Archer Heights Healthcare

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow their infection control policies and procedures for one of three residents (R3) in the sample of five.Findings include:1.17.2025 at 3:45 PM, observed V7 (CNA-Certified Nursing Assistant) walking out of R3's room down the hallway with gloves on her hands. V7 returned to R3's room, then came back out, walked down the hallway, with gloves on, to the linen cart and removed a facecloth from the cart. V7 returned to R3's room and performed incontinence care. V7 was not wearing a gown while performing incontinence care. The privacy curtain was not pulled around R3's bed, the door to the room was open. EBP (Enhanced Barrier Precautions) sign posted on R3's door documents, in part: Providers and staff must also: Wear gloves and a gown for the following High-Contact Resident Care Activities. Changing briefs or assisting with toileting. A soiled brief was noted on the floor next to R3's bed.1.17.2026 at 4:02 PM, V7 said, I believe R3 is 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 a homelike environment due to uncleanliness of resident's rooms noted with paper, trash, and debris throughout residents' rooms. This failure affected 4 of 5 residents (R1, R2, R4, R6, and R7) reviewed for homelike environment.R1's Minimum Data Set Section C dated 11/3/2025 documents a BIMS (Brief Interview Mental Status) Score of 15 which is indicative of an intact cognition. R2's Minimum Data Set Section C dated 9/4/2025 documents a BIMS (Brief Interview Mental Status) Score of 6 which is indicative of a severely impaired cognition.R4's Minimum Data Set Section C dated 10/27/2025 documents a BIMS (Brief Interview Mental Status) Score of 15 which is indicative of an intact cognition. R6's Minimum Data Set Section C Dated 10/1/2025 documents a BIMS (Brief Interview Mental Status) Score of 15 which is indicative of an intact cognition. R1's care plan dated 8/21/2025 documents, in part, no focus for hoarding.R2's Care Plan dated 9/17/2025 documents, in part, no focus for hoarding.R4's Care Plan dated…

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

Based on observation, interview, and record review, the facility failed to ensure proper administration of medication due to a resident standing at the medication cart taking medication without a nurse's observation to ensure the resident swallowed the medication. This failure affected 1 of 1 resident (R5).The findings include:R5's Physician Order Sheet dated 11/12/2025 does not document a focus for self-administration of medication.R5's Minimum Data Set Section C dated 11/5/2025 documents a BIMS (Brief Interview Mental Status) of a 15 which is indicative of an intact cognition.On 11/12/2025 at 12:32 pm, surveyor observe the medication cart across from the nursing station and R5 putting a medication cup containing several tablets in her mouth followed by drinking water without a nurse present. On 11/12/2025 at 12:33 pm V10, LPN walked pass the surveyor and went behind the nurse's station. V10 stated she (V10) was done passing medication. V10 stated she (V10) did not observe R5 take her medication because she (V10) was doing multiple tasks at one time. V10 stated the purpose 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 provide a clean, safe, and comfortable environment for all 196 residents residing in the facility. Findings include: On 07/01/25, at 10:55 AM, R2 stated the facility is dirty. R2 stated that there are a lot of flies/gnats everywhere inside the facility including in his room, the hallway, the bathrooms, and shower room. R2 stated his garbage is not emptied every day. R2 said, go look inside my bathroom. There is a can of soda that I drank and put into the garbage three days ago and it is still sitting in there. R2 stated the shower room is always dirty and that is unsanitary because that is where he goes to get clean. On 07/01/25, at 11:00 AM, observed can of soda in R2's bathroom trash can and garbage filled half way to the top of the trash can. On 07/01/25 at 11:25 AM, observed the following in the shower room on 2nd floor including empty plastic wrappers, crumbled up brown paper towels, brown soiled/wet toilet paper, a plastic straw, an empty bottle of shampoo, a wet washcloth lying on a shower chair, three…

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, facility failed to follow their policy to ensure a call light was within reach for one (R4) out of three residents reviewed for call lights in a total sample of 9. Findings include: R4's MDS (Minimum Data Set) section C (Cognitive Patterns) dated May 28, 2025, documents R4's Brief Interview for Mental Status (BIMS) as 15/15 indicating R4 has intact cognitive functional abilities. MDS Section GG-Functional abilities documents R4 requires Substantial/maximal assistance with eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, Lower body dressing, putting on/taking off footwear, personal hygiene, roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, toilet transfer, tub/shower transfer, walk 10 feet, walk 50 feet with two turns, walk 150 feet, and R4 is a two person assist. On 06/04/2025, at 12:03 PM, R4 was observed trying to sit up in bed, alert, oriented to person, place, time, and situation. R4 was observed trying to get himself into a sitting…

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 medications were administered as ordered by the resident's physician for one (R8) out of three residents in a total sample of nine residents reviewed. Findings include: On 06/04/2025, at 9:42 AM, surveyor located on the second floor of the facility with V7 (Licensed Practical Nurse/LPN). V7 observed with a medication cart and performing a morning medication administration pass. V7 has R8's eMAR/electronic medication administration record deployed on the computer. Surveyor observes the following order for R8 Procardia XL Oral Tablet Extended Release 24 Hour 30 MG (Nifedipine)- Give 1 tablet by mouth one time a day for HTN (high blood pressure). Can hold if blood pressures are persistently 130/80 mmHg. V7 states it is important to measure a resident's blood pressure reading prior to administering any medications that will lower a resident's blood pressure. V7 states this is to establish the resident's blood pressure in an effort to prevent the administration of unnecessary blood pressure medications. V7 states if a…

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

Based on observations, interviews, and record reviews, the facility failed to provide sanitary drinking water and ice by not maintaining their water and ice machines. This has the potential to affect all 199 residents that receive hydration orally. Findings include: On 5/14/2025, at 10:50 AM, V9 (Nurse) showed surveyor the ice and water machine inside the first-floor nourishment room. V9 stated residents are free to grab water and ice from the machine. The machine had streaks of white and tan mineral buildup along the front panel, around the spout where the water and ice dispense, and around the collection tray. There was also white mineral buildup on the counter under the machine. The machine was continuously dripping throughout the interview. V9 stated housekeeping is supposed to clean the machine daily. On 5/14/2025, at 11:17 AM, V13 (Nurse) stated second floor staff get the residents' drinking water and ice from the first or third floor nourishment area. On 5/14/2025, at 11:33 AM, the ice machine in the third-floor nourishment room had white and gray mineral build-up on 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 observations, interviews, and record reviews, the facility failed to provide a home-like environment by not having enough chairs in the first and second floor day/dining room, thoroughly cleaning and maintaining residents' rooms and common areas. This has the potential to affect 148 residents that reside in the first, second, and fourth floors. Findings include: On 5/14/2025, at 10:44 AM, there were eight chairs in the first-floor day/dining room and one chair just outside of it near the nurses' station. On 5/14/2025, at 10:58 AM, R1 stated there is not enough chairs in the first-floor day room. R1 stated that at best there's maybe ten chairs in the day room and other residents would already be sitting in them. R1 stated it's hard to find anywhere to sit. R1 stated I have to sit on my rollator and that's the best I can do. R1 stated the rollator is not comfortable to sit in for prolonged times. On 5/14/2025, at 11:05 AM, R16 stated [R16] goes into the first-floor day room occasionally but doesn't eat there. R16 stated if there's a chair open, then I'll sit, but sometimes I…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Findings include: On 5/13/25, at 2:32 PM, observed R9 room; mats on both sides of the bed, a reacher/grabber tool on bed, no side rail(s) On 5/13/25, at 2:36 PM, observed R9 in day room sitting in a wheelchair watching television. R9 said he had two falls. The first fall R9 was sleeping in bed. R9 said he was dreaming he was swimming and rolled out of bed. R9 said he got a [NAME] on his head and a black eye. R9 said there were no side rails on the bed. R9 said They don't have those here. On 5/14/25, at 1:10 PM, V2 (Director of Nursing) stated I am familiar with R9. He has had two falls. The first fall was 4/27/25. The patient said he rolled out of bed. He hit his head and was sent out to the hospital. R9 is care planned for fall risk. According to the fall risk assessment, dated 3/20/25, he is moderate fall risk. The floor nurses do the assessments. They look at history of past falls, medications that they are on, monitor the blood pressure when standing and lying, vision, ambulation/walking, level 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 ensure that medication was locked up safely when not in visual proximity of the nurses and not in use to prevent tampering and accidental hazard. This failure affected R13, R15, R16, and R17 whose medications were left at the bedside having the potential to affect residents on the 3rd floor. Findings include: On 04/02 /25 at 11:13am, V15 (family) came out of R13's room stating I don't want my brother (R13) to overdose of pills. This (one pink capsule and a white tablet was on R13's bed just lying there). V17 CNA (Certified Nurses Aide) took the medications and was about to put it in the trash can. The surveyor stopped V17 from doing so. V16 LPN (Licensed Practical Nurse) who was sitting at the nurse's station was shown the medication. V16 stated that I (V16) am not the nurse for R13, but no medication should not be stored at the bed side. The surveyor asked V16 what the facility policy on medication administration was. V16 stated that the nurse giving the medicine should make sure the resident swallows 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 that personal hygiene including nail care is provided for one (R1) out of three residents in the sample who are dependent on staff for Activities of Daily Living (ADLs) personal hygiene. This failure affected R1 who did not receive appropriate personal hygiene care in a timely manner. Findings include: On 03/31/25 at 11:12am, R1 noted in the room in a wheelchair dosing off wearing hospital gown with front of body exposed. R1 noted in wheelchair without incontinent brief and wet. R1 was observed with long nails and blackish particles underneath the nails. A plate of food was noted on R1's lap with whitish yellowish food fallen in between legs and on the floor. R1 was observed using dirty hands to eat without any cutlery. R1's room had a fowl urine odor. R1 stated no one (referring to facility staff) came to help him since yesterday. His hair was unkempt and matted. R1 did not move both lower extremities, these were noted with dry whitish skin peeling off and swollen. At 11:20am, when this observation was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow to reconcile the hospital recommendation with the facility physician for BIPAP/CPAP treatment for one resident (R1) who has chronic hypercapnia and was supposed to wear BIPAP machine at night. This affected R1 who was not set up for BIPAP treatment as ordered. Findings include: R1 is a [AGE] year-old male, with diagnosis that includes but not limited to Chronic embolism and thrombosis of unspecified deep veins of lower extremity, difficulty in walking, chronic obstructive pulmonary disease with acute exacerbation, respiratory syncytial virus as the cause of diseases classified elsewhere, primary insomnia, acute bronchitis, and another pulmonary embolism with acute Cor-pulmonale. R1 was re-admitted to the facility on [DATE] and as at 03/31/25 before surveyor prompting the facility, R1 has not receive any respiratory BIPAP treatment. On 3/31/25 at 11:30am, R1 stated that the only time BIPAP treatment was administered was whenever I…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow physician order in administering correct oxygen liter to one of three residents (R1) reviewed for oxygen administration. This failure affected R1 who was supposed to get three liters of oxygen per nasal cannula and was administered five liters per nasal cannula. Two liters over the ordered dosage. Findings include: R1 is a [AGE] year-old male, with diagnosis that includes but not limited to Chronic embolism and thrombosis of unspecified deep veins of lower extremity, difficulty in walking, chronic obstructive pulmonary disease with acute exacerbation, respiratory syncytial virus as the cause of diseases classified elsewhere, primary insomnia, acute bronchitis, and another pulmonary embolism with acute Cor-pulmonale. On 04/02/25 at 11:32am, R1 observed in bed in the room with oxygen per cannula in use. Oxygen concentrator set at 5liter per nasal cannula. When V4 LPN (Licensed Practical Nurse) was made aware of this observation and…

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

Based on observation, interview, and record review the facility failed to ensure that residents' food items in the facility kitchen are properly labeled, dated when received and when opened; failed to follow proper food storage practices and labeling food to prevent food-borne illnesses; failed to ensure that staff store their food and drinks out of the facility kitchen used for residents; and failed to maintain the proper sanitation levels of the kitchen sanitation bucket. These failures have the potential to affect all 207 residents receiving an oral diet in the facility. Findings include: On 03/24/25 at 9:16 am, Surveyor entered the facility's kitchen and conducted a tour with V6 (Dietary Director) and observed the following: In the walk-in refrigerator Surveyor and V6 observed a box of tomatoes undated and unlabeled on the left middle top shelve. When V6 was asked regarding the box of tomatoes without a date V6 stated, All food should be dated so we know how long we had them. Tomatoes should be dated so we know how long before they will rot. It had a date on the top of the box,…

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

Based on observation, interview, and record review, the facility failed to ensure that housekeeping and maintenance services necessary to maintain a sanitary and comfortable environment were provided for four residents (R18, R27, R129, and R180). This failure affected the four residents reviewed for homelike environment in a total sample size of 128 residents. Findings include: R27's diagnoses include but are not limited to anxiety disorder, chronic systolic heart failure, atrial fibrillation, and essential hypertension. R27's Brief Interview for Mental Status (BIMS) dated 01/13/15 has a sore of 15, which indicates R27's cognition is intact. On 03/24/25 at 11:04am R27 stated that his room is cleaned sometimes but not often. R129's diagnoses include but are not limited to cerebral infarction, essential hypertension, schizoaffective disorder bipolar type, and primary osteoarthritis. R129's BIMS dated 03/06/25 has a score of 10, which indicates R129's cognition is moderately impaired. On 03/24/25 at 10:46am observed R129's closet missing one door and dresser missing top drawer. On…

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

Based on observations, interviews and records review, the facility failed to ensure medication refrigerators and medication carts with narcotic medications are secured and locked; failed to remove expired medications from a medication cart and the medication refrigerator to prevent them from being administered; failed to label multi dose vials and inhalers with opened date and expiration date and failed to accurately document count of narcotic medications. These failures affected six residents (R20, R,22, R23, R61, R134, R173) and have the potential to affect 16 residents on the fourth floor of the facility in a sample of 128. Findings include: On 03/25/25 at 09:35 AM, observed the fourth-floor medication refrigerator unlocked, the latch was not functional leaving the refrigerator unsecured. V12 Licensed Practical Nurse (LPN) was observed opening the narcotic medication box inside refrigerator without a key and stated that she was able to open it without using the keys, that the box was not locked. V12 also stated that the narcotic medication box should be locked. V12 stated that…

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 monitor personal refrigerator temperatures and ensure that personal refrigerators had thermometers for four residents. These failures affected four residents (R47, R100, R110, R190) out of 128 residents in the total sample. Findings include: R100's medical diagnoses include but are not limited to cerebrovascular disease, essential hypertension, major depressive disorder, and chronic kidney disease. R100 has a Brief Interview for Mental Status (BIMS) dated 02/06/25 has a score of 12, which indicates R100's cognition is moderately impaired. On 03/24/25 at 12:02pm R100's refrigerator observed with no temperature log sheet, no thermostat inside the refrigerator, six cartons of expired milk dated 01/13/25 and 02/06/25, one expired yogurt dated 03/13/25, and an opened sandwich undated. R110's medical diagnoses include but are not limited to chronic obstructive pulmonary disease, morbid obesity, acute respiratory failure with hypercapnia,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that staff don PPE (personal protective equipment) while performing wound care for a resident (R199); failed to visibly post Enhanced Barrier Precautions (EBP) signage outside a resident's room door for two residents (R96, R199); failed to place a PPE bin directly outside a resident's (R204) Contact Precautions door; failed to ensure that staff perform hand hygiene when passing meal trays; and failed to ensure that staff perform hand hygiene after touching staff's personal body then passing meal trays. These failures affected R25, R40, R96, R113, R118, R153, R177, R178, R199, R201, and R204 and had the potential to affect the 38 residents on the first floor of the facility. Findings include: On 3/24/25 at 11:50 am, this surveyor observed R204's door open with a Contact Precautions sign posted on the front of the door, and there is no PPE bin directly outside R204's door. On 3/24/25 at 11:54 am, V18 (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.

Based on observation, interview,and record review the facility failed to ensure the call light device for two residents (R35, R41) were within reach of the residents. This failure affected two residents (R35, R41) and has the potential to affect all residents in the sample size of 128. Findings include: R35 has a diagnosis of but not limited to Bilateral Primary Osteoarthritis of knee, Paralytic Syndrome, Hemiplegia and Hemiparesis, Vascular Dementia, Peripheral Vascular Disease and Major Depressive Disorder. R35 has a Brief Interview of Mental Status score of 09. R35's care plan focus for self-care deficit (ADLs/Mobility) dated 1/06/2025 documents, in part, Call light within reach; encourage resident to use prior to attempting self-care. R35's Call light Ability Screen dated 6/01/2023 documents, in part, resident is unable to use the call light due to physical limitations and if resident is unable to use the call light what alternative type of light or device will be put in place. This question was left blank. R35's Minimum Data Set section GG dated 01/03/2025 documents, in part,…

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 refer three residents R61, R104 and R141 to the appropriate state designated authority for a Level II PASARR (Preadmission Screening and Annual Resident Review) evaluation and determination after new mental disorder diagnoses. This deficient practice affected three residents (R61, R104, and R141) in a total sample size of 128 residents. Findings include: R141's PASARR dated 07/13/23 documents in part, Mental Health Diagnoses .No mental health diagnosis is known or suspected. R141's admission date to the facility is dated 07/17/23. R141's medical diagnoses include but are not limited to bipolar disorder (dated 07/17/23) and adjustment disorder with Mixed Anxiety and Depressed Mood (dated 07/17/23. On 03/25/25 at 12:17pm V35 (Business Office Manager) stated that every new resident should have a PASARR screening. V35 stated that the facility reviews the resident's PASARR upon admission to assure that they are correct. V35 stated that while reviewing the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the completion of a new Pre-admission Screening and Resident Review (PASARR) when a new mental health diagnosis is identified. This failure affects 3 residents (R61, R104, and 141) out of a sample of 128. Findings Include: R61's face sheet has an initial admission date of 1/11/2023 and the following diagnosis: Major Depressive Disorder onset date 1/11/23. Unspecified Lack of Expected Normal Physiological Development in Childhood onset date 1/10/23. Unspecified Intellectual Disabilities onset date 12/22/2022. R61's Minimum Data Set (MDS) Section C dated January 9, 2025, has a Brief Interview of Mental Health score of 1 which indicates the resident is severely cognitively impaired. R61's MDS Section D (MOOD) dated January 9, 2025, documents a severity score of 10. R61's OBRA-I Initial screen dated 4/21/2017 documents No reasonable basis for suspecting Developmental Disability (DD) or Mental Illness (MI). R61's Pre-admission Screening…

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

Based on observations, interviews, and record review the facility failed to follow wound care treatment orders. This failure affected one resident (R138) reviewed for wounds in a sample of 128. Findings include: R138's diagnoses include but not limited to orthopedic surgical amputation, Type 2 diabetes with foot ulcers, peripheral vascular disease, absence of other left toes, atrial fibrillation, and hypertension. R138's (2/6/25) Minimal Date Set (MDS) documents in part, Section C. Brief Interview of Mental Status is 15. R138 is cognitively intact. Section M. Other ulcers, wound and skin problems: B. Diabetic foot ulcer(s). C. other open lesion(s) on the foot. On 3/24/25 at 11:15 am, observed R138 in room in bed with bilateral dressings on both great toes. Left toe dressing noted to be dirty with black dark drainage on it. Right toe dressing noted to be dirty. R138 stated that the dressings had not been changed since Friday (3/21/25) and supposed to be changed every day. R138 stated, I sometimes change the dressings myself because it drains so bad then I get the floor dirty. R138'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 thoroughly investigate a fall incident and implement fall interventions listed on revised care plan; and failed to ensure adequate supervision to prevent a resident from smoking in a residential room. These failures affected two residents (R65 and R172) reviewed for accidents and hazards in a sample of 128 residents. Findings include: Facility presented a list of 28 residents on fall list from the last 120 days, R65 was listed down that she had a fall on 1/3/25. R65's Face sheet dated March 25, 2025, documents that R65 was admitted to facility on September 6, 2020 with diagnosis including Polyarthritis, muscle wasting and atrophy, diabetes mellitus, dysphagia, morbid obesity, anemia, hypertension, bilateral primary osteoarthritis of knee, presence of right artificial hip joint, bipolar, schizoaffective disorder. R65's MDS (Minimum Data Set) dated January 13, 2025 section C , shows R65 has a score of 11 which means R65 has moderate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure the CPAP (Continuous Positive Airway Pressure) mask was contained, failed to change oxygen tubing, failed to label humidifier bottle with dates and failed to get an doctor's order for oxygen administration. This failure affected 2 residents (R73 and R98) reviewed for oxygen therapy in a sample of 128. Findings include: R73's diagnoses include but not limited to cerebral palsy, asthma, Chronic Obstructive Pulmonary Disease (COPD), shortness of breath, dependence on Oxygen, and obstructive sleep apnea. R73's (1/2/25) Brief Interview of Mental Status (BIMS) documents a score of 15. R73 is cognitively intact. On 3/24/25 at 11:30 am observed R 73 receiving oxygen thru a nasal cannula at 3 liters. The nasal cannula tubing was dated 3/4. R73 stated I do not know how long it's been since my tubing has been changed. R73's CPAP mask was lying on the night stand uncontained. R73's Order Summary Report Active Orders As of 3/25/25 documents…

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 facility failed to obtain an informed consent before prescribing a psychotropic medication. This failure affected 1residents (R61) out of a sample of 128. Findings Include: R61's face Sheet has an initial admission date of 1/11/2023 and has a diagnosis of Major Depressive Disorder dated 1/11/23. R61's Minimum Data Set Section C dated January 9, 2025, has a Brief Interview of Mental Health score of 1 which indicates the resident is severely cognitively impaired. R61's Physician Order Sheet documents R61 is prescribed Remeron (Mirtazapine) for Situational Depression with a start date of 3/24/23. R61's Consent for Psychotropic Medications documents a verbal consent for the administration of a psychotropic medication dated 3/24/2025. R61's Medication Administration Record dated March 2025 documents Remeron, psychotropic medication administered daily from 3/1/2025 to 3/25/2025 at 8pm. On 3/25/2025 at 2:18 pm, V2 (Director of Nursing- (DON), stated the floor nurse or the Assistant Director of Nursing gets the Psychotropic Medication…

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 honor the resident's right to a sanitary, clean environment throughout the facility. This has the potential to affect all 208 residents residing within the facility. Findings include: Record review of facility provided census documents in part that 208 residents reside within the facility. On 3/10/2025 at 11:30 AM, R8 was observed eating lunch (tuna salad, green beans, mashed potatoes) in the dining room along with other residents that reside within the 4th floor. Underneath the table was unidentified orange food (similar to crumbs of cheese puffs/chips), and splatters of brown dirt. Splatters of brown dirt and dirty footprints were observed throughout the dining room. On 3/10/2024 at 11:34 AM, V7 (Certified Nursing Assistant) affirmed that V7 was assigned to care for R8 and other residents on the floor. V7 affirmed that the dining room is where the residents that reside on the floor eat. V7 observed the orange food and dirt underneath the table and was unable to identify what the food was. V2 (Director 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 interview and record review, the facility staff failed to notify the state survey agency within time reporting requirements of abuse; failed to report witnessed abuse to the abuse prevention coordinator. This failure affects 4 residents (R8, R12, R3 and R15) sampled for abuse reporting. Findings include: 1. Record review of investigation to the state survey agency (SSA) and supplementary investigative documents for R8's fall with injury documents in part, .Analysis and Conclusion . On 2/18/2025, (R8) was ambulating around the unit. (R8) ambulated into the dining room where (R8) lost (R8's) balance and fell to the floor. Staff nursing (were) made aware and immediately went to assess the (R8). While on the floor the (R8) was observed with an open area to the back of (R8's) head. The nurse cleansed the area and applied a pressure dressing to the site. (R8's) guardian and physician were made aware, and an order was received to transport the (R8) to the local hospital where (R8) was later admitted with a diagnosis of anemia. (R8) returned to the facility on 2/21/2025 21:45 and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a thorough investigation after a fall with injury to substantiate if abuse occurred; failed to complete an abuse allegation after an allegation of verbal abuse was reported. This failure affects 4 residents (R8, R12, R3 and R15) sampled for abuse reporting. Findings include: 1. R8's progress notes (dated 2/18/2025) documents in part, Patient fell in dinner are hit the back of head. Small laceration with mild blood drainage noted. Patient vitals with in normal limits BP 122/70 HR 70 Sp02 98.5 Resp 18. Patient is being sent to (Hospital) for Head CT.[NAME] Checks normal . On 2/19/2025, V9 (Nurse Practitioner) documented, Per (Hospital) nurse, Admitting Dx: anemia(9.8 hemoglobin at ER, f/u hemoglobin on 2/19/25 is 12.7). CT head result is unremarkable. She needed staples on her head. Planned for endoscopy. Not sure about discharge plan yet. Will f/u. R8's hospital records (admission date 2/18/2025) document in part, .At the nursing home, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the community survival skills assessment was completed in a timely manner to determine if a resident could safely be out in the community independently. This affected one resident (R13)out of the three residents reviewed for timely completion of community survival skills assessments. As a result, on 3/11/2025 R13 left the facility without supervision for an appointment, did not return to the facility until 3/15/25 approximately at 8:30 pm. Facility and R13 ' s family were unaware of R13 ' s whereabouts and R13 ' s family were concerned for his safety. Findings include: R13's diagnosis includes but are not limited to encounter for other orthopedic aftercare, muscle wasting and atrophy, not elsewhere classified, multiple sites, difficulty in walking, not elsewhere classified, unspecified lack of coordination, cocaine abuse with intoxication, unspecified, unspecified open wound, right thigh, subsequent encounter, and unspecified open…

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 current standard of infection control practices, hand hygiene, during and following provision of care. This failure affected R2 who was administered IVPB medication via PICC without the nurse performing any hand hygiene and without use of gloves. Finding includes: On 04/14/25 at 11:55am, V8 LPN (Licensed Practical Nurse) was noted in the nursing medication room preparing an IVPB. V8 reconstituted the powdered antibiotics with the fluid from the IVPB 250ml (milliliter) then proceeded to R2's room. V8 did not perform any hand hygiene nor put on gloves. V8 observed removing the PICC line two lumen cover caps without any hand hygiene. V8 left the caps on the bedside table then attached the flowmeter line to one of the two lumens line still with no hand hygiene. When this surveyor's observations were made known to V8 and V8 was asked about the facility policy on infection prevention and control regarding PICC Line and hand hygiene, V8 stated that do I have to do all that and walked away and out of the room…

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

Based on observation, interview, and record review, the facility failed to ensure that the community shower room on the third floor was maintained in good repair and sanitary manner. This failure has the potential to affect all 52 residents on the third floor. Findings include: On 2/10/25 at 10:00am after the entrance conference, V1(Administrator) presented the census that shows the third floor has 52 residents. On 2/10/25 at 10:15am with V3(LPN/Licensed Practical Nurse), the following were observed in the third-floor community shower room: The toilet bowl had visible brown stains and stains in a ring form in the toilet bowl; the toilet water tank and water tank cover had visible accumulated dust that showed that the toilet had not been cleaned for several days; the third shower stall shower faucet was broken and not functional. V3 stated, I will call housekeeping and maintenance to come. Inquired from V3 if there is a maintenance logbook where the issues could be documented. V3 stated they use a scanner which will ask a few questions before you can do the documentation, but that it…

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

Based on interview and record review, the facility failed to conduct QAPI (Quality Assurance and Performance Improvement) meetings quarterly and ensure abuse data collection was implemented/coordinated within the QAPI meeting. These failures have the potential to affect all 200 residents residing in the facility. Findings include: Review of facility census dated 10/15/24 documents that there are 200 residents residing in the facility. Record review of facility-provided documentation titled, QPAI Meeting Minutes dated 3/7/2024, does not indicate any reporting, tracking or data regarding abuse or that abuse outcomes was discussed. The template used for the QAPI meeting minutes does not indicate any area for reporting, tracking or data regarding abuse/allegations of abuse. No further QAPI meeting minutes were provided during the survey from 3/7/2024 until 10/21/24. Record review of facility state reportable documents for incidents occurring on 9/26/24 and 10/10/24 documents in part, Once complete, forward a copy and send the original to the QAPI committee . On 10/15/2024 at 11:50 AM,…

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 submit a final investigation report regarding physical abuse to the state survey agency within 5 business days. This failure affects 2 residents (R2, R3) reviewed for reporting. Findings include: Record review of initial report to the state survey agency (Illinois Department of Public Health) dated 9/26/24, documents in part that a physical altercation occurred between R2 and R3. No final report to the state survey agency was noted within the investigative documents. Facility presented e-mail from V1 (Administrator) that documents, in part, Subject: Facility Reported Incident (R2) and (R3) Final 9.26.24. Date: Wednesday, October 16, 2024, at 11:42 AM Central Daylight Time. From: (V1, Administrator). To: (Illinois Department of Public Health), indicating that the final investigative report was sent to the state survey agency on 10/16/2024 (20 days after the incident occurred and 20 days after the initial report was sent). On 10/16/24 at 11:50am, V1 (Administrator) affirmed that V1 is the abuse prevention coordinator for 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 interviews and record reviews, the facility failed to report an allegation of abuse to the Illinois Department of Public Health (IDPH) within two hours of the allegation for one resident (R1) out of a total sample of five residents reviewed for abuse. Findings include: On 9/03/2024 at 10:35 AM, R1 stated about a week and a half to two weeks ago, V12 (Nurse) called R1 a 'crackhead' and threatened to have R1 transferred to a different floor. R1 reported the incident to social services and V1 (Administrator). On 9/03/2024 at 11:05 AM, V1 and V2 (Director of Nursing/Nurse Consultant) stated there were two reportables in the last three months for R1; however, there was no reportable from the incident between R1 and V12. V1 stated R1 had mentioned [R1] was uncomfortable with V12 but did not elaborate further. V1 stated there was an open room on the fourth floor so to avoid further issues, facility transferred R1 from second floor to the fourth floor. During a follow-up interview with V1 at 11:36 AM, V1 stated when facility interviewed V12, V12 stated R1 was referring to someone…

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

Based on interviews and record reviews, the facility failed to ensure coordination of outside services/appointments and have a complete medical record for R3 for one of five residents reviewed for appointments. Findings include: R3's After Visit Summary from 7/20/2024-7/24/2024 hospitalization documents in part to follow-up with hepatology, primary care, and urology. R3 had the 7/31/2024 and 10/14/2024 appointment. R3's After Visit Summary from 8/23/2024-8/26/2024 hospitalization documents in part instructions to schedule a gastroenterology follow-up visit for EGD (esophagogastroduodenoscopy) on 8/27/2024. There was also an appointment with V26 (Podiatry) on 9/30/2024 at 10:30 AM. On 9/03/2024 at 10:25 AM, V3 (Nurse) was R3's primary nurse. Surveyor asked if R3 had any past appointments or upcoming appointments. V3 stated looked at R3's physician orders in the computer. V3 stated R3 had an appointment on 7/31/2024 but did not know if R3 went to 7/31/2024 appointment. V3 did not know what the appointment was for. V3 also stated that R3 had a future appointment on 10/14/2024 but V3…

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

Based on interviews and record reviews, the facility failed to ensure accurate medical records for one resident (R1) out of a total sample of six residents. Findings include: On 9/03/2024 at 10:35 AM, R1 stated medical records list R1 with a diagnosis of schizophrenia. R1 stated [R1] does not have schizophrenia and does not know where the diagnosis came from. Facility did not explain which doctor put it on R1's medical records. R1 stated, I don't want people treating me differently you know because they'll see that schizophrenia on my papers and discriminate against me. R1's admission Record (dated 9/03/2024 1:39 PM) documents in part a diagnosis of Schizoaffective Disorder, Bipolar Type with onset date of 7/10/2024. Reviewed V13's (Psychiatric Nurse Practitioner) 8/06/2024 Psychiatry Note for R1. No mention of schizophrenia. During a telephone interview with V13 on 9/03/2024 at 2:44 PM, V13 stated 'Schizoaffective Disorder, Bipolar Type' is a type of schizophrenia plus bipolar diagnosis. Surveyor read V13's Psychiatry Note from 8/06/2024 over the phone. V13 stated if the note does…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review. The facility failed to provide a clean and sanitary home-like environment for all 221 residents residing in the facility. Findings include: R12 is a [AGE] year-old with diagnoses of but not limited to: Unspecified Dementia, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety, Vitamin D Deficiency, Unspecified, Essential (Primary) Hypertension, Bradycardia, Unspecified, Peripheral Vascular Disease, Unspecified. MDS Section C dated 6/24/24 BIMS score 5 indicating severe cognitive impairment. On 8/23/2024 at 12:26pm tour of fourth floor surveyor observed missing handrail outside of R12'S room with open holes in the wall. On 8/23/2024 at 12:29pm Surveyor observed fourth floor dining room, chairs dirty with dried substance and tattered/torn. On 8/23/2024 at 12:40pm surveyor and V7 (CNA) toured fourth floor shower room. Odor smelled and surveyor asked V7 if she smelled anything. V7 stated, yes, I think it smells like mildew. Surveyor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policy to report allegation of abuse within 2 hours of the incident. This failure affected two (R4, R5) out of six residents reviewed for reporting. Findings include: R4 is [AGE] years old with diagnosis of, but not limited to: Schizoaffective Disorder Bipolar Type, Paraplegia, Suicidal Ideation, Mood Affective Disorder, Auditory Hallucinations, Visual Hallucinations, Major Depressive Disorder, Tourette's Disorder. R5 is [AGE] years old with diagnosis of, but not limited to: Asthma, Difficulty in Walking. Facility initial reportable (8/23/24 at 1:59 pm) to state agency regarding R4 and R5 documents in part: Incident Date: 8/22/24 at 9:45 am. Brief Description of Incident: Alleged Resident to resident physical altercation. R4's (8/22/2024 at 12:33 pm) documents in part: Resident was observed by writer having physical aggression with another peer on same floor, safety precaution in place. Both residents separated and re directed by writer,…

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

Based on observation and interview, the facility failed to provide a sanitary and comfortable environment for two (R2, R4) out of three residents reviewed for sanitary physical environment. Findings include: On 08/01/2024 at 11:00 AM, surveyor noted a hole in the wall outside the 2nd floor elevators. Surveyor observed mold in R2's bathroom and R4's bathroom. Surveyor noted the wall panels starting to peel off the walls in the bathroom. Surveyor also noted a wet bed sheet on the floor that had full of flies flying around on it. V23 (Environmental Services Director) stated he is the housekeeping director. V23 stated he does rounds on every room every day. V23 came to R4's room and noticed the wet sheet on the floor. V23 stated that probably the housekeeper has been down here to pick it up yet. V23 stated that soiled linen should not be left on the floor. Surveyor observed V23 pick up the wet linen without any gloves and take it to the dirty linen room. Surveyor showed V23 R4's bathroom and asked him what was on the bathroom floors and ceiling. V23 stated that it is mold on the floors…

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, facility failed to affirm the right of the resident to be free from verbal abuse. This deficient practice has the potential to affect two (R2, R12) out of three residents reviewed for abuse. Findings Include: 1. On 07/30/2024 at 11:20AM, R2 stated on the day of the altercation he was sitting in the dining room talking to another resident. R2 stated a CNA staff member (identified as V20) did not like the nature of his conversation and told him to stop talking way and using the words he was using. R2 stated he used the N word and V20 did not like. R2 stated V20 then called him crippled. R2 stated V20 was holding a push broom and took the stick off the push brush and held it in his hand. R2 stated by this time they were located at the nurses station where a nurse (identified as V12) witnessed V20 called R2 crippled. R2 stated he then grabbed a supplement shake from on top of the nurses cart, opened it and splashed the chocolate supplement on V20 then R2 wheeled himself back to…

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

Based on interview and record review, the facility failed to report and investigate verbal abuse for two (R2, R12) of three residents reviewed for verbal abuse. Findings include: On 07/30/2024 at 11:20AM, R2 stated on the day of the altercation he was sitting in the dining room talking to another resident. R2 stated a CNA staff member (identified as V20) did not like the nature of his conversation and told him to stop talking way and using the words he was using. R2 stated he used the N word and V20 did not like. R2 stated V20 then called him crippled. R2 stated V20 was holding a push broom and took the stick off the push brush and held it in his hand. R2 stated by this time they were located at the nurses station where a nurse (identified as V12) witnessed V20 call R2 crippled. R2 stated he then grabbed a supplement shake from on top of the nurses cart and opened it and splashed the chocolate supplement on V20 then R2 wheeled himself back to his room. On 07/31/2024 at 10:56AM, V12 (Licensed Practical Nurse/LPN) stated she was working on the third floor of the facility 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 interview and record review the facility failed to provide resident with the bed hold notice for 1of 3 residents (R8) reviewed for transfer and discharges in a sample of three residents. On 8/1/2024 at 11:198 V27 (Hospital Social Worker) stated, I have made numerous attempts to send that resident (R8) back to the facility. I spoke to V25 (Care Coordinator) facility liaison 7/16/2024 and informed her (R8) will be returning to facility and will be ready for discharge 7/18/2024 or 7/19/2024. The MD put in the order for discharge 7/19/2024 and I sent over (R8) progress notes. An hour later they called informing me that no beds were available. On the tenth day they gave (R8) bed away. I also spoke to V26 (Director of Development), and he told me that they should have an available bed 7/23/2024 or 7/24/2024. On 7/23/2024 I spoke with both V25 and V26 and was told no beds are yet available. I sent multiple referrals out for resident placement. They said they would accept her back at facility. I left message with V26 (Director of Development) his story changed many times. Yesterday…

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 permit a resident to return to facility within the 10-day bed hold period for1 of 3 residents (R8) reviewed for transfer and discharges in a sample of three residents. On 8/1/2024 at 11:19AM V27 (Hospital Social Worker) stated, I have made numerous attempts to send resident (R8) back to the facility. I spoke to V25 (Care Coordinator) facility liaison 7/16/2024 and informed her (R8) will be returning to facility and will be ready for discharge 7/18/2024 or 7/19/2024. The MD put in the order for discharge 7/19/2024 and I sent over (R8) progress notes. An hour later they called informing me that no beds were available. On the tenth day they gave (R8)'s bed away. I also spoke to V26 (Director of Development), and he told me that they should have an available bed 7/23/2024 or 7/24/2024. On 7/23/2024 I spoke with both V25 and V26 and was told no beds are yet available. I sent multiple referrals out for resident placement. They said they would accept her back at facility. I left a message with V26 (Director of Development). His…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review the facility failed to ensure medication ordered by physician to be administered was documented per their policy; failed to ensure all medications are being administered by license professional per their policy; and facility failed to ensure all medication administered to residents was ordered by physician per their policy. These failures apply to 2 out of 3 residents (R5, R6) in a total sample of 3 residents reviewed for pharmaceutical services. These failures have the potential to affect 2 residents (R5, R6) in not administering medication by trained professional, not receiving correct medication, and receiving medication not ordered by physician. Finding includes: 1. R5 is [AGE] years old, initially admitted on [DATE], with diagnosis includes hemiplegia, epilepsy, diabetes, schizophrenia. R5 is cognitively intact with BIMS (brief interview of mental status) of 15 dated 7/18/2024. On 7/30/2024 at 11:21 AM, R5 stated at the night before he did not get his…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and review of records the facility failed to ensure all medications are stored in an appropriate containers not exposed to unclean environment; failed to ensure medication in resident's possession has an order by the physician to be administered; failed to ensure all accessible medications are properly processed per facility policy. These failures apply to 1 out of 3 residents (R6) in a total sample of 3 residents reviewed for pharmaceutical services. These failures have the potential to affect 1 resident (R6) in receiving medication that are not stored in a clean environment, in not receiving correct medication, and receiving medication not ordered by physician. Finding includes: R6 is [AGE] years old, initially admitted on [DATE], with diagnosis of chronic obstructive pulmonary disease (COPD). R6 is cognitively intact with BIMS (brief interview of mental status) of 14 dated 7/18/2024. On 7/30/2024 at 11:38 AM, R6 was seen with a carton box on tray table with a bottle of Tums…

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

Based on observations, interviews, and record reviews, the facility failed to provide adequate laundry services to ensure adequate clean linen and timely wash for resident clothing for all 220 residents residing in the facility. This failure resulted in substandard quality care resulting in an extended survey. Findings include: On 5/28/2024 at 12:40 PM, R313 waited for staff to change [R313]. R313 stated sitting soiled for the past two to three hours. R313 stated staff said facility didn't have enough linen and was waiting for laundry to be done. At 12:47 PM, there was a linen cart in the second-floor hallway. Linen cart had two flat sheets, one blanket, and one bath towel. V37 (CNA-Certified Nurse Aide) stood by the nurses' station and said not to touch the cart. Surveyor explained role and V37 stated mistaking surveyor for floor staff and thought surveyor was going to take the linens. V37 stated linens were the only clean ones left for [V37's] assigned residents. At 12:49 PM, surveyor reviewed two additional linen carts visible in the second-floor hallway. One cart had two face…

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 there were sufficient nursing staff in the facility to provide adequate care and assistance for residents, resulting in long call light response times, medications not being administered timely, activities of daily living (ADL) care not provided timely, and Resident Council concerns not addressed. This has the potential to affect all 220 residents residing in the facility. Findings Include: On 5/28/24 at 10:56 AM, R132 stated that the facility is short in nursing staff and sometimes R132 gets R132's medications late. R132's Minimum Data Set (MDS) dated [DATE] shows R132 is cognitively intact. At 11:01 AM, R85 stated that the facility is short in staff. R85 stated, I don't get my medications especially on weekends are really bad. If I could walk, I would walk out of here. Night shift is really bad. When I press the call light it would be hours until they see me. If I ask for a nurse, it would be hours until they come in and help.…

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) Food is labeled, dated, and discarded after use by date. (b) Food and beverage were covered during transport or distributed to residents. (c) Meat was thawed or stored at appropriate temperature. (d) Kitchen staff wear beard restraint to prevent hair from contacting food. (e) Garbage bins were covered inside the kitchen preparation area. (f) Boxes with food were stored off the floor. These failures have the potential to affect 219 residents living in the facility with 1 resident on Nothing by Mouth (NPO) for a total facility's census of 220 dated 5/28/24. The findings include: On 5/28/24 at 9:12 AM Initial tour to kitchen conducted with V8 (Dietary Aide), observed 2 garbage bin / container by the sink and food preparation area with no lid and waste inside the garbage bin. Surveyor toured Refrigerator #1 with V9 (Cook), observed open jar of Jalapeno, discard date showed 5/11/24 but still inside the refrigerator. V9 said it should be discarded. Surveyor found the following food items inside 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 (a) dispose of garbage properly in a contained dumpster; (b) keep the dumpster area clean and free of garbage or waste to maintain a sanitary condition and to prevent harborage and feeding of pest. These failures could potentially affect all 220 residents that reside in the facility as of census 5/28/24. The findings include: On 5/28/24 at 10:05 AM Dumpster outside the building inspected with V10 (Dietary Manager from another facility). V10 stated he is training the new dietary manager. Dumpster area observed with empty boxes, soiled gloves, trash, debris on the ground around the dumpster. V10 stated all garbage / waste should be placed inside the dumpster. V10 said housekeeping and kitchen staff mainly uses the dumpster. On 5/29/24 at 12:25 PM Interviewed V10 (Dietary Manager from another facility) with V13 (Dietary Manager in training). V10 said dumpster area should be clean to prevent rodents / pests from harboring, recommended to be power washed. Facility's census dated 5/28/24 showed a total of 220…

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 maintain an effective pest control program to keep flying insects out of the facility. This deficient practice has the potential to affect all 220 residents residing at the facility as of census 5/28/24. The findings include: On 5/28/24 at 9:30 AM Inspected dry storage area in the kitchen with V9 (Cook) and observed hamburger buns in clear plastic packaging opened / torn unable to read the expiration date with multiple black insects flying around the hamburger buns. V9 said the clear plastic was torn and unable to read the expiration date. These buns will be discarded. Observed nearby garbage bin with no lid or cover, waste inside the garbage bin. At 2:05pm Survey team observed multiple black insects flying around drain, garbage bin in the bathroom. On 5/29/24 at 12:25 PM Interviewed V10 (Dietary Manager from another facility) stated he is training V13 (Dietary Manager). V10 stated no insects or flies should be in the kitchen for sanitation purposes. It's not okay for insects or flies in the kitchen. On…

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

Based on observations, interviews, and record reviews the facility failed to (a) ensure call lights were within reach for R50 and R81, (b) answer call lights in a timely manner and respond to R67's request, and (c) provide furniture and adequate lighting to accommodate needs/preferences for R414. There failures affected four out of a total sample of 35 residents. Findings include: 1. R67's admission Record documents in part medical diagnoses of cerebral infarction (stroke), unsteadiness on feet, muscle weakness (generalized), flaccid hemiplegia (paralysis) affecting the right dominant side, lack of coordination, ataxia (without coordination), and history of falling. R67's care plan documents in part that R67 has a self-care deficit with activities of daily living and mobility related to hemiplegia. Interventions last revised 9/29/2023 document in part that R67 requires supervision to limited assistance with transfers and minimal to moderate assistance with bed mobility, turning and sitting up in bed. R67's Restorative Assessment/Note dated 4/29/2024 documents in part that R67…

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 complete the Non-Comprehensive Minimum Data Set (MDS) assessment using the CMS-specified Resident Assessment Instrument (RAI) process within the regulatory timeframe for 5 (R6, R38, R49, R110, R192) of 7 residents reviewed for resident assessment in a sample of 35. The findings include: 1. R6's health record documented admission date on 6/22/2022 with diagnoses not limited to Spondylolysis cervical region, Emphysema, Other dislocation of left shoulder joint, other seizures, Blindness, Chronic kidney disease, Unspecified osteoarthritis, Liver disease, Altered mental status. 2. R38's health record documented admission date on 10/16/2023 with diagnoses not limited to Unspecified sequelae of cerebral infarction, Covid-19, Type 2 diabetes mellitus without complications, Cerebrovascular disease, Essential (primary) hypertension, Unspecified convulsions, Hemiplegia, and hemiparesis following cerebral infarction affecting right dominant side. 3. R49's health record documented admission date on 12/17/2013 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to (a) obtain physician order for oxygen administration for R111, (b) follow oxygen liter flow as ordered for R88, (c) label/change oxygen tubing and bubbler per policy for R14, R88, and R111, (d) provide oxygen tubing extension for R14, and (e) store R81's positive airway pressure (CPAP) mask in a bag when not in use. These failures affected 4 out of a total sample of 35 residents. Findings include: 1. R14's admission Record documents in part medical diagnoses of chronic obstructive pulmonary disease (COPD) and dependence on supplemental oxygen. R14's Order Summary Report includes an active order started on 6/14/2020. It documents in part: Change and date [oxygen] tubing weekly. Every night shift, every [Sunday]. R14's care plan has a focus, last revised on 10/17/2023, that documents in part: [R14] is at risk for activity intolerance [related to] inadequate oxygenation [secondary to] [diagnosis] COPD and receiving oxygen therapy 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 maintain accurate controlled substance documentation for four residents out of total of seventy-six residents in the sample. Findings On 5/28/2024 at 10:16 AM the Four North medication cart controlled substances were observed with V17 (LPN). Lorazepam 0.5 mg for R263 was documented as a quantity of one remaining. Lorazepam count for R263 by V17 was that two tablets were in stock. On 5/28/2024 at 10:16 AM the Four North medication cart controlled substances were observed with V17 (LPN). Hydrocodone for R52 has a count of twenty-six tablets, but twenty-five tablets were observed in stock. V17 stated that one tablet of Hydrocodone was administered to R52 at 9 AM on 5/28/2024 and not yet signed off. On 5/28/2024 at 10:16 AM the Four North medication cart controlled substances were observed with V17 (LPN). Morphine Sulfate for R148 had 5 ml recorded as remaining. Morphine Sulfate count by V17 was that 6 ml remained in the bottle. On 5/28/2024 at 12:20 PM the Two B medication cart was observed with V19 (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.

Based on observation, interview and record review, the facility failed to properly store medications and medication administration supplies. This failure has the possibility of impacting 123 residents who are cared for using the medication cart on the first floor, second floor side B, third floor north and forth floor north. Findings On 5/28/2024 at 9:23 AM, V15 (LPN) was observed dispensing Readycare with a date of 5/24/2024 handwritten on the container. Just prior to administration, V15 was stopped and asked about the expiration date. V16 discarded the Readycare and left the medication cart to speak to another nurse. Upon return to the medication cart, V15 stated that he spoke with the Director of Nursing who said that Readycare was good for 24 hours after opening. Readycare container was observed to state, Store at room temperature. Do not freeze. Refrigerate after opening and use within three days. On 05/28/24 at 10:16 AM the 'Four North Medication Cart was observed with V17 (LPN). Levothyroxine 25 mg was found in drawer with no resident name and no expiration date on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to administer consented pneumococcal vaccinations in a timely manner for four (R10, R48, R76, R90) of five residents reviewed for influenza and pneumococcal immunizations in a sample of 35. Findings include: On 05/29/24 at 10:07 AM, V5 (Infection Preventionist/Licensed Practical Nurse) stated the influenza vaccine is offered during flu season (October 1 - March 31st) and are done in-house. V5 stated pneumococcal and COVID-19 vaccines are offered upon admission/yearly and are completed by an outside vendor on site. V5 stated there are influenza and pneumonia vaccine consent forms which are filled out by the resident or resident representative indicating consent or no consent for the vaccine to be given. V5 stated education is provided and documented on these forms. V5 stated if a resident refuses to be vaccinated this would be document into the resident's electronic health record (EHR) under the immunization tab. V5 stated V5 obtained several consents 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.

Based on interview and record review, the facility failed to follow their abuse policy and procedure to ensure staff participated in a yearly abuse, neglect, and exploitation prevention training program and failed to have a process in place to track attendance. The facility's census on the first day of survey was 220. Findings Include: On 5/30/24 at approximately 10:30 AM, interviewed V1 (Administrator) about abuse in-services. V1 stated that abuse training and education should be provided to staff upon hiring and annually thereafter. The purpose of the abuse training is to educate staff on the facility's abuse prevention program policy and procedures. When asked to provide documented evidence that all staff received/participated in the abuse trainings/in-services within the last 12 months, V1 could not provide any documentation. The facility's Abuse Prevention Program policy and procedure documents in part that on an annual basis, staff will receive a review of the abuse prevention program policy and procedure.

Based on observation, interview, and record reviews, the facility failed to maintain a resident's (R23) dignity and conceal R23's urine collection bag with a privacy bag for 1 out of a total sample of 35 residents. Findings include: R23's admission Record documents in part medical diagnoses of artificial openings of urinary tract status and obstructive and reflux uropathy. R23's care plan contains a focus for R23's urostomy (artificial opening to redirect urine). Interventions do not include how the facility will maintain R23's dignity and privacy with a urine collection bag. On 5/28/2024 at 12:28 PM, R23 was lying in bed. Bed is the closest to the hallway door. R23's urine collection bag was not in a privacy bag and visible from the hallway. On 5/30/2024 at 9:42 AM, V2 (Director of Nursing) stated residents' urine collection bags should be in privacy bags. Facility's Policy & Procedure Catheter Care, issued 10/31/18, does not document in part how the facility will maintain the dignity and privacy of residents' with urinary collection bags.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the code status documented in the care plan matched the physician order and POLST (Physician Order for Life Sustaining Treatment) form for 1 (R52) of 3 residents reviewed for Advance Directives in a sample of 35. Findings Include: R52 has diagnosis not limited to Major Depressive Disorder, Intervertebral Disc Degeneration, Lumbar Region, Long Term (Current) use of Anticoagulants, Chronic Obstructive Pulmonary Disease, Anemia, Peptic Ulcer, History of Falling, Morbid (Severe) Obesity, Presence of Right Artificial Hip Joint, Personal History of other Venous Thrombosis and Embolism, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Syncope and Collapse, Slow Transit Constipation, Gastro-Esophageal Reflux Disease, Dementia, Dependence on Supplemental Oxygen, Spondylosis, Dermatophytosis, Chronic Respiratory Failure, Immunodeficiency, Iron Deficiency Anemia, Vitamin D Deficiency and Osteoarthritis. IDPH (Illinois Department of Public Health) Uniform…

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 complete the comprehensive Minimum Data Set (MDS) assessment using the CMS-specified Resident Assessment Instrument (RAI) process within the regulatory timeframes for 1 (R166) of 7 residents reviewed for resident assessment in a sample of 35. The findings include: R166' s health record documented admission date on 9/26/2023 with diagnoses not limited to Encounter for orthopedic aftercare following surgical amputation, Rhabdomyolysis, Chronic obstructive pulmonary disease, Type 2 diabetes mellitus, Gout, Unspecified complications of amputation stump, Encephalopathy, Peripheral vascular disease, Unspecified atrial fibrillation, Acquired absence of other left toe(s), Essential (primary) hypertension. On 5/30/24 at 9:51am V34 (MDS coordinator, LPN/Licensed Practical Nurse) said she has been working in the facility since 2020. MDS assessment is done for all residents upon admission, quarterly, annually, and significant changes. admission MDS assessment should be completed within 14 days from entry date. V34 said 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 meet professional standards as indicated in their policy and procedure by giving medications outside of the timeframe and failing to check the blood pressure prior to administering blood pressure medication for 1 (R182) resident in a sample of 35. Findings include: R182 has diagnosis not limited to Diastolic (Congestive) Heart Failure, Personal History of other Venous Thrombosis and Embolism, Atherosclerotic Heart Disease of Native Coronary Artery, Abdominal Aortic Aneurysm, Paroxysmal Atrial Fibrillation, Chronic Obstructive Pulmonary Disease, Type 1 Diabetes Mellitus, Psychosis, Essential (Primary) Hypertension, Hyperlipidemia, Heart Failure, Chronic Kidney Disease, Stage 2, Dementia, Moderate, with Agitation and Chronic Respiratory Failure with Hypoxia. R182 MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 14 indicating intact cognitive response. R182's Medication Administration Record Vital Signs dated 05/27/24 01:36 document in part: 126 / 74 mmHg Lying, 05/26/24 08:58 122 / 68…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure ADL (Activities of Daily Living) care were done in a timely manner for two dependent residents (R112 and R313), failed to follow policy and procedures for incontinence care for R112, and failed to provide adequate equipment to assist R313 out of bed. This failure affected two out of a total sample of 35 residents. Findings include: 1. R313's admission Record documents in part medical diagnoses of pain to bilateral lower extremities, morbid (severe) obesity due to excess calories, and difficulty walking. R313's Weights and Vitals Summary document in part 584 pounds on 4/10/2024 as the last recorded weight. R313's care plan documents in part [R313] has mixed bladder incontinence related to impaired mobility. Intervention last revised on 8/04/2023 documents in part: Check as required for incontinence. Wash, rinse and dry perineum. Change clothing [as needed] after incontinence episodes. R313's care plan documents [R313] has…

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

Based on observations, interviews, and record reviews, the facility failed to follow an order to apply a hand splint to prevent decreases in range of motion and update a resident's (R67) care plan for splint use for 1 out of a total sample of 35 residents. Findings include: R67's admission Record documents in part medical diagnoses of cerebral infarction (stroke), muscle weakness (generalized), flaccid hemiplegia (paralysis) affecting the right dominant side, lack of coordination, and ataxia (without coordination). R67's Order Summary Report documents in part an active order dated 2/14/2024 to Please apply splint to right hand due to right hand contractures. Please apply during AM care (7-3) and remove second shift (3-11). R67's Restorative Assessment/Note dated 4/29/2024 recommends continuing restorative programs for splint/brace application. R67's care plan documents in part that R67 was noncompliant with splint use (last revised 1/05/2023). Intervention read, Resident will be able to tolerate right hand splint [six to seven times a week] for a minimum of 15 minutes. This…

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

Based on observation and interview the facility failed to (A) prevent urinary catheter bag from touching the floor, (B) obtain physician order for indwelling catheter, (C) develop a care plan for indwelling catheter for one (R171) out of 3 residents reviewed for urinary catheter in a sample of 35. Findings Include: On 05/28/24 at 12:42 PM, observed R171 lying in bed and R171's urinary catheter bag containing urine lying on the floor next to R171's bed. On 05/28/24 at 12:46 PM, V14 (Licensed Practical Nurse) observed R171's urinary catheter bag on the floor and stated it should not be on the floor due to infection control concerns. On 05/29/24 at 03:13 PM, review of R171's orders in R171's Electronic Health Record (EHR) indicate R171 does not have an order for indwelling urinary catheter and does not have a care plan for indwelling catheter. R171 was admitted to the facility 03/26/24 and has a diagnosis including but not limited to Ileus, Bacteremia, Catatonic Disorder Due to Unknown Psychological Condition, Schizoaffective Disorder, Legal Blindness as Defined In USA, Hypertension,…

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

Based on observation, interview, and record review the facility failed to provide dedicated covered garbage receptacles for used personal protective equipment inside a contact isolation room. These failures have the potential to affect one (R111) of eight residents reviewed for infection control in a total sample of 35. Findings include: On 05/28/24 at 10:34 AM, observed Contact Isolation Precautions sign posted outside R111's room. At 10:48 AM, V14 (Licensed Practical Nurse) stated R111 is on Contact Isolation for C. Diff (Clostridium Difficile). V14 stated personal protective equipment (PPE) is kept in plastic drawers outside R111's room and when staff goes into R111's room they must perform hand hygiene before entering and don PPE including gown, face mask, and gloves. V14 stated these PPE are doffed inside R111's room and placed in the designated black garbage can inside R111's room. On 05/28/24 at 12:15 AM, observed small sized garbage container inside R111's room by the doorway. This small garbage container did not have a lid and was therefore not covered. Did not observe a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to assess eligibility, provide education on the COVID-19 vaccine, and offer COVID-19 vaccination to 1 (R413) of 5 residents reviewed for COVID-19 immunizations out of a sample of 35. Findings include: R413's electronic health record (EHR) showed initial admission date 04/04/24 with diagnoses including not limited to COVID-19 (dated 5/29/24), Anemia in Chronic Kidney Disease, Diabetes Mellitus Due To Underlying Condition with Hyperglycemia, Hyperlipidemia, Dehydration, Dementia, Dysphagia, Gastroesophageal Reflux Disease without Esophagitis, Duodenal Ulcer, Muscle Weakness Generalized, Osteomyelitis, Urinary Tract Infection, Altered Mental Status, Chronic Fatigue, Syncope and Collapse, Peripheral Vascular Angioplasty Status, Lack Of Coordination, Abnormal Posture, Hypothyroidism, Hypertension, Atherosclerotic Heart Disease, Gastrointestinal Hemorrhage, Chronic Kidney Disease, Metabolic Encephalopathy, Difficulty Walking. R413's EHR indicates R413 was…

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

Based on observation, interview, and record review the facility failed to follow professional standard of medication administration documentation after administration of medication in preventing medication error of double dosing residents for 21 of 21 (R5, R15, R16, R17, R18, R19, R20, R21, R22, R23, R23, R24, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, and R34) residents reviewed for medication pass in a timely manner. This failure affected (R5, R15, R16, R17, R18, R19, R20, R21, R22, R23, R23, R24, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, and R34) whose medications were not documented in a timely manner and has the potential to affect all residents on 1st and 2nd floor of the facility. Findings include: On 04/29/24 at 11:25am, V8 LPN (Licensed Practical Nurse) was noted passing medication, V8 stated the medication pass is for 9:00am medication pass and had just given the last resident medications and the breathing treatment is still on right now. While talking with V8 the resident electronic MAR (Medication Administration Record) showed some resident medication list…

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 sufficient dietary staff are provided to meet resident needs and services in meal preparation. This failure affected all residents eating from the facility kitchen. This affected R3, R6, R9, R10, R11, and R12 who were supposed to get double portions, but due to insufficient dietary staff to prepare the food and insufficient ingredients to prepare the menu, the resident needs were not met. This has the potential to affect all residents eating from the kitchen. Findings include: On 04/29/24 at 10:54am, upon entering the kitchen, a red sanitizing bucket was observed with a towel placed inside the bucket soaking. When V3 (Dietary Director) tested the water, it read 0 (Zero). V13 (dietary Aide) stated, I was busy with cooking these greens pointing to the pot of green beans I forgot to add sanitizer because we are short. Yes, we are short of staff, I am the cook for the breakfast and lunch today. The listed menu for lunch 04/29/24 includes but not limited to, frosted yellow cake, macaroni, and cheese. None 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 ensure the sanitizing bucket has sanitizer solution; the food items are not stored on the bare floor; and the garbage cans have cover lids. This failure has the potential to cause food borne illnesses and has the potential to affect all 223 residents residing in the facility. Findings include: On 04/29/24 at 10:54am, the following observations were made: A red sanitizing bucket was observed with towel placed inside the bucket soaking. When V3 (Dietary Director) tested the water, it read 0 (Zero). V13 (dietary Aide) stated, I was busy with cooking these greens pointing to the pot of green beans and I forgot to add sanitizer, because we are short. Yes, we are short of staff, I am the cook for the breakfast and lunch today. Three (3) large garbage cans in the middle of the kitchen were full of garbage with no cover lids. Food items delivered were stored on the bare floor in the storage area. V3 stated he has not been able to re-arrange the food items so they would not be touching the floor. V7 (Dietary Aide)…

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 current standard of infection control practices and prevention, hand hygiene and failed to ensure that beverages were served in a sanitary way to prevent contamination and prevent spread of food borne illnesses. This failure has the potential to affect all 33 residents on the 1st floor. Findings include: On 04/29/24 at 11:39am, V9 CNA (Certified Nurse's Aide) noted preparing to serve lunch time trays. V9 was observed dipping her fingers in the plastic cup to separate them out and then pour the beverage in the cup. During the same observation at 11:41am, V9 noted adjusting face mask over the nose and then without hand hygiene proceeded to touch resident food trays and pass them to the residents. V9 was observed passing food trays to residents in their rooms and the dining area without in-between hand hygiene. At 11:46am, when V9 was made aware of these observations and was asked about the facility policy on infection control and prevention regarding hand hygiene, V9 stated, Before serving the food I'm…

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 resident's environment remains free of accidental hazard by leaving medication at resident's bed side table and not in visual proximity of nurse; and failed to ensure sharp items (scissors) in resident's room, visible from hallway without supervision for two residents (R3, R16) in the sample. This failure has the potential to affect R3 whose medication was left on the bed side table and R16 who had two pair of scissors and nail clippers stored on the side table and has the potential to affect all 66 residents residing on the 2nd floor of the facility. Findings include: On 04/29/24 at 12:40pm, R3 observed in bed with three tablets of medication on bed side table in a medication cup. R3 stated, My morning medicine I'm going to take it. I took some only that is left. My nurse gave it to me. V5 (RN) was asked about the facility policy on medication administration and professional standard of medication administration. V5 said, Yes, That's the 9:00am medicine. I did not know (R3) did not take all 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 therapeutic diet orders for 2 of 2 (R3 and R11) were followed. This failure affected R3 and R11 who were supposed to receive mechanically altered diet but were served regular green beans, putting these residents at risk for choking and has the potential to affect all 223 residents residing in the facility. Findings include: On 04/29/24 between 11:30am to 1:30pm, lunch mealtime observation showed R3 and R11 were served regular green beans on their lunch tray without being mechanically altered. R3's medical record Diet order with order date 9/20/22 showed R3 should be on a Mechanical Soft texture, Regular Thin Liquids consistency. This order was not followed. R11 medical record documented diet order showed R11 is on mechanical soft texture, regular thin liquids consistency, double portions. This order was not followed. Both V2 and V3 were unable to present any documentation physician/ dietician order was changed. On 04/30/24 at 1:55pm, V3 (Dietary Director) stated the food texture is printed on the ticket…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to ensure one resident (R3) was provided with a working television for 14 days after admission to the facility and the facility failed to ensure one resident (R3's) bed had linen on it for two of three days during investigation. This failure affected one of ten residents reviewed for Homelike Environment. Findings include: R3 is [AGE] year old with diagnosis including but not limited to: anxiety disorder, insomnia, unspecified urinary incontinence, unspecified fall, chronic kidney disease and hypertensive heart disease. R3's BIMS (Brief Interview for Mental Status) score is 15, which indicates cognitively intact. On 04/01/2024 during investigation, R3 was observed sitting on his bed. No sheets were observed on R3's mattress and no television was noted at R3's bedside. On 04/01/2024 at 12:03 PM, R3 said, I don't know what happened to my sheets. I thought they were changing my linen. I have been asking for a TV (television) since I got here…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to ensure that proper incontinent care was rendered to one resident (R3) in a sample of ten residents reviewed for Improper Nursing Care. Findings include: R3 is [AGE] year old with diagnosis including but not limited to: Unspecified urinary incontinence, unspecified fall, chronic kidney disease, hypertensive heart disease and chronic obstructive pulmonary disease. R3's BIMS (Brief Interview of Mental Status) score is 15, which indicates cognitively intact. On 04/01/2024 during investigation, surveyor was walking on the third floor near R3's room and smelled a strong odor of urine. Surveyor asked V25 (Certified Nurse Assistant/CNA) where the urine smell was coming from. On 04/01/2024 at 12:00 PM, V25 (CNA) said, I smell the urine, but I don't know where it is coming from. At that time, Surveyor entered R3's room and the urine odor became stronger. R3 was observed sitting on his bed. No sheets were observed on R3's bed and R3 reeked of urine.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a resident's treatments for pressure ulcers were provided. This failure affected 1 resident (R1) reviewed for pressure ulcer/injury treatment. Findings Include: R1's admission record documents, in part, R1's diagnoses include dysphagia, quadriplegia, cervical spine fracture, substance abuse, depression, respiratory failure, tracheostomy, and pressure ulcers. R1's admission date to the facility is documented as 11/16/23. R1's (11/22/23) Minimum Data Set, documents, in part, Brief interview for Mental Status (BIMS) score is 15, which indicates R1 is cognitively intact. Section M- Skin Condition documents R1 has one stage 1 pressure ulcer. R1 has one stage 3 pressure ulcer that was present upon admission. R1 has one unstageable deep tissue injury noted at time of admission. R1's (11/16/23) hospital discharged record documented in part, Wound Care: healing stage 2 sacrum area, cleanse with soap and water and apply a wound dressing daily. Right heel…

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

Based on interview and record review, facility failed to follow their policy to ensure vaccinations were administered to prevent disease for 1 (R1) out of three residents reviewed influenza immunizations. Findings include: On 01/23/2024 at 11:50 AM, R1 was seen in her room laying on her bed sitting upright. R1 stated that she wants a flu shot but was not given any. On 01/23/2024 at 11:58 AM, V5 (Licensed Practical Nurse) stated the last vaccine that R1 received was for TB. There is no flu or COVID vaccine documented. On 01/23/2024 at 1:49 PM V11 (Infection Preventionist) stated consent to administer any immunizations will be on the immunizations tab. If the consent is not there, then the immunizations or receiving the vaccine has not been done. If the consent is refused, then we provide education and that is documented in the immunization tab. We're getting consents for RSV but we do not have the vaccine for RSV. Corporate will send out a clinic for COVID and RSV to provide residents with the appropriate vaccines. Flu vaccine is supposed to be offered back in Oct. No one on 4th…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and records review, the facility failed to follow infection control policy by failing to clean IV (Intravenous) site as required for one (R2) of one resident reviewed for IV care. Findings include: R2 is a [AGE] year-old individual admitted to the facility on [DATE]. R2 diagnosis as documented in R2's current face sheet include but not limited to: Lower back pain, Acute Osteomyelitis, Psychoactive substance abuse, discitis unspecified, Lumbosacral region, lower back pain, auditory hallucinations, visual hallucinations, etc. On 12/23/2023 at 10:04 am, R2 was observed in the hallway walking to his room. R2 was oriented to person, place, time, and situation. R2 said his PICC line is not being dressed on time, is difficult to be flushed sometimes and R2 thinks it is clogged. R2 said he is receiving antibiotics to treat for an infection in his spine and he is worried his PICC line might get infected if the dressing change is not done on time. R2 said his PICC line is flushed before…

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

Based on review of records and interview, the facility failed to provide PBJ (payroll-based journal) information in a uniform format which excludes information to determine category of data to review and verify for accuracy. These failures have the potential to affect determination of staffing needs that may affect residents' care. Findings include: On 11/7/2023 to 11/8/2023 facility was reviewed for lack of staffing related to low weekend staff. Facility has three floors occupied by residents. For the month September and October 2023, weekend schedules for nursing staff were reviewed. Facility provided daily staffing form dated 7/10/2023 and timecards for all the nursing staff working on 7/9/2023 to 7/22/2023. Per daily staffing form dated 7/10/2023, V37 (Licensed Practical Nurse) was on schedule to work on a floor. V37's timecard documents that V37 did not work in the facility from 7/9/2023 to 7/12/2023. On 11/7/2023 at 3:30 PM, V10 (Staffing Coordinator) stated that there are times when facility has problems with staffing and V10 must call staff that are not working to fill in.…

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

Based on interviews and records review the facility failed to ensure sufficient nursing staff on a 24-hour basis to care for 4 (R3, R4, R5 and R8) residents' needs, out of 7 residents (R1, R2, R3, R4, R5, R7and R8) reviewed. This failure resulted on R3, R4, R5 and R8 not receiving their night medications. Findings includes: On 11/7/23 at 12:20 pm there is only one nurse working on the 3rd floor V8 (ADON). V8 stated, We have one nurse and five CNAs working on the 3rd floor. On 11/7/23 at 3:20 pm V8 (ADON) stated, If V35 (Registered Nurse- RN) passed the medication he should have signed off, if he was here. I don't know if the medication is given. If it is not signed off, it was not done. If staff is not showing up, they will call the scheduler (V10) and let her know. Surveyor showed V8 the nursing schedule provided by facility dated 10/11/2023. V8 stated, I see that V35 (RN) worked from 7 pm on 10/11/23 to 7 AM of 10/12/23. On 11/7/23 at 3:30 pm V10 (staffing coordinator) stated, We don't have agency nurses. In case we are short of nurses, we call people who are working and offer if…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and records review the facility failed to follow policy to account for narcotics for 1 resident (R2) and failed to document medications administration as per ordered by physician for 6 residents (R2, R3, R4, R5, R7, R8) out of 7 residents (R1, R2, R3, R4, R5, R7, R8) reviewed for medication administration. Findings include: A concern regarding medication administration was identified by the surveyors for R1, R2, R4, R5, R7 and R8. The review of the Medication Administration Record (MAR) of R3, R4, R5 and R8 shows that there is no record of medication administered during the night shift. The column where the nurse should sign off is blank. On 11/7/23 at 3:20 pm V8 (ADON) stated, If V35 (Registered Nurse- RN) passed the medication he should have signed off, if he was here. I don't know if the medication was given. If it is not signed off, it was not done. The grievance log was reviewed and documents R8's concern about no nurses and no medications received on 7/10/23. V9 (Social Worker)…

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 maintain medical records that were accurately documented, complete and readily accessible for 1 (R2) of 2 residents reviewed for documentation by failing to a.) provide a signature on a resident's Controlled Drug Receipt/Record/Disposition Form for 3 of 30 entries; b.) failing to document narcotic administration on the Medication Administration Record and c.) failing to provide Controlled Drug Receipt/Record/Disposition Form for the dates of 09/10/23 -10/03/23. Findings Include: R2 was admitted to the facility on [DATE] with diagnosis not limited to Alcoholic Cirrhosis of Liver Without Ascites, Acute Hepatitis C Without Hepatic Coma, Alcohol Dependence, Opioid Dependence, Cocaine Dependence, Cardiac Arrhythmia, Localized Swelling, Mass and Lump, Lower Limb, Bilateral, Bradycardia, Iron Deficiency Anemia, Thrombocytopenia, Liver Cell Carcinoma and Metabolic Encephalopathy. R2 MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 14…

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

Based on observation, interview, and record review the facility failed to ensure that call lights are within reach for six of six residents (R2, R13, R14, R15, R16, and R21) reviewed for call light. Findings Include: On 09/18/23 at 11:27am, R2 noted sitting on the bed with call light not within reach. On 09/18/23 at 11:49am, R13, R14, and R15 observed in the same room with their call lights not within reach and on the floor under their beds. R13 was verbally calling for help to urinate in the urinal. R13 asked the surveyor for help to locate the urinal which was observed under R13's bed. R13 was unable to locate call light and did not understand what the surveyor meant by call light. On 09/18/23 at 11:50am, R16 noted in bed with call light not within reach under the bed. On 09/18/23 at 11:59am, interview conducted with V5 LPN (Licensed Practical Nurse) regarding facility protocol/policy on call light. V5 stated in part that the call light should be kept in reach of the resident, everyone can answer the call light and the urinal should not be under the bed. On 09/18/23 at 12:30 pm…

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 sufficient nursing staff are provided to meet residents needs and services. This failure affected R4, R13, R14, R15, and R21 in the sample reviewed for ADLs (Activities of Daily Living). Findings include: On 09/18/23 at 11:10am, R4 was observed sitting in the wheelchair in the dining area with pants noted to be soaked in-between the legs. V17 CNA (Certified Nurse's Aide) stated R4 should not be sitting in the dining room wet but may be is from the water R4 was drinking. V17 stated R4 is assigned to V18 (CNA). When R4 was shown to V18, V18 moved R4 to the room for incontinent care. V18 stated R4 was last changed around the beginning of the shift as she was busy with another resident care. On 09/18/23 at 11:14 am R4 was moved from the dining room. Upon lifting R4 from the wheelchair with the lifting device to be put in the bed, R4's individualized lifting cloth device was also noted soaked. R4's adult brief was observed wet to the pant in the back. V17 stated in part, Yea it's from urine (referring to 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 follow current standards of infection control practices during incontinent care and following the provision of care for three residents (R11, R21, R22) in the sample reviewed for infection control and prevention. This failure affected R11, R21 and R22 and has the potential to affect all resident residing on the 2nd and 4th floor of the facility. Findings include: On 09/18/23 at 11:32am, observed dirty linen placed on the floor in the bathroom and leg rest noted stored on the floor. V17 CNA stated the wheelchair leg rest belongs to R11. V17 stated the leg rest should not be stored in the bathroom and the dirty linens should be thrown in the dirty linen chute for infection control reasons (control and prevention). V17 stated, I don't know who put them there (referring to the linen and the wheelchair leg rest). The bathroom floor noted with brownish stains. On 09/18/23 at 12:35pm, V12 CNA (Certified Nurse's Aide) was observed removing soiled linen from R21's bed and throwing them on the floor. When V21 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.

Based on observation, interview, and record review, the facility failed to provide sanitary environment free of urine odor; failed to ensure that the facility temperature did not exceed 81 degrees Fahrenheit; and failed to ensure a functional environment free of accidental hazard. This failure affected has the potential to affect all the resident's residing in the facility. Findings include: On 09/18/23 at 11:06am, upon coming out of the elevator to the 4th floor observed the whole floor with urine and foul odor. On 09/18/23 at 11:24 am noted half eaten cookies with blackish and brown particles on the floor and a safety mat between R5 and R6's bed. On 09/18/23 at 11:27am, noted base board on the walls with holes and one drawer missing on the cupboard. On 09/18/23 at 11:39am V21 (Housekeeping) stated he had not cleaned the room and will go back and clean it. R7's bedroom noted with safety mattress on the floor with whitish and brownish particles. On 09/18/23 at 12:21pm, on the 3rd floor shower room the following observation were made: Base board peeling and off the wall, toilet seat…

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 report an injury to IDPH (Illinois Department of Public Health) within regulatory requirements for one resident (R1) reviewed for incident and incident with injury. This failure affected R1 who had an injury while toileting self which resulted in R1 having an acute fracture of the distal phalanx. Finding include: R1 's medical record showed documentation that R1 was admitted to the facility on [DATE] with diagnosis that includes but not limited to fracture of unspecified fracture of shaft of left fibula, Major depressive disorder single episode, specified, Laceration without foreign body unspecified subsequent encounter for closed fracture with routine healing, unspecified multiple injuries subsequent encounter, and Fracture of unspecified phalanx of the left index finger subsequent encounter for fracture with routine healing. On 09/18/23 at 12:15pm, R1 observed sitting on the bed with left index finger blackish in color with a finger (immobilizer). R1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure personal hygiene care and incontinent care was provided for R4, R13 and R21 in the sample of residents dependent on staff assistance for ADLs (Activities of Daily Living). This failure affected R4, R13 and R21 who did not receive appropriate personal hygiene and incontinent care in a timely manner. Findings include: On 09.18/23 at 11:10am, R4 was observed sitting in a wheelchair in the dining area with pants noted to be wet between R4's legs. V17 CNA (Certified Nurse's Aide) stated R4 should not be sitting in the dining room wet but maybe it is from the water R4 was drinking. V17 identified V18 as the assigned CNA to R4. V17 and V18 moved R4 to his room for incontinent care. V18 stated R4 was last changed around the beginning of the shift. At 11:14am, upon lifting R4 from the wheelchair with the lifting device to be put in the bed, R4's lifting cloth device was also noted wet. R4's adult brief was observed wet, and R4's pants were…

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.