Ambassador Nursing & Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY F554Based on observations, interviews, and record reviews the facility failed to: 1. Obtain a physician order to keep medication at bed side for two (R107, and R126).2. Determine if self-administration of medication was appropriate for one (R107) out of two residents observed with medications at bed side table in a sample of 35. Findings Include:R107's Minimum Data Set/ MDS dated [DATE], Brief Interview Score (14) indicates she is cognitively intact. R107's Physician Order Sheet (POS) with active orders as of 8/5/25 shows Ventolin HFA inhalation aerosol solution 108 (90 base) MCG/ACT (Albuterol Sulfate) 2 puff inhale orally every 6 hours as needed for shortness of breath. R126's Minimum Data Set/ MDS dated [DATE], Brief Interview Score (15) indicates he is cognitively intact. R126's Physician Order Sheet (POS) with active orders as of 8/5/25 shows Ventolin HFA inhalation aerosol solution 108 (90 base) MCG/ACT 2 puff inhale orally every 6 hours as needed for shortness of breath. On 8/5/25 at 11:23 AM, 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.

Number of residents sampled: 172Number of residents cited: 3 Based on observations, interviews, and record reviews, the facility failed to ensure a homelike environment for three residents (R42, R88, R172) out of a total sample of 172 residents in the facility.Findings include: On 8/05/2025 at approximately 10:20 AM, R172 stated facility is slow to fix broken furniture and fixtures. R172 stated ceiling panel by the window has been missing for weeks. There was some type of leak from the ceiling and someone from maintenance took the panel out and never finished fixing it. When surveyor entered bedroom, surveyor observed the missing ceiling panel by R172's foot of the bed. Piping exposed and there were multiple towels and linen on the floor under the ceiling panel. On 8/05/2025 at 10:36 AM, R42 (roommate) stated the ceiling panel fell off and there was some water leak. R42 stated it's been this way for weeks. R42 stated the facility isn't doing anything to fix it or put it back. R42 also pointed to the cabinet in front of the bed. The left side panel and left cabinet door are missing.…

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 Number of residents sampled: 35Number of residents cited: 1 Based on interviews and record reviews the facility failed to submit an accurate Level I PASRR (Pre-admission Screening and Resident Review) assessment for R10 and failed to refer R10 to the appropriate state-designated authority for a Level II PASRR evaluation and determination after a significant change for one out of a total sample of 35 residents. Findings include: On 8/05/2025 at 11:14 AM, R10 was sitting in bed staring at room curtain. Surveyor attempted to interview R10 but R10 was quiet and mostly to self with a flat affect. During other random observations, R10 was on the first floor dining room or walking in the hallway. R10 kept mostly to self with flat affect. On 8/05/2025 at approximately 11:30 AM, V17 (Nurse) stated that R10 is alert and oriented to person and place. V17 stated R10 used to be more alert but has considerably slowed down. V17 stated R10 is quieter, keeps to self and requires more encouragement and queuing now. On 8/05/2025…

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.

Number of residents sampled: 35Number of residents cited: 1 Based on interviews and record reviews, the facility failed to follow-up and refer a resident with mental illness (R78) to the appropriate state-designated authority for a Level II PASRR (Pre-admission Screening and Resident Review) evaluation and determination for one out of a total sample of 35 residents. Findings include: R78's 'admission Record' documents in part an initial admission date of 6/02/2025. Diagnosis information includes schizoaffective disorder, bipolar disorder, insomnia, and depression. R78's 'Clinical Physician Orders' include orders for Ziprasidone Hydrochloride for schizophrenia, Trazadone for insomnia, and Amitriptyline Hydrochloride for depression. R78's 5/31/2025 'Notice of PASRR (Pre-admission Screening and Resident Review) Level I Screen Outcome' documents in part a determination of Refer for Level II Onsite. Requested R78's Level II PASRR multiple times from V1 (Administrator), V2 (Director of Nursing), V33 (Social Service Coordinator), V36 (Nurse Consultant) and V48 (Social Service Director)…

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.

Number of residents sampled: 35Number of residents cited: 1 Based on interviews and record reviews, the facility failed to follow physician orders and perform daily wound care for R177 and failed to ensure accurate Treatment Administration Records (TAR) for R177 for one out of a total sample of 35 residents.Findings include: R177's 'admission Record' documents in part diagnosis information of acquired absence of left leg below knee, encounter for orthopedic aftercare following surgical amputation, encounter for change or removal of surgical wound dressing, type 1 diabetes mellitus, and type 2 diabetes mellitus. R177's 'Care Plan Report' documents in part a focus that R177 has an amputation of left below knee amputation (BKA). Interventions include to do dressing change per doctor's order. R177's 'Order Summary Report' documents in part wound care orders for left below knee amputation site. Staff are to cleanse with normal saline solution, pat dry, apply nonadherent dressing pad, loose gauze bandage, and compression/elastic bandage every day shift and as needed for wound care. 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 ensure hazardous items were stored securely for one R12 resident reviewed for safety in a sample of 35.Findings Include:R12 has diagnosis not limited to Dementia in Other Diseases Classified Elsewhere, Unspecified Severity, with Psychotic Disturbance, Dependence on Wheelchair, Disorder of Adult Personality and Behavior, Mood [Affective] Disorder, Cerebral Ischemia, Paranoid Personality Disorder and Altered Mental Status. R12's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 99 indicating resident is rarely/never understood. Section GG - Functional Abilities document in part: Personal hygiene: The ability to maintain personal hygiene, including combing hair, shaving (Dependent) Helper does all of the effort. R12's Care Plan Document in part: Dressing/Grooming: Focus: I have a Self-Care Deficit with impaired Dressing and Grooming abilities and I would benefit from participation in a Dressing/Grooming Restorative Nursing Program as evidenced by the following risk factors and potential…

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.

Number of residents sampled: 35Number of residents cited: 1 Based on interviews and record reviews, the facility failed to follow provider orders and provide radiology services to one resident (R78) out of a total sample of 35 residents.Findings include: On 8/05/2025 at 11:20 AM, R78 stated experiencing coughing spells sometime last month. A provider evaluated R78 and ordered a chest x-ray. R78 stated facility never did it. R78's 7/14/2025 11:15 AM progress note by V32 (Nurse Practitioner) documents in part that R78 complained of chronic cough. As part of treatment plan, V32 ordered a chest x-ray. R78's 'Order Audit Report' documents in part that V30 (Nurse) entered the two-view chest x-ray on 7/16/2025 (two days later) at 4:47 PM on behalf of V32. On 08/06/2025 at approximately 9:30 AM, V1 (Administrator) informed surveyor that there was no chest x-ray results for R78. On 08/06/2025 at 12:22 PM, V34 (Nurse) stated the nurse practitioners or doctors will communicate to the nurses if there are new orders. The providers will put the orders in the computer unless it's a verbal or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews, the facility failed to ensure the outgoing nurse signed the First Floor Team II Controlled Substances Check Form. This failure affected 4 (R2, R8, R9, and R10) residents reviewed for controlled medications in the total sample of 10 residents.Findings include: On 07/14/2025 at 11:34am, V6 (Licensed Practice Nurse) stated the First Floor Team II medication cart is for residents from room [ROOM NUMBER] to 118. The (07/14/2025) Daily Roster indicated that R2, R8, R9, and R10 resided in First Floor Team II.On 07/14/2025 at 11:58am, during the medication storage and labeling task with V6 (Licensed Practice Nurse) of the First Floor Team II medication cart, the Controlled Substances Check Form has a missing signature on day 7/11/2025, 3-11 shift, Nurse Off. This was pointed out to V6. V6 stated that nurses are signing the form to document the controlled medications are counted to ensure there are no missing controlled medications.On 07/15/2025 at 11:26am, 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 interview and record review the facility failed to notify a physician of a residents (R7) condition/status. This failure affected 1 resident in the total sample of 10 residents.Findings include:R6 has a diagnosis which include but are not limited to: Repeated falls, Alzheimer's disease, lack of coordination, abnormalities of gait and mobility, weakness, dementia, ataxic gait, unsteadiness on feet, and insomnia. R6 has a Brief Interview for Mental Status (BIMS) dated 07/10/25 with no score and indicates that R6 has memory impairments.R7 has a diagnosis which includes but are not limited to: cocaine abuse, disorientation, other disorders of the brain, cerebral infarction, cerebral ischemia, and anxiety.R7 has a Brief Interview for Mental Status (BIMS) dated 04/30/25 with a score of 6 and indicates that R6 has memory impairments. During this survey R6 was able to answer surveyor questions appropriately.On 07/15/25 at 11:30 am, Surveyors observed V23 (Licensed Practical Nurse, LPN) (R6 and R7's nurse on 07/13/25) leave the facility via 911 emergency due to V23 not feeling well.…

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

Based on observation, interviews and record reviews, the facility failed to ensure controlled substance is properly labeled. This failure affected 1 (R2) resident reviewed for labeling of controlled substance in the total sample of 10 residents.Findings include:On 07/14/2025 at 3:34pm, this surveyor requested V6 (Licensed Practice Nurse) to show the label on R2's Morphine Sulfate. R2's Morphine sulfate label on the packages of the medication indicated Take 0.25ml (5mg) for moderate pain or take 0.5ml (10mg) by mouth under the tongue every 1 hour as needed for severe pain. This surveyor requested V6 to check for R2's order of Morphine Sulfate. V6, looking at R2's electronic health record, stated the order is to may give 0.25ml or 0.5ml every 4 hours. This surveyor requested V6 to check the label on the package of R2's Morphine Sulfate and the actual order for R2's Morphine sulfate. V6 stated the label on the package and the active order for Morphine Sulfate don't match. The expectation is the label on the packaging should match the order for accuracy. On 07/15/2025 at 11:29pm, V2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to prevent resident to resident physical abuse for 1 (R2) of 4 (R1, R3, R4) residents reviewed for abuse. This failure resulted in R2 sustaining swelling to the left side of R2's face near the eyebrow. Findings Include R2 has diagnosis not limited to Long Term (Current) use of Anticoagulants, Insomnia, Fall, Adult Failure To Thrive, Low Back Pain, Cerebrovascular Disease, Aphasia Following Cerebral Infarction, Nontraumatic Subarachnoid Hemorrhage from Unspecified Intracranial Artery, Acute Embolism and Thrombosis of Unspecified Deep Veins of Unspecified Lower Extremity, Acute Kidney Failure, Seizures, Respiratory Failure, Unspecified with Hypoxia, Emphysema, Dysphagia, Hypertensive Heart Disease, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side. R2's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 12 indicating moderate cognitive impairment. R2's Progress note dated 04/22/25 13:19 document 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to a.) provide appropriate supervision b.) reduce the risk of a fall for one (R5) resident out of five residents reviewed for falls, in a total sample of five residents. This failure resulted in R5 sustaining a fall without injury. Findings include: On 01/08/2025, at 11:45 AM, V6 (Certified Nursing Assistant) states that she is working the middle set assignment. Surveyor asked V6 which residents on her set are high fall risk. V6 states that R5 fell this morning. V6 continues that she was barely arriving to work when the night shift nurse found R5 on the floor, his bottom on the floor, in his room, next to his bed. 01/08/2025, 11:50 AM, R5 in bed lying down and in no apparent distress. R5 wearing white socks but not non-skid socks. R5's bed is not at the lowest position. Urinal noted approximately 5 feet away from R5's bed on the floor, sideways, no urine inside the urinal noted. Black shoes noted near R5's nightstand, next to R5's bed.…

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 an allegation of abuse was reported to the Illinois Department of Public Health (IDPH), within two hours of notification of the allegation and withing five days of the abuse allegation for one of three residents (R2) reviewed for abuse in the sample of three. Findings include: 11/3/2024, at 11:20 AM, R1 said, on Tuesday 10/15/2024, at 5:04 AM, he heard someone (female) say, don't push me, don't push me, followed by a thump. R1 said the conversation was coming from the room directly above him. R1 said he then heard the same female voice say, why did you do that, you pushed her down, she's hurt, you threw her on the floor, and don't push me. R1 identified the voice as R3, R2's former roommate at the time of the incident but could not identify the staff member's voice. R1 said he recorded the incident on his phone. R1 said he reported the incident to V3 (ADON-Assistant Director of Nursing) on 10/15/2024, at approximately 10:30 AM. I made her aware of what happened; she listened to the recording. R1 said V4 (Minimum…

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 on abuse. This failure resulted in R1 and R3 bumping into one another while on the patio smoking , causing R1 to fall and sustain a right hip fracture. Findings Include: On 10/17/24 at 11:21 AM, R1 stated that R3 pulled R1on R1's left wrist at the smoking patio, and R1 fell on the concrete floor on R1's right hip. R1 stated that there was a staff monitoring at the smoking patio. R1 stated that the nurse told R1 to go to the hospital but R1 refused. R1 later agreed to go to the hospital and report to the police. On 10/17/24 at 12:15 PM, R3 stated R3 speaks Polish with little English. Via the phone V11 (Polish Interpreter) stated that R3 stated that R3 did not punch or pulled R1. R3 stated that R1 pulled R3's wheelchair. On 10/17/24 at 3:17 PM, V4 (Social Service Director) stated that staff reported to V4 that R1 and R3 had verbal altercation outside the smoking patio on 9/13/24 (Friday) R1 bumped R1's rollator into R3's wheelchair, and R1 and R3 exchanged profanity words. V4 stated on 9/16/24 R1 told V4…

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 make reasonable accommodations toward assisting one resident, R1 of three R5, R6 residents to maintain independent functioning and well being with R1's own needs and preferences. Findings inlude, R1's clinical record indicates in part, R1 is an eighty-five-year-old admitted with medical diagnosis of transient cerebral ischemic attack, vitamin D deficiency, atherosclerotic heart disease of native coronary artery, chronic obstructive pulmonary disease, weakness and retention of urine. R1's minimum data set indicates R1 is cognitively intact. On 8/27/24 at 1:45 PM, R1 stated I have back pain and need to use my cane for short distance. I use my walker for long distances. I have not hit anyone with my cane. I have not fallen since I been here in the facility. One day the social worker lady took my cane and did not tell me why. Therapy told me I could use my cane for short distance and use the wheelchair for long distance. I do not know why the social worker took my cane; she did not tell me the reason. I came here with my own…

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, label, and protect food items in accordance with professional standards for food service safety. This failure has the potential to affect 135 residents that eat food from the kitchen. Findings include: 07/09/2024 09:44 AM, V9 (Cook) states that the kitchen director is currently on vacation. V9 states that V10 (Dietician consultant) is currently assisting V9 with the kitchen director's duties. V9 states that she will walk through the kitchen with the surveyor. 07/09/2024 9:47 AM, the walk-in cooler's outside thermometer reads 36-degrees Fahrenheit and the inside thermometer reads 37-degrees Fahrenheit. Peeled eggs dated 7/4/24 with no use by date are observed. V9 states that peeled eggs expire in two weeks. One whipped cream bottle is seen with a use by date of 06/24/2024. 07/09/2024 9:55 AM, opened, uncovered meat is observed on the counter. No staff are around. V9 states the second cook was in the middle of cutting the meat, then the second cook is observed walking around the counter. 07/09/2024 10:00…

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.

Based on observation, interview, and record review the facility failed to properly contain waste in dumpsters and failed to ensure dumpster lids were securely closed. Findings include: 7/10/2024 10:23 AM V16 (Maintenance Director) showed surveyor where the facility's two dumpster's were located at. Surveyor observed two large dumpsters, one dumpster (recycling) is noted with open lid, and the second dumpster (garbage) did not have a lid for half of the dumpster. Surveyors observed the facility's garbage dumpsters overfilled with clear trash bags with disposable chucks and briefs, V16 states yes, this one doesn't have a lid, maybe it got thrown away. V16 states that he hasn't had a chance to call the dumpster company to order a new lid. Facility document dated 04/2022, titled Garbage Disposal documents in part, keep dumpsters closed at all times. If the dumpster becomes full contact the garbage service for removal.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and review of records, the facility failed to ensure staff management is managed by the administration by allowing staff to work with multiple abuse allegations per policy. These failures have the potential to affect all the residents in the facility related to nursing staff to resident services. Findings include: 1. According to R119's facesheet printed 7/11/24, R119 is [AGE] years old and have diagnoses that include but are not limited to unilateral primary osteoarthritis, right and left knee; venous insufficiency; need for assistance with personal care. According to R119 MDS (Minimum Data Set), 6/3/24, R119 has a BIMS (Brief Interview for Mental Status) score of 15, indicating intact cognition. R119's care plan initiated 2/13/24 reads in part: R119 is an adult living with chronic health conditions and comorbidities that include orthopedic aftercare, unsteadiness on feet, gait and mobility issues, anxiety; that requires the support, services and structure of this care setting to maintain…

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 failures are as follows: Failed to follow laundry policy on maintaining clean environment/equipment used in air circulation and failed to sort and handle soiled linen to prevent overflowing in the laundry areas. Failed to follow Legionella policy on establishing preventive measures (worksheet, checklist, and other preventive means). Failed to follow its medication administration policy on handwashing while administering medications. These failures have the potential to affect all 139 residents in the facility who are receiving laundry and water services, and 20 residents receiving medications from the first-floor team two cart. Findings include: 1. On 07/10/2024 at 1:10 PM, V20 (Laundry Aide) was observed in the laundry room folding clean linens on the table near the wall. A large fan was facing directly on V20. Upon request to turn off the fan, V20 stated that it is hot in the laundry room when the fan is off. When the fan made a complete…

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 records review, the facility failed to follow its policy on disposing expired medication for one (R127) resident, and failed to properly store insulin for three (R4, R7, R90) of six residents reviewed in a sample of 28. Findings include: R28's current face sheet documents R127 is a [AGE] year-old individual with medical diagnosis that include but not limited to unspecified fracture of lower end of right tibia, subsequent encounter for closed fracture with routine healing, displaced fracture of lateral malleolus of right fibula, subsequent encounter for closed fracture with routine healing R28's current POS (Physician Order Sheet) documents: 7/25/2023 -Ibuprofen Tablet 600 MG -Give 1 tablet by mouth every 8 hours as needed for pain alternate with norco-Discontinued 7/25/2023 R90's current face sheet documents R90 is a is a [AGE] year-old individual with medical diagnosis that include but not limited to: type 2 diabetes mellitus with foot ulcer R90's current POS (Physician…

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

Based on observation, interviews and record reviews, the facility failed to follow their policy to ensure correct food temperatures were maintained when delivering food to residents for three (R50, R121, R104) residents reviewed for dietary services in a sample of 28. Findings include: 7/9/2024 12:40 PM R50 said the facility food is bad and cold. 07/09/24 1:06 PM R121 is observed sitting on his motorized wheelchair in his room, dressed in his own clothes, in no apparent distress. R121 states the food is 90% always cold. 07/09/2024 1:08 PM R104 states that the food is cold probably because it is handed out late. 7/10/2024 12:11 pm, the last tray is put in the 2nd floor's lunch cart, test tray placed in the 2nd floor's lunch cart. Staff observed taking the cart upstairs, surveyor follows. 7/10/2024 12:13 pm, tray cart arrived on the 2nd floor dining area. V18 (Cook) arrived with a thermometer. 7/10/2024 12:15 pm, several staff observed passing out trays. 7/10/2024 12:20 PM the last resident on the 2nd floor received their lunch tray. 7/10/2024 12:20 PM, test tray consisted of one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews the facility failed to provide the right of every resident to formulate an advance directive and advance care planning for 1 of 1 resident (R29) reviewed in a sample of 28 residents. These failures have the potential to affect 1 resident (R29) to exercise the option for advance directives and choose treatment. Findings include: R29 is [AGE] years old, initially admitted on [DATE], with a medical diagnosis of schizophrenia. Per Minimum Data Set (MDS) dated [DATE], R29 has a brief interview for mental status (BIMS) score of 7, meaning R29's cognition is impaired. R29's documented code status per physician's order is full code. The hospital record dated 5/15/2024 documents on care planning wound care provided to promote comfort needs (Hospice). On 07/10/24 at10:19 AM, V2 (Director of Nursing) stated that Social Service spoke with R29 and R29 chooses full code. A request of care plan for advance directive was made to V2. V2 stated that Social Services did not have any 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to protect the privacy and confidentiality of one (R40) resident's personal and medical records of six reviewed in a sample of 28. Findings include: R4's current face sheet documents R4 is a [AGE] year-old individual with medical diagnoses that include but are not limited to: schizophrenia, Major depressive disorder, bipolar. On 07/09/2024 at 9:55am, V4 (Registered Nurse-RN) was observed on the 1st floor using team two cart administering medication to R40. V4 was observed leaving the computer screen open, showing R40's information on the screen. There were other residents and staff passing by the medication cart glancing at the computer screen. R28 was observed sitting in his wheelchair directly facing the open computer screen, and R40 was standing near the open computer screen waiting for V4 to come back and continue administering R40's medications. V4 stated she had walked to the nursing station after R28 had informed V4 that he (R28) had…

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, interview and review of records, the facility failed to maintain a homelike environment for one (R80) out of 3 residents reviewed for homelike environment in a sample of 28. Findings include: On 07/09/2024 at 11:37 AM, surveyor observed R80's bathroom and saw there was a one foot size hole broken from the ceiling tile above the toilet. R80 stated that the hole has been there for about a month. She stated that she asked to have it repaired but no one has come to patch it up. On 07/10/2024 at 10:00 AM, surveyor observed R80's bathroom and saw the same hole unattended to. R80 stated that no one has come in to fix it. On 07/11/2024 at 10:28 AM, V16 (Maintenance Director) stated that he is the maintenance director for the facility. V16 stated that he started working at the facility since January 14, 2024. V16 stated that he does rounds on every floor every morning when he starts his shift. V16 stated that he starts on the 3rd floor and peaks into everybody's rooms to see what needs to be fixed. He observes what is going on with the lights. V16 stated that depending…

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 assure that a resident who was incontinent of bowel and bladder received the appropriate services to restore continence to the extent possible for one (R111) resident reviewed for bowel and bladder in a sample of 28. Findings include: R111's Face sheet dated 7/11/2024 documents that R111 is a [AGE] year-old male who has diagnoses not limited to: end stage renal disease, weakness, need for assistance with personal care, unspecified abnormalities of gait and mobility. R111's MDS/Minimum Data Set Section C dated 04/22/2024 shows R111 has a BIMS/Brief Interview for Mental Status score of 15/15, indicating that R111 is cognitively intact. R111's Minimum Data Set (MDS) section GG dated 04/22/2024 documents R111 needs substantial/maximal assistance for toilet transfer. R111's Minimum Data Set (MDS) section H dated 04/22/2024 documents R111 is not put on a trial of bowel and bladder toileting program, R111 is frequently incontinent for both bladder and bowel.…

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

Based on observation, interviews, and review of records the facility failed to ensure that a resident's head was elevated during administration and flushing of enteral feeding for 1 out of 1 resident (R398) for a total sample of 28 residents. This failure has the potential to affect 1 resident (R398) in preventing aspiration related to enteral feeding. Findings include: On 07/09/2024 at 12:01 PM, R398 was on the bed having their feeding tube flushed by V8 (Registered Nurse) using a syringe via enteral tube. R398 was laying on her side, head dangling off the bed on the level of her knees. V8 was seen flushing R398's enteral tube twice, after it was done. V8 was asked if R398's head is in the right position when enteral tube was being flushed. V8 stated that it was upright before but R398 moved to her right. After pointing out to V8 that R398's head is at the level of her knees. V8 went back to R398's bedside and repositioned R398 in an upright position. V8 then went out of the room and stated, the head should be maintained to at least 30 degrees to avoid aspiration. On 07/10/2024 at…

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

Based on review of records and interview the facility failed to provide education for the benefits and risks of influenza and pneumococcal vaccinations for 2 out of 5 residents (R147 and R29) per policy. These failures have the potential to affect 2 residents (R147 and R29) in understanding the benefits and risks of vaccination and prevention of infections. Findings include: Per resident's record under immunization, it documents: R147 Pneumococcal vaccine (Prevnar 13) documents consent required. R29 Pneumococcal vaccine (Pneumovax 23) and Influenza refused to give consent. On 07/10/2024 at 12:20 PM, V19 (Infection Control Preventionist / Licensed Practical Nurse) stated that education was provided to the granddaughter of R147 and not to R147. R147 has a documented BIMS (Brief Interview of Mental Status) score 13 that indicates R147 cognition is intact. V19 stated education should have been provided to R147 since R147 is cognitively intact. R29 only heard a part of the education on the risk and benefit of the vaccinations. All vaccination education was given and refused on the same…

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, observation, and record review, the facility failed to ensure that the resident's bathroom sink and toilet were maintained and working properly for 2 of 3 residents, R4 and R6 (R4, R6, R3) reviewed for physical environment in the sample of 3. Findings include: On 6/18/2024 at 9:21AM surveyor observed R4 shared bathroom with broken sink faucet, no water coming out when turned on and a non-working toilet not flushing properly. Toilet with water surrounding all area on the floor. At 9:23AM V1 (Administrator) approached surveyor in R4's bathroom and observed non- working faucet and toilet with water coming out of the bottom of the toilet. R4 not present in room at the time. R4 observed in dining room sitting at a table with a walker participating in activities. V1stated, he was unaware of this and will inform maintenance. On 6/18/2024 at 11:00AM R4 states, yes, my bathroom sink has been broken for about a month now. I keep telling them nothing is done. I have to brush my teeth and use 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, interviews, and record reviews, the facility failed to ensure waste management and odors were maintained regarding the facility's sewage pit. This failure has the potential to affect all 155 residents that reside in the facility. Findings Include: During the survey date of 2/24/24, upon entry of the facility, observed a light smell of sewage. V3[ MDS Coordinator] escorted surveyor to the basement conference room. Upon exiting the elevator, odor of feces and sewage was strong and offensive. V3 moved surveyor to another conference room on the first floor. On 2/24/24 at 12:04 PM, V3 [MDS Coordinator] stated, The smell in the basement is from the sewer. I am not sure why the odor is strong. Let's go to another conference room on the first floor, where the odor is not as strong. On 2/24/4/24 at 12:13 PM, V4 [Receptionist] stated, There is a strong odor in the basement, and it makes me sick to smell it every time I have to punch in and punch out. The smell is coming up from the basement throughout the facility. On 2/24/24 at 1:07 PM, V5 [Certified Nurse Assistant]…

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 housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior on 3 of 4 floors of the facility. Findings include: On 11/14/23 at 2:01pm, the floor in R2's room was visibly soiled with a thick grime buildup on the floor. Surveyor inquired about the appearance of R2's bedroom floor. V6 (CNA) stated, They can be mopped. The floors need to be stripped, mopped and waxed. On 11/14/23 at approximately 2:10pm, surveyor inquired about housekeeping in resident rooms. V7 (CNA) stated, It should be every day. On 11/15/23 at 9:35AM a 3rd Foor room was observed with a toilet room that was heavily soiled with feces smeared all over the floor and toilet. A clear plastic bag containing feces and paper towels was next to the toilet. On 11/15/23 at 9:37AM R9's toilet room was observed with a heavily stained floor with black substance and debris. On 11/15/23 at 9:40AM R6's room was observed with a toilet room hand sink half full of yellow water. The drain was clogged. On 11/15/23…

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 develop and implement a discharge care plan for three of three residents (R1, R11, R12) reviewed for discharge planning. On 11/16/23 V2 (Director of Nursing) provided R1's entire care plan as requested. Review of R1's care plan showed no care plan for potential discharge. R1's social service notes for the last full year was requested. On 11/20/23 V14 (Social Service Director) provided one page of notes dated 11/24/23. This note was reviewed and did not contain any information on R1's potential discharge. On 11/20/23 at 11:05am, V14 (Social Service Director) stated, there is only one page of notes for R1. V14 stated, I do not know why there is only one note. V14 stated, we do not develop a care plan for discharge unless they are discharging. On 11/20/23 R11 and R12's comprehensive care plans were reviewed however neither resident had a discharge care plan. Facility (undated) policy titled Transfer Requests, Discharge Planning Policy, Protocol and Procedure states Discharge planning needs and concerns will be addressed in 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 document timely skin assessments upon readmission and failed to ensure that treatment orders were obtained and/or administered to R1 on readmission Findings include: 1. On [DATE], IDPH (Illinois Department of Public Health) received allegations that R1 was sent to the emergency room and found to have severe infected wounds on the spine (to the bone) and heels. R1 expired [DATE] (per complainant). R1's diagnoses include but not limited to dementia, peripheral vascular disease, severe protein-calorie malnutrition, and unstageable sacrum pressure ulcer. R1's ([DATE]) BIMS (Brief Interview Mental Status) affirms resident is rarely/never understood. Cognitive skills for daily decision making are severely impaired. R1's ([DATE]) functional assessment affirms (2 persons) physical assist is required for bed mobility and toilet use. On [DATE] at 2:20pm, surveyor inquired about R1's functional status. V8 (Wound Care Coordinator) stated, I believe he…

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 staff are aware of how to transfer residents (from chair to bed) safely, failed to implement fall prevention interventions, and failed to provide supervision for one of three residents (R2) reviewed for falls. Findings include: The fall log affirms that R2 fell on [DATE], 10/20/23, and 10/29/23. R2's diagnoses include dementia, restlessness, and agitation. R2's (10/3/23) BIMS (Brief Interview Mental Status) determined a score of 1 (severe impairment). R2's (10/3/23) functional assessment affirms moderate assistance is required for sit to stand and chair/bed to chair transfer. R2's care plan states (9/27/23) Resident is at risk for falls as evidenced by cognitive impairment, decreased strength and endurance. Interventions: If resident is awake upon rounds offer to assist resident up to wheelchair and bring to Nurse's station. Resident will join morning and afternoon activities. Intervention: I would like staff to provide me…

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, interview and record review, the facility failed to follow its policy on infection control and prevention to prevent the spread of COVID -19 by not having biohazard garbage bins in a room of residents with confirmed COVID-19 infections and staff not wearing proper PPE (Personal Protective Equipment) when entering a room of a resident with confirmed COVID-19 infection. This deficiency has the potential of affecting all 123 residents residing in the facility. Findings include: On 10/07/2023 at 8:57am, V4(Licensed Practical Nurse -LPN) was observed by the first-floor nursing station without a face mask talking to residents and staff. V4 said she started work this morning at 7am and was not wearing a mask. V4 said she is supposed to be wearing a mask while in the facility because there is an outbreak of COVID-19 at the facility and wearing a mask can prevent further spread of COVID-19 in the facility. V4 said there was a resident on the first floor (R3) with COVID-19. On 10/07/2023 at 9:09am, V10 (Licensed Practical Nurse -LPN/Weekend wound Nurse) was 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 observation, interview, and record review, the facility failed to document temperature reading on the reach-in cooler temperature log and ensure food is being discarded on or before the expiration date. This has the potential to affect all 124 residents in the facility who receive an oral diet. Findings include: On 07/31/2023 at 9:36am upon initial tour of the kitchen, observed the temperature log for reach-in cooler. The temperature log was missing documentation of a temperature reading for the following date 7/30/2023. On 7/31/2023 at 9:37am observed two half pint cartons of vitamin A & D fat free milk, both cartons labeled with an expiration date of 7/29/2023. On 8/02/2023 at 9:44am V9 (Dietary Director) stated the purpose of checking the temperature logs for the freezers and coolers is to make sure the freezers and coolers are functioning properly and to maintain a proper temperature for the coolers and freezers. V9 stated the cooks are responsible for checking the temperature in the reach in cooler for every shift. V9 stated if the temperatures are too high in 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 interview and record review the facility failed to follow Quality Assurance/ Performance Improvement Program (QAPI) policy and procedure by not analyzing, identifying, and implementing corrective actions. This failure has the potential to affect 128 residents in the facility receiving care and services. Findings include: On 8/2/2023 at 1:00 PM, during QAPI meeting with V1 (Administrator), reviewed QAPI binder provided by V1. QAPI binder excluded QAPI Tools or QAPI Plan. Surveyor inquired about the facility's system to monitor and measure specific areas of care. On 8/2/2023 at 1:30pm V1 said, We don't have a tool to measure different areas of care at this time. What we have here is not a QAPI. I am familiar with the program I have been trying to change the way the facility does QA here. The managers have been doing things a certain way for so long, so it takes time to break habits and implement new systems. V1 presented facility assessment that reads: QAPI program feedback, data systems and monitoring. The policies and procedures must include a minimum, the following:…

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

Based on observation, interview and record review, the facility failed to clean the lint screen thoroughly in an effort to provide a safe environment to the residents. This failure has the potential to affect all 128 residents at the facility. Findings include: On 8/2/23 at 11:10 am, observed 2 dryers inside the laundry room. Dryer #1 and Dryer #2 were both in use. Surveyor requested V40 (Laundry Aide) to stop dryer #1 and open the lint compartment. The lint compartment floor was clean however the lint screen was fully covered with lint. On 8/2/23 at 11:15 am, surveyor requested V40 to stop Dryer #2 and open the lint compartment. The lint compartment floor had loose lint on the floor. The lint screen was fully covered with lint. On 8/2/23 at 11:17 am, V40 stated, I have not cleaned the lint compartment today because I've been too busy. V40 stated the lint compartment is cleaned every hour or after every drying cycle, but I haven't had time today to clean it. On 8/2/23 at 12:00 pm V19 (Housekeeping Supervisor) stated the lint traps are checked every hour. V19 stated the expectation…

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 (Activities of Daily Living) care related to shaving for four residents (R6, R10, R65, and R71). This failure affected four residents from a sample of 64 residents. Findings include: R6 is a [AGE] year-old with diagnosis including but not limited to: Encephalopathy, Asthma, Chronic Obstructive Pulmonary Disease, Diabetes, Dependent on oxygen, weakness and need for assistance with personal care. R6's 5/17/23 BIMS (Brief Interview for Mental Status) documents a score of 12, which indicates moderately impaired. R6's MDS (Minimal Data Set) functional status: personal hygiene- how resident maintains personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face, and hands (excludes baths and showers), documents, requires extensive assistance with one-person physical assist. On 7/31/23 at 11:10 am, Surveyor observed facial hair on R6's upper lip and chin. R6 stated, I do not like having…

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 that facility failed to ensure that CPAP/ BIPAP (Continuous Positive Airway Pressure/ Bilevel Positive Airway Pressure) machines were cleaned after each use for four residents (R55, R57, R121, and R433) that were reviewed in a sample of 66 residents. This failure has the potential to affect all eight residents that use CPAP machines. Findings include: R55 is [AGE] year old with diagnosis including but not limited to: Obstructive Sleep Apnea, Asthma, Allergic Rhinitis, Weakness and Need for assistance with personal care. R55 has a BIMS (Brief interview of Mental Status) score of 14, which indicates cognitively intact. R57 is a [AGE] year old with diagnosis including but not limited to: Chronic Obstructive Pulmonary Disease, Dyspnea, Asthma, Shortness of Breath, Need for assistance with personal care, Weakness, and Morbid obesity with Alveolar Hypoventilation. R57 has a BIMS (Brief interview of Mental Status) score of 15, which indicates cognitively intact. R433…

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 5) R116 is [AGE] year old with diagnosis including but not limited to: Elevated of levels of Liver Transaminase levels, Alcoholic cirrhosis of liver, Anxiety disorder, Hypertensive heart disease and Localized edema. On 7/31/23 at 11:28 PM, Surveyor observed 2 half pint cartons of expired milk in R116's personal refrigerator. Both cartons of milk were dated 7/24/23. Old fruit observed on the side of the refrigerator, and temperature log with missing signatures on it. R116's refrigerator temperature log was missing temperature recordings for 7/22/23- 7/31/23. The dates of 7/22/23- 7/20/23 documents random dates. On 7/31/23 at 11:35 AM V17 LPN (Licensed Practical Nurse) said, Housekeeping is responsible for checking the temperature logs daily. Housekeeping are also responsible for cleaning the refrigerators and removing old and spoiled food. The milk in R116's refrigerator is expired. 6) R55 is [AGE] year old with diagnosis including but not limited to: Vitamin D deficiency, Morbid Obesity due to excess calories,…

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 the food cart was not left unattended without staff presence and failed to ensure staff perform appropriate hand hygiene prior to touching a resident's food tray. These failures affected R26 and have the potential to affect all 9 residents receiving an early tray on the 3rd floor. Findings include: The (undated) list of 3rd Floor Residents on 1st food cart batch documented that R14, R15 R23, R25, R26, R56, R85, R98, and R102 were on the list. On 07/31/23 at 12:04 PM, the food cart was brought by staff to 3rd floor. The individual food items on the tray were covered, however, the food cart was left by the nurse's station without staff presence. Surveyor counted 10 trays in the food cart. Surveyor observed one resident get close to the food cart, getting a surgical mask from the counter of the nurse's station. On 07/31/23 at 12:09 pm, V7 (Certified Nursing Assistant) got out of the elevator, touched a food tray without performing hand hygiene and brought the food tray inside a resident's room and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to provide accommodation of call device system for one resident (R9) with physical limitations in a sample of 66 residents. Findings include: R9 is [AGE] year old with diagnosis including but not limited to: Hemiplegia and Hemiparesis affecting right dominant side, paraplegia, Dysarthria, Adult failure to thrive, Pressure ulcer and Hypertensive heart disease. R9's Functional Status section of MDS (Minimal Data Sheet) documents, R9 is totally dependent with bed mobility and Activities of Daily Living. On 7/31/23 at 11:03 AM, during floor rounds, R9 was observed in bed reaching for her call device. R9's Call device was observed on R9's right side above her head. R9's right arm appeared immobile with a splint in her hand. R9 tried to reach for the call light but could not reach it. V17 Licensed Practical Nurse (LPN) said, The call device shouldn't be up here. I don't know who put it here. They put it on the wrong side. V17 then removed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that a resident received mail timely in the facility and failed to ensure that a resident received personal mail unopened which affected R10 and R66 in the sample of 66 residents reviewed. Findings include: On 8/1/23 at 2:59 pm, R10 stated that her personal mail had been opened by facility staff prior to receiving it from the activity staff. R10 stated, It was personal mail with R10 describing R10's personal mail as a card in a letter, and they opened it. R10 stated that she gets cards and letters from V50 (R10's Family Member, and that activities staff members deliver R10's personal mail to R10. R10 stated that she could not recall the exact date when R10 received this personal mail from activities staff, but it was opened before I got it. On 8/2/23 at 11:15 am, R10 stated that the mail letter from V50 that R10 received opened in the facility was around 2 months ago. R10 stated that when R10 received the personal mail open, R10 was upset. R10…

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 inventory and document a resident's personal belongings and failed to ensure that a resident's personal belongings are labeled appropriately with the resident's name which affected one (R42) resident in the sample of 66 residents reviewed. Findings include: On 7/31/23 at 3:25 pm, V36 (R42's Family Member) stated that some of the clothes that R42 came to the facility with are not present in R42's room, and the facility is doing R42's laundry but that the clothes had R42' name on them. V36 stated that during visits to the facility, V36 observed R42 wearing odd clothes. On 7/31/23 at 4:18 pm, this surveyor informed V2 (Director of Nursing, DON) about V36's concerns and requested R42's inventory list of personal belongings. On 8/1/23 at 11:29 am, this surveyor was asking V2 for follow up about R42's inventory list. V2 stated, I couldn't find any inventory list for (R42). V2 stated that it should be completed on admission with all belongings…

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 the low air loss mattress is set on an appropriate setting for 1 resident (R123) reviewed for pressure ulcer prevention in the total sample of 66 residents. Findings include: On 07/31/2023 at 11:11am, R123 was lying on low air loss mattress Se A*r. The setting was between 300lbs - 400lbs and the 'Static' light was on. There were 4 mode options noted. 1. Static 2. Alternate 3. Pulsate and 4. Seat Inflate. This surveyor inquired if R123 has wound. R123 stated no but I (R123) can't move my legs. On 07/31/2023 at 11:17am, V4 (Licensed Practice Nurse) checked the setting of R123 low air loss mattress and stated static mode is on. On 07/31/23 11:44am, V8 (Wound Care Nurse/LPN) stated the purpose of the low air loss mattress is to prevent wounds and to keep a wound from getting worst. We (facility) use it (low air loss mattress) for stages 3 and 4 and for multiple stage 2s. It helps the wounds from getting worst. If they (resident) don't have a wound, we try to incorporate the low air loss mattress to…

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

Based on observation, interview, and record review, the facility failed to ensure nursing staff properly documented the medication administration record. This failure affected one resident (R37) in the sample of 66 residents. R37's diagnosis includes, but are not limited to, other cerebrovascular disease, gastrostomy malfunction, chronic respiratory failure with hypoxia, chronic respiratory failure with hypercapnia, anemia, unspecified, chronic obstructive pulmonary disease, unspecified, left ventricular failure, unspecified, atherosclerotic heart disease of native coronary artery without angina pectoris, dysphagia, oropharyngeal phase, difficulty in walking, not elsewhere classified, muscle weakness (generalized), thrombocytopenia, unspecified, personal history of transient ischemic attack , and cerebral infarction without residual deficits, hyperlipidemia, unspecified, moderate protein-calorie malnutrition, essential (primary) hypertension, benign prostatic hyperplasia without lower urinary tract symptoms, anxiety disorder due to known physiological condition, and insomnia,…

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.