because apparently the light was on. She comes in and says, What is it that you want?. R1 replied saying, I don't like to be treated that way. The CNA then says, I don't have time to fool around with you. I have other patients to see. Are you going to be pushing that call button all night because I don't have time for you? R1 replies saying that the call button wasn't even near him and that he didn't push the call button. R1 stated that he told her to get the F* out. The CNA then says, Don't be cursing at me. R1…

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, facility failed to ensure activities of daily living (ADL) are provided for dependent residents by getting them out of bed for one (R1) out of three residents reviewed for ADL care in a sample of four. Findings include: On 12/09/2025 at 10:00 AM, surveyor observed R1 in his room. Surveyor did not see R1's wheelchair in his room or near his room. R1 was lying in bed still with his night gown on. R1 stated that he wants to get out of bed, but they won't put him in his wheelchair. R1 stated that he doesn't know where his wheelchair is.On 12/10/2025 at 10:30 AM, surveyor again observed R1 lying in bed with the same night gown on. R1 stated that he wants to get out of bed, but no one has gotten him up.R1's Minimum Data Sheet Section C (12/5/2025) documents in part: R1 has a Brief Interview of Mental Status (BIMS) score of 12. R1 is cognitively intact.On 12/10/2025 at 11:15 AM, V5 (Licensed Practical Nurse) stated that she is familiar with R1. V5 stated that R1 can get out of bed but he usually refuses to get out of bed.On 12/10/2025…

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 the fall prevention interventions for cognitively impaired residents who are also at risk for falls. This failure has the potential to affect 5 residents, R3, R4, R5, R6, and R7 out of 7 reviewed for proper footwear as a fall prevention intervention. Findings include: On 5/27/25 at 11:20am during observation of residents in the second-floor dining room, the following were observed: R3 was observed sitting in the wheelchair in the day room with white socks that are smooth on the bottom. R4 was observed sitting in the wheelchair in the day room with other residents with grey/white socks that are smooth on the bottom. R5 was observed sitting in the wheelchair in the day room with other residents with grey/white socks that are smooth on the bottom. R6 was observed sitting in the wheelchair in the day room with other residents with dark grey socks that are smooth on the bottom. R7 was observed sitting in the wheelchair in the day room…

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 record review and interview the facility failed to follow their abuse policy for two residents (R1,R2,) out of four residents reviewed for abuse. This failure resulted in staff members not immediately intervening in a situation where residents became abusive to each other. Staff did not intervene in time resulting in R1 and R2 engaging in a physical altercation that lead to them both putting scratches/abrasions on each other's faces. Finding Include: R1's wound assessment sheet dated 4/25/25 reads upon assessment writer noted skin alteration to face. Classification abrasion. Doctor made aware , staff to continue to monitor. R1s Nursing Note 4/25/2025 08:35 reads: was notified of the situation that occurred and will notify the rest of her family. MD has also been notified.MD wants wound care to evaluate and treat. Resident does not need to go out to the hospital at this time. Resident was separated and in stable condition. No c/o(complaints of) pain or discomfort at this time. First aid applied. R2's wound assessment sheet dated 4/25/25 reads upon assessment writer noted…

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 notify a resident's responsible party about a room change prior to being moved to a new room on a different unit within the facility. This affected one (R1) of one resident reviewed for resident rights. Findings include: R1 was initially admitted to 1st floor nursing unit on 12/03/24 and has diagnosis which includes but not limited to Neurocognitive Disorder with Lewy Bodies, Type 2 Diabetes Mellitus, Cerebral Infarction, Personal History of Transient Ischemic Attack, Unspecified Dementia With Other Behavioral Disturbance, Age-Related Osteoporosis, Unspecified Severe Protein Calorie Malnutrition, Difficulty Walking, Lack of Coordination, Dysphasia, Generalized Anxiety, Unspecified Psychosis. R1's MDS (Minimum Data Set) assessment dated [DATE] documents in part, resident is rarely/never understood. BIMS (Brief Interview for Mental Status) was not able to be conducted. R1's electronic health record (EHR) lists R1's daughter, V16 as R1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and review of records the facility failed to ensure proper supervision and monitoring was provided to 1 (R1) out of 3 residents reviewed for risk of elopement. Facility also failed to establish preventive measures for recurrent of elopement to the same resident (R1). These failures are not in accordance with elopement and out on pass policies of facility. Failures affected 1 resident (R1) who was able to leave premises of facility without authorization or awareness of facility staff. Findings include: R1 is [AGE] years old, initially admitted on [DATE] in the facility. R1's medical diagnosis includes cerebral infraction, diabetes mellitus, dementia, and pathological gambling. Facility document titled State Report of Abuse Allegation reads: On 12/29/2024 R1 was unable to be found in the facility. Facility suspected daughter (V4) took R1 out. Final addendum reads that it was determined that R1 was assisted in exiting the facility into the casino but does not mention who took R1.…

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 posted nursing staffing information was accurate and failed to ensure the posted staffing information included all required data. This failure affects all 190 residents residing within the facility. Findings include: Record review of facility census documentation indicates that 189 residents reside within the facility. On 1/5/2025 at 9:50 AM, observed posted nursing staffing information near the front door of the facility. The posted nursing staffing information was dated for 1/3/2025 (incorrect date) and did not have the facility's name, or current census numbers. No other staffing information (other sheets) were noted to be dated 1/5/25 behind the 1/3/2025 staffing posting. On 1/6/2025 at 1:31 PM, V38 (Staffing Coordinator) affirmed that V38 is responsible for updating the staffing information and that the receptionist is responsible for updating it on the weekend. V38 stated that the staffing information for the weekend is located behind the staffing posting and the receptionist just pulls it…

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 snacks to the facility's residents when the duration between meals (dinner and breakfast) exceeded 14 hours. This failure affects all 190 residents that reside within the facility. Findings include: Record review of facility census documentation indicates that 189 residents reside within the facility. Record review of facility mealtimes documents in part, first floor meal times (7:30 AM, 11:30 AM, and 4:45 PM), second floor meal times (7:45 AM, 11:30 AM, and 5:00 PM), and third floor meal times (7:45 AM, 11:30 AM, and 5:00 PM). This indicates that the mealtimes are greater than 14 hours. On 1/6/2025 at 10:42 AM, during the resident council meeting, all residents present unanimously affirmed that the facility does not serve snacks and that they would want snacks if they were available. R114 stated that if the facility does have snacks, there is never enough for all the residents. On 1/7/2025 at 10:40 AM, V1 (Administrator) stated that snacks are served nightly to all the floors. Surveyor requested documentation from…

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 environment was free from hazards. This failure has the potential to affect all 46 residents on the first-floor unit. Findings include: On 01/05/25 V2 (Director of Nursing, DON) presented a facility census of 46 residents on the first-floor unit. On 01/05/25 at 11:00 am, Surveyor toured the first-floor unit and observed three oxygen cylinder tanks across from the first-floor nursing station, free standing and not in a holder. On 01/05/25 at 11:04 am, Surveyor brought this observation to V20 (Registered Nurse, RN, Weekend Supervisor) and V20 stated that when oxygen is not in use it should be stored downstairs in the oxygen room. Surveyor and V23 observed one of the three oxygen tanks, full, with 2000 psi (pounds per square inch) and two oxygen tanks with 1000 psi. When V20 was asked regarding what can happen if an oxygen cylinder tank is free standing and not in a holder, V20 stated that oxygen tanks should be in a holder because they can tip over and explode. On 01/07/25 at 9:41 am, 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.

Based on observation, interview and record review the facility failed to properly label, date and store prepared food items and store unthawed meats, to complete daily temperature logs to prevent the spread of foodborne illnesses. This failure has the potential to affect all residents receiving oral nutrition. Findings include: On 1/5/2025 surveyor observed the temperature logs for the refrigerator, freezer and cooler missing temperatures (morning and afternoon) for 1/1/2025-1/03/2025 and the afternoon temperatures for 1/05/2025. On 1/5/2025 at 9:18am surveyor observed 5 long steel pans of flavored gelatin (2 raspberry, 2 orange and 1 green) that was not dated and uncovered. On 1/5/2025 at 9:18am V5 (Cook)stated the flavored gelatin was made last night and it should have a date and that it should not have a covering because it would not set right. On 1/5/2025 at 9:22am surveyor observed 2 uncovered black tubs of pork chops, out of the original packaging, sitting on the bottom shelf in the refrigerator. The first tub was sitting on top of the second tub of pork chops uncovered. 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 observations, interviews, and record reviews, the facility failed to ensure staff don appropriate PPE (personal protective equipment) prior to performing ADL (activities of daily living) care to 3 (R100, R139, and R189) residents; and failed to ensure an EBP (enhanced barrier precaution) sign was posted for 2 (R53 and R189) residents on EBP. These failures affected 4 residents (R53, R100, R139, and R189) reviewed for infection control and has the potential to affect all the residents on 2nd floor and 3rd floor. Findings include: The (01/05/2024) facility census documented that there were 71 residents on the 2nd floor and 72 residents on the 3rd floor. On 01/05/25 at 10:35 AM, surveyor inquired about the acuity of the floor, V10 (Restorative Director) stated (R53) and (R189) have an indwelling catheter. On 01/05/25 10:37 AM, there was no EBP sign posted by R189's door. On 01/05/25 at 10:40 AM, this observation was pointed out to V10. V10 stated there is no EBP sign posted by his (R189) room. Anyone who has a gtube, foley, and wound should have an EBP sign posted. Informed…

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 interview, the facility failed to follow their own policy of getting a physician' order and completing a care plan when initiating resident self-administration of medication. This failure affected 1 (R53) resident reviewed for self-administration of medication and has the potential to affect all residents on the 3rd floor. Findings include: The (01/05/2024) facility census documented that there were 72 residents on the 3rd floor. On 01/05/25 at 10:52 AM with V10 (Restorative Director), there was a container of Nystatin Powder on top of R53's nightstand. R53 stated I have a rash at the back of my thigh. Nobody taught me how to apply the medication. Somebody is doing it for me. This surveyor requested V10 to read the label on the container and stated this is Nystatin Powder. It has to be applied every morning and at bedtime. V10 shook the container and stated there is still some powder inside the container. On 01/05/25 at 10:55 AM outside of R53's room, V10 stated there…

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 prevention policy and failed to report abuse to the state survey agency within required time parameters. This failure affects 1 resident (R45) in a sample of 74 residents. Findings include: R45's admission record documents in part the following diagnosis: right-sided hemiplegia, type 2 diabetes mellitus, unspecified dementia without behavioral disturbance, cerebral infarction. R45's minimum data set (11/18/2024) documents in part a brief interview of mental status score of 13, indicating that resident is cognitively intact. On 1/5/2025 at 10:40 AM, R45 was observed lying in bed. Observed bruises to R45's left wrist and inner forearm. R45 stated that the bruises were from the staff handling me (R45) too rough and began to cry. R45 could not name a staff member or a time when this occurred. Additionally, R45 stated that R45's nurse (V40, Registered Nurse) had yelled at him this morning and had threatened him saying if you don't take your fucking medication, I will not help you!. On 1/5/2025 at 10:50 AM, V1…

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 Pre-admission Screening and Resident Reviews (PASRR) was completed prior to resident's admission for one resident R137. This failure affects 1 (R137) resident in a sample of 74. Findings include: R137 has a diagnosis of but not limited to Hemiplegia and Hemiparesis, Aphasia, Vascular Dementia, Bipolar Disorder, Major Depressive Disorder and Weakness. R137 has a Brief Interview of Mental Status score of 08. R137's admission date is 12/07/2021. On 1/05/2025 surveyor could not find in the facility's electronic records a PASRR for R137. On 1/6/2025 at 12:20pm V41 (admission Coordinator) stated that R137 was admitted prior to the start of the Maximus program and his information was not submitted to the program. V41 also stated that staff will be coming out soon to complete the Level ll determination than the care plan will be updated with their recommendations. On 01/06/25 at 1:49 pm V41 stated that they did not have a PASRR for R137 and that they (facility) initiated a new PASRR after the start of the survey 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 review the baseline care plan with the resident/resident's representative and failed to provide a copy of the baseline care plan to the resident/resident's representative. This failure affects 1 resident (R398) in a sample of 74. Findings include: Record review of R398's face sheet documents in part the following diagnosis: gout, type 2 diabetes mellitus, end stage renal disease, chronic obstructive pulmonary disease, Alzheimer's disease, heart failure. Record review of R398's minimum data set (dated 1/7/2024) documents in part a brief interview of mental status (BIMS) summary score of 11, indicating resident is cognitively impaired. On 1/5/2025 at 11:42 AM, V39 (R398's family member) stated that V39 was upset because we don't really know what's going on. V39 clarified, stating that V39 and R398 were confused about R398's plan of care. R398 and V39 affirmed that R398 has not been provided a copy of R398's baseline care plan or invited to participate in…

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 a person center care plan focus PASRR (Pre-admission Screening and Resident Reviews) for one resident (R137). Findings include: R137 has a diagnosis of but not limited to Hemiplegia and Hemiparesis, Aphasia, Vascular Dementia, Bipolar Disorder, Major Depressive Disorder and Weakness. R137 has a Brief Interview of Mental Status score of 08. R137's admission date is 12/07/2021. R137's Order Summary Report with active orders as of 1/6/2025 documents, in part, Escitalopram Oxalate oral tablet 5mg daily (Major Depressive Disorder) and Quetiapine Fumarate oral tablet 3 times a day for Bipolar Disorder. R137's Level I PASRR (Pre-admission Screening and Resident Review) dated 1/5/2025, documents, in part, diagnosis of Major Depression and Bipolar disorder and PASRR Level 1 Determination: Refer for Level ll onsite. R137's care plan focus-PASRR Level 2 dated 1/5/2025 documents, in part, R137 has been screened by an agency and determined to have persistent mental illness and require LT (long Term Care) placement. Level 2…

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

Based on observation, interview and record review the facility failed to provide ADL care (Activities of Daily Living) to two dependent residents (R137, R176) to maintain grooming and personal hygiene. This failure affected two residents (R137, R176) in a sample of 74 residents. Findings include: R137 has a diagnosis of but not limited to Hemiplegia and Hemiparesis, Aphasia, Vascular Dementia, and Weakness. R137 has a Brief Interview of Mental Status score of 08. R176 has a diagnosis of but not limited to Myopathies, Dysphagia, Hypo-Osmolality and Hyponatremia, Glaucoma, Hypertension, Lack of Coordination and Megaloblastic Anemia. R176 has a Brief Interview of Mental Status score of 15. R176's admission date 7/15/2024. R176 census documents that she has been in her current room (307-1) since 11/06/2024. On 1/05/2025 at 11:02am surveyor observed R176 with facial hair, and long fingernails on both hands. On 1/05/2025 at 11:05am R176 stated that she had not had a shower since she's been on this floor, and they (facility staff) offered to shave the hair off her face once, but they never…

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 Low Air Loss Mattress were set based on the resident's weight. This failure affected 1 resident (R100) reviewed for pressure ulcer/injury prevention and treatment in a sample of 74 residents. Findings include: R100's diagnoses include but not limited to Alzheimer's, Atherosclerotic Heart Disease, hypertension, and chronic kidney disease. R100's (10/31/24) MDS (Minimal Data Set) documents in part, Section C: Brief Interview of Mental Status (BIMS) score is blank. Section M: Skin Condition 1. Number of Stage 4 pressure ulcer - 1 checked in box. On 1/5/25 at 10:25 am, R100 was lying on a low air loss mattress with a setting at 300. R100's monthly weight report documents in part, November 2024 weight 132.4, December 2024 weight 133.6 and January 2025 weight 132.8. R100's (11/18/24) care plan documented in part, Focus: R100 has a pressure injury R/T (Related/To) self-care deficits impaired mobility and comorbidities DX (Diagnosis)of Alzheimer's, CKD (Chronic Kidney Disease), Covid-19, HTN (Hypertension),…

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 foot care for one resident (R64) who is dependent on staff for Activities of Daily Living (ADL) care (foot care). This failure affected one resident reviewed for foot care in the total sample of 74 residents. Findings include: R64's Face sheet shows that R64 has diagnosis which include but not limited to pain in right knee, rheumatoid arthritis, generalized osteoarthritis, and essential hypertension. R64's Brief Interview for Mental Status (BIMS) dated 11/25/24 shows that R64 has a BIMS score of 12 which indicates that R64 has moderate cognitive impairment. On 01/06/25 at 11:18 am, Surveyor observed R64 in bed awake and alert. Surveyor observed R64's right and left foot toenails, long, thick, and ridged (ungroomed, in need of foot care). Surveyor also observed R64's right great toe and second toenails with a white dry substance, and white tissue paper adhered to R64's right great toe and 2nd toe. R64 stated, They hurt (referring 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 label and date oxygen equipment (nebulizer mask); failed to change oxygen tubing (nasal cannula tubing) per facility policy; and failed to properly contain oxygen equipment (nebulizer mask). These failures affected two residents (R132 and R349) reviewed for oxygen equipment, in a total sample of 74 residents. Findings include: R349's face sheet shows that R349 has a diagnosis which includes but not limited hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side, acute congestive heart failure, and hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease. R349's Brief Interview for Mental Status (BIMS) dated 01/02/25 (in progress) shows that R349 has a BIMS score of 15 which indicates that R15 is cognitively intact. On 01/05/25 at 11:05 am, R349 was observed in bed awake, alert, and oriented. Surveyor observed R349 with a nebulizer mask undated and uncontained on R349's nightstand. When R349 was asked when the last time R349 used R349'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 follow policy of reconciling controlled substances at the end of the shift. This failure has a potential to affect all 3 residents (R116, R144, and R172) receiving controlled substances on the 2nd floor. Findings include: Facility presented Shift Change Accountability Record for Controlled Substances dated January 2025 on the 2nd floor medication cart containing medications and controlled substances for rooms 201 to 218 which was missing a signature to verify a controlled substance count was conducted during the 3rd shift to shift change on 1/5/2025. Facility presented a list of residents recorded on the Shift Change Accountability Record For Controlled Substances on the 2nd floor receiving controlled substance medication which includes R172, R116 and R144. On 1/6/2025 at 10:45 am, observed 2nd floor medication cart missing narcotic count on 3rd shift dated 1/5/2025. V29, Licensed Practical Nurse (LPN), stated that the narcotic count is done shift to shift by the oncoming and outgoing nurse. On 1/7/25 at 11:00…

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 upon observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that prescribed medications are available for two of three residents (R1, R3) reviewed for pharmacy services, failed to ensure that the location of medication in the convenience box is accurate, and failed to ensure that staff utilize the convenience box when medications are unavailable in the medication cart or not received from pharmacy. These failures have the potential to affect 191 residents. Findings include: On (9/24/24) IDPH (Illinois Department of Public Health) received allegations that a resident has not been receiving prescribed medications and the facility blames the pharmacy for medication issues. The (10/2/24) facility census includes 191 residents. On 10/2/24 at 2:50pm, surveyor inquired about medication administration concerns at the facility V6 (Family) stated When my mother (R1) got there, they (facility) didn't have her medication. The Nurse said the medication wasn't there.…

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 upon observation, interview, and record review the facility failed to ensure that five of thirteen residents (R1, R3, R8, R9, R10) in the sample remained free of significant medication errors. Findings include: On (9/24/24) IDPH (Illinois Department of Public Health) received allegations that medications (including antihypertensive and hypoglycemic) are not administered at the facility as ordered. R1's (9/27/24) BIMS (Brief Interview Mental Status) determined a score of 9 (moderate impairment). On 10/2/24 at 9:49am, surveyor inquired if prescribed medications are received as ordered R1 stated I don't know. On 10/2/24 at 2:50pm, surveyor inquired about facility concerns V6 (Family) stated When my mother (R1) got there (facility) they (staff) didn't have her medication. The Nurse said the medication wasn't there. R1 was admitted [DATE] with hypertensive heart disease and type II diabetes mellitus. R1's POS (Physician Order Sheets) include but not limited to the following significant medications 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.

Based upon record review and interview the facility failed to ensure that a baseline care plan includes required ADL (Activities of Daily Living) care assistance for one of three residents (R1) reviewed for quality of care. Findings include: On (9/24/24) IDPH (Illinois Department of Public Health) received allegations that a resident residing in the facility has no plan of care. R1 was admitted (9/20/24) with diagnoses which include but not limited to morbid obesity, cerebral infarction, and history of falling. On 10/2/24 at 9:49am, surveyor inquired why R1 was admitted to the facility, R1 stated I had a stroke. R1 affirmed she now has left sided weakness and requires physical therapy. R1's (9/25/24) Care Conference states resident is receiving physical therapy. Physical Therapy focus: bed mobility and transfers. R1's (9/27/24) functional assessment affirms resident is dependent on staff for sit to stand, chair/bed to chair transfer, and toilet transfer. Dressing requires substantial/maximal assistance. R1's care plan (initiated September 2024) includes self-care deficit, impaired…

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 upon observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that care requirements are documented in the plan of care, failed to implement care plan interventions, and failed to provide timely ADL (Activities of Daily Living Care) to one of three dependent residents (R1) reviewed for quality of care. Findings include: On (9/24/24) IDPH (Illinois Department of Public Health) received allegations that a facility resident is often found soaked due to not being changed overnight. R1's (9/27/24) functional assessment affirms resident is dependent on staff for sit to stand, chair/bed to chair transfer, and toilet transfer. Dressing requires substantial/maximal assistance. R1's (9/23/24) care plan includes self-care deficit/impaired mobility, Intervention: provide peri-care after each incontinent episode. Elimination: assistance and instruction are given as required. [dressing assistance is excluded]. R1's (9/27/24) BIMS (Brief Interview Mental Status) determined a score of 9 (moderate impairment). On 10/2/24 at 9:49am, R1 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 upon observation, interview, and record review the facility failed to follow policy procedures, failed monitor blood glucose levels, failed to ensure that medication administration records include actual times for administration, failed to follow physician orders, and/or failed to ensure that medications/supplements were administered and documented within regulatory requirements for nine of thirteen residents (R1, R3, R5, R6, R7, R8, R9, R10) in the sample. The facility also failed to ensure that (R2's) Humalog was ordered and administered before meals, this failure resulted in R2's frequent blood glucose levels above 200. On 9/2/24, R2's blood glucose level was 399 (critical high). Findings include: On (9/24/24) IDPH (Illinois Department of Public Health) received allegations that medications are not administered at the facility as ordered and there's no set schedule for when medications are given. In addition, blood glucose and blood pressure are not being monitored at the facility. R2's diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure that residents who are dependent on staff assistance for toileting receive the care needed. This failure applies to 1 (R2) of 3 residents reviewed for improper nursing care. The findings include: On 07/09/24 at 11:26 AM, observed R2 sitting in a wheelchair in the unit dining room with other residents. R2 stated R2 was admitted to the facility this past Friday, 07/05/24. R2 stated R2 cannot use the bathroom because R2 cannot bear weight on R2's leg so R2 uses incontinence briefs. R2 stated R2 knows when R2 is wet or soiled. R2 stated, I'm wet right now and I've been wet for a couple of hours now R2 stated the last time R2 was changed was around 6:45-7:00 AM this morning and that no one had asked R2 since then if R2 was wet or needed to be changed. On 07/09/24 at 11:43 AM, V6 (Certified Nursing Assistant) stated V6 has been a CNA for four years and has been working at the facility since November 2023. V6 stated V6 checks on V6'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 properly log refrigerator temperatures; failed to label food items with a date; and failed to discard food items placed in the dining room refrigerator for residents personal use. This failure has the potential to affect all 49 residents on the first-floor unit. Findings include: On 06/17/24 at 10:15 am, Surveyor, V8 (Registered Nurse, RN) and V9 (Housekeeper) inspected the facility's first floor dining room refrigerator for residents personal use and observed residents personal food items stored without being labeled with a residents name, or date the item was placed in the refrigerator used for residents personal food items. Surveyor and V8 observed five bags of food with not labeled with a date or a residents name, five small containers that V8 stated was applesauce labeled with a date of 06/10/24, a small black container with brown gravy and mashed potatoes adhere to the back of the refrigerator bottom shelf without a residents name or date, and another container of an unknown food item without a residents…

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 review of pertinent facility documentation on 3/26/24 and 3/27/24, it was determined the facility failed to provide an accurate record of the actual experience for one [R1] of 6 sampled resident's vital signs. Findings Include: R1's clinical record indicated in part; R1 was admitted to the facility on [DATE] with medical diagnosis of pneumonitis due to inhalation of food and vomit, dysphagia, cerebral infarction due to thrombosis of right middle cerebral artery, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, visuospatial deficit and spatial neglect, memory deficit, , protein-calorie malnutrition, muscle weakness, cognitive communication deficit, dysphagia, essential (primary) hypertension, attention-deficit hyperactivity disorder, weakness, gastrostomy, and generalized anxiety disorder. R1's physician order: 2/28/24- Monitor vital signs every shift for 30 days then daily. R1's Medication administration sheet was printed on 3/26/24 without any…

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 Certified Nursing Assistant (CNA) on weekends to care for residents' needs based on the staffing scheduling and PBJ (Payroll Based Journal) staffing data report. This failure could potentially affect 189 residents residing in the facility as of census 3/5/24. The findings include: On 3/5/24 at 10:13am R116 observed sitting on the side of the bed, alert, and oriented x 4, verbally responsive. She said she has concern with short staff on weekend, staff/help is not enough. R116 said care or assistance is not being done in a timely manner. She said that usually there are 4-5 CNA's working on 3rd floor but on weekends there were times that there were only 3 CNAs working so care / assistance was not done promptly. R116's health record documented admission date on 6/20/23 with diagnoses not limited to Chronic obstructive pulmonary disease, Essential hypertension, Chronic kidney disease, Obesity, Hyperlipidemia. Minimum Data Set (MDS) 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 observations, interviews, and record reviews, the facility failed to follow sanitary standard and hand hygiene before handling clean side of the dishwashing machine to unload the sanitized dishes and utensils. This deficient practice has the potential to affect all 183 residents receiving food prepared in the facility kitchen. Findings Include: Facility diet type report provided by facility dated 3/7/24 documents that a total of six residents residing in the facility are NPO/nothing by mouth. On 03/05/24 at 10:11 AM, surveyor observed V17 (Food Handler) walked to the clean side of dish washing area. V17 did not perform hand washing before handling clean dishes. V17 stated V17 should wash hands and wear a pair of gloves before handling clean dishes. V17 stated handling clean dishes without hand washing could cause cross contamination. On 03/5/24 at 10:16 AM, V9 (Registered Dietitian) stated that the staff on the clean side of the dishwashing machine should perform hand washing before handling clean dishes to prevent cross contamination, and infection. On 03/05/24 at 10:20…

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 review of records the facility have the following failures related to infection control, procedures, practices, and prevention: Failed to follow policy on putting signage on a COVID-19 positive resident (R168). Failed to follow hand hygiene and Enhanced-Based Precaution policies by not performing hand hygiene during care and not using Personal Protective Equipment (gown and gloves) for a resident on Enhanced-Based Precaution (R336). Failed to ensure Enhanced Barrier Precaution signage was posted on the door of one resident (R152). Failed to dispose Personal Protective Equipment (gown) in a designated disposal equipment (large red bin with lid closure) for one resident (R21) Failed to ensure reusable medical equipment was cleaned and disinfected between four (4) residents (R19, R110, R111, R128) used to prevent cross contamination. Failed to follow policy on proper handling of linens (linens overflowing in the linen cart and not covered exposing to environment) and…

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

Based on review of records and interview the facility failed to follow COVID-19 vaccination policy for resident in determining and documenting COVID-19 immunization status. And failed to follow COVID-19 vaccination for staff in tracking COVID-19 immunization status of staff. These failures have the potential to affect all 189 residents. Findings include: Five (5) residents were sampled for COVID-19 vaccination determination and documentation offering: - R57 no immunization on record. - R60 influenza 10/18/2023 (Historical) no other immunization on record. - R336 no immunization on record. - R337 influenza and pneumococcal vaccinations documents consent required. - R338 no immunization on record. On 03/05/2024 at 11:25 AM, V6 (Licensed Practical Nurse) stated that she only got flu/influenza vaccine. That her most recent COVID-19 vaccination was a long time ago. And that facility does not offer COVID-19 vaccination and got her flu vaccine in the hospital. On 03/06/2024 at 01:13 PM, V40 (Infection Control Preventionist) All vaccination (Pneumococcal, Influenza and Covid-19) must 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 Findings include: R77 has medical diagnoses of chronic obstructive pulmonary disease, emphysema, acute and chronic respiratory failure, and asthma. R77's physician orders document in part orders for continuous oxygen (ordered 1/5/2024) and to change the oxygen tubing weekly (ordered 11/13/2023). R77's comprehensive care plan does not contain a focus for R77's oxygen use/needs. On 03/05/2024 at 11:08 AM, R77 was lying in bed receiving oxygen via nasal cannula. The nasal cannula and humidifier bottle were not dated. Facility's Oxygen Use, Storage and Labeling policy last revised on 1/2024 documents in part: Oxygen tubing, nasal cannula and masks are changed weekly and PRN [as needed]. Tubing and Humidifier bottle should be dated. Facility's Comprehensive CarePlan policy dated 1/2023 documents in part: The facility must develop a comprehensive person-centered care plan for each resident. The care plan will include a focus, measurable goal, and interventions specific to the resident's medical, nursing, mental, and…

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

Based on observation, interview and record review the facility failed to ensure a.) medications were labeled when opened, b.) ensure medications were stored to present cross contamination and c.) ensure medications for discharged residents were removed from the medication cart in 3 of 3 medication carts reviewed for medication storage and labeling. Findings Include: On 03/05/24 at 01:04 PM the second-floor medication cart 1 was reviewed with V6 (Licensed Practical Nurse). R53 (Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 100-62.5-25 MCG/ACT (microgram/activated clotting time) 1 puff daily and Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML (milligram/milliliter) 1 vial inhale orally Twice a day was observed opened in the medication cart and undated. V6 stated I think they are good for 30 days after opening. R99 Combigan Solution 0.2-0.5 % (Brimonidine Tartrate-Timolol) Instill 1 drop in both eyes twice a day was observed open in the medication cart and undated. V6 (Licensed Practical Nurse) stated it is good for 45 days from the date that it was opened. The eye drops…

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 review of records and interview the facility failed to follow immunization policies for both influenza and pneumococcal vaccination in determining and documenting influenza and pneumococcal status to record under immunization tab on electronic heath record (EHR) of 4 out of 5 residents (R57, R60, R336, R338) for a total sample of 5 residents reviewed for vaccination / immunization services. These failures have the potential to affect 4 residents (R57, R60, R336, R338) in receiving information of the benefits and risks of the vaccines. Findings include: Five (5) residents for influenza and pneumococcal were sampled for pneumococcal and influenza vaccination determination and documentation under immunization tab of the electronic health record (EHR): - R57 no immunization on record. - R60 influenza 10/18/2023 (Historical) no other immunization on record. - R336 no immunization on record. - R337 influenza and pneumococcal vaccinations documents consent required. - R338 no immunization on record. On 03/06/2024 at 01:13 PM, V40 (Infection Control Preventionist) All vaccination…

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 refer one resident (R21), out of thirty six residents in a total sample reviewed, for a Level II Preadmission Screening and Resident Review (PASARR) in alignment with facility policy. Findings include: On 03/06/24 at 12:19 pm V11 (Director Social Services) confirmed that OMBRA I - Part IV was not completed for R21. R21's Record review noted that state-designated authority initial screen was completed 11/4/2022. Answer to Part III (Reasonable Basis to Suspect a Mental Illness), Question 4 (There are other indicators of mental illness) is answered Yes. Indicators were noted to be schizophrenia and major depressive disorder. The form states that if any part of Part III is marked yes, Part IV is to be completed. Part IV is not completed. R21's state-designated authority document dated 11/2/2022 states that No Level II required - No SMI/ID/RC. Page 2 states diagnosis of schizophrenia (current), acute psychosis, serious difficult interacting with others, serious difficulty thinking through or completing tasks, excessive…

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 include a resident's (R286) high-risk medications on the baseline care plan for one out of a total sample of 36 residents. Findings include: R286's physician orders contain medication orders for Hydroxyzine (antianxiety), Trazodone (antidepressant), Mirtazapine (antidepressant), and Duloxetine (antidepressant). R286's baseline care plan does not include these medications. On 03/07/24 at 9:17 AM, V4 (Assistant Director of Nursing) stated the facility is to care plan for psychotropic medications including antianxiety and antidepressants upon admission and after any change in the physician's orders for high-risk medications. Facility's Baseline Care Plan dated 1/2023 documents in part: The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care. The baseline care plan will include necessary information to properly care for a resident including physician orders.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of records and interview the facility failed to provide a individualized care plan related to code status of 1 out of 36 resident (R57) reviewed for care plan. This failure has the potential to affect 1 resident (R57) right to choose code status. Findings include: R57 is [AGE] years old, with medical diagnosis of cerebral infraction, traumatic ischemia of muscles, metabolic encephalopathy. R57's physician order dated [DATE] for code status documents, do not attempt resuscitation or DNR. Practitioner Order for Life-Sustaining Treatment (POLST) Form dated [DATE] also documents No CPR (Cardiopulmonary Resuscitation): Do Not Attempt Resuscitation (DNAR). Care Plan of R57 dated [DATE] on advance directive documents that R57 has no advance directive at this time and that R57 is a Full Code. If becomes unresponsive, call help immediately and begin Basic Life Support. On [DATE] at 12:25 PM, V11 (Social Service Director) stated that care plan should reflect R57 status as DNR and not full code. Care plan…

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 [A] failed to provide incontinence care timely, [B] failed to provide scheduled showers for 1 resident [R36] who requires assistance with activities of daily living and [C] failed to provide eating assistance per MDS [Minimum Data Set] assessment for one resident (R21) out of thirty-six residents in the total sample reviewed. Findings Include: On 3/5/24 at 10:45 AM, during the initial tour, surveyor entered R36's room and smelled a strong odor of urine. Surveyor and V29 [Certified Nurse Assistant] with the permission of R36, allowed surveyor to observed ADL care. Surveyor and V29 observed R36 with an under brief in place, and she was laying on a bed pad. The bed pad was wet with dark color rings extending off the bed on to the bed linen. Inside R36's under brief the under brief lining was soaked with urine and the cotton was coming out the under brief. On 3/5/24 at 11:00 AM, V29 stated, I started work at 6AM, I made rounds then started getting residents up for therapy, appointments, and need to be up for breakfast.…

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 policy and a physician's order for weights for one (R74) out of a total sample of 36 residents. Findings include: R74's face sheet documents in part an admission date of 1/23/2024. R74's dietary evaluation dated 2/21/2024 documents in part: significant weight loss over one month related to pneumonia, flu, and poor oral intake. R74's weights are as follows: 135 lbs (pounds) on 1/24/2024, 135 lbs on 2/05/2024, and 127.2 lbs on 2/19/2024. No other recent weights listed. R74's physician orders document in part: Weekly Weight Times 4 Then Monthly every day shift every [Wednesday] for 30 Days ordered 2/19/2024. On 03/07/2024 at 9:17 AM, V4 (Assistant Director of Nursing) stated the Restorative Department is supposed to do the residents' weights and chart them on their electronic medical records. V4 stated the ones provided to the survey team are the entirety of R74's weights. On 03/07/24 at 11:44 AM, R74 stated facility does not weigh [R74] weekly. Facility's Weight Management policy, last revised 1/2024,…

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 observation, interview and record review, the facility failed to ensure that 2 residents with limited range of motion receives appropriate treatment and services to prevent further decrease in range of motion by not applying / maintaining left hand splint and right-hand roll. The facility also failed to obtain orders for splint / device use. These failures could potentially affect 2 (R48 and R87) of 6 residents reviewed for limited range of motion in a sample of 36. The findings include: R48's health record documented admission date on 5/21/2021 with diagnoses not limited to Cerebral infarction, Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, Ulcerative colitis, Unspecified asthma, Type 2 diabetes mellitus with hyperglycemia, Flaccid hemiplegia affecting right dominant side, Hypertensive heart disease without heart failure, Hypertensive urgency, Hyperlipidemia. R87's health record documented admission date on 5/21/2021 with diagnoses not limited to Cerebral…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to obtain order, comprehensively assess, and develop care plan for indwelling urinary catheter use. These failures could potentially affect 1 (R87) resident reviewed for urinary catheter in a sample of 36. The findings include: R87's health record documented admission date on 5/21/2021 with diagnoses not limited to Cerebral infarction, Rhabdomyolysis, Other seizures, Essential (primary) hypertension, Chronic kidney disease, Gastro-esophageal reflux disease without esophagitis, Type 2 diabetes mellitus, Obstructive and reflux uropathy, Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Hyperlipidemia, Benign prostatic hyperplasia with lower urinary tract symptoms, Atherosclerotic heart disease of native coronary artery without angina pectoris. On 3/5/24 at 10:23am R87 observed lying in bed, alert and verbally responsive, with indwelling urinary catheter draining to yellow colored urine, no privacy bag.…

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 a resident's (R286) food preferences for one out of a total sample of 36 residents. Findings include: R286's Mini Nutritional assessment dated [DATE] documents in part that R286 is malnourished. V9's (Registered Dietician) Dietary Evaluation dated 2/27/2024 documents in part: moderate muscle and fat loss in arms, clavicle, and temporal region. R286's body mass index is low for [R286's] age. R286 would like to gain some weight, requested sandwich with lunch and double protein at meals. R286's physician's orders did not include the double protein. R286's care plan documents in part that R286 is at nutrition risk. Interventions include but are not limited to Modify diet as appropriate according to resident's food tolerances and preferences (2/27/2024) and 'Provide additional snacks/D portions as ordered.' On 03/05/2024 at 11:30 AM, R286 stated losing a lot of weight since hospitalization. R286 spoke to V9 last week regarding 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 accurate documentation and reconciliation of narcotic medications for 2 (R179, R286) of 2 residents reviewed in 1 of 3 medication carts. Findings Include: On 03/05/24 at 02:28 PM the first-floor medication cart 1 narcotic count was reviewed with V16 (Agency Registered Nurse). Review of document titled Shift Change Accountability Record Sheet for Controlled Substances dated March 2024 was reviewed with missed nurse's initials for the date of 03/04/24 11-7 and 7-3. Surveyor asked V16 was the change of shift narcotic count done by the oncoming and off going nurse, V16 responded yes. R179 Controlled Drug Receipt/Record/Disposition Form document in part: Hydrocodone/APAP (Acetaminophen) tab 5-325 mg (milligrams) take 1 tablet by mouth every 6 hours as needed. Quantity received 24, amount remaining 15. Fourteen Hydrocodone/APAP 5-325 mg tabs were observed in R179 medication punch card. R286 Controlled Drug Receipt/Record/Disposition Form document in part: Oxycodone HCl (hydrochloric acid) Tablet 10 MG Tabs…

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 review of records and interview the facility failed to follow antibiotic stewardship policy in monitoring and maintaining record for 2 out of 5 residents (R88 and R21) on antibiotic therapy per physician orders. These failures have the potential to affect 2 residents (R88 and R21) proper use of antibiotic therapy. Findings include: On 03/05/2024 at 02:02 PM, V40 (Infection Control Preventionist) was informed to bring antibiotic stewardship binder for October to present on all residents taking antibiotic therapy. V40 agreed and affirmed the request. On 03/06/2024 at 01:13 PM, V40 (Infection Control Preventionist) stated, I do not have December 2023 files of residents on antibiotic and for March 2024 it is not complete. During infection control review under antibiotic stewardship topic. IP does not have any documentation for the month of December 2023 and March 2024. IP out to print out documentation from EHR in the middle of the review and took more than an hour to finish printing. After printing no documentation were presented for R88 and R21 who has order for antibiotics.…

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 residents call light was within reach for 5 residents (R1, R5, R6, R7, and R8) reviewed for call light. Findings include: On 12/04/23 at 9:36am, R1 and R5 were observed in bed in their room with call light observed under their beds and not within their reach. On 12/04/2023 at 9:40am, V11 LPN (Licensed Practical nurse) identified as the 1st floor manager stated, call light should be attached to the pillow or bed sheet and within the resident reach. On 12/04/2023 at 9:42am R6 observed in bed with call light observed under the bed. On 12/04/2023 at 9:43am, R7 was observed in bed and call light was not within reach. On 12/04/2023 at 9:50am, V5 CNA (Certified Nurse's Aide) stated, call light should be placed where the resident can reach it and clipped to the bed linen. R1's MDS (Minimum Data Set) dated 10/09/2023 scored R1's BIMS (Brief Interview for Mental Status) as 15. R1's fall plan initiated 08/23/23 documented listed interventions that includes but not limited to promoting placement of call light within…

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 to IDPH (Illinois Department of Public Health) within the required regulation time, an allegation of abuse for two residents (R3 and R4) reviewed for abuse. Findings include: R4's admission record diagnosis listed information documentation includes but not limited to Acute Embolism and Thrombosis of right femoral vein, muscle weakness (Generalized), abnormal weight loss, hemiplegia, unspecified lack of coordination, adult failure to thrive, and Epilepsy. On 12/04/23 at 3:45pm, V18 (Family) complained to the surveyor that R4's wallet was stolen from R4's room and. R4's wallet has not been found. Surveyor asked whether this had been reported to the facility staff, V1 (administrator) or V2 DON (Director of Nurse's). V18 stated, yes and there has been activity noted on R4's credit card and bank account. V18 stated, V21 (Social Services) was notified on 11/29/23. On 12/04/3 at 3:52pm, V21 acknowledged V18 informed her (V21) on 11/29/23 about the missing purse and V19 (Customer Services) was made aware. V21 stated, they…

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 immediately initiate an investigation into alleged physical abuse and misappropriation of resident property for two residents (R3 and R4) reviewed for abuse. This failure affected R3 who alleged staff mistreatment and being physically aggressive during care and R4 who alleged theft and misappropriation of property. This failure has the potential to affect all 190 resident residing in the facility. Findings include: R4's admission record diagnosis listed information documentation includes but not limited to Acute Embolism and Thrombosis of right femoral vein, muscle weakness (Generalized), abnormal weight loss, hemiplegia, unspecified lack of coordination, adult failure to thrive, and Epilepsy. On 12/04/23 at 3:45pm, V18 (Family) complained to the surveyor that R4's wallet was stolen from R4's room and R4's card and wallet cannot be found. Surveyor asked whether this has been reported to the facility staff, V1 (administrator) or V2 DON (Director of Nurse's). V18 stated, yes and there was activity noted on R4's credit card…

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 ADL (Activities of Daily Living) care was provided for dependent residents who required assistance with bladder and bowel incontinence for one of two residents (R6) reviewed for ADL care. Findings include: On 10.26.2023 at 12:59 PM the 3rd Floor Census was 70 (residents). There were two nurses and four CNAs (Certified Nursing Assistants) on the unit to take care of residents. 10.26.2023 at 1:20 PM, R6 was observed awake and alert, sitting up in bed. A slight odor of feces noted. R6 said there isn't enough staff. R6 said she is wet and needs to be changed, she was last changed on the 11-7 shift. R6 said she put the call light on several times to let staff know that she is wet but still hasn't been changed. 10.26.2023 at 1:36 PM V11 (CNA-Certified Nursing Assistant) came into R6's room to change resident. V11 said that she last changed R6 at 6:00 AM. V11 said there aren't enough CNAs to take care of the residents. V11 said she, today, she is responsible for the care of about 17 residents; of those…

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 Certified Nursing Assistant staff were scheduled on the overnight shift. This has the potential to affect all residents that reside in facility. Findings include: R15 is [AGE] years old with diagnosis including: Multiple Sclerosis, Impacted cerumen, Joint pain and Muscle weakness. R15 ' s BIMS (Brief Interview for Mental Status) Score is 15, which indicates cognitively intact. R16 is [AGE] years old with diagnosis including but not limited to: Weakness, Difficulty Walking, Peripheral Vascular Disease, Pressure Ulcer of Sacral Region, Hypertension and Heart Failure. R16 ' s BIMS (Brief Interview of Mental Status) score of 14, which indicates cognitively intact. On 8/22/23 at 11:15 AM during investigation, R15 and R16 were observed in their bedroom in bed. At this time, R15 said, There are not enough CNAs (Certified Nurse Assistants) on the overnight shift. Sometimes I have to wait a long time to get help. On 8/22/23 at 11:17 AM R16…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide a homelike environment for the residents. This failure applies to all 181 residents in the facility. Findings include: On 8/21/2023 at 11:00am surveyor observed broken areas on the railings along the stairwell leading into and out of the facility. On 8/22/2023 at 9:34am surveyor observed R6's room bathroom, R6's bathroom did have a missing ceiling panel located above the toilet and white spackle was located on two places on the bathroom walls, no paint was applied over the spackled area. On 8/22/2023 at 9:45am observed missing ceiling tiles above the toilet in room [ROOM NUMBER]. On 08/22/2023 at 10:00am surveyor observed peeling paint located on a left side panel of the second-floor south elevator. On 8/23/2023 at 11:20am V21(Maintenance Assistant) stated the ceiling tiles were ordered three months ago, but the ceiling tiles never came to the facility. V21 stated the ceiling tiles have been missing from the bathroom in room [ROOM…

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 doctor's orders for two residents (R5, R6) for medication administration. This failure affected two residents R5 and R12 out of a sample of 2. Findings: R5 has a diagnosis of but not limited to Dysarthria and Anarthria, Hypertension, Hyperlipidemia, Gastro-Esophageal Reflux Disease and Vitamin D Deficiency. On 8/22/2023 at 4:00pm surveyor reviewed R5 MAR (Medication Administration Records) for June 2023 that indicated medications were not given on many days. On 8/24/2023 at 9:00am surveyor reviewed R5's June 2023 MAR that documents prescribed and scheduled AM 1 (8:00am-10:00am) were not given on 6/06/2023, 6/07/2023 and 6/22/2023. R5's scheduled and prescribed medications were Aspirin, Atorvastatin, Multivitamin Women 50+, Norvasc and Vitamin D3. On 8/24/2023 at 9:00am surveyor reviewed R5's June 2023 MAR that documents prescribed and scheduled Bedtime (8:00pm-10:00pm) were not given on 6/06/2023, and 6/20/2023. The scheduled and prescribed medication was Famotidine. On 8/23/2023 at 12:20pm V31 (LPN) stated an empty…

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 adequately supervise two high fall risk residents (R1 and R5) to prevent further falls, and facility failed to ensure that a fall care plan was updated after each fall for (R1). Findings include: R1 is [AGE] year old with diagnosis including but not limited to: Disorder of brain, Unsteadiness on feet, Muscle weakness, Need for assistance with personal care, Dementia, Lack of coordination, Hemiplegia and Hemiparesis. R1 has a BIMS (Brief Interview for Mental Status) score of 5, which indicates severe cognitive impairment. On 8/21/23 at 9:45 AM during investigation, R1 was observed in bed. Surveyor inquired about R1 ' s fall on 6/11/23. At that time, R1 said, I don ' t remember how I fell. I think I was trying to get in bed. On 8/22/23 at 9:51 AM, V31 (LPN/ Licensed Practical Nurse) said, R1 is mostly bed bound. She gets up sometimes but with a mechanical lift. R1 is total assist resident and does not ambulate. R1 props her feet to the wall and pushes…

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.