Elevate Care Chicago North

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a visitor entering a contact isolation room was wearing proper personal protective equipment (PPE) for one resident (R67), and failed to ensure staff wore the proper PPE when providing care for 3 (R41, R72, R219) residents on Enhanced Barrier Precautions. These failures has the potential to affect 60 residents residing on the third floor, and 60 residents residing on the fourth floor. Findings Include: 1. R219 was admitted to the facility on [DATE], with diagnoses not limited to Type 2 Diabetes Mellitus with Hyperglycemia, Acute Kidney Failure, Dependence on Renal Dialysis, Gastrostomy, Hypertensive Heart Disease, Shaken Infant Syndrome, Cerebral Palsy, Epilepsy, Abnormalities of Gait and Mobility, Polycystic Ovarian Syndrome, and Blindness, Both Eyes. R219's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) indicates resident is rarely/never understood. R219's Order Summary Report documents: Enhanced Barrier…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff provided privacy during care for 1 (R219) resident observed for resident rights in a sample of 32. Findings Include: R219 was admitted to the facility on [DATE], with diagnoses not limited to Type 2 Diabetes Mellitus with Hyperglycemia, Acute Kidney Failure, Dependence on Renal Dialysis, Gastrostomy, Hypertensive Heart Disease, Shaken Infant Syndrome, Cerebral Palsy, Epilepsy, Abnormalities of Gait and Mobility, Polycystic Ovarian Syndrome and Blindness, Both Eyes. R219's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) indicates resident is rarely/never understood. On 05/13/25 at 12:08 PM, R216 was observed from the doorway in bed. V8 (Restorative) was observed in R216's room adjusting R216's brief, with the door open, the privacy curtain open, and R216's roommate, R28, privacy curtain open. Enhanced Barrier Precaution signage was observed at R216 room entry. V8 did not have a gown on while providing care. V8…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide an specialized call light within reach for a resident with limited movement. This affected one (R56) out of six residents reviewed for call lights in a total sample of 32. Findings include: R56 has diagnoses which includes but not limited to Quadriplegia, Neuromuscular Dysfunction Of Bladder, Unspecified, Pressure Ulcer Of Sacral Region, Stage 4, Anxiety Disorder, Chronic Embolism And Thrombosis Of Other Specified Veins, Post-Traumatic Stress Disorder, Chronic, Hydronephrosis With Renal And Ureteral Calculous Obstruction, Hypokalemia, Unspecified Protein-Calorie Malnutrition, Iron Deficiency Anemia, Constipation, and Encounter For Attention To Ileostomy. R56's MDS (Minimum Data Set), dated 01/23/25, documents intact cognitive function. MDS, dated [DATE], documents R56's primary medical condition is Traumatic Spinal Cord Dysfunction and impairment in range of motion on both sides of upper/lower extremities and dependency on staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 refer residents to the appropriate state designated authority for re-screening and Level II referral. This failure affects three residents (R17, R84, R93) out of five residents reviewed for Preadmission Screening and Annual Resident Review (PASARR) in a total sample of thirty-two. Findings Include: 1. R84's Minimum Data Set (MDS), dated [DATE], shows R84 is moderately cognitively intact. R84's face sheet shows she is [AGE] years old, initially admitted to the facility on [DATE] with diagnoses of bipolar disorder current episode depressed, severe with psychotic features. There is no documentation to show R84 was referred to the appropriate state-designated authority for Level 2 PASARR evaluation and determination. On 5/14/25 at 1:52 PM, surveyor asked V24 (Social Services Consultant) for a Level 2 PASARR screening for R84; she provided the surveyor with an omnibus budget reconciliation act (OBRA) initial screening dated 12/15/20. V24 stated R84 was not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide one to one feeding assistance and properly position a resident in bed consistent with the plan of care during meals. This deficient practice was observed for 1 (R28) resident observed during the dining task in a sample of 32. Findings include: R28 was admitted to the facility on [DATE], with diagnoses not limited to Dementia, Flaccid Hemiplegia Affecting Left Nondominant Side, Dysphagia, Oropharyngeal Phase, Type 2 Diabetes Mellitus with Hyperglycemia, Epilepsy, Diastolic (Congestive) Heart Failure, Chronic Kidney Disease, Stage 3, Depression, Anxiety Disorder, Hypertensive Heart Disease with Heart Failure, Unspecified Intellectual Disabilities, and Gastro-Esophageal Reflux Disease. R28's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 03, indicating severe cognitive impairment. R28's Care Plan documents: Focus: R28 requires a Mechanically Altered Diet r/t (related to) dysphagia. Per nurse, resident C/O…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 communication assistive materials were readily accessible for a resident (R67) who speaks a foreign language, and failed to provide communication tools or communicate with one resident (R161) who has communication deficit out of three residents reviewed in a final sample of 32. Findings Include: 1. R67's clinical records show an admission date of 6/5/24. R67s Minimum Data Set, dated [DATE], shows R67's preferred language is Urdu. R67's communication care plan shows R67 presents with an alteration in ability to communicate related to speaking a foreign language. On 5/13/25 at 12:49 PM, R67 was observed in bed alert and verbally responsive. V37's (R67's Family Member) was at bedside, visiting. Surveyor attempted to interview R67 and V37. R67 stated, Urdu. No English. Surveyor asked and gestured if R67 has communication board to use to communicate in English, but R67 was unable to understand. Surveyor could not find any type of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide Peripherally Inserted Midline Catheter care for 1 (R66) resident reviewed for Midline care and failed to manage one residents (R112) low blood pressure, for 2 of 7 residents reviewed for quality of care in a sample of 32. Findings Include: 1.R66 was admitted to the facility on [DATE], with diagnoses not limited to Cerebral Palsy, Rheumatoid Arthritis, Chronic Pain Syndrome, Depression, Anxiety Disorder, Urinary Incontinence, Chronic Embolism and Thrombosis of Unspecified Deep Veins of Right Lower Extremity, Neuromuscular Dysfunction of Bladder and Anemia. R66's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15, indicating intact cognitive response. R66's Oder Summary report documents: Midline IV catheter - change catheter dressing every night shift every 7 days for IV therapy R66's MAR (Medication Administration Record), dated 05/01/25 - 05/31/25, documents: Midline IV Catheter - Change Catheter Site…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 physician order to ensure assistive device was applied to one (R118) resident with a left hand contracture for residents reviewed for limited range of motion in a final sample of 32. Findings Include: On 5/13/25 at 10:34 AM, R118's electronic health records show R118 was admitted in the facility on 3/7/23, with diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Chronic Respiratory Failure with Hypoxia, Dementia, and Depression. R118's Minimum Data Set, dated [DATE], shows R118 is moderately impaired with cognition, and is dependent on staff's assistance on dressing, grooming, and personal hygiene. R118's physician order reads: Apply left hand palm protector at all times or as tolerated for contracture management. Check for skin irritation, redness and pain. Off during adl [activities of daily living] care and as needed (ordered on 3/13/25). R118's care plan reads: [R118] would benefit from use of Palm Protector due to he is…

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

Based on observation and interview, the facility failed to prevent urinary drainage bag from touching the floor for one (R57) out of three residents reviewed for urinary catheter in a sample of 32. Findings Include: R57 has diagnoses including but not limited to Benign Prostatic Hyperplasia, Obstructive and Reflux Uropathy, Hematuria, Chronic Kidney Disease Stage 3, Cognitive Communication Deficit, Weakness, and Abnormalities of Gait and Mobility. R57's MDS (Minimum Data Set) indicates R57 is cognitively intact and has an indwelling catheter. R57's Order Summary Report, dated 05/13/25, documents diagnosis for indwelling catheter: Obstructive Uropathy and change indwelling catheter and drainage bag as needed. On 05/13/25 at 12:18 PM, R57 was lying in bed, and urinary drainage bag was lying directly on the floor next to R57's bed. On 05/13/25 at 12:20 PM, V19 (Nursing Supervisor/Registered Nurse) observed R57's urinary drainage bag lying on the floor next to R57's bed. V19 stated, The urinary bag should not be touching the floor due to infection control concerns and to prevent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one resident (R2) for self-administration of medications. This failure affected one resident (R2) reviewed for medications. Findings include: R2's medical diagnoses include but are not limited to type 2 diabetes with hyperglycemia, chronic kidney disease stage 2, essential hypertension, major depressive disorder, long term use of insulin, and hyperlipidemia. R2 Brief Interview for Mental Status (BIMS) score, dated 04/02/25, is 15, which indicated R2's cognition is intact. R2's physician order, dated 04/09/25, documents, Creon Oral Capsule Delayed Release Particles 36000-114000 unit .Give one capsule by mouth before meals for indigestion. R2's physician order, dated 03/27/25, documents, Tramadol tablet 50mg (milligrams) give 1 tablet by mouth every 12 hours for moderate to severe pain. On 04/21/25 at 12:13pm, R2 removed two pill bottles from R2's top drawer. R2 opened one pill bottle Creon and ingested one pill. R2 showed surveyor both pill bottles. First pill bottle observed was Tramadol 50mg…

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

Based on observation, interview, and record review, the facility failed to ensure the call light was within reach for 1 resident (R3) out of 3 residents reviewed for call lights. Findings include: R3's diagnosis includes but are not limited to end stage renal disease, hypertensive heart and chronic kidney disease with heart failure, type 2 diabetes mellitus with hyperglycemia, acute respiratory failure, unspecified whether with hypoxia or hypercapnia, dysphagia, oropharyngeal phase, encephalopathy, unspecified, epilepsy, unspecified, not intractable, without status epilepticus, hyperlipidemia, aphasia, pressure ulcer of sacral region, unstageable, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and other lack of coordination R3's care plan documents, Focus: R3 has alteration in musculoskeletal status related to joint stiffness. Intervention: Be sure call light is within reach and respond promptly to all requests for assistance. R3 has potential risk for falls due to generalized weakness, impaired…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 date the oxygen tubing per facility policy for two residents (R3 and R4) in a sample of three residents reviewed. Findings include: 1. R3's diagnosis includes but are not limited to end stage renal disease, hypertensive heart and chronic kidney disease with heart failure, type 2 diabetes mellitus with hyperglycemia, acute respiratory failure, unspecified whether with hypoxia or hypercapnia, dysphagia, oropharyngeal phase, encephalopathy, unspecified, epilepsy, unspecified, not intractable, without status epilepticus, hyperlipidemia, aphasia, pressure ulcer of sacral region, unstageable, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and other lack of coordination. R3's MDS (Minimum Data Set) Section O., dated 04/13/2025, documents, 00110.Special Treatments, Procedures, and Programs, Respiratory Treatments C1. Oxygen Therapy b. While a resident. R3's Physician Order Summary Report, dated 04/22/25, documents, Oxygen at 2…

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

Based on observation, interview, and record review, the facility failed to provide a homelike environment for eight (R1-R8) out of eight residents reviewed for homelike environment, with the potential to affect all the residents who reside on the second floor. Findings include: R2 is no longer a resident of the facility, but R2's census report documents R2 previously resided on the second floor in March 2025. Facility Feedback Alert, dated 3/08/2025 8:55 PM, documents a concern regarding broken window blinds in R2's room. On 4/08/2025 at 11:28 AM, the ceiling panels in front of the main elevators (elevator 2) were missing. [NAME] and black cords were exposed and dangling from the ceiling. There were missing floor trims in the hallway exposing the gaps between the wall and floor. On 4/08/2025 at 12:13 PM, there were multiple areas with chipped paint to R1 and R5's room. R1 stated the overhead light to R1's bed has been broken since January, but V1 (Administrator) recently provided a portable light fixture. R1 stated facility is slow to fix anything. At 1:42 PM, R1 stated the right…

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

Based on interview and record review, the facility failed to provide timely incontinence care for two (R1, R5) out of seven residents reviewed for improper nursing care, with the potential to affect all the dependent residents V9 (Certified Nurse Aide) cares for in the facility. Findings include: 1. R1's admission Record documents diagnoses of radiculopathy in the lumbar region, idiopathic progressive neuropathy, morbid obesity, osteoarthritis, abnormalities of gait and mobility, reduced mobility, and need for assistance with personal care. R1's 3/28/2025 Quarterly MDS (Minimum Data Set) assessment documents R1 is cognitively intact, and is dependent on staff for toileting. R1's Care Plan Report documents R1 has a functional deficit in bed mobility and ADL (Activities of Daily Living) self-care performance deficit due to generalized weakness, impaired gait/balance, pain, musculoskeletal impairment, impaired mobility, physical limitations secondary to mechanical fall, lumbar radiculopathy, and rotator cuff injury (revised 12/2024). It also documents R1 has alteration in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide timely incontinence care for four dependent residents (R1, R4, R5, R9) reviewed for improper nursing care. Findings include: 1. R1's admission Record documents in part diagnoses of difficulty in walking, lack of coordination, abnormalities of gait and mobility, spinal stenosis-cervical region, irritable bowel syndrome, and obesity. R1's Care Plan Report documents R1 has bowel and bladder incontinence due to generalized weakness, impaired gait/balance, shortness of breath, and physical limitations (last revised 3/12/2025). Interventions last revised on 2/06/2025 document to check for incontinence; wash, rinse, and dry perineum; change incontinence products; and change clothing as needed. R1's Care Plan Report also documents R1 had a pressure injury to right buttock and is at risk for delayed wound healing. R1 was also at risk for further alteration in skin integrity (last revised 2/06/2025). Staff were to keep R1's skin clean and…

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

Based on observation, interview, and record review, the facility failed to provide proper and adequate care (oral hygiene, grooming and shower / hair wash) and develop an individualized plan of care for 1 (R3) resident who is dependent with care. These failures affected one (R3) of three residents reviewed for improper nursing care. Findings include: R3's MDS (Minimum Data Set), dated 1/7/2025, showed R3's cognition was severely impaired. R3 needed total assistance / dependent with oral, toileting and personal hygiene, shower / bathe self, upper and lower body dressing. R3' order summary report, dated 1/26/25, with active order, Oral Care every 8 hours and as needed. R3's care plan date, initiated on 5/22/20, documented: R3 has a tracheostomy and ventilator due to chronic respiratory failure. Care plan interventions included but not limited to Provide good oral care every shift and PRN (as needed). R3's care plan, dated 6/9/2020, documented: Is Ventilator dependent related to Respiratory Failure. Care plan interventions included but not limited to Provide good oral care every shift.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a resident's care plan, failed to follow their seizures policy to assess and document findings and observations of a resident's seizure activity, and failed to send a resident to the hospital for further evaluation who got punched in the face and is on anti-coagulant therapy with active seizures. These failures affected one (R2) out of three residents reviewed for abuse. Findings Include: R2's face sheet shows R2 diagnoses including Hemiplegia Affecting Right Dominant Side, Vascular Dementia, Schizoaffective Disorder, Anxiety Disorder, Right Hand Contracture, and Epilepsy. R2's Minimum Data Set/MDS, dated [DATE], shows R2 has moderately impaired cognition with BIMS (Brief Interview for Mental Status) of 12, and requires substantial maximal assistance from staff with activities of daily living. R2's December Medication Administration Record shows R2 is receiving anticoagulant therapy; Heparin injection every 12 hours. R2's comprehensive care plan…

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

Based on observation, interview, and record review, the facility failed to follow R3's care plan to apply Bilateral Palm Protectors due to actual contracture. This failure affected one (R3) of three residents reviewed for improper nursing care. Findings include: R3's admission record showed initial admission date of 5/21/20, with diagnoses not limited to Chronic respiratory failure, Encounter for attention to tracheostomy, Dependence on respirator [ventilator] status, Encounter for attention to gastrostomy, Heart failure, Epilepsy, Anoxic brain damage, Hypoxic ischemic encephalopathy, Pressure ulcer of sacral region stage 4, Hypertensive heart disease with heart failure, Neuromuscular dysfunction of bladder, Contracture of muscle multiple sites, Pneumonia. R3's record showed hospitalization on 1/7/25, and readmission date on 1/16/25. R3's MDS (Minimum Data Set), dated 1/7/2025, showed R3's cognition was severely impaired. She needed total assistance / dependent with oral, toileting and personal hygiene, shower / bathe self, upper and lower body dressing. MDS showed impairment 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 follow R3's plan of care to ensure additional tracheostomy tube at bedside for an emergency. This failure could potentially affect one (R3) of three residents reviewed for improper nursing care. Findings include: R3's admission record showed initial admission date of 5/21/20, with diagnoses not limited to Chronic respiratory failure, Encounter for attention to tracheostomy, Dependence on respirator [ventilator] status, Encounter for attention to gastrostomy, Heart failure, Epilepsy, Anoxic brain damage, Hypoxic ischemic encephalopathy, Pressure ulcer of sacral region stage 4, Hypertensive heart disease with heart failure, Neuromuscular dysfunction of bladder, Contracture of muscle multiple sites, and Pneumonia. R3's record showed hospitalization on 1/7/25, and readmission date on 1/16/25. R3's MDS (Minimum Data Set), dated 1/7/2025, showed R3's cognition was severely impaired. Care plan date, initiated on 5/22/20, documented: R3 has a tracheostomy and ventilator due to chronic respiratory failure. Care plan…

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

Based on interview and record review, fthe acility failed to follow their policy to ensure safe mechanical lift transfers are practiced for one (R15) out of three residents in a sample of 15. Findings include: On 10/16/2024, at 2:14 PM, V20 (Restorative Nurse) stated he is familiar with R15. V20 stated he was on vacation during this time, and so the previous Director of Nursing should have investigated the fall incident. V20 stated R15 had a fall on 4/29/2024. V20 stated according to the progress note, they were trying to transfer R15 from the bed to the speciality chair. The next thing that is documented is the aide called for the nurse's attention because R15 was on the floor due to transferring to the dialysis chair. R15 fell in her room. R15 was being transferred from her bed to the speciality chair via mechanical lift and fell off the lift. V20 stated he doesn't know what exactly happened. V20 stated the staff members who were taking care of R15 that day were V21 (Registered Nurse) and V23 (Certified Nursing Assistant). V20 stated during the time of the fall, V22 (Former…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 food in the main cooler was discarded after the used by date, and failed to ensure frozen meat products were dated inside the main freezer. This failure has the potential to affect 122 residents in the facility who are receiving oral diet. Findings include: On 6/04/24 at 9:01 AM, during the initial kitchen tour with V35 (Food Service Director), a container of grape jelly was found in the main cooler with the label that shows prepared on 3/29 and use by 4/31. A pack of frozen sausages and a pack of frozen meat with no labelled dates were found in the freezer. At 09:28 AM, V35 stated all foods stored in the coolers and freezer are supposed to be dated so kitchen staff knows what to take first. V35 stated staff follows the first in and first out policy. V35 stated prepared foods are supposed to be dated when it was prepared and the discard date. V35 stated foods should be discarded on the Use By date for food safety. The facility's policy titled; Food Storage with no date documents: All stock must be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide Enhanced Barrier Precautions while providing wound care to 1 (R137) resident; failed to post Enhanced Barrier Precautions (EBP) signage and have Personal Protective Equipment bin outside 1 (R93's room); and failed to provide enhanced barrier precautions to 1 (R143) resident with an indwelling medical device. This has the potential to affect all residents living in the facility. Findings Include: 1. R137's Face Sheet shows R137 is a [AGE] year-old, with Brief Interview for Mental Status (BIMS) score of 0 (05/11/24), which means R137 is cognitively impaired. Physician Order Sheet shows R137's diagnoses include Acute and Chronic Respiratory Failure with Hypoxia, Dependence on Renal Dialysis, Dependence on Respirator Ventilator Status, Encounter for Attention to Gastrostomy, and Chronic Pressure Wound. Signage posted on R137's door reads in part: Wear gloves and a gown for the following high-contact resident care activities: Wound…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility failed to maintain resident personal fund accounting for five residents (R4, R22, R55, R138, R218) out of a sample of six residents (R4, R22, R55, R74, R138, R218). Findings Include: On [DATE] at 11 AM during Resident Council interview, R4 stated she used to get money each month, but now gets no money. R121 stated, Everyone has brought the money issue up. I feel entitled to money that I don't get. I get nothing. I spoke to the office. They said 'Well, maybe later, maybe next year'. R121 stated many residents have raised the issue of money and allowances. It comes up all the time. There has been no response from administration. R74 stated he feels that he is owed money that he is not getting. R121 stated the subject of money and allowances is a very horrible subject for people here. R121 stated, At least half of the residents here will tell you that they know that they are entitled to money, but can't get it. They go every month and ask. Some residents get money, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review, the facility failed to follow the residents comprehensive care plans to ensure communication boards/books were readily accessible at all times for 4 (R30, R63, R49, R71) out of 4 residents who speak foreign language in a final sample of 34. Findings include: 1. R30's clinical records show a re-admission date of 12/30/21. R30's Minimum Data Set (MDS), dated [DATE], shows R30 has the ability to understand others and has the ability to express ideas and wants. R30's communication care plan, initiated on 8/04/20, shows R30 speaks Spanish and has communication book near bedside. One intervention reads, Help [R30] acquire and learn to use appropriate device(s). On 6/04/24 at 10:01 AM, R30 was resting in bed alert and verbally responsive. Surveyor attempted to interview R30, but R30 started talking in a different language. R30 stated, Only Spanish. Surveyor could not find any type of communication board or binder in R30's room to communicate with R30. 2. R63's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure pressure reducing air mattresses were set according to the resident's weight for 5 (R75, R93, R134, R318, R418) of 8 (R27, R101, R571) residents reviewed for pressure ulcers in a sample of 34. Finding Include: 1. R75 has diagnoses not limited to Hyperlipidemia, Urinary Incontinence, Depression, Anxiety Disorder, Functional Quadriplegia, Urinary Tract Infection, Morbid (Severe) Obesity Due to Excess Calories, Cerebral Palsy, Chronic Pain Syndrome, Rheumatoid Arthritis and Ataxic Gait. R75's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15, indicating intact cognitive response. R75's Care Plan documents: Resident is at risk for alteration in skin integrity related to: Limited Joint Mobility, Overweight/Obesity R75's Order Summary Report documents: Low Air Loss Mattress in use. Check for proper functioning and settings. every day shift Wound Care -Start Date- 04/26/24. R75's Preventive Interventions…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 secure their Central Supply Room to ensure it is inaccessible by residents and visitors. This failure has the potential to affect the 55 residents that are mobile about the facility. The facility also failed to ensure equipment that could cause a fire hazard was out of a resident's room for 1 (R78) out of a final sample of 34 residents reviewed for safety hazards. Findings Include: 1. On 6/04/24 at 10:36 AM, R78 was resting in bed alert and verbally responsive. Surveyor noted a black space heater by R78's bed that was turned on. R78 stated the facility provided the space heater to use. On 6/05/24 at 9:55 AM, Surveyor and V21 (Director of Environmental Services) entered R78's room and noted R78's space heater by R78's bed that was turned on. R78 stated the Maintenance Department provided the space heater because R78 is always cold. V21 stated space heaters are not allowed anywhere inside the building because they are fire hazards. V21 stated the residents are not supposed to have space heaters in their rooms.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 2. R133's admission Record documents in part medical diagnoses including but not limited to chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia. R133's Order Summary Report documents in part active orders to change oxygen tubing and humidifier every night shift every seven days and as needed (ordered 4/25/2024). On 6/04/2024 at 9:59 AM, R133 was lying in bed and receiving oxygen via nasal cannula. The nasal cannula was not dated or labeled. Facility's Oxygen & Respirator Equipment-Changing/Cleaning policy, last revised 1/7/19, documents the nasal cannula will be dated with the date the tubing was changed. 3. On 6/04/24 at 12:11 PM, R35 was lying in bed alert and verbally responsive. R35's nebulizer machine was turned on, but R35 was not using it. Nebulizer mask was sitting on top of the nebulizer machine, not inside a clear bag, and not labeled with a date when it was last changed. R35's clinical records show as admission date of 9/7/23 with listed diagnoses not limited to Chronic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their Storage of Medications policy and store medications in locked compartments for 2 [R69, R107] residents on 2 of 5 medication carts and 1 of 4 medication storage rooms; failed to label individual resident's insulin [NAME] with an open/expiration date for 2 [R157, R571] residents; failed to follow their policy to discard expired insulin for 1 [R34] resident; and failed to follow pharmaceutical storage instructions to refrigerate unopened insulin for 2[R112, R157 ]in 1 of 5 medication carts reviewed for medication storage, in a sample of 34. Findings include: 1. On [DATE] at 9:03AM, surveyor observed V20 [Licensed Practical Nurse] and surveyor inventoried the first-floor medication cart. The following were observed: *R34- Insulin Aspart solution 100 units/ml, expiration date of [DATE] written on the vail. [Physician order dated [DATE]. Give per slide scale with meals] *R112- A closed vail of Humalog insulin solution 100 units/ml.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 label and date food items in resident personal refrigerator; failed to monitor and document personal refrigerator temperatures daily to ensure temperature is maintained at or below 41 degrees F (Fahrenheit) for safe food storage; failed to discard unlabeled/undated food or foods whose date is outside facility food storage policy of three days; and failed to clean personal refrigerators regularly to maintain a safe and sanitary environment for food storage. This has the potential to effect 4 residents (R23, R97, R105, R164) out of 7 residents reviewed for personal food storage in a total sample of 34. Findings include: 1. R105's diagnoses includes but not limited to Cerebral Vascular Disease, Cerebral Aneurysm Non-Ruptured, Unspecified Protein Calorie Malnutrition, Abnormalities of Gait and Mobility, Glaucoma, Unspecified Cataract, Other Visual Disturbances, and Adult Failure to Thrive. R105's Order Summary Report, dated 06/05/24,…

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

Based on interview, and record review, the facility failed to follow a resident's (R53) preference for a shower schedule for one out of a total sample of 34 residents. Findings include: R53's Care Plan documents R53 has an Activities of Daily Living (ADL) self-care performance deficit related to limited mobility, generalized weakness and pain due to chronic pain, and rheumatoid arthritis (initiated 5/20/2019). Interventions initiated 5/20/2019 include to encourage R53 to participate to the fullest extent possible with each interact and praise all efforts at self-care. On 6/04/2024 at 10:15 AM, R53 was alert and oriented to person, place, and time. R53 wanted to change shower schedules to mornings. R53 stated R53 informed V29 (Assistant Social Services Director) about wanting to change the Friday evening shower to a morning shower months ago, but facility has not changed it. R53 showed surveyor text message from R53 to V29, dated 1/05/2024 11:11 AM. It documents: can they possibly change my shower from Friday night to Saturday mornings? I'm just curious, it would be so much better…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility failed to follow facility policy and standards of professional practice in documenting the code status of two residents (R31, R138); failed to educate one resident (R138) on Advanced Directives; and failed to engage the healthcare representative in the care of one resident (R138) out of 34 total residents in the sample. Findings: 1. On [DATE] at 11:08 AM, a POLST form (Provider Orders for Life-Sustaining Treatment) for R138, dated [DATE], stated, No CPR (Cardiopulomonary Resuscitation): Do not attempt resuscitation (DNAR) and Selective treatment: Primary goal is treating medical conditions with limited medical measures. Do not intubate or use invasive mechanical ventilation. May use non-invasive forms of positive airway pressure, including CPAP (Continuous Positive Airway Pressure) and BIPAP (Bi-level Positive Airway Pressure). May use IV fluids, antibiotics, vasopressors, and antiarrhythmics as indicated. Transfer to the hospital if indicated. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to refer a resident to the appropriate state designated authority for re-screening and Level II referral after admission extended beyond initial 30 days. This failure has the potential to effect one resident (R55) out of 2 residents reviewed for PASARR in a total sample of 34. Findings include: R55 admitted to the facility [DATE]. R55's diagnosis includes but not limited to Anxiety Disorder, Schizoaffective Disorder, and Borderline Personality Disorder. R55's Order Summary Report, dated [DATE], documents: Lithium Carbonate Capsule 300 mg give 1 capsule by mouth one time a day for antipsychotics/antimanic agents ordered date [DATE], Mirtazapine Tablet 15 mg give 1 tablet by mouth one time a day for antidepressants, Olanzapine Tablet 5 mg give 1 tablet by mouth one time a day for antipsychotics/antimanic agents related to Schizoaffective Disorder, Sertraline HCl Tablet 50 mg give 1 tablet by mouth one time a day for antidepressant, Trazodone HCl Tablet 50…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their policy and procedure and the comprehensive care plan to ensure incontinence care was provided for a dependent incontinent resident in a timely manner for 1 (R2) of 2 residents reviewed for ADL (Activities of Daily Living) care in a final sample of 34. Findings Include: R2's clinical records show R2 has diagnoses not limited to Hemiplegia Affecting Right Dominant Side, Right Hand Contracture, and Vascular Dementia. R2's Minimum Data Set, dated [DATE], shows R2 is moderately impaired with cognition and require substantial/maximal assistance from staff with toileting. R2's comprehensive care plan shows R2 is incontinent of bowel and bladder with one intervention that reads: Provide pericare [perineal care] after each incontinent episode. On 6/04/24 at 10:16 AM, R2's room was noted with a strong urine odor. R2's was lying in bed alert and able to verbalize needs. R2 was still wearing a night gown, and R2's incontinence pad 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 ensure a resident's bilateral splints were placed per the plan of care and update the care plan to reflect the resident preferences for 1 (R101) of 2 residents reviewed for positioning and limited range of motion in a sample of 34. Findings Include: R101 has diagnosis not limited to Quadriplegia, C5-C7 Incomplete, Quadriplegia, C1-C4 Incomplete, Moderate Protein-Calorie Malnutrition, Acute Embolism and Thrombosis of Unspecified Deep Veins of Unspecified Lower Extremity, Autonomic Dysreflexia, Epilepsy, Hypertensive Heart Disease, Depression, Anemia, Neuromuscular Dysfunction of Bladder, Insomnia, Gastro-Esophageal Reflux Disease, Post-Traumatic Stress Disorder, Personal History of Sudden Cardiac Arrest, and Peripheral Vascular Disease. R101 MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15, indicating intact cognitive response. R101's Order Summary Report documents: Apply wrist Splint to bilateral upper extremities. on during morning, off during ADL (Activities of Daily Living) care…

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

Based on observation, interview, and record review, the facility failed to prevent urinary drainage bag from touching the floor for one (R318) out of 1 resident reviewed for urinary catheter in a sample of 34. Findings Include: R318's diagnoses include Pressure Ulcer of Sacral Region Stage 4, Pneumonia, Type 2 Diabetes Mellitus with Hyperglycemia, Dilated Cardiomyopathy, Enterocolitis due to Clostridium Difficile Not Specified As Recurrent, Chronic Kidney Disease Stage 3B, Elevated [NAME] Blood Cell Count, Hypothyroidism, Peripheral Vascular Disease, Abnormalities of Gait Mobility, Unsteadiness on Feet, Unspecified Atrial Fibrillation, Hypertension, Embolism and Thrombosis of Other Specified Veins, Hyperlipidemia, Anemia, Slowness, And Poor Responsiveness. R318's care plan, dated 05/16/24, documents R318 has an indwelling catheter neurogenic bladder and interventions include to monitoring for signs and/or symptoms of urinary tract infection. R318's MDS (Minimum Data Set) from 05/15/24 BIMS (Brief Interview for Mental Status) score is 08 out of 15 indicating cognition is moderately…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. R108 has diagnosis not limited to Displaced Comminuted Fracture of Shaft of Right Femur, Traumatic Subdural Hemorrhage with Loss of Consciousness of 30 Minutes or Less, Type 2 Diabetes Mellitus with Hyperglycemia, Type 2 Diabetes Mellitus with Diabetic Nephropathy, Obesity, Anemia in Chronic Kidney Disease, Atherosclerotic Heart Disease of Native Coronary Artery, Hypertensive Heart and Chronic Kidney Disease with Stage 5 Chronic Kidney Disease, Dependence on Renal Dialysis, Epilepsy, Dysphagia, Abnormalities of Gait and Mobility, Lack of Coordination, Abnormal Posture, Cognitive Communication Deficit, and Elevated [NAME] Blood Cell Count. R108's Order Summary Report documents: Nepro one time a day 1 carton for supplementation. Dialysis (Renal) Consistent Carbohydrate diet Regular texture. R108's Care Plan documents: Resident is on therapeutic diet. Nepro 1 carton qd (every day). On 06/04/24 at 09:14 AM, surveyor and V20 [Licensed Practical Nurse] during medication administration, observed R108 medication preparation. V20 stated, I will sign out (R108's) nutritional supplement,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a physician's order and Dietary recommendation for feeding rate were followed for 1 (R418) out of 3 residents reviewed for enteral feedings in a final sample of 34. Findings Include: R418's clinical records show R418 was admitted on [DATE] and weighed 147.2 pounds. R418 has diagnoses not limited to Dysphagia and Dementia. R418's clinical admission form, dated 6/1/24 at 10:59 PM, shows R418 is comatose. R418's physician order shows R418 to receive enteral feeding of Nepro 1.8 at 70 ml/hr for 18 hours to infused 1260 ml total. This was ordered on 6/03/24. R418's Dietary Evaluation, dated 6/3/24 at 8:07 AM, shows R418 was assessed to be underweight and has pressure ulcers. V33 recommended for the enteral feeding to be increased at 70 ml/hr for 18 hours that will provide 33 kcal/kilogram. On 6/4/24 at 10:46 AM, R418 was sleeping in bed. R418 was receiving Nepro 1.8 enteral feeding at a rate of 45 ml (milliliters)/hour (hr). V13…

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

Based on observation, interview, and record review, the facility failed to follow resident's food allergy and food preferences. This failure affected 1 (R143) out of 3 residents reviewed for nutrition in a sample of 34. Findings include: R143's diagnosis included but not limited to End Stage Renal Disease, Dependence on Renal Dialysis, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus with Hyperglycemia, Acute on Chronic Systolic (Congestive) Heart Failure, Unspecified Glaucoma, Abnormalities Of Gait And Mobility, Abnormal Posture, Unsteadiness On Feet, Sensorineural Hearing Loss Bilateral, Anemia In Chronic Kidney Disease, Insomnia, and Constipation. R143's Order Summary Report dated 06/05/24 documents in part Allergies: Eggs. R143's nutrition care plan, dated 04/11/24, documents in part, allergy: eggs R143's MDS (Minimum Data Set) from 05/09/24 BIMS (Brief Interview for Mental Status) score is 15 out of 15, indicating intact cognition. R143's Dietary Profile, dated 04/12/24, by V5 (Diet Tech) documents R143 allergies: eggs. R143's Dietitian Evaluation, dated…

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

Based on interview and record review, the facility failed to ensure accurate medical records for one (R148) out of a total sample of 34 residents. Findings include: R148's admission Record documents in part medical diagnosis of adult failure to thrive. Dietary progress note, dated 3/21/2024 9:10 AM, documents, secondary to significant weight loss, writer recommends increasing House Supplement 1 carton to [three times a day] to promote additional [kilocalorie] and protein for weight maintenance or gain. R148's Order Summary Report documents an active order for House Supplement three times a day 1 carton for supplementation (ordered 3/21/2024). R148's Care Plan documents in part an intervention initiated on 3/22/2024 for house supplement one carton three times a day. On 6/04/2024 at 11:10 AM, R148 was alert and oriented to person and place. R148 stated R148 was hungry and R148 was asking about food. At 12:23 PM, R148 was eating lunch. Lunch tray had chili dog, green beans, sweet potato, banana pudding, apple juice, and 2% milk. Surveyor asked if facility provides nutritional shakes.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon observation, interview, and record review, the facility failed to ensure adequate staff were available to meet the needs for four of four dependent residents (R2, R3, R4, R5) in the sample. This failure has the potential to affect a total of 114 residents residing on 1st, 2nd and 4th floor. Findings include: 1. The (4/30/24) census includes 27 (1st floor) residents. On 4/30/24 at 1:17pm, surveyor inquired about the current (1st floor) staffing. V3 (CNA/Certified Nursing Assistant) stated, We got 2 CNAs and 1 Nurse. I have 14 residents. Sometimes we need 3 (CNAs). Surveyor inquired about the acuity of V3's assigned residents. V3 responded, I got 2 feeders and 6 incontinent residents, it's 7 if you count the urinal. Surveyor inquired if the (1st floor) staffing was adequate considering resident acuity. V3 replied, It's a lot, it's a lot of charting. On 4/30/24 at 1:30pm, surveyor inquired about the current (1st floor) staffing. V4 (CNA) stated, It's 2 CNAs and 1 Nurse on the floor. I'm assigned to 13…

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

Based on record review and interview, the facility failed to inventory personal belongings and failed to locate and/or replace a reported missing watch for one of four residents (R2) reviewed for misappropriation/exploitation. Findings include: R2's (11/10/23) concern form states resident is missing: (brand name) watch, bottle of Vitamin C, denture (and other personal belongings). Responsible Department: Nursing, Guest Relations, Social Service, Laundry, and Administrator. Corrective actions taken guest relations went through resident's belongings with resident where we (staff) found: bottle of vitamin C, denture (and other items). Staff is still looking for (brand name) watch. Was the complainant satisfied with the outcome and actions taken? Yes/No (neither is circled). Required staff signature(s) are excluded. On 5/2/24 at approximately 10:30am, surveyor requested inventory logs for R2, R3, R4 and R5. On 5/2/24 at 11:19am, V2 (Director of Nursing) stated I looked in (electronic medical records), I couldn't find any inventory logs. On 5/8/24 at 11:20am, surveyor inquired about…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (R5) was on the get up list and failed to provide ADL (Activities of Daily Living) care to two of three dependent residents (R3, R5) reviewed for ADL care. Findings include: 1. R3 is [AGE] years old with diagnoses which include quadriplegia. R3's (4/25/24) functional assessment affirms resident is dependent on staff for chair/bed to chair transfer. R3's (6/22/23) care plan states resident requires use of full body lift for transfer. Intervention: full body lift with 2-person assists for all transfers. R3's (4/25/24) BIMS (Brief Interview Mental Status) determined a score of 15 (cognition intact). On 4/30/24 at 1:42pm, R3 was observed lying in bed. R3 stated, It seems as if they're (staff) always in a rush to get things done. Today is a day I would usually get up, but today they're changing diapers so I couldn't get up. use the lift with 2 people to get me up. I get up 2 or 3 times a week since November, and affirmed he prefers to…

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

Based upon observation, interview, and record review, the facility failed to ensure nursing staff are aware of required LALM (Low Air Loss Mattress) settings; failed to ensure LALM settings are correct (re: weight, mode); failed to follow the LALM operational manual; failed to ensure staff timely report skin integrity impairments; and failed to ensure staff turn/reposition dependent residents as needed for two of four residents (R3, R4) reviewed for pressure ulcers. Findings include: 1. R3's diagnoses include quadriplegia. R3's care plan states (3/30/22) Potential for pressure ulcer development related to quadriplegia. Intervention: needs monitoring/assistance to turn/reposition every 2 hours or as needed. (4/11/24) Resident has pressure injury to right heel. R3's (10/12/23) POS (Physician Order Sheets) includes LALM for prevention of wounds. R3's (4/25/24) functional assessment affirms resident is dependent on staff for rolling left and right. R3's (4/25/24) BIMS (Brief Interview Mental Status) determined a score of 15 (cognition intact). R3's (1/2/24) initial wound assessment…

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

Based upon interview and record review, the facility failed to provide restorative services as directed for three of four residents (R2, R3, R5) reviewed. Findings include: 1. R2's diagnoses include osteomyelitis, low back pain, unsteadiness on feet, abnormalities of gait/mobility, lack of coordination, and weakness. R2's (7/21/23) POS (Physician Order Sheets) state discontinue skilled PT (Physical Therapy) services, recommending restorative program. R2's (1/5/24) restorative contracture observation states resident's range of motion is currently within functional limits and is at high risk for developing contractures. R2's (January 2024) documentation survey report affirms PROM (Passive Range of Motion) was documented for 15 minutes on 1/1, 1/4, 1/5, 1/7 and 1/8, however, the directions state resident will participate in PROM program for 15 minutes a day and for 6-7 days. On 5/7/24 at 2:26pm, V14 (Nurse Practitioner) stated, He (R2) had spastic movements likely due to refusing dialysis and hypercalcemia. 2. R3's diagnoses include quadriplegia. R3's (11/15/23) POS states discontinue…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policies and procedures to ensure residents received their medications according to the physician's order for 3 (R3, R4, R5) out of 3 residents reviewed for improper nursing care. Findings Include: 1. R3's clinical records show an initial admission date of 4/26/06, with listed diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Gastro-Esophageal Reflux Disease (GERD), and Stage 4 Chronic Kidney Disease. R3's Minimum Data Set (MDS), dated [DATE], shows R4 is cognitively intact. R3's POS (Physician Order Set) with active orders as of 1/28/24 shows the following physician orders: Omeprazole 20 MG by mouth for GERD, Advair Diskus inhaler for COPD, and Bacitracin-Polymixin ointment to both eyes. R3's MAR shows that these medications were not signed off as administered to R3 on 1/9/24 at 6:00 AM. On 1/28/24 at 10:18 AM, V12 (Licensed Practical Nurse) stated a couple of weeks ago, R3 complained R3 did not receive R3's 6:00 AM medications.…

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

Based on observation , interview, and record review, the facility failed to provide comfortable and safe temperature levels on 2 of 4 resident floors in resident occupied areas. (1st and 4th floors). This had an affect on the comfort of 8 residents (R1,R2,R3,R4,R5,R6,R7,R8) in a sample of 8 . Findings include: The following temperatures were taken with facility thermometer on 1/17/24 between 10 am and 12:30 pm with V2 (Maintenance Director) . R1's room- 59 degrees Fahrenheit R6's room- 65 degrees Fahrenheit 4th floor day room- 48.4 degrees Fahrenheit. This room was occupied by R1 , R3 , R4, and R5 during observation. No staff were present in room . 1st floor physical therapy room- 53 degrees Fahrenheit. No staff were present in the room at this time. R7's room- 63 degrees Fahrenheit R8's room- 64 degrees Fahrenheit R2's room- 53 degrees Fahrenheit On 1/17/24 at 10:00 am, R1 was observed with just a hospital gown on in front of TV on 4th floor day room. R1 stated, I'm cold. Its too cold in here. No staff were present in room. On 1/17/24 at 10:46 am, R2 stated, The heat is not working…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document review, the facility failed to ensure each resident receives adequate supervision to prevent accidents in 4 ( R1,R3,R4 and R5 ) of 8 residents included in the sample. Findings include : The following temperatures were taken with facility thermometer on 1/17/24 between 10 am and 12:30 pm, with V2 (Maintenance Director) . R1's room- 59 degrees Fahrenheit R6's room- 65 degrees Fahrenheit 4th floor day room- 48.4 degrees Fahrenheit. This room was occupied by R1 , R3 , R4, and R5 during observation. No staff were present in room . 1st floor physical therapy room- 53 degrees Fahrenheit. No staff were present in the room at this time. R7's room- 63 degrees Fahrenheit R8's room- 64 degrees Fahrenheit R2's room- 53 degrees Fahrenheit On 1/17/24 at 10 am, R1 was observed with just a hospital gown on in front of TV on 4th floor day room . R1 stated, I'm cold. Its too cold in here. No staff was present in the room. The room temperature was 48.4 degrees . Residents R3, R4, R5 and were also in the room and responded per interviews. No staff 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 provide needed care or services and failed to establish plan of care to ensure a midline catheter was removed or discontinued that was not in used from 10/5/23 to 12/7/23 for 1 (R2) resident, in a sample of 3 residents reviewed for improper nursing care. The findings include: R2's electronic heath record (EHR) documented admission date of 7/18/2023, with diagnoses not limited to Respiratory failure, Encounter for attention to tracheostomy, Dysphagia, Encounter for attention to gastrostomy, Cognitive social or emotional deficit following nontraumatic intracerebral hemorrhage, Other encephalopathy, Kidney disease stage 4 (severe), Chronic diastolic (congestive) heart failure, Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, Epilepsy, unspecified, not intractable, without status epilepticus, Unspecified abnormalities of gait and mobility, Unsteadiness on feet, Contracture of muscle multiple sites, Abnormal posture, Need for assistance with personal care,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 treatment or services by not ensuring a splint was applied to maintain range of motion (ROM) and to prevent further contractures to right and left ankle for 1 (R2) resident out of 3 residents reviewed for improper nursing care. The findings include: R2's electronic heath record (EHR) documented admission date of 7/18/2023, with diagnoses not limited to Respiratory failure, Encounter for attention to tracheostomy, Dysphagia, Encounter for attention to gastrostomy, Cognitive social or emotional deficit following nontraumatic intracerebral hemorrhage, Other encephalopathy, Kidney disease stage 4 (severe), Chronic diastolic (congestive) heart failure, Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, Epilepsy, unspecified, not intractable, without status epilepticus, Unspecified abnormalities of gait and mobility, Unsteadiness on feet, Contracture of muscle multiple sites, Abnormal…

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

Based on observation, interview, and record review, the facility failed to follow the policy on preventive maintenance and inspection of a resident's room, with baseboard that has screws that are unsafe for 1 out of 1 resident (R5) reviewed for physical environment safety. Findings include: On 1/2/2024 at 1:57 pm, R5's room on the wall near the head of the bed, the baseboard was detached from the wall, and had screws attached and pointing upwards. In the hallway, V59 (Maintenance Staff) was informed and went to inside R5's room. Upon seeing the baseboard, V59 stated he saw the baseboard earlier this morning, and was planning to get rid of it and just paint it. V59 stated he should have taken it immediately, because any person can step on the screw. As random rooms were checked, a single room was seen with detached baseboard without a screw. On 1/3/2024 at 3:15 pm, V27 (Maintenance Supervisor) stated baseboard with screws that may be stepped on needs to be removed immediately. Staff should inform maintenance about the baseboard if they observe. V27 stated it is his responsibility to…

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

Based on interview and record review, the facility failed to thoroughly investigate allegations of abuse for two of two residents (R1, R2) reviewed for abuse. Findings include: Facility's final incident report, date 10/24/2023 documents: On 10/17/2023 at approximately 3:30 PM, it was reported to the administrator that a CNA was rude to these residents (R1, R2) during care. (V4-Former Certified Nursing Assistant) alleged perpetrator declined comment. (R2) said (V4) told me to shut up. (R1) said when (V4) was providing care to me, she was not nice. Social Service Designee (V12-Director of Social Service) said (R2) and (R1) reported to me that the CNA was being discourteous and rude to them when she was providing them care. I reported it to the administrator. I did not witness the event. Based on the investigation, the CNA was suspended from the facility and then terminated from employment for discourteous behavior to residents. No other residents or staff interviews were documented in the incident report. On 11/7/2023 at 11:11 AM, 12:03 PM, and 2:16 PM, V3 (LPN-Licensed Practical…

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

Based on interview and record review, the facility failed to follow their policy to ensure diagnostic tests were performed, and to assure test results are reported to the physician so that prompt, appropriate action may be taken if indicated for the resident's care. This failure affected 1 (R1) of 3 residents reviewed for improper nursing care. The findings include: R1's health record documented admission date of 9/22/2023, with diagnoses not limited to Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Dysphagia oropharyngeal phase, Dysarthria and anarthria, Difficulty in walking, Unsteadiness on feet, Other lack of coordination, Weakness, Major depressive disorder, Insomnia, Pericardial effusion, Hypertensive heart disease without heart failure, Hypothyroidism, Hyperlipidemia, Anemia in other chronic diseases classified elsewhere, Vitamin d deficiency, History of falling, Tobacco use, and Adult failure to thrive. R1 was discharged to facility on 10/19/23. MDS (Minimum Data Set), dated 9/28/23, showed R1's cognition was moderately impaired,…

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

Based on observation, interview, and record review, the facility failed to ensure the Low Air Loss Mattress was set based on the resident' weight, and failed to ensure the Low Air Loss Mattress was set on appropriate mode. These failures affected 1 (R13) resident reviewed for pressure ulcer/injury prevention and treatment in the total sample of 16 residents. Findings include: R13's admission Record documented R13's diagnoses include but not limited to chronic respiratory failure, attention for tracheostomy, attention to gastrostomy, need for assistance with personal care, attention to ileostomy. R13's (Printout Date: 10/11/2023) Patient Risk Assessment documented, Braden Score: 14. (Moderate Risk) (At moderate risk for acquiring pressure wounds). Date Assessed: 10/09/2023. Preventive Interventions - Recommendations. Use pressure redistribution surface bed if bed or chair bound. R13's (07/17/2023) Minimum Data Set documented, Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 06., indicating R13's mental status as severely impaired. Section…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow policy for incontinence care by not checking and providing proper incontinence care at least every 2 hours. This failure applies to one (R1) of 3 residents reviewed for improper nursing care. The findings include: R1 admission date was on 11/5/2022 with diagnoses not limited to Acute respiratory failure with hypoxia, Encounter for attention to tracheostomy, Dysphagia oropharyngeal phase, Encounter for attention to gastrostomy, Type 2 diabetes mellitus, Chronic embolism and thrombosis of deep veins of bilateral upper extremities, Other symptoms and signs involving cognitive functions following other non-traumatic intracranial hemorrhage, Hypertensive heart disease with heart failure, Conjunctival hemorrhage left eye, Diastolic congestive heart failure, Hidradenitis suppurativa, Other psychoactive substance abuse, Cyst of kidney. On 8/8/23 At 12:12 pm R1 was observed lying in bed, alert and responsive, non-verbal but able to make…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to follow their policy and procedure to notify the physician for a resident who was having an acute change in condition. This failure affected 1 (R4) of 3 residents reviewed for improper nursing care. Findings Include: R4's clinical records indicate diagnoses not limited to paraplegia, chronic kidney disease stage 4, unspecified atrial fibrillation, and neuromuscular dysfunction of bladder. R4's Minimum Data Set (MDS) dated [DATE] shows R4 was cognitively intact. R4's progress notes dated 6/29/23 at 10:49 PM written by V4 (Licensed Practical Nurse) reads, The patient has blood in his foley catheter and was lethargic. Foley catheter was removed and vitals was taken, midline was ordered and put in with NS bolus 500. [Private] ambulance was called to pick him up to [Acute] hospital at 8:45pm but were not here at the close of shift. Endorsed to the next nurse. This note does not document if the physician was notified regarding R4's change in condition. R4'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 a.) ensure food items were properly labeled, dated, and stored, b.) clean walk-in refrigerator ceiling, c.) allow service ware equipment to air dry before using. These deficient practices have the potential to affect all 130 residents receiving food prepared in the facility's kitchen. Findings include: On 07/18/23 at 9:20 AM, during initial kitchen tour, V7 (Food Service Director) stated all food items should be labeled and dated with a delivery date, an open date, and an expiration date. On 07/18/23 at 9:28 AM, observed spots of gray and black fuzzy material covering the ceiling of the walk-in refrigerator extending from the refrigerator fans toward the door. V7 stated the material looked like dust and wiped V7's hand across the ceiling surface as the material rubbed onto V7's fingers. V7 stated the material should not be there because it could fall onto the food in the walk-in refrigerator especially the ready to eat items such as fruits and vegetables. On 07/18/23 at 9:30 AM, observed the following items in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow call light policy to ensure call light is within easy accessibility to the resident at the bedside. This failure affected 6 (R34, R86, R130, R148, R156, R161) residents reviewed for accommodation of needs in a total sample of 38 residents. The findings include: R34's health record documented admission date of 10/31/18 with diagnoses not limited to Unspecified dementia without behavioral disturbance, Type 2 diabetes mellitus, Chronic kidney disease, Chronic obstructive pulmonary disease, Anxiety disorder, Gastro-esophageal reflux disease, Iron deficiency anemia, Major depressive disorder, Generalized atherosclerosis, Essential hypertension, Hyperlipidemia, Encounter for attention of ileostomy. R86's health record documented admission date of 10/23/20 with diagnoses not limited to Respiratory failure, Encounter for attention to tracheostomy, Dysphagia oropharyngeal phase, Morbid obesity, Type 2 diabetes mellitus, Chronic obstructive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 user manual operating instructions to maintain appropriate setting of low air loss mattress for 9 (R12, R30, R64, R70, R105, R123, R137, R173, R223) residents. This failure affected 9 (R12, R30, R64, R70, R105, R123, R137, R173, R223) residents reviewed for pressure ulcer in a total sample of 38. The findings include: R12's health record documented admission date of 1/12/21 with diagnoses not limited to Acute respiratory failure, Encounter for attention to tracheostomy, Dependence on respirator / ventilator status, Encounter for attention to gastrostomy, Dysphagia oropharyngeal phase, Type 2 diabetes mellitus, Epilepsy, Schizoaffective disorder, Glaucoma, Encephalopathy, Hypertensive heart disease without heart failure, Anemia in chronic diseases, Vitamin D deficiency. R30's health record documented admission date of 9/16/22 with diagnoses not limited to Acute and chronic respiratory failure with hypoxia and hypercapnia, Encounter…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a.) to provide G (Gastrostomy) -Tube care and G-tube dressing changes as ordered for four (R116, R118, R120, R173) residents, b.) follow the gastrostomy tube feeding policy to follow physician's order for the type of formula administered for three residents (R12, R118, R372) residents, c.) label G-tube feeding formula containers for two (R118, R159) residents and d.) follow the enteral feeding administration physician orders for one (R116) resident. This failure has the potential to affect seven (R12, R116, R118, R120, R159, R173, R372) out of eleven (R123 R151, R160, R226) residents reviewed for tube feeding in a total sample of 38. Findings Include: R116 has diagnosis not limited to Pressure Ulcer of Sacral Region, Stage 4, Gastrostomy, Diarrhea, Lack of Coordination, Gastro-Esophageal Reflux Disease, Obstructive and Reflux Uropathy, Anemia and Retention of Urine. R116 MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is…

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

Based on observation, interview, and record review the facility failed to follow facility policy and procedure for labeling, dating, and changing oxygen and respiratory care equipment for four residents (R25, R73, R92, R100) and failed to develop care plan for R92's oxygen use in a total sample of 38 residents reviewed. Findings Include: On 07/18/23 at 11:35 AM, observed R100 lying in bed with nebulizer mask sitting on top of bed side table with tubing attached. Nebulizer mask and tubing was not in a bag or container and no bag or container was seen near or around R100's bed or table. The Nebulizer mask and tubing was not observed to be dated. Also, observed oxygen concentrator next to R100's bed with a humidifier bottle filled with water in it dated 09/19/22. On 07/18/23 at 11:46 AM, V5 (Licensed Practical Nurse) observed the nebulizer mask and tubing on R100's bed side table and stated R100 received a nebulizer treatment early in the morning. V5 stated the nebulizer mask and tubing should be placed in a plastic bag to prevent any contamination. V5 stated the tubing for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to (a) double-lock controlled substances, (b) discard expired and loose medications, (c) ensure medications remained in their original packaging, (d) ensure only authorized staff had access to the keys for the medication storage areas, (e) label insulins with open dates, and (f) ensure a medication cart was clean to prevent contamination for 2 of 2 medication rooms and 3 of 4 medication carts reviewed for medication storage and labeling. Findings include: On [DATE] at 11:24 AM, checked the second floor's medication room with V4 (Nurse). The medication fridge in the room did not have a lock. A list of controlled substances in the fridge were: R66's Lorazepam, R85's Dronabinol, R31's Hydromorphone and Lorazepam, and R172's Lorazepam. Surveyor and V4 left the medication room at 11:33 AM, V4 did not lock the fridge. Reviewed the second floor's medication cart with V4. The second large drawer in the medication cart had R35's Amiodarone 100 MG…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 practice proper hand hygiene during medication administration for R140 and during wound care treatment for R2 and failed to follow their policy and procedure to ensure proper personal protective equipment (PPE) were used during high contact resident care activities for 4 (R2, R116, R118, R120, R151) of 8 residents reviewed for infection control and prevention in a total sample of 38. Findings Include: On 7/18/23 at 11:39 AM, V10 (Treatment Nurse) was about to perform wound care treatment for R2. R2's door has a signage indicating R2 is on an Enhanced Barrier Precaution. The following was observed during R2's wound care observation: V10 was not wearing gown and with her gloves on entered R2's room to start wound care treatment. While wearing gloves, V10 removed the old wound dressing on R2's left foot and cleaned the wound. V10 removed V10's gloves, applied new gloves, and applied a clean wound dressing to R2's left foot. V10 removed V10's gloves, went to get skin treatment solution from the treatment cart,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reviews, the facility failed to provide eligible residents and/or resident representatives education regarding the benefits and potential side effects of all available pneumococcal and influenza vaccinations and assess eligibility and offer pneumococcal vaccination to five (R2, R67, R70, R85, R322) of six residents reviewed for pneumococcal and influenza vaccinations. Findings Include: 1. R2's electronic medical record (EMR) revealed R2 was admitted to the facility on [DATE] and is [AGE] years of age with diagnoses that included but were not limited to: paraplegia, chronic obstructive pulmonary disease, obstructive sleep apnea, and heart failure. R2's current physician orders with active orders as of 7/19/23 revealed Pneumococcal Vaccine Unless Contraindicated. Record in Immunization Tab. R2's EMR revealed no documentation indicating the facility assessed R2's eligibility to receive the pneumococcal vaccination and/or that R2 was provided education related to the pneumococcal and…

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

Based on interview and record reviews, the facility failed to provide education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine to 4 (R67, R70, R85, R322) of 6 residents reviewed for COVID-19 vaccinations in a total sanple of 38 residents. Findings Include: On 7/18/23 at 3:30 PM, V3 (Infection Preventionist) stated that all COVID-19 vaccines information for the residents, their consents, and education should be in the resident's electronic health record. V3 stated, I don't have anything in paper. V3 stated that V3 has an immunization log that V3 just initiated since V3 started in February of this year as the Infection Preventionist, but V3 does not have any of the residents' COVID-19 vaccination consents and education provided. On 7/19/23 at 9:34 AM, R67, R70, R85, and R322's electronic health records (EHR) were reviewed. No documentations were found regarding these residents' COVID-19 vaccination status, no consents found, and there were no documentations found if education regarding the benefits and risks and potential side effects…

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

Based on observation, interview, and record review the facility failed to ensure a resident's dignity was maintained by not providing privacy during incontinence care for one resident (R151) reviewed for dignity in a total sample of 38 residents. Findings include: On 07/18/23 at 2:35 PM, during the facility tour V18 (Certified Nursing Assistant) was observed from the doorway providing incontinence care for R151 with R151's door open and no privacy curtain used. On 07/18/23 at 2:40 PM, V18 stated that when V18 does continence care the privacy curtain and the door should be closed. V18 stated R151 does not have a privacy curtain in R151's room and I should have closed the door to provide privacy for the resident. On 07/18/23 at 3:07 PM, observed R151's privacy curtain in place and pushed into the corner. On 07/19/23 at 4:38 PM, V2 (Director of Nursing) stated incontinence care should be provided with the door closed or the curtain pulled around the resident. V2 state the purpose of these actions is to maintain the resident's privacy and dignity. On 07/20/23 at 2:35 PM, R151 stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess the resident's bilateral hand mittens restraint at least quarterly to determine if restraint is still appropriate and warranted, failed to follow physician's order to release restraint at least every two hours (for meals) for 1 (R85) of 1 resident reviewed for restraints in a total sample of 38 residents. Findings Include: On 7/18/23 at 10:28 AM, R85 was quietly sleeping in bed noted with bilateral hands mittens. At 10:31 AM, V4 (Licensed Practical Nurse) stated that R85 was applied with the mittens for both hands because R85 has behaviors of pulling R85's dialysis catheter. At 12:44 PM, V12 (Certified Nursing Assistant) was feeding R85 in R85's room. R85 was calm and cooperative. R85 was noted still wearing mittens to both hands. On 7/19/23 at 12:01 PM, V24 (MDS/Care Plan Coordinator) stated that the restraint assessment is done by the restorative nurse. V24 stated that restraint assessment should be done quarterly, annually, 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 observations, interviews, and record reviews, the facility failed to follow standards of practice for medication administration for 1 (R136) out of 4 residents reviewed during medication pass. Findings include: On 07/19/2023 at 8:33 AM, V21 (Nurse) stated [V21] will prepare medications for R136. V21 placed R136's blister packs on top of the medication cart. V21 also pulled multiple house stock medications and placed them on top of the mediation cart. V21 stated they were all R136's morning medications. V21 prepared the medications in a medication cup. One of the house stock medications included a Multivital tablet (Multiple Vitamins-Minerals). On 07/19/2023 at 8:40 AM, V21 asked if R136 was in pain. R136 stated pain was ten out of ten (severe pain) to lower back and right hip. R136 requested Tramadol for the pain. V21 returned to the medication cart in the hallway. V21 pulled R136's Tramadol 50mg (milligram) blister pack from the narcotic bin. V21 popped one tablet into the medicine cup. R136 took the medication at 8:53 AM. Reviewed R136's July Medication Administration…

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

Based on observations, interviews, and record reviews, the facility failed to ensure an accurate controlled substance record for a resident (R85) in 1 out of 4 medication carts reviewed. Findings include: On 07/18/2023 at 11:24 AM, reviewed second floor's controlled medication count with V4 (Nurse). R85 had one capsule of Dronabinol 2.5 MG (milligram) left. R85's corresponding Controlled Drug Receipt/Record/Disposition Form documents in part there should be zero left with the last administration from 07/13/2023 at 9:00 AM. V4 stated the medication should be empty already and was not sure how the miscount happened. R85's Controlled Drug Receipt/Record/Disposition Form for Dronabinol documents in part: Every dose must be accounted for and requires charting on the Medication Administration Record.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to follow policy for psychotropic medication: 1. Failed to obtain consent of psychotropic medication use for 1 (R161) resident. 2. Failed to ensure that care plan is develop with suitable goals and approaches related to use of psychotropic drug for 1 (R161) resident. 3. Failed to ensure that residents who use psychotropic medication shall receive gradual dose reductions for 2 (R64 and R161) residents. 4. Failed to ensure that as needed (PRN) antianxiety medication shall not be use used beyond 14 days for 1 (R161) resident. These failures affected 2 (R64 and R161) of 2 residents reviewed for unnecessary medications in a sample of 38. The findings include: R64's health record documented admission date of 3/13/23 with diagnoses not limited to Acute respiratory failure with hypoxia, Encounter for attention to tracheostomy, Dependence on respirator / ventilator status, Encounter for attention to gastrostomy, Dysphagia oropharyngeal phase, Contracture of…

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

Based on observations, interviews, and record reviews, the facility failed to ensure that their medication error rate was less than five percent for 2 (R43, R136) of 4 residents observed during medication pass. Three errors during 27 opportunities for errors during medication pass. This resulted in a medication error rate of 11.11 percent. Findings include: On 07/19/2023 at 8:33 AM, V21 (Nurse) stated [V21] will prepare medications for R136. V21 placed R136's blister packs on top of the medication cart. V21 also pulled multiple house stock medications and placed them on top of the mediation cart. V21 stated they were all R136's morning medications. V21 prepared the medications in a medication cup. One of the house stock medications included a Multivital tablet (Multiple Vitamins-Minerals). Surveyor asked if V21 placed one in the medication cup. V21 stated no and proceeded to put one in the medication cup. On 07/19/2023 at 8:40 AM, V21 asked if R136 was in pain. R136 stated pain was ten out of ten (severe pain) to lower back and right hip. R136 requested Tramadol for the pain. V21…

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

Based on observations, interviews, and record reviews, the facility failed to ensure that a resident (R136) was free of any significant medication error for 1 of 4 residents reviewed during medication pass. Findings include: On 07/19/2023 at 8:33 AM, V21 (Nurse) stated [V21] will prepare medications for R136. At 8:40 AM, V21 asked if R136 was in pain. R136 stated pain was ten out of ten (severe pain) to lower back and right hip. R136 requested Tramadol for the pain. V21 returned to the medication cart in the hallway. V21 pulled R136's Tramadol 50mg (milligram) blister pack from the narcotic bin. V21 popped one tablet into the medicine cup. V21 documented in the 'Controlled Drug Receipt/Record/Disposition Form' for R136's Tramadol that [V21] removed one tablet on 07/19/2023 at 8:52 AM. R136 took the medication at 8:53 AM. Reviewed R136's July Medication Administration Record (MAR) at 12:15 PM. It did not document in part an order for Tramadol. Reviewed R136's active physician orders at 12:17 PM. R136 did not have an order for Tramadol. Reviewed R136's discontinued physician orders 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 follow the pureed menu spreadsheets for three residents (R40, R48, R166) out of 17 residents receiving a pureed diet consistency in a total sample of 38 residents. Findings Include: On 07/19/23 between 9:07-9:45 AM, observed V19 (Head Cook) prepare pureed food items for lunch. V19 did not prepare pureed dinner roll. On 07/19/23 at 9:47 AM, V7 (Food Service Director) stated the pureed diets get the same food items as the residents on regular consistency diets except they receive those items in pureed form. On 07/19/23 at 11:19 AM, during lunch tray line service observed pureed diets being served pureed pork, pureed Cheesy Hashbrown Casserole, pureed baked beans, and pureed lemon pie. There was no pureed dinner roll prepared or served. Mechanical soft and regular diet consistency diets received pulled pork, Cheese Hashbrown Casserole, baked beans, dinner roll with margarine and lemon pie. On 07/19/23 at 11:47 AM and 12:01 PM, observed R40, R48, and R166 receive for lunch pureed pork, pureed Cheesy Hashbrown…

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

Based on observations, interviews, and record reviews, the facility failed to ensure accurate medical records for 1 (R136) resident out of a total sample of 38 residents. Findings include: On 07/19/23 at 8:33 AM, V21 (Nurse) stated [V21] will prepare to administer morning medications to R136. While preparing the medications, V21 stated [V21] was not sure if R136 was due to get any Novolog injection because V21 did not know R136's blood sugar. V21 stated the night nurse did not document it from the morning and it did not cross over to the electronic Medication Administration Record (MAR). V21 stated [V21] will ask R136 because R136 is alert and oriented and usually writes down medical information. At 08:40 AM, V21 asked R136 if the night nurse took R136's blood sugar in the morning. R136 stated [R136] thinks so but was not too sure due to R136 being groggy from just waking up. At around 9:00 AM, V21 stated [V21] was complete with medication administration. V21 stated could not administer Novolog because [V21] was not sure what R136's blood sugar was and V21 already ate breakfast. 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.