Aperion Care Lakeshore

Based on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) to one resident (R46). This failure affected one resident out of sample size of 72.Findings include:R46 has a diagnosis is Hemiplegia and Hemiparesis, Disorders of Muscle, Hypertension, History of Falling, and Vitamin D Deficiency.R46 has a Brief Interview of Mental Status score of 10, indicating moderate cognition impairment.R46's Minimum Data Set Section GG, dated 01/02/2026, documents, Toileting hygiene: the ability to maintain perineal hygiene indicates 01: Dependent-Helper does ALL of the effort.R46's Task for Toileting Hygiene for 3/03 documents a time of 12:14am. There is no time listed for the 7:00am-3:00pm shift for toileting hygiene.R46's care plan focus, dated 7/26/2023, documents, I have bladder and bowel incontinence related to impair mobility: Check and change Q2-3H (every 2-3 hours) and PRN (As needed).On 3/03/2026 at 10:55am, R46 stated he had not been changed since 8:30pm on 3/02/2026.On 3/03/2026 at 11:08am, R46's incontinence brief had a dark yellow…

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

Based on observation, interview, and record review, the facility failed to label and date oxygen equipment (tubing and humidifier bottle) and failed to contain suction tubing. These failures affected one resident (R59) reviewed for oxygen in a total sample of 72 residents.Findings include:R59's diagnosis includes but is not limited to paraplegia, tracheotomy, cerebral infarction, iron deficiency, hypoglycemia, anemia, and venous thrombosis and embolism.R59's Brief Interview of Mental Status (BIMS) score is 13. R59 is cognitively intact.R59's Physician Order Sheet (POS), dated 2/13/26, documents, Trach: Change out date and label trach tubing weekly. Every night shifts every Sunday.R59's care plan, dated 10/28/26, documents: Focus: Risk for ineffective airway clearance. Intervention: Perform nasotracheal/oropharyngeal suctioning as appropriate to maintain airway. Provide oxygen as indicated by resident conditions and or provider order. Suction as needed. Utilize humidity (humidified oxygen or humidifier). Focus: I have a tracheostomy r/t impaired breathing mechanics. Interventions:…

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

Based on observation, interview, and record review, the facility failed to ensure the residents' personal refrigerator temperature logs were monitored. This failure affected three residents (R59, R167, and R197), reviewed for personal refrigerators in a sample of 72 residents. Findings include:R59's diagnosis includes but is not limited to paraplegia, tracheotomy, cerebral infarction, iron deficiency, hypoglycemia, anemia, and venous thrombosis and embolism.R167's diagnosis includes but is not limited to Chronic Obstructive Pulmonary Disease (COPD), Glaucoma, benign prostatic hyperplasia, gastritis, and arthritis.R197's diagnosis includes but is not limited to fracture of shaft of left femur, chronic kidney disease, quadriplegia, disorders of muscle, multiple sclerosis, hyperlipidemia, hypertensive heart disease, and obstructive reflux uropathy.On 3/2/26, R59, R167 and R197's personal refrigerator temperature log sheet had multiple days of missing temperature checks in February 2026. The month of March R197 had a missing temperature check on 3/3/26. On 3/4/26 at 10:36 am, V36,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain environment free of bedbugs for residents reviewed for a safe and comfortable environment. These failures affected 7 residents that were exposed to bed bugs and has the potential to affect 74 residents living on the same floor.Findings include: On 12/17/2025 at 1:54 PM, R4 was seen in her room with R5. R4 spoke more Bangladesh, less English. R4 would start with a few words of English, then would continue with Bangladesh. R5 was able to express her thoughts clearly within topic during conversation. R5 stated she transferred into another room last month because this room she currently occupies was infested with bed bugs. R5 stated she was bitten by bed bugs scratching her arms. R5 stated people came to fumigate the room due to bed bugs. On the same floor, at the door, a tape was seen with Do Not Enter written with R6's, R7's, and R8's names written as occupants in the room. V10 (Registered Nurse) was asked about the room. V10…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policy to ensure one resident (R6) was free from abuse. This failure affects 1 resident (R6) reviewed for abuse.Findings include: According to R6 face sheet provided by facility, R6 has diagnoses that include but not limited to moderate protein-calorie malnutrition, autistic disorder, bipolar disorder, anxiety disorder, and chronic obstructive pulmonary disease with (acute) exacerbation. R6's MDS (Minimum Data Set), dated 7/17/2025, indicates R6 has a BIMS (Brief Interview for Mental Status) score of 8, indicating moderately impaired cognition. According to R9 face sheet provided by facility, R9 has diagnoses that include but not limited to autistic disorder, Tourette's disorder, epileptic seizures, schizoaffective disorder, generalized anxiety, major depressive disorder, Asperger's syndrome, violent behavior. R9's MDS, dated [DATE], indicates R9 has a BIMS score of 11, indicating moderately impaired cognition. According to R9's Aggressive…

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 accurately complete Fall Assessments for one resident (R1). This failure affects one resident (R1) in a sample of 4 residents reviewed for falls. Findings include: R1's face sheet documents R1 was admitted to the facility on [DATE]. R1's face sheet documents diagnoses that include but are not limited to repeated falls, dementia, schizophrenia, anxiety disorder, and major depressive disorder. R1's care plan, revised date 10/27/22, documents, I (R1) am at risk for falls r/t (related to) convulsion, dementia, anxiety and MDD (major depressive disorder) with interventions that document, in part, Ensure resident wearing non-skid footwear . Frequent rounding to ensure resident is wearing nonskid socks . R1's care plan, date initiated 5/6/23, documents, WANDERING/ELOPEMENT: (R1) has been observed to be disoriented to place, have impaired safety awareness, wander aimlessly throughout the facility, and have a history of attempting to exit the facility without…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement a resident's (R1) care plan, who was assessed at risk for fall and has a history of falls. This affects 1 resident (R1) out of 4 residents reviewed for care plans. Findings include: R1's face sheet documents R1 was admitted to the facility on [DATE]. R1's face sheet documents diagnoses that include but are not limited to repeated falls, dementia, schizophrenia, anxiety disorder, and major depressive disorder. R1's care plan, revised date 10/27/22, documents, I (R1) am at risk for falls r/t (related to) convulsion, dementia, anxiety and MDD (major depressive disorder) with interventions that document, in part, Ensure resident wearing non-skid footwear . Frequent rounding to ensure resident is wearing nonskid socks . R1's care plan, date initiated 5/6/23, documents, WANDERING/ELOPEMENT: (R1) has been observed to be disoriented to place, have impaired safety awareness, wander aimlessly throughout the facility, and have a history of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to have one (R1) resident assessed by Physical Therapy in a timely manner. This affects 1 resident (R1) out of 4 residents reviewed for quality of care. Findings include: R1's face sheet documents R1 was admitted to the facility on [DATE]. R1's face sheet documents diagnoses that include but are not limited to repeated falls, dementia, schizophrenia, anxiety disorder, and major depressive disorder. R1's care plan, revised date 10/27/22, documents, I (R1) am at risk for falls r/t (related to) convulsion, dementia, anxiety and MDD (major depressive disorder) with interventions that document, in part, Ensure resident wearing non-skid footwear . Frequent rounding to ensure resident is wearing nonskid socks . R1's care plan, date initiated 5/6/23, documents, WANDERING/ELOPEMENT: (R1) has been observed to be disoriented to place, have impaired safety awareness, wander aimlessly throughout the facility, and have a history of attempting to exit the facility…

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 correct diet was served in accordance to physician orders and Dietician recommendations. This failure affects 1 resident (R2) out of 4 residents reviewed for diet orders. Findings include: R2's Face sheet, dated 4/21/202,5 documents a diagnosis of but is not limited to Failure to thrive, Dysphagia, Major Depressive Disorder. R2's Minimum Data Set Section C documents a Brief Interview Mental Status of 14, which indicates R2 is cognitively intact. R2's Physician order sheet documents an active diet order, dated 3/14/2025 at 12:31pm, for General Diet Pureed in texture; regular/thin consistency, super cereal at breakfast (x2), whole milk with meals, ice cream lunch and dinner, pudding with meals. On 4/21/2025 at 12:04 pm, V23 (Certified Nurses Aid) passed R2's dietary tray, and exited R2's room. R2's dietary slip served with R2's lunch (4/21/24) documents, Diet: Regular; Texture: Mechanical Soft; Beverages: Lemonade-1 cup; Notes: Shake on Tray, add cream soup with lunch and dinner tray. On 4/21/2025 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 upon interview and record review, the facility failed to conduct a thorough investigation, and failed to determine the root cause of an altercation for two of four residents (R2, R3) reviewed for abuse. These failures have the potential to affect 241 residents. Findings include: The (4/8/25) facility census includes 241 residents. The (4/2/25) initial FRI (Facility Reported Incident) states resident abuse. (R3) was agitated in the 1st floor common area. While (R2) was exiting the elevator, (R3) was about to enter the elevator. While (R3) was entering the elevator, he swiftly turned around pointing his finger at the elevator and his right hand made contact with (R2) forehead. Both residents were immediately separated. (R2) was noted with redness to his forehead. (R3) will be sent out for a psychiatric evaluation. R2's progress notes include (4/2/25), receptionist notified there is an altercation on the 1st floor between two residents. Nurse on duty performed a head-to-toe assessment observed redness on forehead, resident verbalized pain 2/10 on forehead. (4/3/25), zzz'Patient…

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 interview and record review, the facility failed to ensure two of five residents (R2, R3) in the sample remained free from abuse. These failures resulted in a physical altercation between R2 and R3. R2 sustained a large bruise on the forehead, bump on the back of the head, and pain rated 2 out of 10. Findings include: On 3/27/25, IDPH (Illinois Department of Public Health) received an allegation regarding facility abuse. The (4/2/25) initial FRI (Facility Reported Incident) states resident abuse. (R3) was agitated in the 1st floor common area. While (R3) was entering the elevator, he swiftly turned around pointing his finger at the elevator and his right hand made contact with (R2) forehead. (R2) was noted with redness to his forehead. (R3) will be sent out for a psychiatric evaluation. R2's (4/3/25) progress notes states, patient seen and examined today, noted to have a large bruise on the front of his head. Reports he got into an altercation with another resident. Patient reports he was repeatedly punched in the head. On 4/9/25 at 1:38pm, V1 (Administrator) stated,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon interview and record review, the facility failed to revise comprehensive care plans for two of four residents (R2, R4) reviewed for abuse and community access. Findings include: 1. The ([DATE]) Final FRI (Facility Reported Incident) affirms (R3's) right hand made contact to (R2's) forehead. Plan of care will be updated as needed. R2's ([DATE]) progress notes state, patient seen and examined today, noted to have a large bruise on the front of his head. Reports he got into an altercation with another resident. Patient reports he was repeatedly punched in the head. R2's comprehensive care plan (received [DATE]) excludes risk for abuse and/or [DATE] abuse incident. On [DATE] at 1:56pm, V2 (Director of Nursing) was asked about requirements for comprehensive care plan development. V2 stated, Upon admission, we establish their needs especially for people who are coming from a psychiatric hospital. It's individualized and there's a requirement that if there's a significant change, we revise it. V2 was asked…

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 bedtime snacks to residents who want to eat outside of scheduled meal service times. This failure has the potential to affect all 235 residents receiving oral diets in the facility. Findings include: R200 is [AGE] year old, with diagnoses including but not limited to: Type 2 diabetes mellitus, hypomagnesemia, hypo- osmolality and hyponatremia and major depressive disorder. R200's BIMS (Brief Interview of Mental Status) score is 15, which indicates cognitively intact. R589 is an [AGE] year old, with diagnoses including but not limited to: Type 2 diabetes mellitus with hyperglycemia, hyperlipidemia, depression, unspecified convulsions and anemia. R589 has a BIMS (Brief Interview of Mental Status) score of 14, which indicates cognitively intact. On 2/3/25 at 11:20 am, R589 was observed in bed with a slice of pizza in her bed near her pillow. R589 said she had the pizza in her bed since last Friday, and had forgoten to throw it out.…

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

Based on observation, interview, and record review, the facility failed to ensure two medication carts were free of loose tablets; failed to ensure multi-dose insulin vials and inhalers were labeled with an open date; failed to ensure expired house stock medications, insulin vials, and nebulizers were removed from medication carts and discarded; failed to ensure medication requiring refrigeration was properly stored; failed to ensure and maintain appropriate temperature recording for medication fridge; and failed to ensure medication for a discharge resident was removed from medication cart. These failures affected ten (R3, R44, R64, R66, R133, R149, R174, R228, R739, R740) residents reviewed for medication storage and labeling, and has the potential to affect all 158 residents residing on first, second, and third floor of the facility. Findings include: Facility census provided by V1, Administrator, documents the following: First floor nine residents, second floor 68 residents, third floor 81 residents for total of 158 residents. 1. On 02/03/25 at 10:54 am, during observation of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of five residents (R79, R141) did not have expired milk in their personal refrigerators; failed to ensure four of five residents (R51 R79, R141 and R216) personal refrigerators had both thermometers and temperature logs; and failed to ensure one of five residents (R61) personal refrigerator temperature log was completed daily. These failures has the potential to affect all residents with personal refrigerators in the facility. Findings include: 1.R141 is a [AGE] year old, with diagnoses including Type 2 diabetes mellitus without complications, mild protein-calorie malnutrition, hyperlipidemia, essential hypertension, and unspecified convulsions. R79 is [AGE] year old, with diagnoses including Type 2 diabetes mellitus without complications, hyperlipidemia, vitamin D deficiency, gastro-esophageal reflux disease, and essential hypertension. On 2/3/25 at 11:50 am, R141's personal refrigerator had no thermometer, no temperature log,…

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 staff don appropriate PPE (Personal Protective Equipment) while providing high contact care for a resident (R80) with Enhanced Barrier Precautions (EBP). This failure has the potential to affect all 69 residents on the second floor. Findings include: On 02/03/25 at 9:50 am, V1 (Administrator) presented a facility census of 69 residents on the second floor. R80's face sheet shows R80's has diagnosis including disruption of wound. R80's Brief Interview for Mental Status (BIMS), dated 01/20/25, shows R80 has a BIMS score of 15, which indicates R80 is cognitively intact. R80's Physician Order Sheet (POS) active orders, dated 02/03/25, shows R80 has orders for Wound: Right Heel: Cleanse with ¼ Dakin's, pat dry, apply Santyl and dry dressing daily. Every day shift for wound care. Santyl Ointment 250 unit/gram (GM) (Collagenase) Apply to right heel topically every shift for Wound. On 02/03/25 at 10:39 am, observed a sign on R80's door that read, Enhanced Barrier Precautions and a Personal Protective Equipment…

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 an indwelling catheter drainage bag was covered in a privacy bag. This failure affected two residents (R56 and R101) reviewed for privacy and dignity in the sample of 84 residents. Findings include: 1. On 02/03/2025 at 10:48 am, R101 was observed in bed resting, with R101's indwelling catheter hanging on the lower part of R101's bed, facing the entrance of the doorway, and without a drainage bag cover. R101's face sheet shows R101 has a diagnoses which includes, but not limited to, obstructive and reflux uropathy and unspecified hydronephrosis. R101's Brief Interview for Mental Status (BIMS), dated 1/1/25, shows R101 has a BIMS score of 11, which indicates that R11 has some cognitive impairments. R101's care plan, dated 01/30/25, documents: Focus: R101 has a indwelling catheter. Intervention: Catheter : R101 have a FR (French) 16 catheter. Position, catheter bag and tubing below the level of the bladder and away from entrance room door. 2. On 02/03/2025 at 11:00 am, R56 was observed in a wheelchair…

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 call light was within reach for two residents (R13, R41). This failure affects two residents (R13, R41) reviewed for call lights. Findings include: 1. R13 has diagnoses of Cerebral Palsy, Contracture, Unspecified Hand, Gastrointestinal Hemorrhage, Peptic Ulcer, Gastro-Esophageal Reflux Disease Without Esophagitis, Type 2 Diabetes Mellitus, and Mild Intellectual Disabilities. R13 does not have a Brief Interview of Mental Status score, because R13 is rarely/never understood. R13's Minimum Data Sheet, section GG (12/18/2024), documents Functional Limitation in Range of Motion: Upper extremities: Impairments on both sides. R13's care plan focus for ADL (Activities of Daily Living), dated 9/10/2022, documents an intervention on 2/08/2022 encourage the resident to use bell to call for assistance. On 2/3/2025 at 11:02am, R13's call light device was wrapped around side rail on left side, and not within reach it. had a hand splint on her left hand. On 2/3/2025 at 11:05am, V11 (Licensed Practical Nurse-LPN),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to obtain a doctor's order for an Advanced Directive, which affected two residents (R56 and R133) reviewed for Advanced Directives in the sample of 84 residents. Findings include: 1. R133's admission record history documents CODP (Chronic Obstructive Pulmonary Disease), diabetes, end stage renal disease, and hypertensive heart disease. R133's Minimum Data Set (MDS), dated [DATE], documents Brief Interview for Mental Status (BIMS) score of 14, which indicates R133 is cognitively intact. R133's Order Summary Report active orders as of [DATE] has no physician order for an Advanced Directive (Full code or Do not Resuscitate) status for R133. R133's admission Record Form for Advanced Directive section is blank. There are no Advanced Directives selected for this resident. On [DATE] at 1:00 pm, V26, LPN (License Practical Nurse), stated the nurse should get the Advanced Directive order on admission and enter it into the computer. On [DATE] at 1:10…

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 ensure one resident's (R589) bed was free from old food, condiments, and a meal tray. This failure affects R589 in the sample reviewed for a safe, clean, home-like environment. Findings include: R589 is an [AGE] year old, with diagnoses including but not limited to: Type 2 diabetes mellitus with hyperglycemia, hyperlipidemia, depression, unspecified convulsions and anemia. R589 has a BIMS (Brief Interview of Mental Status) score of 14, which indicates cognitively intact. On 2/3/25 at 11:20 am, R589 was observed in bed with a tray of food in her bed, bread and condiments on top of her bed sheet, and a slice of pizza in her bed near her pillow. At that time, R589 said she had the pizza in her bed since last Friday, and had forgot to throw it out. R589 also said she had been eating on the pizza whenever she gets hungry because she would sometimes get hungry in between meals, and never got a snack. On 2/3/25 at 11:24 am, V20 (CNA/ Certified…

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 complete a new pre-admission screening and resident review (PASARR) when resident was admitted to the facility. This failure affects 1 resident (R137) out of a sample of 84. Findings include: R137 has ]diagnosi]es of Hemiplegia and Hemiparesis affecting Left Non-Dominant Side, Dementia with other Behavioral Disturbance, Major Depressive Disorder, Bipolar Disorder, and Mood Disorder due to Known Physiological Condition with Manic Features. R137 has a Brief Interview of Mental Status score of 10. R137's Order Summary Report ,with active orders as of 2/05/2025, document Quetiapine Fumarate Oral Tablet 100mg: Give 1 tablet by mouth at bedtime related to Bipolar Disorder. On 2/03/2025 at 1:23pm, there was no Level 1 or Level 2 PASARR for R137 in the facility's Point Click Care software. On 2/04/2025 at 10:15am, surveyor requested R137's Level 1 and Level 2 PASARR from V1 (Administrator). On 02/04/2025 at 12:03pm, V29 (Assistant Administrator) stated, I monitor the Maximus program and if a resident is due for an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one dependent resident (R74) received her scheduled showers. This failure affected one of three residents reviewed for ADL care (Activities of Daily Living). Findings include: R74 is a [AGE] year old, with diagnoses including Contracture of muscle, muscle spasm of back, cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting left side, and essential hypertension. R74 has a BIMS (Brief Interview of Mental Status) score of 13, which indicates cognitively intact. R74's Section GG- Functional Abilities assessment, dated 11/1/24, documents R74 is dependent with showers, baths, and transfers. R74's Care plan documents R74 has an ADL functional ability self-care and mobility deficit related to late effects of cerebral infarction. R74 has a bathing order for Sundays (AM) and Wednesdays (PM) entered on 6/24/23. On 2/3/25 at 12:05 pm, R74 said before 1/26/25, she had not had a shower in over a month. and she…

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

Based on observation, interview, and record review, the facility failed to ensure the low air loss mattress was not layered with multiple linens for 1 resident (R13). This failure affected 1 resident reviewed for pressure ulcer/injury prevention and treatment in a sample size of 84. R13 has diagnoses of Cerebral Palsy, Contracture, Unspecified Hand, Gastrointestinal Hemorrhage, Peptic Ulcer, Gastro-Esophageal Reflux Disease Without Esophagitis, Type 2 Diabetes Mellitus, and Mild Intellectual Disabilities. R13 does not have a Brief Interview of Mental Status score, because R13 is rarely/never understood. R13's Minimum Data Sheet, section GG (12/12/2024), documents Functional Limitation in Range of Motion: Upper and lower extremities: Impairments on both sides, and dependent (Helper does all the effort) for all self-care and mobility performance. R13's Braden Observation, dated 9/27/2024, documents R13's Braden scale score of 12 high risk, mobility: ability to change and control body position: Very limited. On 2/3/2025 at 11:01am, R13 was in bed with an incontinence brief, mattress…

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

Based on observation, interview, and record review, the facility failed to ensure residents at risk for falls were supervised while at the dining room. This failure affected 2 (R82 and R88) residents reviewed for fall prevention program in the total sample of 84 residents. Findings include: 1. R82's (Active Order as Of: 02/04/2025) Order Summary Report documented Diagnoses: (include but not limited to) hypertension, schizophrenia, schizoaffective disorder and type 2 diabetes mellitus. R82's (01/13/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 03., indicating R82's mental status as severely impaired. R82's (08/29/2024) Fall risk Assessment documented, Score: 13. Category: At Risk for Falls. R82's (02/04/2025) Fall risk Assessment documented, Score: 15. Category: At Risk for Fall. R82's (Revision on: 10/22/2024) care plan documented, I am at risk for falls r/t (related to) Gait/balance problems. I will not sustain injury. Anticipate and meet the resident's needs. 2. R88's (Active Order as Of:…

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

Based on observation, interview, and record review, the facility failed to change oxygen equipment (nebulizer mask) per the facility policy. Thia failure affected one resident (R68) reviewed for oxygen equipment, in a total sample of 84 residents. Findings include: R68's face sheet shows R68 has diagnoses which includes asthma and hypertensive heart disease with heart failure. R68's Brief Interview for Mental Status (BIMS), dated 12/10/24, shows R68 has a BIMS score of 6, which indicates R68 has cognitive impairments. R68's Physicians Order Sheet (POS) active orders, dated 02/03/25, shows R68 has orders for Budesonide Suspension 0.25 MG (milligrams)/2ML (milliliter)1 vial inhale orally via nebulizer two times a day for asthma and Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 3 ml inhale every 6 hours as needed for SOB (shortness of breath or Wheezing via nebulizer. Record Pulse / O2 (oxygen) Saturation/ Breath Sounds Code: 0= Clear 1 = Crackles 2 = Wheezes 3 = Rales 4 = Rhonchi. On 02/03/25 at 10:35 am, R68 was observed in bed, resting with a nebulizer mask next to R68'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 observation, interview, and record review, the facility failed to ensure narcotic count was recorded on each shift; failed to record accurate narcotic medication counts; and failed to have a shift change controlled substance inventory count sheet available to ensure accurate count and review of narcotic medications are recorded and signed each shift by a nurse. These failures affected one resident (R46) out of one resident reviewed for controlled drug administration. Findings include: Facility presented a list of residents receiving narcotic medications on the first floor. Only R46 is on the list. Facility census documents a census of eight on the first-floor unit. On 2/3/25 at 11:45am, during first floor medication cart review, the narcotic binder was reviewed, and the Shift change controlled substance inventory count sheet was not observed in the narcotic binder. R46's Controlled drug administration record displayed 21 tablets of Tramadol 50 milligrams (mg), but the medication bingo card only has 20 tablets of Tramadol 50 mg in narcotic box. The Controlled Drug…

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 no pests were in resident's rooms. This failure has affected three residents (R3, R4, and R5), with the potential to affect 242 residents that currently are residing in the facility. Findings include: R3 is [AGE] year old with diagnosis including but not limited to: Type 2 diabetes mellitus, heart failure, essential hypertension, insomnia, localized swelling and bilateral primary osteoarthritis of knee. R3's BIMS (Brief Interview of Mental Status) score is 13, indicating cognitively intact. R4 is [AGE] year old with diagnosis including but not limited to: Asthma, type 2 diabetes mellitus, major depressive disorder, overactive bladder, dysphagia and essential hypertension. R4's BIMS (Brief Interview of Mental Status) score is 12, indicating moderate impairment. R5 is [AGE] year old with diagnosis including but not limited to: Major depressive disorder, obesity, chronic kidney disease, abnormalities of gait and balance, and essential…

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 develop safety precautions to address resident risk and environmental hazards to minimize the likelihood of accidents related to residents smoking inside their rooms/bathrooms/lounge in the facility for two (R3, R5) of six residents reviewed for safety. Findings include: 1. R3 current face sheet documents R3 is a [AGE] year-old individual, initially admitted to the facility on [DATE], and re-entered facility on 12/26/2022. R3's medical diagnosis includes but not limited to paranoid personality disorder, delusional disorders, schizophrenia, unspecified. R3's smoking assessment, dated 5/23/2024, documents R3 was observed smoking in her bathroom. R3's care plan, last updated 07/07/2024, documents R3's Inappropriate Smoking behavior. R3's Social Services notes, dated 7/7/2024, 5/23/2024, 4/30/2024, 4/11/2024, documents R3's history of smoking in R3's room/bathroom. R3's Brief Interview for Mental Status (BIMS), dated 08/15/2024, documents R3…

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 residents participated in care planning conferences for 3 (R1, R6, R7) out of 3 residents reviewed. Findings Include: R1's clinical records show an original admission date of 3/29/24. R1's Quarterly MDS assessment, dated 6/30/24, shows R1 is cognitively intact. R1's clinical records lacked documentation of a care conference for R1. On 8/11/24 at 9:13 AM, R1 stated the facility has not conducted any care plan meeting since R1's admission. R1 stated, They have not given me a care plan meeting. I'm leaving at the end of the month and they still have not done any meeting. I told [V1 Administrator], and V1 said that V1 would schedule one, but there is no point anymore since I'm leaving end of the month. R6's clinical records show an original admission date of 3/6/24. R6's Quarterly MDS assessment, dated 6/6/24, shows R6 is cognitively intact. R6's clinical records lacked documentation of a care conference for R6. At 9:41 AM, R6 stated the facility has not done any care plan conference since R6's admission. R6 stated, I'd…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide mail services to residents on Saturdays. This has the potential to affect all 213 residents residing in the facility. Findings include: On 05/01/2024 at 1:49PM, during the resident council group meeting, all residents (R4, R88, R109, R118, R121, R129, R155, and R162) in attendance stated there is no mail delivered to the residents on Saturdays. Residents stated mail is first checked by the business office, then the business office gives it to the receptionist, and then the receptionist gives it to the Activity department, and then the Activity department is who delivers mail to the residents. Residents states they have to wait until Monday to get their mail at the facility. Residents state sometimes their mail is already opened when they receive it. On 05/02/2024 at 9:53AM, V41 (Activity Director) stated she has a total of four Activity Aide staff members that she oversees. V41 stated she has one employee in the Activity department who works…

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 there was adequate staffing to provide care for the residents. This failure has the potential to affect all 213 residents residing in the facility. Findings include: On 4/30/24 at 10:00 AM, V28 [Certified Nurse Assistant/CNA] stated, On the weekends there are times, we are short a CNA. It makes it more challenging, however we help each other with the residents. On 4/30/24 at 10:55 AM, V26 [Certified Nurse Assistant] stated, I work every other weekend, and there is always a call off, especially during the weekends. Which make it harder to complete our job, and take care of the residents. On 4/30/24 at 1:00 PM, V12 [Licensed Practical Nurse] stated, I work on the weekends. Most of the time we have sufficient staffing. There call offs during the week and weekends. However, the past few months staffing has gotten better, than before. On 5/2/24 at 11:22 AM, V37 [Human Resource Director/Nursing Staff Scheduler] stated, I started taking over 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 food items were labeled and dated, failed to properly store scoops when not in use, failed to store food based on manufacturer's guidelines, and failed to sanitize cooking equipment based on manufacturers' directions. These failures have the potential to affect all 209 residents receiving food prepared in the facility's kitchen. Findings include: On 04/30/24 at 9:10 AM, V7 (Cook) conducted the initial kitchen tour with surveyor. V1 (Administrator) was present for part of the kitchen tour. On 04/30/24 between 9:18 AM - 9:31 AM, observed the following items in the walk-in cooler: 1.) Tray of left over gelatin mixed with fruit not labeled or dated. V7 stated this was made two days ago and should have been labeled with a prepared and use by date. 2.) One opened bag of liquid eggs not labeled or dated. V7 stated since the bag was opened it should have been labeled with an open and use by date. 3.) Eleven meat sandwiches wrapped in plastic on a sheet pan not labeled or dated. V7 stated whoever made 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 dumpster was covered to prevent the harborage and feeding of pests, insects, and rodents. This deficient sanitation practice has the potential to affect all 213 residents who reside in the facility. Findings include: On 05/01/24 at 8:25 AM, during observation of the outside garbage dumpsters with V21 (Former Food Service Manager), observed two out of the four dumpster lids fully opened. V21 stated the lids on the dumpsters should be fully shut to prevent rodents from getting inside and to prevent garbage from flying outside the dumpster. V21 stated V21 instructs the kitchen employees to make sure all the dumpster lids are closed and that the dumpsters are not overfilled. On 05/01/24 at 8:30 AM, V20 (Housekeeping Director) stated V20 instructs the housekeeping staff to make sure there is no trash around the outside dumpsters and to always keep the lids to the dumpsters closed. V20 stated the dumpster lids should always be kept shut to keep away animals/pests to prevent rodents/animals from being…

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 medications were labeled when opened, and failed to ensure discontinued medications were removed from the medication cart in 4 of 5 medication carts reviewed for medication storage and labeling. This affects 9 residents (R3, R47, R82, F195, R35, R52, R74, R136, and R76) reviewed for medication storage. Findings Include: On 04/30/24 at 10:39 AM, the 3 Southwest medication cart was reviewed with V12 (Licensed Practical Nurse). R3's Advair Diskus Aerosol Powder Breath Activated 100-50 MCG (Microgram)/Dose 1 inhalation inhale orally every 12 hours was observed in the medication cart opened and undated. The Advair label reads (Discard 1 month after opening). V12 stated, After opening it they are supposed to date it. R47's Symbicort Inhalation Aerosol 160-4.5 MCG/ACT 2 puff inhale orally two times a day. The Symbicort label reads discard within 3 months, and R82's Trelegy Ellipta Aerosol Powder Breath Activated 100-62.5-25 MCG/INH 1 puff inhale orally one time a day was observed in the medication cart opened…

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 multi-use blood pressure device and glucometer was properly cleaned and disinfected between resident use for 5 (R97, R120, R176, R183, R271) residents; failed to ensure signage on the door or wall outside of the resident room indicating Enhanced Barrier Precaution (EBP) was posted for 1 (R145) resident; and failed to ensure PPE (Personal Protective Equipment) was readily accessible and worn when providing care for 3 (R23, R39, R47) of 10 residents on Enhanced Barrier Precautions. These failures have the potential for cross contamination for 9 (R23, R39, R47, R97, R120, R145, R176, R183, R271) residents reviewed for infection control in a sample of 35. The findings include: 1. R97's health record documented admission date on 7/23/2014, with diagnoses not limited to Type 2 Diabetes mellitus with diabetic neuropathy, Hypothyroidism, Hypertensive heart disease without heart failure, Hyperlipidemia, Other epilepsy, Major depressive disorder, Other hereditary and idiopathic neuropathies, Essential…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policy and procedure to ensure the residents medical records includes documentation if influenza and pneumococcal immunizations were received or did not received for 3 residents (R208, R205, R139); failed to ensure the residents medical records includes documentation education was provided to eligible residents and/or resident representatives regarding the benefits and potential side effects of all available pneumococcal and influenza immunizations for 5 residents (R208, R205, R58, R77, R139); failed to assess eligibility and offer influenza immunization to 1 resident (R208); and failed to assess eligibility and offer pneumococcal immunization to 1 (R208) out of 5 residents reviewed for pneumococcal and influenza immunizations in the final sample of 35. Findings Include: R208's face sheet shows R208 was admitted on [DATE] and is [AGE] years of age with diagnoses not limited to Dementia and Type 2 Diabetes Mellitus. R205's face sheet shows…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policy and procedure to ensure the residents medical records includes documentation if COVID-19 immunizations were received or not received for 3 residents (R208, R205, R139), and failed to ensure the residents medical records includes documentation education was provided to residents and/or resident representatives regarding the benefits and potential side effects of COVID-19 immunization for 5 (R208, R205, R58, R77, R139) out of 5 residents reviewed for COVID-19 immunization in the final sample of 35. Findings Include: R208's face sheet shows R208 was admitted on [DATE] and is [AGE] years of age with diagnoses not limited to Dementia and Type 2 Diabetes Mellitus. R205's face sheet shows R205 is [AGE] years of age admitted on [DATE] with diagnoses not limited to Heart Failure, Hypertension, Type 2 Diabetes Mellitus, and Hyperlipidemia. R139's face sheet shows R139 was admitted on [DATE] and is [AGE] years of age with diagnoses not limited…

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 privacy and promote dignity for one resident [R38] reviewed for urinary catheters in the sample of 35. R38's clinical record indicates the following medical diagnoses of neuromuscular dysfunction of bladder, acute kidney failure, hematuria, essential (primary) hypertension, chronic obstructive pulmonary disease with (acute) exacerbation, and schizoaffective disorder. On 4/30/24, at 11:15 AM, R38 was lying in bed with his urinary bag half filled, with urine noted from the hallway. On 4/30/24 at 11:18 AM, R38 stated, I have a urinary catheter, due to my bladder not working. I am not sure when the nurse aide emptied my urine bag. I do not want anyone seeing my urine or urinary bag. On 4/30/24, at 11:22AM, V6 [Licensed Practical Nurse] stated, I see (R38's) urinary bag from the hallway half filled with urine. The Certified Nurse Assistants should keep the urinary bags emptied and covered for the resident privacy. I will have the Certified Nurse Assistant come empty the urinary bag, and place the bag into…

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 call light was within reach for 3 (R39, R82, R114) of 5 residents reviewed for accommodation of needs in a sample of 35. Findings Include: 1. R82 has diagnoses not limited to Cognitive Communication Deficit, Essential (Primary) Hypertension, History of Falling, Hypothyroidism, Obesity, Atrial Fibrillation, Transient Cerebral Ischemic Attack, Hyperlipidemia, Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, Asthma with (Acute) Exacerbation, Dysphagia, Oropharyngeal Phase, Chronic Kidney Disease, Hypokalemia, Dementia, Major Depressive Disorder, Diabetes Mellitus Abnormalities of Gait And Mobility, Thyrotoxicosis, Osteoarthritis of Knee, and Chronic Diastolic (Congestive) Heart Failure. R82's Care plan documents: Focus: (R82) has an ADL (Activities of Daily Living) and functional ability for self-care and mobility performance/deficit. Interventions: Encourage the resident to use bell to call for assistance. Focus: (R82) is at risk for falls r/t (related/to) impaired mobility.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to make a referral for re-evaluation after a change in mental health status for 1 (R2) of 2 residents reviewed for Preadmission Screening and Resident Review (PASRR) in a sample of 35. Findings Include: R2 was admitted to the facility on [DATE], with diagnoses not limited to Cocaine Abuse, Abnormal Posture, Seizures, Bipolar Disorder, and Essential (Primary) Hypertension. R2's Care plan documents: Focus: (R2) has a mood problem r/t (related/to) Bipolar Date Initiated: 10/28/22. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. R2's Interagency Certification of Screening Results for Long Term Care documents: Date client received screening: 03/13/1998. Screening is valid for 90 days from date of screening. Screening indicated nursing facility services are appropriate. R2's OBRA (Omnibus Budget Reconciliation Act) screen, dated 03/13/1998, documents: Based upon all information and data available to me 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 initiate a new Level I screen for residents with known mental illness for one (R59) of two residents reviewed for Pre-admission Screening and Record Review (PASARR) in a total sample of 35. Findings include: R59's Facehsheet documents R59 was admitted to the facility on [DATE], with diagnoses not limited to: major depressive disorder, single episode, unspecified, generalized anxiety disorder, bipolar disorder, and unspecified dementia, unspecified severity, with other behavioral disturbance. R59's Interagency Certification of Screening Results OBRA-I Initial Screen, dated 11/26/2008, indicates R59 has no reasonable basis for suspecting MI (mental illness). R59's Minimum Data Set (MDS) Section I, dated 03/04/2024, indicates active diagnoses of anxiety, depression, and bipolar disease. On 05/01/2024 at 1:10PM, surveyor inquired to V2 (Assistant Administrator) about level II PASSAR screenings for residents who are admitted to the facility with a diagnosis…

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 include Advance Directives in the resident's plan of care. This failure affected three (R12, R91, R186) residents reviewed for Advanced Directives and comprehensive care plans in a total sample of 35 residents. Finding include: 1. R12 has diagnoses including, but not limited to Parkinson's Disease Without Dyskinesia, Idiopathic rogressive Neuropathy, Chronic Obstructive Pulmonary Disease with Acute Exacerbation, Type 2 Diabetes Mellitus with Hyperglycemia, Schizophrenia, Hypothyroidism, Hyperlipidemia, Dysphasia, Hypertension, Overactive Bladder, Abnormalities of Gait Immobility, Anemia, Major Depressive Disorder, and Psoriasis Vulgaris. R12's Order Summary Report, dated 05/01/24, documents full code status ordered on 07/10/23. Per review of R12's electronic health record (EHR), R12 does not have a care plan for Advanced Directives. 2. R91 has diagnoses including but not limited to Seizures, Type 2 Diabetes Mellitus with Hyperglycemia, Major Depressive Disorder, Schizophrenia, Iron Deficiency,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policy to ensure resident will have a comprehensive care plan that is current with the medical regimen for 1 (R81) resident reviewed for individualized revision of care plan in a total sample of 35. Findings Include: R81's Minimum Data Set (MDS), dated [DATE], shows R81 is not cognitively intact. According to the admission Record, R81 was admitted to the facility on [DATE], and readmitted on [DATE], with the following diagnoses of, but not limited to Paranoid Personality Disorder, Dementia, Parkinson's disease, and Chronic Obstructive Pulmonary Disease. R81's Physician Order Sheet (POS) shows R81 has an active order as of 5/1/24 for Do Not Resuscitate (DNR). Practitioner Orders for Life Sustaining Treatment (POLST), dated 6/16/23, documented: Do Not Resuscitate (DNR). R81's comprehensive care plan, completed on 4/22/24, documented: Advance Directive Status-Full Code. On 05/2/24 at 8:40 AM, V32 (MDS/Care Plan Coordinator) stated V32…

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 fingernail care for one (R169) dependent resident in a total sample of 35 residents reviewed for ADL/Activities of Daily Living care Findings include: R169's Minimum Data Set/MDS, dated [DATE], documents R169 is dependent with ADL care and requires a two person assist with ADL care. R169s' care plan, dated 01/29/2024, documents R169 is care planned for ADL and mobility self-care deficit. R169s' care plan documents R169 is totally dependent on staff for baths and shower and requires maximal assistance with other ADL care tasks. On 04/30/2024 at 11:46AM, R169 stated he informed a male CNA/Certified Nursing Assistant staff member approximately 2-3 days ago he would like his fingernails cut. R169 stated his nails are too long, and he does not prefer them to be that long. R169 stated it has been a long time since he had his nails cut. R169 is able to freely lift his right hand and surveyor observed R169's fingernails on his right hand…

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 adequate oxygenation, failed to ensure head of bed was elevated, and failed to change and properly store oxygen tubing for 1 [R18] resident reviewed for oxygen in the sample of 35. R18's clinical record indicates R18' s following medical diagnoses include but no limited to chronic obstructive pulmonary disease with exacerbation, muscle wasting, hypertensive disease, and schizophrenia. R18's Care plan, dated 11/9/21, indicates: R18 have to chronic obstructive pulmonary disease and should be free of signs. Interventions: -Elevated head of bed to prevent shortness of breath while lying flat -Oxygen settings: Oxygen at 3liters per nasal canula for chronic obstructive pulmonary disease R18's Minimum Data Set section [J], dated 3/4/24,- shortness of breath, R18 have trouble breathing when lying flat. On 4/30/24 at 10:52 AM, surveyor observed R18 lying flat in bed with labored breathing, and R18's nasal canula oxygen tubing was hanging off the bed touching the bed frame, while V26 [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 follow their policy and procedure for respiratory equipment by not ensuring handheld nebulizer was changed weekly and not providing a clean plastic bag with a zip loc or draw string for each set up for 1 (R133) resident reviewed for respiratory care in a sample of 35. The findings include: R133's health record documented admission date on 10/9/2019, with diagnoses not limited to Respiratory failure, Type 2 diabetes mellitus, Anemia, Acute pulmonary edema, Essential (primary) hypertension, Bipolar disorder, Anxiety disorder, Major depressive disorder, Borderline personality disorder, Unspecified tracheostomy complication, Skin graft (allograft) (autograft) infection, Burn of unspecified body region, unspecified degree, Dysphagia following nontraumatic subarachnoid hemorrhage, Encounter for prophylactic measures, Insomnia due to other mental disorder, Chronic pulmonary edema, Encounter for attention to tracheostomy, Nicotine dependence, and Other psychoactive substance abuse. On 4/30/24 at 11:18 AM, handheld…

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 bed rails and review them with the resident or the resident's representative prior using them; failed to obtain informed consent prior to using the bed rails; and railed to implement person-centered comprehensive care plan addressing the use of the bed rails. These failures have the potential to affect 2 (R32, R158) out of 2 residents reviewed for bed rails in a final sample of 35. Findings Include: 1. R158's clinical records show R158 has diagnoses not limited to Dementia, Cognitive Communication Deficit, Restlessness and Agitation, and Altered Mental Status. R158's Minimum Data Set (MDS), dated [DATE], shows R158 is cognitively impaired and requires staff assistance with bed mobility. R158's comprehensive care plan does not address the use of the bed rails. R158's electronic health records (EHR) show the last side rail assessment was completed on 7/19/23, and the use of bed rails were not…

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

Based on interview and record review, the facility failed to follow their policy and procedure to ensure consent was obtained prior to administering psychotropic medication to 1 (R122) out 5 residents reviewed for psychotropic medications in a final sample of 35. Findings Include: R122's Order Summary Report, printed on 5/2/24, shows R122 is on antipsychotic medication Quetiapine 25 mg by mouth at bedtime related to diagnosis of Dementia with behavioral disturbance ordered on 12/11/23 and Mirtazapine 15 mg by mouth at bedtime related to diagnosis of major depressive disorder ordered on 3/15/23. R122 had an order for Seroquel 50 mg by mouth two times a day on 3/15/23. R122's Medication Administration Record (MAR) for March 2023 showed R122 started receiving the Seroquel 50 mg twice a day and Mirtazapine 15 mg at bedtime on 3/15/23. R122's psychotropic consents were not obtained until 5/1/23. On 5/02/24 at 11:17 AM, V3 (Director of Nursing) stated psychotropic medication consents should be obtained prior administering the medications to the resident. Surveyor requested for R122's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the call light was within reach for 3 (R39, R82, R114) of 5 residents, and failed to ensure resident's room call lights were functioning for the residents to call for staff assistance when needed for 2 (R2, R82) of 3 residents reviewed for accommodation of needs in a sample of 35. Findings Include: 1. R82 has diagnosis not limited to Cognitive Communication Deficit, Essential (Primary) Hypertension, History of Falling, Hypothyroidism, Obesity, Atrial Fibrillation, Transient Cerebral Ischemic Attack, Hyperlipidemia, Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, Asthma with (Acute) Exacerbation, Dysphagia, Oropharyngeal Phase, Chronic Kidney Disease, Hypokalemia, Dementia, Major Depressive Disorder, Diabetes Mellitus Abnormalities of Gait And Mobility, Thyrotoxicosis, Osteoarthritis of Knee, and Chronic Diastolic (Congestive) Heart Failure. R82's Care plan documents: Focus: R82 have an ADL (Activities of Daily…

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, interviews, and record review, the facility failed to follow the housekeeping cleaning schedule, and failed to ensure that adequate staff are available to ensure the building is maintained in a clean sanitary condition. These failures have the potential to affect 218 residents residing in the facility. Findings include: The (4/21/24) facility census includes 218 residents. On 4/22/24 at 10:29am, surveyor inquired why soiled towels were on the bathroom floor. V7 (Maintenance Director) stated, I'm not sure why they're here. On 4/22/24 at approximately 10:38am, the (4th floor) NW (North-West) shower room was inspected. A pink basin, soiled toilet paper, towels, popcorn, cigarette butts and ashes were observed on the floor. Ashes were also in the bathtub, and the trash can was full. Surveyor inquired about the appearance of the shower room. V7 stated, When there's towels and linens on the floor it's a Nursing issue. There's garbage, there's towels on the floor and it smells like smoke. That bin (referring to pink basin) shouldn't be here too. Housekeeping isn'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 observation, interview, and record review the facility failed to ensure staff are aware of the smoking safety policy, failed to follow policy procedures, failed to implement care plan interventions, failed to ensure (R8, R9) smoking materials were confiscated, and failed to ensure smoking did not occur inside the facility. These failures have the potential to affect 218 residents residing in the facility. Findings include: The (4/21/24) facility census includes 218 residents. On 4/22/24 at approximately 10:38am, an electronic keypad was observed on the (4th floor) NW (North-West) shower room door. V7 (Maintenance Supervisor) entered the door code and inspected the (locked) shower room with surveyor. A cigarette smoke odor was noted upon entry. Cigarette butts and ashes were on the floor, ashes were also observed in the bathtub. Surveyor inquired about the odor in the shower room, V7 stated, Somebody was smoking in here. It smells like smoke. On 4/22/24 at 10:42am, an electronic keypad was observed on the (4th floor) NE (North-East) shower room door. V7 entered the door…

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 (R5) who depends on staff's assistance for their ADL (Activities of Daily Living) care received incontinence care. This failure affected one out of four residents reviewed for ADL care. Findings include: R5's Brief Interview for Mental Status (BIMS), dated 01/24/24, shows R5 has a score of 13, which indicates R5 is cognitively intact. R5 has diagnoses which includes but not limited to: overactive bladder, hereditary and idiopathic neuropathy, bilateral primary osteoarthritis of knee, chronic obstructive pulmonary disease with acute exacerbation, type 2 diabetes mellitus without complications, anxiety disorder, drug induced subacute dyskinesia dysphagia oral phase, bipolar disorder, and long-term current use of oral hypoglycemic drugs. R5's Minimum Data Set (MDS), dated [DATE], shows R5 requires partial/moderate assistance from staff for personal hygiene. R5's care plan, dated 01/31/24, documents, Interventions: Toilet…

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 serve a resident's food preference based on religious beliefs, which affected one resident (R3) in a sample of four residents (R3, R4, R6 and R8) reviewed for menus and meal variety. Findings include: R3's admission Record, documents diagnoses of chronic obstructive pulmonary disease, acute angle closure glaucoma bilateral, chronic pain syndrome, bipolar disorder, psychosis, major depressive disorder, anemia, hyperlipidemia, and abnormalities of gait and mobility. R3's Minimum Data Set (MDS), dated [DATE], documents, the Brief Interview for Mental Status (BIMS) score is 11, which indicates R3 has moderate cognitive impairment. On 3/25/24 at 11:39 am, R3 stated with R3's religious beliefs from the [NAME] religion, R3 believes in the reincarnation of animals, so R3 eats plant-based foods and no meat. R3 stated R3 communicated R3's vegan food preferences based on religious beliefs to V17 (Dietary Manager) about two months ago. R3 stated R3…

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 (R1) who developed pressure ulcer at the facility did not develop sepsis from the wound; failed to have low air loss mattress (LALM) connected to power(R12); and failed to have LALM at the correct weight settings(R13 and R14), for residents with current pressure ulcers(R13) and for residents with recently healed pressure ulcers(R12 and R14) who are at risk for further pressure ulcers. These failures affected four residents, R1, R12, R13, and R14, reviewed for pressure ulcers and pressure ulcer prevention interventions. Findings include: Face sheet lists diagnoses which include but are not limited To Dementia, Pressure Ulcer of Sacral Region, Major Depressive Disorder, and Abnormalities of Gait and Mobility. R1's Pressure Ulcer Risk Assessment, dated 11/20/23, shows risk for pressure ulcer. Minimum Data Set/MDS section M says to use pressure reducing device for bed. MDS section C shows BIMS score 5 (cognitively impaired).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the safety and supervision of a resident at risk for falls who had repeated falls, and failed to prevent the resident (R10), with a documented history of alcohol abuse and alcohol intoxication, from obtaining and using alcohol. Findings include: R10's Face sheet shows admitting diagnoses which include both are not limited to Alcohol Abuse, Acute Pancreatitis, Anxiety Disorder, Bipolar Disorder, Suicidal Ideations, and Repeated Falls. MDS (Minimal Data Status) section GG, dated 12/14/23, states R10 requires touching assistance only for usual abilities for everyday activities. R10's Care plan, dated 11/24/23 and reviewed on 12/10/23, states R10 has a history of engaging in substance use (alcohol) and has brought alcohol in the building. R10's Care plan, dated 9/12/23, states: R10 is at risk for fall/injury from weakness and tiredness related to: Osteoarthritis and recent fall, intoxication. R10's Fall Risk Assessment, dated 11/30/23 and 1/8/24,…

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.

Based on observation, interview, and record review, the facility failed to provide food prepared at a safe and appetizing temperature. This failure has the potential to affect 80 residents living on the 4th floor of the facility. Findings include: On 01/23/2024 at 12:42PM, surveyor located on the fourth floor of the facility observed meal carts and staff passing lunch meal trays to residents. Surveyor located inside of R2's room and observes staff entering R2's room to deliver R2's lunch meal tray to R2. R2 states, Majority of the time, the hot foods are not served hot. On 01/23/2024 at 1:29PM, V21 (Certified Nursing Assistant/CNA) observed delivering R12's lunch meal tray to R12 in his room. V21 states R12's lunch tray was the final food tray delivered to residents on the fourth floor of the facility. Surveyor asks R12 how is the temperature of his food? R12 states his lunch meal is a little chilled, and states he would like his food to be reheated. On 01/23/2024 at 1:52PM, V4 (Dietary Manager) states the final food cart that leaves the kitchen for lunch service goes to the fourth…

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 a lock per the resident's preference to aid in securing personal valuables for one (R3) resident out of three residents reviewed for resident's rights. Findings include: R3's Social Services progress note, dated 10/18/2023 at 1:22 PM, documents the following: Note Text: Grievance Initiated Staff interviewed (R3's) roommate, floor staff, and reminded (R3) to lock up his personal belongings. Staff notified Maintenance to install a lock holder on (R3's) drawer so that he can put a lock on his dresser drawer. (R3) was reminded of the setting that he is in and was encouraged and educated to lock all of his personal belongings up especially when he is out of the room or out on pass. (R3) was receptive to this information. Administrative was made aware. Will follow-up as needed. On 01/23/2024 at 11:45am, R3 was lying in bed, alert, and responsive. R3 agreed to speak to surveyor, sat up on his bed. R3 pointed to his dresser under the television. Surveyor observed a gold latch on the third drawer of R3's…

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

Based on interview and record review, the facility failed to keep two residents (R2, R6) free from abuse resulting in R6 receiving minor injuries. Findings include: R2 nurse progress note, 12/30/23, 18:45, documents in part: Resident involved in an altercation with another resident. Both residents separated. Police notified. R6 social service note, 12/30/23, 07:42, documents in part: Resident involved in altercation with peer. Staff intervened immediately. Both residents separated. Facility Resident Abuse Investigation Form, 1/4/24, documents in part: R2 and R6 was in an argument in their room that escalated. R2 lost footing and landed on top of R6 making contact with R6's lip resulting in a small superficial cut with minimal blood noted. On 1/23/24 at 12:33 PM, R6 said, They (R2 and other residents) were partying in the room. I asked them to leave. There were verbal assaults back and forth. Somehow, I got poked in the eye. On 1/23/2024 at 12:40PM, R2 stated R2 was involved in a physical altercation with R6. R2 stated R2 sent R6 to the store to buy something for R2, and R6 did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report and investigate misappropriation of property for one (R3) of three residents reviewed for misappropriation of resident property. Findings include: R3's Minimum Data Set (MDS), dated [DATE], documents R3 has a Brief Interview for Mental Status (BIMS) of 15 out of 15, indicating R3 is cognitively intact. Facility grievance log, dated October 2023 to December 2023, was reviewed. Grievance form, dated 10/18/2023, documents that a concern was made for R3's missing money. Facility reported incidents, dated October 2023 to January 2024, were reviewed and does not document a report was submitted to the State Agency for an allegation related to misappropriation of property for R3. On 01/23/2024 at 11:46 AM, R3 stated his uncle sent him money via wired and R3 spent some of it and R3 had about $100 dollars in cash missing sometime in September 2023 or October 2023. R3 stated he informed V6 (Social Services Assistant) R3 thinks R4 stole his $100 dollars 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 interview and record review, the facility failed to ensure blood pressure medications were administered prior to a resident's appointment. This failure affected R9 whose blood pressure registered at 180/93 while at the clinic, which put R9 at an increased risk for stroke. Findings include: R9's admission Record documented R9's diagnoses include but not limited to type 2 Diabetes Mellitus, Type 1 diabetes mellitus, stiff-man syndrome, and essential (primary) hypertension. R9's (09/05/2023) Minimum Data Set documented, Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15., indicating R9's mental status as cognitively intact. R9's (9/21/2023) ambulatory Progress Note documented, History of Present illness. She is not happy with the facility since they skip her meds. Her BP (blood pressure) is high today since she did not take her BP meds before leaving the facility. Vitals: 09/21/23 1218 (12:18pm) BP: 184/95. 09/21/23 1224 (12:24pm) 180/93. Assessment and Plan.…

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

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of <5% for 2 (R10 and R11) of 3 (R9, R10, and R11) residents observed for medication administration. There were 36 opportunities and 8 errors resulting in 22.2% medication error rate. Findings include: 1. On 10/03/2023 at 9:38am during the medication observation with V14 (Licensed Practice Nurse), V14 dispensed the following medications for R10: 1. Aspirin 81mg Adult dose low dose chewable 2. Vit D 25mcg equivalent 1000IU 2tabs 3. Linzess 145mcg 1cap 4. Docusate Sodium 100mg 1tab 5. Nuedexta 20-10mg 1cap 6. Jardiance 10mg 1tab 7. Metformin 500mg 1tab 8. Seroquel 50mg 1tab 9. Tizanidine 2mg 1tab 10. Gabapentin 100 1cap 11. Eliquiz 2.5mg 1tab. On 10/03/2023 at 9:42am, V14 counted the medications that were to be administered to R10, and stated, 12 pills. R10's (10.2023) MAR (Medication Administration Record) documented R10 was also due the following medications: 12. Lisinopril 2.5mg at 9am once daily, 13. Polyehtylene Glycol 17gm at 9am once daily, 14. Senna Tablet 8.6mg at 9am…

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 on the medication administration record (MAR). This failure affected one resident (R6) in the sample of 82 residents residing on the third floor. Findings Include: R6's diagnosis includes, but are not limited to, fibromyalgia, covid-19, pneumonia due to sars-associated coronavirus, chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, other coronavirus as the cause of diseases classified elsewhere, acute pancreatitis without necrosis or infection, unspecified, chronic obstructive pulmonary disease with (acute) exacerbation, alcohol abuse, uncomplicated, rheumatoid arthritis, unspecified, anxiety disorder, unspecified, post-traumatic stress disorder, chronic, other lack of coordination, insomnia, unspecified, bipolar disorder, unspecified, unspecified osteoarthritis, unspecified site, gastro-esophageal reflux disease without esophagitis, suicidal ideations, repeated falls, anemia, unspecified, obsessive-compulsive disorder, unspecified and…

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

Based on observation, interview, and record review, the facility failed to provide a functional and sanitary homelike environment. This has the potential to affect all 206 residents in the facility. Findings include: 1. On 8/22/2023 at 10:50 AM, V7 (Housekeeper) stated V7 floats to all the floors. V7 stated there is supposed to be two housekeepers during the day, but V7 works alone most of the week. When short staffed, V7 has 35 residents' rooms to clean. V7 stated, It is difficult because some resident rooms are a lot dirtier than others. There is only one housekeeper in the evenings, but that housekeeper does not clean residents' rooms regularly. On 8/22/2023 at 12:43 AM, V8 (Housekeeper) stated V8 floats to all the floors. V8 stated, There should be two housekeepers on the floor during mornings, but most of the time there is only one. It is a lot to clean 35 resident rooms alone. At times, I cannot thoroughly clean all the rooms, so the minimum I can do is empty out the residents' garbage. I cannot sweep or dust when housekeeping is short staffed. V8 stated there is also no…

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

Based on observation, interview, and record review, the facility failed to follow their insulin pen procedure policy for 1 (R7) of 3 residents observed for insulin administration. This failure has the potential to affect all 21 residents in the facility that receive insulin from an insulin pen. Findings included: R7's electronic medication administration record documented 276mg/dl. R7 physician orders: (1) Dated: 2/1/23 Humalog Kwik Pen Subcutaneous Pen injector 100unit/ml-inject 10 units before meals. (2) Dated: 2/1/23 Humalog Kwik Pen Subcutaneous Pen injector 100unit/ml per slide scale. On 8/22/23 at 12:45 PM, observed V5 (Licensed Practical Nurse) obtain R7's blood glucose level. The glucometer read R7's level at 276mg/dl. V5 used an insulin syringe with needle attached to withdraw 15units of insulin from R7's Humalog Kwik Pen tip end. V5 administered R7 15 units of Humalog insulin. On 8/22/23 at 12:55 PM, V5 stated, I used a syringe to withdraw insulin from R7's Humalog Kwik Pen whenever there are no insulin pen needles. There are no pen needles available on my cart. On 8/22/23…

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 observation, interview, and record review, the facility failed to ensure 1 of 6 medication carts were locked while not in use or in view. This failure has the potential to affect 31 residents residing on the third floor of the facility. Findings included: On 8/22/23 at 12:12 PM, R1 stated, (V36, Registered Nurse) always keeps the medication cart unlocked and unattended with needles and diabetic supplies on top of the cart. On 8/22/23 at 12:28 PM, V5 (Licensed Practical Nurse) walked away from the 3 south west medication cart, leaving the medication cart unlock and unattended. V5 returned four minutes later. V5 stated, I forgot to lock the medication cart. I was moving fast to complete my medication pass. On 8/23/23 at 11:38 AM, V3 (Director of Nursing) stated, My expectation of the medication cart is the nurses to keep the cart locked when the cart is not in view, or the nurse walks away. Before walking away, the nurse should remove any supplies or medications off the top of the medication cart. If the cart if left open and unattended, a resident, visitor, or unauthorized…

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 food under sanitary conditions in the walk-in freezer. This has the potential to affect 201 of 206 residents who receive nutritional services from the kitchen. Findings include: On 8/22/2023 at 10:08 AM, surveyor conducted kitchen tour with V48 (Food Service Director). At 10:18 AM, entered facility's walk-in freezer. Compressor had ice build-up on one of the tubing hanging from it. There were multiple pieces of ice on the floor underneath the compressor. There were stacked boxes of food underneath the compressor. The top box was a box of 144 breadsticks. Box was moist and had ice buildup in some parts. Box was warped and concaved in. V48 stated it was an unopened box of breadsticks, but the tape on the box was no longer sticking to the box, leaving it unsealed. V48 stated, The box of breadsticks is no longer good. Facility's Food Storage (Dry, Refrigerated, and Frozen) policy from the Guideline & Procedure Manual Copyright 2020 documents in part: Food shall be stored on shelves in a clean, dry areas…

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 handle and store linens in manner that prevent cross-contamination. This has the potential to affect 47 residents that reside in Two South and Four North. Findings include: On 8/23/2023 at 10:11 AM, there was an open, green, transparent bag with linen on the floor outside of R9's room. No staff or residents were in R9's room. The bag remained on the floor at 10:17 AM. At 10:21 AM, there was a clean linen cart in the Four North hallway. Linen cart was not covered. Linens were facing out to the hall. At 10:22 AM, R13 went up to the cart and grazed R13's hands over some of the linens. R13 pulled some of the linens and put them back in the cart. R13 eventually grabbed a towel and went to the bathroom. At 10:26 AM, surveyor went back down to R9's floor. Open linen bag remained on the floor outside of R9's room. At 10:27 AM, V11 (Housekeeper) stated did not know who left the bag. At 11:21 AM, V28 (Housekeeping Director) stated the policy is for staff to bag up dirty linen in the green clear bags. Staff are to tie…

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 dignified treatment of a residents by failing to empty the urinals for 1 (R3) of 3 residents reviewed for ADL (Activities of Daily Living) care. Findings Include: R3 has diagnosis not limited to Essential (Primary) Hypertension, Dysphagia, Major Depressive Disorder, Obesity, Insomnia, Lack of Coordination, Bipolar Disorder, Dysarthria Following Cerebral Infarction, Chronic Embolism and Thrombosis Of Left Tibial Vein, Bipolar Disorder, Hemiplegia And Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Heart Failure, Cerebral Infarction, Asthma with (Acute) Exacerbation, Combined Systolic (Congestive) And Diastolic (Congestive) Heart Failure, Atrial Fibrillation, Acute Embolism And Thrombosis Of Left Tibial Vein, Bipolar Disorder and Current Episode Manic Severe With Psychotic Features. R3's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15, indicating intact cognitive response. MDS Section H Bladder and Bowel: documents in part: Urinary continence,…

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 call light was within reach for 1 (R4) of 3 (R3, R5) residents reviewed for call lights. Findings Include: R4 has diagnoses not limited to Psychoactive Substance Abuse, Gastro-Esophageal Reflux Disease Without Esophagitis, Acute Embolism and Thrombosis Of Unspecified Deep Veins of Unspecified Lower Extremity, Human Immunodeficiency Virus [HIV] Disease, Cognitive Communication Deficit, Major Depressive Disorder, Psychotic Disorder With Delusions Due To Known Physiological Condition, Suicidal Ideations, Schizophrenia, Schizoaffective Disorder, Bipolar Type and Schizoaffective Disorder, Depressive Type. R4's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15, indicating intact cognitive response. On 08/22/23 at 12:12 PM, R4 was observed lying in bed with the bed elevated to the highest position. R4 sat up on the edge of the bed with his legs dangling in the air. R4 was asked the location of the call light, and R4 responded, You see where it is. R4's call light was observed on…

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

Based on observation, interview, and record review, the facility failed to ensure the bed was at the appropriate height to prevent the potential for a fall for 1 (R4) of 4 residents reviewed for falls. Findings Include: R4 has diagnoses not limited to Psychoactive Substance Abuse, Gastro-Esophageal Reflux Disease Without Esophagitis, Acute Embolism and Thrombosis Of Unspecified Deep Veins of Unspecified Lower Extremity, Human Immunodeficiency Virus [HIV] Disease, Cognitive Communication Deficit, Major Depressive Disorder, Psychotic Disorder With Delusions Due To Known Physiological Condition, Suicidal Ideations, Schizophrenia, Schizoaffective Disorder, Bipolar Type and Schizoaffective Disorder, Depressive Type. R4's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15, indicating intact cognitive response. R4's Care plan documents in part: (R4) is at risk for falls r/t (related/to) Vision problems Date Initiated: 08/16/23. Intervention: Bed height to be placed where my feet are flat on the floor. Ensure that the resident is wearing appropriate footwear. (R4)…

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 administer medications as ordered by the physician and to notify the physician when medication is not administered in accordance with the facility policy for 1 (R4) of 4 residents reviewed for medications. Findings Include: R4 has diagnoses not limited to Psychoactive Substance Abuse, Gastro-Esophageal Reflux Disease Without Esophagitis, Acute Embolism and Thrombosis Of Unspecified Deep Veins of Unspecified Lower Extremity, Human Immunodeficiency Virus [HIV] Disease, Cognitive Communication Deficit, Major Depressive Disorder, Psychotic Disorder With Delusions Due To Known Physiological Condition, Suicidal Ideations, Schizophrenia, Schizoaffective Disorder, Bipolar Type and Schizoaffective Disorder, Depressive Type. R4's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15, indicating intact cognitive response. On 08/23/23 at 2:17 PM, R4 stated Yesterday (V12, Licensed Practical Nurse) walked in when I was walking to take my breakfast tray to the cart. (V12) had my medication in her hand…

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.