Bria Of Forest Edge

Based on interview and record review, the facility failed to obtain informed consent for psychotropic medication prior to administering the medication. This failure affects 1 resident (R103) in a sample of 77. Findings include: R103's admission record documents in part, the following diagnoses: major depressive disorder, recurrent and anxiety disorder. R103's Minimum Data Set (dated 8/1/2024) documents in part a brief interview of mental status summary score of 15, indicating R103 is cognitively intact. R103's order audit report documents in part, bupropion HCl Oral Tablet 150 MG (Bupropion HCl) (antidepressant Medication) Give 1 tablet by mouth one time a day related to anxiety was ordered on 5/3/2023. The dose was decreased to 100 mg on 10/1/2024. R103's order summary report documents in part, R103 has an active order for Sertraline HCl Oral Tablet 50 MG (Sertraline HCl) (antidepressant medication) Give 37.5 mg by mouth one time a day for Anxiety, with a start date of 5/18/2024. R103's PSYCH: Consent for Psychotropic Medications (dated 5/3/2024) documents in part R103 consented 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 the call light was within reach for 1 resident (R136) out of 77 residents reviewed for call lights. Findings include: On 9/29/2024 at 11:53am observed R136 lying in the bed watching television, alert and oriented. Surveyor asked R136 Where is your call light pull string located? R136 stated, I don't know where my call light string is at, it's a little green string. On 9/29/2024 at 11:55am observed R136's call light string (a little green string with a clip attached on the end) hanging on top of the light fixture located above the head of R136's bed. On 9/29/2024 at 11:57am surveyor asked V4(LPN/Licensed Practical Nurse) to come into R136's room. V4 was asked, Where is R136's call light string? V4 stated the call light string is located on top of the light above R136's bed. V4 stated the call light is supposed to be within reach of the resident. On 9/29/2024 at 12:00pm surveyor observed V4(LPN/Licensed Practical Nurse) take the call light string from the top of the light fixture and clip the call light…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 refer two residents R34 and R103 to the appropriate state designated authority for a new Level I PASARR (Preadmission Screening and Annual Resident Review) evaluation and determination after R34 was admitted to facility without Mental Diagnosis disclosure on the Level I PASARR and R103 diagnosed with a new mental disorder. This deficient practice affected two residents (R34 and R103) in a total sample size of 77 residents. Findings include: R34's PASSAR dated 06/28/24 documents in part, PASRR Level I Determination: No Level II Required - No SMI (Serious Mental Illness)/ID (Intellectual Disability)/RC (Related Condition). R34's admission date to the facility is 06/28/24. R34's medical diagnosis includes but are not limited to Schizoaffective Disorder, Bipolar Disorder, Brief Psychotic Disorder, Depression, Impulsiveness. Facility's policy titled PASARR dated 04/2020 documents in part, General: The PASARR screening with be provided to the facility prior to admission so that the facility can make appropriate decisions…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 refer one resident (R178) to the state agency for Preadmission Screening and Resident Review (PASRR) for rescreening before R178's Short Term Approval without Specialized Services determination's expiration date. This deficient practice affected one resident (R178) in a total sample size of 77 residents. Findings include: R178's PASRR dated 11/06/23 documents in part, PASRR Determination: Short Term Approval without Specialized Services .Date Short Term Approval Ends: February 4, 2020 .This determination allows you a limited number of days in a Medicaid-certified nursing facility .If you or your care provider thinks you need you stay after that date, a nursing facility staff member must submit a new Level I screen .The new Level I screen must be submitted no later than 10 days before the Date Short Term Approval Ends. R178's PASRR Level I rescreen dated 06/07/24. R178's medical diagnosis' include Schizoaffective Disorder Bipolar Type, Type 2 Diabetes Mellitus, Asthma, Unspecified Psychosis Not Due to A Substance or Known…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that wound care treatment was completed and documented in a timely manner for one resident (R87) in a total sample size of 77 reviewed for wound care. Findings include: R87's admission diagnoses include but not limited to hypertension, cerebrovascular disease, and furuncle unspecified. R87's Brief Interview for Mental Status (BIMS) dated 07/29/24 shows R87 has a BIMS score of 14 which indicates that R87 is cognitively intact. On 9/29/24 at 11:10 am, R87 observed in room lying in bed with a soiled undated dressing noted to the left side of R87's neck. There was a dark color drainage noted on the dressing. R87 stated that the dressing had not been changed in about three days. On 9/30/24 at 2:55 pm, surveyor observed R87 in room with same soiled dressing noted on the left side of R87's neck. R87 stated the dressing had not been changed and is the same dressing from yesterday. Surveyor requested for V26 (Wound Care Nurse) to look at R87's dressing and inquired about R87's dressing change. V26 looked 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 observations, interviews, and record reviews, the facility failed to ensure nebulizer mask and oxygen tubing was contained. These failures affected 2 residents (R6 and R88) reviewed for respiratory care in the sample size of 77 residents. Findings include: R88's admission diagnoses include but not limited to chronic obstructive pulmonary disease, chronic congestive heart failure, pacemaker, and atrial fibrillation. R88's Brief Interview for Mental Status (BIMS) dated 7/29/24 shows R88 has a BIMS score of 05 which indicates that R88 has severe cognitive impairment. On 9/29/24 at 11:45 am, R88's nebulizer mask was on top of a plastic bin in R88's room not contained. On 9/30/24 at 2:40 pm, R88's nebulizer mask was on top of R88 bed side table not contained. On 9/30/24 at 2:43 pm, this observation was pointed out to V9 License Practical Nurse (LPN). V9 stated that the mask should be in bag because it could get contaminated if not in a bag. It is not proper practice to have a respiratory mask laying on a bin not covered when not being use. On 10/1/24 at 11:02 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 observation, interview, and record review the facility failed to ensure a residents had a privacy curtain which extended around the bed. This failure affected one resident (R62), out 77 residents in the total sample. Findings include: R62's Face sheet documents R62 has a diagnosis which include but not limited to versus complete obstruction, prediabetes, alcohol abuse with alcohol- induced psychotic disorder, conversion disorder with seizures or convulsions, essential hypertension, and presence of cerebrospinal fluid drainage device. R62's Brief Mental Status Interview (BIMS) dated 09/23/24 documents R62 has a BIMS score of 15 which indicates R62 is cognitively intact. On 09/29/24 at 11:35 am, Surveyor observed R62's room without a privacy curtain. R62 stated, I (R62) have been at this facility for six months and I (R2) have never had a privacy curtain. I (R2) would like a privacy curtain for my (R62) privacy and especially when I (R62) am sleeping. On 09/29/24 at 11:38 am, Surveyor questioned V15 (Housekeeper) regarding R62's missing privacy curtain and V15 stated, I (V15)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff protected one resident (R394) (out of three residents who were screened at risk for abuse) from employee to resident physical abuse. Findings include: R394's diagnosis includes but are not limited to chronic obstructive pulmonary disease with (acute) exacerbation, unspecified asthma, uncomplicated, anxiety disorder, unspecified, shortness of breath, bipolar disorder, unspecified, schizophrenia, unspecified, and dyspnea, unspecified. R394's MDS (Minimum Data Set) dated 9/19/2024 indicates a Brief Interview for Mental Status was not completed. Staff Assessment of Mental Status documents in part, C0700. Short-term Memory OK 0. Memory OK. C1000. Cognitive Skills for Daily Decision Making 0. Independent-decisions consistent/reasonable. R116's diagnosis includes but are not limited to schizophrenia, unspecified, drug induced subacute dyskinesia, major depressive disorder, recurrent, unspecified, other migraine, not intractable, with status migrainosus, and idiopathic progressive neuropathy. R116's Brief Interview for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review the facility failed to ensure one resident (R2) had clothes that fit properly. Facility failed to keep inventory of four resident's personal belongings. (R2, R3, R4 and R5). This failure affected four of four residents reviewed for personal property and has the potential to affect 196 additional residents have personal belongings in the facility. Findings include: R2 is a [AGE] year old with diagnosis including but not limited to: Major depressive disorder, anxiety disorder, morbid (severe) obesity, congestive heart failure, type 2 diabetes mellitus with unspecified complications, and moderate persistent asthma with acute exacerbation. R3 is a [AGE] year old with diagnosis of essential hypertension. R3's BIMS (Brief Interview of Mental Status) score is 15, indicating cognitively intact. R4 is [AGE] year old with diagnosis including but not limited to: Essential hypertension, other asthma, and pain in unspecified joint, and iron deficiency anemia. R4's BIMS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure a diagnostic appointment was scheduled for one resident (R5), who had an abnormal mammogram and doctor's order for a follow-up appointment. This failure affected one of three residents reviewed for nursing care. Findings include: R5 is a [AGE] year old with diagnosis including but not limited to: Major depressive disorder, anxiety disorder, unspecified asthma, chronic obstructive pulmonary disease with acute exacerbation and essential hypertension. R5's BIMS (Brief Interview of Mental Status) score is 15, which indicates cognitively intact. During investigation on 09/10/2024 at 11:31 AM R5 said, I had a mammogram done in February (2024) that came back abnormal. I was supposed to return for a follow-up appointment and the appointment was never made. I have mentioned it a couple of times to several nurses. I don't know what is going on with my breast and I am concerned. On 09/11/2024 at 12:15 PM V3 (DON/Director of Nursing) said, I thought that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report and investigate mental abuse for one (R2) of three residents reviewed for mental abuse. Findings include: On 08/29/2024 at 10:51AM, R2 stated on the day of the altercation he was standing in the medication line to receive his medication. R2 stated the nurse (identified as V7/LPN) gave R2 his medication and noticed a pill was missing so R2 let V7 know. R2 stated V7 works at the facility periodically and V7 forgets his pill often. R2 stated this particular time after R2 reminded V7 to give him his pill, V7 told R2, I'm going to beat the $h!+ out of you. R2 stated he reported this to V5 (Psychiatric Rehabilitation Service Coordinator/PRSC) the next day. R2 stated he reported to V5 that V7 was being ignorant with him, giving him a hard time, and that V7 threatened to beat the $h!+ out of R2. On 08/29/2024 at 11:10AM, V5 (PRSC) stated R2 reported to her that V7 (Licensed Practical Nurse/LPN) yelled at him, V7 does not give R2 his medication, and R2…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 affirm the right of the resident to be free from physical abuse. This failure has affected 1 (R6) of 6 residents reviewed for abuse. Findings Include: On 8/13/24 at 10:52 AM, R6 stated about a month ago R10 punched R6 in the face because R6 entered R10's bathroom without knocking while R10 was inside the bathroom. R6 stated R6 did not sustain any injury, but R6 was moved to another room and R10 was moved to the 3rd floor because of the incident. R6 told V18 (Certified Nursing Assistant/CNA)) and V36 (R6's Complainant) R6 was punched in the face by R10. R6 stated R6 has seen R10 since the incident, and R10 has threatened R6 with R10's walking cane. R10 stated R10 was transferred to the 3rd floor because of R6, but R6 always ignores R10, and R6 did not tell anyone. On 8/13/24 at 11:10 AM, V11 (Social Worker) stated the administrator is the abuse coordinator; therefore, V11 will report any abuse to the administrator immediately. The incident between R6…

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

Based on interviews and record reviews, the facility failed to follow their abuse policy and procedure to ensure abuse allegation was reported to the abuse coordinator and to ensure abuse allegation was reported no later than two hours to the State Agency (SA) for 2 (R6, R10) out of 6 residents reviewed for abuse. Findings Include: On 8/13/24 at 10:52 AM, R6 stated about a month ago R10 punched R6 in the face because R6 entered R10's bathroom without knocking while R10 was inside the bathroom. R6 did not sustain any injury but R6 was moved to another room and R10 moved to the 3rd floor because of the incident. R6 told V18 (Rehab Certified Nursing Assistant/CNA)) and V36 (R6's Complainant) R6 was punched in the face by R10. R6 stated R6 has seen R10 since the incident, and R10 has threatened R6 with R10's walking cane. R10 stated R10 was transferred to the 3rd floor because of R6, but R6 always ignore R10, and R6 did not tell anyone. On 8/13/24 at 11:35 AM, R10 stated R10 punched R6 in the face when R6 opened the washroom without knocking at the door when R10 was in the washroom.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 notify residents of their trust fund balances before they exceeded the $2000.00 resource limit for Social Security Administration (SSI) for an individual for 17 of 17 residents (R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, and R20) who were reviewed for trust fund in the sample. This failure has the potential to affect the Medicaid and SSI eligibility for R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, and R20 listed as having trust fund over the $2000 limit and has the potential to affect all the 189 residents residing at the facility. Findings include: On 06/25/24 review of the facility Resident Fund Management Service Trial Balance dated 06/25/24 showed the following resident trust fund balances: R4 Trust fund balance as at 06/25/23 =$3752.49 R5 Trust fund balance as at 06/25/23 = $14,942.58 R6 Trust fund balance as at 06/25/23 =$2036.95 R7 Trust fund balance as at 06/25/23 =$2074.04 R8 Trust fund balance as at 06/25/23 =$3319.71 R9 Trust fund balance as at 06/25/23…

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

Based on observation, interviews, and review of the facility failed to maintain dishwasher equipment in clean condition; failed to maintain testing strips used to determine concentration of solution in the three-compartment sink. Dishwasher and three-compartment sinks are used to sanitize dishes and utensils used by residents during mealtime. Failures have the potential to affect all 190 residents that are taking food by mouth. Findings include: On 5/14/2024 at 1:06 PM, V3 (Dietary Manager) was asked what the kitchen staff used to determine concentration of solution when cleaning or sanitizing dishes and utensils used by residents. V3 replied, We have strips to determine solution concentration. V3 then reached up on the top of the shelf-like structure above the three-compartment sink and grabbed a cylindrical clear plastic container. Inside were strips within a paper that showed labels had expiration date of 04/01/2022. V3 was informed that the strips are expired more than two years ago. V3 stated that he did not know that the strips were expired. V3 stated that kitchen staff cannot…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medication administration policy on documenting inhaler medication ordered by physician; failed to observe proper time in administering inhaler medication; and failed to follow respiratory care plan to administer medication as ordered by physician. These failures apply to 1 out of 3 residents (R2) for a total sample of 3 residents reviewed for pharmaceutical services. Potential effect of these failures involved 1 resident (R2) diagnosed with COPD that needs inhaler medication to address symptoms of disease. Findings include: R2 is [AGE] years old, admitted initially on 03/03/2023. R2's primary diagnosis dated 3/6/2023 is chronic obstructive pulmonary disease (COPD). Per CDC (Centers for Disease Control and Prevention) Chronic obstructive pulmonary disease (COPD) prevents airflow to the lungs, causing breathing problems. It is a leading cause of death in the United States. On 5/14/2024 at 11:40 AM, R2 was seen lying on his bed,…

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

Based upon observation, interview and record review the facility failed to ensure nursing staff arrive timely to work, failed to ensure medications are dispensed for one resident at a time, failed to ensure that dispensed medications are discarded if not administered, failed to ensure medication administration is documented, failed to ensure medications are not left at the bedside, failed to administer (R1, R3, R4) medications (as prescribed) and failed to ensure staff administer medications within regulatory requirements for 37 of 37 residents (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, R36, R37) in the sample reviewed for medication administration. These failures have the potential to affect 45 (6th floor) residents. Findings include: On 3/21/24, IDPH (Illinois Department of Public Health) received allegations that R1's medications were not administered. R1, R2, R3 and R4 reside on 6th floor. The (3/27/24) census includes 45 (6th floor) residents. On 3/27/24…

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

Based upon observation, interview, and record review the facility failed to ensure medications were administered as ordered and failed to ensure that four of four residents (R1, R2, R3, R4) reviewed for medication administration remained free from significant medication errors. Findings include: On 3/21/24, IDPH (Illinois Department of Public Health) received allegations that pain, blood pressure and neurological medications were not administered to R1. On 3/27/24 at 10:36am, surveyor inquired if R1 received prescribed (9am) medications today. V5 (Licensed Practical Nurse) stated, Yes she did. However, R1's name was highlighted red (indicating late administration) on the EMAR (Electronic Medical Record). V5 accessed R1's EMAR (as requested) and affirmed all (9am) medications were not documented as warranted. Surveyor inquired why R1's (9am) medications were not documented if they were administered. V5 responded, I thought I did. Surveyor inquired about the regulatory requirement for medication administration. V5 replied, You sign, you document it after resident has taken 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 upon observation, interview, and record review the facility failed to follow the staffing policy, failed to ensure that nursing staff arrive on time and/or as scheduled, and failed to ensure that sufficient nursing staff were available to meet the needs for three of four dependent residents (R5, R10, R11) reviewed for ADL (Activities of Daily Living) care. These failures have the potential to affect 251 residents. Findings include: On 9/7/23, 9/15/23 and 9/18/23 IDPH (Illinois Department of Public Health) received allegations regarding facility lack of staff. The (9/19/23) census includes 251 residents. R10 resides on 2nd floor. R10's (6/26/23) BIMS (Brief Interview Mental Status) determined resident is rarely/never understood. R10's (6/26/23) functional assessment affirms (2 person) physical assist is required for toilet use. On 9/19/23 at 11:40 am, R10's incontinence brief was saturated with urine and stool. The pad beneath R10 was also soiled with stool. V13 (CNA/Certified Nursing Assistant) affirmed she is assigned to R10. V13 stated, I got to work late today, around…

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

Based upon record review and interview the facility failed to report accurate information to IDPH (Illinois Department of Public Health) and failed to substantiate physical abuse resulting in serious injuries (laceration, subdural hematoma) for one of four residents (R2) reviewed for abuse. Findings include: On 9/15/23, IDPH (Illinois Department of Public Health) received allegations that (R2) was hit in the head a few times by an unknown resident weeks ago and has a brain bleed. On 8/19/23 at 10:23 am, V1 (Administrator) presented the (July-September 2023) abuse binder as requested however R2's abuse incident was excluded. Surveyor inquired if R2 was abused by another resident in the facility. V1 affirmed she was unaware of the allegation. On 9/19/23 at 11:09 am, surveyor inquired if R2 was involved in a physical altercation with another resident. V3 (Assistant Director of Nursing) stated, He had an incident about 2 months ago with another resident. I believe it was reported to (V1) so she will have the details. Surveyor advised that the (July-September 2023) abuse binder 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 provide ADL (Activity of Daily Living) care to three of four dependent residents (R5, R10, R11) reviewed for ADL care. Findings include: 1. R5's diagnoses include history of traumatic brain injury, hemiplegia and hemiparesis affecting right side. R5's (8/9/23) BIMS (Brief Interview Mental Status) determined a score of 14 (cognitively intact). R5's (8/9/23) functional assessment affirms (2 person) physical assist is required for toilet use. On 9/19/23 at 1:40 pm, surveyor observed an incontinence brief and soiled saturated washcloth lying on the bed next to R5. Surveyor inquired when R5's incontinence brief was last changed. R5 stated, This morning on the night shift. Surveyor inquired what was lying next to R5. V12 (Registered Nurse) stated, It's a diaper, I can ask the CNA (Certified Nursing Assistant) taking care of him to come. Surveyor inquired why a soiled wet washcloth was also on R5's bed. V12 responded, I know it's bad, but I need to check to see, this should not be there definitely not. R5's Care Plan…

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

Based on observation, interview, and record review the facility failed to a.) ensure medications were labeled and dated in 2 of 4 medication carts, b.) properly store insulin pens in 1 of 3 medication rooms reviewed and c.) ensure the medication carts were locked during medication administration in a sample of 35 residents. Findings Include: On 08/29/23 09:56 AM V18 (Licensed Practical Nurse) prepared R122 medications then entered R122's room and administered the oral medications leaving the medication cart unlocked. V18 returned to the medication cart, retrieved R122's eye drops, put on a pair of gloves, entered R122's room leaving the medication cart unlocked and administered the eye drops. On 08/29/23 10:06 AM V18 (Licensed Practical Nurse) entered R151's room leaving the medication cart unlocked then realized R151 was not in the room. On 08/29/23 10:11 AM V18 (Licensed Practical Nurse) entered R133's room leaving the medication cart unlocked and administered R133's medications. On 08/23/23 10:16 AM V18 (Licensed Practical Nurse) continued passing medications and entered R243'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 Based on observation, interview and record review, the facility failed to properly defrost meat, discard expired food from the refrigerator and failed to store dish racks off the floor. This failure affected 248 residents residing in the facility. Findings include, On 8/29/23 at 10:40 AM during the initial kitchen tour with V4 (Dietary Manager) the following were observed: 4 boxes of yogurt with expiration date of 8/7/23. V4 said, the yogurt should have been discarded by the expiration date. On top of the sink, there was a plastic bin with defrosting rolls of ground beef. V4 said the proper way to defrost is to have running water on the beef rolls and not to have them defrosting on top of the sink. Further observed, 7 dish racks were stored on the floor. V4 said no items should be on the floor and always 6 to 12 inches above the floor the floor. Facility did not provide as requested a policy that addressed timely removing of expired food from the refrigerator and storing items off the floor. Facility's policy Food: Preparation documents in part: 5. The cook thaws frozen items…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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: 1. Failed to ensure door signage for Enhanced Barrier Precautions was available for 1 (R512) resident. 2. Failed to ensure staff wore and discarded proper PPE (Personal Protective Equipment) while caring for 3 (R11, R76, R512) of 3 residents on Enhanced Barrier Precautions. 3. Failed to ensure staff performed hand hygiene before donning gloves for resident on Enhanced Barrier Precaution for 1 (R11) resident and during medication administration. 4. Failed to ensure soiled linens were properly placed inside a clear plastic bag. These failures can potentially affect 123 residents residing on the 2nd, 3rd and 6th floor as of facility roster dated 8/29/23 reviewed for infection control. The findings include: R11's health record documented admission date of 3/23/10 with diagnoses not limited to Chronic obstructive pulmonary disease, Chronic bronchitis, Metabolic encephalopathy, Hyperlipidemia, Nicotine dependence, Generalized osteoarthritis, Benign prostatic hyperplasia, Hypothyroidism, Schizoaffective disorder, Major…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policy of Pneumococcal vaccination: 1. Failed to provide eligible residents and/or resident representatives education regarding the benefits and potential side effects of all available pneumococcal vaccinations for 7 (R4, R11, R88, R98, R124, R178, R257) residents. 2. Failed to screen or assess eligibility and offer pneumococcal vaccinations for 7 (R4, R11, R88, R98, R124, R178, R257) residents. 3. Failed to administer dose of PCV15 (Pneumococcal Conjugate Vaccine) or PCV20 at least 1 year after the most recent PPSV23 (Pneumococcal Polysaccharide Vaccine) for 2 (R4 and R257) residents. These failures could potentially affect 7 (R4, R11, R88, R98, R124, R178, R257) residents eligible to receive the Pneumococcal vaccinations in a sample of 35. The findings include: 1. R4's health record documented admission date of 3/17/15, [AGE] years of age with diagnoses not limited to Chronic obstructive pulmonary disease, Chronic bronchitis, Metabolic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 n interview and record review the facility failed to ensure 1 (R4) resident had an order for the Code Status/Advance Directive that is documented on the POLST (Physician Order for Life Sustaining Treatment) as DNAR (Do Not Attempt Resuscitate) in a sample of 35. Findings Include: R4 has diagnosis not limited to Chronic Obstructive Pulmonary Disease With (Acute) Exacerbation, Hyperlipidemia, Nicotine Dependence, Schizoaffective Disorder, Depressive Type, Simple Chronic Bronchitis, Benign Prostatic Hyperplasia, Peptic Ulcer, Hypothyroidism, Major Depressive Disorder, Overactive Bladder, Primary Generalized (Osteo) Arthritis, Metabolic Encephalopathy, Other Disorders of Brain in Diseases Classified Elsewhere and Retention of Urine. Review of R4 Order Summary Report dated [DATE] has no documented Code Status/Advance Directives. Care Plan documents in part: Advance Directive: R4 has chosen to have no advanced directive. R4 is a full code. Date initiated [DATE]. Goal: R4 is a full whole status as specified 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 n observation, interview and record review the facility failed to protect private health information for 1 (R76) resident by leaving confidential medical information unattended in an area accessible to the public on 1 medication cart during medication administration. The facility also failed to knock on the door before entering in 1 (R76) resident's room in a sample of 35. Findings Include: R76 has diagnosis not limited to Type 2 Diabetes Mellitus Without Complications, Extrapyramidal And Movement Disorder, Mixed Hyperlipidemia, Hypertensive Heart Disease Without Heart Failure, Atherosclerotic Heart Disease Of Native Coronary Artery, Major Depressive Disorder, Conversion Disorder With Seizures or Convulsions, Gastro-Esophageal Reflux Disease, Paranoid Schizophrenia, Personal History Of Covid-19, Chronic Obstructive Pulmonary Disease With (Acute) Exacerbation, Encephalopathy, Pneumonitis Due To Inhalation Of Other Solids And Liquids, Gastrostomy Status, Severe Protein-Calorie Malnutrition, Muscle Weakness, Dysphagia and Lack Of Coordination. On 08/30/23 at 08:11 AM V19 (Agency…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Smoking Policy by not conducting smoking assessments quarterly for two (R146, R156) residents out of a total sample of 35 residents. Findings include: On 8/29/2023 at 12:22 PM, R146 stated R146 is smoking three cigarettes a day. R146's last SS [Social Service]: Safe Smoking Risk Assessment was on 5/9/2023. The previous assessment was from 11/9/2022. R146's MDS [Minimum Data Set] Assessments document in part quarterly assessments from 8/8/2023, 5/8/2023, and 2/6/2023. No smoking assessment related to 8/8/2023 and 2/6/2023 quarter. Later in the survey, facility provided Safe Smoking Risk Assessments 8/8/2023 and 2/6/2023 but they were not completed and signed until 8/30/2023, the time of the survey. Facility's Smoking Policy, last revised 9/2022, documents in part: Residents will be educated upon admission about the smoking policy and those that smoke will be assessed not only upon admission (within the first 72 hours of admittance), 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to update the care plan for 1 (R4) to accurately reflect the code status as documented on the POLST (Physician Order for Life Sustaining Treatment) form as DNAR (Do Not Attempt Resuscitate) in a sample of 35. Findings Include: R4 was admitted to Hospice on [DATE] with a diagnosis not limited to Chronic Obstructive Pulmonary Disease With (Acute) Exacerbation, Hyperlipidemia, Nicotine Dependence, Schizoaffective Disorder, Depressive Type, Simple Chronic Bronchitis, Benign Prostatic Hyperplasia, Peptic Ulcer, Hypothyroidism, Major Depressive Disorder, Overactive Bladder, Primary Generalized (Osteo) Arthritis, Metabolic Encephalopathy, Other Disorders of Brain in Diseases Classified Elsewhere and Retention of Urine. Review of R4 Order Summary Report dated [DATE] has no documented Code Status/Advance Directives. Care Plan document in part: Advance Directive: R4 has chosen to have no advanced directive. R4 is a full code. Date initiated [DATE]. Goal: R4 is a…

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

Based on interviews and record reviews, the facility failed to follow their policies and protocol by not documenting attempts to contact the resident or representative, not contacting local law enforcement, and immediately notifying the physician when the resident failed to return to the facility for one out of three closed records in a sample of 35 residents. Findings include: R260's census report and face sheet document in part a discharge date of 6/27/2023. V21's (Nurse) progress note dated 6/27/2023 1:03 PM documents in part that R260 left out on pass with family. R260 was scheduled to return the evening of 6/30/2023. The subsequent progress notes document in part that R260 remained out on pass. The last progress note was from 7/27/2023. No further update charted. R260's physician order sheets did not contain a discharge order. On 8/31/2023 at 9:38 AM, V31 (Social Service Director) stated R260 was not discharged . V31 stated family picked up R260 for out on pass but did not return to the facility during scheduled date. V31 stated no calls were going through with attempts 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure low air loss mattress device was in the correct setting for a dependent resident with a current pressure ulcer. This failure has the potential to affect 1 (R177) of 4 residents in a sample of 35 residents reviewed for pressure ulcers. Findings Include: On 8/29/23 at 10:44 AM, R177 sleeping in bed and noted on a low air loss mattress with the dial set to 180 pounds (lbs.). At 10:56 AM, V13 (Wound Care Nurse) stated R177 has stage 4 sacral pressure ulcer and dressing changes on Monday, Wednesday, and Friday. R177 stated skin assessments are done weekly. V13 stated R177 is on the low air loss mattress to help release some of the pressure on R177's wound. V13 stated the purpose of the low air loss mattress is to help prevent the wound to get worse and develop more wounds. V13 stated the low air loss mattress should be set based on the resident's weight. V13 stated if the setting is incorrect then the mattress would not deliver the…

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

Based on observation, interview and record review the facility failed to ensure an intravenous catheter dressing was sealed to prevent the potential for contamination for 1 (R512) resident reviewed for intravenous catheter care in a sample of 35. Findings Include: On 08/30/23 at 09:19 AM V3 (Director of Nursing) donned gloves then entered R512 room and asked R215 to let him (V3) check her (R512) line, V3 then exited the room. On 08/30/23 at 09:24 AM V3 (Director of Nursing) said to R512, I will have them come and change your dressing. V3 was referring to R512 right arm single lumen PICC (Peripherally Inserted Central Catheter) line dressing that was observed to be unsealed at the lower end of the dressing and undated. Signage was observed on R76 door indicating Enhance Barrier Precautions. Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: wear gloves and a gown for the following Device care or use: central line. V3 did not put on an isolation gown. On 08/30/23 at 09:28 AM V3 (Director of Nursing) prepared R512 IVPB…

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

Based on observation, interview and record review the facility failed to a.) obtain an order for oxygen administration, and b.) failed to change the oxygen humidity bottle, label, and date the nasal cannula per the Physician orders and per the facility policy for 1 (R247) resident in a sample of 35. Findings Include: R247 has diagnosis not limited to Hyperlipidemia, Benign Prostatic Hyperplasia, Essential (Primary) Hypertension, Anorexia, Anemia, Chronic Viral Hepatitis, Chronic Combined Systolic (Congestive) And Diastolic (Congestive) Heart Failure and Chronic Obstructive Pulmonary Disease. Order Summary Report dated 08/30/23 documents in part: change end date oxygen tubing, nasal cannula and humidifier every night shift, every Sunday for prophylaxis. Progress note dated 08/28/23 12:16 document in part: Nurses Note Text: Resident on Doctor Appointment. Writer received a call that resident vitals need urgent attention Blood pressure 61/42, Heart rate 45, oxygen saturation 81 despite being on 02 (oxygen) 2 liters. On 08/29/23 at 11:53 AM R247 was observed lying in bed with oxygen 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 and interview, the facility failed to maintain a resident's wheelchair in a safe operating condition for 1 (R42) resident reviewed for equipment safety in a sample of 35. Findings Include: R42 was observed sitting in a wheelchair that appeared to be too small with no arm rest at the end of the hallway. The wheelchair seat was observed leaning to the right. When R42 was asked if that was his wheelchair R42 stated, I need another one because it is leaning to the right. On 08/30/23 at 11:44 AM V25 (Rehabilitation Director) pointed to a wheelchair and stated, This is the wheelchair that (R42) had, and we gave (R42) another wheelchair yesterday. The back of the wheelchair is torn and that is the only thing that is wrong with it. It was brought to my knowledge yesterday. I told (V24) (Rehabilitation Certified Nurse Assistant) to get (R42) another wheelchair. On 08/30/23 at 11:51 AM Resident # 42 stated, I let them know that the wheelchair was leaning. 08/30/23 at 11:56 AM V24 (Rehabilitation Certified Nurse Assistant) stated, I changed (R42's) wheelchair yesterday…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to follow their policy and procedure to report an incident/unusual occurrence that resulted in a serious harm within twenty-four hours to the State Survey Agency (SA) for 1 (R412) out of 1 resident in a sample of 35 reviewed for incidents and accidents. Findings Include: R412's medical records show an admission date of 7/5/23 with diagnoses including but not limited to Schizophrenia, Major Depressive Disorder, Bipolar Disorder, and Epileptic Seizures. R412's progress notes dated 7/5/23 at 7:24 PM written by V3 (Director of Nursing) shows R412 was admitted in the facility from an acute hospital with history of alcohol and drug abuse. R412's Minimum Data Set (MDS) dated [DATE] shows R412 was cognitively intact and required supervision with locomotion on and off unit. Progress notes dated 7/27/2023 at 9:36 PM written by V8 (Licensed Practical Nurse/LPN) documents in part: [R412] noted in bed lethargic unresponsive. [R412's] pupils pin point. [R412'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 thoroughly investigate a resident's incident of drug overdose for 1 (R412) out of 1 resident in a sample of 35 reviewed for incidents and accidents. Findings Include: R412's medical records show an admission date of 7/5/23 with diagnoses including but not limited to Schizophrenia, Major Depressive Disorder, Bipolar Disorder, and Epileptic Seizures. R412's progress notes dated 7/5/23 at 7:24 PM written by V3 (Director of Nursing) shows R412 was admitted in the facility from an acute hospital with history of alcohol and drug abuse. R412's Minimum Data Set (MDS) dated [DATE] shows R412 was cognitively intact and required supervision with locomotion on and off unit. Progress notes dated 7/27/2023 at 9:36 PM written by V8 (Licensed Practical Nurse/LPN) documents in part: [R412] noted in bed lethargic unresponsive. [R412's] pupils pin point. [R412's] speech slurred and altered mental status V/S B/P 166/125, pulse 103, Temp., 98.7, O2 98, B/G 126 ADON 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 observations, interviews and records review, the facility failed to maintain an effective pest control program. This failure has the potential of affecting all 256 residents residing at the facility. Findings include: On 8/15/2023 at 10:34am, R3 was observed in his room, seated on his bed. R3 said there are roaches in his room and he killed one this morning by stomping on it with his foot. R3 said he does not like bugs in his room and when the facility sprays the bugs, the roaches are still there. On 8/15/2023 at 10:39am, R10 was observed lying in his bed. A black mouse trap was on the floor near R10's window. R10 said there are roaches and bugs running around in his room and he does not like bugs. R10 said R10 is constantly cleaning his windowsill and his bathroom, then housekeeping comes to go over his cleaning after he has cleaned. V10 said he has seen roaches in the hallways and in the elevator and hears mice running around especially at night. R10 said he tells staff (no name provided) when he sees bugs and mice and that is why there is a trap in his room to try 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 one (R7) of five residents reviewed remained free from abuse. This failure resulted in R7 being verbally abused. Findings include: R7 is a [AGE] year-old individual admitted to the facility on [DATE]. R7's medical diagnosis includes but not limited to: dysphagia following cerebral infarction, hemiplegia and hemiparesis following unspecified, cerebrovascular disease affecting right dominant side, unspecified lack of coordination. R7's MDS (Minimum Data Sheet) section C documents R7's Brief Interview for Mental Status (BIMS), dated Wed [DATE], as 14/15, and his Functional Abilities and Goals dated Thu [DATE], document R7 as: Dependent for all ADLS (Activities of Daily Living) such as eating, toileting, bathing, oral hygiene, seating, lying. MDS section G dated 8/10/2023, documents R7 is extensive assist, two plus person assist for ADL care on bed mobility, transfer, locomotion on/ off unit, dressing assistance, eating, toilet…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide ordered antibiotic medication to 1 (R5) resident of 3 residents reviewed for medication administration. Findings include: On 8/16/23 at 3:00 PM, V2 (Director of Nursing) stated R5 was ordered Ceftriaxone 2GM and Amoxicillin 500MG. According to the MAR (Medication Administration Record) and the progress notes, R5 Ceftriaxone and Amoxicillin was not given on 6/15/2023 because the medication was not available. The note dated 6/16/2023 does not indicate the medication was administered. V2 stated, If it is not written it was not done. V2 stated the pharmacy delivers twice a day, in the AM and PM. If a medication is not available, we call the pharmacy and order. Pharmacy should get the medication to the facility the same day or the next day. We have an emergency medication box. The box is refilled right away. The two medications R5 did not receive are antibiotics. Antibiotics are given for infection or prophylactically to prevent infection.…

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

Based on interviews and record reviews, the facility failed to ensure complete Treatment Administration Records (TAR) for 2 (R4, R9) of 3 residents reviewed for wounds. Findings include: R4's face sheet and Physician Order Sheets (POS) document in part that R4 had pressure ulcers to sacrum and bilateral ischium. R4's June TAR documents in part to cleanse sacrum wound with wound cleanser, apply leptospermum, and cover with dry dressing every Monday, Wednesday, Friday and as needed until resolved to promote wound healing. Start date was 5/29/2023. Discontinued date was 6/13/2023. No documentation for 6/9/2023 and 6/12/2023. R4's June TAR documents in part to apply Dakin's solution 1/4 strength wet to moist packing to left ischium and cover with dry dressing daily and as needed until resolved to promote wound healing. Start date was 6/17/2023. Discontinued 7/3/2023. No documentation from 6/17/2023-6/21/2023, 6/24/2023, and 6/27/2023. R4's June TAR also documents in part to apply Dakin's solution 1/4 strength wet to moist packing to right ischium and cover with dry dressing daily and 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.

Based on observation, interview and record review, the facility failed to label with date food items in the freezer and dry storage room, failed to ensure staff's water bottles were not stored in the kitchen's freezer, failed to ensure food were discarded by use by date to prevent foodborne illnesses. These failures have the potential to affect all 258 residents taking oral nutrition in the facility. Findings include: The (10/16/2022) resident census was 261. The (undated) list of NPO (nothing by mouth) residents include 3 residents. On 10/16/2022 at 9:46 am, during the initial tour of the kitchen, there were 2 water bottles (Aquafina and Ice Mountain) inside the kitchen freezer. V26 (Lead Dietary Aide) stated, The staff are not supposed to keep these in the freezer. There were boxes of chicken and potato crunch not labeled with dates. V26 stated These should be dated. Everything that goes in the freezer should be dated. On 10/16/2022 at 9:54am, on the spice racks, the bottle of salt, chili powder, ground cinnamon, Dijon mustard, Worcestershire sauce and picante sauce were not…

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

Based on observation, interview and record review the facility failed to prevent rodents from entering one residents room (R22), failed to prevent insects from entering the building and failed to prevent flies from entering in one resident's room (R248) by not maintaining the area. This failure has the potential to affect all residents residing in the facility. Findings: On 10/16/2022 at 12:11pm surveyor observed an insect/rodent sticky board attached to the baseboard behind R22's bed. R22 stated that there is a hole in the wall and the sticky board is there to prevent mice from coming through the hole. R22 stated that she has seen mice running around in her room. On 10/18/2022 at 12:24pm V43 (Housekeeper/Floor Tech) stated that he does put down rodent/insect sticky board if the residents complain of seeing mice or bugs in their rooms. V43 stated that he was not aware that there was a hole in the wall in R22's room and that sticky board should be laid on the floor and not stuck to the wall. Surveyor asked V43 to remove the sticky board from the baseboard behind R22's bed and tell…

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

Based on observation, interview and record review, the facility failed to ensure the Low Air Loss Mattresses were set at the recommended settings, failed to ensure the Low Air Loss Mattresses were not layered with multiple linens and padding, failed to ensure the Low Air Loss Mattress was inflated before use and failed to ensure a resident at risk for pressure ulcer/injury was not lying on a Hoyer lift sling while on Low Air Loss Mattress. These failures affected 5 (R6, R37, R45, R188, and R204) residents reviewed for pressure ulcer/injury prevention and treatment in the total sample of 98 residents. Findings include: On 10/16/22 at 11:12 AM, there was a low air loss mattress on R188's bed with setting between 320 and 350. On 10/16/22 at 11:17AM, this surveyor inquired about R188's Low Air Loss Mattress. V8 (Licensed Practice Nurse) stated, R188's Low Air Loss Mattress is to prevent pressure wounds. V8 then checked the setting of R188's Low Air Loss Mattress, per this surveyor's request and stated, Setting at 330lbs, low pressure. Setting of the Low Air Loss Mattress is based on the…

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

Based on observation, interview and record review, the facility failed to ensure that unopened insulin was refrigerated for one resident (R196), failed to properly store insulin and lancets when not in use, failed to ensure a medication cart was locked when unattended, failed to discard expired medication and medication for one resident (R369) who expired that were stored in the medication refrigerator, and failed to ensure that two opened and expired emergency medication kits were removed from the facility once a new emergency medicine dispensing machine was implemented. Findings include: On 10/17/22 at 9:03 AM, V23 (LPN/Licensed Practical Nurse) was observed entering the medication storage room while leaving a plastic caddie containing insulin pens and blood sugar checking supplies including lancets on the medication cart next to the nurse's station on the 3rd floor. The surveyor inquired if medications should be left unattended. V23 replied, No. On 10/17/22 at 9:23 AM, the surveyor observed V24 (LPN) enter R116's room on the 4th floor. The medication cart was left in the doorway…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 indwelling catheter drainage bag is covered for dignity. This failure affected 1 (R45) resident reviewed for dignity in the total sample of 98 residents. Findings include: On 10/16/2022 at 12:55pm, R45's indwelling catheter drainage bag has no cover. On 10/16/2022 at 1:06pm, surveyor inquired about R45's indwelling catheter drainage bag. V4 (Assistant Director of Nursing) stated, It is not in a privacy bag. On 10/18/2022 at 9:51am, during wound care observation with V25 (Wound Care Nurse/LPN), R45's indwelling catheter drainage bag was still not covered. On 10/18/2022 at 9:53am, surveyor inquired about R45's indwelling catheter drainage bag. V25 (Wound Care Nurse/LPN) stated, It is not covered. It is supposedly covered for privacy. On 10/18/2022 at 10:14am, surveyor inquired, again, about R45's indwelling catheter drainage bag. V4 stated, (R45) needs the privacy bag only if (R45) is on (R45)'s wheelchair. On 10/18/2022 at 10:15am, V25 stated, (R45) has a roommate. On 10/18/2022 at 12:27pm,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 call light string was within reach for one dependent resident (R111) and failed to ensure that there was a call light string attached to the call system for another dependent resident (R181) in the sample of 98 residents reviewed for call lights. Findings include: On 10/16/22 at 10:57 AM, R111's call light string was observed on the floor on the right side of R111's bed. R111 stated that he (R111) cannot reach it. On 10/16/22 at 11:03 AM, this observation was brought to the attention of V18 (CNA/Certified Nursing Aide) who stated that the call light is, Right here on the floor. V18 added that the call light should be, Within reach. R111's 8/27/22 BIMS (Brief Interview for Mental Status) determined a score of 7, indicating R111's cognition is moderately impaired. R111's admission Record documents diagnoses including but not limited to cerebral infarction, glaucoma, abnormal posture and bipolar disorder. R111's 10/14/22 care plan documents, in part, Focus: FALL: (R111) is at risk for falls…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 cleanliness of one resident's (R111) personal wheelchair in the sample of 98 residents reviewed for a home-like environment. Findings include: On 10/16/22 at 11:01 AM, R111's wheelchair at the bedside was observed soiled with crumbs/debris on the cushion and a large stain in the middle of the cushion. At 11:03 AM, the surveyor inquired if the wheelchair appears clean. V18 (CNA/Certified Nursing Aide) replied, No it doesn't. V18 stated that housekeeping would be responsible for cleaning the wheelchair. When asked who gets R111 up into the wheelchair, V18 stated, We (CNAs) do. So, the surveyor inquired if she (V18) would place the R111 in a soiled wheelchair. V18 replied, No, I'd wipe it. On 10/18/22 at 12:27 AM, V3 (DON/Director of Nursing) stated that the nursing staff should maintain the cleanliness of the wheelchair. V3 added that the wheelchair is part of the resident's environment. R111's admission Record documents diagnosis including but not limited to cerebral infarction, abnormal posture, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to timely submit a resident's Minimum Data Set (MDS) assessment after a resident was discharged which affected one resident (R3) of three residents (R3, R90, R269) reviewed for resident assessments. Findings include: R3's admission Record documents, in part, that R3's initial admission date to the facility was 6/3/22, and R3's date of discharge was 7/10/22. R3's Census List documents, in part, that R3's active status starting 6/3/22 until 7/10/22 when action code of discharge date is documented. On 7/9/22 at 3:35 pm, V49 (Licensed Practical Nurse, LPN) documented, in part, Staff followed up with (R3) in regard to (R3's) interest in discharging back to (R3's) home in the community with family. (R3) stated that (V52, R3's Family Member) will be picking up (R3) tomorrow (7/10/22). R3'S MDS Assessment, dated 6/3/22 and titled Minimum Data Set (MDS) - Version 3.0, Resident Assessment and Care Screening, Nursing Home and Swing Bed Tracking (NT/ST) Item 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 interview and record review the facility failed to timely submit a resident's Minimum Data Set (MDS) assessment as required at least every 92 days and no later than 14 days after the Assessment Reference Date (ARD) which affected one resident (R2) of three residents (R2, R10, R103) reviewed for resident assessments. Findings include: R2's admission Record documents, in part, that R2's initial admission date to the facility was 12/2/21. R2's Census List documents, in part, that R2's only transfer out to hospital was 3/15/22, and transfer in from hospital was 3/21/22. R2'S MDS Assessment, dated 6/13/22 and titled Minimum Data Set (MDS) - Version 3.0, Resident Assessment and Care Screening, Nursing Home Comprehensive Quarterly (NCQ) Item Set, documents, in part, that the Type of Assessment for Federal OBRA (Omnibus Budget Reconciliation Act) reason for assessment is coded as 2 which indicates a Quarterly review assessment. R2'S MDS Assessment, dated 10/12/22 and titled Minimum Data Set (MDS) - Version 3.0, Resident Assessment and Care Screening, Nursing Home Comprehensive (NC)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 enteral tube medications were administered according to the physician order and according to professional standards of quality for one resident (R116) out of 5 residents reviewed in the total sample of 98 residents. These failures affected R116 and have the potential to affect all 3 residents on the 4th floor receiving medications via an enteral tube. Findings include: On 10/17/22 at 9:10 AM, while preparing R116's morning medications for enteral tube administration, V24 (LPN/Licensed Practical Nurse) pulled a bottle of Colace (docusate sodium) out of the medication cart and explained to the surveyor that because it's a capsule, it cannot be crushed. Instead, V24 pulled out a bottle of Geri-kot (constipation treatment) and stated, I'm not supposed to change it, but she needs a stool softener. The surveyor inquired if V24 can give a medication that is not ordered by a physician. V24 replied. No. I should call the doctor. V24 proceeded to put the Geri-kot away thus omitting the dose. On 10/17/22 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 provide ADL (Activities of Daily Living) care related to grooming and nail care for two residents (R12 and R181) in the sample of 98 residents reviewed for ADL care. These failures affected R12 and R181 and have the potential to affect all dependent residents residing on the 4th floor. Findings include: On 10/16/22 at 11:22 AM, the surveyor observed R181 with grey and black facial hair about a quarter-inch long on R181's chin. When the surveyor inquired if R181 would like to be shaved, R181 stated, Yes. On 10/16/22 at 11:29 AM, this observation was brought to the attention of V21 (LPN/Licensed Practical Nurse) who stated that R181 has hair on her chin. V21 added that the CNAs (Certified Nursing Aide) are responsible for shaving residents when they are bathed. The surveyor inquired why it's important to make sure a female resident does not have facial hair. V21 replied, What she just said .you don't want to mistake her for a man. R181's 9/25/22 BIMS (Brief Interview for Mental Status) determined a score of 7,…

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

Based on observation, interview and record review, the facility failed to have a five percent or lower medication error rate. There were 7 medication errors out of 28 medication opportunities, resulting in a 25% medication error rate and affected two residents (R66 and R116) out of 5 residents reviewed for medication pass. Findings include: On 10/17/22 at 8:46 AM, the surveyor observed V23 (LPN/Licensed Practical Nurse) prepare and administer medications for R66 residing on the 3rd floor. After medicine reconciliation was completed, the following medication errors were determined: 1. Wrong medication given: Geri-kot (Senokot) 8.6 mg 1 tablet was administered while the physician order dated 05/19/2021 was for Senna S (Sennosides-Docusate Sodium) tablet 8.6-50 mg give 1 tablet by mouth two times a day for constipation. 2. Omission error: Multi-Vitamin/Minerals tablet (Multiple Vitamins-Minerals) Give 1 tablet by mouth one time a day was the physician order. However, there was none stocked in V23's medication cart. At 9:03 AM, V23 checked the medication storage room and brought back a…

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