Belhaven Nursing & Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of records and interview facility the failed to follow abuse reporting policy for 2 out of 4 residents (R1, R2) in a total sample of 4 residents reviewed. This failure has the potential to affect R1 and R2 in timely determination of abuse incidents and providing necessary interventions to prevent possible recurrence.The findings include:R1 is a [AGE] year-old resident, initially admitted in the facility on 03/27/2022. R1's medical diagnosis includes hemiplegia and hemiparesis following cerebrovascular disease. R2 is a [AGE] year-old resident, initially admitted in the facility on 01/06/2026. R2's medical diagnosis includes schizophrenia, schizoaffective disorder, major depressive disorder. R2 has intact cognition with BIMS score of 15 dated 01/13/2026.Facility's initial abuse reportable incident report was submitted by facility dated 01/20/2026 between R1 and R2. Per report it was alleged that R2 made contact with R1. Final report was sent on 02/04/2026 at 11:49 AM, which is the current date. 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 observation, interview and record review, the facility failed to update the daily nurse staffing information. This failure affected all 199 residents residing in the facility.Findings include:On 12/14/25 at 8:55 am, Surveyor entered the facility at 8:55 am, and observed the daily staff posting displayed in a clear standing frame holder, at from the receptionist desk dated 12/13/25. On 12/15/25 at 11:20 am, V33 (Receptionist) stated that receptionist arrives at the facility at 6:30 am and are responsible for changing the daily staff posting every day. V33 stated that the daily staff posting shows how many residents, Certified Nursing Assistants, CNA's, and nurses are present in the building each day. V33 stated that she does not know why the daily staff posting was not updated on 12/14/23.The facility's document dated 12/13/25 and titled Daily Nursing Staff For Direct Resident Care shows the daily staff was not posted for 12/14/25 at the facility. (Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17) S483.35(g) Nurse Staffing Information. S483.35(g)(1)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 meet safe food temperatures for four residents (R48, R50, R83, and R182), sanitize food preparation table and clean kitchen environment. All has the potential to cause foodborne illnesses. This applies to 196 residents receiving oral nutrition. Finding includes: During the initial kitchen tour on 12/14/2025 at 9:48 AM, there were no paper towels available to dry hands at the only kitchen sink. The kitchen floor contained buildup of dry brown substances, dark food particles and sticky liquids especially the area in the back where the macaroni pasta was boiling/setting in 20-gallon kettle. There was also residue liquid from the pasta pot that leaked onto the floor. The perimeter of the floor behind the 50-gallon pot was compacted with dark brown particles. These dark brown substances appeared throughout the kitchen preparation areas and on the walls. On 12/14/2025 at 10:05 AM, personal items were in the walk-in cooler on a serving tray. The items included bottled water, can soda pop, large can of tea,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 properly dispose of dietary trash in their garbage disposal bins. This applies to 199 residents living in the facility. Finding includes:On 12/16/2025 at 9:00 AM, there were four dumpsters outside the back of the kitchen. Two of the four dumpsters closest to the building were open that contained dietary food trash. The side sliding doors of each of dumpsters were open and there was trash on the ground surrounding the two dumpsters. Trash items included small packets of what appeared to be coffee creams or butter, and sanitizing gloves too numerous to count. And there were two large clear bags that were bulging out of the open window of the sliding door of one of the dumpsters. V9 (Regional Director of Dietary) stated that he was not certain of the trash pick-up dates and times for the facility. And that dumpster lids/sliding doors should be closed. On 12/16/2025 at 2:11 PM, V2 (Director of Nursing) stated that it is expected that the garbage area should be monitored on a regular basis for fallen trash and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that Enhanced Barrier Precaution (EBP) sign was visibly posted; failed to provide Personal Protective Equipment (PPE) for a resident who requires EBP; failed to don PPE and perform hand hygiene in a contact isolation residents room; failed to follow infection control protocols by not tracking for legionella's; and failed to track antibiotic per facilities guidelines. These failures affected four residents (R140,R158 and R161,R197) and has the potential to affect all 199 residents reviewed for infection control. Findings include: R161 face sheet shows that R161 has diagnosis which include but not limited to difficulty in walking, type 2 diabetes mellitus with hyperglycemia, weakness, chronic obstructive pulmonary disease with (acute) lower respiratory infection, R161 Physician Order Sheet (POS) shows active order dated 12/14/25 documents, in part: Right Heel: 1. Cleanse with normal saline. 2. Apply Betadine moistened gauze to base of…

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

Based on interview and record review the facility failed to maintain an adequate antibiotic stewardship program to prevent the spread of infectious Disease throughout the facility. This failure affected one resident (R140) and has the potential to affect all 199 residents residing in the facility. R140 has a diagnosis of but not limited to is currently a discharged resident but was admitted to facility on 10/17/2025-12/2/2025 with diagnosis documented in part: Neuralgia and neuritis, chronic pain, anxiety, abnormal liver function, personal history of COVID -19,anemia,benign prostatic hyperplasia with lower urinary tract symptoms, pressure ulcer of right buttock stage 4,pressure ulcer of right hip stage 4,neurogenic bowel.R140's record review of Order Summary Report displays that R140 in November 2025 R14o was on Doxycycline x 14 days from 11/20/25 -11/29/2025 . In review of R140's medical record and Monthly infection log for November 2025 ABT tracking surveillance R140 was not recorded on November log as receiving any antibiotics.On 12/14/2025 at about 10:30, surveyor requested from…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 vaccinate eligible residents with the influenza and pneumococcal vaccine. The facility failed to document the declination and/or the benefits and side effects in the resident's electronic medical records. This deficient practice affected 6 residents (R4,R50,R114,R183,R197,R210) sampled in a total sample size of 72 and has the potential to affect all eligible residents that reside at the facility. Review of records for R4, R50, R114, R183, R197, R210, from admission dates to 12/16/25 have no findings of documentation of pneumococcal and or Influenza vaccine offering or education of the vaccine. Review of physician orders for R4, R50, R114, R183, R197, and R210 from admission to 12/16/25 show no orders of pneumococcal and or influenza vaccination. Immunization records do not reflect any tracking for pneumococcal and or influenza vaccination listed on the logs.On 12/16/2025 at 12:04pm, V11( Infection Control Nurse/LPN) stated all immunizations are recorded…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 COVID vaccine was offered to residents and documented and failed to offer and provide education to staff regarding COVID vaccination. this failure has the potential to affect all 199 residents that reside in the facility. On 12/15/2025 at 11:09 am,V14 (Certified Nursing Assistant) stated that he was offered Influenza vaccine and declined the vaccine because he received the vaccine at his clinic on 11/19/25, V14 stated he gave human resource director a copy of his immunization records and signed the declination form.On 12/16/2025 at 12:10 pm,V11 ( Infection Control Nurse) stated that she has not offered the COVID vaccine to residents for 2025 and does not have any records to display that the residents consented or declined the vaccine and stated it was an oversight on her part. V11 stated that she does not document or have staff document on the declination forms, and she ask the staff verbally and if they decline that she takes a mental note. V11 stated she also offers Influenza and pneumococcal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prevent insects from flying above and around food and food preparation areas. All has the potential to cause foodborne illnesses. This applies to 196 residents (census of 199 residents minus 3 residents with gastronomy tubes) receiving food from the facility's kitchen. Finding includes:During the initial kitchen tour on 12/14/2025 at 9:48 AM, there were two insects flying around the kettle bowl containing uncovered pasta and over the stove where the ground beef or ground meat was cooking. The flying insects were in the aisle between the three stoves and the food preparation area. On 12/15/2025 at 11:55 AM, there were multiple flying insects within 12 inches of the sticky walls. The insects were also flying in the back area near the large 20-pound kettle and near the greasy sticky brown substances on the walls. V9 (Regional Director of Dietary) said that the flying insects were fruit flies. On 12/16/2025 at 11:42 AM, there were two fruit flies flying around the steam table where food temperatures were taken.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 respect a resident's dignity by not maintaining a resident's urinary catheter drainage bag in a privacy bag for 1 of 1 (R209) reviewed for residents right in a sample of 72. Findings include: On 12/14/2025 at 12:29pm, R209 was lying in bed with clean linen and in a clean gown; on air mattress with appropriate layers; urinary catheter and urinary bag not in privacy bag draining to gravity with 330 milliliters of urine; and dressing to his left foot clean. R209 stated the care is good for the most part and staff gets him up, dresses him and takes him to the dining room when requested. R209 stated sometimes the staff takes a long time to answer his call light. R209 can't remember the last time he waited a long time for his call light to be answered and what day it was. R209 stated he participates in activities at times, and he doesn't like the food because it is cold at times. On 12/14/2025 at 12:39 pm, V6 (Certified Nurse Assistant) verified R209's urinary catheter drainage bag was not in a privacy bag. V6…

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

Based on observation, interview, and record review the facility failed to ensure the call light device was within reach for one resident, (R67). This failure affected one resident (R67) and has the potential to affected all residents in the sample size of 72.Findings include:R67 has a diagnosis of Acute Right Heart Failure, Acute Pulmonary Edema, Lack of Coordination, Shortness of breath and Reduced Mobility.R67 has a Brief Interview of Mental Status score of 11 that indicates moderate cognitive impairment.On 12/14/2025 at 11:14am surveyor observed R67's call light device attached to the bottom of the quarter hand rails not within reach of the resident. On 12/14/2025 at 11:17am R67 said, the call light is normally on the floor and no I cannot reach it. R67 said my right hand does not work and I cannot reach the call light with my other hand as he is showing me that he cannot reach it.On 12/14/2025 at 11:32am V15 (Licensed Practical Nurse-LPN) stated call light should be within reach of the resident and that R67 can reach it, but R67 showed us (surveyor and V15) that he could not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that a code status physician's order was in a resident's electronic medical record (EMR). This failure affected one resident (R16) in a sample of 72 residents reviewed for advance directives. Findings include:R16 face sheet shows that R16 has diagnosis which include but not limited to peripheral vascular disease, type 2 diabetes mellitus, primary osteoarthritis, pneumonia, acute kidney failure, chronic diastolic heart failure, unspecified dementia, anemia, lack of coordination, need for assistance with personal care, unsteadiness on feet, weakness, dysphagia, impulsiveness, left bundle-branch block and transient cerebral ischemic attack. R16's physician Order Sheet (POS) shows active order dated [DATE] with no orders for R16's code status. R16's Care plan dated [DATE] documents, in part: Advance Directives R16 resident elected to be full code status. However, there are no code status orders on R16 physician order sheet (POS). R16's 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 that resident's equipment is clean for two residents (R4, R116) and the privacy curtains are clean and not tattered for one resident (R6). This failure affected 3 residents (R4, R6, R116) and has the potential to affect all 72 residents in the sample size.Findings include: R6 has a diagnosis of Vitamin D Deficiency, Presence of Urogenital Implants and Osteomyelitis. R6 has a Brief Interview of Mental Status score of 15 that indicates cognition intact. On 12/14/2025 at 10:47am surveyor observed R6's privacy curtains with two large holes in the netted area (mid-way to top) and a large pinkish stain at the bottom of the curtain. On 12/14/2025 at 10:52am R6 stated I have been asking for another curtain since I got here in June of 2024 and was told he will get new privacy curtain when they become available. R6 also stated the privacy curtain has been stained for months. On 12/15/2025 at 10:54am V20 (Housekeeper) stated yes, we are responsible removing, cleaning and replacing residents' privacy curtains and if…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to refer one resident (R8) for rescreening to the state agency for Preadmission Screening and Resident Review (PASRR) before R8's Short Term Approval without Specialized Services determination had expired. This deficient practice affected one resident (R8) in a total sample size of 72 residents.Findings include:R8's PASRR dated 0523/25 documents in part, PASRR Determination: Short Term Approval without Specialized Services.Date Short Term Approval Ends: [DATE].R8's medical diagnoses include but is not limited to type 2 diabetes mellitus without complications, lack of coordination, cognitive communication deficit, schizophrenia, anxiety disorder, essential hypertension.On [DATE] at 12:21pm V22 (Social Service Director) stated that R8 had a short term PASSR approval. V22 stated that she should have submitted a new PASSR request for R8.Facility's policy titled Pre-admission Screening and Resident Review dated 12/2023 documents in part, Policy: Comply 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 Number of residents sampled:72Number of residents cited:1Based on Observation, interview, and record review, the facility failed to ensure that restorative rehabilitation program for splint device application was being thoroughly implemented as documented in plan of care. This failure affected one resident (R183) reviewed for splint devices in a sample of 72 residents. On 12/14/2025 at 11:00am, R183 was observed sitting in his wheelchair next to side of his bed, no leg rest were observed on the wheelchair and AFO splint was on shelf directly in front of where R183 was sitting, right lower extremity/foot was laying on the floor in an inward position.R183 stated that staff places the splint on sometimes but that they did not place the AFO on today and that he would like the AFO placed on.On 12/14/2025 at 11:25 am, V14 (Certified Nursing assistant/CNA) came into the room of R183 and read the sign on the wall that read Certified nursing assistant (CNA) please put R183's AFO on upon getting him up. Place it 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 properly label oxygen nasal cannula tubing to ensure specialized care needs for the provision of respiratory care. This failure affected 1 of 1 resident (R44) reviewed for respiratory care in a sample of 72. R44's Face Sheet dated 12/17/2025, documents a diagnosis of but not limited to Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, Acute and Chronic Respiratory Failure, Unspecified Whether with Hypoxia or Hypercapnia, Hypertensive Chronic Kidney Disease Stage 1 Through Stage 4 Chronic Kidney Disease, Chronic Bronchitis, and Dependence On Supplemental Oxygen.R44's Physician Order Sheet documents an active order with a date of 6/25/2025 and start date of 6/29/2025 to change oxygen tubing and bottle weekly on Sunday every night shift every Sunday for Chronic Obstructive Pulmonary Disease (Acute) Exacerbation.R44's Care Plan dated 12/8/2025 has a focus for Oxygen Therapy related to Ineffective gas exchange, Respiratory risk related to Asthma and Chronic Obstructive Pulmonary Disease. R44's…

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

Based on observations, interviews, and record review, failed to ensure the narcotics accountability of controlled medication was accurate. This failure affected one resident (R196) and have the potential to affect all 64 residents on the third floor unit. Findings include:On 12/14/25 the V1(Administrator) provided a facility census of 31 residents on the 3 [NAME] unit.On 12/14/25 at 11:03 am, Surveyor and V3 (Licensed Practical Nurse, LPN) performed the narcotics accountability for the 3 [NAME] medication cart and observed the Narcotics accountability on/off signatures signed for 12/14/25 day shift. During the controlled medication count of R196's Lorazepam 2 mg/ml (milligram/milliliter) oral solution and morphine sulfate 20 mg/ml solutions the Individual Controlled Substance Records were observed in the 3 [NAME] medication cart narcotics accountability book however, Surveyor did not observe these medications on the 3 west medication cart. V3 stated, I called hospice for the medication yesterday because I did not see it. I have to follow up. V3 explained that R196's Lorazepam 2…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents had a privacy curtain which extended around the bed. This failure affected one residents (R78) residents in the total sample of 72 residents.Findings include: R78's face sheet documents that R78 has a diagnosis which include but not limited to heart failure, unspecified dementia, atrial fibrillation, dysphagia, gastro-esophageal reflux disease without esophagitis, hyperlipidemia, restless legs syndrome, sepsis, and falls. R78 Brief Mental Status Interview (BIMS) dated 09/15/25 indicates that R78 has memory problems.On 12/14/25 at 10:25 am, Surveyor observed R78's room without a privacy curtain that extended around R78's bed. R78 was not able to state how long her privacy curtain was missing. On 12/15/25 at 9:45 am, V16 (Environmental Service Director ) stated, The privacy curtains are to give the residents privacy. V16 explained that R78's privacy curtain was taken down on 12/13/25 to be washed. V16 further explained that she only allow the male housekeepers to replace the privacy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide a comfortable environment for one resident (R140). This failure affected one resident (R140) reviewed for environmental concerns.Findings include:R140's diagnoses include but are not limited to paraplegia, osteomyelitis, pneumonia, pressure ulcer of sacral region, major depressive disorder, chronic kidney disease, peripheral vascular disease, anxiety.R140's Minimum Data Set, dated [DATE] has a Brief Interview for Mental Status score of 15, indicating R140's cognition is intact.Facility's resident council minutes dated 10/30/25 documents in part, R140 ask for maintenance to check his room [ROOM NUMBER]B.Facility's resident council minutes dated 11/20/25 documents in part, resident in room [ROOM NUMBER] asked if maintenance can stop by his room.On 12/15/25 10:51am surveyor and V13 (Maintenance Director) assessed multiple cracks in the window in room [ROOM NUMBER], R140's bedroom before discharge.On 12/15/25 at 10:51am V13 (Maintenance…

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

Based on observation, interview, and record review the facility failed to ensure residents received meal preferences and substitutes as requested. This failure affected 3 of 3 residents (R1, R2, R3) reviewed for meal preferences and substitutions. Findings Include:On 9/15/2025 at 1:46 pm, R1 stated he (R1) has informed staff several times that his dislikes should be noted on his meal ticket as ham, turkey, dressing, and oatmeal. R1 stated his meal ticket documents No Pork and he has informed staff that he eats pork but not ham. On 9/15/2025 at 1:31 pm, V7 (Certified Nurse's Assistant) stated residents are made aware of the meal substitutions every morning by the activity aide. V7 stated sometimes during mealtimes, a meal substitution will look appealing to a resident who has not requested a substitution meal, and the resident will make a request for that substitution. V7 stated the kitchen is being ran by a new company and the company's staff provides the wrong meals on the residents tray all the time. V7 stated a resident's dislikes are printed on the meal ticket and the kitchen…

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

Based on observation, interview, and record review, the facility failed to ensure that residents were provided meals and snacks at appropriate times, in accordance with 42 CFRS483.60(f)(1) Each resident must receive and the facility must provide at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care. These failures have the potential to affect all 199 residents who receive oral meals from the facility's kitchen. Findings Include:On 08/25/2025 at 09:45 AM Surveyor was provided with facility census listing 199 residents residing in the facility.On 08/25/2025 at 1:00pm surveyor observed the Dining Rooms on the 2nd floor that revealed:Food Carts had been brought to the 2nd Floor Dining so staff could start the lunch meal service. Residents had been sitting at the tables waiting for food trays to be passed out. Only some residents received food trays because staff was waiting for the rest of the meals to be sent up from the kitchen.On 08/25/2025 at 1:00pm V16(Certified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, facility failed to administer resident's medications according to physician orders and instructions. This failure affected one out of three residents reviewed for medication administration and has the potential to affect all 26 residents on the second - floor unit receiving medications from the split medication cart. Findings include:On 8/25/2025 at 10:00 AM, Review of the facility's provided census (dated 8/25/2025), showed that 199 residents live within the facility (26 residents on the second-floor unit receiving medications from medication cart titled the split cart). On 8/25/2025 during review of R1's EMAR, (printed on 8/25/2025 at 3:29 PM), observed empty spaces (8/11/2025 at 9 AM, 8/15/2025 at 6 PM, 9 PM and 8/17/2025 at 5 PM, 6 PM and 9 PM) without a checkmark code or any other code documenting if the medications were held, refused, or administered. The undocumented medications included all R1's seizure medications, blood pressure and blood thinning…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement resident-directed care consistent with the resident's comprehensive assessment, professional standards of practice by a.) provide feeding assistance to two (R9, R10) residents b.) help a resident maintain their dignity during mealtime for one resident (R10) in a total sample of 10 residents. This failure places the resident at risk for more than minimal harm.Findings include:On 08/13/2025 at 12:49 PM, R10 sitting on a wheelchair, in the dining area, wearing a towel on his chest, falling asleep. R10 has a plate with pureed food covered with clear plastic in front of him on the table. Staffing seen passing out meal trays. On 08/13/2025 at 12:53 PM, R10 still positioned the same, falling asleep. One staff next to him, uncovered (plastic cover) the plate of pureed food and walked away with three other staff to pass out meal trays. R10 lifts his head a little, attempts to eat by himself, head is tilted to left side, with his right…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to a.) ensure drinks consumed are in the appropriate form as ordered by the physician for one resident (R10) b.) provide the appropriate nutrient content as ordered by the physician order for two (R8, R9) out of ten residents reviewed for dietary services. This failure places the resident at risk for more than minimal harm.Findings include:On 08/13/2025 at 12:24 PM R8 stated I'm supposed to get two cheeseburgers as he is showing his diet slip to a staff member. V12 (Dietary Aide) nodded her head no, they didn't make another one. then she looked at surveyor and said give me a minute.On 08/13/2025 at 12:39 PM, R8 standing at the nurse's station, stated that he did not receive another cheeseburger. R8 stated sometimes they do give me my double portions but not today or yesterday. R8's MDS/Minimum Data Set, dated [DATE] documents that R8 has a BIMS/Brief Interview for Mental Status score of 15/15, indicating that R8 has intact cognition. R8'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 interview and record review, the facility failed to follow a physician order and monitor a resident's vital signs for one (R1) out of four residents reviewed for quality of care in a total sample of four. This failure places residents at risk to be provided with inappropriate care and services to meet the resident's physical, mental and/or psychosocial needs. This failure places the resident at risk for more than minimal harm. Findings include: On 07/01/2025, at 12:56 PM, R1 stated that he saw V10 (Nurse Practitioner) about three weeks ago. R1 stated that he informed V10 that R1 has been having a lot of migraines which R1 stated that he never had in his life. R1 stated, I'll be sitting there and physically feel that my blood pressure is high. R1 stated that V10 ordered a medication which has been helping R1. R1 stated that the staff do not check his blood pressure daily. R1 stated that the nurse did not check R1's blood pressure today nor any vital signs. On 07/01/2025, at 11:49 AM, V6 (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.

Based on observations, interview and record review, the facility failed to ensure that the resident's call light system was working properly. This failure has the potential to affect 64 residents that reside on the second floor. Findings include: On 5/13/2025 at 12:05 PM during investigation, Surveyor heard a constant beeping sound on the second floor near the nurse's station. V17 (RN/ Registered Nurse) said that the beeping sound was the call light system and that she (V17) was unable to determine if or when a resident was calling for help because the call light system was malfunctioning. On 5/13/2025 at 12:10 PM, V14 (Housekeeping Staff) said that he was not aware of any call light system issues and was unable to disarm the call alarm. On 5/13/2025 at 12:11 PM V18 (CNA/ Certified Nurse Assistant) said, From the beeping, I can't tell which room activated their call light. I would have to walk around to find out who needs help because the light outside of the patient room don't always light up when they call. It's important for the call lights to work properly because the patient…

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

Based on observation, interviews, and record reviews the facility failed to maintain a safe, comfortable home like environment,[A] failed to maintain room temperatures for four [R4, R5, R6, R7] of seven [R1, R2, R3] residents reviewed for heating. Findings include, R1's clinical record indicates in part: R1 was admitted with the following medical diagnosis of paraplegia, essential hypertension, opioid abuse, anxiety disorder, colostomy, abnormal posture, malaise, and limitations of activities due to disability. R1's minimum data set [MDS] section [C] indicates R1 is cognitively intact. R1's care plan documents in part: R1 presents with moderate to extreme anxiety related to: worry regarding medical symptoms and conditions mood distress, anger, fear, and paranoia. This problem is manifested by verbal expressions of distress and frequent complaints. R1 displays manipulative behavior which is disruptive, insensitive, and disrespectful to staff and peers. This behavior is related to anger and depression symptoms are manifest by frequent threats to call state survey agency officials,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that resident's medications are administered as ordered by the physician. This failure affected three residents (R1, R2 and R3) of three residents reviewed for quality of care. Findings include: On 04/10/2025 at 12:30pm V2(DON/Director of Nursing) presented R1's, R2's and R3's MARs (medication administration records) to the surveyor, which were reviewed. There were missing entries of nurses' signatures/initials or codes on the MARs for April 2025(4/1/2025 to 4/30/2025). R1's diagnosis includes but are not limited to metabolic encephalopathy, unspecified severe protein-calorie malnutrition, vitamin d deficiency, unspecified, bradycardia, unspecified, weakness, unspecified intellectual disabilities, essential (primary) hypertension, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, dysphagia, oral phase, aphasia, type 2 diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma, altered mental status,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review, the facility failed to provide necessary treatment and services to promote healing of existing wounds for one (R1) of three residents reviewed. This failure has the potential for R1's wounds to get worse. Findings include: R1 is a [AGE] year-old individual admitted to the facility on [DATE]. R1 discharged to a nearby hospital on [DATE]. R1's medical diagnosis includes but not limited to: paraplegia, unspecified, colostomy, type 2 diabetes mellitus without complications status, other mechanical complication of cystostomy catheter, subsequent encounter, chronic obstructive pulmonary disease, unspecified. R1's progress notes dated 2/25/2025, further document R1 has multiple sacral wounds and hospital records dated 1/25/2025 document R1 has Fournier's gangrene extending from the perianal region, large right sacral ulcer and necrotizing fasciitis involving gluteal fat. MDS (Minimum Data Set) section C dated 03/04/ 2025, documents R1's Brief Interview for Mental Status (BIMS) as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to respond to call lights used for staff assistance for 2 dependent residents (R5 and R6). This failure affected two of five residents reviewed for call light assistance. Findings include: R5's admission diagnoses include but not limited to Chronic Obstructive Pulmonary Disease, Hypertension, unsteadiness on feet, and weakness. R5's Minimal Data Set (MDS), dated [DATE], documents in part, Brief Interview of Mental Status (BIMS) score is 15. R5 is cognitively intact. R5's functional abilities for mobility requires a wheelchair. R5's self-care for toileting hygiene and shower/bath is coded as dependent. (Helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity.) R6's admission diagnoses include but not limited to osteoarthritis left hip, congestive heart failure, spinal stenosis lumbar region, hypertension, and…

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

Based on observation, interview, and record review the facility failed to follow their policy for scheduled medication administration time frame. This failure affected one resident (R2) reviewed for medication administration. Findings include: R2's admission diagnoses include but not limited to paraplegia, hypertension, anxiety, contracture, colostomy, and anxiety. R2's (2/7/25) Brief Interview for Mental Status score is 15. R2 is cognitively intact. R2's Functional status for mobility requires a wheelchair. Selfcare toileting hygiene, shower/bathe, toilet transfer requires substantial maximal assistance. On 3/3/25 at 11:20 am, during the initial tour on the 1st floor observed V2 LPN (License Practical Nurse) in hallway by R2's room with the medication cart. V2 stated that R2 just got his 9:00 am medications around 10:50 am. R2's Medication Administration Audit Report for February 2025 indicates that on multiple days through out the month, medications were given outside of the scheduled time on all shifts. Medications were given more than the time frame of one hour before or one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a functioning call device for a dependent resident requiring assistance from staff. This failure affected 1 resident (R6) reviewed for resident call system. Findings include: R6's admission diagnoses include but not limited to osteoarthritis left hip, congestive heart failure, spinal stenosis lumbar region, hypertension, and glaucoma. R6's Minimal Data Set (MDS), dated [DATE], documents in part, Brief Interview of Mental Status (BIMS) score is 12. R6 has moderate cognitive impairment. R6's functional abilities for mobility requires a wheelchair. R6's self-care for toileting hygiene and shower/bath is coded as dependent. (Helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity.) On 3/3/25 at 11:40 am, surveyor noted R6's call light on in room. At 11:50 am, surveyor noted that the call light board at the…

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

Based on interview and record review, the facility failed to ensure that a resident is free from physical assault from another resident. This failure affected one resident (R2) who was physically assaulted by another resident (R1) with a history of physical aggression toward others. Findings include: R1's diagnoses include but are not limited to Dementia with Behavioral Disturbance, Schizophrenia, Strange and Inexplicable Behavior, and Bipolar Disorder. Record of BIMS (Basic Interview for Mental Status) score states 99(Severe Cognitive Impairment unable to assess). R2's diagnoses include but are not limited to Depression, Hallucinations, and Delusional Disorders. BIMS score is 12 out of 15(Mild Cognitive Impairment). On 2/19/25 at 11:30am, the surveyor observed R1 to be non-verbal and unable to respond to questions. On 2/19/24 at 10:45am, R2 was observed and asked about what happened. R2 was reluctant to say what happened. R2 stated that she (R2) is okay and does not want to get anyone in trouble. On 2/19/25 at 10am, V1(Administrator) presented the facility's incident report dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to a.) provide adequate supervision and monitoring for residents, b.) ensure medications were administered as ordered by the residents' physician, c.) ensure medications were given when the Medication Administration Record was signed, d.) notify physician of residents not receiving medications, e.) ensure medications were locked and secured while unattended, f.) provide sufficient nursing coverage to ensure adequate resident care and support, and g.) provide care and services that meet professional standards. These failures have the potential to affect 125 residents residing in the facility. Findings include: On 01/22/2025, at 8:56 AM, surveyor located on the second floor of the facility with V6 (Licensed Practical Nurse/LPN). V6 states she started her shift today at 7:00 AM and is currently the only nurse working on the second floor. V6 states management is aware, and she is awaiting another nurse to arrive to assist with resident care. V6…

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

Based on observation, interviews and record review the facility failed to accurately log dish machine temperatures and failed to ensure that that the dish machine was functioning properly. This failure has the potential to affect 162 residents who receive meals from the facility kitchen. Findings include: On 10/28/2024 at 9:46AM, during kitchen tour, Surveyor observed V16 (Dietary Aide) operating the facility dishwasher. At that time, V16 placed a temperature strip on a dish to run through the dishwasher in order to test the temperature of the dishwasher. On 10/28/2024 at 9:46 AM, V16 removed the temperature stick from the dishwasher. At that time, Surveyor noted a white box on the temperature stick. Surveyor asked what the white box on the temperature stick indicated. On 10/28/2024 at 9:46 AM, V16 stated that if the white box on the strip does not turn black, that means that the dish washer is not getting hot enough and that the dishwasher should reach a temperature of 160 degrees F (Fahrenheit) to properly sanitize the resident's dishes. Surveyor asked how long the dishwasher has…

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

Based on observations, interviews, and record review, the facility failed to ensure a resident (R57) on enhanced barrier precaution (EBP) has an EBP sign posted by the resident's room, failed to ensure residents (R32, R57, R94, and R100) on enhanced barrier precautions have readily available PPE (personal protective equipment) for the staff, failed to ensure staff don appropriate PPE when performing ADL (Activities of Daily Living) care for 2 resident (R109 and R148, failed to ensure soiled linens coming out of laundry chute and soiled linens on laundry room floor were contained, and failed to monitor measures to prevent the growth of Legionella and other opportunistic waterborne pathogens in building water systems that is based on nationally accepted standards. These failures affected 6 (R32, R57, R94, R100, R109, and R148) residents and have the potential to affect all the residents at the facility. Findings include: The (10/28/2024) List of Residents on Enhanced Barrier Precautions on 2nd floor include R32, R57, R94, and R100. On 10/28/24 at 10:48 AM, there was no EBP (enhanced…

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

Based on interview and record review, the facility failed to follow policies and procedures for immunization of residents against pneumococcal disease in accordance with national standards of practice. The facility failed to vaccinate eligible residents with the pneumococcal vaccine. The facility failed to document the refusal and/or the benefits and side effects in the resident's electronic medical records. This deficient practice affected 9 residents (R40, R46, R55, R74, R104, R118, R132, R148 and R159) sampled in a total sample size of 74 and has the potential to affect all eligible residents that reside at the facility. Findings include: Review of records for R40, R46, R55, R74, R104, R118, R132, R148 and R159 from their dates of admission up to 10/30/24 have no findings of documentation of pneumococcal vaccine offering or education of the vaccine. Review of physician orders for R40, R46, R55, R74, R104, R118, R132, R148 and R159 from admission to 10/30/24 show no orders of pneumococcal vaccination. Immunization records for R40 R46, R55, R74, R104, R118, R132, R148 and R159 has…

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

Based on observations, interviews, and record review, the facility failed to ensure incoming and outgoing nurses counted the controlled medications/substances during shift change. This failure affected 7 (R15, R41, R66, R82, R152, R158 and R164) residents taking controlled medications on 1-West and 5 (R16, R56, R135, R144, and R314) residents taking controlled medications on 2-East. Findings include: On 10/28/24 at 12:11pm during the medication storage and labeling task with V3 (Licensed Practice Nurse) of the 1-West medication cart, V3 stated 1 [NAME] includes rooms from 101 and 117. On 10/28/2024 at 12:26pm, observed the 1-West Shift Change Accountability Record for Controlled Substances has missing signatures. This was pointed out to V3. V3 stated the accountability form has missing signatures. On 10/28/2024 at 12:30pm, the controlled substance count for R15, R41, R66, R82, R152, R158 and R164 was completed with V3. V3 stated we have 7 residents taking controlled substances in 1 West. On 10/29/2024 at 10:21am during the medication storage and labeling task with V20 (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, interviews and record review the facility failed to ensure that four residents (R55, R104, R116 and R118) had psychotropic consents signed prior to administering antipsychotic medication. This failure has the potential to affect 85 other residents who have orders for psychotropic medication. Findings include: R55 is [AGE] year old with diagnosis including but not limited to: Alzheimer's disease, dementia without behavioral disturbance, major depressive disorder, impulsiveness, and delusional disorders. R55's MDS (Minimal Data Set), Cognitive Patterns assessment dated [DATE] documents severe cognitive impairment. R104 is [AGE] year old with diagnosis including but not limited to: Unspecified Dementia, schizophrenia, strange and inexplicable behavior, and unspecified symptoms and signs involving cognitive functions and awareness. R104's MDS (Minimal Data Set), Cognitive Patterns assessment dated [DATE] documents severe cognitive impairment. R116 is [AGE] year old with diagnosis including but…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 multidose medications have open and discard dates and failed to ensure a multidose medication of a discharged resident was removed from the medication cart. These failures affected 4 (R14, R41, R154, and R165) residents reviewed for Medication Storage and Labeling in the total sample of 74 residents. Findings include: On 10/28/24 at 12:11pm during the medication storage and labeling task with V3 (LPN) of the 1-West medication cart, V3 stated 1 [NAME] includes rooms from 101 and 117. On 10/28/2024 at 12:15pm, V3 checked R41's Novolin N and Basaglar insulin pens, R154 Lantus insulin pen, and R165 Lispro insulin pen and stated the insulin pens are opened and have no open and discard dates. On 10/28/2024 at 12:16pm, V3 checked R14's Humulin R vial and stated the vial is opened and has no open and discard date. On 10/28/2024 at 3:48pm, inquiring if R165 was still admitted at the facility. V3 checked R165's electronic health record and stated he (R165) is no longer here at the facility. On 10/29/2024 at…

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

Based on observation, interview, and record review, the facility failed to ensure that the two wall heating unit vents in dining room and the hallway on the third floor are maintained in good repair and in a sanitary manner. This failure has the potential to affect all 50 residents on the third floor. Findings include: On 10/28/24 at 10am after the entrance conference, V1(Administrator) presented the census that shows that the third floor has 50 residents. On 10/28/24 at 11am and at 12:45pm, on the third-floor dining room, the hallway heating unit vent and the 2 wall heating unit vents were observed to be without covers and filthy with some garbage items such as paper, straws, plastic cups, hairbrush, and medication cups. V22 (Memory Care Director) was shown these and V22 stated those items should not be inside the vent units, and that she(V22) would notify Maintenance. On 10/31/24 at 9:25am, V31(Maintenance Assistant) stated that he was just notified about the heating vents in the dining room and he's working on cleaning them out and getting the appropriate covers for them, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to obtain and document the code status in the resident's electronic medical record which affected two residents (R9 and R41) reviewed for advanced directive in the sample of 74 residents. Findings include: R9's admission record documents in part, paraplegia, chronic kidney disease stage 2, urinary tract infection, and hypertension. R9's Minimum Data Set (MDS), dated [DATE] documents in part, Brief Interview for Mental Status (BIMS) score of 15 which indicates that R9 is cognitively intact. R9's Physician Order Summary (POS) active orders as of 10/30/2024, documents that no physician order for advance directives (Full code or DNR status) for R9. R9's admission Record Form for Advance Directive section is blank. R41's admission Record documents in part, epilepsy, encephalopathy, diabetes, respiratory failure, pulmonary embolism, asthma, heart failure, and hypertension. R41's Minimum Data Set (MDS), dated [DATE], documents in part, a 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.

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's (R115) privacy curtain in his room was clean and free of a brown substance. This failure has affected one of five residents reviewed for nursing care. Findings include: R115 is [AGE] year old with diagnosis including but not limited to: Unspecified dementia, altered mental status, weakness, chronic obstructive pulmonary disease and asthma. On 10/28/2024 11:05 AM, Surveyor observed R115's privacy curtain with large amounts of a brown substance on it. On 10/28/2024 11:10 AM, V10 (Housekeeping) went with Surveyor to R115's room to observe R115's curtain. At that time, V10 said that R115's curtain appeared to have feces on it and that he (V10) would change the curtain. Surveyor asked who was responsible for changing the resident's curtains. On 10/28/2024 11:10 AM, V10 said, Housekeeping is responsible for changing the curtains, but I did not work this past weekend and this unit (third floor) is not my regular floor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Activity of Daily Living (ADL) care to one resident seeking assistance with care (R109) in a total sample size of 74 resident. On 10/28/24 at 10:40am observed V33 (Certified Nursing Assistant/CNA) leaving R109's room with bag of soiled linen from R109's roommate. On 10/28/24 at 10:41am R109 observed laying in bed on R109's left side with incontinence brief exposed. R109 observed with stool draining from side of incontinence brief. On 10/28/24 at 10:41am R109 stated that he informed V33 (CNA) that he needed to be cleaned. R109 stated that his call light has been on for assistance to clean him. R109 stated that he has had two bowel movements in the incontinence brief and has been waiting to be cleaned since the first bowel movement was made. On 10/28/24 at 11:06am observed call light to R109's room remained on. Observed call light system at facility's second floor nurse's station with call light to R109's room documented time of eighty-four minutes. On 10/28/24 at 11:25am V33 stated that R109 did inform…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 implement pressure ulcer prevention interventions for residents at risk for pressure ulcers. This failure has the potential to affect two residents (R39 and R118), reviewed for wheelchair cushions as a pressure ulcer prevention intervention, in a total sample of 74 residents. Findings include: On 10/28/24 at 10:25am during observation of residents in the third-floor dining room, R39 and R118 were observed in the dining room sitting in the wheelchair without pressure relieving cushion devices as indicated in the facility's policy. V28(CNA/Certified Nurse Assistant) was with the residents at the time and stated that she(V28) would call Restorative. Again at 11:45am, both residents were still in the wheelchairs without cushions. At this time, V22(Memory Care Director) was notified. V22 stated We will get cushions from Restorative department. On 10/28/24 at 3:19pm, V2(Director of Nursing) stated They should have cushions in the wheelchair to prevent pressure ulcers. On 10/30/24 at 10:40am, V29(ADON/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 observation, interview, and record review, the facility failed to provide the fall prevention interventions as stated in the care plans for residents with Dementia who are also at risk for falls. This failure has the potential to affect two residents, R132 and R215, reviewed for proper footwear as a fall prevention intervention, in a total sample of 74 residents. Findings include: On 10/28/24 at 10:25am during observation on the third floor, the following were observed: R132 was observed in the day room with red/white socks that are smooth on the bottom. R215 was observed in the day room with white socks that are smooth on the bottom. The surveyor inquired about R132 and R215, from V24(CNA/Certified Nurse Assistant) in the dayroom/dining room. V24 gave the names of the residents and stated, We will change the socks for them. On 10/28/24 at 11:45am, the two residents still did not have the appropriate footwear. At this time, V22(Memory Care Director) was notified. V22 stated They are supposed to wear…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that the urinary drainage bag was hanging below the bladder. This failure affected one resident (R9) reviewed in a sample of 74. Findings include: R9's admission record documents in part, Paraplegia, Chronic Kidney Disease Stage 2, Urinary Tract Infection, and hypertension. R9's Minimum Data Set (MDS), dated [DATE] documents in part, Section C. Brief Interview for Mental Status (BIMS) score of 15 which indicates that R9 is cognitively intact. Section H. Bladder and Bowel- Appliances A. Indwelling catheter. On 10/28/24 at 10:00 am, R9 in room in bed laying on his right side with the indwelling catheter lying in bed next to R9. 10/28/24 at 10:15 am, V4 LPN (License Practical Nurse) stated that the catheter (Indwelling) should not be on the bed next to the resident it should be hanging to drain with gravity. On 10/30/24 at 11:20 am, V29 ADON (Assistant Director of Nursing) stated, The catheter (indwelling) should be flowing to gravity…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that the nebulizer mask was contained and failed to post oxygen signage outside of the resident's room. These failures affected one resident (R159) reviewed for respiratory care in the total sample of 74 residents. Findings Include: R159's history documents in part, COPD, (Chronic Obstructive Pulmonary Disease) chronic respiratory failure, and shortness of breath. R159's Minimum Data Set (MDS), dated [DATE] documents in part, Section C. Brief Interview for Mental Status (BIMS) score of 15 which indicates that R159 is cognitively intact. Section J. Health Conditions: C. Shortness of Breath or trouble breathing when lying flat. On 10/28/24 at 11:40 am, observed R159 in room sitting in chair receiving oxygen through a nasal cannula at 3 liters and nebulizer mask laying on the bedside table face down uncontained. No oxygen in use sign noted on R159's door. On 10/30/2024 at 1:00 pm, R159 nebulizer mask laying on the oxygen machine face…

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

Based on observation, interview, and record review the facility failed to ensure that call lights are within reach for 7 of 7 residents reviewed for call lights in the sample. This failure affected R5, R7, R8, R9, R12, R13, and R14 whose call lights were not within reach while in bed. Findings include: On 10/15/24 at 10:12am, R5 did not have a call light. When shown to V4 CNA (Certified Nurse's Aide) and was asked about the facility policy for call light placement. V4 stated that R5 never has a call light. At 10:15am, R6 noted in bed with call light not within reach. V5 LPN (Licensed Practical Nurse) stated the call light should be placed within the resident reach. At 10:17am, R7 noted in bed with call light noted not within reach. During the same rounds observation R8 was observed in bed and call light not within reach. At 10:23am, R9's call light noted not within reach and was asking the surveyor to help in adjusting it. V5 stated the call light should be placed within reach attached to linen. At 10:40am, R12 noted on the bed with call light not within reach. At 10:42am, R13…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to report to IDPH (Illinois Department of Public Health) within required time unwitnessed fall incident with injury for one resident (R2) reviewed for falls in the sample. This failure affected R2 who had unwitnessed fall resulting in a laceration to the head and was sent to a local emergency room. This has the potential to affect all 163 residents residing in the facility. Finding include: R2's emergency report dated 9/26/24 showed documentation that R2's reason for visit was fall and laceration. R2's medical record showed that R2 was admitted originally to the facility on [DATE] and latest admission date documented as 09/22/24 listed diagnosis including but not limited to Fracture of unspecified part of neck of left femur, initial encounter for closed fracture, weakness, unsteadiness, need for assistance with personal care, Wernicke's encephalopathy, encounter for surgical after care following surgery on digestive system, unspecified dementia unspecified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 four patients (R2, R5, R6 and R8) were provided with incontinent care. This failure resulted in these four residents being soiled with urine and/ or feces for extended periods during the overnight shift. Findings include: R2 is [AGE] year old with diagnosis including but not limited to: Unilateral primary osteoarthritis, need for assistance with personal care, bilateral primary osteoarthritis of hip and weakness. R5 is [AGE] year old with diagnosis including but not limited to: Limitation of activities due to disability, muscle weakness, other reduced mobility, hemiplegia and hemiparesis following unspecified cerebrovascular disease, and unspecified lack of coordination R5's BIMS (Brief interview of mental status) score is 13, indicating cognitively intact. R6 is [AGE] year old with diagnosis including but not limited to: Hidradenitis suppurativa, overactive bladder, repeated falls and hereditary and idiopathic neuropathy. R6's…

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

Based on interview and record review the facility failed to ensure that resident's medications are administered as ordered by the physician. This failure affected three residents (R1, R2, and R3) out of the three resident reviewed for quality of care and administration of prescribed medications. Findings include: On 08/28/2024 at 2:30pm V1 (Administrator) presented R1's, R2's, and R3's August 2024 MAR (medication administration record) to the surveyor, which were reviewed. There were missing entries of nurses' signatures/initials or codes on the MAR for August 2024(08/1/2024 to 08/31/2024) for R1, R2 and R3. R1's diagnosis includes but are not limited to chronic obstructive pulmonary disease, unspecified, other asthma, essential (primary) hypertension, benign prostatic hyperplasia with lower urinary tract symptoms, other retention of urine, unspecified cystostomy status, gross hematuria, constipation, unspecified, homelessness unspecified, gastro-esophageal reflux disease without esophagitis, and hyperlipidemia. R1's Brief Interview for Mental Status (BIMS) dated 8/20/2024 documents…

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

The facility failed to follow provider orders and change the wound treatment plan for one resident (R4) out of a total sample of three residents (R4, R10, R11) for review. Findings include: 7/11/2024 at 2:45PM V7 (wound care nurse) states, after wound rounding with the doctor all orders should be carried out the same day. I (V7) do them no later than the next day. We are expected to change or update all orders in PCC (point click care-charting system). The doctor gives us verbal orders and I write them down and put orders in the system. On 6/18/2024 V20 (wound doctor) did change and gave me a verbal order for R4. I don't remember why I didn't carry the order out. I don't think it's a big issue if the orders are not changed immediately because there is an old order in place. On 7/10/2024 at 1:23PM V15 (Wound coordinator) states, we monitor wounds through weekly wound evaluations and that's usually when the doctors come around. Treatment record should be signed out when treatment is completed and orders should be carried out the same day and if it's not signed out or orders are not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were free from physical restraints imposed for three of three residents (R8, R9, R10) reviewed for restraints, resulting in the restriction of mobility and a potential for decline in physical functioning and psychosocial wellbeing. Findings Include: 5/23/2024 at 2:00 PM, R8, R9, R10 observed sitting in wheelchairs at Dining Room table; back wheels of each resident's wheelchair positioned up against the wall behind them, table positioned up against the armrests of resident's wheelchairs restricting residents' movements. R8, R9, and R10 were observed attempting to stand up multiple times. No meal or activity was in progress. R10 was eventually able to position legs over side of wheelchair allowing her to stand up and move from behind table. 5/23/2024 at 2:15 PM, V3 (Activity Aide) said, all three residents (R8, R9, R10) are fallers. V3 added, I don't know who put them there, but that's where they always sit. 5/23/2024 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 interview and record review, the facility failed to ensure radiological services were provided, as indicated by the physician's order, to a resident who sustained a fall with injury for 1 resident(R2) of 6 (R1, R4, R7, R8, R9) residents reviewed for falls. This failure resulted in R2 sustaining a Right Femur Fracture eight days prior to receiving an x-ray that indicated R1 had a questionable right sub capital fracture, was sent to the hospital for further evaluation and treatment and was admitted with a confirmed right sub capital fracture. Findings Include: R2 was readmitted to the facility on [DATE] with diagnosis not limited to Fracture of Unspecified Part of Neck of Right Femur, Subsequent Encounter for Closed Fracture with Routine Healing, Transient Cerebral Ischemic Attack, Pneumonia, Acute Respiratory Failure with Hypoxia, Chronic Systolic (Congestive) Heart Failure, Primary Osteoarthritis, History of Falling, Dementia, Ataxia, Lack of Coordination, Muscle Wasting and Atrophy, Cognitive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that a resident (R7) remained free from abuse, in a sample of three residents reviewed. This failure resulted in R7 being verbally abused by R6. Findings include: R6's current face sheet documents R6's medical diagnosis to include but not limited to violent behavior, bipolar disorder, current episode manic severe with psychotic features, malignant neoplasm of bladder, unspecified. R6's MDS (Minimum Data Set) dated 12/15/2023 document R6 BIMS score of 15/15, indicating R6 has intact cognation. R7's current face sheet documents R7's medical diagnosis to include but not limited to: Aphasia following unspecified cerebrovascular disease, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting unspecified side, dementia in other diseases classified elsewhere, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R7's Brief Interview for Mental Status (BIMS), dated 1/5/2024 documents R7 has a BIMS score of 12/15, indicating R7 has moderate cognitive impairment. On…

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

Based on observations, interviews, and record reviews, the facility failed to ensure the proper amount of fabric layers were used for one resident (R1) using a low air loss mattress out of three dependent residents with current pressure ulcers in a sample of three reviewed for pressure ulcer care. Findings include: R1's current face sheet documents R1's diagnoses to include but not limited to: hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, type 2 diabetes mellitus without complications, aphasia, unsteadiness on feet, weakness, cellulitis, unspecified, hypertensive heart disease without heart failure, unsteadiness on feet, unspecified osteoarthritis, unspecified site. Brief Interview for mental status (BIMS) dated 1/1/24: R1 does not score on the BIMS and documents R1 has memory problems, Cognitive Skills for Daily Decision Making is severely impaired, and R1 requires total care with feeding, dressing, and positioning. On 1/16/2024 at 11:55am, V5(Certified Nursing Assistant -CNA) and surveyors observed R1 laying on an air mattress that was…

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

Based on observation, interview and record review the facility failed to ensure that sufficient nursing staff were available to meet the needs for three of four dependent residents (R1, R3, R4) reviewed for ADL (Activities of Daily Living) care, failed to ensure (R5's) blood sugar was obtained as scheduled, and failed to ensure (R5, R6) medications were administered as ordered. These failures have the potential to affect a total of 106 residents residing on 1st & 3rd floor. Findings include: The (11/27/23) census includes 52 (1st floor) residents and 54 (3rd floor) residents. On 11/1/23, 11/7/23, 11/8/23 and 11/17/23 IDPH (Illinois Department of Public Health) received allegations regarding lack of facility staff on the weekends. On 11/27/23 at 2:42pm, surveyor inquired about the (1st floor) CNA (Certified Nursing Assistant) staffing. V3 (LPN/Licensed Practical Nurse) stated, My shift starts at 3pm. They (facility) normally have 4 sometimes 5 on my shift and affirmed there are 2 Nurses scheduled. Surveyor inquired about the facility weekend staffing. V3 responded, On weekend, most…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and failed to ensure that ADL (Activities of Daily Living) care was provided to three of four dependent residents (R1, R3, R4) reviewed for ADL care. Findings include: 1. On 11/1/23, IDPH (Illinois Department of Public Health) received allegations that the facility is not assisting R1 with toileting. R1 is wearing soiled diapers and clothing. The facility lacks staff on the weekends. R1's diagnoses include multiple sclerosis, end stage renal disease, dependence on renal dialysis, malaise, and need for assistance with personal care. R1's (11/7/23) BIMS (Brief Interview Mental Status) determined a score of 15 (cognitively intact). R1's (11/7/23) functional assessment affirms resident is dependent on staff for toileting hygiene and requires maximal assistance for shower/bath and dressing. R1's (4/17/23) care plan states resident has a self-care deficit and requires assistance with ADL's as evidenced by range of motion deficits and generalized weakness. Resident usually requires extensive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 physician orders, failed to ensure that medications were administered as ordered, failed to notify the physician regarding late medication administration, failed to document medication administration at the correct time for two of seven residents (R5, R6) in the sample, and the facility failed to ensure (R5's) blood sugar was obtained as scheduled (before meal). Findings include: 1. On 11/27/23, IDPH (Illinois Department of Public Health) received allegations that a resident was not receiving medications as ordered and not receiving medications in a timely manner. R5's diagnoses include type II diabetes mellitus. R5's (11/13/23) POS (Physician Order Sheets) include Humalog (Insulin) per sliding scale (if blood sugar is 150 or above) with meals. R5's (November 2023) MAR (Medication Administration Record) includes blood sugar checks and sliding scale Humalog scheduled for 7am, 11am, and 5pm administration. On 11/27/23 at 2:46pm, V4 (LPN/Licensed Practical Nurse) was observed accessing the EMAR (Electronic…

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

Based on observations, interviews, and record reviews, the facility failed to ensure food trays and beverages were covered during transportation to residents' rooms to prevent contamination; failed to wear beard covering's in the kitchen and while serving food; failed to store knives under sanitary conditions; failed to maintain cookware condition to avoid chemicals contaminating the food; and failed to air dry the blender after staff washed it in the three-compartment sink. These failures have the potential to affect all 171 residents that receive nutrition from the kitchen. Findings include: On 10/31/2023 at 9:33 AM, surveyor conducted the initial kitchen tour with V7 (Food Service Director). Observed V41 (Dietary Aide) with a beard that was not well-trimmed. V41's hairs on chin were longer than hairs on jawline. V41 was not wearing a beard cover. V41 walked in and out of the refrigerator, freezer, food storage room, and food prep areas. At 9:46 AM, surveyor observed the kitchen's knives holder with dust and yellow, sticky residue. V7 stated facility tries to clean the knives…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a Registered Nurse was on duty 8 consecutive hours 7 days a week. This has the potential to affect 175 of 175 residents residing in the facility. Findings include: The survey team was presented with the staffing schedule from August 2023 - November 2023. During review of the staffing schedule, it was noted that the schedule did not indicate a Registered Nurse assigned to a nursing unit for 8 consecutive hours a day on 08/02/23, 08/04/23, 08/12/23, 08/13/23, 08/18/23, 08/21/23, 08/24/23, 08/25/23, 08/26/23, 08/27/23, 08/28/23, 08/30/23, 09/01/23, 09/04/23, 09/08/23, 09/09/23, 09/10/23, 09/11/23, 09/15/23, 09/18/23, 10/07/23, 10/08/23, 10/16/23, 10/21/23, 10/22/23, 10/25/23, 10/27/23 and 10/30/23. On 11/02/23 at 08:39 AM V24 (Staffing Coordinator) stated We staff the facility based on the acuity of care. On 11/02/23 the surveyor was presented with a list of four Registered Nurses that are employed by the facility including V2 (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 observations, interviews, and record reviews, the facility failed to ensure food trays and beverages were covered during transportation to residents' rooms to prevent contamination; failed to wear beard covering in the kitchen and while serving food; failed to store knives under sanitary conditions; failed to maintain cookware condition to avoid chemicals contaminating the food; and failed to air dry the blender after staff washed it in the three-compartment sink. These failures have the potential to affect all 171 residents that receive nutrition from the kitchen. Findings include: On 10/31/2023 at 9:33 AM, surveyor conducted the initial kitchen tour with V7 (Food Service Director). Observed V41 (Dietary Aide) with a beard that was not well-trimmed. V41's hairs on chin were longer than hairs on jawline. V41 was not wearing a beard cover. V41 walked in and out of the refrigerator, freezer, food storage room, and food prep areas. At 9:46 AM, surveyor observed the kitchen's knives holder with dust and yellow, sticky residue. V7 stated facility tries to clean the knives holder…

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

Based on observations, interviews, and record reviews, the facility failed to follow their Garbage and Refuse policy by not disposing garbage in a sanitary manner. This has the potential to affect all 175 residents. Findings include: On 11/01/2023 at 10:59 AM, there were two large, transparent bags filled with food waste and opened milk cartons on the floor near the entrances to the kitchen. At 11:20 AM, V13 (Dietary Aide) showed surveyor how kitchen staff dispose of the garbage and refuse from the kitchen to the dumpster. When we exited the kitchen, the two large, transparent, garbage bags remained on the floor near the kitchen entrances. V7 (Food Service Manager) and V13 passed by the garbage bags and did not address them. When we returned from the outside dumpsters, the garbage bags were a few feet closer to the exit to the dumpsters. There were white liquid streaks from the original spots to the garbage bags' new spots. V13 stated the garbage bags came from the kitchen. V13 returned to the kitchen without picking the garbage off the floor. Facility's Garbage and Refuse policy…

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

Based on observation, interview and record review the facility failed to follow their policy to ensure proper infection control protocols are followed such as performing hand hygiene while distributing food trays to 4 (R56, R66, R156, R473) residents and ensuring food trays on a food cart were covered to prevent contamination. The facility also failed to follow their policy to develop an infection prevention surveillance plan to decrease the risk of infection for the population served. This failure affects all 171 residents in the facility. Findings include: On 11/01/2023 at 11:13 PM, V14 (Infection Prevention Nurse) stated that they track residents with infection and the antibiotics prescribed. Surveyor asked V14 if they do an infection prevention surveillance plan. V14 replied that the facility currently does not do one. Surveyor showed V14 the Surveillance Plan policy, Infection Prevention Plan forms, and the Surveillance Plan form that are required to be filled out. V14 states she has never seen this policy or the forms. On 11/02/2023 at 1:37 PM, surveyor showed V2 (Director of…

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

Based on observations, interviews, and record reviews, the facility failed to have an effective pest control program. This has the potential to affect all 171 residents residing at the facility. Findings include: On 10/31/2023 at 12:15 PM, lunch service was ongoing on the third-floor dining room. R1, R4, R96, R124, R133, and R140 sat at the same table towards the back of the dining room. At 12:34 PM, R133 stated shooo and swatted at a flying insect. R96 also swatted [R96's] hand over [R96's] food to deter the flying insect. Surveyor observed two flying insects hovering around the residents' table. At 12:55 PM, R124 ate lunch in their bedroom. A flying insect hoovered over R124's lunch tray. V43 (R124's Family Member) asked how can the facility get rid of them? I see them from time to time when I visit. At 1:03 PM, surveyor observed a flying insect at the nurses' station on the third floor. On 11/01/2023 at 10:19 AM, surveyor interviewed V33 (Social Services). During interview, V33 swatted at a flying insect. V33 stated gnats do appear sometimes. At 11:01 AM, V40 (Cook) prepared 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 follow their policy to ensure call lights are within reach for 1 resident (R373) out of three residents reviewed for call lights in a sample of 36. Findings include: On 10/31/2023 at 11:17 AM, surveyor observed R373 laying in her bed. Surveyor observed R373's call light on the floor. R373 stated she cannot find or reach for the call light. On 11/01/2023 at 12:00 PM, surveyor observed R373's call light on the floor not within reach of the resident. On 11/02/2023 at 1:00 PM, surveyor observed R373's call light on the floor. R373 stated that she cannot get out of bed on her own. R373 stated that she cannot reach her call light. On 11/02/2023 at 1:05 PM, surveyor asked V22 (Licensed Practical Nurse) to come to R373's room. V22 stated R373 is totally dependent on staff for getting out of bed. V22 stated that R373 needs help transferring to the wheelchair. Surveyor asked V22 if she could locate R373's call light. V22 found R373's call light on the floor. V22 then picked up the call light and clipped it to R373'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 interviews and record reviews, the facility failed to follow their Guidelines for Cardiopulmonary Resuscitation-CPR by not clarifying and updating a resident's (R66) advanced directive for 1 out of a total sample of 36 residents. Findings include: R66's face sheet documents in part medical diagnoses of cerebral infarction (stroke) and dementia. On [DATE] at 10:57 AM, R66 was oriented only to self. At 11:53 AM, surveyor reviewed R66's IDPH (Illinois Department of Public Health) Uniform Practitioner Order for Life-Sustaining Treatment (POLST) form dated [DATE] and signed by V32 (R66's Family Member/Durable Power of Attorney). It documents in part Do Not Attempt Resuscitation/DNR with Selective Treatment. At 11:56 AM, surveyor reviewed R66's physician order sheet (POS). It documents in part an order for Full Code (Attempt Resuscitation) dated [DATE]. At 11:57 AM, surveyor reviewed R66's comprehensive care plan. Advance Directives initiated on [DATE] documents in part Full Code. On [DATE] at 10:19 AM, V33…

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

Based on observation, interview and record review the facility failed to administer medications as ordered by the physician for 1 (R43) of 2 (R105) residents reviewed for providing care according to professional standards during medication administration in a sample of 36. Findings Include: R43 has diagnosis not limited to Convulsions, Abnormal Levels Of Other Serum Enzymes, Vitamin D Deficiency, Anxiety Disorder, Folate Deficiency Anemia, Post-Traumatic Stress Disorder, Chronic, Anemia, Heart Failure, Epilepsy, Unspecified, Intractable, with Status Epilepticus, Acute Respiratory Failure, Type 2 Diabetes Mellitus, Schizophrenia, Major Depressive Disorder, Recurrent, Down Syndrome, Abnormalities Of Gait And Mobility, Dysphagia, Weakness, Lack of Coordination, Unsteadiness on Feet, Malaise, Morbid (Severe) Obesity, Metabolic Encephalopathy, Bipolar Disorder, Unspecified and Asthma. R43 MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response. On 11/01/23 at 08:17 AM while preparing R43's medication V18 (Licensed Practical 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.

Based on observations, interviews and record reviews, the facility failed to follow their policy and procedure on use of linen with an air loss mattress for 3 residents (R10, R87, and R104) of 8 residents reviewed for pressure wound treatment services out of a total sample of 36. Findings include: On 10/31/23 at 12:09 PM, observed R87 lying on a low air loss mattress with multiple layers of linen underneath R87. R87 stated she has a wound on her backside, and that she was wearing a brief. On 10/31/23 at 12:15 PM, V9 (Certified Nursing Assistant) showed surveyor that R87 was lying on top of one flat sheet, one quilted reusable under pad, one material blanket and R87 was wearing an incontinent brief. V9 stated the blanket should not be there because it could make R87 hot. V9 stated R87 is allowed to have as many layers of linen underneath her as long as the sheet is a flat one and not a fitted sheet. V9 stated R87 has a pressure wound on her back/butt area. On 10/31/23 at 12:27 PM, observed R104 lying on a low air loss mattress. Observed R104 lying in bed on top of multiple layers 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 observations, interviews, and record reviews, the facility failed to follow their Urinary Catheters policy by not placing a resident's (R38) urinary drainage bag in a privacy bag for 1 of 3 residents reviewed for urinary catheters out of a total sample of 36 residents. Findings include: R38's face sheet documents in part a medical diagnosis of neuromuscular dysfunction of the bladder. R38's physician order sheets document in part that R38 has a suprapubic urinary catheter. On 10/31/2023 at 11:44 AM, V21 (Nurse) stated R38 has a suprapubic urinary catheter. V21 stated instructing the Certified Nurse Aides to put on a leg bag for R38 for privacy because R38 was sitting in dining room. At 12:34 PM, R38 was in the dining room for lunch. Urinary catheter tubing and drainage bag visible from across the dining room. Catheter drainage bag was not covered for dignity or privacy. There were 33 other residents in the dining room. On 11/01/2023 at 10:06 AM, R38 was sitting in the dining room. Urinary catheter tubing and drainage bag visible from across the dining room. There were 23…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review the facility failed to follow their midline intravenous catheter and peripherally inserted central catheter line policy for one [R92] of three [R10, R92, R159] residents to ensure their intravenous access was changed every seven days, in a sample of 36. R92's clinical record indicates but not limited to; R92 is a [AGE] year-old re-admitted back to the facility on [DATE] with medical diagnosis of infection and inflammation due to urinary catheter, bacteremia, and weakness. R92's physician orders: -10/14/23 IV-PICC [peripherally inserted central catheter line] right single lumen-change transparent dressing on admission then weekly and as needed [Dressing was to be changed on 10/14/23 then every 7 days] -10/14/23 -Micafungin Sodium intravenous Solution 100mg. Give one time per day for antifungal until 10/25/23. On 10/31/23 at 11:15 AM, surveyor and V19 [Licensed Practical Nurse] observed R92 right arm midline transparent dressing halfway lifted off [dressing was…

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

Based on observations, interviews, and record reviews, the facility failed to follow their Oxygen Administration Guidelines by not following physician orders and changing oxygen tubing weekly for 1 (R66) out of 2 residents reviewed for oxygen out of a total sample of 36 residents. Findings include: R66's face sheet documents in part medical diagnoses of chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, other acute and subacute respiratory condition due to chemicals, gases, fumes and vapors, and dependence on supplemental oxygen. R66's physician order sheet documents in part an order for oxygen at three liters per minute via nasal cannula every shift for shortness of breath related to chronic obstructive pulmonary disease. R66's comprehensive care plan contains a focus initiated 7/25/2022 for R66's respiratory risk and need for oxygen three liters via nasal cannula. Intervention initiated 7/25/2022 documents in part to administer oxygen per physician order. On 10/31/2023 at 10:57 AM, R66 was receiving oxygen via nasal cannula. Oxygen concentrator was set…

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

Based on observations, interviews, and record reviews, the facility failed to ensure that a resident (R15) was free from unnecessary anti-psychotic medications for 1 out of 5 residents reviewed for unnecessary medications out of a total sample of 36 residents. Findings include: R15's face sheet documents in part diagnoses of conversion disorder with seizures or convulsions, bipolar disorder, and major depressive disorder. R15's physician order sheets document in part an order for Haloperidol Tablet (anti-psychotic) 2 MG (milligram) by mouth every 24 hours as needed for psychotic disorder. Original order date was 6/13/2022. It was reordered on 10/19/2023. Reviewed R15's Psychotropic Medication Consent for Haloperidol PRN dated 6/13/2022. Consent documents in part a limitation of 14 days. Reviewed R15's October and November Medication Administration Records. Staff did not administer Haloperidol PRN. R15's Screening Assessment Aggression dated 7/31/2023 documents in part: Category is Minimal or Low Risk with a score of 4. In the comment section, it documents in part a moderate to low…

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

Based on observation, interview and record review the facility failed to ensure a medication error rate of less than 5% for 1 (R43) of 2 (R43, R105) residents observed during medication administration. Four errors were observed during 27 opportunities resulting in a 14.81% medication error rate. Findings Include: R43 has diagnosis not limited to Convulsions, Abnormal Levels Of Other Serum Enzymes, Vitamin D Deficiency, Anxiety Disorder, Folate Deficiency Anemia, Post-Traumatic Stress Disorder, Chronic, Anemia, Heart Failure, Epilepsy, Unspecified, Intractable, with Status Epilepticus, Acute Respiratory Failure, Type 2 Diabetes Mellitus, Schizophrenia, Major Depressive Disorder, Recurrent, Down Syndrome, Abnormalities Of Gait And Mobility, Dysphagia, Weakness, Lack of Coordination, Unsteadiness on Feet, Malaise, Morbid (Severe) Obesity, Metabolic Encephalopathy, Bipolar Disorder, Unspecified and Asthma. R43 MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response. On 11/01/23 at 08:17 AM while preparing R43 medication V18…

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

Based on observation, interview, and record review the facility failed to ensure a resident was free from a significant medication error related to anticonvulsant medication administration for 1 (R43) of 2 (R43, R105) residents reviewed for medication administration in a sample of 36. Findings Include: R43 has diagnosis not limited to Convulsions, Abnormal Levels Of Other Serum Enzymes, Vitamin D Deficiency, Anxiety Disorder, Folate Deficiency Anemia, Post-Traumatic Stress Disorder, Chronic, Anemia, Heart Failure, Epilepsy, Unspecified, Intractable, with Status Epilepticus, Acute Respiratory Failure, Type 2 Diabetes Mellitus, Schizophrenia, Major Depressive Disorder, Recurrent, Down Syndrome, Abnormalities Of Gait And Mobility, Dysphagia, Weakness, Lack of Coordination, Unsteadiness on Feet, Malaise, Morbid (Severe) Obesity, Metabolic Encephalopathy, Bipolar Disorder, Unspecified and Asthma. R43 MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response. On 11/01/23 at 08:17 AM while preparing R43's medication, the surveyor asked…

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

Based on observation, interview, and record review, the facility failed to ensure that the two community shower rooms on the first floor and the only available shower room on the third floor were in a functional and sanitary condition. This failure has the potential to affect all 56 residents on the first floor and all 58 residents on the third floor of the facility. Findings include: On 9/25/23 at 9:50am during the entrance conference with V1(Administrator), the facility census shows that there are 56 residents on the first floor and 58 residents on the third floor. On 9/25/23 at 11:35am during observation of residents on the first floor with V3(LPN/Licensed Practical Nurse), the two shower rooms were observed to have soiled diapers on the floor, soiled wet washcloths and towels on the floor, and unpleasant odor. V3 stated that the housekeeper would be notified to come and clean the two shower rooms. On 9/25/23 at 12:20pm on the third floor, V6(LPN) stated that the east wing shower room was under repairs and that only the west shower room is available for use. V6 accompanied 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 provide a shower chair to accommodate a resident's need due to physical limitations. This affected one resident (R4) out of 2 residents reviewed for accommodation of needs. As a result, R4 did not receive showers as scheduled. Findings include: On 9/25/23 during this investigation, the surveyor interviewed R4 regarding getting showers. R4 stated that she had not had a shower for a while because the CNA (Certified Nurse Assistant) refused to give the shower. On 9/25/23 at 11:30am, V3(LPN/Licensed Practical Nurse) was interviewed about R4 not getting showers. V3 stated that the only shower chair that R4 could use was broken since last week and she informed maintenance about the broken shower chair. V3 added that since last week, she(V3) has not seen the shower chair. The surveyor went with V3 to observe the two shower rooms on the first floor, and there was no large shower chair available for R4 to shower; V3 added I will call Maintenance to see if the shower chair has been repaired or if they are going to…

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

Based on observation, interview, and record review, the facility failed to ensure that residents who depend on staff's assistance for their ADL (Activities of Daily Living) care receive showers. This affected two residents (R4 and R8) out of 3 residents reviewed for ADL care. Findings include: On 9/25/23 during this investigation, the surveyor interviewed R4 regarding getting showers. R4 stated that she had not had a shower for a while because the CNA (Certified Nurse Assistant) refused to give the shower. On 9/25/23 at 11:30am, V3(LPN/Licensed Practical Nurse) was interviewed about R4 not getting showers. V3 stated that the only shower chair that R4 could use was broken since last week and she informed maintenance about the broken shower chair. V3 stated that since last week, she(V3) has not seen the shower chair. The surveyor went to the shower room with V3 to observe the shower room and there was no large shower chair available; V3 added I will call Maintenance to see if the shower chair has been repaired or if they are going to replace the shower chair. On 9/25/23 at 11:55am,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 administer medications as ordered by the physician and failed to document the reasons for not administering medications as ordered. This failure affected one resident (R14) of two residents reviewed for medication administration and documentation of medications not given. Findings include: On 10/2/23 at 11:02am, V2(Director of Nursing) presented the MAR (Medication Administration Records) and POS (Physician Order Sheets) for R14 for September 2023. The physician orders and missed doses (without chart codes for explanation of why the doses were not given) are as dated below: 9/15/23 - Heparin Sodium Injection 1 ml(milliliters) subcutaneous every 12 hours missed at 9pm from 9/18/23-9/20/23. 9/15/23 - Trazodone HCL 50 mg(milligrams) oral tablet at bedtime missed at 9pm from 9/18/23/-9/20/23. 9/16/23 - Renal Multivitamin Oral Tablet daily missed at 9am on 9/19/23. 9/16/23 - Allopurinol Oral Tablet 100mg in the morning missed at 9am on 9/19/23. 9/20/23 - Furosemide 80 mg tablet 2 times daily missed at 9pm on 9/2/23 and 9/7/23.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide dressers for residents to keep personal clothing items. This failure affects two residents (R5 and R6), reviewed for availability of bedroom furniture. Findings include: During this investigation on 9/25/23 between 10:00am and 1:00pm, R5(in room [ROOM NUMBER]) and R6(in room [ROOM NUMBER]) were observed without a dresser in the room. R5's television set (TV) was observed on the floor while the roommate's TV was on the dresser. R6's bed was observed with several clothes on the bed, however, R6 was non-verbal and did not respond to the surveyor's questions regarding not having a dresser. R4(R5's roommate) stated that the dresser was broken a long time ago and it was not fixed and was later removed and not replaced. On 9/25/23 at 11:50am, V4(CNA/Certified Nurse Assistant), was interviewed regarding why R6 does not have a dresser. V4 stated that R6 has been in the room for almost a week, and she(V4) has not seen any dresser there for…

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