Center Home Hispanic Elderly

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to monitor one (R66) resident of six reviewed in a sample of 24. This failure led to R66 wandering into other residents' rooms.R66 is a [AGE] year-old individual whose current face sheet documents medical diagnosis to include but not limited to: dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance, delusional disorders, depression, unspecified, and anxiety disorders. R66's MDS (Minimum Data Set) C-Cognitive Patterns dated [DATE], documents R66''s Brief Interview for Mental Status (BIMS) as 1/15, indicating severe cognitive impairment.On 01/20/2026 at 11:00AM, R66 was observed in another resident's room sitting on one of the beds and remained sitting for forty minutes. R66 was not able to answer questions.On 01/20/2026 at 11:25AM, V5 (Certified Nursing Assistant-CNA) observed R66 in another resident's room and stated R66 wanders in other resident's rooms. V5 stated the room R66 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and records review, the facility failed to refer two residents (R40, R92) with newly diagnosed serious mental illness for PASRR (Pre-admission Screening and Resident Review) screenings in a total sample of 24 residents reviewed for PASRR.Findings include: R40 Notice of PASRR (Pre-admission Screening and Resident Review) Level I Screen Outcome, review date 5/14/24, has a determination of No Level II Required – No SMI/ID/RC (Severe Mental Illness/Intellectual Disability/related condition). R40 face sheet, printed 1/21/26, documents diagnoses that include but are not limited to delusional disorder with onset date 3/24/25; generalized anxiety disorder with onset date 3/24/25; major depressive disorder with onset date 4/17/25. According to Psychiatry Note 2/13/25, Per staff patient (R40) has no changes in baseline behaviors. According to Psychiatry Note, 3/13/25, Per Staff patient (R40) frequently presents with paranoid delusions. Will start patient (R40) on quetiapine to manage delusional…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview facility failed to acquire preadmission screening and resident review for 1 out of 5 residents (R63) in a total sample of 24 resident reviewed for resident assessment. These failures affect 1 resident (R63) in determining correct care settings for a resident with serious mental illness. Findings include:R63, a [AGE] year-old resident, initially admitted in the facility on [DATE]. R63 was diagnosed with bipolar disorder and alcohol use upon admission.On [DATE], facility received notice of PASRR level 1 screening that documents R63 referred to PASRR level 2 screening with suspected or confirmed mental health disability. Under PASRR level 1, R63 has mental health diagnosis of bipolar disorder, substance related diagnosis which is alcohol abuse or dependency and currently on Lurasidone 60 MG which is an antipsychotic. Outcome of PASRR level 1 documents that a PASRR level 2 evaluation must be conducted.On [DATE], facility received notice of PASRR level 2 screening that…

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

Based on observation, interview, and record review, the facility failed to assist a resident in maintaining their vision by not following physician orders to obtain corrective lenses for one (R94) resident in a total sample of 24 residents reviewed. Findings include: On 01/20/2026 at 1:17PM, R94 states he has visited the eye doctor twice already and the eye doctor prescribed him eyeglasses. R94 states he gave the prescription to the nurses in the facility, and they lost his prescription both times. R94 states he is still without the eyeglasses that he needs.On 01/22/2026 at 10:01AM, V20 (Social Services Assistant) states R94 informed her last month and a few months ago that when he went to the eye doctor, he received a prescription for corrective lenses. V20 states that R94 told her that he gave his prescription to the escort who accompanied him to the eye doctor. V20 states R94 also told her that the escort gave his prescription to the social services department. V20 states no one in the social services department received a prescription for eyeglasses for R94. V20 states 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 implement infection control measures during storage of oxygen tubing for one resident (R114) out of five residents reviewed in a total sample of 24 residents. This failure places residents at risk to be provided with inappropriate care and services to meet the resident's physical, mental and/or psychosocial needs.On 1/20/2026 at 12:43 PM, R114's oxygen concentrator's oxygen tubing not covered and, on the floor, next to R114's bed.On 01/21/2026 at 12:47 PM, V2 (Director of Nursing) stated that the facility does have an oxygen equipment policy. V2 stated that for oxygen tubings, staff change the oxygen tubings weekly, and when not in use, staff keep them in bags. V2 stated that the tubing should not be on the floor because of infection control and the residents can place the oxygen tubing back in their nose.R114's current face sheet documents R114 is a [AGE] year-old individual admitted to the facility on [DATE] and has diagnoses not limited…

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

Based on observation, interview, and record review, the facility failed to follow their policy to ensure appropriate wound care treatment is met and carried out for one (R1) out of 3 residents reviewed for pressure ulcers in a sample of 9.Findings Include:Section C documents in part BIMS (brief interview of mental status) of 11 which indicates that R1 is moderate cognitive impaired.On 12/23/2025 at 9:49 AM, surveyor observed R1 laying down on her bed, in an upright position while watching television. R1 seemed comfortable, under no pain or distress. R1 is alert and oriented to person. R1 is not alert and oriented to place and time, and has frequent confusion. Surveyor observed R1 holding the call light with her right hand. Surveyor observed a catheter bag; it was secured and off the ground. Surveyor observed a wheelchair and a walker at the bedside. There were no odors present, and the room was clean and free clutter. On 12/23/2025 at 10:01 AM, R1 stated she went to the hospital a few months ago and was told she had infection. R1, stated she developed the infection while being 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation , interview and document review the facility failed to maintain all mechanical equipment in safe operating condition. This failure affected all residents in the facility by not providing hot water due to equipment failure. Findings include: On 4/30/25 the facility was toured and hot water accessible to the resident was measured with V5 (Maintenance Director) with a facility provided dial stem thermometer. 3rd floor mens common toilet at hanksink 11:10AM 90F . 3rd floor womens common toilet room. 11:13AM . No water supply at both handswashing sinks. 3rd floor womens shower and bathroom across room [ROOM NUMBER]. At shower 89F 11:16AM 89F. At handsink 91F. 3rd floor mens shower room across room [ROOM NUMBER] 11:20AM at handsink 90F. At shower 80F. 2nd floor mens shower room [ROOM NUMBER]:29AM handsink 87F, at shower 86F. 2nd floor womens shower room [ROOM NUMBER]:35AM handsink 88F, at shower 88F. 1st floor womens restroom/shower room [ROOM NUMBER]A 11:45 AM at handsink 83F at shower 88F. 1st…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 lights are within reach for 9 of 9 residents (R1, R2, R3, R6, R8, R10, R12, R13 and R14) reviewed for call lights. Findings include: On 03/24/25 at 12:01pm, R1 noted in the room eating with call light not within reach, R3 noted in bed with call light not within reach, and R14 noted in wheelchair on the right side of the bed with call light not within reach on the left side of the bed. R14 stated I can't reach it. At 12:11pm, V6 CNA (Certified Nurses Aide) stated call lights should be within reach of the resident whether in bed or chair. On 03/24/25 at 12:20pm, R6 noted in bed that was positioned very high and call light noted under the bed, R10 in bed with call light noted on the floor under the bed and not within reach. R13 noted in bed with call light noted under the bed. On 03/24/25 at 12:21pm, R2 noted in the room in a chair with call light not placed within reach. When this was shown to V8 RN (Registered Nurse), V8 stated that R2 is a fall risk and should be monitored, 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 follow their abuse policy to complete a thorough abuse investigation for one of three residents reviewed for abuse (R4) in the sample of seven. Findings include: 1/29/2025, at 12:37 PM, V11 (Human Resource Director) stated (V11) was told by other staff that V5 (Certified Nursing Assistant/CNA) said bad words to R4. I went to V7 (Former Administrator) and reported that I was told V5 said some bad words to a resident. I don't think he (V7) did a complete investigation. He did not involve social services to interview R4 and other residents and didn't interview additional staff. He kept me out of the loop. Anytime I asked him about the investigation he would say, don't worry about it, I'm handling it. 1/29/2025, at 2:50 PM, via telephone, V7 (Former Administrator) said, it was reported to him, by V6 (CNA) that V5 (CNA) used profanity while performing direct resident care to R4. V6 reported the incident to V2 (Director of Nursing) who reported it to me. I did an investigation; I think I interviewed staff on the unit. I…

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

Based on interview and record review the facility failed to follow the care plan addressing the resident will maintain adequate nutritional and hydration status and failed to implement current professional standards of practice to follow up and/or address a Registered Dietician's recommendations for one resident (R2) out of four residents reviewed for hydration. This failure places residents at risk to be provided with inappropriate care and services to meet the resident's physical, mental and/or psychosocial needs. The findings include: R2's face sheet documents that R2 has diagnoses including but not limited to: severe sepsis with septic shock, unspecified atrial fibrillation, encounter for attention to gastrostomy, adult failure to thrive, type 2 diabetes mellitus without complications, pressure ulcer of other site, unspecified stage, chronic kidney disease, stage 3a, obstructive and reflux uropathy, unspecified, hemiplegia and hemiparesis. R2's MDS/Minimum Data Set Section C dated 12/11/2024 documents that R2 has a BIMS/Brief Interview for Mental Status score of 00/15,…

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 upon observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that staff were available to provide restorative care, failed to ensure that staff are aware of residents' restorative care needs, and/or failed to ensure that restorative care was provided as directed for four of 64 residents (R26, R49, R55, R86) in the sample. These failures have the potential to affect 104 residents. Findings include: The (1/13/25) census includes 114 residents. On 1/13/25 at 10:52am, surveyor inquired about the current (2nd floor) staffing. V12 (CNA/Certified Nursing Assistant) stated It's 3 CNAs right now and affirmed that 1 of the assigned CNAs is V16 (Restorative Aide) that was pulled to work the floor. On 1/13/25 at 11:15am, surveyor inquired who provides restorative care if V16 (Restorative CNA) was pulled to work on the unit, V16 stated My supervisor (V34/Restorative Nurse) is here however a total of 104 residents require restorative care per (1/15/25) facility [NAME]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 upon observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that nursing staff arrive on time and/or as scheduled, failed to implement the emergency staffing policy and failed to ensure that sufficient nursing staff were available to meet the needs for 15 of 64 residents (R11, R15, R26, R30, R34, R37, R43, R46, R48, R49, R55, R56, R57, R86, R169) in the sample. These failures have the potential to affect 114 residents. Findings include: On 12/17/24, the facility was cited by IDPH (Illinois Department of Public Health) for insufficient Nursing staff. The (1/13/25) census includes 114 residents. On 1/13/25 at 10:48am, surveyor inquired about the current (2nd floor) staffing, V11 (RN/Registered Nurse) stated, I have 3 CNAs (Certified Nursing Assistants) sometimes we have 4 and affirmed there are 40 residents currently residing on the unit. On 1/13/25 at 10:52am, surveyor inquired about the current (2nd floor) staffing, V12 (CNA) stated It's 3 CNAs right…

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

Based on observations, interviews, and record reviews, the facility failed to ensure staff performed hand hygiene when entering the kitchen, failed to ensure food storage temperatures were monitored, failed to ensure staff hair was fully covered, failed to label food upon opening, failed to ensure the solution used for the sanitation sink was checked, failed to ensure the kitchen drain was not clogged, and failed to ensure paint on the kitchen ceiling was not disintegrating in an effort to prevent foodborne illness. These failures have the potential to affect all 111 residents receiving oral nutrition at the facility. Findings include: The (01/13/2025) facility census was 114. The (01/14/2025) email correspondence with V10 (Assistant Administrator) documented that there were 3 residents not taking oral nutrition at the facility. On 01/13/2025 at 9:28am, V3 (Administrator in Training) was inside the Kitchen. This surveyor inquired with V3 where the hand washing facility is in the kitchen. V3 stated I don't know. This surveyor inquired if V3 washed his hands when he entered 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 the dumpster was not overflowing with trash and the dumpster's lid was closed in an effort to prevent pest and rodents migration to the facility. This failure has the potential to affect all the residents at the facility. Findings include: The (01/13/2025) facility census was 114 residents. On 01/13/2025 at 9:51am with V4 (Dietary Supervisor) made an observation of the outside dumpster. The outside dumpster was overflowing with black and white trash bags and one of the 3 lids was open. V4 stated the big dumpster was overflowing with trash and one of the lids was open. V4 stated the black trash bags are from the Dietary. Maintenance is in charge of the dumpster. On 01/15/2025 at 10:06am, V32 (Maintenance Director) stated the dumpster lid should be closed always so nothing could go in the dumpster like rats and flies because if these live in the dumpster they could go anywhere inside the building. The (undated) Waste Management Policy documented, in part Purpose: to prevent the spread of 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 upon observation, interview, and record review the facility failed to ensure that isolation signs are posted properly, failed to ensure that assigned staff/visitors were made aware that (R11) requires contact isolation, failed to ensure that visitors don required PPE (Personal Protective Equipment) prior to entering an isolation room, and failed to ensure that staff perform hand hygiene during dining services. These failures have the potential to affect all 114 residents residing in the facility. Findings include: The (1/13/25) census includes 114 residents. R11's (8/7/24) care plan states, resident is on isolation related to ESBL (Extended Spectrum Beta Lactamase). Interventions: set up isolation per facility protocol. Educate resident/family on isolation. On 1/13/25 at 11:17am, V11 (Registered Nurse) was assigned to R11. Surveyor inquired which type of isolation R11 requires. V11 stated He (R11) had ESBL, he's not on it no more, the sign needs to come down. However, R11's name was noted to be on the facility isolation log (received 1/13/25). On 1/13/25 at 11:30am, two pieces…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview, the facility failed to follow their own policy of completing self-administration review, getting a physician' order to self-administer, and completing a careplan when initiating self-administration of medication. This failure affected 3 (R13, R66, and R84) residents reviewed for self-administration of medication and has the potential to affect all residents on the 2nd floor. Findings include: The (01/13/2025) facility census indicated that there were 41 residents on the 2nd floor. On 01/13/25 at 11:03 AM with V12 (Certified Nursing Assistant/CNA), there was an inhaler on top of R66's bedside table. R66 stated that's mine. My doctor gave it to me a long time ago. I am taking it by myself. The staff did not teach me how to take it. V12 checked the inhaler and stated there is no label. V12 showed this surveyor the inhaler which read Albuterol Sulfate HFA and the counter at the back of the inhaler indicated there were 127 doses left in the inhaler. On 01/13/25 at 11:11 AM, there was an inhaler and a bottle of Iron on R84's window…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure that medications were administered and/or documented within regulatory requirements for seven of 64 residents (R30, R34, R43, R46, R48, R57, R169) in the sample. Findings include: On 1/14/25 at 9:46am V26 (LPN/Licensed Practical Nurse) dispensed three of R48's prescribed medications (Azelastine, Divalproex, Levetiracetam) in a medication cup and affirmed that she was going to administer them however they were scheduled for 8:00am administration (1.75 hours prior). Surveyor inquired why R48's 8:00am medications were highlighted red on the EMAR (Electronic Medication Administration Record), V26 replied It's gonna turn red cause you're late with the administration. Surveyor inquired about the regulatory requirement for medication administration, V26 stated It's one hour before or after, you have to give for the time that it said and affirmed its within 1 hour before or 1 hour after the scheduled time. On 1/14/25 at 11:37am, V2 (Director of Nursing) stated I'm (V2)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 environment was free from hazards for two residents (R44 and R95). This failure has the potential to affect all 39 residents on the third-floor unit. Findings include: On 1/13/25 V10 (Assistant Administrator) presented a facility census of 39 residents on the third-floor unit. On 01/13/25 Surveyor toured the facility's third-floor unit and observed residents ambulating throughout the unit freely. R44's face sheet shows that R44 has a diagnosis which includes but not limited to transient cerebral ischemic attack, encounter for attention to gastrostomy, and dysphagia oral phase. R44's Brief Interview for Mental Status (BIMS) dated 12/11/24 shows that R44 does not have a BIMS score and documents that R44 could not recall which indicates that R44 has some cognitive impairments. During interview with R44, R44 was able to answer yes and no to surveyor questions. R95's face sheet shows that R95 has a diagnosis which includes but not limited pure hypercholesterolemia, Type 2 diabetes mellitus, personal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review the facility failed to ensure controlled medication for two residents (R8 and R103) were securely locked in the medication room refrigerator; failed to ensure that insulin and eye medication for four residents (R14, R20, R51 and R113) had open and expiration dates; and failed to ensure that expired insulin for one resident (R113) was removed from the medication cart. This failure has the potential to affect all residents that reside on the first floor and four residents on the third floor (R14, R20, R51 and R113). Findings include: R8 is a [AGE] year old with diagnosis including but not limited to: Acute kidney failure, unspecified dementia, unspecified protein-calorie malnutrition and encounter for palliative care. R103 is an [AGE] year old with diagnosis including but not limited to: Unspecified dementia, malignant neoplasm of colon, senile degeneration of brain and personal history of transient ischemic attack. R14 is a [AGE] year old with diagnosis…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 upon observation, interview, and record review the facility failed to ensure that a thermometer was in (R3's) refrigerator, failed to ensure that (R3's) daily temperature log was not pre-signed, failed to ensure that staff are aware of the required refrigerator temperature range, failed to ensure that refrigerated perishable items were maintained below 40F (Fahrenheit), failed to defrost resident refrigerators, and failed to document daily refrigerator temperatures for six of 64 residents (R3, R15, R26, R49, R66, R84) in the sample. Findings include: On 1/13/25 at 11:04am, R49's personal refrigerator temperature was last documented (on the daily refrigerator temperature log) on 1/7/25 (6 days prior). A thick ice build-up (roughly 1 inch) was also observed on R49's freezer. On 1/13/25 at 11:06am, R15's personal refrigerator contained perishable items including juice and cheese however the refrigerator temperature was noted to be 76F. R15's refrigerator temperature was last documented on the daily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide a home-like environment by not replacing missing window coverings which affected one resident (R51) reviewed in the total sample of 64 residents. Findings include: On 1/13/25 at 11:20 AM, R51 observed sitting in black recliner-type chair in room, close to windows on the outside facing wall. The sun coming in the room from one (left window when looking at the outside facing wall) of the 2 windows is hitting R51 in the eyes when R51 is sitting forward in the chair. This surveyor observed hanging vertical blinds on both windows with missing vertical blinds on both windows. The left window (when facing windows) has approximated 6 inch gaps in between 5 vertical blind panels and there is no roll down curtain hanging from the brackets at the top of the window frame. The right window (when looking at the outside facing wall) has missing vertical blind panels, but there is a roll down curtain hanging and is closed blocking the sun. 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 ensure that ADL (Activities of Daily Living) care was provided to three of 64 dependent residents (R11, R37, R56) in the sample. Findings include: 1) R11's diagnoses include dementia, benign lipomatous neoplasm, encounter for palliative care, hemiplegia and hemiparesis affecting the left side. R11's (8/31/20) care plan states resident has a self-care deficit and requires assistance with ADL's. Intervention: provide assistance with all ADL's as required per the residents need dependence: personal hygiene. On 1/13/25 at 11:30am, V17 (Chaplain) affirmed that R11 speaks Spanish and agreed to translate interview. R11's hair was long, unkempt, and appeared greasy. R11's beard and nails were also long. Surveyor inquired if R11 prefers the long hair and unshaven appearance V17 stated He said that he shave himself and affirmed (R11) is confused. Surveyor inquired about the appearance of R11's nails V17 responded They look a little long. Surveyor inquired if R11 usually appears disheveled (as he does today) V17 stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon observation, interview, and record review the facility failed to ensure that a residents (R22) low air loss mattress (in use) was functioning properly, failed to obtain PRN (as needed) wound care orders for R37, failed to ensure that R56's (left) buttock treatment orders were transcribed on the TAR (Treatment Administration Record), failed to obtain treatment orders for R56's (right) buttock wound, and failed to follow Physician orders. These failures affected 3 residents (R22, R37, R56) in the sample. Findings include: 1) R37's (12/26/24) POS (Physician Order Sheets) include Hydrocol External Pad (Wound Dressing) apply to sacrum every day shift every Friday for wound care prevention for 1 month (PRN orders were excluded). R37's (2/12/20) care plan states resident is at risk for skin impairment related to bladder incontinence. Interventions: skin checks daily, inform staff Nurse of any concerns. On 1/13/25 at 11:58am, R37 affirmed that his incontinence brief was soiled however was unable to state 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 policy procedures, and failed to ensure that gastrostomy tube (g-tube) feedings were labeled for one of three residents (R11) reviewed for tube feeding. Findings include: On 1/13/25 at 11:30am, R11's g-tube feeding was infusing however the bag was not labeled with resident's name, type of feeding, date, and/or time the infusion started (as required). On 1/13/25 at 12:40pm, surveyor inquired about R11's g-tube feeding V11 (Registered Nurse) stated He gets Jevity 55cc's per hour. I (V11) hung that bag this morning, but I didn't have no sticker or didn't put no date on that. The (6/14) gastrostomy feeding policy states label container with resident's name, name of formula, concentration flow rate, date, and time.

Based on observation, interview and record review, the facility failed to label and date oxygen equipment (nasal cannula tubing); and failed to properly contain oxygen equipment (nasal cannula tubing). These failures affected two residents (R3 and R109) reviewed for oxygen equipment, in a total sample of 64 residents. Findings include: R3's face sheet shows that R3 has a diagnosis which includes but not limited to chronic obstructive pulmonary disease (COPD), and asthma. R3's Brief Interview for Mental Status (BIMS) dated 12/22/25 shows that R3 has a BIMS score of 13 which indicates that R3 is cognitively intact. R109's face sheet shows that R109 has a diagnosis which includes but not limited to obesity and cardiac arrhythmia. R109's Brief Interview for Mental Status (BIMS) dated 12/19/25 shows that R109 has a BIMS score of 14 which indicates that R109 is cognitively intact. On 01/13/25 at 11:13 am, R109 was observed in bed awake, alert, and oriented. Surveyor observed R109 with a concentrator next to the bedside with the oxygen tubing (nasal cannula) hanging across the top of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and, record review the facility failed to obtain a physicians order for a resident (R3) who requires dialysis. This failure affected one resident in the sample of 64 residents. Findings include: R3's face sheet shows that R3 was admitted to the facility on [DATE] and has a diagnosis which includes but not limited to dependence on renal dialysis, chronic kidney disease stage 5, and renal sclerosis. R3's Brief Interview for Mental Status (BIMS) dated 12/22/25 shows that R3 has a BIMS score of 13 which indicates that R3 is cognitively intact. On 01/14/25 upon review of R3's Active Physician Order Sheet no physicians orders for R3 to receive hemodialysis. On 01/15/25 at 9:51 am, V2 (Director of Nursing, DON) stated that when a resident is admitted to the facility it is the admitting nurses responsibility to carry out and verify orders for residents from the sending facility including orders for residents who require receiving dialysis. V2 explained that the facility receives residents dialysis…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medications were re-ordered timely, and failed to ensure that prescribed medications were available for two of six residents (R48, R57) reviewed for medication administration. Findings include: R48's (1/16/24) POS (Physician Order Sheets) include Cetirizine 5mg (milligrams) daily. On 1/14/25 at 9:46am V26 (LPN/Licensed Practical Nurse) dispensed R48's prescribed medications in a medication cup. However, Cetirizine (scheduled for 9am administration) was not dispensed. Surveyor inquired if R48's Cetirizine was available, V16 searched to no avail and responded, We have none. R57's POS includes (10/22/24) Fenofibrate 54mg daily and Trulicity 1.5mg/0.5ml (milliliters) every Tuesday. On (Tuesday) 1/14/25 at 11:44am, R57's 9:00am medications were highlighted red on the EMAR (Electronic Medication Administration Record) indicating late administration. V26 (LPN) dispensed R57's (9:00am) prescribed medications in a medication cup. However, Fenofibrate and Trulicity…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain a medication error rate below 5%. There were 12 medication errors out of 26 opportunities, resulting in a 46.15% medication error rate. Two of six residents (R48, R57) in the medication administration sample were affected. Findings include: On 1/14/25 at 9:46am V26 (LPN/Licensed Practical Nurse) dispensed three of R48's prescribed medications (Azelastine, Divalproex, Levetiracetam) in a medication cup and affirmed that she was going to administer them however they were scheduled for 8:00am administration (1.75 hours prior). Surveyor inquired why R48's 8:00am medications were highlighted red on the EMAR (Electronic Medication Administration Record). V26 replied It's gonna turn red cause you're late with the administration. Surveyor inquired about the regulatory requirement for medication administration. V26 stated It's one hour before or after, you have to give for the time that it said and affirmed its within 1 hour before or 1 hour after the scheduled time.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure that two of six residents (R48, R57) reviewed for medication administration remained free from significant medication errors. Findings include: R48's diagnoses include unspecified convulsions and Parkinson's disease. R48's (1/16/24) Physician Orders include Divalproex 250mg (milligrams) twice a day related to unspecified convulsions and Levetiracetam 750mg twice a day related to Parkinson's disease. On 1/14/25 at 9:46am V26 (LPN/Licensed Practical Nurse) dispensed R48's Divalproex (Anticonvulsant) and Levetiracetam (Anticonvulsant) in a medication cup and affirmed that she was going to administer them however they were scheduled for 8:00am administration (1.75 hours prior). Surveyor inquired why R48's Divalproex and Levetiracetam were highlighted red on the EMAR (Electronic Medication Administration Record). V26 replied It's gonna turn red cause you're late with the administration. Surveyor inquired about the regulatory requirement for medication administration.…

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

Based on observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that 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 three dependent residents (R1, R2, R3) reviewed for ADL (Activities of Daily Living) care. These failures have the potential to affect all 38 residents on the 2nd floor. Findings include: The (12/9/24) facility census includes 117 residents. The (12/9/24) Nursing Daily Staffing Sheet affirms the following: 3 CNAS (Certified Nursing Assistants) called off for day shift. 1 Nurse and 2 CNAS called off for evening shift. The (12/9/24) timecard reports affirm 1 scheduled CNA clocked in at 6:03am, 1 scheduled CNA clocked in at 6:09am, 1 scheduled CNA clocked in at 6:53am, 1 scheduled CNA clocked in at 7:19am and 1 scheduled CNA clocked in at 8:25am (the shift started at 6am) therefore 5 CNAS arrived late. Evening shift starts at 2pm however 1 scheduled CNA clocked in at 2:52pm and 1 scheduled Nurse clocked in at 8:26am…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policy procedures, failed to ensure that staff were available to provide restorative care, and failed to ensure that restorative care was provided as directed for three of three residents (R1, R2, R3) in the sample. These failures have the potential to affect all 38 residents on the second floor. Findings include: The (12/9/24) facility census includes 117 residents. On 12/9/24 at 1:39pm, surveyor inquired about the current (2nd floor) staffing. V4 (RN/Registered Nurse) stated Today I (V4) have 38 (residents) and two CNAS (Certified Nursing Assistants), one's restorative. On 12/9/24 at 1:49pm, surveyor inquired about the current (2nd floor) staffing. V5 (Certified Nursing Assistant) stated It's only two of us with the Nurse (referring to V4) so we got the whole floor. We got 38 patients. Surveyor inquired which CNA was currently working with V5, V5 responded She's a CNA but she's the Restorative Aide too (referring to V8/Restorative CNA). When it's short, they pull restorative to the floor so there's no restorative…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policy procedures, failed to implement care plan interventions, and failed to provide ADL (Activities of Daily Living) care to two of three dependent residents (R2, R3) in the sample. Findings include: 1) R3 is [AGE] years old with diagnoses which include retention of urine and contracture of right elbow. R3's (9/10/24) BIMS (Brief Interview Mental Status) determined a score of 8 (moderate impairment). R3's (9/10/24) functional assessment affirms resident is dependent on staff for personal hygiene and toileting. R3's care plan includes (6/17/24) Resident has bladder incontinence. Intervention: administer appropriate cleansing and peri-care after each incontinent episode. (10/16/24) Resident has a self-care deficit and requires assistance with ADL's. Interventions: Provide assistance with all ADL's as required per the residents need dependence: personal hygiene. On 12/9/24 at 1:39pm, surveyor inquired about R3's cognitive 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 record review and interview the facility failed to ensure they have a policy for scheduling/rescheduling appointments, failed to ensure that reported concerns were resolved and failed to re-schedule a Neurology appointment for one of three residents (R1) in the sample. Findings include: The (12/9/24) facility census includes 117 residents. R1's diagnoses include Multiple Sclerosis. R1's (11/11/24) progress notes state Resident out for appointment for Neurology clinic. On 12/11/24 at approximately 11am, surveyor requested R1's (11/11/24) Neurology Consultation. V2 (Director of Nursing) stated I (V2) did see in the documentation on November 11, but she (R1) was complaining that she's hungry, so she didn't go to the appointment. On 12/11/24 at 1:32pm, surveyor inquired if R1 and/or family reported care concerns. V16 (Minimum Data Set Coordinator) stated Her daughter (V3/Family) worries about (R1's) Neurology appointments but they're not getting done. I tell the DON (Director of Nursing) about her (V3's) concerns and that she wants a Neurology appointment but nothings being…

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

Based on observation, interview, and record review the facility failed to follow policy procedures, failed to transcribe Physician Orders, failed to ensure that indwelling urinary catheter treatments are on the TAR (Treatment Administration) record, and failed to monitor/record/report abnormal urine findings to the Physician for one of three residents (R1) in the sample reviewed for bowel/bladder incontinence. Findings include: R1's diagnoses include neuromuscular dysfunction of bladder. R1's (9/24/24) care plan states resident has an indwelling catheter related to skin breakdown. Interventions: monitor/record/report to Medical Doctor signs/symptoms of UTI (Urinary Tract Infection). R1's POS (Physician Order Sheets) include (5/15/24) Change urinary drainage bag monthly on the 15th and as needed. (8/19/24) Change (Indwelling Urinary) catheter as needed for blockage, leaking, or malfunctioning. (8/23/24) Clean urethra catheter site daily and as needed. R1's (November-December 2024) TAR excludes catheter treatment and/or clean urethra orders. R1's (November-December 2024) MAR…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 thoroughly investigate four separate incidents involving allegations of resident-to-resident physical abuse, verbal and physical abuse or neglect by a Licensed Practical Nurse (LPN) and Certified Nursing Assistant (CNA). The facility also failed to separate the residents from the alleged perpetrator(s). These failures affected 5 residents (R1, R2, R5, R6, and R7) and has the potential for abuse and neglect to further occur, affecting all 119 residents residing in the facility. Findings include: Record review of facility census for 8/26/24 documents 119 residents reside in the facility. 1. R1's admission Record documents in part the following diagnosis: rheumatoid arthritis, hypertension, alcohol abuse, ascites. R1's Minimum Data Set, dated [DATE] documents in part a brief interview for mental status score of 15, indicating that R1 is cognitively intact. R2's admission Record documents in part the following diagnosis: bacterial intestinal 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 report 4 separate allegations of abuse/neglect to the state survey agency. This failure has the potential to affect 5 residents (R1, R2, R5, R6, and R7) reviewed. Findings include: 1. R1's admission Record documents in part the following diagnosis: rheumatoid arthritis, hypertension, alcohol abuse, ascites. R1's Minimum Data Set, dated [DATE] documents in part a brief interview for mental status score of 15, indicating that R1 is cognitively intact. R2's admission Record documents in part the following diagnosis: bacterial intestinal infection, schizophrenia, unspecified dementia without behavioral disturbance. R2 no longer resides in the facility. R2's Minimum Data Set, dated [DATE] documents in part a brief interview for mental status score of 2, indicating that R2 has severe cognitive impairment. Record review of grievance form dated 2/27/24 indicates that R1 stated to V4 (MDS Nurse, Licensed Practical Nurse), I was in bed a resident came in my room…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 unusual occurrence, which resulted to a serious injury, was reported to the State Agency within the mandated time frame and failed to develop policies and procedures for reporting unusual occurrence, which resulted to a serious injury, within the mandated time frame. These failures affected 1 (R2) resident reviewed for reporting of unusual occurrence in the total sample of 6 residents. Findings include: R2's admission Record documented that R2's diagnoses (include but not limited to) epilepsy, laceration without foreign body of scalp (onset date: 05/11/2024) and restlessness and agitation, and failure to thrive. R2's (Date Of Occurrence: 05/12/2024) Smartsheet Email to V2 (Director of Nursing) documented, in part Sent: Monday, May 13, 2024 (at) 1:34pm. Subject: Confirmation -Facility Reported Incidents. Incident description: It was reported that resident had an unwitnessed fall. Body assessment completed and laceration observed to the right lateral side of forehead. Resident sent out 911. Resident returned from…

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

Based on interview and record review, the facility failed to complete a thorough investigation of resident unusual occurrence which resulted in an injury. This failure affected (R2) resident reviewed for investigation of unusual occurrence in the total sample of 6 residents. Findings include: R2's admission Record documented that R2's diagnoses (include but not limited to) epilepsy, laceration without foreign body of scalp (onset date: 05/11/2024) and restlessness and agitation, and failure to thrive. R2's (Date Of Occurrence: 05/12/2024) Smartsheet Email to V2 (Director of Nursing) documented, in part Sent: Monday, May 13, 2024 (at) 1:34pm. Subject: Confirmation -Facility Reported Incidents. Incident description: It was reported that resident had an unwitnessed fall. Body assessment completed and laceration observed to the right lateral side of forehead. Resident sent out 911. Resident returned from hospital with six staples to area. Describe occurrence: it was reported that resident had an unwitnessed fall. Body assessment completed and laceration observed to the right lateral…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide bed hold notification when transferring to another facility, for 1 resident (R3) in a total sample of 3 residents reviewed. This failure affected 1 resident (R3) who was not afforded notification on the option to return to the facility after discharge. Findings include: R3 is [AGE] years old, initially admitted on [DATE] with depressive disorder. R3 cognition has impaired cognition based on his brief interview of mental status dated 3/22/2024 scoring at 3. Per R3's progress notes resident was discharge to hospital on 4/13/2024. Progress notes: Dated 4/13/2024 by V3 (Licensed Practical Nurse/LPN) documents that R3 was trying to set his clothes on fire. R3 was placed under involuntary petition for being danger to self and others. On 4/30/2024 at 12:41 PM, V3 (LPN) stated that she was the nurse in-charge of R3 during the time R3 was involuntarily transferred to the hospital on 4/13/2024. On 5/1/2024 at 10:45 AM, V2 (Director of Nursing/DON)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 determine current status of resident before denial of re-admission for 1 resident (R3) in a total sample of 3 residents reviewed. This failure affected 1 resident (R3) that was not accepted and therefore did not receive services in the facility after discharge. Findings include: R3 is [AGE] years old, initially admitted on [DATE] with depressive disorder. R3 cognition has impaired cognition based on his brief interview of mental status dated 3/22/2024 scoring at 3. Per R3's progress notes resident was discharged to hospital on 4/13/2024. Progress notes: Dated 4/13/2024 by V3 (Licensed Practical Nurse) documents that R3 was trying to set his clothes on fire. R3 was placed under involuntary petition for being danger to self and others. On 4/30/2024 at 12:41 PM, V3 (Licensed Practical Nurse) stated that she was the nurse in-charge of R3 during the time R3 started fire on his clothes. V3 said, When I told him what are you doing? He (R3) said I don't…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of records and interview the facility failed to address behavioral concerns in the care plan for a resident that manifest self-harm for 1 resident (R3) in a total sample of 3 residents reviewed for person-centered care plan. This failure affected 1 resident (R3) resulting in a lack of intervention on resident behavioral services' needs. Findings include: R3 is [AGE] years old, initially admitted on [DATE] with depressive disorder. R3 cognition has impaired cognition based on his brief interview of mental status dated 3/22/2024 scoring at 3. Per R3's progress notes resident was discharge to hospital on 4/13/2024. Progress notes of R3 dated 12/28/2024 (7 days after admission) by V11 (Social Service Director) it documents that R3 states he may have considered suicidal ideation at one point but never wanted to act on any such thoughts. Multiple notes of R3 were documented on R3's behavioral concerns are as follows: Dated 4/13/2024 by V3 (Licensed Practical Nurse/LPN) documents that R3 was trying 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 record review and interview, the facility failed to monitor vital signs and to identify a change in condition for 1 resident (R2), out of a total sample of 3 residents reviewed for nursing services. This failure potentially affected 1 (R2) resident who was transferred to the hospital and diagnosed with septic shock. Findings include: R2 is [AGE] years old resident was initially admitted in the facility on 6/20/2018. R2 medical diagnosis includes diabetes mellitus with hyperglycemia, hyperlipidemia, hypertension, anemias, dementia, anxiety disorder, bipolar disorder, head injury. R2's has impaired cognition, based on his brief interview of mental status (BIMS) score of 4. Per V9 (Registered Nurse / Hospital) R2 was admitted to Intensive Care Unit (ICU) due to sepsis. Progress notes of R2 dated 4/9/2024 at 6:56 AM by V4 (Licensed Practical Nurse-LPN) documents that R2 was congested, hypotensive, tachycardic, (blood pressure 86/56, respirations 18, temperature 98.6 degrees Fahrenheit, hear rate 113 oxygen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 their policy on involuntary transfer by failing to send the appropriate paperwork with one resident (R2) who required involuntary transfer to the hospital and as a result R2 returned to the facility without treatment and had to wait for the paperwork to be send out to emergency again for treatment. This failure has the potential to affect one of three residents (R2) reviewed for transfer/discharge on the total sample of 23. Findings include: On 04/10/2024 at 12:06pm V11 (LPN/Licensed Practical Nurse) stated on 3/26/2024 I sent R2 out to the hospital. V11 stated R2 started saying that, we all have the devil in us. V11 stated R2 was making cat like noises. V11 stated R2 seemed as if she was possessed. V11 stated I called R2's psychiatrist and R2's doctor regarding the behaviors R2 was exhibiting and both doctors stated to send R2 out to the hospital for evaluation. V11 stated I called 911 and 911 came to the facility to take R2 to the hospital. V11 stated R2 returned from the hospital during my shift. V11 stated R2 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 interview and record review the facility failed to send the appropriate paperwork with one resident who required involuntary transfer to the hospital and notify a resident's power of attorney that a psychotropic medication was discontinued. This failure had the potential to affect all three residents (R2, R5 and R6) reviewed for facility's policy and procedures. Findings include: On 04/10/2024 at 12:06pm V11(LPN/Licensed Practical Nurse) stated on 3/26/2024 I sent R2 out to the hospital. V11 stated R2 started saying that, we all have the devil in us. V11 stated R2 was making cat like noises. V11 stated R2 seemed as if she was possessed. V11 stated I called R2's psychiatrist and R2's doctor regarding the behaviors R2 was exhibiting and both doctors stated to send R2 out to the hospital for evaluation. V11 stated I called 911 and 911 came to the facility to take R2 to the hospital. V11 stated R2 returned from the hospital during my shift. V11 stated R2 was exhibiting the same behaviors and I told the emergency medical technicians I was not accepting R2 back into the facility.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 develop and implement fall prevention interventions for three of three residents (R2, R3 and R4) reviewed for accidents on the total sample list of seven. Findings include: R2 is a [AGE] year old with diagnosis including but not limited to: Fracture of left pubis, history of falling, traumatic subdural hemorrhage and unspecified injury of head. R2 has a BIMS (Brief Interview of Mental Status) score of 5, which indicates severe impairment. R3 is a [AGE] year old with diagnosis including but not limited to: History of falling, Unsteadiness on feet, and Lack of coordination, abnormal posture, mild cognitive impairment and fracture of nasal bones with routing healing. R3 has a BIMS (Brief Interview of Mental Status) score of 3, which indicates severe impairment. R4 is a [AGE] year old with diagnosis including but not limited to: Huntington's disease, unspecified fall, restlessness and agitation, depression and personal history of COVID-19. R4…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure that the wiping cloths for the food contact surfaces are properly sanitized, failed to ensure that dry food is stored six inches above the floor, and failed to ensure that the fan blowing on the clean dishes is free of accumulated dust. These failures have the potential to cause food borne illness in a total of 103 residents who receive oral diets from the facility's kitchen. Findings include: On 11/6/23 during the facility entrance, V1 (Assistant Administrator) reported the facility census as 105, minus 2 residents who are NPO (Nothing by mouth - list provided by V1) making a total of 103 residents receiving oral diets. On 11/6/23 between 10:49 AM and 11:15 AM, with V18 (Cook) and V19(Dietary Aide), the following were observed: 5 wet wiping cloths were observed in the green buckets not stored in a sanitizing solution. The sanitizing solution with one wiping cloth each in the two red buckets were tested but the color did not…

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

Based on observation, interview and record review, the facility failed to ensure that the outside dumpster lid was closed to prevent pest and rodents from entering the garbage bin. This failure has the potential to affect all 105 residents in the facility. Findings include: On 11/6/23 at 11AM after the entrance conference, the facility census was 105 as reported by V1 (Assistant Administrator). On 11/6/23 at 9.20 AM, two outside dumpsters were observed. Each dumpster had a lid attached. The dumpster on the left had the lid flipped to the back of the dumpster, while the dumpster on the right had the lid partially covering the dumpster. Again, on 11/6/23 at 10:45 am, with V19 (Dietary Aide), the outside dumpsters were observed still in the same conditions. V19 was asked why the dumpsters were not closed. V19 stated that the dumpsters should be completely closed to prevent rats from entering the dumpster. Facility's policy titled Waste Management dated 5/14 states in #4: Trash containers will be emptied when full but at least at the end of each shift. Plastic liners shall be tied 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, interviews and record review, the facility failed to ensure that one resident (R32) did not receive insulin from a personal insulin pen that belonged to another resident, failed to ensure hand hygiene was performed during medication administration for one resident (R32), failed to ensure oxygen tubing was properly stored while not in use for one resident (R249), and failed to ensure a urinary drainage bag was not directly touching the floor for one resident (R24) reviewed for infection control on the total sample list of 47. Findings include: R32 is [AGE] year old with diagnosis including but not limited to: Type 2 Diabetes Mellitus with unspecified complications, Personal history of COVID-19, Unspecified Dementia and Unspecified Adult Maltreatment. On 11/7/23 at 9:15 AM, surveyor observed V7 (Registered Nurse) administer medication to R32. At that time, V7 proceeded to prepare insulin from an insulin pen for R32. On 11/7/23 at 9:17 AM, V7 injected insulin in R32's abdomen with an unlabeled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure that the call light was within reach for one resident (R249) out of the 47 residents reviewed for call lights on the total sample list of 47. Findings include: R249's diagnosis include, but are not limited to, Traumatic Subdural Hemorrhage With Loss Of Consciousness Status Unknown, Encounter For Attention To Gastrostomy, Adult Failure To Thrive, Unspecified Severe Protein-Calorie Malnutrition, Acute Respiratory Failure With Hypoxia, Lobar Pneumonia, Unspecified Asthma, Helicobacter Pylori, Hypothyroidism, Senile Feeding Difficulties, Essential Hypertension, Gastro-Esophageal Reflux Disease Without Esophagitis, Repeated Falls, Other Osteomyelitis, Ankle And Foot, Hyperlipidemia, Type 2 Diabetes Mellitus With Unspecified Complications, Anemia, Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety. R249 has a Brief Interview for Mental Status (BIMS) dated 10/19/2023 which documents that R249 has a BIMS score of 02, indicating R249's cognition 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.

Based on observation, interview and record review, the facility failed to provide individualized fall prevention interventions, according to the care plan, for a cognitively impaired resident, who had repeated falls. This failure affected one resident (R30) of three residents, reviewed for falls, in a total sample of 47 residents. Findings include: On 11/7/23 at 2:54PM, R30 was observed in the wheelchair in the day room and there was no chair alarm attached to the wheelchair as stated in the care plan. V22 (R30's Family) stated that she (V22) looked everywhere in the room and the chair/bed alarm was nowhere to be found. V22 stated she asked the nurse and CNA (Certified Nurse Assistant) and they both said they did not know where the chair alarm was. On 11/8/23 at 11AM during this investigation, V15 (Assistant Director of Nursing) was interviewed about R30's fall of 8/29/23. V15 stated I observed him (R30) on the floor and saw that he had hit his head and there was some bleeding. We called the ambulance and sent him to the hospital. V1 (Assistant Administrator) later presented the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review the facility failed to ensure an oxygen tank was not empty and oxygen tubing was connected for one resident (R31), and an oxygen humidifier bottle was not empty (without water) for one resident (R40). This failure has the potential to affect two of three residents reviewed for oxygen use on the total sample list of 47. Findings include: R31 is [AGE] year old with diagnosis including but not limited to: Unspecified Asthma, Dizziness, Hypertension, Hyperlipidemia and Gastritis. R40 is [AGE] year old with diagnosis including but not limited to: Acute Respiratory Failure with Hypoxia, Acute Pulmonary Edema, Dependence on Supplemental oxygen, Pneumonia and Heart Failure. On 11/6/23 at 11:33 AM, R31 was observed sitting in the activity room with an oxygen tank on the back of her (R31's) wheelchair. At that time Surveyor observed the meter on the oxygen tank in the red area. No oxygen tubing was observed connected to R31 or the oxygen tank. On 11/6/23 at 11:33 AM,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 expired insulin medication was removed from medication cart and discarded for two residents (R86 and R28) of six residents reviewed for insulin use on the total sample list of 47. Findings include: R86 is [AGE] year old with diagnosis including but not limited to: Type 2 Diabetes Mellitus with unspecified complications, Chronic Kidney Disease, Unspecified Severe Protein- calorie malnutrition and Colostomy status. R28 is [AGE] year old with diagnosis including but not limited to: Type 2 Diabetes Mellitus, Chronic Kidney Disease, Unspecified Protein- calorie malnutrition and Hyperlipidemia. On [DATE] during floor rounds, Surveyor reviewed medication cart located on the 2nd floor. On [DATE] at 11:40 AM, Surveyor observed the following: Humalog insulin labeled with R86's name and with an expiration date of [DATE]; Insulin Aspart labeled with R28's name and with an expiration date of [DATE]; Liraglutide Insulin labeled with R28's name…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and arrage dental services and follow Dentist's recommendation for a dental appliance for one resident (R31) of one residents reviewed for dental appliances on the total sample list of 47. Findings include: R31 has a diagnosis of but not limited to Hyperlipidemia, Hypertension, Peripheral Vascular Disease, Asthma, and Sequelae of Vitamin A Deficiency. R31 has a Brief Interview of Mental Status score of 11. Admission/Readmissions Screener dated 3/11/2021 documents, in part, R31 has dentures but does not wear them and Dentures Fit: No. On 11/06/2023 at about 11:40AM R31 stated that she wanted dentures because she has trouble eating meat. On 11/06/2023 at 11:41AM surveyor observed R31's mouth and she had no teeth. On 11/06/2023 at 9:15AM V5 (Social Service Director) stated that R31 did not have dentures when she returned to the facility in June of 2023. V5 stated that the last time R31 was seen by the dentist was on 8/21/2021 and that R31 was not in the facility when the dentist came in 2022. V5 stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to maintain a supply of towels and washcloths for residents and staff to perform incontinence and bathing care. This deficient practice has the potential to affect all 35 residents residing on the third floor. Findings include: On 9.5.2023 at 1:20 PM, R7 said the facility does not have enough towels and washcloths; staff cut up towels and sheets or use patient gowns when they run out of washcloths. When there are no towels and washcloths, staff will use gowns and strips of sheets to clean incontinent residents; the facility does not use disposable wipes. On 9/6/2023 at 10:10 AM, V12 (CNA-Certified Nursing Assistant) said, Laundry did deliver linen (towels and washcloths) this morning and its gone; nada and nada (sic) pointing to linen closets at either end of the hallway. V12 accompanied surveyor to west linen closet; noted five incontinent pads (V12 states not enough), 10 patient gowns (V12 states not enough), no towels or washcloths. V12 stated, we cut up…

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