Carlton At The Lake, The

Based on observation, interviews and records review, the facility failed to follow its call light policy for one (R1) of four residents reviewed in a sample of seven.R1's medical diagnosis in current face sheet includes but not limited to hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, major depressive disorder, recurrent, moderate, dysphagia following cerebral infarction.MDS (Minimum Data Set) section C-Cognitive patterns dated February 16, 2026, documents R1's Brief Interview for Mental Status (BIMS) as 15/15 indicating R1 has intact cognitive abilities. Section GG- Functional Abilities document R1 requires set up and cleaning assistance with eating, partial/moderate assistance with oral hygiene, substantial/maximal assistance with personal hygiene, toileting hygiene, lower body dressing, putting on/taking off footwear, and shower/bathe self, partial/moderate assistance with upper body dressing.02/28/2026 at 12:26PM R1 was observed to be clean sitting on mechanical chair placed on the right side of his bed. R1's 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 observations, interviews and record reviews, the facility failed to provide clean and odor-free shower rooms. This applies to 1 resident (R1) in the sample of 3 reviewed for clean shower rooms.Findings include:R1's Face Sheet documents R1's diagnosis of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, major depressive disorder, weakness, dysphagia, severe protein-calorie malnutrition, and hypertension. R1's last quarterly Minimum Data Sheet (MDS) documents a Brief Interview for Mental Status (BIMS) score of 15 indicating cognitively intact with little to no impairment. On 3/4/2026 at 1:55 PM, R1 stated the showers in the facility are dirty and contained soiled incontinence briefs especially on the 5th floor where R1 used to live. On 3/4/2026 at 2:07 PM, the 4th floor two shower rooms had strong feces and urine odors permeating throughout the air. The foul odors were neck jerking, and surveyor could not enter shower room located in the East wing. The second-floor shower rooms had similar strong permeating odors 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 interviews and records review, the facility failed to follow their policy on following physician orders related to diabetes blood sugars and lab monitoring for one (R5) of three residents reviewed in a sample of seven.R5's current face sheet documents R5 medical diagnosis to include but not limited to metabolic encephalopathy, bipolar disorder, current episode manic without psychotic features, unspecified, difficulty in walking, not elsewhere classified, chronic embolism and thrombosis of femoral vein, bilateral, schizoaffective disorder, bipolar type, type 2 diabetes mellitus with hyperglycemia.MDS (Minimum Data Set) section C dated 01/29/2026 documents R5's Brief Interview for Mental Status (BIMS) as 3/15 indicating R5 has severe cognitive impairment.On 02/28/2026 at 1:25PM, R5 was observed lying in bed, R5 stated she had a blood draw recently and finger blood tests. R5 showed her right-hand front elbow side and was observed with a bruise. R5 stated she drinks a lot of water, sugar free drinks therefore she does not have diabetes.On 02/28/2026 at 4:07PM, V5(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 interviews and record reviews, the facility failed to provide on a consistent basis the dietary needs and food preferences of a resident. This applies to 1 resident (R2) in the sample of 3 reviewed for dietary preferences.Findings include:R2's Face Sheet documents R2's diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, muscle wasting and atrophy, dysphagia, oropharyngeal phase, benign prostatic hyperplasia without lower urinary tract symptoms, hypertension, and depression. R2's last quarterly Minimum Data Sheet (MDS) documents a Brief Interview for Mental Status (BIMS) score of 14 indicating cognitively intact with little to no impairment.On 3/2/2026 at 2:50 PM, R2 was sitting in a chair beside R2's bed. He was alert, oriented and talkative. R2 confirmed complaints of wrong food orders were still valid. On 3/4/2026 at 2:55 PM, V19 (Dietician) V19 described R2's prescribed diet as receiving double-portions with scrambled eggs at every meal. V19 stated R2 was upset because R2 did not receive scrambled eggs with R2's breakfast…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and Neglect policy by failing to verify background checks of contracted staff, failing to obtain a copy of their professional licenses, and failing to train contracted staff on issues related to abuse and neglect. These failures have the potential to affect all 174 residents residing in the facility. Findings include: On 11/14/2025 at approximately 10:16 AM, V2 (Assistant Administrator) stated contracted security staff started working at the facility a couple of weeks ago. On 11/14/2025 at approximately 11:10 AM, V9 (Contracted Security) stated started work for facility on Wednesday (11/12/2025). V9 stated received training through contracted employer. Did not receive facility specific training on abuse and neglect. On 11/14/2025 at approximately 2:30 PM, requested contracted security staff's background checks, copies of the licenses or certificates, and training from V2, V3 (Director of Nursing), and V11 (Nurse Consultant).On 11/18/2025 at approximately 9:23 AM, V2 stated contracted security company…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and Neglect' policy and report an allegation of abuse to the Illinois Department of Public Health (IDPH) for one (R1) out of three residents reviewed for abuse. Findings include: R1's admission Record documents in part diagnosis of anxiety disorder.During interviews with R1 on 11/14/2025 at approximately 9:39 AM and 11:00 AM, R1 stated facility hired security to antagonize and intimidate R1. R1 stated V9 (Security) curls [V9's] lips and mean mugs R1. R1 stated V9 puts hand on the gun in front of R1 to intimidate R1. R1 stated [R1] had to call police a few days ago (11/11/2025) because V9 threatened R1 and held gun. R1 stated a receptionist (later identified as V7) and V12 (Human Resources) were present for the incident. On 11/14/2025 at 10:16 AM, V2 (Assistant Administrator / Abuse Coordinator) stated being aware that R1 called police because R1 alleged that V9 was threatening R1. V2 stated did not report the incident to Illinois Department of Public Health and there is no open reportable related 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 interviews and record reviews, the facility failed to follow their 'Abuse and Neglect' policy and report an allegation of abuse for one (R3) out of three residents reviewed for abuse. Findings include:R1's admission Record documents in part diagnoses of bipolar disorder, major depressive disorder, and anxiety disorder.R1's Care Plan documents in part that R1 presents with a difficult or troubled past secondary to severe mental illness. R1 presents with abuse risk factors related to acting as a recipient or perpetrator of mistreatment and/or neglect, exploitation, psychiatric history, and present mental health symptoms. R1 presents with behavioral symptoms including verbal aggression, agitation, and manipulative behavior (focus initiated on 10/24/2025). R1 displays manipulative behavior which is disruptive, insensitive and/or disrespectful to staff and peers (initiated 10/17/2025). R1 has the potential to demonstrate verbally aggressive behaviors related to ineffective coping skills, mental illness, and poor impulse control (initiated 10/17/2025).R3's admission Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their abuse policy and procedure to ensure that abuse allegation was reported no later than two hours to the State Agency (SA) for one (R1) out of three residents reviewed for abuse. Findings Include:R1's clinical records revealed an admission date of [DATE] with included diagnoses but not limited to major depressive disorder, epilepsy, bipolar disorder, anxiety disorder, and dissociative and conversion disorder. R1's admission minimum data set (MDS) assessment dated [DATE] shows R1 is cognitively intact with BIMS (Brief interview for Mental Status) score of 15 and requires supervision with activities of daily living.On [DATE] at 9:42 AM, interviewed R1 regarding his out on pass incident on [DATE]. R1 stated, I had a pass with an escort. That day somebody signed me out. It was my cousin [V3 (R1's Cousin)]. It was Friday he [V3] signed me out around 4:30 PM. We went out to dinner with family. We went down past Diversey. There were so many people…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policies and procedures to ensure (a) the police were contacted to assist with finding a resident who was on supervised community pass and did not return as indicated on the sign out sheet, (b) a resident was reviewed for risk for elopement concerns upon admission, and (c) a person-centered care plan was initiated timely to address community pass privilege. These failures affected one (R1) out of three residents reviewed for community pass privileges.Findings Include:R1's clinical records revealed an admission date of 7/24/25 with included diagnoses but not limited to major depressive disorder, epilepsy, bipolar disorder, anxiety disorder, and dissociative and conversion disorder. R1's admission minimum data set (MDS) assessment dated [DATE] shows R1 is cognitively intact with BIMS (Brief interview for Mental Status) score of 15 and requires supervision with activities of daily living. R1's electronic health records (EHR) revealed no…

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

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program for two (R1, R2) residents out of three residents reviewed for pest control. This failure has the potential to affect all 169 residents residing in the facility. Findings include:On 08/24/2025 at 10:08AM, R1 states about three weeks ago, the facility found bed bugs in his room and he and his roommate (R2) had to be moved to another room on the second floor. On 08/24/2025 at 10:18AM, R2 states he does not know why he was moved to another room, but the facility took his clothes and moved him to another room temporarily. R2 states he has not seen any bed bugs in his room. Surveyor observes multiple, small, dried blood spots on R2's bed sheets and one red bed bug crawling on his bed. R2 then grabs the bed bug and smashed it with his fingers and throws it into the garbage bin. R2 states that was not a bed bug that he just smashed with his fingers.On 08/24/2025 at 10:57AM, V3 (Maintenance) states about a month ago, bed bug sightings were reported in R1 and R2's room. V3…

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

Based on interview and record review, the facility failed to ensure residents have access to their personal clothing and belongings. This failure affects two (R1, R2) residents out of three residents reviewed for resident rights. Findings include:On 08/24/2025 at 10:08AM, R1 states about three weeks ago, the facility found bed bugs in his room and he and his roommate (R2) had to be moved to another room on the second floor. R1 states the facility placed all of his clothing and important documents inside of bags during the relocation process. R1 states he received some of his clothing items back but has not received all of his belongings. R1 states his remote to his TV is working and has no concerns with it.On 08/24/2025 at 10:18AM, R2 states he does not know why he was moved to another room, but the facility took his clothes and moved him to another room temporarily. R2 states none of his clothes or documents have been returned to him yet. R2 states one day he was about to walk to the store in his gown because he had no clothes to wear. R2 states a staff member in the facility then…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review of records and interviews, the facility failed to administer physician-prescribed medications to treat hypotension or low blood pressure. The failure applied to 1 (R2) of 3 residents evaluated for pharmacy services. This failure resulted in R2 experiencing low blood pressure and a fall sustaining injuries of laceration on the forehead and left arm. Findings include: R2 is [AGE] years old, initially admitted on [DATE]. R2's diagnosis includes, hypotension, abnormalities of gait and mobility, lack of coordination, muscle wasting and atrophy. R2's cognition is intact with BIMS score of 15 dated 02/13/2025. R2's bed mobility and transfer is supervision and touch assist. R2 is ambulatory based on MDS assessment dated [DATE]. On 03/09/2025 at 08:00 AM, R2 fell sustaining injuries of laceration on the forehead and left arm. During the fall, R2 has hypotension with blood pressure result of 85/63 mm/Hg. Normal blood pressure accepted by current professional standard is 120/80 mm/Hg. R2 was prescribed by…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 physician orders and plan of care for restorative services and failed to complete quarterly restorative assessments that detail the progress or lack of progress in the restorative services for 4 (R6, R71, R87, R159) residents out of 5 reviewed for limited range of motion and/or restorative services in the sample of 36. Findings Include: On 4/8/25 at 11:09 AM, R87 was lying in bed alert and able to verbalize needs. R87 was noted with left arm paralysis and contracture. When asked if R87 has been receiving some type of range of motion exercises for his left arm and hand in the last 30 days, R87 answered No. R87 stated that staff does not perform any exercises on his left arm/hand. Surveyor observed left hand splint was not applied on R87's left hand and was sitting on top of his bed side table. R87's clinical records show R87 was initially admitted in the facility on 3/25/19 with included diagnosis but not limited to hemiplegia and hemiparesis…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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: 1. Failed to change and maintain proper storage of nebulizer mask when not in use for 1(R30) resident. 2. Failed to change oxygen nasal cannula tubing and humidifier bottle for 1(R50) resident. 3. Failed to maintain proper storage of nebulizer mask when not in use for 1(R145) resident. 4. Failed to follow oxygen liter flowrate as ordered for 2 (R50, and R159) residents. These failures could potentially affect 4 (R30, 50, R145, and 159) of 4 residents reviewed for respiratory care in a sample of 36. Findings Include: R30's Minimum Data Set (MDS) dated [DATE], Brief interview score (15) indicates R30 is cognitively intact. R30's Physician Order Sheet (POS) dated 4/8/25 shows an active diagnosis of Chronic Obstructive Pulmonary Disease (COPD), and Dyspnea unspecified with active order for Ipratropium-Albuterol 3ml inhale orally every 6 hours as needed for shortness of breath (SOB)/Congestion. R50's MDS dated [DATE], Brief Interview Score (15)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to follow their policy and procedures to ensure (a) signage outside of the resident's room indicating Enhanced Barrier Precaution (EBP) was posted for 1 resident (R167); and (b) proper Personal Protective Equipment (PPE) were worn by staff when providing high contact resident care activities to 2 (R24 and R68) residents. These failures have the potential for cross contamination or transmission of infection to 11 residents assigned to V22 (Licensed Practical Nurse/LPN). The findings include: R24's admission record showed admission date on 12/15/20 with diagnoses not limited to Acute and chronic respiratory failure, Dependence on respirator [ventilator] status, Tracheostomy status. R68's admission record showed admission date on 10/8/22 with diagnoses not limited to Acute and chronic respiratory failure, Dependence on respirator [ventilator] status, Tracheostomy status, Acute on chronic diastolic (congestive) heart failure, Dysphagia…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 call light was in reach for two (R49, R118) out of eight residents reviewed for call lights in a total sample of 36. Findings include: On 04/08/25 at 11:57 AM, observed R118 lying in bed sleeping. Call light was lying on the floor underneath R118's bed, out of reach of R118. On 04/08/25 at 12:16 PM, R49 was lying in bed awake. Call light was clipped to chair at the side of the bed. R49 stated she could not reach the call light and that is where the call light has been since this morning. R49 stated if she needed help from staff, she could do nothing, she would have to wait until someone came into her room to check on her. On 04/08/25 at 12:21 PM, V10 (Certified Nursing Assistant) stated R49 requires full care, and she is able to use her call light when she needs help. V10 observed R49's call light clipped to the chair near R49's bed and stated she (R49) cannot reach her call light where it is. V10 stated she (V10) clipped the call light onto the chair when she was changing her this morning and she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 1 (R68) resident was free from physical restraint. This failure could potentially affect 1 (R68) of 2 residents reviewed for physical restraint in a sample of 36. The findings include : R68's admission record showed admission date on 10/8/22 with diagnoses not limited to Acute and chronic respiratory failure, Dependence on respirator [ventilator] status, Tracheostomy status, Acute on chronic diastolic (congestive) heart failure, Dysphagia oropharyngeal phase. On 4/9/25 at 9:58 AM Surveyor observed R68 lying in bed on moderate high back rest, with G-tube feeding infusing Glucerna 1.2 At 70ml/hr via pump machine. R68 with tracheostomy tube, indwelling urinary catheter. Observed R68 wearing bilateral mittens. On 4/9/25 At 11:49 AM V18 (Licensed Practical Nurse / LPN, Restorative Director) stated he has been working in the facility since 2018. He said restraint use should be assessed on admission, readmission, quarterly or significant…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a.) ensure fall preventative measure was followed for a resident (R6) at high risk for falling, and b.) prevent a second fall post-hospitalization for an initial fall which occurred at the facility for one (R32) out of eight residents reviewed for falls in a total sample of 36. Findings include: R32 is a [AGE] year-old male, admitted to the facility 02/13/25 with diagnosis not limited to Idiopathic Peripheral Autonomic Neuropathy, Abnormalities of Gait and Mobility, History of Falling, Adult Failure to Thrive, Unspecified Severe Protein-Calorie Malnutrition, Chronic Pain, Rheumatoid Arthritis, Osteoarthritis of Knee, Systemic Involvement of Connective Tissue, Spinal Stenosis. R32's MDS (Minimum Data Set) dated 03/04/25 document R32's BIMS (Brief Interview of Mental Status) score of 14/15 indicating intact cognition. R32's Activities of Daily Living (ADLs) Assistance documents that R32 requires partial/moderate assistance with toileting…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 appropriate care and services were provided to residents by not applying dressing to G-tube site and not following enteral feeding formula as ordered by physician. These failures have the potential to affect 2 (R141 and R149) of 3 residents reviewed for Tube Feeding in a sample of 36. The findings include: R141's admission record showed admit date on 10/12/23 with diagnoses not limited to Severe hypoxic ischemic encephalopathy, Chronic respiratory failure with hypoxia, Dependence on respirator [ventilator] status, Unspecified diastolic (congestive) heart failure, Chronic embolism and thrombosis of deep veins of unspecified upper extremity, Peripheral vascular disease, Dysphagia oropharyngeal phase, Pressure ulcer of sacral region stage 4, Type 2 diabetes mellitus with other skin ulcer, End stage renal disease, Anoxic brain damage, Unspecified protein-calorie malnutrition, Gastrostomy status, Tracheostomy status. R149's admission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the appropriate side rails were used for one resident (R87) out of a total sample of 36 residents reviewed for accidents/hazards. Findings Include: On 4/8/25 at 11:09 AM, R87 was lying in bed alert and able to verbalize needs. R87 was noted with left arm paralysis and contracture. R87's bed had three half side rails up: 2 half upper rails and 1 half lower rail. On 4/9/25 at 10:26 AM, R87 was sleeping in bed and noted with three half side rails up. On 4/9/25 at 10:53 AM, interviewed V18 (Restorative Director/Licensed Practical Nurse) and stated, We have to get consent and see what the use of the side rail is for. The side rail assessment should be under restorative assessment and should be re-evaluated quarterly, annually, and as needed. The side rail consent should be signed prior to using them. The purpose of the side rail assessment is to determine the appropriate use of the side rail and prevent resident's entrapment. The purpose…

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

Based on interview and record review facility failed to follow their policy for residents that meet the Subpart S guidelines for one resident (R138) out of three residents reviewed for specialized rehabilitation service. This failure resulted in the facility not following R138's individualized treatment plan to receive psychotherapy and did not document that R138 was not attending or had refused attend psychotherapy since October 27, 2024. Findings Include: Facility's list of residents receiving Psychotherapy services does not refelct R138s' name on it. R138's care plan reads: Feeling down, depressed, or hopeless, Little interest or pleasure in doing things, Poor appetite or overeating, Trouble concentrating on things, such as reading the newspaper or watching television, Trouble falling or staying asleep, or sleeping too much Meet with me to discuss ideas to moderate and reduce mood distress symptoms, such as: becoming more active and engaged in the life of the facility, reconciling conflicts/making amends with family or old friends and sharing thoughts and feelings that have…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a physician's order for a resident (R1) in a timely manner. This failure affected one resident (R1) out of three residents reviewed for improper nursing care and resulted in R1 not receiving the medication from 10/22/24 to 10/31/24. Findings include: R1's admission Record documents diagnoses including but not limited to Vitamin D deficiency, unspecified, unsteadiness on feet, unspecified protein-calorie malnutrition, slowness and poor responsiveness, rhabdomyolysis, other specified metabolic disorders, other lack of coordination, other abnormalities of gait and mobility, metabolic encephalopathy, iron deficiency anemia, unspecified, hyperosmolality and hypernatremia, hyperkalemia, homelessness unspecified, fatty (change of) liver, not elsewhere classified, delusional disorders, constipation, unspecified, cognitive communication deficit, altered mental status, unspecified, alcohol induced acute pancreatitis without necrosis or infection, and alcohol use, unspecified with other alcohol-induced disorder. R1'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 appropriately document in the eMAR (Electronic Medication Record). This failure affected one resident (R3) of three residents reviewed for improper nursing care. Findings include: R3's admission Record documents diagnoses including but not limited to heart failure, unspecified, type 2 diabetes mellitus with hyperglycemia, gastro-esophageal reflux disease without esophagitis, psychotic disorder with delusions due to known physiological condition, essential (primary) hypertension, anemia, unspecified, schizoaffective disorder, bipolar type, chronic obstructive pulmonary disease, unspecified, and pure hyperglyceridemia. R3's Brief Interview for Mental Status (BIMS) dated 9/27/2024 documents R3 has a BIMS score of 06, which indicates R3's cognition is severely impaired. On 11/06/2024, V1(Administrator) presented R3's MAR (Medication Administration Record) and POS (Physician Order Statement) which were reviewed. There was a missing entry for Nurses' signature on the MAR for October 2024 as follows: October 7th 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 upon observation, interview, and record review the facility failed to follow policy procedures and failed to revise comprehensive care plans with preventive interventions to ensure resident safety for two of three residents (R3, R4) reviewed for injury of unknown origin. Findings include: 1. R3's (7/3/24) facility reported incident includes x-ray of right-hand: non-displaced fracture of the proximal third phalanx. (R3) is a poor historian due to diagnosis of dementia, so he is unable to give account of the fracture. When asked how he (R3) sustained the fracture, he pointed at the bedside table. On 7/5/24 while being interviewed, (V2/Director of Nursing) observed (R3) suddenly swing the affected hand but the side table was not in close proximity, otherwise the hand would have hit the table. It is concluded that the injury is a result of (R3) bumping the affected hand on his bedside table when he swung the right hand. R3's (7/9/24) care plan includes risk for injury related to poor safety awareness due to dementia. Resident noted with acute fracture of right 3rd finger as 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 upon observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that enteral feedings are administered as ordered, and failed to document enteral intake for two of three residents (R1, R4) reviewed for dehydration. Findings include: 1. On 7/2/24, IDPH (Illinois Department of Public Health) received allegations that the facility failed to monitor and adjust resident liquid intake thereby causing dehydration. The following concerns were identified: R1's diagnoses include anoxic brain damage, tracheostomy status, gastrostomy status, and dependence on respirator (ventilator) status. R1's POS (Physician Order Sheets) include (4/17/24) NPO (nothing by mouth) diet. Enteral feeding flush with 250ml water every 6 hours. (4/25/24) Enteral feeding Jevity 1.5 @ 60ml (milliliters)/hr (hour) start at 7am and turn off at 5am. R1's (12/21/23) care plan states resident is at risk for alteration in nutritional status related to NPO and tube feeding. Intervention: Give g (gastrostomy) tube feeding and water flush as ordered. Monitor for signs 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 remove and discard expired medications that had been open in one of two medication carts reviewed for medication labeling and storage. This failure has the potential to affect 20 residents residing in the facility. Findings Include: On 04/13/2024 at 9:09AM, surveyor located on the second floor of the facility with V3 (Registered Nurse/RN). Surveyor observes V3 performing a medication administration pass using medication cart (identified as Team 1 medication cart). V3 states he is responsible for Team 1 medication cart. Surveyor observes inside medication cart (identified as Team 1 medication cart) a bottle of opened house stock medication labeled Docusate Sodium 100mg with an expiration date of December 2022. V3 states expired medications should not be stored in the medication carts and should be discarded. V3 states he last checked for expired medications on Team 1 medication cart approximately two to three weeks ago. V3 states if he 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to convey funds to the resident's family after a resident expired. This failure affects one of three residents (R4) reviewed for resident funds in a total sample of five residents. Findings include: On [DATE], at 11:19 AM, V5 (R4's Family Member) stated, I have spoken to V6 (Business Office Manager). R4 had a trust. V6 explained to me that the trust goes to pay for the funeral if the resident is deceased . My father passed away [DATE]. He did not have insurance. My Aunt paid for his cremation. V6 stated it goes to the funeral home and whatever is left over is sent back to the state. I did ask for policies, and she was not able to provide them to me. I called the Department of Aging, and they referred me to the ombudsman. The ombudsman stated that since my father and my mother are married the funds will go to my mother. My mother filled out a small state affidavit and we gave it to the nursing home. V6 and I went back and forth over this. V6 stated this is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide incontinence care for one (R5) dependent resident out of three residents reviewed for ADL care. Findings include: On 04/13/2024 at 9:19AM, R5 states no one has come to her room today to change her incontinence briefs. R5 states she is soiled now and often has to stay soiled for long periods of time. R5 states this is an on-going issue and happens all the time. On 04/13/2024 at 9:34AM, V4 (Certified Nursing Assistant/CNA) states she started her shift at 7AM but did not get the chance to change R5's incontinence briefs yet. V5 states she was trying to find a colleague to help her change R5's incontinence briefs. On 04/13/2024 at 9:38AM, V4 observed checking R5's incontinence briefs and V4 states R5's incontinence briefs are soiled with urine. V4 states she will now change R5's incontinence briefs. R5s' Face sheet documents that R5 has diagnoses not limited to: CREST syndrome, post-laminectomy syndrome, urinary tract 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a Preadmission Screening and Resident Review (PASARR) in alignment with facility policy for eight residents (R19, R21, R26, R27, R40, R49, R60, R136) out of 39 residents in a total sample reviewed. On 3/13/2024 at 10:43 AM, PASARR Level One presented by V1 (Administrator) was reviewed for R19. R19 PASARR Level One Screen has been completed by outside agency and is dated 3/13/2024. PASARR Level One determination for R19 was a referral for Level II onsite. Suspected or confirmed PASRR condition was noted to be (MH) Mental Health Disability. On 3/14/2024 at 9:10 AM, V1 (Administrator) presented the admission record for R19 noting an initial admission date of 8/3/2018 and a readmission date of 4/20/2020. admission record includes diagnoses of bipolar disorder, current episode mixed, severe with psychotic features with onset date of 4/1/2019, other bipolar disorder with onset date of 8/30/2018, anxiety disorder with onset date of 8/30/2018,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure low air loss mattress devices were on the correct settings for 2 dependent residents (R21, R78) who are high risk in developing pressure ulcers and for 4 (R49, R160, R168, R285) out of 6 dependent residents with current pressure ulcers in a sample of 39 residents. Findings Include: 1. On 3/12/24 at 11:34 AM, Surveyor asked V6 (Registered Nurse) to check on R168's low air loss mattress. V6 stated that it was set to 350 pounds. On 3/13/24 at 9:52 AM, V36 (Certified Nursing Assistant/CNA) and V35 (Certified Nursing Assistant) were observed providing incontinence care to R168 in bed. R168's low air loss mattress weight control knob was set to 250 pounds. V19 stated that R168 has stage 4 sacral and unstageable left heel pressure ulcers and R168's BRADEN score (assessment tool facility uses to assess a resident's risk of developing pressure ulcer) is 10 which means R168 is high risk for developing pressure ulcer. V19 stated that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. On 03/12/24 at 12:18 PM, observed R91 lying in bed with oxygen infusing via nasal cannula. Observed oxygen concentrator set and infusing at four liters per minute. Observed nasal canula tubing wrapped in a circle laying on R91's side table uncovered, not in a storage bag. R91 did not have any Oxygen in Use signage posted outside R91's room or doorway. R91 stated I am on oxygen all the time now and it is set at 3L and I use that tubing (pointing to the tubing wrapped in a circle on side table uncovered, not in a storage bag) when I am out of bed because it is longer. I used it over the weekend. On 03/12/24 at 12:24 AM, V9 (Registered Nurse) observed R91's oxygen concentrator and stated it is set at 4 liters per minute but should be set between 2-3 liters per minute. Observed V9 adjust infusion rate down to 3 liters per minute. V9 stated R91 receives continuous oxygen and R91 does not adjust the oxygen infusion rate on her own. V9 observed nasal canula tubing wrapped in a circle laying on R91's side table…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to properly: (a) date opened multi-dose insulin for 1 resident (R13); (b) date opened multi-dose eye drops for 1 (R117) resident; (c) store / refrigerate unopen multi-dose insulin for 2 residents (R97 and R141) reviewed for medication storage and labeling. The findings include: R13's health record documented admission date on [DATE] with diagnoses not limited to Heart Failure, Type 2 Diabetes Mellitus, Essential Hypertension, Chronic Obstructive Pulmonary Disease. R97's health record documented admission date on [DATE] with diagnoses not limited to Type 2 Diabetes Mellitus, Unspecified visual loss, Essential Hypertension, Hyperlipidemia. R117's health record documented admission date on [DATE] with diagnoses not limited to Dilated Cardiomyopathy, Supraventricular Tachycardia, Essential Hypertension, Primary Osteoarthritis. R141's health record documented admission date on [DATE] with diagnoses not limited to Type 2 Diabetes Mellitus,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the appropriate use of personal protective equipment (PPE) worn by staff while providing high contact resident care activities; (b.) post appropriate EBP (Enhanced Barrier Precaution) sign on the door of resident on EBP; (c.) ensure PPE supplies were easily accessible for resident on EBP; (d.) clean or disinfect shared reusable equipment in between resident's use to prevent cross contamination. These failures could potentially affect 40 residents residing on the 2nd floor and 58 residents residing on the 5th floor as of census 3/12/24 reviewed for infection control. The findings include: On 3/12/24 at 9:28 am, During medication administration observation with V4 (RN/Registered Nurse), he checked R175's vital signs: BP (blood pressure) =107/69; PR (pulse rate) =84; Temperature=97.4F. R175's room with door signage Enhanced Barrier Precautions (EBP). R175 with indwelling urinary catheter. At 9:54 am, V4 (RN) checked R52'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 reviews, the facility failed to ensure a call light was in reach for one (R235) out of a total of 39 sampled residents. Findings include: On 03/12/2024 at 10:54 AM, R235 was lying in bed. Call light was hung over the bedside drawer to R235's left side. R235 stated [R235] could not reach the call light and asked surveyor to call for a Certified Nurse Aide. R235 stated the facility usually clips the call light to the left bedrail but forgot to do it this morning. At 11:04 AM, V10 (Nurse) and V17 (Certified Nurse Aide Supervisor) were in R235's room. They did not place the call light within R235's reach. R235's comprehensive care plan contains focuses for risk for alteration of bowel and bladder functioning (03/07/2024), risk for altered cardiovascular functioning (03/07/2024), antibiotic therapy use (03/07/2024), potential for bruising/hemorrhage due to anticoagulant use (03/07/2024), and use of psychoactive medications (03/07/2024). Intervention for the listed focuses read to keep R235's call light within reach (initiated 03/07/2024). 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to update two residents' (R115, R235) comprehensive care plan for advanced directives for two out of a total sample of 39 residents. Findings include: R115's IDPH (Illinois Department of Public Health) Uniform Practitioner Order For Life-Sustaining Treatment (POLST) Form dated [DATE] documents in part: NO CPR: Do Not Attempt Resuscitation (DNAR) and Selective Treatment. R115's face sheet and physician orders document in part DNR (Do Not Resuscitate). R115's comprehensive care plan contains a focus for advance directives status dated [DATE]. Focus and interventions document in part Full Code (full treatment). R235's IDPH (Illinois Department of Public Health) Uniform Practitioner Order For Life-Sustaining Treatment (POLST) Form dated [DATE] documents in part NO CPR: Do Not Attempt Resuscitation (DNAR) and Comfort-Focused Treatment. R235's face sheet and physician orders document in part DNR (Do Not Resuscitate); Comfort-Focused Treatment. R235's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure drainage collection device will have a dignified intervention ensuring elimination is covered for 2 (R165 and R175) residents and catheter tubing and drainage bag were kept off the floor for 2 (R120 and R165) residents reviewed for urinary catheter care in a sample of 39. The findings include: 1. R165's health record documented admission date on 2/6/2024 with diagnoses not limited to Other intervertebral disc degeneration lumbar region, Atrial fibrillation, Benign prostatic hyperplasia with lower urinary tract symptoms, Flaccid neuropathic bladder, Atherosclerotic heart disease, Essential (primary) hypertension, Pulmonary hypertension. At 10:56 am, R165 sitting up on chair at bedside. Observed with indwelling urinary catheter draining to yellow colored urine. Urinary catheter and drainage bag on the floor and not inside the privacy bag. R165 activated call light and responded by V14 (CNA / Certified Nursing Assistant) and V13…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 2 (R156 and R175) of 7 residents in the sample reviewed for medication administration. There were 28 opportunities and 6 errors resulting to 21.43% medication error rate. The findings include: R156's health record documented admission date on 2/14/2024/with diagnoses not limited to Other cervical disc degeneration at C5-C6 level, Right heart failure, Rhabdomyolysis, Secondary pulmonary arterial hypertension, Emphysema, Cerebral ischemia, Encounter for prophylactic measures, Chronic respiratory failure with hypoxia, Chronic obstructive pulmonary disease, Essential (primary) hypertension, Chronic kidney disease, Atherosclerotic heart disease of native coronary artery, Non-st elevation (nstemi) myocardial infarction, Benign prostatic hyperplasia, Human immunodeficiency virus [hiv] disease. R175's health record documented admission date on 1/24/2024 with diagnoses not limited to Other pulmonary embolism without acute cor pulmonale, Pain in right shoulder, Pain in…

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

Based on interview and review of records, facility failed to follow their policy to ensure appropriate skin evaluation management are done in order to prevent worsening of pressure ulcers for 1 of 3 residents (R9) reviewed for pressure ulcer. Findings include: R9's Facesheet documents in part: essential (primary) hypertension, hypertensive urgency, chronic diastolic (congestive) heart failure, dementia, Alzheimer's disease, primary generalized osteoarthritis, mixed hyperlipidemia, history of falling, other cervical disc degeneration, cervicothoracic region, overactive bladder, bipolar disorder, traumatic subdural hemorrhage. R9's comprehensive skin evaluation (04/14/2023) documents in part: Resident has no alteration in skin integrity. R9's comprehensive skin evaluation (11/15/2023) documents in part: Resident has no alteration in skin integrity. R9's comprehensive skin evaluation (11/26/2023) documents in part: Sacral Pressure ulcer: deep tissue injury. Measurements: 9.0 cm x 10.0 cm x 0.1 cm. Irregular margins and edges. Scant, serosanguineous drainage noted. Wound bed with 90%…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure that the appropriate side rails were used for 2 out of 3 residents (R1, R3), with multiple history of falls. Findings Include: 1. On 12/05/23 at 11:41 AM, R1 was eating in R1's room in bed with head of bed up to 90 degrees and all four side rails up. R1 was alert and verbally responsive but with some disorientation noted. R1 stated R1 does not know why all R1's side rails are up. R1 stated, I'd rather not have them up. I'd rather have them down. I can't really move when they are all up like this. At 11:47 AM, V6 (Agency Registered Nurse) stated that R1 is high risk for falls and can walk with assistance with a walker. V6 stated that R1 can move all R1's extremities. V6 stated that R1 has four side rails up so R1 can't get out of bed by herself due to being high risk for falling. At 11:52 AM, V7 (Certified Nursing Assistant) stated that R1 is high risk for falls and that R1 has four side rails up so R1 can't get out of bed by…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain an effective pest control program to ensure that facility is free of roaches. This failure affected R6 and has the potential to affect all 181 residents in the facility. Findings include: R6 has a diagnosis of idiopathic peripheral autonomic neuropathy, infection, and inflammatory reaction due to other cardiac and vascular devices implants and grafts subsequent encounter, hypoosmolality and hyponatremia, benign prostatic hyperplasia without lower urinary tract symptoms, bacteremia, type 2 diabetes mellitus without complications, and cardiomyopathy. R6's Brief Interview for Mental Status (BIMS) dated 09/26/23 documents a BIMS of 15 which indicates that R6 is cognitively intact. On 10/30/23 V3 (Assistant Administrator) presented a census of 181 residents in the facility. On 10/30/23 at 9:05 am, Surveyors entered the facility and observed a dead brown cockroach in the lobby area in front of the receptionist desk. On 10/30/23 at 9:36…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 homelike environment for four residents (R1, R7, R10, and R11) reviewed for home like environment in the sample of 18 residents. Findings include: On 10/30/2023 at 11:04 am, there were scratches at the head of R1's bed, and the wall paint was chipped. On 10/30/2023 at 11:06 am, this surveyor pointed out to V18 (Social Services) R1's wall. V18 stated, there are couple of scratches on the wall and the paint is chipped. On 10/30/2023 at 11:07 am, inside R1's and R7's the bathroom, bottom wall was observed with a hole. This observation was pointed out to V16 (Certified Nursing Assistant) and V16 stated, there is a big hole here. I (V16) will talk to maintenance about this. On 10/30/2023 at 11:40 am, there was a hole on R7's corner wall, missing a piece of the baseboard. This was pointed out to R7. R7 stated, it has been like that when I (R7) first got here. I (R7) don't like how it looks. I (R7) hope they (facility) do something about it. On 10/30/2023 at 11:44 am, pointed out to V21 (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 observations, interviews, and record reviews, the facility failed to ensure one resident's (R9) call device was within reach of the resident. This failure affected one of three residents (R9) reviewed for call device. Findings include: On 10/30/2023 at 1:06 pm, this surveyor and V10 (Maintenance Assistant) entered R9's room. R9's call device was on the floor. This surveyor inquired where was R9's call device. V10 looked for R9's call device and stated, it's on the floor. The CNA should have put it right next to (R9) so she (R9) can use it whenever she (R9) needs assistance. It's very critical. It is life safety. On 11/01/2023 at 12:40 pm, R9's call device was on the floor. Surveyor inquired about R9's call light. R9 stated I (R9) don't know. On 11/01/2023 at 12:41 pm, this observation was pointed out to V43 (Restorative Aide) and stated it's on the floor. (R9) can't reach it. (R9) knows how to use the call light. On 11/01/2023 at 11:33am, V2 (Director of Nursing) stated, call light should be placed close to the resident; within the resident's reach so they can utilize it 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 interview and record review, the facility failed to provide a dependent resident oral suctioning per the facility's procedure which affected one (R4) of four residents reviewed for improper nursing care. Findings include: R4's admission Record documents, in part, quadriplegia, chronic respiratory failure, dependence on ventilator, tracheostomy status, syringomyelia, syringobulbia, neuromuscular dysfunction of bladder, pressure ulcer buttock stage 4, ventilator associated pneumonia, gastrostomy status, type 2 diabetes mellitus, anxiety disorder, chronic pain syndrome, anemia, hypotension, neurogenic bladder, chronic pulmonary edema, and resistance to multiple antimicrobial drugs. R4's admission date to the facility is documented as 10/13/23. R4's Minimum Data Set (MDS), dated [DATE], documents, in part, that a Brief Interview for Mental Status (BIMS) score was not performed, and a Staff Assessment for Mental Status was done with R4's short term memory as OK, and R4's Cognitive Skills for Daily Decision…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 administration failed to carry through the facility's Abuse policy regarding identification of potential abuse. As a result, the administration failed to determine abuse when a resident with a BIMS of 15 pulled the pants down of a resident with a BIMS of 00. This deficient practice created a systemic failure having the potential to affect all 179 residents in the facility. Findings Include: R2's Abuse assessment prior to 11/19/22 is not accurate. The Facility does not have an effective Abuse Policy and V1 (Administrator) failed to identify the allegation as abuse. R11 was admitted to the facility on [DATE] with diagnosis not limited to Essential (Primary) Hypertension, Anemia, Presence of Right Artificial Shoulder Joint, Localized Edema, Chronic Postprocedural Pain, Major Depressive Disorder and Cardiomyopathy. R11 MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating cognitively intact. R2 was admitted to the facility on [DATE]…

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