Alta Rehab At Fairmont

Based on observation, interview and record review, the facility failed to properly position one resident (R24) of 29 reviewed for activities of daily living. Findings include:9/9/25 at 12:23 PM, writer observed R24 lying in bed with the head of the bed not in an upright position, approximately 30 degrees. R24 was not pulled up in the bed. R24s lunch tray was on the bedside table across the bed. Writer observed the tray had been eaten from. Writer observed R24 take spoonsful from the tray and eat them. 9/9/25 at 12:27 PM, V24 (Licensed Practical Nurse) stated R24s head of bed was almost flat. V24 stated R24 feeds self. V24 stated R24 could have choked, aspirated with the head of bed low and R24 not positioned upright.9/9/25 at 2:04 PM, V41 (Certified Nursing Assistant) stated residents should not be flat to eat because they could aspirate. V41 stated V41 placed R24s meal tray down and R24 reached for the food to eat. V41 stated next time V41 will reposition R24 first before giving the meal tray.9/11/25 at 9:54 AM, V2 (Director of Nursing) stated when setting up a resident to eat, 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 feeding assistance was provided to a resident on aspiration precaution. This failure affected one (R83) resident reviewed for activities of daily living (ADL) care out of 29 residents in the final sample.Findings Include: On 9/9/25 at 12:18 PM, R83's in bed eating lunch independently with head of bed up to 90 degrees. R83's meal ticket reads in part: 1200 fluid restriction with 1:1 [one-to-one] feeding. Surveyor observed a signage posted on R83's closet documents in part: Feeding-Aspiration precautions. Patient requires 1:1 feeding. Small teaspoon presentation at a time. Do not provide secondary bites until patient swallows and clears mouth. Do not leave patient alone with tray.On 9/9/25 at 12:28 PM, R83 was observed still eating lunch unassisted in her room. Surveyor called the attention of V5 (Certified Nursing Assistance). On 9/9/25 at 2:28 PM, V12 (Speech Pathologist) stated that R83 was discharged from skilled speech therapy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow their policy and procedure to (a) measure upper circumference and exterior catheter length, (b) change midline dressing timely, (c) provide maintenance flush, and (d) develop comprehensive care plan of midline use for 1 (R12) resident. The facility also failed to ensure physician's order was followed for a resident (R1) with aspiration precaution. These failures affected two (R1, R12) residents out of 29 residents in the final sample reviewed for quality of care.Findings Include: R12's admission record showed admit date on 5/9/25 with diagnoses not limited to Malignant neoplasm of central portion of left male breast, Secondary and unspecified malignant neoplasm of axilla and upper limb lymph nodes, Secondary malignant neoplasm of retroperitoneum and peritoneum, Secondary malignant neoplasm of pleura, Malignant neoplasm of abdomen, Malignant pleural effusion, Secondary malignant neoplasm of unspecified lung, Essential (primary)…

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 implement fall interventions for two residents (R24, R151) of 29 reviewed for falls.Findings include:9/9/25 at 12:05 PM, writer observed R151 lying in bed watching television. A fall mat was observed on the floor next to R151's bed. R151's bed was observed not in the lowest position. R151's bed was approximately knee height. R151 said the bed has been like this all day. R151 said R151 needs assistance to get out of bed.9/9/25 at 12:23 PM, writer observed R24 lying in bed and the bed was not at the lowest position. 9/9/25 at 12:27 PM, V24 (Licensed Practical Nurse) stated R24s bed was raised to about knee level. The bed was not at the lowest position. V24 stated R24 tries to get up from bed. V24 stated R24 could have fallen out of bed and been injured with the bed not at lowest position. V24 stated R151's bed should be lower to prevent a fall with injury.9/9/25 at 2:04 PM, V41 (Certified Nursing Assistant) stated R151 is a fall risk because there is a fall mat on the floor by the bed. The bed should be low for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that the water ordered for flushes is administered per doctor orders for one (R99) out of five residents reviewed in a total sample of 29. This failure places residents at risk to be provided with inappropriate care and services to meet the resident's physical, mental and/or psychosocial needs. Findings include:On 09/09/2025 at 11:21 AM, R99 was observed laying down on his bed, head of the bed elevated, gastrostomy tube feeding rate set at 65 ml (milliliter) per hour, water flush set at 160ml every 6 hours. Noted with 599 ml fed and 160 ml flushed. R99's water flush bag dated 09/08/25 and feeding formula labeled with R99's name, room number, rate, and date 09/08/25. On 09/10/2025 at 11:12 AM, with V25 (Registered Nurse), R99 is not in his room but R99's g-tube feeding pump noted in R99's room. V25 stated that R99's g-tube is disconnected and turned off when R99 goes to dialysis. V25 stated I am the one that disconnected it this…

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 (R83) received the correct oxygen flow rate as ordered by the physician and to ensure nasal cannula tubing was applied to a resident receiving oxygen for 1 (R1) of 2 residents reviewed for respiratory care in a final sample of 29.Findings Include:On 9/9/25 at 10:43 AM, R1 was lying in bed alert and awake noted with bouts of confusion. R1's oxygen (O2) concentrator was turned on and flow rate set to 2 liters per minute (lpm). R1's nasal cannula (nc) tubing was wrapped around her left side rail; the nasal prong was on the floor and was not applied in her nose. R1 was not in distress. On 9/9/25 at 10:59 AM, V5 (Certified Nursing Assistant) entered R1's room and applied the nasal cannula tubing for R1. V5 stated that it should have been in her nose. On 9/9/25 at 10:57 AM, R83's sleeping in bed noted receiving oxygen (O2) via nasal cannula that was set to 3 liters per minute (lpm).On 9/9/25 at 11:10 AM, V6 (Agency Licensed…

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 assess the risk versus benefits of using side rails and review them with the resident prior to use and failed to implement person-centered comprehensive care plan addressing the use of the side rails. These failures affected two (R4, R52) out of three residents reviewed for side rails in a final sample of 29. Findings Include: On 9/9/25 at 11:47 AM, R4 was sitting on the side of the bed and noted with two upper half side rails up. R4 stated she gets out of bed by herself and uses a wheelchair to get around. On 9/10/2025 at 11:37 AM, R4 was sleeping in bed and noted with two half upper side rails up. On 9/10/25 at 10:43 AM, V22 (MDS Coordinator) stated that the purpose of the care plan is to notify the staff how to provide care for the residents. V22 stated if the resident has a change in condition the care plan should be updated as soon as possible. V22 stated that comprehensive care plan should be initiated on admission MDS (Minimum Data…

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 a medication error rate of less than 5% for three (R55, R58 and R147) of five residents with 12 errors for 35 medication administration opportunities. This resulted in a medication error rate of 34.29%. The findings include:On 9/9/2025 at 9:44AM Medication administration observation conducted with V6 (Agency Licensed Practical Nurse / LPN). Observed V6 prepare and administer the following medications to R58: Guaifenesin 400 MG (milligrams) 1 TabletJanuvia 50 MG 1 TabletClopidogrel 75 MG 1 TableNifedipine 60 MG Extended Release 1 TabletIron ferrous gluconate 27mg 1 TabletEliquis 5 MG 1 Tablet Observed R58 take prepared medications by mouth.R58's POS (Physician Order Sheet and MAR (Medication Administration Record) showed medication orders not limited to: Mucinex cough and chest congestion oral capsule 10-200mg give 1 capsule by mouth two times a day at 9AM and 9PM. Ferrous sulfate 325 MG (65 Fe) give 1 tablet by mouth two times a day at 8AM and 8PM.Observed medication errors due to wrong dose for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Discharge Instruction was completed and provided to a resident upon discharge to ensure a safe and effective transition of care. This failure affected 1 (R5) resident reviewed for discharge requirement in the total sample of 12 residents. Findings include:On 09/02/2025 at 12:09pm, V9 (Assistant Administrator) stated when a resident discharges, there is a Discharge Assessment the nurse prints out at the time of discharge. Nursing will print the Discharge Assessment and the resident or family signs the Discharge Assessment. On 09/02/2025 at 12:14pm, this surveyor opened R5's EHR (Electronic Health Record). V9 stated the Discharge Assessment is on the Assessment tab. Upon opening R5's Discharge Instruction on Assessment tab, Sections A and B were highlighted 'Green', and Sections C, D, E and G were not highlighted. V9 stated if the section is completed it will be in 'green'. V9 checked R5's Discharge Instruction and stated his (R5) Discharge…

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 reviewed the facility failed to assure that a resident (R1) with a pressure ulcer received necessary treatment and services for prescribed wound care as ordered by the physician in order to promote healing. These failures affected one resident (R1) reviewed for wound care in a total sample of four residents. Findings include: R1 has a diagnosis which includes but not limited to: bacteremia, iron deficiency anemia secondary to blood loss chronic, other staphylococcus as the cause of disease classified, morbid (severe) obesity due to excess calories, obstructive sleep apnea adult, mucopurulent conjunctivitis bilateral, acute, and chronic respiratory failure, intramural leiomyoma of uterus, chronic kidney stage 3, and essential hypertension. R1 has a Brief Interview for Mental Status dated 12/18/24, with a score of 15 which indicates that R1 is cognitively intact. R1's Minimum Data Set (MDS) dated [DATE], section M indicates that R1 has unhealed pressure ulcer injuries. On 05/27/25,…

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 that a resident (R1) remained free from physical abuse from another resident (R2) reviewed for physical abuse in the sample of 4. This failure affected R1 who was pushed down on the bed by R2. Findings include: On 5/6/25 at 8:50 am, V14 (Certified Nursing Assistant, CNA) stated that on 4/14/25 at approximately 7:30 am, I (V14) had worked night shift and was sitting at the computer, finishing my charting. I heard cursing, it was 2 (residents). I told the nurse (V3, Registered Nurse, RN) who was at nurse's station, do you hear that? We jump and run in (R1 and R2's) room. Both (R1 and R2) were cursing, and (R2) jumped up and run and pushed (R1) down on the bed. When asked for more details when V14 responded to R1/R2's room, V14 stated, They were both yelling at the same time. V14 stated, (R1) was standing up. And (R2) was sitting (on R2's bed). They were arguing. I tried to calm them down. I was trying to get (R2) to leave out of room with 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 upon observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that staff/visitors are aware of required PPE (Personal Protective Equipment) prior to entering isolation rooms, failed to ensure that PPE is properly disposed of, and failed to ensure that required isolation signs were posted for two of four residents (R1, R4) reviewed for infection control. These failures have the potential to affect 153 residents. Findings include: The (2/18/25) facility census includes 153 residents. The weekly isolation log affirms: R1 is on droplet/contact isolation for Influenza A and RSV (Respiratory Syncytial Virus) start date: 2/15/25, end date: 2/21/25. R4 is on droplet/contact isolation for Influenza start date: 2/16/25, end date: 2/22/25. On 2/18/25 at 12:07pm, a sign was posted on R1 and R4's (roommates) door which states, Enhanced Barrier Precautions [droplet/contact isolation and required PPE were excluded] and the door was wide open. On 2/18/25 at 12:11pm, surveyor inquired if R1 is on isolation V4 (LPN/Licensed Practical Nurse)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon observation, interview, and record review the facility failed to follow policy procedures, failed to address reported pest/rodent sightings and failed to maintain an effective pest control program for three of three residents (R1, R2, R3) reviewed for pests/rodents. These failures have the potential to affect 153 residents. Findings include: The (2/18/25) facility census includes 153 residents. R1's (1/3/25) BIMS (Brief Interview Mental Status) determined a score of 14 (cognition intact). On 2/18/25 at 12:23pm, surveyor inquired about concerns at the facility R1 stated Mice was in the other room where they (staff) moved me (R1), while this room (current room) was being repaired. I (R1) reported it to (V1/Administrator). He (V1) got maintenance (staff) they searched around the room and found holes in the wall. R1 affirmed that (R2) and (R3) currently reside in the other room where mice were sighted. R3's (1/16/25) BIMS determined a score of 15 (cognition intact). On 2/18/25 at 12:45pm, surveyor…

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

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 the building was maintained, and failed to provide a clean, comfortable homelike environment for three of three residents (R1, R2, R3) reviewed for resident rights. Findings include: R1's (1/3/25) BIMS (Brief Interview Mental Status) determined a score of 14 (cognition intact). On 2/18/25 at 12:23pm, R1 stated (R2) refuses to get up and go to the bathroom and refuses to wear a diaper. He (R2) dumps the urinal in the garbage or in the sink. 9 out of 10 times he would miss the sink and it would hit the floor. He was recently moved (to another room) but the problem is it's been going on for over a year [the census affirms that R2 was admitted [DATE]]. Surveyor inquired if R2 is oriented R1 replied He gets himself up to go to activities and stuff. He knows where he's at and knows where he's going. He has a bathroom now (in other room) and will not get up to use the bathroom. R1 presented…

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

Based on interview and record review, the facility failed to follow their policy to update family on their grievance regarding insulin ordering issues for 1 (R4) out of three residents reviewed for grievance. Findings include: On 09/24/2024 at 12:00 PM, R4 was seen sitting in his room. R4 state he was not sure about his insulin being monitored. On 09/24/2024 at 11:32 AM, V2 (Director of Nursing) stated, the doctor will order the insulin then it will be confirmed by the nurse. After the nurse confirms the order, it goes to the pharmacy. The pharmacy will dispense on their next delivery. We request from the pharmacy exactly what the doctors' order. Pharmacy said that when it is ready to refill, they will dispense a new order.V2 was informed that R4 has a lot of insulin being billed to him. Lyumjev was the name of the insulin. Even though R4 doesn't take it, we have to discard it after 28 days. R4 is private pay. The pharmacy is charging the family extra. V2 stated we are talking to pharmacy but we are not sure if R4's insulin issue has been taken care of. V2 stated that this issue was…

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

Based on observation, interview, and record review, the facility failed to implement interventions to prevent development of deep tissue injuries (DTIs) for one of three residents (R6) reviewed for pressure ulcers. Findings include: R6's Face Sheet documents resident was admitted to the facility on 7.10.2023 with diagnoses including but not limited to: Displaced fracture of greater trochanter of right femur (hip fracture), Chronic obstructive pulmonary disease, Hypertension, and Hypothyroidism. R6's MDS (Minimum Data Set, dated 7.10.2024) documents the following - BIMS: 14 (cognitively intact). On 9.24.2024 at 12:45 PM, R6 was observed awake and alert. R6 was sitting up in bed with head of bed elevated. R6 had pillows under her legs, with her legs externally rotated. R6 said she developed pressure ulcers to her ankles after staff crossed her legs (at the ankles) during care. Staff did not reposition ankles when they were through providing care. R6 said my legs stayed like that for maybe eight hours. I told the nurse. They uncrossed my legs and some skin came off. Resident 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 upon observation, interview, and record review the facility failed to ensure that the staff are aware of resident equipment needs, failed to ensure that [NAME]'s include mobility devices, and failed to ensure that required devices were provided to two of three residents (R2, R5) reviewed for transfer assistance. These failures have the potential to affect 153 residents. Findings include: The (9/2/24) census includes 153 residents. R2's (6/24/24) functional assessment affirms resident is dependent on staff for chair/bed to chair transfer. Mobility device: wheelchair. R2's (7/2/24) care plan states resident has an ADL (Activities of Daily Living) self-care/mobility performance deficit. Intervention: Chair/bed to chair transfer: my usual performance is dependent. I use a mechanical lift for transfer assist. I use an assistive mobility device (wheelchair). R2's (9/4/24) [NAME] (summary of resident information) includes transferring: (mechanical) lift x2 dependent [mobility devices are excluded]. R2's (6/24/24)…

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 record review and interview the facility failed to develop a comprehensive care plan including potential for abuse/neglect for four of five residents (R2, R3, R4, R5) in the sample. This failure has the potential to affect 153 residents. Findings include: The (9/2/24) census includes 153 residents. R2 was admitted to the facility on [DATE] (7 months ago). R3 was admitted to the facility on [DATE] (7 months ago). R4 was admitted to the facility on [DATE] (23 months ago). R5 was admitted to the facility on [DATE] (8 months ago). R2, R3, R4, and R5's (2024) comprehensive care plans (received 9/4/24) exclude potential for abuse/neglect. On 9/9/24 at 12:35pm, surveyor inquired about comprehensive care plan requirements, V9 (Care Plan Coordinator) stated We do comprehensive care plans for admissions, quarterly, annual, and significant changes. Surveyor inquired if R2's care plan includes potential for abuse or neglect, V9 reviewed the electronic medical records and responded I don't see any behavior, 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 upon observation, interview, and record review the facility failed to follow policy procedures and failed to ensure that the menu was followed. These failures affected 155 residents. Findings include: The (9/5/24) FRI (Facility Reported Incident) states the Health Department issued a non-serve citation, resulting in the facility enacting the Emergency Management Plan. On 9/10/24 at 9:46am, surveyor inquired about the (9/5/24) FRI, V1 (Administrator) stated The Health Department came to the facility due to a new license. Upon inspection, mouse droppings were found in the employee dining room, so they closed our kitchen due to that matter. Right now, the kitchen is completely closed were transporting food from our sister facility. On 9/10/24 at 12:23pm, surveyor inquired if the facility kitchen was closed, V11 (Assistant Dietary Manager) stated They found some roaches and mice drop and they closed it last Thursday (9/5/24) after lunch. Surveyor inquired what foods are being served since the kitchen is currently closed, V11 responded The menu of, follow what the menu says.…

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 required infection control signs are posted, failed to ensure that the infection log includes required symptom, the date of onset and/or date of prophylactic treatment, failed to follow physician orders, failed to ensure that skin integrity impairments are documented, failed to report ongoing rash/itching to the Physician/Nurse Practitioner, failed to provide treatment timely, and/or failed to ensure that skin scrapings were obtained for two of four residents (R3, R5) reviewed for scabies. These failures have the potential to affect 153 residents. Findings include: On 8/27/24, IDPH (Illinois Department of Public Health) received allegations that the facility has an ongoing scabies outbreak for at least a month. Scrapings are not being done on residents complaining of itching and other residents are affected each day. The (9/2/24) census includes 153 residents. The (August 2024) Infection…

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 and failed to ensure that two of three residents (R2, R5) reviewed for transfer assistance remain free from involuntary seclusion. Findings include: 1. R2's (6/24/24) functional assessment states resident is dependent on staff for chair/bed to chair transfer. Mobility device: wheelchair. R2's (7/2/24) care plan includes ADL (Activities of Daily Living) self-care/mobility performance deficit. Intervention: Chair/bed to chair transfer: my usual performance is dependent. I use a mechanical lift for transfer assist. I use an assistive mobility device (wheelchair). [potential for abuse, neglect mistreatment are excluded]. R2's (6/24/24) BIMS (Brief Interview Mental Status) determined a score of 15 (cognition intact). On 9/4/24 at 11:26am, R2 was observed lying in bed. Surveyor inquired about transfer assistance R2 stated They (staff) don't move me that much; they always say they're understaffed, or somebody didn't…

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

Based upon record review and interview the facility failed to ensure that scheduling and/or colonoscopy policies/procedures are available, failed to follow physician orders, failed to ensure that transportation was arranged prior to colonoscopy, failed to ensure that scheduled appointments/transportation records are retained, failed to receive required bowel prep medication, NPO (Nothing by Mouth) and/or clear liquid diet orders prior to scheduled colonoscopy, failed to provide timely services, and failed to ensure that diagnostic results were received for one of three residents (R1) reviewed for significant weight loss. Findings include: R1's Physician Orders include (2/28/24) Need colonoscopy, abnormal weight loss, date: 7/5/24 [scheduled 4 months later]. (7/9/24) Need colonoscopy, abnormal weight loss, date: 8/5/24 [scheduled approximately 1 month later]. [Required bowel prep medication, NPO and/or clear liquid diet orders are excluded on or about both dates]. R1's (6/5/24) nutrition progress notes state significant weight loss 11.6% x 6 months. On 9/3/24 at 1:58pm, surveyor…

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

Based on observation, interview, and record review, the facility failed to ensure the Daily Nursing Staffing was posted daily and failed to ensure previous Daily Nursing Staffing were maintained. These failures have the potential to affect all 160 residents residing at the facility. Findings include: On 08/05/24 at 10:19 AM, there was no daily nursing staffing sheet posted by the reception area. V28 (Lead Receptionist) stated I (V28) don't have the staffing sheet that has the nursing hours. We used to have the daily nursing staffing posted on the wall, but we are having issues with the wall so I (V28) don't know where they posted the daily staffing. On 08/05/24 at 10:31 AM, V21 (Staffing Coordinator) stated I (V21) am the one who does the schedule. The master schedule is in the supervisor's office. On 08/05/24 at 10:37 AM by the supervisor's office, this surveyor requested V21 to provide the current daily nursing staffing. V21 pulled a blank sheet of the daily nursing staffing and handed it to the surveyor. This surveyor inquired if V21 already filled out the daily nursing staffing…

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

Based on observation, interview, and record review the facility failed to ensure that residents' food items in the facility kitchen are dated when received and when opened; and failed to discard expired food items. These failures have the potential to affect all 157 residents receiving an oral diet in the facility. Findings include: On 08/05/24 at 9:30am, with V6 (Dietary Cook), during observation of the facility's walk-in freezer the following was observed: A bag of corn opened with no open date. A bag of peas opened, exposed to air (not closed), with freezer burn. A bag of chocolate chips opened with no open date. Peach cobbler with an expiration date of 7/27/2024. When asked the policy on opened food, V6 (Dietary Cook) replied, When bags or boxes are opened they should be labeled with an open date and expiration date. When asked the reason for labeling opened food with an open date and expiration date, V6 replied, So we (staff) know when the food is expired. When asked what can happen if residents eat expired food, V6 replied, They can get sick. On 8/05/24 at 9:37am, with V7…

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 dumpster was closed. These failures have the potential to affect all 160 residents residing at the facility. Findings include: On 8/05/24, V1 (Administrator) stated that the resident census was 160 residents at the facility. On 8/05/2024 at 9:42am, the outside facility dumpster area was observed with V7 (Dietary Supervisory). Two dumpster lids were observed open at the outside facility dumpster area. When asked about the opened dumpsters, V7 replied, Housekeeping comes out here too and throws stuff out. I (V7) do not know who left it open. They (dumpster lids) should be closed. When asked why the dumpsters should be closed, V7 replied, Mice scatter around. Little mice's go inside. On 8/06/24 at 10:12am, V20 (Housekeeping Director) said, We (housekeeping staff) use the outside dumpsters. When asked if the outside dumpsters should be closed with a lid to ensure the dumpster is covered, V20 replied, Yes. Definitely closed at all times when not in use. When asked why the dumpsters should 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.

Based on observation, interview, and record review, the facility failed to ensure oxygen tanks were properly stored for one resident (R3) and failed to discard a lancet for one resident (R83). These failures affected 2 (R3 and R83) reviewed for hazards and have the potential to affect all 20 residents on the Team 2A unit and 14 residents on the Team 4 unit. Findings include: 1. Record review of R3's admission record documents in part the following diagnoses: primary generalized osteoarthritis, unspecified dementia without behavioral disturbance, mood disturbance, and anxiety. Record review of R3's care plan (dated 4/25/24) identifies that R3 uses oxygen therapy related to respiratory illness and conversational dyspnea. On 8/5/2024 at 10:29 AM, surveyor observed R3 lying in bed. Additionally, surveyor observed an unsecured oxygen cylinder on the floor behind the head of the resident's bed. On 8/5/2024 at 10:34 AM, V4 (Licensed Practical Nurse) observed the unsecured oxygen cylinder behind R3's bed. V4 affirmed that the oxygen tank was not secured in a holder and proceeded to remove…

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 nebulizer tubing was changed weekly per facility policy, the nasal cannula was contained when not in use by the resident, and the nasal cannula and humidifier canister were labeled/dated. These failures affected two residents from Team A (R123 and R98), one resident from Team 3 (R79), and one resident from Team 4 (R32); out of a sample of 65 residents. Findings include: R79's diagnosis includes but are not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, acquired absence of left leg above knee, chronic obstructive pulmonary disease, unspecified, peripheral vascular disease, unspecified, hyperlipidemia, unspecified, combined forms of age-related cataract, bilateral, essential (primary) hypertension, gastro-esophageal reflux disease without esophagitis. R79's Brief Interview for Mental Status (BIMS) dated 7/4/2024 documents R79 has a BIMS score of 13, which indicates R79 is cognitively intact. R79's Physician Order Sheet (POS) with active orders as…

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 discard expired medication from the medication cart, failed to discard expired medication from the medication supply room and failed to ensure medication carts were free of loose pills. These failures affected one resident (R54) for medication and storage labeling and have the potential to affect all sixty-eight residents assigned to carts Team 2A, Team 3, and Team 5. This failure also has the potential to affect all ninety-six-residents assigned to the medication storage room on Team 1. Findings include: On 08/06/24 at 9:59 AM V8 (Registered Nurse, RN) observed in Team 1 medication room removing Sodium chloride irrigation water bottle with expiration date 7/19/23 from drawer. V8 The water bottle should not be here because it is expired already. The water bottle should be disposed of. If expired medication is given to a resident, then it is a medical error. On 08/06/24 at 10:20 AM V8 (RN) removed R54's medication bottle (Rosuvastatin 10…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to properly log refrigerator temperatures for resident's personal refrigerators for 10 residents (R29, R46, R55, R62, R79, R107, R120, R141, R401, & R402) and failed to adequately maintain the freezer for resident's personal refrigerators for 2 residents (R24 & R99). These failures have the potential to affect all 12 residents reviewed for safety of personal food items, in a total sample of 65 residents. Findings include: On 8/05/2024 at 10:29AM, during observation of R401's personal refrigerator the following was observed: R401's REFRIGERATOR TEMPERATAURES & CLEANING LOG Month: Aug. Year: 2024 had missing initials on 8/4/2024. On 8/05/2024 at 10:29AM, R401 stated, I (R401) haven't been here that long, but I (R401) have not seen any staff check anything in my fridge. I (R401) ask the nurses to get something out of it, but that's it. R401's diagnosis includes, but are not limited to: cardiac arrest, bacteremia, and type 2 diabetes mellitus.…

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 update a resident's (R89) isolation status; failed to ensure staff did not bring the clean linen cart inside the resident's (R21) room; failed to wear Personal Protective Equipment (PPE) for a resident (R12) with Enhanced Barrier Precautions (EBP); and failed to maintain infection control practices in effort to prevent the spread of microorganisms for a resident (R79). These failures affected four residents (R12, R21, R79, and R89) and has the potential to affect all 20 residents on Team 2A unit and all 17 residents on Team 3 unit. Findings include: R89 has a diagnosis which includes but not limited to methicillin resistant staphylococcus aureus infection as and enterocolitis due to clostridium difficile. R89's Brief Interview for Mental Status (BIMS) dated 07/12/24 documents that R89 has a BIMS score of 15 which indicates that R89 is cognitively intact. On 08/05/24 V1 (Administrator) presented the facility census of 160 residents with 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.

Based on observation, interview, and record review, the facility failed to ensure a handrail was firmly secured to the wall in an effort to prevent falls. This failure has the potential to affect all residents in Unit 2B. Findings include: On 08/05/24 at 10:45 am, the handrail in Unit 2B was not fixed to the wall. This observation was pointed out to V34 (Certified Nursing Assistant). V34 stated the handrail has been like that for a long time. On 08/05/24 at 10:55 am, V20 (Housekeeping Supervisor/Maintenance Director/Laundry Director) checked the handrail located in unit 2B and stated the handrail is not fixed to the wall. On 08/05/2024 at 11:23 am, V20 stated I (V20) was not aware the handrail in unit 2B was not fixed to the wall. It is pretty dangerous if the handrail is not fixed to the wall. On 08/06/2024 at 3:30 pm, V2 (Director of Nursing) stated handrails should be fixed on the wall to prevent accidents. Residents use handrails for support when they are ambulating. If not fixed to the wall and the resident grabs the handrail, they will lose their balance and they may fall. 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 indwelling catheter drainage bags were covered to maintain the resident's dignity. This failure has affected 2 residents (R27 and R109) reviewed for catheter care in a total sample of 65 residents. Findings include: 1. Record review of R109's admission record documents in part that R109 has a diagnosis including, but not limited to, retention of urine and other specified disorders of bladder. Record review of R109's care plan (dated 2/23/24) identifies that R109 utilizes an indwelling urinary catheter due to a diagnosis of neurogenic bladder. On 8/5/2024 at 11:49 AM, R109 was observed lying supine in bed from the hallway. R109's urinary drainage bag was observed hanging on the left side of the resident's bed frame. A black bag was hanging next to the exposed urinary drainage bag on the frame of the bed. On 8/5/2024 at 11:52 AM, V9 (Licensed Practical Nurse) observed R109's exposed urinary drainage bag and affirmed that the drainage bag should be kept in the black privacy bag hanging next to the drainage…

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 electronic health records were kept in a private manner. This failure has the potential to affect 1 resident (R102) in a sample of 65. Findings include: On 8/5/2024 at 10:46 AM, surveyor observed the Team 5 nursing cart and noted R102's medication administration record (part of the electronic medical record) open on the attached laptop. Surveyor did not observe any staff present near the medication cart. Surveyor observed V9 (Licensed Practical Nurse) walking out of a resident room. Surveyor asked V9 why R102's electronic medical record was left open and unattended, and V9 stated that V9 forgot to close the laptop. V9 affirmed that V9 should have closed the screen prior to walking away from the medication cart. On 8/7/2024 at 10:20, V2 (Director of Nursing) affirmed that the facility expectation is that whenever a nurse walks away from the computer, is that the electronic medical record is not be left open; the screen should be closed or minimized. V2 stated that if the medical record is left open 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 observation, interview, and record review, the facility failed to provide a homelike environment for 2 (R96 and R108) residents reviewed for homelike environment in the total sample of 65 residents. Findings include: R96 has diagnosis which include but are not limited to acquired absence of right foot, non-pressure ulcer of other part of right foot with necrosis of muscle, peripheral vascular disease, type 2 diabetes mellitus with diabetic neuropathy, severe protein calorie malnutrition. R96's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status (BIMS) score of 15, which indicates R96's cognition is intact. R108 has diagnosis which include but are not limited to Chronic obstructive pulmonary disease, necrotizing fasciitis, Type 2 diabetes mellitus, Chronic kidney disease, End stage renal disease, Bipolar disorder. R108 MDS dated [DATE] has a BIMS sore of 15, which indicates R108's cognition is intact. On 08/05/24 at10:05 AM R96 stated, My bathroom door doesn't close. I would 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a new Pre-admission Screen and Resident Review (PASARR) assessment was completed when a new diagnosis of schizoaffective disorder was identified. This failure affects 1 resident (R49) in a sample of 65. Findings include: Record review of R49's admission record documents in part that R49 was initially admitted to the facility on [DATE]. Additionally, R49's admission record documents in part a diagnosis of schizoaffective disorder, bipolar type (onset date 8/20/2022), Major Depressive Disorder (onset date 8/20/2022). Record review of R49's Minimum Data Set (dated 6/21/2024) documents in part in section S1200. Primary and Secondary SMI (Serious Mental Illness) Diagnosis (7-day look back period) that R49 has a secondary diagnosis of schizoaffective disorder and major depression, recurrent. Record review of R49's Notice of PASARR Level I Screen Outcome notice date 6/16/2022, documents in part, that no mental health diagnosis is known or suspected for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide ADL (Activity of Daily Living) care for two residents (R45, R74) to maintain personal hygiene. This failure has the potential to affect the sample size of 65. Findings include: 1. R45 has a diagnosis of but not limited to Hemiplegia and Hemiparesis following Cerebral Infarction, Dementia, Atrial Fibrillation and Hypertension. R45 has a Brief Interview of Mental Status score of 11, moderate cognitive impairment. R45's Minimum Data Set (MDS) dated [DATE] section GG documents Toileting hygiene: partial/moderate assistance, Functional Limitation in Range of Motion documents, no impairment of upper or lower extremities and Mobility Devices documents, R45 uses a wheelchair and Chair/bed-to-chair transfer requires substantial/maximal assistance. R45's care plan focus ADL dated 3/27/2024 documents, in part, assist resident with task after resident has attempted the task and is unable to complete. On 8/05/2024 at 11:06am surveyor observed…

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

Based on interview and record review the facility failed to ensure that resident's medications are administered as ordered by the physician. This failure affected two residents on Team 4 (R32 and R81) of 65 residents reviewed for quality of care and administration of prescribed medications. Findings include: On 08/06/2024 at 2:30pm V2 (DON/Director of Nursing) presented R32's August 2024 MAR (medication administration record) to the surveyor, which was reviewed. On 08/07/2024 at 11:30am V2 (DON/Director of Nursing) presented R81's August 2024 MAR (medication administration record) to the surveyor, which was reviewed. There were missing entries of nurses' signatures/initials or codes on the MAR for August 2024 (08/1/2024 to 08/31/2024) for R32 and R81. R32's diagnosis includes but are not limited to acute on chronic systolic (congestive) heart failure, type 2 diabetes mellitus with diabetic polyneuropathy, end stage renal disease, dependence on renal dialysis, chronic respiratory failure with hypoxia, bilateral primary osteoarthritis of knee, essential (primary) 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.

Based on observation, interview, and record review, the facility failed to ensure equipment used for catheter care was discarded after use in an effort to prevent contamination. This failure affected 1 (R21) resident reviewed for indwelling catheter care in the total sample of 65 residents. Findings include: On 08/05/2024 at 11:59am, there was an unlabeled piston syringe inside R21's room. This was pointed out to V13 (Licensed Practice Nurse). V13 checked the piston syringe for label and stated the piston syringe was not labeled with a date. We (facility staff) use the piston syringe to irrigate her (R21) foley (indwelling) catheter. The piston syringe is reusable 3 times for 24 hours. Three times, once every shift to prevent infection. On 08/06/2024 at 3:22pm, V2 (Director of Nursing) stated a piston syringe used for irrigation of the catheter or bladder should be disposed of after use to prevent infection. Once used, the piston syringe could be contaminated already. On 08/06/2024 at 3:42pm, V3 (Infection Preventionist/RN) stated a piston syringe used for irrigation of the bladder…

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 be free of medication error rate of 5% or more. There were a total of 3 medication errors out of 25 opportunities. The medication error rate is 12% and affects one resident R99. Findings include: R99 has a diagnosis of but not limited to Type 2 Diabetes Mellitus, Spinal Stenosis, Lumbosacral Region, Diabetes Mellitus with Diabetic Neuropathy, Chronic Obstructive Pulmonary Disease and Asthma. R99 has a Brief Interview of Mental Status score of 15, indicating R99 is cognitively intact. R99's Order Summary Report with active orders as of 8/06/2024 that documents, in part, Insulin Lispro Kwikpen 100U/ML (milliliters), Lantus SoloStar Subcutaneous Solution and Pregabalin. R99's Medication Administration Audit Report documents, in part, Insulin Lispro (sliding scale: 3 units) is scheduled at 7:30am and was administered at 9:13am, Insulin Lispro 12 units, Lantus 17 units and Pregabalin 50 mg capsule is scheduled for 8:00am and was administered at 9:13am. On 08/06/2024 at 9:01am surveyor observed R99's EMAR…

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 allegation of physical abuse to the State Agency, failed to inform local law enforcement when an allegation of physical abuse involved physical injury, and failed to implement their policy and procedure in reporting injury of unknown origin. These failures affected 1 (R2) resident reviewed for reporting of physical abuse and injury of unknown origin in the total sample of 8 residents. Findings include: R2's 06/05/2024 23:56 (11:56pm) Nurses Note states, Resident came back at 23:30 (11:30pm) with dx (diagnosis) of Rib Fracture. R2's 06/06/2024 Initial reportable documented, in part Sent 06/06/2024 3:15pm. Incident Category: Injury of Unknown Origin. Of note, report was sent more than 2 hours after the facility was made aware of the rib fracture. The 06/06/24 Investigation of Injury of Unknown Origin documented, in part Resident: (R2). 1. Type of Injury: Fracture. Describe: Closed fracture of one rib of (on) left side. 2. Date and time injury first noted: 6/5/24. 6. Statements: A. Resident's Statement about injury:…

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 staff was appropriately transferring a resident (R5) and failed to ensure staff appropriately provide supervision during incontinence care to a dependent resident (R4). These failures affected 2 (R4 and R5) residents reviewed for supervision in the total number of 8 residents: Findings include: 1. On 07/29/2024 at 10:44am, R4 stated I (R4) know what happened, the CNA (V16-Certified Nursing Assistant) was changing me (R4), and she (V16) rolled me (R4) towards her (V16) and all I (R4) know I (R4) was on the floor. There was no one else but her (V16). She (V16) was by herself (V16). On 08/01/2024 at 8:53am, V16 stated she (R4) slid off the bed; she (R4) did not fall. I (V16) was changing her (R4). I (V16) turned her (R4) but she did not hold onto the rail; she (R4) let go of herself (R4). There were two (V16 and V23-unknown agency CNA) of us, I (V16) don't know her (V23) name. She (V23) was from Agency. On 07/31/2024 at 2:21pm, V22 (Wound Care…

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 failed to follow pest control policy and establish effective pest control program in conducting pest control prevention on a regular and as needed basis. These failures have the potential to affect all 153 residents in maintaining to be free from pest concerns. Findings include: On 4/2/24 at 10:41 AM, at room [ROOM NUMBER] where R10 and R11 were seen. R10 stated that she saw roaches from time to time. And that it was near the sink near R11 is located. At the cabinet under the sink on the right side beside R11's bed upon opening the door there is a small roach seen. On 4/2/2024 at 2:23 PM with V16 (Assistant Housekeeping Director) on the same closet after opening the door and lifting pinkish-brown plastic container, there were 4 small roaches seen. V16 stated that it needs to be address and informed housekeeping staff at the hallway to address the problem. V18 (Director of Maintenance) made aware. On 4/3/2024 at 1:08 PM, per V18 he only respond…

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 failed to maintain resident rights to privacy and dignity per their policy for 4 out of 4 residents (R6, R7, R8, R9) with common restroom that is able to access from female to male occupancy and vice-versa without assessment and care plan. These failures have the potential to affect 4 residents (R6, R7, R8, R9) in their right to privacy and dignity. Findings include: On 4/2/2024 at 10:44 AM, with V4 (Certified Nursing Assistant) two rooms were seen with adjoining restroom (room [ROOM NUMBER] and room [ROOM NUMBER]) inside room [ROOM NUMBER] two female residents was seen R8 and R9 and room [ROOM NUMBER] occupied by two male residents (R6 and R7). In between room [ROOM NUMBER] and 56 is a single restroom that can access both rooms via room [ROOM NUMBER] and 56 and vice-versa. With V4 we went inside room [ROOM NUMBER] door going inside the restroom. Inside the restroom there is another door that access room [ROOM NUMBER]. In the same manner going…

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 follow proper transfer procedure based on resident assessment by transferring resident done by a single staff that needs 2-person extensive assist. Facility also failed to update plan of care on transfers per assessment. These failures apply to 1 out of 3 residents (R2). And have the potential to affect 1 resident (R2) on safely transferring and prevention of accidents. Findings include: R2 is [AGE] years old currently a resident in the facility. R2 medical diagnosis includes systemic lupus erythematosus. R2 is cognitively intact with brief interview for mental status of 15 dated 3/13/2024. On 4/2/2024 at 11:03 AM, R2 stated during transfers she used to use slide board with the help of two Certified Nursing Assistants (CNA) from bed to her wheelchair. And now she needs to use sit-to-stand lift. R2 accurately described sit-to-stand as putting a thick belt and hooking to the lift as she holds on to the lift while the lift moves her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations, and review of records the facility failed on administering insulin as ordered by physician in accordance with resident five (5) rights during medication administration for 1 out of 3 residents (R1) reviewed for pharmaceutical services. These failures have the potential to affect 1 resident (R1) in depriving the benefits of insulin to manage his medical diagnosis of diabetes mellitus. Findings include: R1 is a [AGE] year-old resident, with medical diagnosis of diabetes mellitus. R1 was initially admitted in the facility on 1/29/2024. R1 cognition is intact with BIMS score of 15 dated 2/4/2024. On 4/2/2024 at 12:19 PM, R1 was seen in his room alert and able to express thoughts well during conversation. R1 stated that although his blood sugar was 197, he did not received insulin as scheduled. R1 said that V8 (Registered Nurse) informed him that his Lantus insulin is not available. Review of Medication Administration Record of R1 for April 2024 documents that on April 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 observations, interviews, and review of records the facility failed to maintain privacy curtain to provide visual privacy to a room that has no restroom for 1 out 1 resident (R5) reviewed for facility environment. These failures has the potential to affect 1 resident (R5) in maintaining visual privacy inside the room. Findings include: On 4/2/2024 at 11:12 AM, inside room [ROOM NUMBER] that has the capacity of 4 beds. Room was seen without a toilet or sink. Upon entering the room there were 4 beds. Two beds on the left and two beds on the right. On the right side where 2 beds are located there was no privacy curtain that can be used to provide visual privacy. V3 (Assistant Director of Nursing/Registered Nurse) stated that maintenance was informed and was followed up last week about the room was without privacy curtain. And that some weeks ago a resident (R5) used to be on that bed and needs privacy curtain. On 4/3/2024 at 1:08 PM, V18 stated that he knew about room [ROOM NUMBER] not having a privacy…

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 and interview the facility failed to provide safe, sanitary, and comfortable environment in a room that has prior incident of electrical burning due to urine contact with electricity for 1 out of 1 resident (R15) reviewed for physical structure. These failures has the tendency to reoccur and to affect 1 resident (R15) when left without proper precautions. Findings include: On 4/2/2024 at 12:19 PM inside room [ROOM NUMBER] where R15 was seen. Left side of R15's bed near the corner wall was a black colored similar to electrical burn, walls with chip paint and smell of urine. On 4/2/2024 at 3:20 PM V18 (Maintenance Director) stated that urinal of R15 spilled causing a pool of urine, got to the extension cord that connects with television cord causing an electrical reaction. Because of that incident R15's television was replaced. The next day, 4/3/2024 at 1:25 PM, V18 stated that to prevent similar incident from happening, R15 was instructed to put the urinal on the other side. With V18 we went…

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 failed to provide sufficient supplies of incontinent wipes and gowns for 120 out of 165 residents. These 120 residents were identified by facility as incontinent and needs incontinent care. These failures have the potential to affect 120 residents in receiving proper hygiene and incontinence care due to lack of supplies of incontinent wipes and gowns. Findings include: On 2/6/2024 at 11:45 AM, R2 was seen laying on his bed with V17 (Spouse of R2). R2 was able to verbalize thoughts but with slight difficulty of hearing. V17 stated that facility has shortage of wipes that is needed to clean R2 for his incontinence. V17 then pointed on the container with dry wipes and said that she brought her wipes from home because facility was not providing any to R2. V17 then said, Staff sometimes clean R2 with chucks (pointing at the thin pad that was on the bed underneath R2 ). R2 then said that there were times that the facility does not have any gowns 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 follow their call light policy and provide reasonable accommodation of resident needs for two (R1, R3) residents out of three residents reviewed for call light response. This failure resulted in extended wait times for residents attempting to have their needs met. Findings Include: On 08/26/2023 at 9:32AM, R1 stated that she has waited up to a couple of hours for someone to come and answer her call light. R1 then states that she will call a family member to give the surveyor more information. On 08/26/2023 at 9:40AM via telephone, V9 (R1's family member) stated On 07/13/2023, R1 called me and told me that she couldn't breathe. R1 told me that she had pressed her call light and no one had come to answer her call light. Me and my family had just left the facility so we turned back around. My daughter got back to the facility first and noticed that R1's call light was still on and staff still had not come to check on R1. It had been about 45…

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 store, prepare, distribute and serve food in accordance with professional standards for food service safety. This deficient practice has the potential to affect all 148 residents who consume food prepared in the facility. Findings include: On 7/17/23 10:20AM walk in freezer was observed with 1 box of wheat flour, one box of pizza crust, one box of bread loaves and two boxes of waffles. These boxes were contaminated from frozen condensation (thick ice) originating from ceiling refrigeration unit. On 7/17/23 at 10:25AM a dietary staff personal water bottle of V15 (Dietary Aid) was observed in the dietary victory reach in refrigerator. On 7/17/23 at 10:25AM V15 (Dietary Aid) stated that is my personal water bottle. It is not supposed to be stored in that reach in refrigerator. On 7/18/23 at 12:55PM 5 small baking sheets and 5 large baking sheets were observed under the food prep counter next to stoves. The baking sheets were heavily encrusted with baked on black substance and not in easily cleanable condition. 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 document review the facility failed to maintain an effective pest control program so that the facility is free of pests. This deficient practice affects all 154 residents in the facility. Findings include: On 7/17/23 at 10:35AM four dead and one live roach was observed under the dietary area dishwasher. On 7/17/23 at 10:40AM the dry food storage room was observed with two dead roaches under the shelf on floor. On 7/18/23 at 12:50PM a nymph stage roach was observed on the food prep counter immediately next to sliced bell peppers during preparation. On 7/18/23 at 12:50 V14 (Cook) stated it must have fallen from the ceiling while I was cutting the peppers. On 7/19/23 at 3PM V1 (Administrator) was asked to provide the facility pest control policy. V1 provided the following document . Facility Policy document titled Pest Control, Purpose, states including. To restrict access by pests to the facility and prevent the risk of contamination of products, inputs, premises and equipment.

Based on observations, interviews, and record reviews, the facility failed to assess residents' ability to safely self-administer medications and/or treatments. This failure has affected 3 (R70, R83, and R118) residents reviewed for self-administration of medications in the total sample of 48 residents and has the potential to affect all 40 residents residing in Team Unit 5 and Team Unit 6. Findings include: The (07/17/2023) Resident Demographic Detail Report documented there were 17 residents on Team Unit 5 and 23 residents on Team Unit 6. On 07/17/23 at 11:25am, inside R70's room was a tube of metronidazole cream with R70's identifier. On 07/17/23 at 11:34am, V6 (Registered Nurse) checked the tube of medication and stated it is (R70)'s Metronidazole cream. On 07/17/23 at 11:45 AM, V6 stated the cream came over the weekend and the wound care nurse might have forgotten to put it back in the treatment cart. We (facility) cannot leave the treatment at bedside. It should be in the cart that way we (facility) know the treatment is available. I (V6) don't think (R70) 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that the resident environment remains free of hazards for four residents (R52, R109, R121 and R126). This failure has the potential to affect all 29 residents on the Team 3 unit and all 17 residents on the Team 5 unit. Findings include: On 07/17/23 at 11:27 am, R52 was observed in R52's bed awake and alert. Surveyor observed a chemical solution of bleach on top of R52's refrigerator. R52 stated, The staff left that there. It has been there all day. On 07/17/23 at 12:44 pm, V17 (Maintenance/Environmental Service Director) stated that the housekeepers should not keep cleaning solutions in the residents room after use. V17 stated that chemical solutions should be stored away on the housekeepers cart. V17 stated that if a resident gets the chemical solutions such as bleach and ingest them the resident can get poisoned. On 07/17/23 at 1:47 pm, V11 (Housekeeper) was asked regarding the chemical solution bleach on top of R52's refrigerator…

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 treatment cart was kept locked when not in use by staff. This failure has the potential to affect all 48 residents in the sample. Findings include: On 07/17/23 at 12:31 pm, Surveyor observed V10's (Licensed Practical Nurse, LPN, Treatment Nurse) treatment cart unattended and unlocked on the Team 5 unit/hallway area and no staff in site. At 12:36 pm, V10 returned to V10's unlocked treatment cart and stated, I (V10) thought I (V10) locked my cart. Someone must have unlocked it. When V10 was asked regarding the importance of locking the treatment cart when the treatment cart is not in use, V10 stated, If a resident drinks the Betadine (referring to the chemical solution inside of the treatment cart) they can aspirate or get poisoned. On 07/19/23 at 10:01 am, Surveyor observed V10's (Licensed Practical Nurse, LPN, Treatment Nurse) treatment cart unattended and unlocked on the Team 3 unit/hallway area and no staff in site. At 10:03 am, V10 returned to V10's unlocked treatment cart and stated, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that an oxygen tubing was changed in a timely manner for one resident (R96), who depends on supplemental oxygen, from a sample of 48 residents. Findings include: R96 is a [AGE] year old with diagnosis including but not limited to: Chronic respiratory failure with hypoxia, Asthma, Emphysema, Pleural Effusion and Anxiety. On 7/18/2023 at 11:11am during floor rounds, R96 was observed lying in bed with head of bed elevated and NC (Nasal Cannula) in place. R96 was receiving supplemental Oxygen via NC. The NC/ Oxygen tubing did not have a label on it to indicate the last day in which the tubing was changed. On 7/18/2023 at 12:20pm V19 (Registered Nurse/ RN) said, No there is no label or date on the oxygen tubing. There is only a date and label on the humidifier bottle. The night nurses said that she changed the tubing last night. There should be a label on the oxygen tubing so that we (nurses) know when it is time to change the tubing…

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 temperature thermometer for two residents (R52 and R62) refrigerators; and failed to properly log refrigerator temperatures for four residents (R32, R52, R55, and R62). These failures have the potential to affect all 48 residents in the sample. Findings include: On 07/17/23 at 11:26 am, surveyor observed R52's room refrigerator temperature without a temperature thermometer and R52's refrigerator temperature log sheet with missing temperatures for July 12, 2023; July 13, 2023; July 14, 2023; and July 15, 2023. R52 stated that R52 did not know when the last time R52's refrigerator was checked by staff at the facility. On 07/17/23 at 11:28 am, surveyor observed R62's room refrigerator temperature without a temperature thermometer and R62's refrigerator temperature log sheet with missing temperatures for July 12, 2023; July 13, 2023; July 14, 2023; and July 15, 2023. R62 stated that R62 did not know when the last time R62'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 and interview the facility failed to dispose of garbage and refuse properly. This deficient practice has the potential to affect all 154 residents in the facility. On 07/17/23 at 10:30AM facility outside dumpster area observed with torn open large garbage bags containing spoiled food piled behind dumpster. The ground surface was heavily soiled with liquid food spill and debris. One of the 3 dumpsters was missing the lids. Heavy fly infestation was observed throughout dumpster area. On 7/17/23 at 10:30AM V30 (Dietary Aid) stated the dumpster area is supposed to be maintained in clean condition. This area is not supposed to be in this condition. On 7/19/23 at 3:30PM V1 (Administrator) was asked to provide policy on maintaining dumpster area. On 7/19/23 at 3:30PM V1 stated we do not have a policy for that.