Austin Oasis, The

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to display, in a public and accessible location, posters informing residents of their rights to explore or decline community transition under the [NAME] Consent Decree, and their right to be free from retaliation, regardless of their decision on transition. This has the potential to affect all [NAME] Class Members. Findings include: On 03/04/2025 at 10:56 AM, conducted first floor observations at the main entrance and main dining room. No [NAME] Consent Decree postings or signs related to residents' rights to explore community transition with the program. On 3/04/2025 at 11:01 AM, there was no sign at the second-floor nurses' station, in front of the elevator or at the dining room pertaining to the [NAME] Consent Decree. V5 (second floor Nurse) and V7 (second floor Nurse) stated they do not know who the facility works with to help residents transition into the community. V5 and V7 could not locate a sign related to the [NAME] Consent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to follow their policy and procedure by not obtaining a physician's order for 4 residents' (R44, R63, R129, R332) code status and failed to develop a comprehensive person-centered care plan for 2 (R44, R63) out of 2 residents' code status in a final sample of 35 reviewed for advance directives. Findings Include: R44's face sheet shows an admission date of [DATE] and the advance directive section was blank. R44's minimum data set (MDS) dated [DATE] shows R44 is cognitively intact with BIMS (Brief Interview for Mental Status) of 14. R44's order summary report with active orders as of [DATE] shows no physician order for R44's code status. R44's comprehensive care plan does not address R44's advance directive/code status. R332's face sheet shows an admission date of [DATE] and the advance directive section was blank. R332's MDS dated [DATE] shows R332 is cognitively intact with of 15. R332's order summary report with active orders as of [DATE] shows no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to refer 9 (R1, R22, R35, R55, R59 R70, R83, R99, R136) residents to the appropriate state designated authority for a Level II Preadmission Screening and Resident Review (PASARR) evaluation out of 9 residents reviewed for PASARR in a total sample of 35. Findings Include: 1. R22 was admitted to the facility on [DATE] with diagnosis not limited to Multiple Sclerosis, Muscle Spasm, Personal History of Suicidal Behavior, Bipolar Disorder, Schizoaffective Disorder, Bipolar Type and Major Depressive Disorder, Recurrent. R22's Document titled Notice of PASRR Level II Outcome dated 09/26/24 document in part: PASRR Determination: Approved without Specialized Services. This Level II evaluation is good within 90 calendar days of the Notice date listed on the Notice of PASRR Level II Outcome that came with this letter. You fall into the category of having a diagnosis that the PASRR program was designed to assess. Your condition is likely to require expert treatment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complete a quarterly smoking assessment for one resident (R1) and have individualized smoking care plans for independent smokers. This has the potential to affect R1 and all the independent smokers in the facility. Findings include: R1's admission Record documents in part a diagnosis of nicotine dependence. R1's 12/18/2024 Minimum Data Set (MDS) Assessment documents in part that R1 is cognitively intact. On 3/04/2025 at 10:40 AM, R1 was in the smoking patio. R1 was holding a lighter and igniting other residents' cigarettes. At 10:43 AM, V29 (Psychosocial Aide) stated R1 is a smoker and smokes in the smoking patio. V29 stated R1 also volunteers to help other residents during smoke break by assisting residents into the patio and igniting their cigarettes. V29 stated R1 does this in front of staff and does not keep the lighter. At 10:48 AM, R1 stated [R1] typically smokes five to six cigarettes a day. R1 stated [R1] has been helping out during the smoke breaks for the past month by lighting other residents' cigarettes. R1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to label open insulins for 4 [R36, R282, R283, R284] residents on 2 of 8 medication carts reviewed for medication storage in a sample of 35. Findings Include, On 3/4/25 at 9:12 AM, V7 [Licensed Practical Nurse] and surveyor conducted inventory of the second-floor south medication cart observed the following: A plastic open cup with [28] dark green pills. R36's open vail of Basaglar Kwik Pen, inject 12 units at bedtime. R283's Lantus (Glargine Insulin) Pen, inject 20 units one time per day. A label on the pen Refrigerate. [Pen was in top drawer of med cart] R284 's Humalog, inject per sliding scale, before meals and at bedtime. R282's Insulin NPH Isophane and Regular Subcutaneous 70/30, inject 12 units in the morning. On 3/4/25 at 9:20 AM, V7 stated, This morning I did not have any iron supplement pills on my medication cart available. I borrowed from the north cart. The facility has house stock, but I was trying to pass out my morning…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prepare food items listed on menu for pureed diets and prepare adequate food portions as documented on the recipe. This failure has the potential to affect 165 residents receiving pureed and regular diets prepared in the facility's kitchen based on the diet order list dated 03/04/25. Findings Include: On 03/04/25 at 12:00 PM, observed lunch tray line. Regular diets were receiving Sweet and Sour Chicken, Steamed Rice, and Oriental Vegetables. Pureed diets were receiving Pureed Sweet and Sour Chicken, Mashed Potatoes, and Pureed Spinach. V19 (Cook) stated she did not make pureed rice and the pureed diets were receiving mashed potatoes in place of pureed rice. On 03/04/25 at 12:54 PM, surveyor tasted pureed vegetable which was spinach. There was no spinach in the Oriental vegetables. On 03/04/25 at 12:59 PM, V17 (Dietary Manager) stated the pureed diets should have received pureed rice, not mashed potatoes based on the spreadsheets/menus. V17 stated the pureed diets should have received pureed oriental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prepare ground/mechanical soft and pureed food in appropriate diet consistency form. This failure has the potential to affect 10 residents on mechanical soft/ground diets (R15, R19, R26, R36, R39, R60, R79, R81, R82, R95) and 8 residents on pureed diets (R68, R71, R84, R94, R106, R114, R115, R116) prepared in the facility kitchen based on list of residents receiving mechanical soft with ground meat and pureed diets dated 03/04/25. Findings Include: Facility had 10 residents on mechanical soft/ground diets and 8 residents on pureed diets. On 03/04/25 at 12:16 PM, observed V19 (Cook) portioning out food on the tray line. Observed large pan of Sweet and Sour Chicken and smaller container of pureed Sweet and Sour Chicken. V19 stated the regular diets and mechanical soft/ground diets are receiving the same entrée in the same form for lunch. V19 stated a separate ground Sweet and Sour Chicken was not prepared. V19 stated the chicken already comes in diced up. Observed multiple large chunks of chicken mixed in with…

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

Based on observations, interviews, and record reviews, the facility failed to provide double portions as part of the therapeutic diet as prescribed by the physician for 19 (R9, R17, R18, R23, R47, R78, R97, R98, R100, R107, R134, R136, R155, R164, R165, R174, R176, R232, R433) residents reviewed for dining services in a total sample of 35. Finding include: On 03/04/25 at 12:16 PM, during tray line observation observed V19 (Cook) portioning out food onto resident's trays for lunch. V19 stated the serving size for regular diets was 6-ounce ladle Sweet & Sour Chicken, #8 scoop (4-ounces) [NAME] Rice, and 4-ounce ladle Stir Fry Oriental Vegetables. V19 stated the residents with orders for double portions receive a double portion of the white rice (8-ounces total), and a standard portion of the Sweet and Sour Chicken (6-ounces) and Stir Fry Oriental Vegetables (4-ounces). V19 stated only the rice/starch is doubled, not the protein/main entrée or vegetables. On 03/04/25 at 12:17 PM, observed V19 portion out food for double portion diets based on their meal tickets for R47, R97, R134, R174…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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: (1) provide eligible residents and/or resident representatives education regarding the benefits and potential side effects of all available pneumococcal vaccinations; (2) assess eligibility and offer pneumococcal vaccinations to five (R61, R85, R156, R44, R332) of five residents reviewed for pneumococcal vaccinations; (3) update the facility's Pneumococcal Screening and Immunization policy to reflect the recent Centers for Disease Control and Prevention (CDC) Adult Vaccination Schedule and guidance. This had the potential to affect any residents eligible to receive the Pneumococcal vaccinations. Findings include: 1. Review of R61's electronic health record (EHR) revealed R61 was admitted to the facility on [DATE] and is [AGE] years of age with diagnoses that included, but not limited to diabetes mellitus, alcohol abuse, cerebral infarction, and hyperlipidemia. R61's minimum data set (MDS) dated [DATE] shows R61 is cognitively intact with BIMS (Brief…

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

Based on observation, interview, and record review the facility failed to ensure the residents were treated with respect and dignity by not passing out meals to all residents sitting at a table at the same time. These failures affected 3 residents (R27, R43, R125) reviewed during dining in a total sample of 35 residents. Findings include: On 03/04/25 at 12:20 PM, observed R43 and R332 sitting at the same table in the main dining room with R332 eating lunch from his tray. Observed R43 watching R332 eat. R43 did not have a lunch tray in front of her. R43 stated, I'm hungry. Sometimes I have to wait to get my meal. On 03/04/25 at 12:24 PM, observed R27, R35, R125 and R174 sitting at a table in the main dining room. Observed R35 and R174 eating from their lunch trays. Observed R27 and R125 watching R35 and R174 eating their lunch and the staff passing out other resident trays. R35 and R174 did not have a lunch tray in front of them. R27 stated, I wish we were served all at the same time. I'm hungry. R125 stated, I'm hungry. I want my lunch. On 03/04/25 at 12:34 PM, as R35 was eating R35…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure (A) The five administration rights were followed for one [R151] of three [R108, R139] residents reviewed for medication administration in a sample of 35 residents. Findings Include, R151's Physician orders: 6/25/24 Insulin Glargine 100unit/ml, inject 30units daily. On 3/4/25 at 9:40 AM, observed V5 [Licensed Practical Nurse] prepare R151's insulin: V5 administered R151's insulin in the upper left arm. Surveyor observed the open half-filled insulin Glargine vail was labeled with R59's name, no open or expiration date on the vail. On 3/4/25 at 9:46AM, V5 stated, I was aware that I obtained R151's insulin dose from R59's multi use insulin vial, R151 did not have any more insulin. I re-ordered R151's insulin and should be delivered sometime tonight. The facility has an emergency Insulin Box. I am under the weather, and I did not feel like going to the other nursing floor to get the insulin from the emergency Insulin Box. I did not…

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

Based on observation, interview, and record review the facility failed to a.) ensure oxygen tubing and nebulizer mask were labeled and dated, b.) ensure nebulizer supplies were properly stored when not in use to prevent contamination for and c.) ensure oxygen signage was posted for residents receiving oxygen therapy. This failure has the potential to affect 3 (R10, R63, R104) residents reviewed for oxygen therapy in a sample of 35. R10 has diagnosis not limited to Generalized Anxiety Disorder, Heart Failure and Chronic Obstructive Pulmonary Disease. R10's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response. R10's Physician Orders document in part: Oxygen via NC (Nasal Cannula) at 3L (Liters) continuous every shift. Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG (milligrams)/3ML (milliliter) inhale orally two times a day. R10's Care Plan document in part: Focus: R10 has head of bed elevated while in bed or lays on extra pillows to facilitate easier breathing related to diagnosis of COPD (Chronic Obstructive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reviews, the facility failed to document the information on the resident's (R332) COVID-19 vaccine and failed to document if education was provided regarding the benefits and potential risks associated with the COVID-19 vaccine to 3 (R61, R156, R332) out of 5 residents reviewed for COVID-19 immunizations in a final sample of 35. Findings include: On 3/5/25 at 9:24 AM, R61, R156, and R332's electronic health records (EHR) were reviewed for immunizations. R61 and R156 revealed both refused the COVID-19 vaccine. R332 had no documentation regarding each dose of COVID-19 vaccine administered to R332 or if he did not receive the COVID-19 vaccine due to medical contraindications or refusal. R61, R156, and R332's EHR also do not have documentation if education was provided to them or their representatives regarding the benefits and potential risks associated with the COVID-19 vaccine. There were no COVID-19 consents found in R61, R156, and R332's EHR. On 3/6/25 at 10:35 AM, Surveyor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to administer right dosage of a prescribed medication as per physician order for one resident (R3,) out of three residents reviewed. This failure affected R3 who has a physician order to receive Ibuprofen oral tablet 800mg (milligrams) as needed every eight (8) hours for pain but was administered 600 mg instead with potential that R3's pain may not be controlled. Findings include: R3's medical record admission Record showed that R3 was admitted to the facility on [DATE]. Listed diagnosis includes but not limited to chronic obstructive pulmonary disease, bipolar disorder, Anemia, progressive vascular leukoencephalopathy and anogenital herpes viral infection. On 12/16/24 at 1:05pm, R3 was observed on the 4th floor at the nurse's station requesting for pain medication Ibuprofen from V13 LPN (Licensed Practical Nurse). V13 checked the order and proceeded to prepare the medication. V13 looked for the medicine it was unavailable. V13 found…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 proper sanitation in the kitchen to prevent food-borne illnesses; and failed to ensure that staff store their food and personal items out of the facility kitchen used for residents. These failures have the potential to affect all 177 residents receiving an oral diet in the facility. Findings include: On 10/15/24 at 12:40 pm, Surveyor and V3 (Dietary Manager) toured the facility's kitchen and observed poor cleaning all over the entire kitchen area (food on kitchen floor, trash on kitchen floor, soiled floors, soiled stagnant draining water, and dirty walls). V3 explained that is the entire kitchen staff responsibility to maintain cleanliness in the kitchen. Surveyor and V3 observed a staff coat hanging on the food rack in the dry storage area. When Surveyor asked V3 regarding the coat hanging in the clean utility area V3 stated, That is an employee coat. It (referring to the employee coat) should be in the locker room. That doesn't should not be in here. When V3 was asked regarding what could happen 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.

Based on observation, interview, and record review, the facility failed to ensure that the dumpster was closed and fee from overflowing trash. These failures have the potential to affect all 178 residents residing at the facility. Findings include: On 10/15/24, V2 (Director of Nursing , DON) stated that the facility census was 178 residents at the facility. On 10/16/24 at 2:15 pm, Surveyor and V24 (Dietary Aide) toured the facility dumpster area and observed the dumpster area open with two broken lids and overflowing with trash. V24 stated, Someone broke this (referring to the broken dumpster lids). They (referring to garbage pickup) come and get the trash every other day. They (referring to garbage pickup) should be here today. When V24 was asked regarding who is responsible for the dumpster lids to be repaired V24 stated, V21 (Maintenance Director). When V24 was asked regarding the importance of the dumpster lids to remain close V24 stated, So that it (referring to the dumpster) does attract rodents to the facility. On 10/17/24 at 1:04 pm, V21 (Maintenance Director) 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.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure that the facility's kitchen is free of insects. This failure has the potential to affect all 178 residents in the facility. Findings include: On 10/15/24 at 12:40 pm, Surveyor and V3 (Dietary Manager) toured the facility's kitchen and observed poor cleaning all over the entire kitchen area (food on kitchen floor, trash on kitchen floor, soiled floors, dirty stagnant draining water, and soiled walls). Surveyor and V3 also observed an infestation of flies (fruit flies, gnats) throughout the kitchen in the food prep area where V18 (Dietary Aide) was preparing sandwiches for residents to eat and in the pots and pans area where V24 (Dietary Aide) placed pots and pans dishes that were cleaned. V3 stated that V3 sees flies infest the kitchen daily and that V3 has seen roaches in the kitchen near the pots and pans area. V3 stated that pest control last visited the kitchen about 2 weeks ago however the flies and roaches are still an issue in the kitchen. Surveyor…

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

Based on observation, interview and document review the facility failed to provide a safe, functional, sanitary and comfortable environment for residents and staff on 4 of 5 resident floors (2nd, 3rd, 4th, and 5th floors) of the facility. Findings include: The following was observed during tour of facility on 7/5/24 with V3 (Housekeeping staff). R6's room was observed with extensive wall damage at the wall/floor junction on all 4 walls. R7's toilet room was observed with heavy ceiling plaster damage on entire ceiling. The plaster was wet and had black mold. The plaster/drywall was sagging . On 7/5/24 at 10:22AM R7 stated it has been in that condition for a long time. R8's room was observed with plaster wall damage at the floor/wall junction next to the window. R10's room was observed with extensive plaster wall damage at the floor/wall junction on all 4 walls. R1's room was observed with wet and collapsing plaster damage above the room window at the ceiling wall junction. The plaster had black mold like growth on the surface. Walls of room had drywall damage on all 4 walls. R20'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 document review the facility fails to maintain an effective pest control program so that the facility is free of insects and rodents on 5 of 6 floors of the facility. Findings include: The following was observed during tour of facility on 7/5/24 with V3 ( Housekeeping staff). R9's room was observed with a live adult roach on the floor in the toilet room. R12's room was observed with a rodent glue board on floor of outside wall, the glue board had 3 dead adult roaches attached. Mouse droppings were observed in the corner of floor next to the window. On 7/5/24 at 10:37AM R12 stated there are roaches and mice in our room all the time. R13's room mouse droppings in the toilet room on the floor. R15's room mouse droppings on the floor in room. Two dead roaches on the floor in the toilet room. On 7/5/24 at 10:55AM R15 stated there are mice and roaches in my room at night. I don't like them in here. R18's room was observed with 4 adult roaches on the floor behind the bedside cabinet…

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

Based on observation, interview and record review the facility failed to ensure food in the refrigerator and freezer was labeled with a date indicating when the item was placed into the refrigerator/freezer, a thermometer was inside of the freezer, and expired food was discarded on or before the expiration date. These failures have the potential to affect 163 residents in the facility who are receiving an oral diet. The findings include: On 5/13/2024 at 9:17am while in the walk-in refrigerator, observed 1 box of chicken base cups- the date on the box was unreadable. On 5/13/2024 at 9:20am surveyor checked the thermometer on the outside of freezer; temperature reading of minus 3 degrees. Surveyor asked V8 (Dietary Manager) to locate the thermometer inside of the freezer. V8 stated there is no thermometer in the inside of the freezer. V8 stated, yes there should be a thermometer in the inside of the freezer. V8 stated a thermometer is needed inside of the freezer to have an accurate temperature inside of the freezer just in case the thermometer on the outside of the freezer goes out…

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

Based on observation, interview and record review the facility failed to ensure the outside dumpster lid was closed and garbage bags were placed into the dumpster to prevent pests and rodents from entry into the garbage bin. This failure has the potential to affect all 163 residents residing in the facility. Findings include: The (05/13/2024) facility census was 163. On 05/13/2024 at 9:55am escorted to the outside dumpsters by V8 (Dietary Manager), observed four dumpsters for the facility. Observed the red dumpster overfilled with trash bags which caused the lid of this dumpster to be opened. Observed a dumpster with three lids, the middle lid was opened. Observed a plastic trash bag sitting on the side of the dumpster. On 5/13/2024 at 9:56am V8 (Dietary Manager) stated the plastic trash bag sitting on the ground next to the dumpster contains charcoals. On 5/13/2024 at 10:00am V8 (Dietary Manager) stated I don't know what was going on this weekend, the staff was just overfilling the trash dumpsters. The garbage disposal company comes to the facility every day to empty the dumpsters.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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: R76's Brief Interview for Mental Status (BIMS) dated shows that R76 has a BIMS score of 15 which indicates that R76 is cognitively intact. R76 has a diagnosis which includes but not limited to: Obesity, major depressive disorder, generalized anxiety, paranoid schizophrenia and essential hypertension. On 05/13/24 at 11:05 am, Surveyor observed R76's room with the window open about six inches and without a window screen. Surveyor observed five flies flying in R76's room. R76 stated that R76 did not know how long R76's window has been without a window screen. On 05/14/24 at 1:27 pm, Surveyor observed R76's room remain with the window open about six inches and without a window screen. Surveyor observed five flies still flying in R76's room. On 05/15/24 at 9:35 am, V17 (Maintenance Director) stated that all residents windows should have a window screen. V17 explained that windows screens are in place to prohibit flies and other insects from entering the resident's window. V17 then explained that 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 the laundry chute in the hallway of the second floor and the fourth floor, are locked to prevent residents from falling through the chute to the ground floor. This failure has the potential to affect all 40 residents on the second floor, and all 44 residents on the fourth floor, reviewed for safety from environmental hazards. Findings include: On 5/13/24 at 11:15am after the entrance conference, V1 (Administrator) presented the facility census as 163 residents as follows: Second Floor - 40, Third Floor - 37, Fourth Floor - 44, Fifth Floor - 42. On 5/13/24 at 10:59am on the fourth-floor hallway, the laundry/linen chute was observed to be unlocked. V15(CNA/Certified Nurse Assistant) was called to see the linen chute. V15 stated It's supposed to be locked for the protection of the residents, so no one will fall and hurt themselves. I used it this morning and it's always likes this. I don't have a key and cannot lock it. I will call maintenance. On 5/13/24 at 11:05am, V17(Maintenance Director) came to…

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

Based on observation, interview, and record review, the facility failed to have sufficient Psychiatric Rehabilitation Services Coordinators/PRSC to meet the individualized psychosocial and mental health needs of residents. This failure has the potential to affect all 49 residents with diagnoses of Severe Mental Illness and other residents in the facility who require psychosocial support. Findings include: On 5/13/24 at 11:15am after the entrance conference, V1 (Administrator) presented the facility census as 163 residents as follows: Second Floor - 40, Third Floor - 37, Fourth Floor - 44, Fifth Floor - 42. V1 later presented the list of 49 residents with diagnoses of Severe Mental Illness (SMI). On 5/13/24 between 10:30am and 12pm, residents including R47, R58, and R83 were observed just sitting in the room with flat affect. R47, R58, and R83 all stated that they have not spoken with any Counselor or PRSC in a while. Nursing staff, including V9(Licensed Practical Nurse, LPN) and V15(CNA/Certified Nurse Assistant) were observed and interviewed on the fourth floor regarding the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to label an opened multi dose vial and discard an expired opened multi dose vial. These failures have the potential to affect all 44 residents on the 4th floor and all 42 residents on the 5th floor, potentially affecting a total of 86 residents at the facility reviewed for labeling and storage of drugs and biologicals. Findings include: On [DATE] at 9:56am, with V9 (Licensed Practical Nurse/LPN), during observation of medication storage on the 4th floor, a house stock vial of Tuberculin PPD (purified protein derivative) was observed opened with no label of when it was opened. The tuberculin label states that once opened discard after 30 days. When asked the purpose of labeling the Tuberculin PPD once opened, V9 (LPN) replied, Because it expires 30 days after opening so the test may not be accurate. On [DATE] at 10:07am, with V10, (LPN), during observation of medication storage on the 5th floor, a house stock vial of Tuberculin PPD was opened…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to you provide appropriate Personal Protective Equipment (PPE) supplies for two residents (R22 and R86) with Enhance Barrier Precautions; and failed to display Enhance Barrier Precaution sign for one resident (R8). This failure affected all 37 residents on the third floor and all 42 residents on the fifth floor reviewed for infection control. Findings include: On 05/13/24 V1 (Administrator) presented a facility census of 37 residents on the third floor and 42 residents on the fifth floor at the facility. On 05/13/24 at 10:26 am, R26, R33 and R86's room was observed with a sign displayed Enhanced Barrier Precautions . Providers and Staff must also wear gloves and gown for the following high contact resident care activities: Dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use: central lines, urinary catheter, feeding tube, tracheostomy, wound care: any…

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

Based on observation, interview, and record review, the facility failed to ensure that the community shower room on the fourth-floor is maintained in a sanitary manner and in good repair, and failed to ensure that the fifth-floor bathroom and day room are kept in good repair. These failures have the potential to affect all 44 residents on the fourth floor and all 42 residents on the fifth floor. Findings include: On 5/13/24 at 11:00am after the entrance conference, V1 (Administrator) presented the facility census which shows that there are 44 residents on the fourth floor and 42 residents on the fifth floor. On 5/13/24 at 10:50am during observation of residents on the fourth floor, the community shower room was observed to be locked. V16 (Housekeeper) was asked to open the shower room. Together with V16, the surveyor observed the following: The toilet water tank was partially covered with a smaller cover that has brown stains that left about one-third of the tank open; The only shower stall in the shower room has blackish brown substance on the wall tiles closer to the front left…

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

Based on Observation, interview and record review the facility failed to administer scheduled medications in the schedule time frame. This failure affected 4 residents (R1, R2, R3, and R4) reviewed for medication administration. This failure has the potential to cause negative outcome to a resident's physical, mental, psychosocial health, or well-being. Findings Include: On 4/30/24 at 12:00 pm, surveyor observed V3 LPN (License Practical Nurse) passing medications to residents. Surveyor inquired to V3 if afternoon medications were being passed. V3 stated, No I'm passing 9:00 morning meds. I was call in to work and didn't get here until 9:00 this morning. I normally work second shift 3 to 11p. Surveyor inquired to V3 how many residents V3 is taking care of. V3 stated, I have 23 residents. V3's timecard preview report for 4/30/24 clock in time is 9:02 am. R1's admission diagnoses include, but not limited to cerebral infarction, diabetes, hypertension, rhabdomyolysis, and depression. On 4/30/24 at 12:20 pm, surveyor observed V3 administer R1's morning medications of Aspirin, Losartan,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 light is within the reach for four residents (R1, R4, R15 and R16) reviewed for call lights. Findings include: On 02/14/24 at 10:38am R4 observed in the room sitting on the chair, R4 stated I need you (referring to the surveyor) to call someone for me to help me get the nurse, when the surveyor asked R4 to use the call light, R4 stated is over there pointing to the wall across from the bed. R4 stated in part that there is no need to use it any way because it does not work. V3 (Maintenance Director) who was present at the time was asked to test the call light for functioning and it was confirmed that the call light was not functioning. At 11:06am, R1 was noted in bed with call light not within reach. When V15 who identified self as the assigned CNA (Certified Nurse Aide) was made aware and shown the observation and was asked about the facility protocol and policy on call light. V15 stated it should be placed within reach of the resident attached to the linen. On 02/15/24 at 10:05am, R15…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review the facility failed to ensure that the call light system was in a working condition for residents to call for staff assistance. This failure has the potential to affect all the resident residing on the 2nd and 4th floor of the facility. Findings include: On 2/15/24 at 10:05am, the shower room on the 4th floor call light was non-functional when pulled, V22 CNA (Certified Nurses Aide) present at the time stated that the light has not been working it does not light up over the door or make any sound at the nurse's station. At 10:57am, V7 (MDS/Care Plan Coordinator) who identified self as the 4th floor supervisor stated that the call light system as being faulty and V1 (Administrator) is aware. When asked about how long the call light system has been faulty, V7 stated I will have to check with V1 before I (V7) can give you (surveyor) the answer. At 11:09am, when this observation was brought to V3 (Maintenance Director)'s attention. V3 stated that the shower rooms and certain room on the 2nd floor and the 4th floor call light wires are…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safe and functional environment in regard call light for resident's staff assistance. This failure affected all the residents in Rooms 202, 204, 207, 209, 210, 211, 212, 214, 215, 216, 220, 406, 407, 408, 409, 410, 420, 42 and has the potential to affect all the residents on the 2nd and 4th floor of the facility. Findings include: On 02/15/24 at 10: 05pm to 12: 15pm, the following observation was made regarding call light not being in working order: -Call light does not light up on the call light dashboard in the nursing station and over the door bulb did not light up in multiple rooms. -Rooms 202, 204, 207, 209, 210, 211, 212, 214, 215, 216, 220, 406, 407, 408, 409, 410, 420, 421. -At 10:15am, V16 LPN (Licensed Practical Nurse) stated that we all (referring to the Staff) knows some of these call lights don't work and it does not light up on the dashboard. V4 stated that the facility wiring is off and V1 (Administrator) is aware of the problem, At 12:15pm, V4 ADON (Assistant Director of Nurses)…

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

Based on observation, interview, and record review the facility failed to provide privacy during glucose monitoring and insulin administration for one resident (R23) reviewed for resident rights in the sample. This failure affected R23 whose glucose monitoring, and insulin administration was done in the hallway at the nursing station while peers are present and watching. And has the potential to affect nine residents identified as needing glucose monitoring and insulin administration. Finding include: On 02/15/24 at 1:15pm, V5 LPN (Licensed Practical Nurse) was observed performing blood glucose monitoring for R23 in the hallway by the nursing station while R20 and R21 were present and watching the task being done. At 1:22pm, V5 proceeded to administer insulin medication on R23 abdomen exposing R23 abdomen by asking R23 to lift the clothing while R20 and R21 were still watching. When the surveyor asked V5 about the facility policy on medication administration and privacy resident rights. V5 stated that I (V5) could have taken (R23) to the room. At 3:19pm, V2 DON (Director of Nursing)…

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

Based on interview and record review the facility failed to report to IDPH (Illinois Department of Public Health) within the required regulation time, unwitnessed fall with injury for one resident (R15) in the sample reviewed for fall with injury. This failure affected R15 who had an un-witness fall and was bleeding from laceration to the right side of the head. R15 was sent to the hospital where R15 received seven staples application to laceration site, this has the potential to affect all 158 residents residing at the facility. Findings include: R15's medical record showed listed diagnosis that includes Schizophrenia, Unspecified, Acute Kidney Failure, Adjustment disorder with mixed anxiety and depressed mood, Bradycardia, and Vitamin D deficiency. R15's medical record documentation showed that R15 had a fall on 02/09/24 with bleeding noted from the head and was sent to the local hospital where seven (7) stitches were applied to close the laceration from the head. According to facility investigation report, V24 CNA (Certified Nurse's Aide) statement dated 02/09/24 documented 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.

Based on observation, interview, and record review the facility failed to ensure that physician order on medication administrations was followed, failed to document insulin administration and blood glucose monitoring as late. This failure affected R23 whose glucose monitoring (accu-check) was done late, and insulin medication was administered. This also have the potential to affect eight other residents identified as dependent on licensed staff to monitor their blood sugar on the 5th floor. Findings include: On 02/15/24 at 1:15pm, R23 came to the nursing station asking V5 to perform glucose monitoring, V5 proceeded in performing the task and it read 162mg/dl. At 1:22pm V5 proceeded in administering one unit of insulin lispro per sliding scale. The surveyor asked R23 whether R23 has eating lunch and R23 stated yes. V5 turned to R23 and stated why did you eat without coming here first to check your blood sugar because you (Referring to R23) know the routine you are not supposed to eat before taken your blood sugar (referring to blood sugar monitoring). The surveyor asked V5 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 privacy was afforded to one of four residents (R14) with urine collection bag in the sample reviewed for privacy. This failure affected R14 whose urine bag was visibly exposed to the hallway and with no privacy. Findings include: On 02/15/24 at 1:09pm, R14 was observed in bed with urine draining bag noted visible to the hallway and not covered with a privacy bag. V18 CNA (Certified Nurses Aide) who was present at the time stated the urine collection bag should have a privacy bag and should not be placed where everyone can walk by and notice that R14 has a urine bag for privacy reasons. R14's diagnosis list includes but not limited to Benign Prostatic Hyperplasia without lower urinary tract symptoms, presence of urogenital implants, schizoaffective disorder unspecified, Acute renal failure unspecified and insomnia. V2 DON (Director of Nurses) stated that the urine drainage bag should be kept in a privacy bag for privacy of the resident. The facility policy on Resident Rights presented documented in…

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

Based on interview and record review, the facility failed to ensure one resident (R2) remained free from verbal abuse. This failure affected one resident (R2) out of three residents reviewed for abuse. Findings include: R2's Face sheet documents that R2 has a diagnosis which include but not limited to: chronic kidney disease, dependence on renal dialysis, unspecified protein-calorie malnutrition, malignant neoplasm of liver primary, malignant neoplasm of pancreas peripheral vascular disease, anemia, anorexia, ascites, essential hypertension, acute kidney failure, hyperkalemia, anuria, and oliguria, hydronephrosis with renal and ureteral calculous, weight loss. R2's Brief Mental Status Interview (BIMS) dated 12/21/23 documents R2 has memory problems. The facility's initial Reported Incident submitted by the facility dated on 12/23/23 at 2:32 pm, by V1 documents in part: On 12/23/23 the administration was notified by a facility nurse that a representative from the local hospital called and alleged that a nursing aide accompany R2 for a dialysis appoint was verbally aggressive towards…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a resident (R1) who depend on staff's assistance for their ADL (Activities of Daily Living) care received showers, nail care and grooming. This failure affected one out of three residents reviewed for ADL care and showers. Findings include: R1's Brief Interview for Mental Status (BIMS) dated 11/28/23 shows that R1 has a BIMS score of 9 which indicates that R1 has some cognitive impairments. R1 was able to answer questions appropriately during R1's interview. R1 has a diagnosis which includes but not limited to: quadriplegia unspecified, type 2 diabetes mellitus without complications, malignant neoplasm of pancreas, neuromuscular dysfunction of bladder, pressure ulcer of left hip stage 4, pressure ulcer of right heel stage 4, pressure ulcer of sacral region stage 4, neurogenic bowel , major depressive disorder, abnormal posture, covid 19, dysphagia oral phase, weakness, anemia. On 01/02/24 at 10:45 am, R1 was observed in room in bed awake and alert. R1 was observed ungroomed with R1's hair matted,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document review the facility failed to provide a clean homelike environment, this failure has the potential to affect all residents Finding include: On 12/15/23, 12/16/23 and 12/17/23 the facility corridor floors on the 2nd, 3rd, 4th, and 5th floor were observed with black soil encrustation in the corridor floor wall junctions and at the floor of resident metal door jams of resident room doors. The facility two passenger elevators were observed with heavy black encrustation in the door tracts at the floor. On 12/17/23 at 10:40AM, V1 (Administrator) stated, we have full time housekeeping staff during week and on weekends cleaning resident rooms and common areas. We are currently stripping resident floors to rewax . V1 stated, I will have staff clean elevator door tracts and the floor wall junctions on all floors. Facility policy titled Housekeeping Guidelines state including:11. Cleaning A. All horizontal surfaces will be cleaned daily and as needed with approved disinfectant.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that residents remain free from staff to resident physical abuse (R2) and staff to resident theft (R3) for two of two residents reviewed for abuse and theft. Findings include: R2's medical record (Face Sheet, MDS-Minimum Data Set) documents R2 is a moderately cognitively impaired [AGE] year-old admitted to the facility with diagnoses including but not limited to: Hemiplegia and hemiparesis following cerebral infarction right dominant side, Type 2 diabetes mellitus, Aphasia following cerebral infarction, and Dysphagia following cerebral infarction. On 11.17.2023 at 4:11 PM, R2 said V3 (Former CNA-Certified Nursing Assistant) slapped her twice on her left arm. On 11.17.2023 at 11:20 AM, V2 (DON-Director of Nursing) said, I believed her (R2) when she said V3 (Former CNA-Certified Nursing Assistant) slapped her. On 11.16.2023 at 3:58 PM V5 (MDS Coordinator/Licensed Practical Nurse) said she was the nurse responsible for R2's care on 10.8.2023 when…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 protect the resident's right to be free from physical abuse by other residents for two (R1 and R4) out of four residents reviewed for abuse. This incident resulted in one (R4) resident having a swollen forehead and bruised eye. Findings include: R4's MDS Section C (07/26/2023) documents in part: BIMS score of 15. Which means R4 is cognitively intact. R4's Care plan documents in part: Medical Diagnosis: violent behavior, psychotic disturbance, mood disturbance, and anxiety, schizophrenia, schizoaffective disorder, bipolar type, depression, anxiety disorder, psychotic disorder. On 09/27/2023 at 11:00 AM, surveyor observed R4 sitting in his room. R4 stated that R3 took his iPad and threw it on the ground and started punching him. R4 stated that he had a swollen forehead and bruised eye. R4 stated that the facility sent R3 to the hospital. R3's MDS Section C (08/23/2023) documents in part: BIMS score of 15. Which means R3 is cognitively intact. R3's Care plan documents in part: type 2 diabetes mellitus with diabetic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review of records the facility failed to provide residents comfortable environment due to insufficient and inefficient air conditioning system. And failed to follow policy in identify high risk residents during extreme heat. These failures affects all 159 residents living in the facility that are at potentially at risk of health-related due to extreme heat. Findings include: On 8/24/2023 at 1:10 PM, V2 (Maintenance Director) stated that an outside company will be coming in the facility to provide portable air conditions. At 1:24 PM, V1 (Administrator) stated that the company that regularly check facility main air conditioning system came earlier today (8/24/2023) and told him that in order to fix the problem they have to shut both chillers off so there will be no air condition for the whole building. V1 came back and said that the issue with facility's main air condition was not today (8/24/2023) but was already having problem yesterday (8/23/2023) submitting report from outside vendor identifying the problem. At 1:31 PM, V3 (Project Manager)…

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

Based on observation, interview, and record review the facility failed to follow their recipes and give adequate portion sizes. This failure has the potential to affect all 163 residents receiving food prepared in the facility's kitchen. Findings Include: On 04/05/23 at 10:08 AM, V13 (Cook) stated that 1 portion of ham is equal to four slices of ham to yield a 3-ounce portion. V13 stated that she has 8 residents on a pureed diet. Observed V13 count off the number of slices of ham as V13 put them into the blender. V13 stated, I put 16 slices into the blender. Observed V13 add 8 - 3 ounce ladles of ham broth to the sliced ham in the blender and then press the on button. Observed the mixture to be very watery. V13 stated that because the consistency was so thin, V13 needed to add thickener to the mixture to make it thicker. Observed V13 add 4-1 ounce ladle of food thickener to the watery ham mixture one ounce at a time until desired consistency was reached. On 04/05/23 at 10:26 AM, surveyor asked V13 if V13 has access to recipes. V13 stated, there are no recipes for me to follow, 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.

Based on observation, interview and record review, the facility failed to a.) ensure food items were properly labeled and dated; b.) the facility failed to clean ice machine; c.) the facility failed to ensure that cook-service ware were air dried after being sanitized; d.) facility failed to reheat prepared pureed food to 165 degrees. These deficient practices have the potential to affect all 163 residents receiving food prepared in the facility's kitchen. Findings include: On 04/04/23 at 9:24 AM, during initial kitchen tour surveyor with V6 (Food Service Manager), surveyor observed the kitchen ice machine door not fully closed. Surveyor opened and closed the ice machine door and observed that the ice machine door did not fully close or make a tight seal. V6 acknowledged that the door of the ice machine did not close all the way. Surveyor observed the inside of the ice machine with drips of condensation pooling in circles and areas of dark gray-black substance on the top ceiling of the ice machine. V6 stated, that looks like mildew or mold and the risk is that it could drop 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 observation, interview and record review, the facility failed to ensure garbage and refuse were disposed of properly by not closing the lids of the dumpsters outside the facility. This deficient sanitation practice has the potential to affect all 164 residents who reside in the facility. Findings include: On 04/04/23 at 10:11 AM, an observation of the outside garbage dumpster was conducted with V6 (Food Service Manager). Surveyor observed the lid of the outside garbage dumpster fully opened. On 04/04/23 at 10:12 AM, V6 stated the lids of the dumpster should be closed when not in use and that leaving the lids open is a hazard because rodents could be attracted to the garbage in the dumpster and get into the dumpster. On 04/04/23 at 1:30 PM, surveyor observed outside garbage dumpster lid opened. On 04/05/23 at 11:21 AM, V10 (Assistant Administrator/Housekeeping Supervisor) stated the outside dumpster lid should be kept closed to keep bugs and pests from getting inside the dumpster which could cause an infestation. Kitchen Facility policy titled, Garbage Disposal undated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a safe system of narcotic storage/disposition for four (R26, R50, R22, R57) residents, failed to accurately reconcile controlled medications for one (R147) resident reviewed for narcotic storage and labelling in two of four medication carts reviewed. Findings include: On 4/4/2023 at 10:58am, during medication storage and cart inspection with V4(Licensed Practical Nurse-LPN) on the fifth floor, observed several narcotic medications bingo cards containing residents' medications with security blister backs opened/broken, then taped up. Observed with V4, security seal broken on medications for R26, R50, R22 as follows: -R26's medication Ativan tablet 0.5mg, #30 on bingo card security seal was broken, then taped back to hold the medication in. - R50's medication -Ativan 1MG, open bingo card, #-7,8, 5, 13, 9 27, 28, security seal was broken, then taped back to hold the medication in. On another bingo card of Ativan 1Mg, security seal broken on bingo card number 8 & 9, then broken seal taped to hold 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 wheelchair arm rest for 1 (R4) and arm rest pads for 2 (R12, R15) of seven residents reviewed for accommodation of needs. Findings include: On 04/04/23 at 11:41AM, observed R4 sitting in wheelchair with right arm resting on right arm rest, left arm hanging down toward R4's lap tipping R4 slightly forward and R4's left arm rest missing from R4's wheelchair. R4 stated his left arm brace has been missing for a long time and R4 would like it replaced. On 04/04/23 at 11:58 AM, V5 (Restorative Director/Licensed Practical Nurse) stated R4 has a customized chair and that V5 was not aware of anything being wrong with R4's wheelchair. V5 stated R4 can transfer himself from R4's bed into R4's wheelchair but needs the side of the wheelchair open without the arm rest for him to transfer himself and that the staff then puts the arm rest back on after R4 has transferred himself into R4's wheelchair. V5 stated the CNA and the restorative aide told V5 that R4's left arm rest bar was on R4's wheelchair this morning.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 address advance directives with residents and ensure documentation of advance directives status for two residents (R140, R132) reviewed for Advance Directives. This failure has the potential to effect 32 residents reviewed. Findings include: On [DATE] at 11:40am, R140 was observed in room and was alert to person and said, I am ok. On [DATE] at 12:05pm V2(Director of Nursing) said that Social Services are responsible of getting residents to signature the PLOST (Physician Orders for Life-Sustaining Treatment) forms on admission. V2 said after the resident signs the PLOST form, the form is given to V2, then V2 gets the nurse practitioner of the physician to sign it. Once the form is signed, V2 puts it in the physician orders, and it automatically updates on the face sheet and shows what care a resident should receive in case of an emergency. V2 said advance directives are used for life saving procedures and they left Nursing staff know what care 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, facility failed to follow their policy to ensure residents are free from physical abuse by providing necessary care in services thus resulting in a female resident having injuries of unknown origin for 1 (R24) out of 32 in the sample residents reviewed for abuse. Findings include: R24's Face sheet dated 4/4/23, documents in part: Diagnosis- catatonic and paranoid schizophrenia, dementia with behavioral disturbance. On 04/04/2023 at 11:00 AM, surveyor observed R24 laying on her bed. Surveyor asked R24 if he can speak with her but she (R24) stated, Just get out. R24's MDS(Minimum Data Set) dated 4/20/23 section C, Cognitive Patterns: Documents in part BIMS score assessment not complete due to R24's cognitive impairment. R24's cognitive skills score for daily decision making indicate cognition is severely impaired. R24 has memory problem for short term and long-term memory. R24 is unable to complete brief interview for Mental Status. R24 has inattention and disorganized thinking. On 04/04/2023 at 12:30 PM, V26 (Licensed Practical Nurse) stated, I…

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

Based on observation, interview, and record review the facility failed to provide an environment free from accident hazards by a.) having an exposed light bulb without a cover and no ability for one resident (R102) to turn the light on and off, b.) not providing supervision or monitoring for one resident (R147) while shaving. These failures affected two (R102, R147) of seven residents reviewed for potential accidental hazards in the survey sample of 32 residents. Findings include: On 04/04/23 at 11:01 AM, observed exposed light bulb installed on the wall over R102's bed without a light cover or pull cord and no overhead light near R102's bed. R102 stated he uses the light at night so he could see. R102 stated, I turn the bulb with my hand to get it on and at night when I turn the light off the light bulb is really hot, so I need to wet my fingers with my spit, so I don't burn my fingers. R102 stated he asked maintenance staff back in January 2023 to fix his light but no one had gotten to it yet. On 04/05/23 at 12:43 PM, V11 (Maintenance Assistant) stated light bulbs should have 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 A) follow their infection prevention and control policy when staff entered a room of one [R61] resident on transmission-based precautions without the appropriate personal protective equipment [PPE], and B) staff failed to perform hand hygiene after touching high touched areas in the isolation room for one [R61] of 32 residents in the sample reviewed of transmission-base precautions. Findings include, On 4/5/23 at 8:30 AM, surveyor observed V18 [Certified Nurse Assistant] walk directly into R61's room with R61's breakfast tray. V18 did not apply any appropriate PPE. V18 was touching R61's personal items moving them on the bedside table to place down the breakfast tray. Also, V18 touched the bed adjusting handle at the foot of R61's bed to rise the head of the bed. V18 exited R61's room without hand washing or applying alcohol gel. On 4/5/23 at 8:35AM, V18 stated, I know R61 is on isolation, but I only went in to give R61 their breakfast tray, I did not provide any personal care. I moved some of R61'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.