Foster Health & Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that each Minimum Data Set (MDS) assessment was certified as complete by a registered nurse (RN) for 7 (R6, R17, R23, R27, R30, R34, R38) out of 26 residents' assessments reviewed. The findings include: 1. R6 Quarterly MDS dated [DATE] showed completion date on 9/19/24 and signed by V17 (LPN/Licensed Practical Nurse). 2. R17 Quarterly MDS dated [DATE] showed completion date on 9/19/24 and signed by V17 (LPN). 3. R23 Quarterly MDS dated [DATE] showed completion date on 9/30/24 and signed by V17 (LPN). 4. R27 Quarterly MDS dated [DATE] showed completion date on 9/19/24 and signed by V17 (LPN). 5. R30 Quarterly MDS dated [DATE] showed completion date on 9/19/24 and signed by V17 (LPN). 6. R34 Quarterly MDS dated [DATE] showed completion date on 9/30/24 and signed by V17 (LPN). 7. R38 Quarterly MDS dated [DATE] showed completion date on 9/30/24 and signed by V17 (LPN). On 10/10/24 at 10:14am V17 (MDS/Care Plan coordinator, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policy to develop a comprehensive, person-centered care plan for each resident that includes measurable objectives and timetables to meet the resident's needs. This failure can potentially affect 5 (R1, R8, R27, R28, R39) of 5 residents reviewed for comprehensive care plan in the sample of 14. The findings include: R1's admission record showed initial admission date on 1/24/2022 with diagnoses not limited to Chronic obstructive pulmonary disease, Essential (primary) hypertension, Alzheimer's disease, Epilepsy, Gastro-esophageal reflux disease, Overactive bladder, Body mass index 19.9 or less, adult, Anemia in other chronic diseases classified elsewhere, Ventral hernia without obstruction or gangrene, Paranoid schizophrenia, Other specified arthritis multiple sites. MDS (Minimum Data Set) dated 8/10/24 showed R1's cognition was severely impaired. R1's POS (physician order sheet) dated 10/10/24 showed FULL CODE. No care plan found in R1's…

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

Based on observations, interviews, and record reviews, the facility failed to follow their policy and procedure to ensure emergency supplies in the crash cart were securely locked at all times when not in used. This failure has the potential to affect 19 ambulatory residents residing in the facility (R12, R32, R33, R6, R22, R17, R19, R4, R35, R9, R39, R30, R37, R27, R28, R31, R13, R20, R10). Findings Include: On 10/08/24 at 9:47AM, observed emergency crash cart parked in the hallway easily accessible to anyone walking by the front lobby and the nurses' station. The emergency crash cart was not locked and some of the items found inside were intravenous (IV) line kits, multiple sizes needles, oxygen tubing, and four 1 Liter IV fluid bags. On 10/08/24 at 10:28 AM, V4 (Registered Nurse) and V5 (Registered Nurse) stated the night shift nurse checks the emergency crash cart. V4 stated that the cart is supposed to be locked. V4 and V5 stated they do not know how long the cart has been unlocked. Both denied unlocking it. Both stated any resident can potentially access what's inside if it'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 perform monthly medication regimen review (MRR) for 4 (R8, R28, R35, and R39) residents reviewed for psychotropics in a sample of 14. Findings Include: R35 was admitted to the facility on [DATE] with diagnoses not limited to Bipolar disorder, Major depressive disorder, Metabolic Encephalopathy, Long term use (current) of anticoagulants, and Anoxic brain damage. R35's MDS shows R35 is moderately cognitively impaired. On 10/10/24 at 10:04 AM, V3 (Director of Nursing/DON) stated that Medication Regimen Review (MRR) should be done monthly by the pharmacist, but V3 does not have any MRR done for R35 or any residents in this facility. V3 stated that it is important for the pharmacist to perform monthly MRR to evaluate the effectiveness, adverse reaction, and the safety of the medication to R35 or any residents. Surveyor requested for the MRR policy from V1, and V3 multiple times on 10/9/24 and 10/10/24 but the facility could not provide the…

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

Based on observation, interview, and record review, the facility failed to properly date opened multi-dose inhalers for 4 residents (R2, R23, R28, R31) and to dispose a house stock medication after the expiration date from one out of one cart reviewed for medication storage and labeling. Findings include: On 10/08/24 at 9:28 AM, the facility's medication cart was inspected with V5 (Registered Nurse). There was a bottle of house stock Famotidine 10 mg (milligrams) medication with expiration date of 9/24 labeled on the bottle. There were also R23's Breo inhaler without the opened date on the label; R28's Incruse inhaler without the opened date on the label and shows to discard 6 weeks after opening; R31's Advair inhaler without the opened date on the label and shows to discard 30 days after opening; and R2's Fluticasone Furoate inhaler without the opened date on the label and shows to discard 42 days after opening. On 10/09/24 at 11:59 PM, V3 (Director of Nursing) stated all inhalers should be labeled with the date it was opened, and discard based on the label. V3 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.

Based on observations, interviews, and record reviews, the facility failed to provide therapeutic diets as prescribed by the physician for 5 (R1, R5, R10, R15, R25) out of 5 residents reviewed in a total sample of 14. Findings Include: On 10/08/24 at 12:02 PM, R10's physician orders document a diet order of NCS (No Concentrated Sweets) diet, Pureed texture, Thin consistency (ordered on 4/28/24). R10's last Dietary Notes dated on 6/28/24 at 9:14 AM written by V18 (Former Dietitian) revealed R10's Diet: NCS, pureed texture, thin liquids. R10's face sheet documented in part medical diagnoses of Unspecified Dementia and Neurocognitive Disorder with Lewy Bodies. On 10/08/24 at 1:12 PM R10 was eating lunch in the dining room. R10 received chunks of chicken and pineapples, rice (no sauce), broccoli, canned mixed fruits, thin juice and water. R10's meal ticket shows STD-mechsoft. On 10/09/24 at 1:43 PM, interviewed V13 (Dietary Manager) and stated, I get the diet order from the nurses they give me a pink slip with the diet order, name, room number and the type of diet. The type of diet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one (R12) out of four residents reviewed in a total sample of 14 for call lights. Findings include: On 10/08/24 at 12:05 PM, R12 was observed lying in bed in R12's room. Call light was not visible. Call light was not within R12's reach. Observed yellow sign above R12's bed titled -Fall Precaution Checklist- which listed interventions including but not limited to call light at reach. R12 said, where is the call light? I don't see it. Observed pull string call light on R12's roommate side of the privacy curtain. Observed two strings attached with one long string which reached to R12's roommates bed and the other string was very short. This short string was not long enough to reach R12's side of the room. On 10/08/24 at 12:15 PM, V12 (Certified Nursing Assistant) stated the call lights should be within reach of the resident(s). V12 observed R12 lying in bed. Observed V12 trying to locate R12's call light. V12 went on the other side of R12's privacy curtain and observed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accurately document advanced directives code status for 1 resident (R12) out of a four residents reviewed in a total sample of 14 residents for advance directives. Findings include: R12 was admitted to the facility on [DATE]. R12 has diagnosis which includes but not limited to Chronic Obstructive Pulmonary Disease, Hyperlipidemia, Alcohol Abuse, Gastro-Esophageal Reflux Disease, Unspecified Psychosis, Major Depressive Disorder, Conversional Disorder with Seizures or Convulsions. R12's MDS (Minimum Data Set) from [DATE] BIMS (Brief Interview for Mental Status) score is 06 out of 15 indicating severely impaired cognition On [DATE] at 3:00 PM, surveyor reviewed R12's IDPH (Illinois Department of Public Health) Uniform Practitioner Order For Life-Sustaining Treatment (POLST) Form signed by V10 (R12's Surrogate), dated [DATE] and documents in part Do Not Attempt Resuscitation/DNR and Selective Treatment: Primary goal of treating medical conditions with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policies and procedures for the Preadmission Screening and Annual Resident Review (PASARR) process for 2 (R2, R8) residents reviewed for a Level 2 PASARR Screening for Mental Disability (MD) and Intellectual Disability (ID) in a total sample of 14. Findings Include: 1. R2's Minimum Data Set (MDS) dated [DATE] shows R2 is cognitively impaired. According to the admission Record, R2 is [AGE] years old, R2 was admitted to the facility on [DATE] with a diagnosis of bipolar disorder. There is no documentation to show that R2 was referred to the appropriate state-designated authority for Level 2 PASARR evaluation and determination. On 10/09/24 at 3:10 PM, the surveyor asked V2 (Assistant Administrator) for a Level 2 PASARR screening for R2. V2 provided the surveyor with a Level 1 PASARR screening dated 4/20/15 for R2. V2 was unable to provide a Level 2 PASARR screening for R2. V2 stated that V2 has no Level 2 PASARR for R2. 2. R8's admission…

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

Based on observations, interviews, and record reviews, the facility failed to maintain a medication error rate of less than 5% for 3 (R6, R22, R27) of 11 residents reviewed for medication administration. There was a total of 28 opportunities with 4 errors observed, which resulted in a medication error rate of 14.29%. Findings Include: On 10/08/24 at 11:31 AM, Surveyor observed V4 (Registered Nurse) checked R6's blood glucose. R6's blood glucose reading was 218. V4 stated, based on R6's insulin sliding scale order, R6 will be getting 1 unit of Fiasp insulin injection. At 11:59 AM, V4 was about to prepare R6's insulin injection, but V4 was unable to find R6's Fiasp insulin medication in the medication cart or the convenience box. V4 stated R6 will not be receiving the ordered insulin injection since it's not available. R6's physician orders show R6 to receive 1 unit of Fiasp Injection (Insulin Aspart) for blood glucose reading of 181-220 (ordered on 8/08/24). R6's progress notes written by V4 dated 10/08/24 at 12:52 PM documents in part, Fiasp Injection Solution 100…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two residents (R6, R27) were free of any significant medication errors out of eleven residents reviewed for medication administration. Findings include: On 10/08/24 at 11:31 AM, Surveyor observed V4 (Registered Nurse) checking R6's blood glucose. R6's blood glucose reading was 218. V4 stated, based on R6's insulin sliding scale order, R6 will be getting 1 unit of Fiasp insulin injection. At 11:59 AM, V4 was about to prepare R6's insulin injection, but V4 was unable to find R6's Fiasp insulin medication in the medication cart or the convenience box. V4 stated R6 will not be receiving the ordered insulin injection since it's not available and V4 will follow up with pharmacy. R6's face sheet documents in part a medical diagnosis of Type 2 Diabetes Mellitus Without Complications. R6's physician orders show R6 to receive 1 unit of Fiasp Injection (Insulin Aspart) for blood glucose reading of 181-220 (ordered on 8/08/24). R6's care plan documents in part, R6 has Diabetes Mellitus with one…

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

Based on observation, interview, and record review the facility failed to provide and follow menus and recipes to ensure menu variety for three (R2, R5, R15) out of three residents reviewed for pureed menus in a final sample of 14. Findings Include: On 10/08/24 at 10:20 AM, V14 (AM Cook) stated there are no recipes in the kitchen to follow for pureed diet consistencies. V13 (Dietary Manager) stated the kitchen does not follow any production or spreadsheets and that the cooks know how to prepare and what to serve different diets because they have been working here a long time. On 10/08/24 at 12:55 PM, observed regular diets receiving Hawaiian Chicken with pineapple, white rice, broccoli, and fruit cocktail. Residents on pureed diets appeared to receive pureed white meat, mashed potatoes, pureed green vegetable and pureed canned fruit. On 10/09/24 at 11:15 AM, observed V14 prepare pureed food for lunch. V14 stated residents on a regular and mechanical soft diet are receiving spaghetti with meatballs in tomato sauce, mixed vegetables, cornbread, and chocolate water cookies. V14 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.

Based on observation, interview, and record review the facility failed to label and date food items in resident personal refrigerators and failed to discard unlabeled/undated spoiled foods in resident personal refrigerators. This has the potential to effect one resident (R29) out of four residents reviewed for personal food storage in a total sample of 14. Findings include: On 10/08/24 at 11:25 AM, observed personal refrigerator in R29's room next to R29's bed. R29 gave surveyor permission to look inside R29's refrigerator. R29 said, I cannot reach inside the refrigerator, so I don't know what's in there. R29 stated R29 likes to buy himself food from outside the facility. Observed the following items inside R29's refrigerator: 1.) Opened one-pound plastic container of Turkey Bologna 50% full, not labeled or dated with an open or use by date. The turkey bologna had a sour, off-putting smell to it. 2.) Opened plastic container of hotdogs with two hot dogs left in the package. The plastic wrapping was covered in black to dark gray spots and the two hotdogs were discolored with a green…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect one (R1) resident's right to be free from physical abuse out of three sampled residents. This failure resulted in R2 becomming physically aggressive to R1. Findings Include: R1's clinical records show R1 was admitted in the facility on 5/16/23 with diagnoses including but not limited to Unspecified Dementia Without Behavioral Disturbance and Chronic Obstructive Pulmonary Disease. R1's Minimum Data Set (MDS) dated [DATE] shows R1 has moderate cognitive impairment. R1's progress notes dated 7/22/24 written by V5 (Registered Nurse/RN) documents in part: On 7/22/24 at about 1:00 PM R1 was allegedly hit on the head and milk was thrown in the face by [R2]. The incident occurred in the dining room and was witnessed by staff. Staff intervened, both residents were separated and initiated one-on-one monitoring. A head-to-toe assessment was completed, and no visible injuries were noted. Medical Doctor and family member made aware. R2's clinical records…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 investigate and report an allegation of abuse for one of three residents (R1) reviewed for abuse. Findings include: R1's face sheet documents R1 is a [AGE] year-old admitted to the facility on [DATE] with diagnoses including but not limited to: Arthritis, Multiple Sites; Type 2 Diabetes Mellitus, Acute Kidney Failure, Auditory Hallucinations, Visual Hallucinations, and Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. R1's MDS (Minimum Data Set of 5/30/2024) documents a BIMS (Brief Interview for Mental Status) of 6 or severe cognitive impairment. 8/29/2024 at 10:26 AM, V5 (Clinical Manager) said during a visit to see ophthalmologist on 8/16/2024, R1 alleged multiple staff (unknown) members punched and slapped resident. R1's escort (V4), who was present in the exam room, left exam room, went outside and called facility's DON (V2-Director of Nursing). V5 said upon V4'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 maintain dignity for three (R1, R2, R3) residents reviewed for dignity bag on indwelling catheter. Findings include: 1.R1 is a [AGE] year-old individual, with diagnoses as listed in the current face sheet to include but not limited to: : unspecified severe protein-calorie malnutrition, cachexia, adult failure to thrive, abnormal weight loss. R1's Minimum Data Set (MDS) section C (Cognitive Status), dated 12/31/2023, documents R1 has a BIMS (Brief Interview for Mental Status) score of 15/15, indicating R1 has intact cognation. R1's MDS(Minimum Data Set) section H (bladder and Bowel), dated 10/03/2023, documents have an Indwelling catheter. R1's POS (Physician Order Set) documents: 10/18/2023 -Foley catheters change 18th of every month on day shift. starting on the 18th and ending on the 18th every month for Prophylaxis. Change Foley bag on the 11th and 25th of every month. On 2/4/2024 at 9:47am, R1 was observed with the urinary bag hang 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 store biologicals in a safe manner, and failed to label opened multi dose vials. These failures have the potential to affect all 35 residents using this medication refrigerator. Findings include: On 11/07/2023 at 11:19 AM, during observation of medication storage room and refrigerator with V10 (Registered Nurse/RN) the following were observed: The medication refrigerator temperature was -18 degrees Fahrenheit (F) and was confirmed by V10. Located in this refrigerator were: R11's unopened Lantus 100/ml with icicles formed on the vial. R287's Novolog 100/ml (back Label states store at 36-46 degrees F, Avoid Freezing). 2 House stock vials of Tuberculin PPD (purified protein derivative). One Tuberculin vial was unopened, and the second Tuberculin vial was opened with no label of when it was opened. The tuberculin label states store at 36-46 degrees Fahrenheit and do not freeze. V10 stated she will discard all these medications and order new ones. V10 also stated the temperature of the refrigerator should 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 perform proper hand hygiene; failed to appropriately don and doff personal protective equipment (PPE) for a contact and droplet isolation room; failed to post a contact and droplet precautions isolation sign outside a positive COVID-19 resident's isolation room; failed to provide a resident with a tracheostomy covering to prevent transmission of COVID-19 droplets when a COVID-19 positive resident exits out of the isolation room; failed to ensure a contaminated item removed from a contact and droplet isolation room does not contaminate surfaces outside of the isolation room; failed to ensure a nasopharyngeal COVID-19 test sample was not stored in the facility's medication refrigerator; and failed to follow the facility's COVID-19 policy and procedures. These failures affected R1, R9, R10, R15 and R29 and has the potential to affect all 35 residents in the facility. Findings include: 1. On 11/6/23, V3 (Assistant Administrator) provided this…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a thermometer for four resident (R10, R30, R33, and R37) refrigerators; failed to properly log refrigerator temperatures for four residents (R10, R30, R33, and R37); failed to discard expired food from a resident (R10) refrigerator; and failed to clean a resident (R33) refrigerator. These failures affected R10, R30, R33 and R37 in the sample of 24 residents. Findings include: 1. R33 has diagnoses which includes, but is not limited to: unspecified severe protein-calorie malnutrition, cachexia, anemia, specified diabetes mellitus with diabetic neuropathy, type 2 diabetes mellitus with diabetic neuropathy, orthostatic hypotension, weakness, adult failure to thrive, abnormal weight loss, enterocolitis due to clostridium difficile, fatty liver, and retention of urine. R33's Brief Interview for Mental Status (BIMS), dated 09/30/23, documents R33 has a BIMS score of 15, which indicates R33 is cognitively intact. On 11/06/23 at 11:31 AM,…

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

Based on observation, interview, and record review, the facility failed to ensure one resident's (R2) indwelling catheter drainage bag was covered. This failure affected one resident (R2) reviewed for dignity in the sample of 24 residents. Findings Include: R2's admission record include diagnoses of hypertension, diabetes, cerebral infarction, urinary calculous, leiomyoma of uterus, and hydronephrosis with renal and urethral calculous obstruction. R2's (7/27/23) Resident Assessment Instrument documented, Section C. is blank. BIMS (Brief Interview for Mental Status) section C is blank. Section H. Bladder and Bowel: H0100. Appliances check all that apply: A. Indwelling catheter. R2's (Active as of 11/8/23) Order Summary Report documented, 16 French (indwelling) and insert 10 ml (Milliliter) balloon. R2's (6/6/23) Care plan documents, Problem: R2 has (indwelling) Catheter. On 11/6/23 at 10:55 AM, R2's indwelling catheter drainage bag was hanging from the bed frame, not covered in a privacy bag. On 11/8/23 at 11:30 AM, V2, DON (Director of Nursing), stated, The (indwelling) catheter…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident's call light was accessible within reach to call for staff assistance, which affected two (R1 and R10) residents in the sample of 24 reviewed for accommodation of needs. Findings include: 1) On 11/6/23 at 10:51 AM, R1 was observed in bed, turned to right side, with the red call light string not within R1's reach, being wedged in the bed frame under the side rail where it connects with the bed frame. On 11/7/23 at 11:00 AM, R1's red call light string remained in the same position as observed on 11/6/23, with it wedged in between the bed frame and the right bed side rail, and was not within R1's reach. R1's admission Record documents diagnoses of chronic obstructive pulmonary disease, hypertension, epilepsy, Alzheimer's disease, schizophrenia, arthritis, ventral hernia, and osteoarthritis. R1's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview of Mental Status (BIMS) score of 5, which indicates that R1 has…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain a doctor's order and document the code status in one resident's (R17) electronic medical record. This failure affected one resident (R17) reviewed for Advanced Directives in a sample of 24 residents. Findings include: R17's admission record includes a diagnoses of but not limited to cerebral palsy, acute respiratory failure, dysphagia, and encephalopathy. R17's ([DATE]) Resident Assessment Instrument documented Section C. is blank. BIMS (Brief Interview for Mental Status) section C is blank. R17's Physician Order Sheet (POS) active orders, dated [DATE], indicate no order obtained for an Advanced Directive. R17's face sheet printed on [DATE] at 12:26 PM indicates no code status in the Advance Directives section. On [DATE] at 11:30 AM, V2, DON (Director of Nursing), stated, There should be an order from the doctor for an Advanced Directive. The nurses get the orders for an Advanced Directive. V2 stated the code status should be in the electronic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that a resident's low air loss (LAL) mattress was not layered with multiple linen layers, which affected one resident (R9) in the sample of 24 residents reviewed for pressure ulcers. Findings include: On 11/6/23 at 12:11 PM, R9 was in bed on a LAL (low air loss) mattress, after being provided care and repositioning in bed by V5 (Certified Nursing Assistant, CNA), V6 (CNA) and V8 (Registered Nurse, RN). R9's sacral wound dressing observed intact, with date marked 11/6/23. This surveyor observed the following layers of linens under R9's body on the LAL mattress: bath blanket, incontinence pad and then a quadruple folded bath blanket (6 linen layers). R9 observed positioned in a supine position on the 6 linen layers on R9's LAL mattress. Surveyor asked R9 if surveyor could observe wound care on 11/7/2023, and R9 refused surveyors request. R9's admission Record documents, diagnoses of severe sepsis with paraplegia, pressure ulcer of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure an extra tracheostomy (trach) tube was stored at a resident's bedside, which affected one (R15) resident in the sample of 24 residents reviewed for tracheostomy status. Findings include: On 11/6/23 at 1:19 PM, R15 was in R15's room, with R15's trach tube secured in placed with trach ties (foam ties with self fasteners) around R15's neck. R15 showed this surveyor R15's type of trach tube, which is a cuffless trach tube. No extra trach tube is observed stored in R15's room, on the bedside table, drawers, or in R15's bags. This surveyor asked R15 is there was an extra trach tube in R15's room, and R15 pointed to the trach tube cleaning kit, which is not an extra trach tube. On 11/8/23 at 9:25 AM, V2 (Director of Nursing, DON) stated an extra trach should be available and close to R15's room for safety to secure R15's airway if R15's trach tube comes out of the trachea stoma and is not able to be reinserted. This surveyor informed V2…

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

Based on observation, interview, and record review, the facility failed to complete grievance forms to document and explain in detail the nature of resident concerns from August 2022 utill July 2023, for residents who reside in the facility. This failure has the potential to affect all 37 residents who resident at the facility. Findings Include: On 06/29/2023 at 9:19 am,V1 (Administrator) was asked for the resident concern/grievance binder. V1 presented the facility grievance binder with the last resident concern documented in August 2022. On 06/29/2023 at 9:57 am, V1 (Administrator) stated, The grievance binder has resident concerns from August of 2022. There are no documented resident concerns after August of 2022. I stopped writing the resident concerns down because they were not legitimate concerns. I listen to the resident concerns and if it's not a legitimate concern, then I don't write them down. I address the resident concerns, but if they are not important, then I won't write them down in the concern binder. If I wrote down every single concern that these residents have…

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

Based on observation, interview, and record review, facility failed to have the services of a full time Director of Nursing. This failure has the potential to affect all 37 residents residing in the facility. Findings include: On 06/29/2023 at 1:00 pm, V1 (Administrator) stated, There is supposed to be one nurse per shift with 4 certified nursing assistants from 7:00 am to 3:00 pm, 3 certified nursing assistants from 3:00 pm to 11:00 pm, and 1 certified nursing assistant from 11:00 pm to 7:00 am. There was no nurse on 06/05/2023 from 5:00 pm till 11:00 pm. There was no Director of Nursing during this time either. The Director of Nursing is part time. V2 (Director of Nursing) works Tuesday, Thursday and Saturday from noon till 10:00 pm. On 06/29/2023 at 3:14 pm, V2 (Director of Nursing) stated, Currently, I am working part time. I only work Tuesday, Thursday and Saturday from noon to 8:00 pm. Today is the first day that I started working at this facility. I am unsure what happens when a nurse calls in. Facility's Staffing Policy (05/25/23) documents in part: It is the policy of this…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policy to administer medications in accordance with the written order of the physician. This failure resulted in all residents in the facility (R1-R37) not receiving medications as ordered by the physician on 6/5/23 and 6/6/23. Findings Include: 1.R1's Face Sheet, dated 6/30/23, documents R1 is a [AGE] year-old with diagnoses including but not limited to: fibromyalgia, low back pain, anxiety disorder, spinal stenosis, cervical region, pain, unspecified, morbid (severe) obesity due to excess calories, major depressive disorder, recurrent, unspecified, hyperlipidemia, unspecified, type 2 diabetes mellitus without complications, repeated falls, and dysphagia, oropharyngeal phase. R1's Minimum Data Set (MDS) section C (dated 06/14/2023) scores R1 as 15, indicating R1 is cognitively intact. R1's Medication Administration Audit Report documents: Pramipexole Dihydrochloride Tablet 0.5mg 06/05/2023 17:00- not administered. Furosemide Tablet 20 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to perform wound care treatment as ordered by physician on 06/05/2023 and 06/06/2023 for 2 out of 2 residents (R1 and R6) reviewed for wound care. Findings Include: 1. R1's Face Sheet, dated 6/30/23, documents R1 is a [AGE] year-old with diagnoses including but not limited to: fibromyalgia, low back pain, anxiety disorder, spinal stenosis, cervical region, pain, unspecified, morbid (severe) obesity due to excess calories, major depressive disorder, recurrent, unspecified, hyperlipidemia, unspecified, type 2 diabetes mellitus without complications, repeated falls, and dysphagia, oropharyngeal phase. Minimum Data Set (MDS) section C (dated 06/14/2023) scores R1 as 15, indicating R1 is cognitively intact. R1's Wound Treatment Order (June 2023) documents: Cleanse wound with normal saline daily and apply silver collagen first, then apply calcium alginate. Keep dressing intact ABD pad and kerlix daily. R1's Wound Treatment Record (month of June 2023) indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete the annual Minimum Data Set (MDS) assessments using the CMS-specified Resident Assessment Instrument (RAI) process within the regulatory timeframes for 35 (R6, R9, R27, R183, R21, R22; R17; R24; R23; R1; R5; R30; R28; R86; R11; R31; R20; R87; R3; R26; R16; R29; R19; R14; R25; R8; R82; R4; R7; R83; R2; R32; R84; R182; R10) of 35 residents reviewed for resident comprehensive assessment. Findings include: On [DATE] at 9:30 AM, V17 (Minimum Data Set Coordinator - Licensed Practical Nurse) stated, I am working part time 3 times per week. I've been working in the facility for 2 years. V17 stated the facility is following Resident Assessment Instrument (RAI) manual as policy in completing Minimum Data Set (MDS) assessment. V17 stated the Director of Nursing (DON) is a Registered Nurse (RN) and is signing the MDS assessment completion. Remote electronic record review was done with V17 for R9's MDS assessment and V17 stated Assessment Reference Date…

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

Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident to meet professional standards of quality care for all 36 (R6, R9, R85, R27, R183, R21, R22, R17, R24, R23, R1, R5, R30, R28, R86, R11, R31, R20, R87, R3, R26, R16, R29, R19, R14, R25, R8, R82, R4, R7, R83, R2, R32, R84, R182, R10) residents. Findings include: On 12/14/22 at 11:15 AM, V2 (Director of Nursing) stated she started working in the facility August, 2022. V2 stated, I think the nurse on the floor is the one doing the baseline care plan. V2 was unable to find baseline care plan in electronic health record. At 11:23 AM, V13 (Licensed Practical Nurse/LPN) stated she is a fulltime nurse, and has been working in the facility for 3 years. V13 stated, I have been doing admission and I am only doing the nursing assessment; I have not heard about base line care plan. V13 further stated, I never did base line care plan. On 12/15/22 at 9:30 AM, V17 (Minimum Data Set…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 stored in the freezer was stored in a sanitary manner. This failure has the potential to affect 35 residents who are on an oral diet. Findings include: On 12/13/2022 at 9:35 AM, Observed with V3 (Dietary manager), raw fish fillets in the freezer stored in a plastic bag knotted on top. Next to the fish fillet were two ready to eat cheesecakes. V3 stated, I don't know who put these raw fish fillets in this freezer. These fish fillets are supposed to be in the other freezer with the other raw meats. V3 stated storing raw foods with cooked or ready to eat foods should not be stored together because of close contamination, which can cause residents to get sick. On 12/14/2022 at 11:14a AM, V12 (Dietitian) said all raw meats including raw fish need to be stored in the raw meet freezer on the lower shelf of the freezer, and never on the same shelf with ready to eat food, to prevent cross contamination with ready to eat foods. V12 said, It is an unacceptable practice to sore raw food near ready to eat…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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) screen visitors and staff upon entering the facility and inform visitors of appropriate infection prevention and control actions to take while in the facility; (b) failed to review their Infection Prevention and Control Program (IPCP) at least annually; and (c) failed to ensure appropriate infection procedures were followed for one residents (R2). These failures have the potential to affect all 36 residents residing in the facility reviewed for infection prevention and control and infection surveillance for COVID-19. Findings include: 1. On 12/13/22 at 9:12 AM, surveyors entered the facility. V8 (Receptionist) did not perform COVID-19 screening at the front desk. V8 did not inquire with the survey team to regarding signs and symptoms of COVID-19, or discuss appropriate infection prevention and control measures to take while in the facility. Survey team did not see any signage posted at the facility entrance alerting visitors when they should not enter the facility such as symptoms of illness, under…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 designate at least one qualified Infection Preventionist (IP) who is responsible for the facility's Infection Prevention and Control Program (IPCP) that has completed the specialized training in infection prevention and control. This failure has the potential to affect all 36 residents residing in the facility. Findings include: Per facility's Resident Census and Condition Form, dated 12/13/22, facility has a census of 36 residents. On 12/13/22 at 10:17 AM, V2 (Director of Nursing), stated, Been a DON here since August 2022. We don't have an Infection Control Nurse. I'm just helping out with some things in regard to infection control. Surveyor requested to see a copy of V2's certification with infection prevention and control. V2 stated, I don't have the certification because I'm not the infection control nurse. Facility's policy titled, Infection Control Program and Procedure, dated 12/17/2019, has no information regarding Infection Preventionist. Surveyor requested copies of the facility's policies on orientation 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 (a) failed to develop policies and procedures of COVID-19 immunizations for the residents; (b) failed to provide education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine to 4 (R8, R10, R30, R183) of 8 residents that refused the COVID-19 vaccine; and (c) failed to document the dates and each dose of COVID-19 vaccine administered to the residents. These failures affect all 36 residents residing in the facility. Findings include: On 12/13/22 at 10:17 AM, 1:38 PM and 1:54 PM, and on 12/14/22 at 9:36 AM and 12:11 PM, Surveyor made multiple requests from V2 (Director of Nursing), V1 (Administrator), and V3 (Assistant Administrator) to provide a copy of the facility's policy on residents' COVID-19 Immunization, but facility was unable to provide. On 12/14/22 at 9:41 AM, surveyor received a residents' vaccination log with no header. V1 (Administrator) stated it's the facility's COVID-19 vaccination log for all their residents. This log has no documentation of the dates and each dose of…

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

Based on observation, interview, and record review, the facility failed to provide non-disposable cutlery and dishware including cups, bowls, and plates at all meals. These failures affected 4 (R3, R5, R23, R31) of 6 residents reviewed for homelike, de-institutionalized environment in the sample of 12 residents. Findings include: On 12/13/22 at 12:34 PM, CNA (Certified Nursing Assistants) was distributing lunch trays and beverages to residents. R3, R5, R23, and R31 received meals in disposable plates, bowls, cups, and silverware. On 12/13/22 at 12:44 PM, R31 was eating lunch from disposable dishware with a plastic fork. R31 stated, They serve on these kinds of plates all the time and always give us plastic silverware. On 12/13/22 at 12:50 PM, R3 stated, They used to give us regular knives, forks, spoon and plate ware, however, now it is (disposable dishes) all the time. I'd like to see my food on a regular plate because the food doesn't look good on these kinds of plates. On 12/13/22 at 11:52 PM, R5 stated, Yes, they serve us all of our food on (dispoable dishes). If I was home, I…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete the quarterly Minimum Data Set (MDS) assessments using the CMS-specified Resident Assessment Instrument (RAI) process within the regulatory timeframes for 21 residents (R6, R27, R21, R17; R24; R1; R5; R28; R86; R11; R31; R20; R87; R26; R16; R19; R14; R7; R2; R32; R84) of 32 residents reviewed for resident assessment. Findings include: On [DATE] at 9:30 AM, Telephone interview was conducted with V17 (Minimum Data Set Coordinator - Licensed Practical Nurse). V17 stated, I am working part time 3 times per week. I've been working in the facility for 2 years. V17 stated the facility is following Resident Assessment Instrument (RAI) manual as policy in completing Minimum Data Set (MDS) assessment. V17 stated the Director of Nursing (DON) is a Registered Nurse (RN), and is signing the MDS assessment completion. Remote electronic record review was completed with V17 for R9's MDS assessment, and V17 stated Assessment Reference Date (ARD) was [DATE],…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide restorative treatment services to prevent the potential for decrease in range of motion for 4 residents (R2, R5, R20, R23) out of 5 residents reviewed for range of motion in a total sample size of 12. Finds include: 1. R23 has diagnoses not limited to Spastic Diplegic Cerebral Palsy. R23's MDS (Minimum Data Set), signed on [DATE], documented a BIMS (Brief Interview for Mental Status) score of 15, indicating intact cognitive response and functional status (section G) functional limitation in range of motion to upper and lower extremity impairment on both sides and extensive assistance with bed mobility, dressing, toileting, personal hygiene and total dependence with transfers. R23's care plan documents, in part, R22 is at risk for contracture development due to impaired mobility, generalized weakness and Cerebral Palsy and interventions include to encourage range of motion activities. R23 Tasks include provide restorative active…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 follow policy on Influenza and Pneumococcal Vaccine for 4 (R25, R10, R83, R183) out of 6 residents who did not receive influenza and/or pneumococcal vaccination, and documentation as to person, time and date of education was provided prior refusal. These failures affect 4 residents (R25, R10, R83, R183) reviewed for vaccine(s). Findings include: On 12/14/22 at 10:31 AM, the electronic health records (EHR) were reviewed for the following residents: 1. R25 is [AGE] years old with diagnosis not limited to COVID-19, and was admitted on [DATE]. R25's EHR (Electronic Health Record) shows pneumococcal vaccine received on 5/26/22, but there was no influenza immunization record found, and there was no documentation as to the person, time, and date R25 was given education as to the benefits and risks of receiving influenza vaccine. R25's physician order sheet (POS) does not have order for an Influenza vaccination. 2. R10 is [AGE] years old with diagnosis not…

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

Based on observation, interview, and record review, the facility failed to ensure call lights were within reach for 1 (R5) out of 6 residents reviewed in a total sample of 12 for call lights. Findings include: R5 was admitted to the facility 4/30/19, with diagnoses which included but not limited to: Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side, Osteoarthritis, Unsteadiness on Feet, Chronic Embolism and Thrombosis of Deep Veins of Unspecified Lower Extremity, Generalized Muscle Weakness, History of Falling, Pain in Lower Leg. R5's MDS (Minimum Data Set) from 7/26/22 documented BIMS (Brief Interview for Mental Status) score is 15, indicating intact cognition, and section G (Functional Status) documents in part R5 requires extensive assistance with 2+ persons physical assist with bed mobility and transfer. R5 does not have a fall risk care plan. R5's nursing care plan for impaired mobility documents, in part, impaired mobility is related to generalized weakness, history of cerebrovascular accident with right side weakness, osteoarthritis, 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, interviews and records review, the facility failed to follow their medication administration policy for one resident (R183) reviewed for safe medication administration, in a sample of 12 residents reviewed. Findings include: R183 is a [AGE] year-old individual admitted to the facility on [DATE]. R183's MDS (Minimum Data Set) section C, dated 11/04/2022, documents R183's BIMS (Brief Interview for Mental Status (BIMS) as 15/15. R183's medical diagnoses are not listed in R183's Electronic Health Medical records. R184's section G, Activities of Daily Living (ADL) Assistance, dated 12/13/22,, document R183 as needing extensive assistance with ADL care. On 12/13/2022 at 11:06 AM, R183 was observed laying in bed watching TV. R183 said R183 has not been taking medication Depakote Oral Tablet Delayed Release 125 MG (Divalproex Sodium). R183 reached for R183's black hat, and pulled a tissue out and unwrapped it. R183 showed surveyor seven orange pills wrapped in a tissue, placed inside a black hat.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement adequate fall prevention precautions during transfer for one resident (R182) of 12 residents reviewed for falls. Findings include: R182 is a [AGE] year-old individual admitted to the facility on [DATE]. R182's medical diagnosis includes but not limited to: Chronic Obstructive Pulmonary Disease, unspecified, Acute Hematogenous Osteomyelitis, unspecified site, Cellulitis of right lower limb, Osteoarthritis, acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure, Lymphedema, not elsewhere classified. R182's MDS (Minimum Data Set), section C -Cognitive Patterns, documents a Brief Interview for Mental Status (BIMS), dated 09/16/2022, as 15/15. R182's MDS Section G - Functional Status, dated 12/14/2022, documents R182 needs extensive assistance in bed mobility, transfer, walking in room, dressing, toileting. R182's Moving from seated to standing position assessment, dated [DATE], documents R182 is not…

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

Based on observation, interview, and record review, the facility failed to date and prevent nasal cannula from touching the floor for 1 (R20) out of 1 resident reviewed for oxygen usage in a sample of 12. Findings include: R20 has diagnoses not limited to: Chronic Obstructive Pulmonary Disease, Sleep Apnea, Acute Respiratory Failure with Hypoxia, Heart Failure, Morbid Obesity, Weakness, Lack of Coordination, and Reduced Mobility. R20 ' s MDS (Minimum Data Set), signed on 11/13/22, documented a BIMS (Brief Interview for Mental Status) score of 15, indicating intact cognitive response, and section O documents in part R2 is receiving oxygen. R20 ' s physician order sheet documents in part oxygen at 2 liters via nasal cannula as needed for shortness of breath, dated 07/07/20, and change oxygen tube once a week (Friday) and as needed, dated 11/26/20. R20 ' s care plan, dated 05/10/21, documents, in part, R20 has altered respiratory status/difficulty breathing related to acute respiration failure with hypoxia. On 12/13/22 at 11:37 AM, R20's nasal canula oxygen tubing was lying the floor,…

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

Based on observation, interview, and record review, the facility failed to ensure a medication error rate was less than 5% for 3 of 4 residents (R183, R86, R27) in the sample reviewed. There were 35 opportunities and 10 errors, resulting in a 28.57% medication error rate. Findings include: 1. Record review of R183's order summary, dated 12/15/22, reads in part: Lactulose Oral Packet 10 GM (Lactulose) Give 10 mg by mouth two times a day; Symbicort Inhalation Aerosol 160-4.5 MCG/ACT 1 application inhale orally every 12 hours changed to as needed on 12/14/22; Vitamin D2 Oral Tablet (Ergocalciferol) Give 50000 unit by mouth one time a day for supplement On 12/13/22 at 9:47 AM, medication administration observation was conducted with V6 (Licensed Practical Nurse). V6 prepared R183's medication: Lactulose Oral Packet 10 mg; Vitamin D2 Oral Tablet 50000 unit; Symbicort Inhalation Aerosol 160-4.5 MCG/ACT 1 application inhale were not available and were not given to R183. V6 stated that Lactulose and Symbicort inhaler were already ordered in the pharmacy, and were not delivered yet. V6…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 1 (R27) of 4 residents observed for medication administration was free of significant medications errors. R27 is a [AGE] year old male admitted on [DATE] with medical diagnoses that include and are not limited to low back pain, unspeficied; spinal stenosis, cervical region; fibromyalgia. R27's order summary report, dated December 15, 2022, reads in part: Bactrim DS Oral Tablet 800-160 MG Give 1 tablet by mouth two times a day; Morphine Sulfate ER Tablet Extended Release 15 MG Give 1 tablet by mouth every 12 hours; Lyrica Capsule 100 MG Give 1 capsule by mouth two times a day; Eliquis Tablet 5 MG Give 1 tablet by mouth two times a day. R27's care plan, initiated on 4/17/2022, reads in part: The resident has a deep vein thrombosis (DVT) r/t disease process. Care plan interventions read in part: Give medications as ordered. Monitor/document for side effects and effectiveness. On 12/13/2022 at 12:32 PM, V6 (Licensed Practical Nurse)…

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

Based on interview and record review, the facility failed to follow their policy and procedure to ensure antibiotic use is monitored and to determine if antibiotics are ordered accordingly based on appropriate diagnosis or based on corresponding assessment tool for 2 (R20, R27) of 2 residents reviewed for antibiotic stewardship. Findings include: On 12/13/22 at 10:17 AM, 1:38 PM and 1:54 PM, and on 12/14/22 at 9:36 AM and 12:11 PM, Surveyor made multiple requests from V2 (Director of Nursing), V1 (Administrator), and V3 (Assistant Administrator) to provide a copy of the facility's September, October, November, and December infection and antibiotic log and tracking that includes assessment tools used to assess residents to start and monitor antibiotic therapy, and a copy of the facility's Antibiotic Stewardship Program, but none were provided. On 12/13/22 at 2:45 PM, R20 and R27's electronic health records were reviewed. R20's physician order sheet (POS) reads in part, BACTRIM DS Give 1 tablet by mouth in the morning every Mon, Wed, Fri for Prophylaxis Take 1 Tablet By Mouth Every…

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