Complete Care at Margate Park

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY F700Based on observation, interview and record review, the facility failed to follow their policy to obtain informed consent and physician's order for the use of bed rails. These failures could potentially affect four (R32, R47, R80 and R129) residents reviewed for Accidents in a sample of 35. The findings include:R32's face sheet shows admission date on 12/10/21 with diagnoses not limited to Essential (primary) hypertension, Type 2 diabetes mellitus, Hyperlipidemia, Iron deficiency anemia, Bipolar disorder, Anxiety disorder, Atherosclerotic heart disease of native coronary artery, Irritable bowel syndrome, Cervicalgia, Unspecified osteoarthritis, Extrapyramidal and movement disorder. MDS (Minimum Data Set) dated 1/22/26 shows R32's cognition was intact.R47's face sheet shows admission date on 9/16/20 with diagnoses not limited to Polyneuropathy, Hyperlipidemia, Low back pain, Major depressive disorder, Bilateral primary osteoarthritis of knee, Anemia, Generalized anxiety disorder. MDS dated [DATE] shows R47…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review, the facility failed to follow their policy to (a) properly date / label multi dose inhalers and nasal sprays after opening, (b) properly discard multi-dose inhalers and nasal sprays, (c) medications were separated from juices or other refreshments in the refrigerator. These failures could potentially affect all residents residing on 5th floor reviewed for medication storage and labeling in two of four medication carts and one of two medication storage rooms. The findings include:On 2/24/26 at 10:15AM 6th floor team 2 cart inspected with V21 (LPN / Licensed Practical Nurse) and found R104's multi dose fluticasone nasal spray opened with no date. On 2/24/26 at 10:21AM 6th floor medication storage room inspected with V21 (LPN). Inside the refrigerator with medications such as insulin pens, insulin vials, Trulicity injection, Prevnar injection. Observed inside the same refrigerator with 1 can of ginger ale, cranberry juice, Glucerna and protein supplement mixed with multiple refrigerated medications. On 2/24/26 at 11:59AM 5th floor Team 2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure advance directive or code status is consistent with the comprehensive care plan of one (R10) out of eight residents reviewed for advance directive in a total sample of thirty-five. Findings Include: R10's Minimum Data Set (MDS) dated [DATE] noted he is cognitively intact. R10's Electronic Medical Record (EMR) noted he was admitted to the facility on [DATE]. He is [AGE] years old with diagnoses not limited to chronic viral hepatitis C, spinal stenosis, atherosclerotic heart disease of native coronary artery without angina pectoris, and non-pressure chronic ulcer of other part of left lower leg with necrosis of muscle, type 2 diabetes mellitus with other circulatory complications. Physician Order Sheet active/POS as of [DATE] noted Do Not Resuscitate/DNR dated [DATE]. On [DATE] at 2:22 PM, V31 (Social Worker) stated she has been in the facility for one year, she oversees the advanced directives care plan, and R10 has an order for a DNR code status…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) re-assessments were completed upon expiration for two (R97, R162) out of nine residents reviewed for PASRR compliance in a total sample of 35 residents. Findings Include: R162's face sheet documents an original admission date of 7/9/24 with diagnoses not limited to Other Psychotic Disorder and Major Depressive Disorder. Review of R162's Notice of PASRR Level II Outcome dated 10/26/25 indicates a short-term approval without specialized services, with an approval end date of 1/25/26. The notice states the short-term approval allowed a limited number of days in a Medicaid-certified nursing facility and required submission of a new Level I screen to Maximus no later than 10 days prior to the short-term approval end date if continued stay was needed. The facility failed to provide documentation that staff completed or initiated a new Level I PASRR screening prior to the expiration date of 1/25/26…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 develop and implement a comprehensive resident-centered care plan for one (R13) resident out of eight residents reviewed for comprehensive care plan in a total sample of thirty-five. Findings Include: R13's Minimum Data Set (MDS) dated [DATE] noted she is cognitively intact. R13's Electronic Medical Record (EMR) noted she was admitted to the facility on [DATE]. She is [AGE] years old with diagnoses not limited to chronic systolic congestive heart failure, unspecified asthma, chronic obstructive pulmonary disease, type 2 diabetes mellitus with unspecified complications. Physician Order Sheet (POS) active order as of 02/25/26 noted isolation; contact precautions related to Extended-Spectrum Beta Lactamase/ESBL from 02/14/26 until 02/28/26. On 02/25/26 at 12:09 PM, observed contact isolation sign on R13's door. R13 stated she has been on contact isolation for few days. On 02/25/26 at 2:42 PM, V2 (Director of Nursing/DON) stated she joined…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 obtain physician orders for oxygen administration and to place oxygen in use signage on the door of one (R75) resident out of two residents reviewed for respiratory care in a sample of 35.Findings include:On 02/24/26 at 11:45 AM, observed R75 lying in bed wearing a nasal cannula with oxygen infusing. R75 appeared to be sleeping. R75's oxygen concentrator was set at five liters per minute. R75's oxygen tubing and humidifier bottle was dated 02/22/26.On 02/24/26 at 11:46 AM, R75 did not have an oxygen in use sign or no smoking sign posted in or outside his room.On 02/24/26 at 3:12 PM, V10 (Licensed Practical Nurse) stated R75 is receiving continuous oxygen via nasal cannula and the oxygen infusion rate is part of the physician order. V10 stated the infusion rate is usually set between two-three liters per minute but that R75 turns the rate up on his own and the staff turns it back down to the appropriate rate. V10 viewed R75 electronic health record orders and stated she does not see any orders for oxygen. V10…

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

F759Based on observation, interview, and record review, the facility failed to ensure a medication error rate was less than 5% for two (R23 and R164) of four residents reviewed for medication administration. There were 39 opportunities and 4 errors resulting in a 10.26% medication error rate. The findings include:On 2/24/26 at 9:18AM Medication administration observation conducted with V8 (Licensed Practical Nurse / LPN). Observed V8 (LPN) prepared the following medications for R164:Acidophilus with pectin 1 capsule Magnesium oxide 400MG 1 tablet.Senna plus 8.6 2 tabletsFerrous sulfate 325MG 1 tablet.Amantadine 100MG 1 capsuleGlipizide 2.5mg 1 tabletEzetimibe10mg 1 tablet Venlafaxine 37.5mg 1 capsuleMetoprolol 100mg 1 tabletMedications were counted in the medication cup with V8 and stated there were 10 medicines in the medication cup. Observed V8 administered prepared medications to R164 and taken by mouth.Reviewed R164's POS (Physician Order Sheet and MAR (Medication Administration Record) and shows order not limited to: Acidophilus with pectin 1capsule by mouth three times a day…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide diet and supplement as ordered by the physician for one (R188) out of three residents reviewed during dining observation in a total sample of 35 residents.Findings Include:On 2/24/26 at 11:12 AM, R188 stated he does not receive his health shake twice a day. On 2/24/26 at 12:39 PM, R188's eating lunch in his room. R188 received one breaded fish patty, pasta noodles, squash, cup of coffee, glass of juice, and canned fruits. R188 did not receive his health shake. R188's meal ticket documents in part, NAS (No Added Salt) Doubled Portions at all meals. R188's meal ticket does not indicate health shake. R188 stated he usually only receives single portion with his meals, and he is supposed to receive double portions. R188 stated he should have received two pieces of fish patties.On 02/25/26 at 11:35 AM, V4 (Food Service Director) stated diet orders and special instructions are printed on the meal tickets so the kitchen staff know what food…

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

Based on interviews and record reviews, the facility failed to ensure that a resident (R185) completed their pneumonia vaccine series for one out of five residents reviewed for immunizations.Findings include: R185's admission Record documents in part multiple comorbidities including but not limited to polyneuropathy, asthma, anemia, hypertension, hyperlipidemia, and heart disease. On 2/25/2026 at approximately 10:03 AM, V3 (Infection Preventionist) stated V3 does annual chart audits to see when the last time residents received the pneumonia vaccine to see who is eligible. V3 provided a vaccine report for the last 12 months. The report had a blank cell/no entry in the column for Pneumonia for R185. V3 did not know why it was blank and stated V3 will follow-up what the blank spot signifies in the report. (V3 did not provide an answer prior to the end of the survey). R185's Immunization Report documents in part that R185 received Pneumo-PCV13 (Prevnar 13) on 3/28/2024. The previous one listed in the electronic medical record was a pneumococcal conjugate PCV 13 on 9/27/2016. 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 interviews and record reviews, the facility failed to offer and administer the COVID-19 vaccine to a resident (R185) for one out of five residents reviewed for immunizations.Findings include: R185's admission Record documents in part multiple comorbidities including but not limited to polyneuropathy, asthma, anemia, hypertension, hyperlipidemia, and heart disease. On 2/25/2026 at 10:39 AM, R185 was alert and oriented to person, place, and time. R185 stated wanting to receive the Covid-19 vaccine but facility did not provide it. R185 stated receiving the last COVID-19 vaccine during the fall in 2024. R185 stated informing V3 (Infection Preventionist) that [R185] wanted the COVID-19 vaccine but V3 has not provided it. On 2/25/2026 at approximately 10:03 AM, V3 (Infection Preventionist) stated V3 does annual chart audits to see when the last time residents received the COVID-19 vaccination to see who is eligible. V3 provided a vaccine report for the last 12 months. The report had a blank cell/no entry in the column for COVID for R185. V3 did not know why it was blank 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 interview and observations the facility failed to ensure that the dumpster lids were properly closed on two dumpsters, resulting in garbage hanging out of dumpster this failure has the potential to affect all 185 residents in the facility .Findings include:On 11/18/25 at 10:45 am, V12 (Housekeeper) stated that she is responsible to clean the 2nd floor and has not observed any rodents on the unit and or in the room on R5. V12 stated if she observed a rodent or dropping from a rodent, she would immediately report that concern to her supervisor, but she thinks pest control comes out to the building weekly and she keeps the area clean.On 11/18/25 at 10:59 am, V30 (Housekeeping Director) stated housekeeping is responsible for managing the dumpsters, and dumpsters should always be free from trash hanging out of it. There are two large trash dumpsters, two small trash dumpsters and three recycle dumpsters that are all in same area behind the facility located in the parking lot. The lid of the dumpsters should be always closed to prevent trash from blowing, rodents and animals 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 observation, interviews, and record review, the facility failed to assess a resident's ability to safely self-administer medication, failed to obtain a doctor's order to self-administer medication, and failed to care plan self-administration of medication prior to initiating self-administration of medication. This failure affects 1 (R16) resident reviewed for self-administration of medication in the total sample of 21 residents. Findings include:On 11/18/2025 at 9:56am during medication administration observation with V37 (Licensed Practice Nurse) for R16's, observed a tube of Hydrocortisone cream on R16's bedside table. R16 requested V37 to give him additional tube of hydrocortisone cream as his tube was almost empty. R16 stated the night shift nurse gave him the tube of hydrocortisone cream a long time ago and the CNA applied the cream on his back because he could not reach his back. On 11/18/2025 at 10:05am, V37 stated he should not have the hydrocortisone cream at bedside because anyone might come in his room and take the medication. On 11/19/2025 at 10:31am, V14 (Unit…

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

Based on interview and record review, the facility failed to maintain a resident's personal privacy. This failure affected 1 (R1) resident reviewed for personal privacy in the total sample of 21 residents. Findings include:On 11/17/2025 at 11:54am, R1 stated she was lying on her bed when she heard a noise coming from her restroom, she got up and saw him (R10) using her restroom. R1 stated he was facing the sink washing his hands. R1 stated she was very upset because he (R10) invaded her space. R1 stated when she asked him why he was in her restroom, he said he (R1) did not give a FK because he had to use the restroom. On 11/19/2025 at 11:25am, V41 (Infection Preventionist) stated she remembered her (R1) yelling 'why are you in my room'. V41 stated she went to the room to see what was going on, and she saw him (R10) in the restroom washing his hands, he was patting his hands dry, and she (R1) was standing outside of her restroom. V41 stated she escorted (R10) out of the room and asked him why he was in the room. He (R10) stated he needed to use the bathroom really bad. V41 stated a…

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

Based on observation, interview, and record review, the facility failed to follow a physician order after administering inhaler sprays to a resident potentially placing a resident at risk for oral thrush. This failure affected 1 (R16) resident out of 5 residents reviewed for medication administration. Findings include: On 11/18/2025 at 9:56am during the medication administration observation with V37 (Licensed Practice Nurse) of R16's medications, V37 placed the mouthpiece of the Budesonide/Formoterol inhaler on R16's mouth, pressed down the canister of the inhaler and instructed R16 to inhale the medication orally. After R16 orally inhaled the medication, V37 instructed R16 to drink water. On 11/18/2025 at 10:00am, inquiring about expectation after R16 orally inhaled 2 puffs of budesonide/formoterol, V37 stated she should have instructed him to swish and spit water to prevent him from having fungal infection. On 11/18/2025 at 10:04am, R16 stated nurses usually asked him to swish and spit after he took his liquid protein (Pro-Heal), and he did not know the purpose of swish 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 interview and record review, the facility failed to ensure a resident's representative was notified of an injury of unknown source. This failure affected 1 (R1) resident reviewed for notification of representative in the total sample of 5 residents.Findings include:On 09/18/2025 at 3:12pm, V10 (Smoke Monitor/Receptionist) stated that on 07/29/2025, he (V10) was in the dining room, opening the door to the patio for the 3pm smoking time. When he saw R1 in the dining room, V10 said, Wow, he got some burn. V10 stated he sent him (R1) upstairs because he (R1) cannot stay in the patio with a big burn on his leg. V10 said there is no way he (R1) got the burn in the patio because it was not hot that day for him to get a huge burn mark. It was like riding a motorcycle and hit the leg on the exhaust of the motorcycle. V10 said he (R1) came in at 3pm to smoke and when he saw the burn mark, he sent him upstairs right away. V10 stated he did not know how he (R1) got the wound and that he (R1) got the wound somewhere upstairs, on the floor.On 09/18/2025 at 3:27pm, V11 (Agency Registered…

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

Based on interviews and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act. This failure affected 1 (R1) resident out of 5 residents reviewed for reporting of injury of unknown source. Findings include:On 09/18/2025 at 3:12pm, V10 (Smoke Monitor/Receptionist) stated that on 07/29/2025, he (V10) was in the dining room, opening the door to the patio for the 3pm smoking time. When he saw R1 in the dining room, V10 said, Wow, he got some burn. V10 stated he sent him (R1) upstairs because he (R1) cannot stay in the patio with a big burn on his leg. V10 said there is no way he (R1) got the burn in the patio because it was not hot that day for him to get a huge burn mark. It was like riding a motorcycle and hit the leg on the exhaust of the motorcycle. V10 said he (R1) came in at 3pm to smoke and when he saw the burn mark, he sent him upstairs right away. V10 stated he did not know how he (R1) got the wound and that he (R1) got the wound somewhere upstairs, on…

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

Based on interview and record review, the facility failed to ensure injury of unknown source was thoroughly investigated. This failure affected 1(R1) resident out of 5 residents reviewed for allegation abuse. Findings include:On 09/18/2025 at 3:12pm, V10 (Smoke Monitor/Receptionist) stated that on 07/29/2025, he (V10) was in the dining room, opening the door to the patio for the 3pm smoking time. When V10 saw him (R1) in the dining room, he (V10) said wow, he got some burn. V10 stated he sent him (R1) upstairs because he (R1) cannot stay in the patio with a big burn on his leg. That there is no way he (R1) got the burn in the patio because it was not hot that day for him to get a huge burn mark. It was like riding a motorcycle and hit the leg on the exhaust of the motorcycle. V10 said he (R1) came in at 3pm to smoke and when he saw the burn mark, he sent him upstairs right away. V10 stated he did not know how he (R1) got the wound. (R1) got the wound somewhere upstairs, on the floor. V10 stated nobody interviewed him on the day the injury was noted. V10 stated he (V1-Administrator)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 protect a resident (R2) from abuse by another resident (R1), in one of three residents reviewed for abuse. As a result, R2 sustained discoloration of the left eye.Findings include:R1 is a [AGE] year-old, originally admitted on [DATE] with medical diagnoses that include and are not limited to: violent behavior, schizophrenia, and schizoaffective disorder. R1 is not currently at the facility.R2 is a [AGE] year-old, originally admitted on [DATE] with medical diagnoses that include and are not limited to: disorders of the brain, chronic obstructive pulmonary disease, and diabetes. On 7-19-2025 at 9:20 am, R2 said, An incident took place several days ago. I was sitting in the dining room waiting for my lunch. (R1) came and told me, you are sitting in my chair. You need to move now. I got up, and (V4 - licensed practical nurse) came and told me: Thank you for letting R1 sit on that spot. I went to my room for a few minutes, and then I came out again. I 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 interview and record review, the facility failed to prevent and protect one (R4) resident from resident-to-resident abuse out of three residents reviewed for abuse. Findings include:On 07/15/2025 at 11:36AM, R4 stated R5 rammed his walker against his left leg while they were waiting on their smoke break on the first floor of the facility. R4 stated this incident happened approximately 2 to 3 weeks ago. R4 stated R6 was present and witnessed the entire incident. R4 stated he has never seen R5 with alcohol in the facility but R5 gets drunk when out on community pass. R4 stated he informed V4 (Receptionist) and V3 (LPN/Nursing Supervisor) of the altercation between himself and R5. R4 stated V3 took a picture of his leg and told him she would report the incident. R4 stated V3 informed him she reported the altercation to V1 (Administrator). R4 stated he overheard the police were called to the facility, but he did not get a chance to speak with a police officer or file a police report. R4 points to his left…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 allegations of physical abuse for one (R4) resident out of three residents reviewed for physical abuse. Findings include: On 07/15/2025 at 11:36AM, R4 stated R5 rammed his walker against his left leg while they were waiting on their smoke break on the first floor of the facility. R4 stated this incident happened approximately 2 to 3 weeks ago. R4 stated R6 was present and witnessed the entire incident. R4 stated he has never seen R5 with alcohol in the facility but R5 gets drunk when out on community pass. R4 stated he informed V4 (Receptionist) and V3 (LPN/Nursing Supervisor) of the altercation between himself and R5. R4 stated V3 took a picture of his leg and told him she would report the incident. R4 stated V3 informed him she reported the altercation to V1 (Administrator). R4 stated he overheard the police were called to the facility, but he did not get a chance to speak with a police officer or file a police report. R4 points to his left…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 adequate supervision and monitoring for residents. As a result of these failures, R1 fell in the facility on 06/08/2025 and sustained a temporal laceration with sutures. This failure affects one (R1) out of three residents reviewed for supervision and monitoring. Findings include: R1's Facesheet documents that R1 has diagnoses not limited to: osteophyte, vertebrae, bladder disorder, moderate protein-calorie malnutrition, obstructive and reflux uropathy, osteoarthritis, unspecified convulsions, other symptoms, and signs involving cognitive functions and awareness, unspecified fall, and laceration without foreign body of other part of head. R1's MDS/Minimum Data Set, dated [DATE], documents R1 has a BIMS/Brief Interview for Mental Status of 3/15, indicating R1 is cognitively impaired. R1 requires substantial/maximal assistance with ADL/activities of daily living care. R1 is incontinent of bowel and bladder and ambulates via wheelchair. R1's Fall…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents remain free from physical abuse and verbal abuse. These failures affected R1 who was physically hit by R2 in the arm and R3 who was verbally abused with derogatory words from a staff member in the sample of 7 residents reviewed for abuse. Findings include: 1) On 4/14/25 at 2:13 pm, R1 stated that on 3/26/25 at around 7:00 pm, R1 was wheeling R1's self into the elevator to go downstairs to smoke. R1 said when R1 was wheeling into the elevator, R2 was inside the elevator in R2's wheelchair, and R7 was standing in the elevator. R1 asked R2 to move back for more space, and R2 said no. R1 stated R1 wheeled in on the side of R2 in R2's wheelchair, and R2 grabbed my arm and swung at me. R1 said R2 hit R1's arm. R1 said, (R2) attacked me. On 4/15/25 at 9:50 am, R2 stated on 3/26/25, R2 was already in the elevator going down to smoke break, and R1 wheeled in the elevator next to R2's wheelchair. When asked if R2 hit R1 in the elevator 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 interview and record review, the facility failed to timely submit an initial abuse report to the state agency within 2 hours which affected one resident (R3) in the sample of 7 residents reviewed for abuse. Findings include: On 4/14/25 at 2:06 pm, R3 stated that on 3/22/25 after midnight, R3 went downstairs to the first-floor lobby via R3's manual wheelchair to get something. When asked did R3 know V5 (Former Receptionist) prior to this incident, R3 stated that R3 knew (V5), and they were friends. When asked what happened on 3/22/25 at 1:45 am when R3 saw V5 at reception desk, R3 stated, I (R3) was talking to my friend (V5). And we had a disagreement. I was about ready to leave. When asked what the disagreement was about, R3 stated, (V5) was saying something, talking about me. When asked what V5 specifically said, R3 stated, That's a personal matter. When asked did V5 say curse words towards R3 during their disagreement, R3 stated, Yeah, (V5) did. R3's admission Record documents, in part, diagnoses of…

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

Based on observation, interview and record review, the facility failed to post required staffing information in a high visibility area and failed to ensure the staffing posting included all required information. This failure has the potential to affect all 192 residents residing within the facility. Findings include: Review of facility-provided census documents in part that 192 residents reside within the facility. On 3/31/2025 at 10:30 AM, facility tour was conducted. Posted staffing information was not noted in any high visibility areas on the resident units, dining rooms, activity rooms, or entry areas. On 3/31/2025 at 12:37 AM, surveyor inquired where the required staffing posting was kept. V36 (Receptionist) stated, We don't have a document that says anything like hours on it, just the staffing schedule. V36 pulled a binder off the side counter of the reception desk area and provided a copy of the facility's nursing schedule from the binder. On 3/31/2025 at 12:39 AM, observed the location of the binder sitting on top of the side counter of the receptionist desk area. 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 ensure foods in the walk-in freezer were labeled with a date indicating when the items were placed in the freezer and labeled with a use by date to prevent expired foods from being served. This failure has the potential to affect all 188 residents in the facility who are receiving an oral diet. The findings include: On 3/31/2025 at 9:30am observed the Walk-In Freezer #3 accompanied by V17 (Dietary Manager). Observed a 10-pound box of flame broiled rib shaped pork patties (53 count per box) and a 10-pound (2- 5-pound packages) box of diced ham which were not dated with a date the item was stored in the freezer, nor dated with a use by date. On 4/2/2025 at 12:09pm V17 (Dietary Manager) stated all kitchen staff are responsible for labeling food items placed in the freezer with a date indicating when it was placed into the freezer. V17 stated it is my expectation that all kitchen staff are labeling all food items with a date when the food item was received and placed into the freezer. V17 stated the food items are…

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

Based on interview and record review, the facility failed to develop a QAPI (Quality Assurance Performance Improvement) plan that meets regulatory standards. This failure has the potential to affect all 192 residents that reside within the facility. Findings include: Review of facility-provided census documents in part that 192 residents reside within the facility. On 4/2/2025 at 10:00 AM, surveyor received QAPI meeting minutes and sign-in sheets for all QAPI activities from 2024 through present. A copy of the facility's QAPI plan was not received and was not received prior to the exit of the survey. On 4/2/2025 at 10:40 AM, V1 (Administrator) provided a copy of the facility's QAPI policy. V1 stated the purpose of QAPI is to have ongoing monitoring of data to ensure quality outcomes. On 4/2/2025 at 1:38 PM, surveyor requested to review the facility's QAPI plan. On 4/2/2025 at 3:02 PM, V1 (Administrator) stated the facility does not have a separate QAPI plan and the QAPI policy is the facility's QAPI plan. Record review of facility policy titled QAPI program (8/2024) documents,…

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

Based on interview and record review, the facility failed to develop policies and procedures on how the facility obtains and uses feedback from residents, resident representatives, and staff to identify high-risk, high-volume, or problem prone issues as well as opportunities for improvement; Develop and implement policies and procedures which include how it ensures data is collected, used and monitored for all departments; Develop policies and procedures for how it will identify, report, and track, adverse events, and high risk, high volume, and/or problem-prone concerns; Establish priorities for its improvement activities, focus on high-risk, high- volume or problem-prone areas, as well as resident safety, choice, autonomy, and quality of care; Conduct at least one PIP annually focuses on high-risk or problem prone areas, identified by the facility, through data collection and analysis; and measure the success of actions implemented and track performance to ensure improvements are realized and sustained. This failure has the potential to affect all 192 residents reside within the…

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

Based on interview and record review, the facility failed to ensure all staff were trained annually on the facility's QAPI program. This failure has the potential to affect all 192 residents residing within the facility. Findings include: Review of facility-provided census documents in part that 192 residents reside within the facility. On 4/2/2025 at 10:16 AM, V35 (Medical Records Director) affirmed V35 manages the QAA and QAPI programming for the facility. V35 stated QAPI stands for Quality assurance performance and . uhh . I don't know. V35 did not know what the term root cause analysis meant. V35 reviewed nearby documents and could not state what QAPI stands for. V35 stated the facility does not train all staff on QAPI as the department heads are the identified staff that participate in QAPI. V35 could not remember the last time V35 had QAPI training, stating it was probably many, many years ago. On 4/2/2025 at 10:40 AM, V1 (Administrator) affirmed V35 is in charge of the QAPI programming but V1 supervises V35. V1 affirmed V1 participates in the QAPI committee as the governing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 4th floor medication cart was locked while unattended. This failure has the potential to affect 51 residents on the 4th floor. Findings include: The (3/31/25) census includes 51 (4th floor) residents. On 4/1/2025 at 11:11 am, with V29 (Licensed Practical Nurse-(LPN), during observation of the medication car on the 4th floor, V29 and surveyor walked away from the nursing medication cart to observe the medication refrigerator behind the nursing station. V29 did not lock and secure the nursing medication cart after leaving the nursing medication cart unattended. Surveyor inquired why the medication cart was left unlocked and unattended and V29 replied, I was rushing and forgot to lock the cart. The cart should be locked when unattended. On 4/2/2025 at 2:11pm, V2, (Director of Nursing-(DON), stated the medication cart should be always locked after medication. V2 stated residents can get into unlocked medication carts. Facility policy titled Storage of Medications dated 5/1/2018, document, in part,…

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

Based on observation, interview, and record review the facility failed to ensure a resident was not interrupted while eating for a scheduled blood glucose monitoring. This failure affected one resident (R88) reviewed in a sample of 62. Findings include: R88's diagnosis includes but not limited to diabetes, gastro esophageal reflux, long term insulin, heart failure and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. R88's (3/7/25) Minimal Data Set (MDS) Section C documents in part, Brief Interview of Mental Status (BIMS) score is 12. R88 has moderate impairment. Section I: Active diagnoses include Diabetes Mellitus. On 3/31/25 at 12:15 pm observed R88 in the dining room eating lunch. R88 had consumed half of the meal when V14 LPN (License Practical Nurse) stopped R88 from eating to take R88 to the room to check R88's blood sugar. R88 was brought back to the dining room after to continue eating. R88's (12/19/24) POS (Physician Order Set) documents in part, Blood Glucose Monitoring three times a day for DM (Diabetic Mellitus). R88's 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 observation, interview, and record review, the facility failed to ensure 1 resident's (R62) bed, with exposed wires, was repaired; failed to ensure 1 resident's (R85) missing closet door was replaced; and failed to repair 1 resident's (R180) leaky ceiling. These failures affected 3 residents (R62, R85 and R180), reviewed for resident's rights to enjoy a homelike environment, in a total sample of 62 residents. Findings include: 1. On 3/31/25 at 11:20am, surveyor observed R62 sitting on the side of his bed. At the end of the bed, the location of the mechanical controls to raise and lower parts of the bed, was broken causing exposed wiring. R62 said, My bed's been broken for weeks. I (R62) told the CNAs (certified nursing assistants) many, many times about my bed because I (R62) don't want to get electrocuted by the wires. They (CNAs) told me to be careful and not to touch the wires. Of course, I'm (R62) not going to touch the wires, but you never know. S* happens. Hell! Those wires might cause a fire.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Minimum Data Set (MDS) assessments accurately in accordance with the Resident Assessment Instrument (RAI) guidelines. This failure affects 1 resident (R165) in a sample of 61. Findings include: Record review of R165's admission record documents in part the following diagnosis: Record review of R165's MDS ([DATE]) documents in part that R165 has a Brief Interview of Mental Status (BIMS) Summary Score of 8, indicating that R165 has cognitive impairment and that R165 has had wandering occur within the lookback period 4 to 6 days but less than daily. A modification request was completed on [DATE] due to a data entry error. Record review of R165's electronic health record for the lookback period does not document any non-purposeful movement or wandering. On [DATE] at 11:22 AM, R165 denied any non-purposeful movement or wandering within the facility. R165 denied ever getting lost or turned around within the facility. R165 stated that R165 has been…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview and record review the facility failed to follow policy procedures, failed to ensure the vaccination consent form includes a refusal option, and failed to ensure staff provide informed consent prior to obtaining resident signature for one of five residents (R19) reviewed for immunization administration. Findings include: The facility Vaccination Consent Form includes signature of patient or authorized representative to receive vaccine however refusal of vaccine is excluded. R19's (8/19/24) Pfizer - Covid 19 and Flu Vaccination Consent Form was endorsed (by R19) and states signature of patient to receive vaccine however evidence that R19 received these vaccines was not received (as requested). On 4/1/25 at approximately 12:43pm, surveyor inquired about R19's vaccinations V4 (Infection Preventionist) stated He (R19) had refused the Flu and Covid. Surveyor inquired about R19's (8/19/24) Covid 19 and Flu Vaccination Consent Form which affirms consent to receive the vaccines. V4 responded, The consent is signed it looks like whoever did the clinic put refused on the…

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

Based on observation, interview, and record review the facility failed to provide ADL (Activity of Daily Living) care to one resident (R138) reviewed for ADL care in a sample of 62. Findings include: R138's diagnoses include but not limited to osteoarthritis, chronic pain syndrome, Transient Ischemic Attack (TIA), artificial shoulder joint, and anxiety. R138's (3/25/25) Brief Interview of Mental Status (BIMS) score is 15. R138 in cognitively intact. R138's functional assessment affirms R138 requires substantial/maximal assistance with personal hygiene (shaving). On 3/31/25 at 11:30 am, R138 was observed in room watching television ungroomed with facial hair on the chin. Surveyor inquired if the facility assists R138 with shaving. R138 stated, Staff never offer to shave me. The hair on my chin makes me feel like a man and I do not like that. On 4/2/25 at 10:57 am, V2 DON (Director of Nursing) stated shaving should be done if the resident request to be shaved or if staff see hair. The staff should ask if the resident wants to be shaved and if the resident does want to be shaved 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.

Based on observation, interview, and record review the facility failed to ensure the low air loss mattress was not layered with multiple linens. This failure affected 1 resident (R16) reviewed for pressure ulcer/injury prevention and treatment in a sample of 62 residents. Findings include: R16's diagnoses include but not limited to COPD (Chronic Obstructive Pulmonary Disease), hypertension, chronic kidney disease, left tibia fracture, tendinitis of left and right leg. R16's Brief Interview of Mental Status (BIMS) score is 15. R16 is cognitively intact. On 3/31/25 at 10:45 am, R16 was lying on a low air loss mattress with multiple layers between R16 and the low air loss mattress. The layers observed under R16 consisted of a flat sheet, a folded bath sheet folded multiple times, and an incontinent brief. On 4/2/25 at 10:23 am, V30 Wound Care Director stated the low air loss mattress should be layered with a single flat sheet. Surveyor asked V30 if a resident on a low air loss mattress should have a folded bath sheet, flat sheet, and incontinent brief under them. V30 stated, That 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 follow policy procedures, failed to follow physician orders, failed to implement care plan interventions, failed to measure/record urine output, and failed to timely report hematuria to the physician for one of 62 residents (R19) in the sample reviewed for incontinence/catheter. Findings include: R19's diagnoses include neuromuscular dysfunction of bladder and retention of urine. R19's Physician Order Sheets include (12/17/24) Xarelto (anticoagulant) 10 milligrams daily to prevent blood clots. (12/28/24) Indwelling catheter measure and record urinary output, color, clarity, and device status every shift. R19's care plan includes (7/6/22) indwelling catheter related to retention of urine and neurogenic bladder, interventions: monitor/record/report to Medical Doctor signs/symptoms UTI (Urinary Tract Infection): pain, burning, blood-tinged urine. (10/2/24) Resident is on anticoagulant therapy, interventions: Monitor/document/report adverse reactions: blood tinged or red blood in urine. R19's (March 2025)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 enteral feed orders include daily total volume, failed to follow physician orders, and failed to provide enteral feedings as ordered for one of 62 residents (R122) in the sample reviewed for hydration/nutrition. Findings include: R122's diagnoses include encephalopathy, dysphagia, and gastrostomy. R122's (3/3/25) BIMS (Brief Interview Mental Status) affirms cognitive skills for daily decision making is severely impaired, inattention and disorganized thinking are present. R122's (3/3/25) functional assessment affirms resident is dependent on staff for eating, resident does none of the effort to complete the activity. R122's (3/4/25) Care Plan states resident is NPO (nothing by mouth) and receives nutrition via G (gastrostomy) tube, intervention: provide tube feeding as ordered. R122's (3/19/25) Physician Order Sheets include Nepro 1.8 (enteral feed) administer continuous via Pump 70ml (milliliters) per hour over 21 hours (daily total volume is excluded). Downtime:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 discard expired medication. This failure has the potential to affect three residents (R64, R144, R189) in a sample size of 62. Findings Include: 1. On [DATE] at 10:05 am, the second-floor's medication cart had R189's Insulin Lispro Injection Solution 100 UNIT/ML labeled with an expiration date of [DATE]. R189's admission diagnosis includes but not limited to Type II Diabetes Mellitus, Hypertension, and Obesity. R189's Physician Order Sheet documents in part an active order for Insulin Lispro (Injection Solution 100 Unit/ML) with an order date of [DATE] and start date of [DATE]. R189's Medication Administration Record (MAR) documents in part Insulin Lispro Injection Solution had a check mark indicating administration dates of [DATE], [DATE], [DATE], [DATE] and [DATE]. On [DATE] at 10:51 am, the fourth-floor's medication cart had R64's Insulin Glargine (Injection 100 Units/ML) labeled with an opening date of [DATE] and expiration date of…

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

Based on observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that staff report maintenance concerns, failed document maintenance requests/repairs, and failed to repair malfunctioning equipment for one of 62 residents (R63) in the sample. Findings include: R63's (3/10/25) functional assessment includes mobility devices: wheelchair. R63's (3/10/25) BIMS (Brief Interview Mental Status) determined a score of 8 (moderate impairment). On 3/31/25 at 12:40pm, surveyor inquired about concerns R63 stated, My leg rest for my chair (referring to the wheelchair) it's broke. V3 (Assistant Director of Nursing) subsequently placed the left leg rest on R63's wheelchair however was unable to lower the foot pedal. Surveyor inquired if R63's foot pedal was broke V3 responded, It won't move, this part (referring to the foot pedal) doesn't slip down. I can't get this one down. Surveyor inquired if V3 was unable to lower R63's foot pedal V3 replied, It's like it's caught up on here and doesn't go through so I'm gonna have maintenance come take a look…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 support requirements for petition to involuntary admit 1 resident (R2) out of 4 residents reviewed for transfer and discharge. These failures affected 1 resident (R2) who was twice petitioned to be transferred to the hospital and did not meet regulatory requirement or documentation during both transfers. Findings include: R2 is [AGE] years old, initially admitted to the facility on [DATE]. R2 was twice transferred to hospital via petition for involuntary admission on [DATE] and 02/28/2025. - Per first petition for involuntary admission dated 01/27/2025, signed by V10 (Social Service Director), documents R2 demonstrates ongoing behaviors of medication refusals and non-compliance with care. R2 is also displaying increase irritability, agitation, aggression, and emotional distress coupled with manipulative behavior. Review of R2's notes dated 01/27/2025, the day R2 was sent via petition for involuntary admission to the hospital, shows there was 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and records review the facility failed to accurately document on resident records for 2 (R1, R2) out of 4 residents reviewed. These failures affected 2 residents (R1, R2) on correct representation of their resident records. R1's physician order and medication administration have identified inconsistency. R2's petition for involuntary / judicial admission to the hospital documentation have identified inconsistency. These inconsistencies resulted to inaccurate representation of R1 and R2's records. Findings include: 1. R1 currently [AGE] years old, initially admitted on [DATE]. R1's medical diagnosis includes alcoholic cirrhosis of liver with ascites, chronic obstructive pulmonary disease, centrilobular emphysema, malignant neoplasm of trachea, atherosclerotic heart disease of native coronary artery. Per clinical notes dated 03/21/2025 by V3 (Licensed Practical Nurse) R1 was sent to the hospital due to altered mental status, very anxious and restless. On the same day (03/21/2025) V4 (Licensed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure individualized and appropriate fall interventions were identified and implemented to provide necessary supervision to prevent a resident from falling for 1 (R1) out of 4 residents reviewed for falls. Findings Include: R1's Fall note dated 2/28/25 at 9:00 PM documented by V4 (Licensed Practical Nurse) reads in part: Noted resident [R1] walking out of room with foley catheter in his hand. [R1] walked in front of the nursing station and fell and hit the back of his head. [R1] unable to give description. Full body assessment with no noted bruises or bumps. Emergency ambulance called and transferred R1 to the hospital. V4's (Licensed Practical Nurse/LPN) witness statement reads in part, Noted resident walking out of room and walk in front of nursing station and fall and hit his back of his head. V5's (LPN) witness statement reads in part, Resident noted walking by nursing station unassisted and lost his balance falling and hit his back and side 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident medication was administered as ordered by the physician. This failure affects 1 (R1) out of 3 residents reviewed for medication administration. Findings Include: R1's Electronic Medical Record (EMR) revealed R1 was admitted to the facility on [DATE] and is [AGE] years of age with diagnoses that included but were not limited to: Hemiplegia and Hemiparesis following cerebral infarction affecting left non-dominant side, Aphasia following cerebral infarction, Dysphagia following cerebral infarction, Essential Primary Hypertension, and Hyperlipidemia. On 2/25/25 at 11:05 AM, R1 is non-verbal and R1 uses a tablet (iPad) voice machine to communicate. R1 stated that he was ignored and was not provided morning medications including R1's blood pressure medication on 2/16/25 and today 2/25/25. R1 stated that most nurses give his medication whole, but V6 (Licensed Practical Nurse/LPN) working today decided to crush R1's medication,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the facility is free of insect pests in one resident's (R2) room. This failure affects one resident (R2) reviewed for effective pest control program. Findings include: R2 is aphasic and utilizes a tablet computer to communicate. On 2/10/25 at 11:05am, R2 typed, There's roaches everywhere. Look! R2 pointed to 3 dead roaches on the floor in his room next to the bed and opened the dresser drawer in his room and there was 1 dead roach that was observed by surveyor. R2's Face Sheet documents medical diagnoses that include but are not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side; aphasia following cerebral infarction; dysphagia following cerebral infarction; major depressive disorder, recurrent, severe with psychotic symptoms; unspecified psychosis not due to a substance or known physiological condition; irritability and anger. R2's Minimum Data Set (MDS), dated [DATE], documents,…

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

Based on interview and record review, the facility failed to follow their Fall Prevention Program policy and procedure to ensure residents fall care plan interventions were revised after each fall for 2 (R1, R2) out 3 residents reviewed for fall incidents. Findings Include: R1's clinical records revealed R1 had fall incidents on 12/15/24, 12/18/24, and 1/8/25. R1's progress notes dated 12/15/24 at 3:20 PM documents R1 fell going to the bathroom. R1's progress notes dated 12/18/24 at 3:20 AM documents R1 lost balance and fell trying to pick up [R1's] phone on the floor. R1's progress notes dated 1/8/25 documents R1 fell on [R1's] knees trying to go to the bathroom. R1's fall care plan date initiated on 4/10/24 do not show interventions were revised after R1's fall incidents on 12/15/24, 12/18/24, and 1/8/25. R1's care plan history printed on 1/14/25 at 3:28 PM shows V3 (Restorative Director) just created a fall intervention on 1/14/25 that reads, Continue to monitor for behavior of falling. R2's clinical records revealed R2 had a fall incident on 1/4/25. R2's progress notes dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their Fall Prevention Program and a resident's comprehensive care plan by not providing appropriate staff assistance to the washroom to prevent a resident from falling for 1 (R2) of 3 residents reviewed for fall incidents. This failure resulted in R2's having a fall incident while using the washroom unassisted and was found on the washroom floor. Findings Include: On 1/14/25 at 1:08 PM, interviewed R2 regarding the fall that happened on 1/04/25. R2 was noted to be alert and oriented to person, place, time, and date. R2 stated that after lunch, [R2] was lying in bed. R2 stated that [R2] pressed the call light to ask for help to go to the washroom to brush [R2's] teeth. R2 stated that [R2] was waiting more than 15 minutes for a staff to come, but no one came, so [R2] decided to transfer himself on the wheelchair and wheel himself to the washroom. R2 stated while in the washroom, R2 stood up from the wheelchair, lost balance, fell backwards and sat…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 help a resident maintain their highest practical level by failing to a.) follow their restorative care policy b.) provide consistent restorative therapy for one (R10) resident out of three residents reviewed for quality of care. 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. Findings include: R10 is a [AGE] year-old individual with the following diagnoses but not limited to heart failure, unspecified, peripheral vascular disease, unspecified, acquired absence of right leg below knee, acquired absence of left leg below knee. R10's Minimum Data Set (MDS) Section C, dated [DATE], documents R10 has a Brief Interview for Mental Status (BIMS) of 14 out of 15, indicating R10 is cognitively intact. On [DATE], at 11:19 AM, R10 stated that he prefers to speak in Spanish. R10 sitting on his wheelchair. R10's prosthesis at the end of R10'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 observation, interview, and record review the facility failed to ensure there are enough restorative nurse aides to provide restorative care and respond to each individual needs as required by the resident's plan of care. This failure resulted in the resident (R10) missing restorative therapy several times in the past 90 days. Findings include: 12/17/24, 11:19 AM, R10 stated he uses prosthesis. R10 stated when he does not perform any therapy, he loses his strength. R10 stated when he goes back it's like starting all over. R10 stated he is not getting better; in fact, he is getting worse. R10 stated if the other CNAs (certified nursing assistants) call off or they are short, the restorative therapy work on the floor. R10 stated right now the therapy room is closed for the patients to go there. R10 stated someone told him because there is an outbreak. R10 stated he does not recall the name of the person told him. 2/19/24, 1:14 PM, V20 (Lead CNA (Certified Nursing Assistant)/Staffing Coordinator) stated she will ask V24 (Restorative Director/Licensed Practical Nurse) if they…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 obtain informed consent for psychotropic medication prior to administering the medication. This failure affects 1 resident (R2) in a sample of 3 residents (R2, R3, R5) reviewed for psychotropic medications. Findings include: R2's diagnoses include schizoaffective disorder bipolar, violent behavior, generalized anxiety disorder, paranoid schizophrenia. R2's Minimum Data Set (dated 10/9/2024) documents in part a brief interview of mental status summary score of 9, indicating that R2's cognition is moderately impaired. Review of R2 medication administration record indicate that R2 received Fluphenazine Decanoate intramuscular injection on 10/24/24, 09/25/24, 08/29/24, 07/04/24, 07/8/24. Review of R2' psychotropic consent dated 11/30/23 indicate R2's refusal of psychotropic medication. R2 had no other consent to indicate R2 consented to psychotropic medication. On 11/18/24 at 11:55am R2 stated that she refused to sign the psychotropic consent because she did not want to take the psychotropic medication. On 11/18/24 at 2:23pm,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one allegation of abuse to the state survey agency. This failure has the potential to affect one resident (R4) reviewed for abuse. Findings include: R4's medical diagnoses include but not limited hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, convulsions, chronic obstructive pulmonary disease, essential hypertension, contracture right elbow, major depressive disorder, anxiety disorder. R4's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status (BIMS) score of 3, which indicates R4's cognition is severely impaired. R4's physician order dated 11/07/24 documents in part, Behavior: Monitor for itching, picking at skin, restlessness, agitation, hitting, kicking, spitting, cursing, elopement, stealing, delusions, hallucinations, refusing care, anxiety, insomnia, depression .Interventions: A. Redirection/Refocus B. Comfort objects .D Remove from situation .F. Offer choices. R4's care plan…

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

Based on interview and record review, the facility failed to thoroughly investigate an incident involving an allegation of injury of unknown origin. This failure affected one resident (R4) out of three residents reviewed for injury (R1, R2, and R4). Findings include: On 11/18/24 at 1:07pm, V29 (R4 family member) stated she was informed by the facility her mom had a bruise on her leg. V29 stated R4 had a purple knot on her right thigh. V29 stated she feels someone from the facility beat her mom's leg. R4's hospital report dated 11/10/24 documents in part, Daughter (V29) reports the patient is occasionally aggressive and is concerned the nursing staff are hitting R4. R4 has a large bruise on her right thigh .patient with history as stated above presenting to the emergency department for right thigh hematoma and concerns for elder abuse .Diagnoses (Active) Elder abuse, hematoma. Untitled document dated 11/11/24 documents in part, R4 - 11/10/24 contacted by DON (Director of Nursing) with regards to bruising. DON confirmed bruising is not concerning and we are not concerned regarding…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accurately complete Fall Assessments for one resident (R1). This failure has the potential to affect one resident (R1) in a sample of 3 residents reviewed for resident injury. Findings include: R1's Facility Reported Incident (IL181167), that occurred on 10/12/24, documents, in part, Incident Date: 10/12/24 . Incident Time: 1015 . Brief description of incident: At 10:15 am nurse on duty observed resident laying on the floor on his right side, in his room close to his bedside. Resident unable to verbalize what happened or how he got on the floor when asked . Action taken: Resident was assessed and noted with a minimal laceration at the back of he's head. Vitals collected and noted to be within normal limits. Writer applied pressure on the cut on the resident's head with a gauze. No other injury noted. Resident was assisted back to his bed with the help of the other nurse on floor. 911 was called. Ambulance arrived and resident was transferred on 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policy and provide sufficient supervision to one (R8) resident out of three residents reviewed for improper nursing care. After interviewing staff, the surveyor identified that the facility did not have a physician pass privilege order in place the day the resident signed himself out to the community unaccompanied. Later that day, the resident got lost and the facility ordered the resident a transportation ride back to the facility. This failure has the potential to cause serious harm to a resident. Findings include: R8's current face sheet document R8 is a [AGE] year-old individual admitted to the facility on [DATE]. Current medical diagnosis are listed to include but not limited to: vascular dementia, moderate, with psychotic disturbance, major depressive disorder, generalized anxiety disorder, unspecified psychosis not due to a substance or known. R8's Minimum Data Set (MDS) Section C, dated 10/08/2024, documents R8 has a Brief…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to properly document one resident's (R9) personal belongings upon admission. This failure has resulted in R9 missing clothes. Findings include: R9 is [AGE] year old with diagnosis including but not limited to: Morbid obesity, cerebral palsy, primary osteoarthritis, other reduced mobility and other specified disorder of bone density and structure. During investigation on 10/02/2024 at 11:36 AM, R9 said, I am missing a lot of my clothes and I have seen a few residents wearing my clothes. In the resident council meetings, I have complained about my missing clothes, and nothing has been done so far. At that time, R9 proceeded to show Surveyor photos on his phone of residents wearing his clothes. On 10/08/2024 at 2:35 PM, V26 (Laundry Attendant) said, I don't have any clothes at this time for R9. The only time that clothes become misplaced is when they are sent down to the laundry room with no name labeled on it. Clothes that are not labeled are kept so that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure a cataract surgery was scheduled for one resident (R13) as ordered resulting in R13 experiencing continued visual difficulties and failed to ensure two residents (R2 and R11) attended Doctor's appointment as scheduled. Findings include: R13 is [AGE] year old with diagnosis including but not limited to: Dry eye syndrome of unspecified lacrimal gland, other visual disturbances, prediabetes, major depressive disorder and anxiety. R13's BIMS (Brief Interview of Mental Status) score is 15, which indicated cognitively intact. R11 is 67 old with diagnosis including but not limited to: Contracture of left hand, unspecified lump in breast, unspecified asthma, hypertensive heart and chronic kidney disease with heart failure. R11's BIMS (Brief Interview of Mental Status) score is 15, which indicated cognitively intact. During investigation on 10/01/2024 at 1:33 PM, R13 said she (R13) was still waiting on her eye appointment for cataract surgery and had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure that one resident's (R1) psychotropic medication/ controlled substance was properly documented after administration. This failure has the potential to affect all residents who are currently prescribed controlled substances. Findings include: R1 is [AGE] year old with diagnosis including but not limited to: Generalized anxiety disorder, post-traumatic stress disorder, primary insomnia, unspecified asthma, personal history of other mental and behavioral disorders. R1's BIMS (Brief Interview of Mental Status) score is 15, which indicated cognitively intact. During investigation on 10/01/2024 at 2:14 PM, R1 stated that she was administered Lorazepam on three occasions without requesting it and that she was never given Lorazepam at 1:00 am on 08/26/2024 (as indicated by controlled substance accountability record). R1 said, I sleep throughout the night, so I don't know why it is documented that I received it Lorazepam on 08/26/2024 at 1:00 AM. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and records review, the facility failed to conduct interviews as appropriate to the allegations of abuse for one (R1) of four residents reviewed. Findings include: R1's current face sheet documents R1 is a [AGE] year-old individual whose medical diagnosis includes but not limited to acquired absence of right leg above knee, chronic kidney disease, stage 4 (severe), generalized anxiety disorder, nicotine dependence, cigarettes, uncomplicated. R1 left ama (against medical advice) 08/01/2024. R1's Brief Interview for Mental Status (BIMS) dated July 22, 2024, documents R1 has a BIMS score of 15/15, indicating R1 has an intact cognition. On 08/16/2024 at 9:44 am, V5 (Dietary Aide) accompanied V6 (Activity Aide) to interpret for V5 who speaks Spanish. V5 stated he takes breakfast upstairs to the units for residents who leave the facility early in the morning to go to dialysis. V5 takes the food cart upstairs from the first floor where the kitchen is located about 6:10am to 6:15am using the fleet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 develop and implement a care plan to address a resident, with history of opioid dependence, for one of three residents (R1) reviewed for illegal drug use. Findings include: R1's Face Sheet documents R1 is a [AGE] year-old admitted to the facility on 2.10.2022 with diagnoses including but not limited to: Resistance to Multiple Antibiotics, Chronic Kidney Disease, Stage 4; Acquired Absence of Right Leg, and Opioid Dependence. R1's MDS-Minimum Data Set of 7.2.2024 documents a BIMS (Brief Interview for Mental Status) score of 15 denoting resident is cognitively intact. 8.21.2024 12:28 PM V8 (5th Floor PRSC) said V8 had to take R1's card (orange pass card) away for two weeks due to cocaine and marijuana found in drop (urine drug test). There should be an addiction care plan, I don't remember doing one. He should have had one because he came from 6th floor to 5th floor. I did not update his care plan. 8/1/2024 12:08 Psychosocial Note: Resident placed on…

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

Based on interview and record review the facility failed to provide quality care to one resident (R5) of three residents reviewed by not scheduling a biopsy in a timely manner. Findings include: On 8/16/24 at 12:12 PM, V3 (Patient Escort) stated, I'm with R5 a lot. R5 is having trouble with the tongue biopsy. The ENT (Ear Nose Throat) doctor from the hospital requested a tongue biopsy on April 15. A nurse from the hospital said she has sent paperwork to get the biopsy done. Many times, at least three to four times, I have brought the paperwork from the hospital saying that R5 needs a tongue biopsy. We (R5 and I) have gone to the hospital for follow-ups for the tongue biopsy, but nothing has been done because R5 has not gotten the tongue biopsy. Every time we go for an appointment, they send the same paperwork requesting a tongue biopsy. The Oncology doctor also wanted to see the results of the tongue biopsy. I was in the exam room with R5, and the Oncology doctor was looking for the results in R5's chart. The ENT doctor said my boss (V15) is supposed to make the appointment.…

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

Based upon record review and interview the facility failed to follow the abuse policy procedures, failed to report abuse to IDPH (Illinois Department of Public Health) within regulatory requirements and failed to report actual time of occurrence for two of four residents (R5, R6) reviewed for abuse. Findings include: R5's (6/9/24) progress notes states (7:08pm) writer observed resident in a verbal altercation with peer. Resident then pushed peer with two hands to the ground, causing peer to fall. The (6/9/24) initial incident report includes Incident Time: Evening [actual time is excluded]. Brief Description of Incident: It was reported that (R5) pushed (R6) on the patio. It was unclear at the time of the cause and what triggered this incident. (R5) was immediately separated from (R6) and the police were called. R5 was sent to the hospital. R6 refused a head-to-toe assessment and confirmed that he had no pain or injury from the incident. He was fine and no further intervention was necessary per the Nurse on duty. (R6) refused any x-ray as well. Analysis/conclusion: after five…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accommodate the needs of residents by failing to ensure call lights were within reach of two (R2, R3) of four residents reviewed. Findings include: R2 R2 is an individual with medical diagnosis that include but not limited to: bipolar disorder, current episode depressed, severe, without psychotic features, other muscle spasm, and R2's Brief Interview for Mental Status (BIMS) dated [DATE] is documented as 11/15, indicating R2 has moderate cognitive impairment, and R2's MDS(Minimum Data Set) section GG (Functional Abilities and Goals) dated 2/15/2024 documents R2 requires Substantial/maximal assistance with Shower/bathe, self/Lower/upper body, dressing/Personal hygiene/Sit to stand, and R2 is frequently incontinent of bladder and bowel. On 07/13/2024 at 10;05am, R2 was observed laying in his bed with head of the bed elevated to about 60 degrees. R2 stated he ate breakfast and has already taken his medication. R2 stated he was having 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility failed to follow professional standards of practice and facility policy in documenting post-surgical wound assessment in two residents (R2, R5) out of 15 residents. Findings: On [DATE] at 12:45 PM R5 was interviewed and stated, I saw Dr. V39 (Spine Surgeon) last week. He took out the stitches. No one has looked at my back since then. V39 was upset that no one was looking at the wound after surgery. They (the nursing staff) did not look at the wound but once when I first got here. On [DATE] At 12:45 PM, R5's wound was observed to be well-approximated and healed with no redness, swelling or drainage. On [DATE] at 12:58 PM V22 (LPN) was interviewed and stated that upon a new resident's admission, nursing staff does a full body, head-to-toe skin assessment. V22 stated, We look at the surgical incision or surgical wound at the time of admission and then the wound care team looks at it for assessment and treatment. Wound team will look at the surgical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 therapy services in a timely manner and failed to follow facility policy for two residents (R1, R5) out 15 residents in the sample. Findings 1. On 7/2/2024 at 10 AM the electronic health record of R1 was reviewed. R1 was admitted to the facility on [DATE]. An order for Physical Therapy to evaluate and treat was entered on 5/7/2024. An order for Speech Therapy to evaluate and treat was entered on 5/7/2024. An order for Occupational Therapy to evaluate and treat was entered on 5/7/2024. An order for Occupational Therapy evaluates and treat related to right hand limited range of motion was entered 5/31/2024. An Occupational Therapy clarification order was entered on 6/17/2024 for Occupational Therapy to evaluate and treat for 2-4 times/week for 41 days to address activities of daily living training, therapeutic exercise, therapeutic activities Neuromuscular Rehabilitation (NMR) and patient education was ordered on 6/17/2024. 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 review the facility failed to give proper notice requirements per their policy to a resident was involuntarily transferred to the hospital for 1 (R1) out of 3 residents reviewed for admissions, transfers, and discharges. These failures affected 1 resident's (R1) right to be informed or notified of the reason for their transfer or discharge. Findings include: R1 is [AGE] years old, initially admitted on [DATE]. R1's initial medical diagnosis opioid dependence and mental and behavioral disorder. Per progress notes, R1 was sent to the hospital through involuntary discharge on [DATE]. V6 (Licensed Practical Nurse) and V5 (Social Worker) noted R1 became upset because his community pass was revoked. As a result, aggressive behavior was directed by R1 to V4 (Social Service Director). R1 referral dated 10/22/2023 prior to initial admission in the facility dated 10/27/2023 documents R1 was medically diagnosed with opioid use disorder and substance abuse. On 6/20/2024 at 10:01 AM, V5 (Social…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review of records the facility failed to provide a copy of Bed Reserve Notification as per policy during involuntary transfer of 1 (R1) out of 3 residents reviewed for admissions, transfers, and discharges. This failure affected 1 resident (R1) on knowing the rights afforded to residents during transfers. Findings include: R1 is [AGE] years old, initially admitted on [DATE]. R1's initial medical diagnosis opioid dependence and mental and behavioral disorder. Per progress notes, R1 was sent to the hospital through involuntary discharge on [DATE]. V6 (Licensed Practical Nurse) and V5 (Social Worker) noted R1 became upset because his community pass was revoked. As a result, aggressive behavior was directed by R1 to V4 (Social Service Director). On 6/20/2024 at 10:01 AM, V5 (Social Worker) stated R1 is a chronic substance abuser. R1 was involuntarily discharged because R1 threatened and was verbally aggressive to V4 (Social Service Director) on 6/3/2024. V5 stated R1 had a previous…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review of records the facility failed to permit 1 (R1) out of 3 residents from returning back to the facility after hospitalization in accordance with their policy. This failure affected 1 resident (R1) to their right to return to the facility they considered as home. Findings include: R1 is [AGE] years old, initially admitted on [DATE]. R1's initial medical diagnosis opioid dependence and mental and behavioral disorder. Per progress notes, R1 was sent to the hospital through involuntary discharge on [DATE]. V6 (Licensed Practical Nurse) and V5 (Social Worker) noted R1 became upset because his community pass was revoked. As a result, aggressive behavior was directed by R1 to V4 (Social Service Director). On 6/20/2024 at 10:01 AM, V5 (Social Worker) stated R1 is a chronic substance abuser. R1 was involuntarily discharged because R1 threatened and was verbally aggressive to V4 (Social Service Director) on 6/3/2024. V5 stated R1 had a previous involuntary discharge in April this year. R1'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, review of records, and interviews the facility failed to document physician coordination of medications not received by resident per medication administration policy. Facility also failed to administer insulin as ordered by physician for 1 (R2) out of 3 residents reviewed for facility pharmaceutical services. These failures have the potential to affect 1 resident (R2) has history of stroke/cerebral infarction and diabetes mellitus in maintaining stable health condition. Findings include: R2 is [AGE] years old, initially admitted on [DATE] with medical diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side and diabetes mellitus. On 6/18/2024 at 12:03 PM, R2 was seen on the hallway near the nurse's station sitting on his wheelchair. R2 was alert and verbally able to express his thoughts and agreed to talk to his room. R2 stated his concern was his medication not given because he has swelling on his left lower leg. R2 took his left shoe off and…

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

Based on observation, interview, and record review the facility failed to ensure two licensed personnel conducted a physical inventory of controlled substances at each change of shift. This failure has the potential to affect 4 residents on the sixth floor (team 1) medication cart who are prescribed controlled substances, 4 residents on the fifth floor (team 1) medication cart who are prescribed controlled substances, 5 residents on the fourth floor (team 2) medication cart who are prescribed controlled substances, 7 residents on the fourth floor (team 1) medication cart who are prescribed controlled substances and 7 residents on the third floor medication cart who are prescribed controlled substances. Findings include: On 02/28/2024 at 10:39 am review of the sixth-floor team 1 medication cart with V23(LPN/Licensed Practical Nurse) surveyor observed the shift change controlled substances check form for February 2024. The Nurse Off box was left blank for February 19, 2024 (7am-7pm shift). The Nurse On box was left blank for February 25, 2024(7am-7pm shift). On 02/28/2024 at 11:10 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.

Based on observation, interview, and record review, the facility failed to ensure that the two community shower rooms on the sixth floor were in good repair. This failure has the potential to affect all 53 residents on the sixth floor of the facility. Findings include: On 2/26/24 at 9:50am during the entrance conference with V1(Administrator), the facility census shows there are 53 residents on the sixth floor. On 2/26/24 at 11:20am during observation of residents on the sixth floor with V5 (LPN/Licensed Practical Nurse), the male community shower room ceiling light cover was observed falling off the ceiling half-way hanging down. V5 stated, I will call maintenance to come and fix it. During observation of the female community shower room with V5, the surveyor and V5 observed several missing wall tiles on both the right and left sides of the bathroom. V5 stated, I have not noticed the walls have so many tiles missing. The surveyor asked V5 if there is a logbook for maintenance repairs list, V5 stated that they just usually call maintenance. On 2/27/24 at 12:50pm, V14 (Maintenance…

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

Based on observation, interview, and record review, the facility failed to ensure that the corridor handrails across from the nursing station on the sixth floor were firmly affixed to the wall. This failure has the potential to affect all 53 residents on the sixth floor of the facility. Findings include: On 2/26/24 at 9:50am during the entrance conference with V1(Administrator), the facility census shows there are 53 residents on the sixth floor. On 2/26/24 at 11:30am during observation of residents on the sixth floor with V5 (LPN/Licensed Practical Nurse), the following were observed: The corridor handrails by the elevator across from the nursing station to the right and to the left, and the handrails were observed to be loose and shaking. The surveyor asked V5 how maintenance gets notified of repairs on the floor, and if there is a logbook for maintenance repairs list. V5 stated that they just usually call maintenance for any repairs needed. V5 stated she would call maintenance. On 2/27/24 at 12:50pm, V14 (Maintenance Director) stated he and the Maintenance Assistant go around…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that R173's and R124's indwelling catheter drainage bags were covered. This failure affected two residents (R173 and R124) reviewed for dignity in the sample of 56 residents. Finding Include: 1. R173's admission record includes diagnoses of pressure ulcer, pleural effusion, cerebral infarction, diabetes, atrial fibrillation, venous insufficiency, and chronic kidney disease. On 2/26/24 at 11:10 am, surveyor observed (R173's) indwelling catheter drainage bag not covered on right side of bed facing the hallway. On 2/28/24 at 2:25 pm, V2 DON (Director of Nursing) stated the Indwelling catheter should be covered in a privacy bag, to provide dignity to the residents. R173's (Active orders as of 2/27/24) Order Summary Report documented, in part, Indwelling Catheter 16 F (French), 10 ml (milliliter) filled balloon. R173's (11/22/23) Minimum Data Set, documents, in part, a Brief interview for Mental Status (BIMS) score is 15 which indicates…

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

Based on observation, interview and record review the facility failed to provide ADL (Activity of Daily Living) for 2 dependent residents (R77, R138). This failure has the potential to affect all 56 residents in the sample. Findings Include: R77 has a diagnosis of but not limited Encephalopathy, Quadriplegia, Interstitial Pulmonary Disease, Lack of Coordination, and Abnormal Posture. R77's Brief Interview of Mental Status score is 15. R138 has a diagnosis of but not limited Metabolic Encephalopathy, Acute Respiratory Failure, Type 2 Diabetes Mellitus and Need for Assistance with Personal Care. R138's Brief Interview of Mental Status score is blank. On 2/26/2024 at 12:30pm surveyor observed R77 with facial hair. R77 stated he would like to be shaved and that not being shaved makes him feel 'like a bum'. On 2/26/2024 at 12:41pm V9 (Certified Nursing Assistant) stated shaving the residents should be offered and done when a shower is given and as needed. On 2/26/2024 at 12:45pm surveyor observed R138 with an unshaven long beard that extended down to midway of the neck. On 2/26/2024 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to provide timely urinary catheter care for one resident (R111), who depends on staff for perineal care. This failure affected one resident reviewed for care from a sample 56 residents. Findings include: R111 is [AGE] year old with diagnosis including but not limited to: Benign prostatic hyperplasia, mild neurocognitive disorder, encounter for fitting and adjustment of urinary device, adult failure to thrive, polyneuropathy, cramp, and spasm. On 02/27/2024 at 9:18 AM, Surveyor observed R111 lying in bed with urinary catheter and urinary bag attached to R111's bed. R111's urinary catheter was darkish brown in color and R111's urinary bag contained 100 milliliters of urine with visible sediment in the bag. At that time, Surveyor asked R111's nurse V18 (LPN/Licensed Practical Nurse) when R111's urinary bag and catheter was last changed. On 02/27/2024 at 9:20 AM, V18 (LPN) said, I'm not sure when R111's urinary catheter and bag was last changed,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 nasal cannula was changed weekly and secured when not in use for one resident (R45) and failed to administer oxygen for one resident (R156). This failure has the potential to affect all 31 resident who use oxygen therapy. Findings include: R45 has a diagnosis of but not limited to Quadriplegia, Chronic Obstructive Pulmonary Disease, Asthma, Type 2 Diabetes, and Pulmonary Embolism without Acute Cor Pulmonale. On 2/26/2024 at 11:30am surveyor observed R45's nasal cannula sitting on top of the concentrator not in a bag with a date of 2/05/2024. On 2/26/2023 at 11:34am V13 (RN/Infection Control Nurse) stated R45's nasal cannula should be in a bag to prevent infection control issues. On 2/28/2024 at 2:25pm V3 (Director of Nursing-DON) stated the nasal cannula should be in a plastic bag and stored near the equipment when not in use. R45's Order Summary Report with active orders as of 2/28/2024 documents, oxygen tubing change 1x (time) weekly and as needed. Undated policy titled Oxygen 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon observation, interview and record review the facility failed to follow policies/ procedures, failed to ensure R1 was provided a wheelchair with functioning brakes, failed to ensure R1 and R4 belongings were inventoried, failed to ensure R2, R3 and R5 have clean clothing available, and failed to ensure that basic clothing requirements were met for two of five residents (R3, R5) in the sample. These failures have the potential to affect 212 residents residing in the facility. Findings include: The (2/21/24) census includes 212 residents. On 2/5/24, IDPH (Illinois Department of Public Health) received allegations regarding lost/ stolen clothing and personal wheelchair replaced with another wheelchair in poor condition (upon return from the hospital). 1. R1's diagnoses include hemiplegia and hemiparesis. R1's (2/5/24) functional assessment includes mobility devices: wheelchair. R1's census affirms (11/2/23) hospital leave and (11/10/23) return to the facility. R1's (2/5/24) BIMS (Brief Interview Mental…

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

Based upon record review and interview the facility failed to provide (R1, R2) timely services; failed to ensure R1's belongings were inventoried; failed to ensure R1 was provided a wheelchair with functioning brakes; and failed to provide adequate reimbursement to one of five residents (R2) reviewed for missing belongings. Findings include: On 2/5/24, IDPH (Illinois Department of Public Health) received allegations regarding lost/stolen clothing and personal wheelchair replaced with another wheelchair in poor condition (upon return from the hospital). 1. R1's diagnoses include hemiplegia and hemiparesis. R1's (2/5/24) functional assessment includes mobility devices: wheelchair. R1's census affirms (11/2/23) hospital leave and (11/10/23) return to the facility. R1's (2/5/24) BIMS (Brief Interview Mental Status) determined a score of 12 (moderate impairment). R1's (11/10/23) record of complaint includes missing wheelchair. Looked for an inventory list, asked to search his room for items, he refused. Per floor staff he only came with the wheelchair that he's currently using. On…

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

Based on interview and record review, the facility failed to notify the resident's (POA) Power of Attorney for Healthcare of changes in condition/treatment which affected one (R1) resident reviewed for policy and procedure in a total sample of 7 residents. Findings include: R1's admission Record documented R1's diagnoses include but not limited to hemiplegia (severe or complete loss of strength or paralysis on one side of the body) and hemiparesis (mild or partial weakness or loss of strength on one side of the body); abnormalities of gait and mobility; lack of coordination; contracture; and systemic lupus erythematous. Contacts. V29 (R1's POA (Power of Attorney for Healthcare). The (undated) facility provided document titled Wound Care Log: Skin Issues documented, in part Patient Name: R1. Area of Concern: Right buttock. Nurse Name: V8 (Licensed Practice Nurse). Date: 12/17/23. R1's Progress Note documented, in part Effective Date: 12/21/2023. Writer spoke with (MD) regarding order r/t (related to wounds and incontinence. Dr. gave order for foley. Orders carried out and NOD (nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure serious bodily injury was reported to the State Agency within the mandated time frame and failed to develop policies and procedures which ensures reporting of serious bodily injury within the mandated time frame. These failures affected 1 (R3) resident reviewed for reporting of incident and accident in the total sample of 7 residents. Findings include: R3's (12/21/2023 at 10:26pm) Health Status Note documented, in part readmitted this [AGE] year-old female from hospital with diagnosis (es) of AMS (altered mental status), STATUS POST FALL, RIB FIX (fracture). R3's (Visit Date: 12/17/2023) Inpatient Discharge Instruction documented, in part, Your diagnosis: Rib Fracture. History of Present Illness: Patient from (facility) presents for evaluation of altered mental status s/p (status post) fall. At ED (Emergency Department) Chest x-ray: Right 6th rib fracture. Consultation Notes: History of Present Illness. The patient is a poor historian, does not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure the low air loss mattresses were set on appropriate setting for 2 residents (R4 and R5) reviewed for pressure ulcer prevention in the total sample of 7 residents. Findings include: On 01/04/2024 at 11:22am, this surveyor and V3 (Licensed Practice Nurse) checked on R4. R4 was lying on a low air loss mattress, The setting of the low air loss mattress was at 420lbs, alternating every 10 minutes. V3 stated setting is at 420lbs. (R4) has a sacral wound. On 01/04/2024 at 11:27am, V3 stated she (R4) weighed 97.6lbs on 12/09/2023. On 01/04/2024 at 12:14pm, this surveyor and V6 (Certified Nursing Assistant) checked R5. R5 was lying on a low air loss mattress. The setting of the low air loss mattress was at 490lbs, alternating every 25 minutes. V6 stated I (V6) don't know why the setting is at 490lbs. Setting is based on resident's weight. On 01/04/2024 at 1:05pm, V7 (Wound Care Coordinator/RN) stated the setting of the low air loss…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, facility failed to follow their policy to be free from physical abuse by providing necessary care in services thus resulting in a male resident (R4) verbally and mentally abusing another female resident (R2) for two out of three residents reviewed for physical abuse. Findings include: On 12/21/2023 at 12:00 PM, R2 was seen laying on her back side. R2 stated yesterday, another resident (R4), looking like [NAME], came in and called her a N .r B h. R2 stated when she yelled, R4 snapped at her and swore at her. R4 told her (R2) to shut up and threated her by saying if she yelled again, he wound 'beat the shit out of her'. R2 stated she was traumatized because she is scared R4 will come into her room and hit her. R2 stated she is so scared she requested to get transferred out to another facility. On 12/21/2023 at 12:37 PM, V5 (Certified Nursing Assistant) stated she was R2's CNA on Tuesday 12/19/2023. V5 stated she started her shift at 7:00 AM and worked until 3 PM. V5 stated 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.

Based on observations, interviews and record reviews, facility failed to ensure wound orders are followed in order to prevent the deterioration of pressure ulcers for one (R1) out of three residents review for pressure ulcer prevention. Findings include: On 12/21/2023 at 12:00 PM, R1 was seen laying on her left side. R1 is not responsive and non-verbal. On 12/22/2023, R1 was observed from 10:30 AM to 1:00 PM. At 10:30 AM, R1 was seen laying on her back. At 11:37 AM, surveyor observed V7 (Licensed Practical Nurse) go into R1's room but did not turn or reposition R1. From 10:30 AM to 1:00 PM, other than V7 no staff member went into R1's room to check if R1 was soiled or turn and reposition her. At 1:00 PM, R1 was still laying on her back. On 12/22/2023 at 1:05 PM, V7 (Licensed Practical Nurse) stated she is the nurse for R1. V7 stated she is the nurse, and she did not change or reposition R1 recently. On 12/22/2023 at 1: 30 PM, V6 (Restorative Aide) stated she is the nurse for R1. V6 stated R1 does have a sacral wound. V6 stated the last time she changed and repositioned R1 was around…

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