Avantara Lincoln Park

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure wound care dressing was in place and intact for 1 (R2) out of 3 residents reviewed for wound care. Findings Include: On 2/2/25 at 10:25 AM, Surveyor entered R2's room with V7 (Licensed Practical Nurse). R2 was lying in bed alert and able to verbalize needs. R2 stated that R2's incontinence brief was soiled and needed to be changed. R2 was unable to verbalize when the last time R2's incontinence brief was changed. R2 stated, I can't tell you how long, but I've been uncomfortable for a while. Surveyor and V7 checked R2's incontinence brief and noted to be saturated with urine and feces. R2's incontinence under pad was also wet. R2's sacral open wound had no dressing in place. V7 stated that the wound is open to air. V7 stated that if a dressing falls off, the nurse should provide wound treatment and apply wound dressing as ordered. On 2/2/25 at 10:36 AM, interviewed V8 (Certified Nursing Assistant/CNA) and stated [V8] is the CNA…

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

Based on observation, interview, and record review the facility failed to provide food at an appetizing temperature for three (R7, R8, R9) of three residents reviewed food temperatures. Findings include: On 02/02/25 at 9:25 AM, R8 lying in bed eating breakfast. R8 stated the hot food is always cold. Observed R8 had consumed 100% hot cereal, 0% eggs, 0% sausage links, 0% toast. R8 stated the eggs are nasty and I couldn't eat them because they are so cold. R8 stated that cold food is not appealing, and that is why R8 won't eat it. On 02/02/25 at 9:27 AM, R7 stated, the food here is always cold. R7 stated the eggs were cold this morning but R7 ate them anyway because R7 was hungry. R7 stated hot food being cold is not just a problem with today's meal, it is a problem with a lot of the meals. R7 stated, I'm hungry so I just eat the food even if it is cold. On 02/02/25 at 9:55 AM, R9 stated the food here is always cold. R9 stated today R9 received eggs and sausage for breakfast. R9 stated the eggs were cold and the sausages were warmish. R9 stated R9 has been here for approximately 6…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policy procedures, failed to ensure that admission fall risk assessments are completed and include a score with actual risk, failed to ensure that Nursing staff are aware of residents at risk for falls, failed to ensure that Nursing staff are aware of resident fall prevention interventions, failed to implement fall prevention interventions, failed to ensure that alarms (in use) are functioning properly, failed to ensure that predisposing factors which contributed to a fall are included on the incident report, and/or failed to provide supervision to three of three residents (R2, R3, R4) reviewed for falls. These failures have the potential to affect 224 residents. Findings include: The (11/6/24) facility census includes 224 residents. On 10/24/24, the State Agency received allegations including a resident fall. R4's diagnoses include dementia, Parkinson's disease, lack of coordination, and abnormalities of gait/mobility. R4's (7/24/24) admission fall risk evaluation was not completed (Did the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to properly assess, monitor, and evaluate one (R2) resident after a fall incident on 3/13/24 and 5/18/24. These failures could potentially affect one (R2) of three residents reviewed for improper nursing care. The findings include: R2's health record documented admission Date on 2/1/2024 with diagnoses not limited to Unspecified fracture of left ilium, History of falling, Dysphagia oral phase, Thyrotoxicosis, Dementia in other diseases classified elsewhere, Major depressive disorder, Restlessness and agitation, Xerosis cutis, Atrophic disorder of skin, Depression, Insomnia, Iron deficiency anemia, Constipation, Alzheimer's disease, Unspecified protein-calorie malnutrition, Difficulty in walking, Other symptoms and signs involving the musculoskeletal system. On 7/10/24 At 10:10am R2 observed sitting up in wheelchair, wheeled by staff, alert and verbally responsive with bouts of confusion. At 12:01pm V17 (Fall and psychotropic Registered Nurse)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to ensure that one resident (R3) had the proper equipment for a daily CPAP (Continuous Positive Airway Pressure) machine as ordered by a Medical Doctor. This failure has affected one of four residents reviewed for improper nursing care. Findings include: R3 is [AGE] year old with diagnoses including but not limited to: obstructive sleep apnea, chronic systolic heart failure, history of sudden cardiac arrest, presence of automatic cardiac defibrillator and essential hypertension. On 06/24/2024 during investigation R3 was observed lying in bed. On 06/24/2024 at 12:15 PM R3 stated, I am ok. I get help when I need it. No one here mistreats me. I just need help with my CPAP. I haven't had my CPAP for two nights and it is hard to breath at night. I really need my CPAP. They say that a piece is missing from my CPAP. Can you help me? Surveyor observed R3's CPAP machine sitting on her night stand. The CPAP was without a face mask. On 06/24/2024 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to follow their policy on Sanitation & Safety Operations by (a) failing to maintain proper food temperatures, (b) failing to date opened food items with open and use by date, (c) failing to store kitchen cleaning supplies/chemicals away from food items and silverware, (d) falling to monitor and make sure dishwasher temperatures reached at least 160 degrees F during the wash/rinse cycle of the dish washer These deficiencies have the potential to affect 204 residents who are on an oral diet and receiving meals from the kitchen. Findings include: On 06/04/2024 at 9:25am during tour of the kitchen with V35 (Food Service Director), observed stored in the walk-in fridge in a clear plastic bag were uncooked open waffles patties with no open date/use by date on them. V35 stated all open food should be dated with a date showing when they were open and use by date to let kitchen staff know if the waffles are still good to be cooked for resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 encourage and assist residents with cognitive impairments to dress in their own clothes, rather than hospital type gowns for 22 (R165, R184, R58, R86, R133, R46, R51, R59, R56, R63, R15, R98, R67, R124, R54, R158, R23, R99, R158, R13, R176, R16) residents, b.) Assist residents in maintaining and enhancing his or her quality of life, by providing equal access to quality care regardless of diagnosis and severity of condition for 3 (R58, R133,R165) residents reviewed for resident rights. Findings include: 6/4/2024 10:47 AM surveyor observed nine residents in the dining area/activity room, sitting in their wheelchair, wearing clothes, appear clean, hair combed, and music playing. 6/4/2024 10:53 AM R165 observed in bed, wearing gown, breakfast tray on bedside table. 6/4/2024 11:05 AM R184 in bed lying down, wearing gown. 06/4/24 11:12pm V20 (Activity Director) states that she has been working for the facility for about 5 and a half months. V20 states that the third floor has their own different calendar being it is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 four (R43, R53, R131, R135) residents had access to the call light system in a total sample of 35 residents reviewed. Findings include: On 6/4/24 at 11:55 AM, surveyor observed R43 lying in bed watching television. Surveyor observed R43's call light clipped to the edge of the mattress on the left side dangling to the floor. Surveyor asked R43 to get the call light. R43 made slight movements attempting to find the call light and then stated I can't reach it. I don't see it. Surveyor asked R43 what the purpose of the call light is. R43 responded I use it to call if I need to be changed. On 6/4/24 at 12:05 PM, surveyor asked V38 (Certified Nursing Assistant) to come to R43's room to observe the call light placement. V38 stated R43 could not reach the call light because it was dangling to the floor. V38 stated I clipped it to the bed and put it on R43's stomach. R43 moves around a lot. R43 is not independent. R43 needs assistance. R43…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 A. Based on observations, interviews, and review of records the facility failed to follow policy to accurately account residents' narcotic medication for 2 out of 6 medication carts for a total of 11 medication carts reviewed for controlled substance or narcotic storage accuracy. These failures have the potential to affect R12 and R95 narcotic medication improperly accounted. B. Based on observations, interviews, and review of records the facility failed to follow policy on labeling and dating insulin vials opened for residents use. Failed to ensure tuberculin vials stored in the refrigeration are not expired. Failed to maintain medication cart free from expired house stock medication. And failed to ensure medication for topical use are in proximity to supplement taken by residents orally. Failure applies to 2 out of 3 medication rooms for a total of 5 medication room. And 2 out of 6 medication carts for a total of 11 medication cart reviewed for medication storage and labelling. These failures have 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 reviews, the facility failed to accurately complete Minimum Data Set (MDS) assessments using the CMS-specified Resident Assessment Instrument (RAI) process for 2 (R59, R133) residents reviewed for resident assessment in a sample of 35. Findings include: 06/04/24 11:09 AM observed R59 lying in bed, wearing a gown, yellow non-skid socks, observed toothless. R59 states that she manages to eat without any teeth, R59 states that she eats really slow and R59 states that she must take her time because sometimes she struggles. R59's dental hygiene encounter form dated 5/8/2024, documents in part: complete oral cancer screening with normal findings, edentulous swab. R59's MDS (minimum Data set) Section L for annual comprehensive assessment (10/17/2023) no documentation of R59's accurate dental status. R133's physician order set documents in part: R133 admitted to hospice 02/03/2024. R133's MDS (minimum Data set) Section O for annual comprehensive assessment (05/13/2024) no documentation of R133's accurate hospice care status. 6/6/24 at 12:05 PM V45…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 with newly evident or possible serious mental disorders to the appropriate state-designated authority for review. This failure affects three residents (R73, R125, R166) reviewed for PASSR (Preadmission Screen and Resident Review) in a total sample of 35 residents. Findings include: R73 face sheet printed 6/6/24, indicates R73 has diagnoses that include but are not limited to psychotic disorder with delusions due to known physiological condition, onset date 11/7/2023; depression, onset date 11/7/2023; anxiety disorder, onset date 11/7/2023. R73 Illinois PASRR Level I Form Preadmission Screening and Resident Review, 10/30/2023, documents in part: Level I Outcome: No Level II Required - No SMI/ID/RC. Rationale: The Level I screen indicates that a PASRR disability is not present because of the following reason: There is no evidence of a PASRR condition of an intellectual/developmental disability or a serious behavioral health…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 2. On 06/06/2024 at 11:41AM, surveyor located inside of R37's room and observes R37's bed in a high position, R37's bed observed to not be in the lowest position. R37 observed in a supine position with head of bed at 45 degrees. R37's bed observed in a high position that reaches surveyor's mid upper thigh measuring approximately 2 feet, 8 inches in height. R37 states she is not sure why her bed is positioned so high. R37 states she doesn't want to fall again because she fell in the facility sometime last year and broke her knee cap. R37 states she is still healing from her injuries. On 06/04/2024 at 11:45AM, surveyor makes V9 (Licensed Practical Nurse/LPN) aware of R37's bed being in a high position. V9 located inside of R37's room and observes R37's bed position and states R37's bed should not be this high. V9 observed operating R37's bed and lowering R37's bed to the lowest position. R37's bed is now in a position that reaches the bottom of surveyor's kneecap measuring approximately 1 feet, 6 inches in height.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 A. Based on observations, interviews, and review of records the facility failed to follow policy to accurately account residents' narcotic medication for 2 out of 6 medication carts for a total of 11 medication carts reviewed for controlled substance or narcotic storage accuracy. These failures have the potential to affect R12 and R95 narcotic medication improperly accounted. B. Based on observations, interviews, and review of records the facility failed to follow policy on labeling and dating insulin vials opened for residents use. Failed to ensure tuberculin vials stored in the refrigeration are not expired. Failed to maintain medication cart free from expired house stock medication. And failed to ensure medication for topical use are in proximity to supplement taken by residents orally. Failure applies to 2 out of 3 medication rooms for a total of 5 medication room. And 2 out of 6 medication carts for a total of 11 medication cart reviewed for medication storage and labelling. These failures have 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 administer the right medication as ordered and failed to administer intended medication dose as ordered per policy. There were 28 (twenty-eight) opportunities with 3 errors resulting in 10.71% (percent) error rate. This applies to 2 (two) residents (R118 and R68) of 8 (eight) residents observed for medication administration. These failures have the potential to affect 2 residents (R118 and R68) in receiving the right medicine and the right dose as ordered by physician. Findings include: On 6/4/2024 at 1:58 PM, during medication administration observation with V9 (Licensed Practical Nurse). Medication of R118 Deep Sea Nostril Spray administered 1 spray to left nostril and Artificial Tears eye drop administered 1 drop to the left eye. Review on R118's physician order, documents that Sodium Chloride Nasal Spray instructed to be administered one (1) application in both nostrils and Artificial Tears eye drop instructed to be administered two (2) drops in both eyes. On 6/4/2024 at 2:05 PM, during 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure staff and family follow recommended isolation guidelines consistent with current standard of practices to prevent cross contamination for 3 of 4 residents (R499, R500, R168,) observed for infection control in the sample of 35. Findings include: On 06/04/2024 at 10:59AM surveyor observed R500 room with enhanced barrier sign on door and precaution set-up outside of room. On 06/04/2024 at 11:30AM surveyor observed V5 and V6 without PPE.V6 observed applying specialized device to R500 left foot. On 06/04/2024 at 11:48AM surveyor observed R499 room with contact isolation sign on door and precaution set-up outside of room. On 06/04/2024 at 11:50AM surveyor observed R499 family member enter R499 room with PPE/personal protective equipment on and exited room with same PPE. Family member walked down the hall to talk to staff with gown on. Family member stopped to talk to surveyor with PPE gown on. Family member observed touching linen cart…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review, the facility failed to follow their hot food policy by failing to provide hot food to one (R172) of 5 residents in a sample of 35 reviewed. Findings include: R172 is a [AGE] year-old individual whose current face sheet documents R172's medical conditions to include but not limited to: methicillin resistant staphylococcus aureus infection as the cause of diseases classified elsewhere, urinary tract infection, site not specified, strain of right quadriceps muscle, fascia and tendon, subsequent encounter, effusion, left knee. R172's Brief Interview for Mental Status (BIMS) dated [DATE], documents R172's BIMS as 15/15, indicating he has intact cognitive abilities. 06/04/2024 at 1:00am The last food cart reached the fourth floor, and the last tray was tested by V35 at 1:14 with surveyor observing. The carrots and cabbage tested at 112 degrees F. V35 stated all the hot food should be at least 135 degrees when it reaches the units so the residents can enjoy warm food…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that a cognitively impaired resident's pain management regimen was followed in accordance with physician's orders as the resident was not assessed for pain consistently. This failure affects one (R2) resident out of three residents reviewed for pain management. Findings include: R2's face sheet dated 04/17/2024 documents that R2 is a [AGE] year-old female with diagnoses not limited to: nondisplaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing, encounter for other orthopedic aftercare, muscle weakness, dementia, history of falling, pain in right knee. R2's MDS (Minimum Data Set), dated 03/27/2024, shows R2 is rarely/never understood and cognitive impaired. On 04/17/24 at 11:35 AM V39 (R2's Power of Attorney/POA) states that she would inquire about R2's right leg swelling to the nurses on duties each day she was there, and the nurses would respond to her that R2 has arthritis. V39 states…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 who depends on staff's assistance for their ADL (Activities of Daily Living) care and grooming receive skin care and grooming. This affects one resident (R1) out of 3 residents reviewed for ADL care and grooming. Findings include: R1's face sheet shows diagnoses to include but are not limited to Sleep Apnea, Morbid Obesity, History of Falling, and Osteoarthritis. On 11/13/23 at 10:40am, R1 was observed in bed with dry scaly skin on the lower legs with visible dried particles from the feet on the white bedsheet. R1's face had dried secretions. At 11:45am, R1 was in the same condition. At this time, V5 (CNA/Certified Nurse Assistant) was notified and asked if R1's feet and legs look like they were wiped or cleaned in the past several days. V5 stated I haven't been here for almost a month, and I was off the weekend. They (staff) were supposed to wash and clean her feet and apply some lotion. I will clean her up. V3 (RN/Registered Nurse) stated We need a male staff to join us to move her…

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

Based on interviews and record reviews, the facility failed to ensure that sexual abuse allegation was reported to State Agency (SA) immediately or no later than 2 hours after the allegation is made. This failure resulted in the allegation not being reported timely. The findings include: R2's health record documented admission date of 1/30/2023 with diagnoses not limited to spastic hemiplegic cerebral palsy, post-traumatic stress disorder, insomnia, acute embolism, and thrombosis of unspecified deep veins of unspecified lower extremity, generalized anxiety disorder, personal history of other venous thrombosis and embolism, other cerebral palsy, paraplegia, unspecified asthma. R2's MDS (Minimum Data Set) dated 8/8/2023 showed that R2 was cognitively intact. R2 needed extensive assistance with bed mobility, transfer, toilet use and personal hygiene, limited assistance with dressing and supervision with eating. On 10/10/23 at 11:09 am observed R2 sitting on wheelchair, alert, and oriented x (times) 4, verbally responsive. Appears clean, well groomed, pleasant. R2 stated that she 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 observation, interview, and record review the facility failed to ensure disposal of expired food items and follow proper cleaning and sanitation practices for the kitchen and dishes. This failure has the potential to affect 192 residents residing in the facility receiving meals from the kitchen. Findings include: On 4/25/23, surveyor observed a container of Lobster Base, expire date 10/14/22, in the refrigerator and 2 packages of hamburger buns, 60 total, good thru date 4/22/2023, in the dry storage. On 4/25/23, surveyor observed kitchen staff using the dishwashing machine to clean dishes. Surveyor observed the final rinse gauge reading between 160-170 degrees. V9 (Maintenance Director) stated the final rinse gauge should read between 180-190 degrees. With V9 and V20 (Food Service Director/Diet Tech), surveyor observed 3 temperature test strips go through the dishwashing machine. All 3 test strips did not indicate, by turning black in color, the dishwashing machine was reaching the correct temperature of above 180 degrees. V9 stuck a kitchen thermometer in the water basin…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dispose of garbage and refuse properly. This failure has the potential to affect 195 residents residing in the facility. Findings include: On 4/25/23, surveyor observed 7 dumpsters overflowing with trash, lids not completely closed. Surveyor observed food particles and debris on the ground. Surveyor observed one trash bag on the ground next to a dumpster. On 4/26/23 at 4:15 PM, V20 (Food Service Director/Diet Tech) stated the dumpster lids were not supposed to be open and they should not have been overflowing with garbage. They should have been securely closed. V20 stated because the lids were open the dumpsters could have attracted rats. V20 stated there should not have been food or garbage bags on the ground. All garbage should have been in the dumpster with a tight lid. On 4/27/23 at 10:21 AM, V24 (Housekeeping/Laundry Director) stated dumpster lids are not supposed to be left open and the dumpsters should not be overflowing for general infection control, it's not good for the environment, and so trash doesn't…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and review of records the facility failed as follows: Failed to properly position resident resulting to failure of giving the right dose to 1 resident (R5) during medication administration. Failed to follow guidelines for giving medication beyond scheduled time to residents. And failed to follow policy to account 2 residents (R133 and R146) controlled substance or narcotic for 2 out of 6 carts reviewed. These failures has the potential to affect residents on 3rd and 6th floors and 1 resident (R133) for a total of 85 residents to receive proper pharmaceutical services. Findings include: During medication administration review with V10 (Licensed Practical Nurse), on 04/26/2023 at 07:50 AM. V10 prepared medication Contulose 10 GM / 15 ML by pouring it in a medication cup for R5. V10 while standing on the ride side of R5 started pouring the medicine on the medication cup while R5's head was in a low position without any elevation. R5 head was not elevated at all resting on her…

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

Based on observations, interviews and records review, the facility failed to follow their infection prevention and control program by failing to (a)date oxygen tubbing for two (R23, R168) of four residents reviewed in a sample of 35 resident. This deficiency has to the potential to affect two of four residents reviewed, (b)failed to follow policy related to cleaning between used blood pressure equipment used by 3 residents (R5, R49, R143 and R25) reviewed during medication administration. Findings Include: On 4/25/2023 at 11:30am, R23 was observed laying in bed with oxygen running via nasal cannula at O2 two liters per minute/ LPM. R23's oxygen tubbing was observed to have no date indicating when it was last changed or ehen it should be changed next. R23's medical diagnosis includes but not limited to: chronic obstructive pulmonary disease(COPD)with(acute) exacerbation, Acute respiratory failure with hypercapnia, Single subsegmental pulmonary embolism without acute cor pulmonale. R23's physician orders include but not limited to: Dated 02/24/2023 and 03/07/2023 documents: O2 2LPM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 develop an individualized care plan for 1 resident (R333) on a high-risk medication out of 35 reviewed for care plans. Findings include: On 4/27/23 surveyor asked for R333 anticoagulant care plan. V25(MDS Coordinator) submitted an anticoagulant care plan for R333 with date initiated and created on is 4/27/2023. Surveyor asked V25 why did the care plan have todays date on it. V25 replied V25 created the care plan today. R333 did not have a care plan for anticoagulant use. On 4/27/23 at 12:40 PM, V25 stated R333 was not care planned for anticoagulant therapy. R333 should have been care planned for anticoagulant use. I put it in today because it's really important. I know the severity. V25 stated the purpose of the care plan is to make sure the services that the resident is receiving is carried out with the IDT (Interdisciplinary Team). Anticoagulants are high risk medications. High risk medications should be care planned to prevent the resident from experiencing risk factors of the medication. Risk factors of anticoagulant…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and review of records the facility failed to maintain bed side rails in safe and stable working condition to a resident with left sided weakness that is using right side rail for bed mobility to change position for 1 resident (R83) out of 4 for a total sample of 35 reviewed for accidents and hazards. This failure has the potential to affect 1 resident (R83) in maintaining safety, free from hazards and prevention of accidents. Findings include: R83 is [AGE] years old during review, initially admitted on [DATE] with medical diagnosis of Hemiplegia and Hemiparesis following Intracranial Hemorrhage affecting left dominant side. That means R83 has right side strength to use for his activity of daily living (ADL) due to left side weakness. R83's brief interview of mental status dated 02/14/2023 was 15 that means R83 cognition is intact. R83's bed mobility that includes how R83 moves to and from lying position needs supervision without assistance. On 04/26/2023 at 10:33 AM. R83 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 observations, interviews, and review of records the facility failed to follow medication labeling of opened insulin for 2 out of 6 medication carts for 3 residents (R82, R147 and R168). Failed to ensure medication cart is free from expired insulin and insulin for resident that was already discharged . These failures have the potential to affect 3 residents (R82, R147 and R168) in managing diabetes via insulin administrations. Findings include: On [DATE] at 11:19 AM. Medication cart review with V17 (Licensed Practical Nurse). The following insulins were found inside medication cart, it was placed on a single semitransparent container: R147's two insulin vials Lantus insulin vial with marker written on the vial as follows: open [DATE] expires [DATE] and another Lantus insulin vial marker not dated. R168's Insulin Lispro pen written open date [DATE] expires [DATE] Lantus pen and insulin Glargine pen both not dated. And a resident that was already discharged Humulin pen not dated. V17 said, Yes, some 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, facility failed to follow their policy to ensure call lights are answered as soon as possible due to defective call light functioning for 1 (R38) out of 10 residents reviewed for call lights in a sample of 36. Findings include: On 04/25/23 at 10:47 AM surveyor observed call light within reach of R38 but call light was not working when R38 pushed the button. On 04/25/2023 at 10:48 AM, R38 stated that no one has come into the room since 8AM. R38 stated that she pushed the button at 8:15 AM but no one has come in. 04/25/23 10:49 AM, surveyor observed R38 pushed the button and noticed her call light was not going on and not alarming at the nurse's station. On 04/25/2023 at 10:50 surveyor called V5 (Licensed Practical Nurse) to R38's room to see if R38's call light is working. V5 checked R38's call light and stated that it is not working and that she will notify maintenance. On 04/27/2023 at 10:34 AM, V9 (Maintenance Director) stated, he is in charge of maintaining the functioning status of call lights. It is an everyday job. Every day…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policy as it relates to emergency food plan and did not have any (or enough) food resources to adequately manage and execute its food nutrition in the event of an emergency. These failures have the potential to affect 190 residents in the facility who is receiving an oral diet. Findings include: On 05/17/2022 at 10:52 AM. V3 (Dietary Supervisor) during initial tour in dry storage room. V3 was asked related to food and water supply for residents and staff in case of emergency. V3 pointed to an empty shelving without food and water supply. V3 said, This is the area that we store food and water in case of emergency. As you can see, we don't have any but was planning to put supplies in there. And since you guys came, we became busy and was unable to do it. V3 was then asked facility procedure to provide food and water to residents and staff in case of emergency. V3 did not replied. Emergency Preparedness Policy related to food and water supply dated 2021 in part reads: Supplies will be maintained to safely serve…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 multiple policies related to the following: Food storage area not maintained in clean sanitary condition, did not check dishwasher machine as required resulting to not reaching desired temperature, labeling of opened food and discarding food that are beyond best used by date, follow First-In-First-Out with evaporated can milk, perform hand hygiene before performing food preparation and after touching high touched area while performing food preparation, maintaining food sanitation by placing cheese sandwiches on stove platform without barriers and maintaining equipment (thermometer) clean when testing food temperatures. These failures have the potential to affect 190 residents in the facility who is receiving an oral diet. Findings include: On 05/17/2022 at 10:52 AM. V3 (Dietary Supervisor) during initial tour the following concerns are seen: At the food preparation area, garbage container about half filled garbage without lid was left unattended. Inside walk-in freezer environment was dirty. Garbage…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reviews, the facility failed to complete the annual and quarterly Minimum Data Set (MDS) assessments using the CMS-specified Resident Assessment Instrument (RAI) process within the regulatory timeframes for 4 (R4, R5, R6, R28 ) of 5 residents reviewed for resident assessment in a sample of 35. Findings include: On 5/20/22 at 11:37 AM, record reviews of the following MDS assessments revealed: - R5's Quarterly MDS assessment with assessment reference date (ARD) of 4/12/22 completed, locked and accepted on 5/16/22. - R28's Annual MDS assessment with ARD of 4/26/22 was completed on 5/16/22; locked and accepted on 5/19/22. - R4's Quarterly MDS assessment with ARD of 4/11/22 was completed, locked and accepted on 5/16/22. - R6's Annual MDS assessment with ARD of 4/12/22 was completed, locked and accepted on 5/16/22. Chapter 2 of the RAI manual pages 16-17 titled RAI OBRA-required Assessment Summary indicates that Annual and Quarterly MDS assessments should be completed no later than 14 days from the ARD. On 05/20/2022 at 01:28 PM. V8 (MDS Coordinator) stated…

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

Based on observations, interviews and records review the facility failed to follow their Smoking Policy and properly assess residents for safe smoking and supervise residents for proper storage of smoking materials. This has the potential to affect 5 of 5 residents (R166, R201, R84, R156, R97) reviewed for smoking material safe storage and smoking risk assessment. Findings include: 05/18/22 10:33 AM, R84 was observed in his room lay watching TV. On R84's bed side table was observed 10 cigarette tubes/filters, and in R84's dresser were two cartons containing 250 tubes each. On the bed side table was 1 pound of the good stuff premium pipe tobacco menthol, a lighter and a cigarette making machine labeled; Top-O Matic Warning label on the machine said, extended injector is very sharp, to avoid serious cuts or lacerations, keep fingers away from tobacco chamber. R84 said R84 makes cigarettes all the time in R84's room and staff are aware. R84 said the cigarette making equipment and the cigarettes are always on R84's dresser. R84 said no-one has asked or told R84 not to make cigarettes 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 observations, interviews and record reviews, the facility failed to (a) properly discard expired medications on expiration dates that could potentially affect all 45 residents residing on the 6th floor; (b) properly date opened multi-dose inhalers, multi-dose insulin pens, and eye drops for 5 residents (R31, R37, R69, R84, R88); and (c) ensure opened multi-dose insulin pens were stored to prevent the potential for cross contamination for 8 residents (R84, R191, R66, R185, R159, R10, R88, R178) from four of six medication carts inspected for medication storage and labeling. Findings include: On 5/18/22 at 10:50 AM, inspected 6 South medication cart with V12 (Licensed Practical Nurse). The following were noted: - R31's Albuterol Sulfate inhaler without the date opened on the label. - R37's Albuterol Sulfate inhaler without the date opened on the label. - R69's Spiriva 18mcg inhaler without the date opened on the label. V12 stated all insulin pens, insulin vials, and inhalers should be dated when opened. At 11:31 AM, inspected 5 South medication cart with V13 (Registered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, facility failed to follow policy in maintaining urinary catheter drainage bag free from possible contamination by leaving it on the floor without any barrier. And failed to ensure isolation precaution signage was posted for 2 of 2 resident (R127 and R463) reviewed for infection control and prevention. These deficient practice has potential to affect 1 resident (R127) for recurrent urinary tract infection and 30 residents residing on the facility's fifth floor. Findings include: On 05/17/2022 at 12:46 PM. R127 was seen on bed alert and verbally responsive. R127 was on his bed with catheter bag about 80% full. Inside was yellow to beige color urine on the floor without any barrier between the floor and the drainage bag. V9 (Registered Nurse) stated that R127 always take it out if it is attached. Further stated that urinary catheter bag needs to be place inside a bag and not to place it on the floor to prevent infection. R127 was [AGE] years old with medical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility policy on COVID-19 testing for 2 staff with waivers and 2 partially vaccinated, V32 (Certified Nursing Assistant/CNA), V33(CNA), V7 (Dietary Aide), and V10 (Licensed Practical Nurse/LPN) without the required testing. These failures have the potential to affect 193 residents for contacting COVID-19 infections. Findings include: On 5/17/2022 at 11:00am, V1 (Vice President/VP of Operation) and V11 (Regional Nurse Consultant) said that there were two staff members with waivers and two staff members who were partially vaccinated. V1 and V11 said that four staff members were out after testing positive for COVID-19. V1 said that there were no residents who were positive for COVID-19. On 5/20/2022 at 11:55 am, V2 said there were seven staff members positive for COVID-19 and off duty as follows: V24 (Infection Preventionist) V26- (Human resources-HR) V27-Director of Nursing V28-(MDS) V29-(Food Services Director) V30-(LPN) V31-LPN Staff with waivers: V32-CNA V33-CNA Staff partially vaccinated V7…

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

Based on interview and record review, the facility failed to ensure residents being discontinued from skilled therapy received both Medicare notices of non-coverage for the skilled therapy for 5 of 5 (R182, R175, R154, R200, R263) residents reviewed for non-coverage of Medicare services in the sample of 35 residents. The findings include: On 05/19/22 at 01:20 PM, V1 (Vice President of Operations) provided the federal form 10123 for R154, R263, R200, R182 and R175. Informed V1 that a list of residents was to be provided and the surveyor chooses the residents. V1 stated he just gave the last 5 residents that were given notices. The Federal form 10055 form was not presented for the 5 residents. At 1:40 PM, V15 (Social Service Director) stated she only knows of the Federal form 10123. V15 stated she has been here for 1 year. The notices are labeled Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) federal form 10055 and the Notice of Medicare Non-Coverage (NOMNC) federal form 10123. The federal form 10123 documents that skilled services will end on the date…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews the facility failed to ensure one resident (R193), considered at risk for abuse, remain free from abuse in the sample of 35 residents reviewed. Findings included: R193 is a [AGE] year-old, admitted to facility on 04/23/22 with diagnosis including, but not limited to, aftercare following joint replacement surgery; other acute postprocedural pain. Minimum Data Set (MDS) shows R193's Brief Interview for Mental Status (BIMS) 13 out of 15 indicting 193's cognition is preserved. R193's care plan documents R193 may be at risk for potential abuse related to mental and emotional challenges and documents interventions to be implemented such as: Explain care tasks step by step to ensure resident understands. If R193 is increasingly upset or agitated during care, ensure resident is safe. Politely excuse yourself and then report situation to supervisor and re-approach resident with assistance or alternative staff. Report any unusual behavior or incident to supervisor. Utilize behavior…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to recognize and to internally report a potential abuse for one resident (R193) in the sample of 35 residents reviewed. This failure has the potential to allow abuse to continue, by preventing the facility from investigating and intervening to stop the abuse. Findings included: R193 is a [AGE] year-old, admitted to facility on 04/23/22 with diagnosis including, but not limited to, aftercare following joint replacement surgery; other acute postprocedural pain. Minimum Data Set (MDS) shows R193's Brief Interview for Mental Status (BIMS) 13 out of 15 indicting 193's cognition is preserved. R193's care plan documents R193 may be at risk for potential abuse related to mental and emotional challenges and documents interventions to be implemented such as: Explain care tasks step by step to ensure resident understands. If R193 is increasingly upset or agitated during care, ensure resident is safe. Politely excuse yourself and then report situation to supervisor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 follow CMS's RAI guidelines on significant change in status assessment (SCSA) by not performing SCSA assessment for within 14 days after admission to hospice of 1 of 1 resident (R32) reviewed for resident assessment. This failure has the potential to affect 1 resident (R32) in receiving incorrect assessment that corelates to care of resident. Findings include: R32 was [AGE] years old, with medical diagnosis Malignant Melanoma and Transient Cerebral Ischemic Attack. Per Hospice admission Record, R32 was admitted on [DATE]. R32 order reads: 7/12/2021 admitted to hospice. And MDS comprehensive assessment significant change in status assessment (SCSA) was dated 8/7/2021. 21 days after hospice admission and 19 days after physician ordered date. On 05/17/2022 at 01:56 PM. V8, MDS Coordinator, said, Yes, significant change assessment was done late because it should have been done within 14 days when R32 was admitted to hospice. I understand that 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 observations, interviews, and record reviews the facility failed to develop a comprehensive resident centered care plan with goals and interventions for 1 (R185) of 2 residents reviewed for respiratory care in a sample of 35. Findings include: On 5/18/22 at 10:21 AM, R185 lying in bed alert and able to verbalize needs. Oxygen on at 2 liters per minute via nasal cannula. R185 stated, I have trouble breathing sometimes. I have COPD (Chronic Obstructive Pulmonary Disease) and sleep apnea. I use the oxygen most of the time to help me breath better. R185's electronic health record (EHR) indicates an initial admission date of 11/12/2011. R185 has listed diagnoses not limited to COPD, sleep apnea, and heart failure. R185's physician order sheet (POS) reads, O2 per nasal cannula to keep SpO2 >90% with revision date of 9/23/21. R185's Minimum Data Set (MDS) with assessment reference date (ARD) of 4/9/22 shows R185 is cognitively intact. Review of R185's comprehensive care plan does not include care areas addressing respiratory care for R185's COPD, sleep apnea, and oxygen use 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews the facility failed to discuss preference for code status upon admission for a resident who wants to be resuscitated, and instead documented code status as Do Not Resuscitate (DNR) in the resident profile. This failure affects one resident (R94) out of 35 residents reviewed and has the potential to prevent cardiopulmonary resuscitation to be provided to R94 in an event of cardiac or pulmonary arrest. Findings included: Surveyor reviewed R94's medical record on [DATE] and R94's electronic face sheet documented code status Do Not Resuscitate/DNR. R94's DNR form uploaded in the electronic chart documents conflicting information by having the Section B: Full Treatment checked and the Section A: DNR box checked. Physician Order shows a DNR order. R94's care plan documents R 94 is a full code and reads: R94 is a FULL CODE - If R94 becomes unresponsive, CALL FOR HELP IMMEDIATELY and begin Basic Life Support sequence. Date Initiated: [DATE] On [DATE] at 03:15 PM V2 (Assistant…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review, the facility failed to provide documentation to support the use of the anti-psychotic medications in dementia residents, failed to have documentation on the type of psychosis being treated and failed to provide documentation of non-pharmacological interventions prior and during the use of the anti-psychotic medications and failed to follow their psychotropic policy for 2 (R133, R156) of 2 dementia residents reviewed for anti-psychotic medication in the sample of 35 residents. The finding include: On 5/17/22 at 12 noon, R156 was sound asleep in the bed. On 5/18/22 at 10:10 AM, R156 is sound asleep. At 1:30 PM, V25 (Certified Nurse Aide/CNA) was assisting R156 with dressing as he laid in the bed. V25 stated since the medication change, R156 does sleep a lot more. Review of the May 2022 Physician Order Sheet and the Medication Administration Record (MAR) documents R156 is taking 50 milligrams twice a day (9 am, 5 pm) of Seroquel and 100 milligrams (mg) of Seroquel…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observation, interview and record review the facility failed to follow policy related privacy and dignity by not providing privacy curtain to 2 residents (R326 and R126) living in a single room. These failures have the potential to affect 2 residents on maintaining their respective privacy (R326 and R126) in a sample of 35 residents. Findings include: On 05/18/2022 at 11:32 AM. With V10 (Licensed Practical Nurse) inside R326 and R126 room two beds are seen. First bed near the door and second bed near the window where R126 was resting. There was no privacy curtain in the middle of both beds to provide privacy. Only a single curtain on the right side of R326 near the door. V10 was asked to extend that curtain, and it reached only the foot of R326 bed. Curtain was unable to provide privacy to both R326 and R126 bed. V10 then said that without the middle curtain, it will not provide privacy for resident when staff are performing care. V10 said, In general when nursing staff performs bedside care, like…

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