Complete Care at the Boulevard

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of records and interviews the facility failed to ensure a Pre-admission Screening and Residential Review (PASSAR) were done for 5 out of 5 residents (R9, R15, R16, R37, R54) prior to admission. These failures have the potential to affect 5 residents (R9, R15, R16, R37, R54) in a total sample of 21. Findings include: On 02/05/2025, at 10:25 AM, V16 (Social Service Director) submitted for R9, R16, and R37's print out document that reads PASRR Level 1 currently queued for review. V16 stated that she just submitted the request on 02/04/2025. V16 stated that PASRR is important to determine proper placement of resident. It should be done before the actual admission in the facility. R9 is [AGE] years old with diagnosis that includes psychosis, schizophrenia, schizoaffective disorder, and major depression. Per R9's PASSR report it documents the following: Notice Date: February 5, 2025: PASRR Level 1 review date February 5, 2025, determination of Level 1 is to refer to Level 11 onsite with suspected or…

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

Based on observation, interview, and record review, the facility failed to a.) administer residents' prescribed medications in a timely manner according to the physician orders and b.) keep an accurate count of all narcotic medications for four (R3, R24, R30, R31) residents reviewed for medications in a total sample of 21 residents. Findings include: On 02/04/2025, at 9:24 AM, surveyor and V4 (Registered Nurse/RN) located on the second floor of the facility performing a controlled substance count and record review. Surveyor observes the following: A medication bingo card labeled R31s' name, Tramadol 50mg, surveyor observes there were 22 pills inside of the medication bingo card. R31s' controlled drug receipt record documents a count of 23 pills. A medication bingo card labeled R31s' name, Pregabalin 25mg, surveyor observes there were 13 pills inside of the medication bingo card. R31s' controlled drug receipt record documents a count of 14 pills. A medication bingo card labeled R31s' name, Diazepam 5mg, surveyor observes there were 19 pills inside of the medication bingo card. R31s'…

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

Based on observation, interview, and record review the facility failed to a.) remove and discard expired medications that had been open in three of six medication carts, b.) remove and discard expired enteral feedings located in one of three medication storage rooms, and c.) properly label medications that had been open for resident use. These failures have the potential to affect 68 residents residing in the facility reviewed for medication labeling and storage. Findings Include: On 02/04/2025, at 9:24 AM, surveyor and V4 (Registered Nurse/RN) located on the second floor of the facility at the medication cart performing a controlled substance count and record review. Surveyor observes the following: 1 open liquid medication bottle labeled R32s' name, Morphine Sulfate 20mg/ml inside of the medication cart. R32s' liquid Morphine medication observed with an expiration date labeled 05/17/2024. V4 states that R32s' liquid Morphine medication should not be stored in the medication cart and should have been discarded once it expired on 05/17/2024. V4 states R32 could experience adverse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 minimize the risk of acquiring, transmitting, or experiencing complications from influenza and Covid-19 for six residents (R27, R62, R73, R207, R257, R307). Findings include: According to R27 progress note, 8/29/2024, R27 was offered and refused the influenza (flu) vaccination in 8/2024. The facility is not able to provide documentation that R27 was offered the influenza vaccination subsequently or provide a refusal of the influenza vaccination by R27 for the current flu season. According to electronic record, immunizations sections for R62, R73 and R307, they were not provided immunization education prior to vaccine administration or refusal. Review of R207 Authorization and Release for Influenza Vaccine, 2/4/25, does not indicate if R207 consented or refused the influenza vaccine. Also, according to V3 (Infection Preventionist / Licensed Practical Nurse), V3 signed the form for R207 and there is no witness signature. Review of R257 Authorization and Release for Influenza Vaccine, no date, indicates R257 consented to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and review of records the facility failed to maintain resident rights pertaining to dignity for 3 out of 3 residents (R 18, R37, R69) for a total sample of 21 residents reviewed for resident rights. Facility failures are as follows: failed to provide feeding assistant with dignity for one resident (R37); failed to protect/promote the right to confidentiality of medical information for two residents (R18 and R69). These failures have the potential to affect 3 residents (R18, R37, R69) in their right to maintain dignity. Finding includes: On 02/04/2025, at 1:09 PM, in the dining room, V21 (Certified Nursing Assistant) brought R37 who was sitting on a Geri-chair near table to be fed. V21 while standing took a spoon, and fed R37 the whole meal. V21 kept on inserting food to R37's mouth while R37 was still chewing. The food inside R37's mouth was hard to see. V21 kept on calling R37 by the first name. R37 does respond with words and was making moaning sounds when addressed by name.…

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

Based on observation, interview, and record review, the facility failed to assess/monitor one of three residents (R30) for self-administration of medication out of a total sample of 21 residents reviewed. Findings include: On 02/05/2025, at 9:07 AM, during a medication administration pass with V17 (Licensed Practical Nurse/LPN), surveyor observes V17 with a nasal medication labeled Fluticasone Propionate 50mcg. V17 gives the Fluticasone medication to R30. R30 asks V17 how many sprays, 2 right? V17 replies Yes. R30 then observed self-administering the Fluticasone medication to herself, administering 2 sprays into both of her nostrils. V17 states she gave R30s' Fluticasone medication to R30 to self-administer because R30 is able to self-administer her medication and does not trust the facility staff nurses to administer it to her correctly. Review of R30s' Physician order sheet/POS, medication administration record/MAR, and electronic health record/EHR documents that R30 does not have a physician order and has not been assessed to self-administer her own medications. Facility policy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and review of records the facility failed the following related to [NAME] Program: facility failed to display [NAME] information in a public and accessible location, a department provided poster informing residents of their right to explore or decline community transition, and their right to be free from retaliation, regardless of their decision on transition. Failure includes 12 out of 12 residents (R1, R6, R13, R25, R42, R47, R69, R98, R99, R103, R207, R307) included in the sample list for December 2024 and January 2025 of residents that can be a part of the [NAME] program. This failure has the potential to affect 12 residents (R1, R6, R13, R25, R42, R47, R69, R98, R99, R103, R207, R307) in their right to exercise community transition given proper information. Findings include: On 02/04/2025, at 2:35 PM, after checking all floors to verify the [NAME] program posting, there was none seen posted. V16 (Social Service Director) was asked about poster for the [NAME] program. V16…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 records review, the facility failed provide privacy and confidentiality of personal information for one (R307) of four residents reviewed in a sample of 21. Findings include: R307 is an [AGE] year-old individual admitted to the facility on [DATE], with medical diagnosis that include but not limited to: acute and chronic respiratory failure with hypercapnia, human immunodeficiency virus [hiv] disease, other abnormalities of gait and mobility. MDS (Minimum Data Set) section C- Section C - Cognitive Patterns, Brief Interview for Mental Status (BIMS) Dated [DATE], documents R307's BIMS as 13/15, indicating R307 has intact cognitive function. On 02/4/2025, at 11:13 AM, R307 was observed in his room sitting on the bed and stated he came to the facility recently. R307 was observed wearing a white wristband which showed R307's full name, date of birth , and medical record number. R307 stated the wristband was from the hospital and the hospital staff were using it to identify him…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide consistent restorative therapy for one of three residents (R61) in a total sample of 21. 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. 02/04/25, 11:33 AM, R61 lying down on his bed, with his personal belongings within reach. R61 alert, responsive, and in no apparent distress. R61 states that this is the first time someone applied his splint in a very long time. R61 states that he understands now probably because the state agency is in the building. R61 reports that staff are supposed to come and exercise his legs, but staff do not do this. R61 states that staff do not come in to talk about restorative therapy or exercises. 2/6/25, 11:17 AM, V12 (Restorative Aide / Certified Nursing Assistant) states that her and another restorative aide split the 4th…

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

Based on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5% for two (R3, R30) residents reviewed for medication administration in a total sample of 21 residents reviewed, resulting in a 7.69% error rate. Findings Include: R3 has diagnoses not limited to: Type 2 Diabetes without complications, Hemiplegia and Hemiparesis Following Cerebrovascular disease, and overactive bladder. R3s' electronic medication administration record (eMAR) dated 02/01/2025 - 02/28/2025 documents: Metformin HCL 500mg- 1 tablet by mouth two times a day scheduled at 9:00 AM. On 02/05/2025, at 8:37 AM, surveyor observed that this medication was not given to R3 during the 9:00 AM medication administration pass with V17 (Licensed Practical Nurse/LPN). R30 has diagnoses not limited to: Multiple Sclerosis, Essential (primary) hypertension, trigeminal neuralgia, and history of falling. R30s' electronic medication administration record (eMAR) dated 02/01/2025 - 02/28/2025 documents: Lidocaine External Patch 5%- Apply to left shoulder topically one time 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 ensure night-time snacks were offered and served consistently in accordance with the facility's policy for one (R87) resident in a sample of 21. 02/05/25, 10:15 AM, during resident council meeting, R87 states that he does not receive or is offered the nighttime snacks consistently and he would like to receive them consistently. 2/6/25, 1:01 PM, V8 (Dietary Manager) states that if a resident is not diabetic, they get the graham crackers or peanut butter crackers and juice at night-time snack. V8 states that everyone is supposed to be offered a night-time snack. V8 continues to state we close at 7:30 PM at night. Before my aids leave, they take the snacks to the floors, and give them, on a tray or in a bag. They are given to the floor CNAs (certified nursing assistants). V8 continues to state at that point, whoever is on the floor at that time, will distribute the evening snacks to the residents.V8 states once we drop them off it…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of records and interview the facility failed to accurately classify resident record on psychotropic medication consent form to 1 out of 1 resident (R37) for a total of 5 residents reviewed for psychotropic medication. This failure has the potential to affect 1 resident (R37) on psychotropic medication side effects. Consent was given with error in classifying psychotropic medication having different side effects for which the consent was given. Findings include: R37 is [AGE] years old with severely cognitive impairment BIMS (Brief Interview for Mental Status) dated 01/02/2025, scored 99 because R37 unable to complete interview. R37 medical diagnosis includes dementia, anxiety disorder, major depression disorder, psychotic disorder. On 02/06/2025, at 11:11 AM, V10 (Psychotropic Nurse / Assistant Director of Nursing) presented R37's Psychotropic Medication Form dated 02/04/2025, for Remeron or Mirtazapine medication. V10 stated that currently he is updating consent for all residents in the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to ensure resident is free from verbal abuse. This failure affected 1 ( R1) of 4 ( R1,R2,R3 and R4) residents reviewed for abuse. Findings include: R1 is a [AGE] year old female with a diagnosis including epilepsy , anxiety disorder and chronic embolism and thrombosis. Resident is alert and oriented x 3, able to make all needs known to staff. Resident is a max assist with all adl cares. Incontinent of bowel of bladder. Uses a manual wheelchair for ambulation. R1 has a BIMS ( Brief Interview Of Mental Status) Score of 13/15. R1 was first admitted to the facility on [DATE]. R1 is care planned for abuse revised (12/3/24) . R1 is assessed as moderate risk for abuse. On 12/17/24, at 12:59 PM, R1 stated I had an incident in October where a CNA (Certified Nursing Assistant) started cursing at me because I asked her to help another resident who needed it. The CNA got mad at me and started yelling at me. I reported it. I haven't seen her since. On 12/17/24, at…

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

Based on observation, interview, and record review the facility failed to ensure that treatment cart and resident medication was not left at the bedside un-attended when not in visual proximity of the nurse and not in use to prevent tampering and accidental hazard. This failure affected R4 whose inhaler was left at bed side over bed-table visible to the hallway and treatment cart left unlocked and un-attended in the hallway. This has the potential to affect all the 39 residents residing on the 2nd floor of the facility. Findings include: On 11/13/24 at 10:32 am R4 was noted sitting on the bed and visible to the hallway, an inhaler was observed on the over-bed side table. R4 stated that's mine, I use it. It helps me to breath. The inhaler Symbicort 160mcg/4.5 not in manufacturer's container and no pharmacy label. On 11/13/24 at 10:35 am, when shown to V8 RN (Registered Nurse). V8 stated the inhaler is for R4 and R4 can self-medicate. The surveyor asked V8 whether R4 has an order to do so. V8 said let me check. On 11/13/24 at 10:40 am, V8 checked and stated I (V8) am supposed to give…

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

Based on interview and record review the facility failed to ensure that there was sufficient staff on duty to meet resident's needs. This failure affected R2 was known to need adequate supervision for trying to get out of bed without help and who was tied to bed rails due to facility short staffing. This failure has the potential to affect all 39 resident residing on the 2nd floor of the facility. Findings include: The facility in-house investigation documented that on Saturday, October 12, 2024, the writer V1 (Administrator) received a phone call informing (V1) that a Nurse (Referring to V6 RN (Registered Nurse) had tied a resident (R2) to the siderail of the bed with a pillowcase. The DON (Director of Nursing) who reported this alleged incident sent the nurse (V6) home pending investigation. V1, wrote that based on known facts from medical records review and interviews conclusion has been determined about allegation of abuse indicating that there was an alleged abuse. On the 11/25/24 facility census report for 10/12/24 presented for the 2nd floor showed that 41-residents were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 immediately report an alleged abuse for one three residents (R2) in the sample reviewed for abuse. This failure affected R2 who was tied up to the bedside rails with pillowcase and this was not reported to IDPH (Illinois Department of Public Health). This has the potential to affect all 39 residents residing on the 2nd floor of the facility. Finding include: On 11/14/24 the facility in-house investigation documented that on Saturday, October 12, 2024, the writer V1 (Administrator) received a phone call informing (V1) that a Nurse (Referring to V6 RN (Registered Nurse) had tied a resident (R2) to the siderail of the bed with a pillowcase. The DON (Director of Nursing) who reported this alleged incident sent the nurse (V6) home pending investigation. V1, wrote that based on known facts from medical records review and interviews conclusion has been determined about allegation of abuse indicating that there was an alleged abuse. On 11/14/24 at 2:30 pm, when the surveyor asked whether this alleged incident was reported to IDPH,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 records review, the facility failed to refer five (R2, R3, R4, R5, R6) of five residents reviewed for newly or possible serious mental disorders for Preadmission Screening and Resident Review (PASRR) Level I and II in a sample of five. Findings include: On [DATE], at 9:53AM, V4 (Director of social Services) stated R2's PASARR 1 ended on [DATE]st, 2023. Another Preadmission Screening and Resident Review (PASRR) 1 should have been renewed when R2 come back from the hospital on [DATE], and a PASSAR II should also have been done because R2 had serious mental illness. V4 stated to date, R2 does not have a PASARR II. R2 has a notification/red flag in assessment tool census stating R2 should be assessed for level II PASARR. V4 stated after surveyor and V4 reviewed documents that showed R2 was flagged for assessment, created a PASARR screening notification for R2 to be assessed for level II by the appointed screening agency. V4 stated R3's assessment tool documents R3 was approved for PASARR level…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident was free from physical and verbal abuse. This failure affected 2 (R1, R2) residents of 4 reviewed for abuse. Findings include: 1. R1 is a [AGE] year old female with a diagnosis including Heart Disease, Chronic Kidney Disease, Alzheimer's, Anxiety Disorder and Repeated Falls. R1 was first admitted to the facility on [DATE]. R1 has a BIMS (Brief Interview of Mental Status) score of 2/15. R1 is non interviewable. Progress note dated 6/13/24 states: It was reported to Nurse that during ADL Care, V3 (CNA), was in the room assisting V4 (CNA). R1 was confused, and combative. R1 scratched V3 (CNA) and out of reflex he (V3) slapped her (R1). Notified MD, notified Abuse Coordinator/Administrator, notified Nursing Management. Sister, POA, aware of incident. Police notified/Report # JH 305102. Resident assessed for injury. Resident with no injury. Resident during assessment with no s/s to indicate pain. V/S Taken: T-97.8 P-72 R-18 B/P 122/76.…

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

On 03/19/24 at 10:48 AM V9 (Wound Care Nurse) stated, V8 (Infection Control Preventionist/Licensed Practical Nurse) is filling in for the nurse. I will not be assigned to the floor for the rest of the day. On 03/19/24 at 10:53 AM V8 (Infection Control Preventionist/Licensed Practical Nurse) left the floor giving the medication cart keys to V9 (Wound Care Nurse) to continue passing the medications. On 03/19/24 at 11:53 AM Surveyor asked V9 (Wound Care Nurse) the meaning when the resident names appear pink on the computer screen. V9 responded, They just popped up. We have a 2-hour window to give the medication. On 03/19/24 at 12:17 PM V9 (Wound Care Nurse) stated, Once the residents name turns pink on the computer screen the medications are overdue. On 03/19/24 at 12:19 PM V8 (Infection Control Preventionist/Licensed Practical Nurse) returned to the nursing unit and retrieved the medication cart keys from V9 (Wound Care Nurse) to continue passing the medications. On 03/19/24 at 01:19 PM when reviewing R63 MAR (Medication Administration Record) with V8 (Infection Control…

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

Based on observations, interviews, and record reviews, the facility failed to follow their policy on storage of food and hand washing by not discarding expired food and staff not washing hands after handling dirty dishes and before handling clean dishes. These failures have the potential to affect all 112 residents receiving food prepared in the facility's kitchen. Findings Include: On 3/19/24 at 9:25 AM, observed V43 (Dietary Aide) and V22 (Cook/Dietary Aide) working in the dish room. V43 was breaking down dirty resident lunch trays scraping food debris from the trays into the garbage. At 9:28 AM observed V22 placed scraped dirty dishes in a rack before pushing the rack into the dish machine to be washed. Observed V22 move to the clean side of the dish machine and pull out the rack containing cleaned dome lids and plates from the dish machine and then placed them on an open cart to dry. V22 did not perform any type of hand hygiene in between handling dirty and cleaned plateware. At 9:30 AM, surveyor asked V22 why hand hygiene was not performed in between dirty and clean dishes? V22…

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

On 03/19/24 at 10:00 AM V8 (Infection Control Preventionist/Licensed Practical Nurse) retrieved the green tray containing the blood glucose supplies, wrist blood pressure cuff and tympanic thermometer from the top of the medication cart then entered R76 room. V8 placed the blood pressure cuff on R76 left wrist and checked R76 temperature using the tympanic thermometer. V8 placed the green tray on R76 overbed table, retrieved the glucometer, glucose strip and alcohol wipe, checked R76 blood glucose with a reading of 196. V8 placed the glucometer back in the green tray then exited R76 room. On 03/19/24 at 10:04 AM V8 (Infection Control Preventionist/Licensed Practical Nurse) placed the green tray with the glucometer, wrist blood pressure cuff and tympanic thermometer on top of the medication cart without cleaning them then began preparing R76 medications. On 03/19/24 at 10:23 AM V8 (Infection Control Preventionist/Licensed Practical Nurse) retrieved the wrist blood pressure cuff from the top of the medication cart, entered R87 room, placed the wrist blood pressure cuff on R87 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.

Based on review of records and interview the facility failed to follow COVID-19 vaccination policy in offering, educating, and documenting COVID-19 for both staff and residents. These failures have the potential to affect residents (R72, R108, R117, R267) on receiving the benefits of COVID-19 vaccination and potential to affect all 112 residents taken care by facility staff that are not vaccinated. Findings include: Five (5) residents were sampled for pneumococcal and influenza vaccination determination and documentation under immunization tab of the electronic health record (EHR): - R72 documentation reads, no immunization for Covid-19 found on record. - R117 documentation reads, no immunization for Covid-19 found on record. - R267 documentation reads, no immunization for Covid-19 found on record. - R108 documentation reads, no immunization for Covid-19 found on record. - R16 documentation reads, SARS-COV-2 (COVID-19) received on 1/25/2021 and 2/22/2021. On 03/20/2024 at 11:39 AM, V28 (Certified Nursing Assistant) stated V28 got her booster a long time ago and she does not know if…

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

2. R10 has diagnosis not limited to Paraplegia, Injury at Unspecified Level of Cervical Spinal Cord, Chronic Obstructive Pulmonary Disease, Chronic Pulmonary Embolism, Neuralgia and Neuritis, Lumbago with Sciatica, Anxiety Disorder, Major Depressive Disorder, Pneumonia, Myalgia, Acute Respiratory Failure, Depression, Cough, Dependence on Supplemental Oxygen and Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation. Care Plan document in part: Focus: R10 has altered respiratory status/difficulty breathing r/t (related/to) Anxiety, dx. (diagnosis) acute respiratory distress, oxygen dependence, morbid obesity with possible complications. Oxygen Settings: O2 via nasal canula. R10 Physician orders document in part: Oxygen Tubing Change Weekly and as Needed every night shift every Sunday. Oxygen Continuous at 2-3 Liters/min (minute) Via Nasal Cannula every shift. Albuterol Sulfate Inhalation Nebulization Solution 1 each inhale orally via nebulizer every 4 hours as needed. Albuterol Sulfate Inhalation Nebulization Solution 0.63 MG (milligram)/3ML (milliliter) 1 application inhale…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 store and label medications and medication administration supplies according to standards as evidenced by expired medications, expired supplies, and refrigerated medications stored in unrefrigerated locations in two medication rooms observed out of three total medication rooms in the facility, and three medication carts out of a total of six medication carts in the facility. In addition, the facility failed to maintain crash carts in alignment with policy as evidenced by missing supplies, supplies in the wrong drawers, and expired supplies in three out of three crash carts in the facility. Findings include, On 03/19/24 10:02 AM, review of medication storage room on the 2nd floor with V12 (RN) demonstrated a bottle of Sodium Chloride open date 11/3/2023 and no end date. Geri Not was opened on 9/17/2023 with no end date. When asked how long a multi-dose can be used once opened, V12 (RN) stated I don't know. Artificial Tears were found open in a box with a resident's name only on label and no last name. When V12…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review of records and interviews the facility failed to follow policy in offering, educating, and documenting influenza and pneumococcal vaccinations to 4 of 5 residents (R72, R108, R117, R267) for a total sample of 5 residents reviewed for vaccinations. These failures have the potential to affect 4 residents (R72, R108, R117, R267) in determining their option by knowing and receiving the benefits of influenza and pneumococcal vaccines. Findings include: Five (5) residents were sampled for pneumococcal and influenza vaccination determination and documentation under immunization tab of the electronic health record (EHR): - R72 documentation reads, no immunization found on record. - R117 documentation reads, no immunization found on record. - R267 documentation reads, all vaccination consent refused. - R108 documentation reads, influenza and pneumococcal immunization required. V10 (Nurse Consultant) stated that it means resident did not get it. - R16 documentation reads, influenza refused no date, last influenza received on 9/23/2020 and received pneumococcal 4/16/2019. 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 observation, interviews, and review of record the facility failed to follow policy on maintaining privacy and dignity of a resident for 1 out of 2 residents (R267) for a total sample of 23 residents. Findings include: R267 is [AGE] years old, initially admitted on [DATE] medical diagnosis includes urinary tract infection. On 03/19/2024 at 12:59 PM, from the hallway, R267 was seen without clothes on through an open door. V14 (Certified Nursing Assistant) was informed about R267 situation, people passing in the hallway can see R267 without clothes. V14 said he always takes off his clothes. V14 did not address the issue and went inside the elevator. At 01:09 PM, V13 (Licensed Practical Nurse) was informed. V13 stated R267 is confused and takes off his clothes or gown every time staff put clothes on R267. V13 stated R267 should not be exposed to people in the hallway. V13 then went to R267's room, and covered the resident, closed privacy curtain and closed the door. On 03/20/2024 at 02:46 PM, V3 (Director…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review of records the facility failed to protect the residents' right to be free from physical and/or mental abuse by resident (R47) against another resident (R64); failed to establish a resident sensitive and resident secure environment per abuse policy after physical abuse was determined. These failures affected 2 out of 23 residents (R64 and R47) right to be from abuse or the threat of abuse. Findings include: R64 is [AGE] years old, initially admitted on [DATE] with medical diagnosis of adjustment disorder with anxiety and acquired absence of left leg below knee. R64 cognition is intact most recent brief interview for mental status (BIMS) dated 01/05/2024 scored 15. Per R64's care plan he has impaired mobility and requires the use of prosthesis due to left extremity below the knee amputation. R47 is [AGE] years old, initially admitted on [DATE] with medical diagnosis of bipolar disorder, schizoaffective disorder, post-traumatic stress disorder. R47 cognition is intact…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 refer R74 to the state-designated authority for Level II PASRR (Pre-admission Screening and Resident Review) evaluation and determination after new onset of possible serious mental disorder for one out of a total sample of 23 residents. Findings include: R74's face sheet documents in part initial admission date of 7/21/2021. Medical diagnoses include but are not limited to schizoaffective disorder, depressive type (onset date 8/17/2023), major depressive disorder, recurrent, moderate (onset date 8/17/2023), anxiety disorder (onset date 8/17/2023), and auditory hallucinations (onset date 8/17/2023). Requested R74's Level II PASRR screening multiple times from V1 (Administrator) and V2 (Assistant Administrator) on 3/20/2024 at 12:20 PM and 4:33 PM and again on 3/21/2024 at 9:38 AM. On 3/21/2024 at 10:38 AM, V33 (Admissions) stated no Level II PASRR evaluation for R74. Facility's undated Pre-admission Screening and Resident Review (PASRR) policy documents in part: It is the policy of this facility to comply with Illinois…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, it was determined the facility failed to provide proper positioning for a dependent resident during mealtime. This deficient practice was observed for 1 (R17) resident reviewed for positioning in a sample of 23. Findings include: R17 has diagnosis not limited to Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Anemia, Gastro-Esophageal Reflux Disease, Dementia in other Diseases Classified Elsewhere, Unspecified Severity, with other Behavioral Disturbance, Abnormal Posture, Contracture, Right Hand, and Lack of Coordination. Care Plan document in part: Focus: R17 has an ADL (Activities of Daily Living) self-care performance deficit. Interventions: Eating: The resident is able to feed self with set up assist. Bed Mobility: The resident requires Extensive assistance by one staff to turn and reposition in bed every shift and as necessary. Focus: R17 is at risk for discomfort, complications related to diagnosis of Right Hemiparesis following a Cerebral Vascular Accident (CVA/Stroke) for possible…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure low air loss mattress devices were on the correct settings for 1 dependent resident (R30) who is high risk in developing pressure ulcer and for 1 (R70) out of 2 dependent residents with current pressure ulcers in a final sample of 23 residents. Findings Include: On 3/19/24 at 10:40 AM R30's lying in bed alert and awake but confused. R30's low air loss mattress weight control knob was set between 350 pounds. At 10:45 AM, R70's lying in bed alert and able to verbalize needs. R70'a low air loss mattress weight control knob was set to 350 pounds. R70 stated R70 has wounds on R70's back and the staff do not reposition R70. R70's legs and hands were noted contracted. At 3/20/24 at 11:35 AM, V9 (Wound Care Nurse) stated if a resident stays primarily in bed and has impaired bed mobility, they are considered high risk for developing pressure ulcer. V9 stated the facility uses the BRADEN score (assessment tool) to assess the resident'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 observations, interviews, and record reviews, the facility failed (a) to follow physician's order and ensure left hand splint was applied and in place and (b) failed to implement an individualized plan of care addressing the use of left hand split for 1 (R75) out of 3 residents reviewed for limited range of motion in a final sample of 23. Findings Include: R75's clinical records show an initial admission date of 8/7/23 with diagnoses not limited to paraplegia and muscle spasm. R75's Minimum Data Set (MDS) dated [DATE] shows R75 is cognitively intact and has impairment on one side of R75's upper extremity. R75's physician orders with active orders as of 3/19/24 shows an order that reads in part: Left Functional Splint. Apply after AM care for 6 hours as tolerated daily ordered on 1/30/24. R75's THERAPY TO NURSING RECOMMENDATIONS dated 12/20/23 shows a recommendation for a left resting hand splint. R75's comprehensive care plan does not address the use of left hand splint. On 3/19/24 at 11:08 AM, R75 was…

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

Based on observation, interview and record review the facility failed to disconnect and flush the gastric tube per physician order for a resident receiving enteral feedings. This failure has the potential for the gastric tubing to become clogged and malfunction for 1 (R50) resident reviewed for enteral feedings in a sample of 23. Findings Include: R50 has diagnosis not limited to Dysphagia, Protein-Calorie Malnutrition, Aphasia, Vitamin D Deficiency, Disorders of Plasma-Protein Metabolism, Gastroesophageal Reflux Disease and Gastrostomy. R50's Physician order document in part: in the afternoon related to Unspecified Protein-Calorie Malnutrition Jevity 1.5 @55ml (milliliter)/hr. (hour) continuous 18hrs: Up at 3PM and down at 9AM Total Volume 990ML. Enteral Feed Order one time a day related to Unspecified Protein Calorie Malnutrition Take down feeding. Scheduled on R50 MAR (Medication Administration Record) at 09:00 AM. Care plan document in part: Focus: R50 currently requires tube feeding to meet nutrition/hydration needs related to diagnosis of Dysphagia, Protein/Calorie…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain an error rate of less than 5%. There were five medication errors out of 31 opportunities which resulted in a 16.13% medication error rate. Findings Include: On 03/19/24 at 10:00 AM V8 (Infection Control Preventionist/Licensed Practical Nurse) retrieved the green tray containing the blood glucose supplies from the top of the medication cart then entered R76 room. V8 placed the green tray on R76 overbed table, retrieved the glucometer, glucose strip and alcohol wipe from the green tray, checked R76 blood glucose with a reading of 196. V8 placed the glucometer back in the green tray then exited R76 room. On 03/19/24 at 10:04 AM V8 (Infection Control Preventionist/Licensed Practical Nurse) placed the green tray containing the glucometer on top of the medication cart then began preparing R76 medications. Surveyor asked V8 the number of pills in R76 medication cup. V8 responded, eight. On 03/19/24 at 10:16 AM V8 (Infection Control Preventionist/Licensed Practical Nurse) entered R76 room then told R76 I…

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

Based on observation, interview, and record review the facility failed to ensure medications were administered as prescribed for 2 (R63, R76) residents reviewed for significant medication errors during the medication administration observation. This failure has the potential to affect R63 blood glucose level and R76 blood glucose level and blood pressure. Finding Include: During medication administration V8 (Infection Control Preventionist/Licensed Practical Nurse) failed to administer R63 scheduled Humalog Insulin, and R76 scheduled Humalog insulin, Metformin 2 tablets, Furosemide and Enalapril. On 03/19/24 at 10:00 AM V8 (Infection Control Preventionist/Licensed Practical Nurse) retrieved the green tray containing the blood glucose supplies then entered R76 room. V8 placed the green tray on R76 overbed table, retrieved the glucometer, glucose strip and alcohol wipe, checked R76 blood glucose with a reading of 196. On 03/19/24 at 10:04 AM V8 (Infection Control Preventionist/Licensed Practical Nurse) began preparing R76 medications. Surveyor asked V8 the number of pills in R76…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medications did not exceed the time frame for medication administration for 5 (R8, R9, R34, R54, R63) of 7 (R63, R76) residents reviewed during medication administration. Findings Include: During medication reconciliation and review of the Medication Administration Audit Report dated 03/20/24 it was determined that the 09:00 AM scheduled medications were given outside of the facilities policies 2-hour window for medication administration. R34's Medication Administration Record document in part: 09:00 AM scheduled medications administered by V9 (Wound Care Nurse) include: Aspirin 81 MG (milligram), Cyanocobalamin Oral Tablet 500 MG, Ergocalciferol Oral Capsule 50 MG, Metoprolol Tartrate Oral Tablet 25 MG, Paxil Oral Tablet 40 MG, Divalproex Sodium Oral Tablet Delayed Release 250 MG, and Memantine HCl Oral Tablet 5 MG. The Medication Administration Audit Report documented the medications were given at 11:38 AM. The actual time medications were observed being administered is 11:27 AM. R8'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.

Based on interviews and record reviews, the facility failed to obtain a physician's order prior to administering a urine drug screen and have a nurse conduct the screening for one (R74) out of a total sample of 23 residents reviewed for residents' rights. Findings include: On 3/19/2024 at 12:12 PM, R74 stated facility asked R74 to do a urine drug test. R74 stated two staff members that were not nurses administered it. On 3/20/2024 at 10:31 AM, V8 (Infection Control Nurse) stated if a resident appears to be under the influence of illicit drugs, the nurse needs to inform the doctor and get an order for a drug screen whether it is by urine or blood. V8 stated only the nurse can administer the urine drug test, not social service. The nurse will hand the urine cup to the resident and watch the resident. The nurse will then notate the results in a progress note in the electronic medical record. On 3/20/2024 at 11:19 AM, V5 (Social Worker) stated V7 (Social Service Director) assisted with R74's recent urine drug test that occurred one to two weeks ago. V5 did not know if there was 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 provide assistance in relocating one [R34] resident to another facility out of 23 residents in the sample Findings include: On 3/19/24 at 9:39 AM, V18 [R34's Family Member] stated, I have asked the facility social worker upon R34's admission to please help me transfer (R34) to a south side suburban facility. I live out south and wanted (R34) close to me so I can visit with him frequently. The current facility is so far away, and it is hard for me to travel almost two hours to and two hours back home with traffic for a visit. The social worker has not assisted me with transferring (R34) closer to the south side of Chicago. (R34) would like to live closer to me as well. It is (R34's) right to transfer to another facility, they are holding him there. On 3/19/24 at 11:44 AM, V7 [Social Service Director] stated, [V5 Social Worker] oversees R34's floor. Social service notes showed V5 reached out to one nursing center, but V5 did not complete a follow up with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the appropriate assistive device was provided for 1 (R34) out of 1 resident with history of multiple falls in a final sample of 23 reviewed for accidents and hazards. Findings Include: On 3/20/24 at 11:22 PM, R34 was observed sleeping in a geriatric chair in the 4th floor dining room. V20 (Licensed Practical Nurse) stated V20 is the nurse in charge for R34. V20 stated R34 was placed on the geriatric (Geri) chair because R34 is high risk for fall and tries to get up on his own. At 2:03 PM, V16 (Restorative Director) stated a Geri chair assessment needs to be completed before using for the resident. V16 stated Geri chair assessment is done if therapy determines the resident has poor trunk control. V16 stated R34 is high risk for falls. V16 stated R34 should not be in a geriatric (Geri) chair because R34 was not assessed to safely use the geriatric chair. V16 stated R34 can still walk with assistance. V16 stated, They probably put…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to a.) ensure pain medications were ordered in a timely manner, b.) failed to maintain a sufficient supply and administer pain medication as ordered by the physician and c.) failed to document a prn (as needed) pain medication administration on the MAR (Medication Administration Record) for 1 (R10) resident reviewed for pain management. This failure resulted in R10 going multiple days without pain medications. Findings Include: R10 was admitted to the facility on [DATE] with diagnosis not limited to Paraplegia, Injury at Unspecified Level of Cervical Spinal Cord, Chronic Obstructive Pulmonary Disease, Chronic Pulmonary Embolism, Neuralgia and Neuritis, Lumbago with Sciatica, Anxiety Disorder, Major Depressive Disorder, Pneumonia, Myalgia, Acute Respiratory Failure, Depression, Cough, Dependence on Supplemental Oxygen and Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation. R10's MDS (Minimum Data Set) BIMS (Brief Interview for…

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

Based on interview and record review, the facility failed to ensure a resident (R1) remained free from physical abuse. This failure affected one resident (R1) out of three residents reviewed for abuse. Findings include: R1's Face sheet documents R1 has a diagnosis which includes, but not limited to, Alzheimer's disease, bilateral primary osteoarthritis of knee, dementia in other diseases classified elsewhere unspecified severity without behavioral disturbance and anxiety, hypokalemia, low back pain, essential hypertension, vitamin d deficiency, hyperlipidemia, urinary tract infection site vascular dementia severe with mood disturbance, COVID 19, and ptosis of bilateral eyelids. R2's Face sheet documents R2 has a diagnosis which includes but not limited to schizophrenia, aphasia, violent behavior, rhabdomyolysis, severe intellectual disabilities, unspecified open wound left lower leg sequela, long term use of anticoagulants, other abnormal involuntary movements, essential hypertension, anxiety disorder, restlessness and agitation, urinary tract infection, and autistic disorder. 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.

Based on interviews and record reviews, the facility failed to (a) carry out physician orders in a timely manner, (b) notify physician of delayed services and family's request for hospital transfer, and (c) administer the correct dosage for one (R5) of 12 residents reviewed for improper nursing care. Findings include: V35's (Nurse) progress note dated 12/06/2023 9:26 AM documents in part: [R5] in shower vomited 5-10 [milliliter] of green emesis with broccoli. States pain in stomach is 10 [severe]. Morning medication given. Evaluated by [Nurse Practitioner]. R5's physician orders document in part that V40 (Nurse Practitioner) ordered a STAT KUB (Kidney, Ureter, Bladder X-ray) on 12/06/2023 at 11:07 AM and STAT blood labs at 11:16 AM. V35's progress note for R5 dated 12/06/2023 4:43 PM documents in part: [Complained of] pain in stomach rated at 8-10. Tylenol 500 given. [Followed-up] with [contracted company] for STAT testing. Arrival anticipated by 7. No documentation that V35 notified V40 or V42 (Physician) of R5's condition or that STAT orders were delayed or not done. 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 interview and record review, the facility failed to maintain a safe resident environment and protect residents from abuse for 4 of four residents (R1, R2, R3, and R4) reviewed for abuse in the sample of four. Findings include: 1)R1's medical record (Face Sheet, MDS-Minimum Data Set of 6.19.2023) documents R1 is a cognitively intact [AGE] year-old admitted to the facility on 6.18.2015 with diagnoses including but not limited to: Chronic Obstructive Pulmonary Disease, Epilepsy, Anemia, Chronic Kidney Disease, Type 2 Diabetes Mellitus. R2's medical record (Face Sheet, MDS-Minimum Data Set of 8.8.2023) documents R2 is a severely cognitively impaired [AGE] year-old admitted to the facility on 2.3.2023 with diagnoses including but not limited to: Schizoaffective Disorder, Bipolar Type; Violent Behavior, Delusional Disorders, and Cognitive Communication Deficit. Additionally, R2's MDS documents R2 exhibits physical (e.g., hitting, kicking, pushing, scratching, grabbing) and verbal (e.g., threatening others,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review and interview the facility failed to meet discharge requirements for one of three residents (R1) reviewed for discharge. Findings include: The (8/14/23) census includes 126 residents. On 6/30/23, IDPH (Illinois Department of Public Health) received the following allegations R1 was discharged without coordination of the following needed services: housing, medications, and/or assistance with social security. R1 currently resides in a cemetery. The census affirms R1 was admitted [DATE] and discharged [DATE]. R1's diagnoses include but not limited to major depressive disorder, anxiety disorder, bipolar disorder, schizophrenia, hypertension and asthma R1's (6/16/23) functional assessment affirms (1 person) physical assist is required for bed mobility, transfers, dressing, toilet use and personal hygiene. R1's POS (Physician Order Sheets) include but not limited to (3/16/23) Haldol Decanoate injection 100mg (milligrams) every month on the 28th related to schizoaffective disorder.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review and interview the facility failed to document a discharge plan of care for one of three residents (R1) reviewed for discharge planning process. Findings include: The census affirms R1 was admitted [DATE] and discharged [DATE]. On 8/15/23, R1's (3/16/23) comprehensive care plan was reviewed however discharge planning was excluded. On 8/15/23 at 10:27am, inquired about R1's discharge plan. V13 (Social Service) stated, He wanted to get his own apartment through (housing provider). On 8/15/23 at 11:25am, inquired if R1's comprehensive care plan includes discharge planning. V2 (Director of Nursing) reviewed R1's care plan and stated, No. The (undated) resident care planning policy states the care plan is initiated on admission, interim care plan is to be completed within 48 hours and comprehensive care plan fully developed by day 21. Long-term goals must be individualized and realistic for resident involved, potential for discharge is considered from the day of admission.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect a resident from physical abuse. This failure affects one of three residents (R3) reviewed for abuse in a total sample of eight residents. Findings include: R3 is a [AGE] year-old male. R3's diagnoses are but not limited to high cholesterol, high blood pressure, mood disorder, depression, and swelling. R3's BIMS (Brief Interview for Mental Status) dated 05/16/2023, notes R3 is alert. R3's MDS (Minimum Data Set) dated 05/16/2023, notes R3 requires extensive one person assistance. R3's care plan notes R3 has impaired cognitive function thought processes due to impaired decision making and developmental disability. R4 is a [AGE] year-old male. R4's diagnoses are but not limited to lung disorders, heart failure, kidney disease, heart failure, and dependance on renal dialysis. R4's BIMS (Brief Interview for Mental Status) dated 07/05/2023, notes R4 is alert. R4's MDS dated [DATE], notes R4 requires limited one person assistance. R4's care plan notes…

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

Based on observations, interview and record reviews the facility failed to 1.) prepare food under sanitary conditions. 2.)failed to ensure that frozen meat have not been left to thaw at room temperature.3.) failed to date perishable items in the refrigerator. 4.)failed to routinely monitor food temperatures on the steam table by not logging the temperature in the food temperature logbook. 5.)failed to ensure that dishwasher draining pipeline is not leaking and 6.)failed to maintain cold food item at 41F or cooler. These failures have the potential to affect 124 residents living in the facility with 4 residents on Nothing by Mouth (NPO) for a total facility's census of 128 dated 4/4/23. The findings include: On 4/4/23 at 9:10 AM observed the following: 1. Kitchen toured with V5 (Dietary Manager) and observed gray garbage bin lid was half open. Observed 2 brown boxes on the floor by garbage bin with garbage on it. Observed V5 throwing garbage in the brown box on the floor. Observed kitchen floor with scattered disposable plates, packet of pepper, silver spoon, multiple plastic lids,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (a) failed to dispose of garbage properly in a contained dumpsters (b) failed to keep the dumpster area clean and free of garbage or waste to maintain a sanitary condition to prevent harborage and feeding of pest. These failures could potentially affect all 128 residents that reside in the facility as of census 4/4/23. The Findings include: On 4/5/23 at 11:10 AM During the 2nd day kitchen tour with V5 (Dietary Manager) observed outside dumpster lid halfway open with overflowing garbage. V5 stated it should be tightly closed then V5 closed the dumpster lid. Observed 3 mattresses on the ground, 2 black plastic bins, brown boxes or cartons, clear plastic and paper waste around the dumpster area. V5 stated maybe maintenance staff was the one who placed those mattresses. V5 stated that kitchen staff is aware that when throwing garbage in the dumpster the lid should be closed after use to prevent rodents / pests harborage around the dumpster area. On 4/6/23 at 8:50 am V13 (Maintenance Director) was interviewed and stated 3…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations, interviews, and review of records the facility failed the following; related to infection prevention and control: Failed to follow policy in perform hand hygiene during bedside care from soiled to clean surfaces for 1 resident (R56). Failed to maintain linen bag off the floor. Failed to clean reusable equipment (blood cuff) used by 3 residents (R2, R49 and R105). The facilty also failed to follow Water management Program related to risk assessment of Legionella and other opportunistic pathogens. These failures have the potential to affect all 128 residents in preventing infections. Findings include: 04/04/23 11:20 AM. R56 was seen on his bed with tracheostomy tubing connected. V10 (Certified Nursing Assistant) and V11 (Certified Nursing Assistant) was performing bedside care including bed bath to R56. V11 was seen placing 2 blue bags, 1 bag was placed on the floor and dirty linen was put inside. And 2nd bag was also placed on the floor for garbage. Both V10 and V11 performing direct care to R56 wore surgical masks and gloves without wearing a gown. After…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review of records and interviews the facility failed to follow policy of Covid-19 testing for resident and staff having close contact or exposed to confirmed case of Covid-19. These failures have the potential to affect all residents on the same floor in preventing infections. Findings include: On 04/04/2023 at 09:28 AM. V4 (Infection Preventionist) stated, A resident (R74) was positive last Saturday (04/01/2023) and she (R74) went to hospital. V4 was asked what measures was done to mitigate or prevent Covid-19 infection transmission to other resident and staff. V4 said, Facility has a scheduled testing twice a week on Mondays and Thursdays. A log was requested on testing documentation to ensure those that were exposed are tested. V4 agreed to present documentation on a later time. Per R74 notes dated 4/2/2023 by V23 (Licensed Practical Nurse) reads that R74 was admitted to hospital for Covid-19 positive. On 04/06/2023 at 09:06 AM. Per V4 outbreak is defined if facility has 1 staff or resident that is positive with Covid-19. On 04/06/2023 at 09:49 AM. After multiple request…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review of records and interviews the facility failed to follow Covid-19 Vaccination policy related to determining facility staff and residents' vaccination status to offer Covid-19 Vaccination, and documentation of education provided to residents. These failures have the potential to affect all 128 residents in preventing infections. Findings include: On 04/04/2023 at 09:56 AM. V4 (Infection Preventionist) submitted Matrix for staff that does not include contractual or agency staff. On the same Matrix facility staff, Covid-19 vaccination does not indicate dates when vaccination received. And all vaccination that needs 2 doses (Pfizer and Moderna) cannot be determine since Matrix does not provide date when it was given. V4 stated, I understand what you mean, it should look the same as resident matrix that has both dates for vaccines that needs 2 doses. On 04/06/2023 at 01:51 PM. V4 submitted staff matrix that now includes contractual / agency staff that includes direct care and facility staff vaccination including dates when they received. Multiple facility staff have 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 review of records, and interviews the facility failed to monitor staff (facility and contracted) vaccination status. And failed to develop policy and procedure to ensure that all staff are fully vaccinated for Covid-19. These failures have the potential to affect all residents on the same floor in preventing infections. Findings include: On 04/04/2023 at 09:56 AM. V4 (Infection Preventionist) submitted Matrix for staff that does not include contractual or agency staff. On the same Matrix facility staff, Covid-19 vaccination does not indicate dates when vaccination received. And all vaccination that needs 2 doses (Pfizer and Moderna) cannot be determine since Matrix does not provide date when it was given. V4 stated, I understand what you mean, it should look the same as resident matrix that has both dates for vaccines that needs 2 doses. On 04/06/2023 at 01:51 PM. V4 submitted staff matrix that now includes contractual / agency staff that includes direct care and facility staff vaccination including dates when they received. Multiple facility staff have no records 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 observations, interviews and record reviews the facility failed to 1.) identify presence of PICC (Peripherally inserted central catheter) line and provide needed care and services for one (R115) resident. 2.) follow the facility's policy for PICC line or midline to (a) change transparent dressing every 7 days for 3 residents (R115, R5, R108); (b) change transparent dressing as needed for one (R226) resident; (c) measure PICC line external catheter and record with each dressing change; (d) failed to flush PICC line or midline for four residents (R115, R5, R108, R226). 3.) failed to develop the comprehensive person-centered care plan for four residents (R115, R5, R108, R226) and 4.)failed to ensure the PICC lumen (Hub) port was cleaned prior to administering IV (intravenous) antibiotic medication for one (R108) resident. These failures resulted in residents with PICC line or midline not receiving treatment and care in accordance with professional standards of practice for four residents (R115, R5, R108,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review of records and interviews the facility failed to follow policy related to monitoring and recording in the immunization log as part of resident record influenza and pneumococcal vaccination for 4 out of 5 residents (R8, R53, R61 and R118) reviewed for immunization. These failures have the potential to affect 4 residents vaccination benefits. Findings include: On 04/05/2023 at 10:28 AM. V4 (Infection Preventionist) and V2 (Director of Nursing) were requested for pneumococcal, influenza and Covid-19 vaccinations of the following residents: Under Immunization Log the following were documented: - R8 Prevnar-13 noted as consent refused without a date, influenza no date, and 2 doses of Covid-19 completed. - R53 most current influenza vaccination record was dated 09/23/2020, Pneumovax 1 historical, Pneumovax 2 dated 11/21/2019, and 2 doses of Covid-19 completed. - R61 most current influenza vaccination recorded was 10/14/2019, no pneumococcal vaccination on record, and 2 doses of Covid-19 completed. - R118 no record for all vaccinations (influenza, pneumococcal and Covid-19)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 2 of 2 (R36, R104) residents call lights were within reach in a sample of 26. Findings Include: R104 has diagnosis not limited to Tracheostomy, Gastrostomy, Heart Failure, Ventricular Tachycardia, Generalized Anxiety Disorder, Major Depressive Disorder, Dementia Chronic Respiratory Failure and Encephalopathy. R104 BIMS (Brief Interview Mental Status) Section C Cognitive Pattern BIMS (Brief Interview Mental Status) score of 09 indicating moderately impaired. R104 Care Plan document in part: Focus: At risk for falls related to assistance needed. Date Initiated: 02/10/23. Interventions: Make sure my call light/personal belongings are in reach. Date Initiated: 02/10/23. Focus: The resident has a communication problem r/t (related /to) Dysphagia Date Initiated: 02/13/23. On 04/04/23 at 10:34 AM V14 (Registered Nurse) was observed standing at the medication cart before entering R104 room. On 04/04/23 at 10:47 AM R104 was observed lying in bed with a tracheostomy tube in place. The call light was observed 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 reviews, the facility failed to revise a resident's (R91) comprehensive care plan after weight loss for 1 of 26 residents reviewed for care plans. Findings include: R91's recorded weights document in part that on 09/19/2022 R91 weighed 158.4 lbs (pounds). On 03/25/2023, R91 weighed 126.7 lbs. R91 had a 20.01 % severe weight loss in six months. V20's (Dietician) progress notes dated 03/20/2023 2:16 PM and 04/06/2023 10:04 AM document in part that R91 triggered for significant weight loss in 1-month, 3-month, and 6-month comparisons. R91's comprehensive care plan did not reflect the 1-month significant weight loss when it occurred, or the 3-month or 6-month. During a telephone interview with V20 on 04/06/23 at 11:17 AM, V20 reviewed R91's comprehensive care plan. V20 stated [V20] did not see a care plan for R91's weight loss. V20 stated [V20] does not update the nutritional care plan. V20 stated it is usually the MDS (Minimum Data Set) Nurse or V5 (Dietary Manager). V20 stated if there is a change in a resident's nutritional status or diet, staff should…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 follow a resident's (R25) comprehensive care plan and provide turning and repositioning every two hours or as needed for 1 of 26 residents reviewed for nursing care. Findings include: R25's face sheet documents in part diagnoses of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side (right-sided paralysis and weakness after a stroke). R25's comprehensive care plan contains a focus initiated on 11/05/2021 that documents in part: [R25] has an ADL (Activities of Daily Living) self-care performance deficit r/t [related to] Confusion, Hemiplegia, Impaired balance, Limited Mobility, Limited ROM [Range of Motion]. Intervention initiated 07/09/2019 documents in part: bed mobility: The resident requires Extensive assistance by one staff to turn and reposition in bed every shift and as necessary. R25's comprehensive care plan also contains a more recent focus initiated on 02/24/2023 that…

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

Based on observation, interview, and record review the facility failed to ensure proper placement of the gastrostomy tube prior to medication administration and provide gastrostomy care per orders for 1 (R98) of 3 (R36, R104) residents with gastrostomy tubes reviewed in a sample of 26. Findings Include: R98 has diagnosis not limited to Gastrostomy, Protein-Calorie Malnutrition, Dysphagia, Gastrointestinal Hemorrhage, Adult Failure to Thrive and Gastro-Esophageal Reflux. Order Summary Report dated 04/05/23 document in part: Enteral Feed Order every shift related to Encounter for Attention to Gastrostomy Check placement prior to feeding, flushing, and medication administration. -Order Date- 05/16/22. Enteral Feed Order every shift related to Encounter for Attention to Gastrostomy Flush G-Tube with 60ml of water before and after medication administration -Order Date-05/16/22. R98 Care Plan Document in part: Check for tube placement and gastric contents/residual volume per facility protocol and record. Date Initiated: 05/05/22. On 04/05/23 at 09:39 AM V14 (Registered Nurse) prepared R98…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interview and record reviews the facility failed to follow policy and procedure on oxygen administration (a) to check physician's order for liter flow and method of administration; (b) to ensure that oxygen tubing and humidifier bottle changed and dated for one (R66) resident in a sample of 26 reviewed for oxygen use. Findings include: On 4/4/23 at 10:44 AM R66 observed with oxygen at 3L/min. Oxygen tubing and humidifier bottle observed with no date on it. R66 stated he (R66) has been using oxygen all the time for couple of years due to COPD (Chronic Obstructive Pulmonary Disease). R66 stated I would have a hard time breathing when I don't use oxygen. On 4/6/23 at 10:15 AM V2 (DON-Director of Nursing) was interviewed and stated that oxygen use should be ordered in resident's electronic health record (EHR) - physician order sheet (POS) including the liter flow, method of administration, change of tubing and humidifier bottle every week and as needed; V2 further stated that these oxygen…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow the comprehensive care plan to ensure pain patch was applied as ordered by the physician for 1 (R37) of 1 resident reviewed for pain management in a sample of 26. Findings Include: On 4/4/23 at 1:09 PM, R37 was eating lunch in R37's room. R37 complained of left shoulder pain radiating to R37's left arm and hand. R37 stated that R37 broke R37's clavicle sometime last year due to a fall. R37 stated, I was wheeling myself in the wheelchair from my smoking break. My wheelchair got stuck in a dirt. It tipped over and I landed on my left side on the ground. I'm supposed to get a pain patch on my left shoulder, but I never got it today. I'm supposed to get it every morning at 6 AM. It's the only thing that takes away the pain on my shoulder. It helps with my muscle pain. Now my pain is at 6. Surveyor immediately notified V9 (Registered Nurse). At 1:14 PM, V9 stated that R37 has an order for Lidocaine patch to apply at 6:00 AM on R37'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 the system used for acceptable standard of practice to account for the receipt, usage, disposition, and reconciliation of controlled medications was followed by staff for 1 of 3 medication carts reviewed. Findings Include: R94 has diagnosis not limited to Unspecified Convulsions, Mood (Affective) Disorder, Repeated Falls and Unspecified Intracranial Injury with loss of consciousness. R94 BIMS (Brief Interview Mental Status) Section C Cognitive Pattern BIMS (Brief Interview Mental Status) score of 07 indicating severe impairment. On 04/05/23 at 12:07 PM during the third-floor low medication cart review with V9 (Registered Nurse) it was observed that R94 Controlled Drug Receipt/Record/Disposition Form dated 03/10/23 document in part: Phenobarb (Phenobarbital) 15 mg (Milligrams) take 1 tablet by mouth daily for seizures, Quantity Dispensed 30. Last documented remaining quantity of 4 dated 04/05/23 09:00 AM. Medication punch card dispended 03/10/23 with a quantity of 30 document in part: Phenobarbital…

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

Based on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5% for 2 (R2, R49) of 6 (R71, R98, R108, R121) residents reviewed for medication administration resulting in a 6.9% error rate. Findings Include: R2 has diagnosis not limited to Hemiplegia and Hemiparesis Following Cerebrovascular Disease Affecting the Right Dominant Side, Cerebral Infarction, Essential (Primary) Hypertension and Intracranial Injury. R2 Administration History Report with administration date of 04/04/23 09:00 AM and the Medication Administration Record dated 04/01/23 - 04/30/23 document Metoprolol Succinate ER Tablet Extended Release 24 Hour 50 MG as not given. R49 has diagnosis not limited to Hemiplegia and Hemiparesis Following Cerebrovascular Disease Affecting the Left Non-Dominant Side, Cerebral Infarction and Essential (Primary) Hypertension. R49 Administration History Report with administration date of 04/04/23 09:00 AM and the Medication Administration Record dated 04/01/23 - 04/30/23 document Amlodipine Besylate Tablet 5 MG as not given. 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 observation, interview, and record review the facility failed to ensure medications were administered as prescribed for 2 (R2, R49) residents reviewed for significant medication errors during the medication administration observation. This failure has the potential to affect R2 blood pressure and heart rate and R49 blood pressure. Findings Include: R2 has diagnosis not limited to Hemiplegia and Hemiparesis Following Cerebrovascular Disease Affecting the Right Dominant Side, Cerebral Infarction, Essential (Primary) Hypertension and Intracranial Injury. R2 Administration History Report with administration date of 04/04/23 09:00 AM and the Medication Administration Record dated 04/01/23 - 04/30/23 document Metoprolol Succinate ER Tablet Extended Release 24 Hour 50 MG as not given. The next documented blood pressure was 130/70, pulse 86 dated 04/05/23. R49 has diagnosis not limited to Hemiplegia and Hemiparesis Following Cerebrovascular Disease Affecting the Left Non-Dominant Side, Cerebral Infarction and Essential (Primary) Hypertension. R49 Administration History Report with…

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

Based on observation, interview, and record review the facility failed to a.) ensure medications were not left on top of the medication cart unattended, b.) ensure medications were properly labeled and stored and c.) remove and discard insulin stored in the medication cart that had been open and in use for more than 28 day in 2 of 3 medication carts reviewed for medication labeling and storage. Findings Include: On 04/04/23 at 09:29 AM V8 (License Practical Nurse) entered R105 room leaving the bottles with Miralax Powder 17 GM/SCOOP 17 gram, Thera-M Tablet (Multiple Vitamins-Minerals) and Loratadine Tablet 10 MG on top of the medication cart unattended. On 04/05/23 at 09:51 AM the fourth-floor high medication cart was reviewed with V15 (Licensed Practical Nurse). R226 Lantus Solution 100 ml (Milliliters) flex pen was observed without a bag, laying in a red plastic tray in the top drawer of the medication cart with an open date of 03/17/23. V15 stated the insulin pen is usually in a bag. R226 Order Summary Report dated 04/05/23 document in part: Basaglar KwikPen Solution Pen-injector…

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