Landmark at 95th Rehabilitation and Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to provide sufficient staffing to ensure ADL (Activities of Daily Living) needs are met in a timely manner for two residents (R4, R8) and medications are being administered as ordered by the physician. The facility's short staffing has the potential to affect all residents residing on the first floor of the facility.Findings include:On 01/25/26 at 10:07 AM, via telephone interview V3 (Staffing Coordinator/Central Supply) stated she does the staffing schedule for all the nurses including RD/LPN and CNAs. V3 stated the nurses do 12 hours shifts 7AM-7PM and 7PM-7AM and the CNAs do 7-3, 3-11 and 7-11 shifts. There are three floors in the building and the second and third floors usually have a higher acuity level than the first floor, so those floors are staffed with more CNAs. V3 stated the first floor is staffed with one nurse depending on the what the census is and V3 will sometimes go up to two nurses. V3 stated when there are 32 residents or more on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that call lights were answered in a timely manner for one (R1) out of three residents reviewed for accommodation of needs.Findings Include:R1's face sheet listed diagnoses, but not limited to, orthostatic hypotension, end staged renal disease, and polyosteoarthritis. R1's Minimum Data Set (MDS) assessment dated [DATE] shows R1 is cognitively intact with BIMS (Brief Interview for Mental Status) score of 15.On 1/25/26 at 9:57 AM, R1 was sitting up in bed alert and oriented to person, place, and time. Able to verbalize needs with no difficulty. R1 stated that his call light was on for more than two hours on 1/21/26 around 4:20 PM to get his urinal emptied and get water to drink. R1 said nobody answered his call light until 6:45 PM. R1 said he called the reception four times to send someone, and nobody came. R1 said that the facility is always short on staff.On 1/25/26 at 1:09 PM, R4 was sitting on the side of her bed alert and oriented to person,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medications were administered as scheduled per physician orders for two (R1, R4) out of three residents reviewed for medication administration.Findings Include:On 1/25/26 at 9:57 AM, R1 was sitting up in bed alert and oriented to person, place, and time. Able to verbalize needs with no difficulty. R1 stated that he did not receive his scheduled morning medications at 6:00 AM today and received it at 8:00 AM instead. R1 also stated that on 1/21/26, he did not receive his scheduled Eliquis, Multivitamin, and Midodrine.1/25/26 at 2:14 PM, a phone interview was conducted with V18 (Registered Nurse) and stated he was R1's nurse on 1/21/26 night shift until 1/22/26 and leaves at 7:30 AM. V18 denied giving R1's Midodrine late on 1/21/26. V18 said that there could be other factors that medications might not be administered either the medication is not available, or it is not ordered.On 1/25/26 at 3:01 PM, a phone interview was conducted with…

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

Based on observation, interview and record review, the facility failed to ensure (a) signage for Enhanced Barrier Precautions (EBP) was posted and (b) staff / visitor wear proper personal protective equipment (PPE) for resident on contact precautions. These failures affected two (R1 and R3) out of four residents reviewed for Infection Control. The findings include:R1's admission record face sheet showed admit date on 12/6/25 with diagnoses not limited to Chronic Obstructive Pulmonary Disease, End Stage Renal Disease, Acquired absence of kidney, Dependence on renal dialysis, Hypertensive heart and chronic kidney disease, Anemia, Chronic diastolic congestive heart failure. MDS (Minimum Data Set) dated 12/13/25 showed R1's cognition was intact.On 1/25/26 at 9:58AM Observed R1 resting in bed, alert and oriented x 3, verbally responsive. Stated he has been residing in the facility since 12/6/25. Stated his Immune system is low due to diagnosis of ESRD (End Stage Renal Disease) and he is on hemodialysis. R1 showed dialysis access site on right chest area with dressing in place. 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 observations, interviews and review of records the facility failed to protect the right of every resident to privacy and dignity by failing to place privacy shower curtain in the shower room for 31 residents using shower room and failed to ensure resident maintain their privacy during shower for 1 out of 4 residents (R3) reviewed for resident rights. These failures have the potential to affect all 31 residents using shower room without privacy curtain and affected 1 resident (R3) who felt exposed during shower.Findings include: R3 is [AGE] years old, with initial admission date of 04/16/2021. R3's primary medical diagnosis acute kidney failure. R3's BIMS score dated 07/22/2025 was 14 which indicates that R3 cognition is intact and without impairment. On 08/14/2025 at 08:33 AM, R3 was seen in her room alert, able to express her thoughts clearly and within topic. R3 stated that it happened on Sunday, 07/27/2025 was in the shower. I hear someone at the door. I yelled out, Hello! Hello! The next thing 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 observations, interviews and review or records the facility failed to maintain complete and accurate resident record for 1 out of 4 residents (R3). These failures affected 1 resident (R3) who felt exposed during shower without documentation as to interventions done to address concerns. Findings include: R3 is [AGE] years old, with initial admission date of 04/16/2021. R3's primary medical diagnosis acute kidney failure. R3's BIMS score dated 07/22/2025 was 14 which indicates that R3 cognition is intact and without impairment. On 08/14/2025 at 08:33 AM, R3 was seen in her room alert, able to express her thoughts clearly and within topic. R3 stated that it happened on Sunday, 07/27/2025 in the shower. I hear someone at the door. I yelled out, Hello! Hello! The next thing I know I saw a man. I don't know who it was. I told the nurse on duty. She was a female nurse. I reported the incident to her. R3 stated that shower room does not have any privacy curtain. Anyone taking shower is exposed when door was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility has failed to ensure that all residents are aware of the grievance process and that resident's concerns are addressed in a timely manner. This failure has affected two residents (R132 and R143) and has the potential to affect 146 additional residents that reside in the facility. Findings include:R132 is [AGE] year-old with diagnosis including but not limited to: type 2 diabetes mellitus, hypertension, functional quadriplegia, spinal stenosis and limitations of activities due to mobility.R132 has a BIMS (Brief Interview of Mental Status) score of 15, which indicates cognitively intact.R143 is [AGE] year-old with diagnosis including but not limited to: paraplegia, other reduced mobility, type 2 diabetes without complications, pressure ulcer of right buttock stage 4 and other cystostomy status.R143 has a BIMS (Brief Interview of Mental Status) score of 15, which indicates intact.During investigation on 7/23/2025 during resident council meeting at 11:30, R143…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility's menu to meet nutritional needs of residents which has the potential to affect the 145 residents receiving oral diets in the facility.Findings include: Facility Week at a Glance menu documents, in part, that on Monday 7/21/2025, the lunch meal is open-faced tuna melt, carrot coins, peach crisp, beverage of choice. On 07/21/2025, during the lunch meal service on all 3 facility floors, the following food items were observed by the survey team being served on residents' meal trays: a scoop of cold tuna salad in between 2 pieces of plain white bread and hot vegetables (green beans on the 1st floor and mixed peas and carrots on the 2nd and 3rd floors). No peach crisp observed being served on all 3 floors on 7/21/2025 during lunch meal service, and on the 1st and 3rd floors, certified nursing assistants handed out graham cracker packets to residents near the end of the lunch meal. Residents' meal tickets read: open-faced tuna melt (1 each), carrot coins (4 ounces), peach crisp (2 ounces) and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to store foods at safe temperatures, Label foods with expiration dates, and document freezer and walk-in cooler temperatures on the tracking logs. This failure has the potential to affect 143 residents on oral diets out of 148 residents in the facility. Facility [NAME], [NAME] (51772) - Kitchen Findings include: On 7/21/2025 at 9:26 pm, V36 (Dietary Aide) and surveyor observed the freezer and cooler log missing temperature checks on the temperature tracking log posted on the outside of the freezer and cooler. V36 stated the freezer, refrigerator, and cooler temperatures are supposed to be measured and logged twice a day in the morning and evening. V36 stated not measuring the temperature on the freezer, refrigerator, and cooler can result in food illness. V36 verified the freezer has been broken for 2 days. Freezer tracking log documents the freezers am temperature on 7/19/2025 is Out at 6 o'clock am and Def at 7pm and on 7/20/2025 at 6…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure staff don appropriate PPE (personal protective equipment) prior to performing ADL (Activities of Daily Living) care and prior to administering medications via a g-tube for residents on EBP (enhanced barrier precaution). The facility also failed to ensure soiled linens were contained in plastic bag and tied when transported via laundry chute to prevent the spread of infectious microorganisms. These failures affected 2 (R21 and R102) residents reviewed for infection control and have the potential to affect all 148 residents at the facility. Findings include: The (07/21/2025) facility census was 148. The (07/17/2025) EBP (Enhanced Barrier Precautions) list of residents include R102. On 07/21/2025 at 10:41am, there was an EBP sign posted by R102's door. A PPE (personal protective equipment) bin was outside of the room. V9 (Certified Nursing Assistant) was inside the room touching R102's gown. V9 was not wearing isolation gown or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to refer seven residents R1, R5,R6,R7,R12, and R88 to the appropriate state designated authority for a Level II PASARR (Preadmission Screening and Annual Resident Review) evaluation and determination after R1,R5,R6,R7,R12,and R88 were all diagnosed with a new mental disorder. This deficient practice affected seven residents (R1, R5, R6,R7,R12,R44and R88) in a total sample size of 64 residents. Findings include: R5's PASSAR dated [DATE] documents in part, PASRR Level II Determination: Level II -Approved No SS – No SS (Specialized Services within the nursing facility). R5's readmission date to the facility is [DATE]. R5's medical diagnosis includes but are not limited to Bipolar Disorder, Diabetes mellitus, Hyperkalemia, Syncope, Hyperlipidemia, Essential Hypertension, Neuralgia and Neuritis, Anxiety. Facility submitted a document titled Understanding the PASRR Process what each facility needs to know, dated [DATE] documents in part, . 3.If a resident enter…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to ensure that one resident (R45) did not have razors at her bedside; the facility failed to ensure that one resident (R12) did not have a filled sharps container on his bedroom floor; and the facility failed to ensure that five residents (R43, R49, R68, R69, and R105) did not have an overfilled sharps container in their room. This failure has the potential to affect 117 Residents that reside on the second and third floor of the facility. Findings include: R45 is a [AGE] year-old with diagnosis including but not limited to: Tremor, abnormal coagulation profile, polyneuropathy, major depression disorder and hypertension. R45's BIMS (Brief Interview of Mental Status) score is 12, which indicates moderate impairment. During investigation on 7/21/2025 at 11:57 AM, R45 was observed in her room in bed and stated that she planned on shaving later. At that time, a pack of 20 shaving razors were noted on R45's bedside table. On 7/21/2025 at 3:15 PM,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 discard expired stock medications in two of five medication carts, and failed to ensure the medication refrigerator was checked for appropriate temperature log recordings. These failures affected 3 (R32, R76, and R123) residents and has the potential to affect all residents on the first and third floor.Findings include:The ([DATE]) Resident Listing Report documented that there was a total of 89 residents in the facility on the first and third floor.On [DATE] at 10:35AM during the medication storage and labeling task with V3 Licensed Practical Nurse (LPN) of the third-floor team 1 medication cart and medication storage room, noted the following observations:1. Magnesium 500mg, 100 tablets dietary supplement house stock medication observed in 3rd floor medication room with expiration date of 6/2025.2. 3rd floor medication room with two refrigerators 1 black fridge and 1 white fridge no temperature log recording for [DATE].On [DATE] at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow the physician's order to conduct a gradual dose reduction(GDR) evaluation as required by the gradual dose reduction order recommendations for unnecessary medication, chemical restraints/psychotropic meds, and medication record review, and discontinue a psychotropic medication for a resident who has a recommendation to discontinue a psychiatric diagnosis. This failure affected 2 residents (R7 and R12) in a sample size of 64.Findings include:R7's face sheet documents a diagnosis of but not limited to NONTRAMATIC INTERCEREBRAL HEMMORRHAGE, UNSPECIFIED, HEMIPLEDIA AND HEMIPARESIS FOLLOWING CEREBRAL INFACTION AFFECTING RIGHT DOMINANT SIDE, EPILEPSY, UNSPECIFIED, UNSPECIFIED CONVULSIONS, CONSTIPATION, LIMITATION OF ACTIVITIES DUE TO DISABILTIY, HYPERLIPEDEMIA, ESSENTIAL HYPERTENSION, ACUTE KIDNEY DISEASE, AND APHASIA. R7's Physician's order sheet documents dated 7/23/2025 documents an active order with a start date of 6/21/2024 at 0600 for Quetiapine…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one resident (R105) for rescreening to the state agency for Preadmission Screening and Resident Review (PASRR) before R105's Exempted Hospital Discharge 30 Day Approval expired and failed to complete a Level I Preadmission Screening and Resident Review (PASRR) for one residents ( R12) This deficient practice affected two residents (R105,R12) in a total sample size of 64 residents. Findings include: R105's PASRR dated [DATE] documents in part, Level I Outcome: Exempted Hospital Discharge. Rationale: Exempted Hospital Discharge 30 Day Approval-A 30 day or less stay in the NF (Nursing Facility) is authorized. Re-screening must occur by or before the 30th day if the individual is expected to remain in the NF beyond the authorization timeframe. During the survey, the facility was unable to produce a document indicating R105 had a PASRR Level I rescreen. R105's diagnosis includes but are not limited to anxiety disorder, unspecified, bipolar disorder,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to ensure that one resident (R118's) with decreased mobility had a properly working Low Air Loss Mattress. This failure resulted in R118 lying on a deflated mattress and verbalizing being uncomfortable.Findings include:R118 is [AGE] year old with diagnosis including but not limited to: Other reduced mobility, weakness, muscle wasting and atrophy, morbid obesity due to excess calories, hypertension and chronic obstructive pulmonary disease.R118 has a BIMS (Brief Interview of Mental Status) score of 14, which indicates cognitively intact. During investigation on 7/21/2025 at 10:45 AM, R118's LALM (Low air low mattress) was noted with a blinking light indicating 'low pressure'. At that time, R118 stated the following, My bed is hard. The mattress is about six years old. You can feel the springs in it. I have pillows under my back to relieve the pressure. I told the medical records staff about my mattress last week because she is the person that…

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

Based on observation, interview, and record review, the facility failed to ensure the nasal cannula was labeled with the date it was changed. This failure affected 1 (R121) resident reviewed for respiratory care in the total sample of 64 residents. Findings include:On 07/22/2025 at 10:57am, R121's was using a nasal cannula. R121's nasal cannula was not labeled. On 07/22/2025 at 11:00am, V8 (Registered Nurse) checked R121's nasal canula and stated her nasal canula is not labeled. Added that (V17-RN) is assigned to her (R121). On 07/22/2025 at 11:02am, V17 stated the nasal canula should be changed every 72 hours. It should be dated with the date it was changed for the accuracy of when it was changed. It should be changed and labeled to prevent accumulation of mucus in the nasal tubing for infection control. On 07/22/2025 at 2:46pm, V29 (Infection Preventionist/LPN) stated every Sunday during the night shift, nurses have to change the nasal cannula and to label the nasal cannula with the date it was changed for infection control and hygiene. The purpose is to prevent transfer 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 label, date, and discard food items in resident 's personal refrigerator in an effort to prevent food borne illness. This failure affected 1 (R36) resident reviewed for personal refrigerator in the total sample of 64 residents. Findings include: On 07/21/2025 at 11:41am, inside R36's personal refrigerator was a black plastic container with translucent lid. The plastic container was not labeled. There is a strong smell coming out of the food container. Inquiring how long the food has been in the refrigerator, R36 stated she did not even know until this surveyor said something about the food in her personal refrigerator. On 07/22/2025 at 10:55am, R36 stated her daughter brought the food. That she could not remember whether it was during her birthday in April or Mother's day in May. On 07/21/2025 at 11:50am, inquiring about the food item in R36's personal refrigerator, V10 (Certified Nursing Assistant) stated housekeeping is in charge of checking the personal refrigerator. V10 took the plastic container out of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to provide a homelike environment by ensuring that there were no visible holes in the ceilings of two shower rooms. This failure has effected one resident (R10), and has the potential to affect 117 residents who utilize these shower rooms.Findings include:R10 is [AGE] year old with diagnosis including but not limited to: other polyosteoarthritis, unilateral inguinal hernia, localized swelling of lower left limb, hyperlipidemia and gastro-esophageal reflux disease.R10's BIMS (Brief Interview of Mental Status) score is 14, which indicates cognitively intact.During investigation on 7/3/2025 at 2:52 PM, V12 (LPN/ Licensed Practical Nurse) stated that the shower room in front of the third floor nurses' station was closed for remodeling and that the shower room in the 3 North hallway was still being used for showers.At that time, V12 (LPN/ Licensed Practical Nurse) toured the shower room located in the 3-North hallway and at that time, Surveyor noted a hole 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.

Based upon observation, interview, and record review the facility failed to follow policy procedures and failed to ensure that call lights were within reach for three of three residents (R3, R4, R7) reviewed for falls. Findings include: R4's (12/10/24) BIMS (Brief Interview Mental Status) determined a score of 3 (severely impaired). R4's (12/10/24) functional assessment affirms resident requires partial/moderate assistance for sit to stand and bed to chair transfers. On 1/27/25 at 11:25am, R4 was observed lying in bed however the call light was on the floor and out of reach. V6 (Licensed Practical Nurse) was at R4's bedside surveyor inquired about R4's fall prevention interventions V6 responded She has floor mats and boosters (referring to bed bolsters) however call light within reach was excluded. Surveyor inquired about R4's cognitive status V6 replied She's alert and oriented 1 to 2 and proceeded to exit the room. Surveyor inquired about the location of R4's call light V6 returned to R4's bedside and stated, It was on the floor. __ R7's (11/14/24) BIMS determined a score of 6…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon record review and interview the facility failed to timely notify the Physician, Nurse Practitioner, and/or Medical Director of change in condition for one of three residents (R4) reviewed for falls. Findings include: On 1/14/25, IDPH (Illinois Department of Public Health) received allegations that R4 fell out of bed and was not sent to the hospital until V17 (Family) arrived and told staff to call an ambulance. R4 is [AGE] years old with diagnoses which include but not limited to altered mental status and history of falling. R4's (12/10/24) BIMS (Brief Interview Mental Status) determined a score of 3 (severely impaired). R4's (1/13/25) fall incident report states CNA (Certified Nursing Assistant) responded to call light; resident observed laying on her side left side of bed. Roommate witnessed incident; roommate stated, She put her feet out the bed then slid down on the floor. Resident stated, I was trying to get something off my table. Resident denies pain, no signs/symptoms of distress or discomfort…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon record review and interview the facility failed to follow policy procedures and failed to timely develop comprehensive care plans for two of seven residents (R4, R6) in the sample. Findings include: R4 was admitted to the facility on [DATE] with diagnoses which include history of falling. R4 is [AGE] years old. R4's (6/13/23) Fall Risk Review determined a score of 17 (high risk). R4's comprehensive care plan states resident is at risk for falls (Date Initiated: 1/21/25) therefore completed roughly 1.5 years after admission. __ R6 was admitted to the facility on [DATE] (10 months ago) with diagnoses which include history of alcohol abuse and history of cocaine abuse. R6's comprehensive care plan (received 1/28/25) excludes history of alcohol and/or cocaine abuse. On 1/30/25 at 12:04pm, surveyor inquired about the requirements for developing comprehensive care plans, V15 (Care Plan Coordinator) stated The primary diagnoses, were care planning it. I've (V15) got 24 to 48 hours to get it done but it gets…

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

Based upon record review and interview the facility failed to follow policy procedures and failed to review and/or revise a comprehensive care plan for two of three residents (R3, R7) reviewed for falls. Findings include: R3's (11/26/24) progress notes state writer got report from the Nurse stating that the resident had an unwitnessed fall. R3's (7/4/23) care plan states resident is at risk for falls however the (11/26/24) fall is excluded, and the Goal Target Date is 8/11/24 (outdated roughly 5.5 months ago). R7's (3/15/23) care plan states resident is at risk for falls. Goal Target Date: 11/12/24 (outdated roughly 2.5 months ago). On 1/30/25 at 12:30pm, surveyor inquired about the requirements for care plan review and/or revision V15 (Care Plan Coordinator) responded Every 3 months, which is every assessment and we do it within 7 days. I (V15) would do it if there's a change in condition, new diagnosis or they came from the hospital then I would update the care plan. Surveyor inquired about concerns with R3's (7/4/23) fall risk care plan, V15 reviewed R3's care plan and stated I'm…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon observation, interview, and record review the facility failed to follow policy procedures, failed to provide supervision, failed to ensure that staff are aware of required fall prevention interventions, and/or failed to implement fall prevention interventions for three of three residents (R3, R4, R7) reviewed for falls. Findings include: R4 is [AGE] years old with diagnoses which include altered mental status, weakness, lack of coordination, abnormalities of gait/mobility, and history of falling. R4's (6/13/23) admission Fall Risk Review determined a score of 17 (high risk). R4's (1/13/25) fall incident report states CNA (Certified Nursing Assistant) responded to call light; resident observed laying on her side left side of bed. Roommate witnessed incident. Predisposing factors: dementia and history of fall. On 1/30/25 at 3:06pm, surveyor inquired if R4 can transfer herself and/or walk V3 (ADON/Assistant Director of Nursing) stated She's (R4) a 1-person transfer, she can't walk. Surveyor inquired…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policy and procedure to prevent R1 from being physically abused by R2. This failure affected 1 (R1) of 4 residents reviewed for abuse. Findings include: R1 is a [AGE] year old male with a diagnosis including Cerebral infarction, Hemiplegia affecting left dominant side, Chronic kidney disease, Mood disorder, Difficulty in walking, Diabetes 2, Opiod abuse, Heart failure and Kidney failure. R1 was first admitted to the facility on [DATE]. R1 has a BIMS (Brief interview for mental status) score of 13/15. R1 is care planned for including Behavior, may demonstrate behavioral distress. 10/19/24. R2 is a [AGE] year old male with a diagnosis including Heart failure, Chronic kidney disease, Bipolar disorder, Alcohol dependence with alcohol-induced persisting dementia and Alcoholic cirrhosis of liver. R2 was first admitted to the facility on [DATE]. R2 has a BIMS (Brief Interview for Mental Status) score of 14/15. On 1/4/25 at 1:35PM R1 stated around…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policy & procedure to prevent R2 from being physically abused by R1. This failure affected 1 (R2) resident out of 4 residents reviewed for abuse. The findings include: R2's admission record documented initial admission date on 6/26/2021 with diagnoses not limited to Unspecified convulsions, Bipolar disorder, Major depressive disorder. MDS dated [DATE] showed R2's cognition was moderately intact. On 12/1/24 at 9:53 AM Observed R2 up and about, ambulatory with walker, alert, and oriented x 2-3, verbally responsive. R2 said about 3 weeks ago around dinnertime by the 1st floor dining room. R1 was cursing staff so she went to R1 and told him not curse out loud. She said R1 got annoyed, pushed her away and fell on her side. R2 said R1 attacked and scratched her on the face. She said she was bleeding and staff attended to her. She said they were separated by staff and other residents. Stated she felt abused. R2 said she feels safe in the facility…

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

Based on observation, interview, and record review, the facility failed to ensure medications were administered as ordered by the residents' physician for one (R5) resident out of three residents reviewed. Findings include: On 11/03/2024, at 9:18 AM, surveyor located on the second floor of the facility with V11 (Licensed Practical Nurse/LPN). V11 observed with a medication cart and performing a morning medication administration pass. On 11/03/2024, at 9:23 AM, V11 observed preparing medication for R6. R6 placed the medications in a clear medication cup and placed it to the side on top of the medication cart. V11 does not administer R6's prepared medications to R6. V11 is observed immediately deploying R7's electronic medication administration record/eMAR and began gathering R7's medications and places them on top of the medication cart. Surveyor asks V11 did she administer R6's prepared medications. V11 states she was preparing both R6 and R7 medication at the same time since they are in the same room but will take it to them separately. Surveyor inquired about the rights 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 upon record review and interview the facility failed to ensure that staff are aware of facility policies, failed to follow policy procedures, and failed to develop a comprehensive care plan including required interventions for three of three dependent residents (R1, R2, R3) in the sample. These failures have the potential to affect 145 residents. Findings include: On 10/3/24 and 10/9/24, IDPH (Illinois Department of Public Health) received allegations that facility residents are not receiving required ADL (Activities of Daily Living) care. The (10/15/24) census includes 145 residents. R1 was admitted on [DATE]. R1's diagnoses include Alzheimer's disease, reduced mobility, lack of coordination, and weakness. R1's (7/15/24) BIMS (Brief Interview Mental Status) determined a score of 1 (severely impaired). R1's (7/15/24) functional assessment affirms partial/moderate assistance is required for eating and bathing, substantial/maximal assistance is required for toileting hygiene, and chair/bed to chair transfers…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 they have a written staffing policy, failed to ensure that the required amount of staff are scheduled, failed to ensure that scheduled staff arrive timely and/or stay for the entire shift, and failed to ensure that sufficient nursing staff were available to meet the needs for three of three dependent residents (R1, R2, R3) in the sample. These failures have the potential to affect 145 residents. Findings include: On 10/9/24, IDPH (Illinois Department of Public Health) received allegations that facility residents are left in urine/feces for 3+ hours due to lack of staff. The (10/15/24) census includes 145 residents. On 10/15/24 at 12:24pm, surveyor inquired about the current (1st floor) staffing V3 (Agency Registered Nurse) stated It's just me (V3) and I have three CNAs (Certified Nursing Assistants). Normally it's just one Nurse on this floor. Surveyor inquired about the 1st floor census V3 responded there's 30. Surveyor inquired if one Nurse on the unit is adequate staffing considering acuity and/or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon observation, interview, and record review the facility failed to follow policy procedures, failed to ensure the building is well maintained, failed to ensure that facility repairs are documented, failed to timely identify an area needing repair, failed to address falling ceiling tiles, and failed to timely repair a malfunctioning actuator. The facility also failed to pay the HVAC (Heating Ventilation Air Conditioning) company. These failures have the potential to affect 145 residents. Findings include: The (10/15/24) census include 145 residents. On (10/9/24) IDPH (Illinois Department of Public Health) received an allegation that the facility (3rd floor) ceiling tiles are falling on one end. On 10/15/24 (6 days later) at 1:32pm, a large trash can was observed in the middle of the hallway (adjacent room [ROOM NUMBER]) and several wet towels were on the floor surrounding the trash can. Two of the ceiling tiles (above the trash can) were missing and water was draining profusely from the ceiling (it 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 upon observation, interview, and record review the facility failed to ensure that staff report hazards and/or housekeeping concerns, failed to ensure that resident rooms are clean and hazard free, failed to ensure that spills are addressed immediately, and failed to ensure that dining rooms are cleaned timely. These failures have the potential to affect 82 residents residing on 1st and 3rd floor. Findings include: On (10/9/24) IDPH (Illinois Department of Public Health) received allegations that the facility floors are not swept/mopped timely, and the dining room is not being cleaned appropriately or timely. The (10/15/24) census includes 30 (1st floor) residents and 52 (3rd floor) residents. R1's (7/10/24) concern form states the room is very dirty and there is trash under the bed. R1's diagnoses include Alzheimer's disease, reduced mobility, and lack of coordination. R1's (7/15/24) BIMS (Brief Interview Mental Status) determined a score of 1 (severely impaired). R1's (7/15/24) functional assessment affirms partial/moderate assistance is required for eating and chair/bed to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon record review and interview the facility failed to follow policy procedures, failed to ensure that care plans include discharge planning on admission, failed to ensure the discharge care plan includes actual discharge plan, failed to follow-up on transfer referral(s), and failed to transfer one of three residents (R1) reviewed for discharge timely. Findings include: On (10/9/24) IDPH (Illinois Department of Public Health) received an allegation that the facility is not providing residents ADL (Activities of Daily Living) care and not assisting (R1) to transfer to another facility in a timely manner. On 10/15/24 at 1:06pm, concerns were identified with R1 not receiving timely ADL care. R1 was admitted [DATE]. R1's comprehensive care plan (received 10/15/24) excludes discharge planning. R1's progress notes include (7/10/24) resident family expressed a desire to be transferred to (South [NAME] LTC/long-term care facility). Residents' referral packet has been faxed to the facility per family request.…

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

Based upon observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that care plans include required assistance, and failed to provide timely ADL (Activities of Daily Living) care to two of three dependent residents (R1, R3) in the sample. Findings include: On 10/3/24 and 10/9/24, IDPH (Illinois Department of Public Health) received allegations that facility residents are not receiving ADL (Activities of Daily Living) care. R1's diagnoses include Alzheimer's disease, reduced mobility, lack of coordination, and weakness. R1's (7/15/24) BIMS (Brief Interview Mental Status) determined a score of 1 (severely impaired). R1's (7/15/24) functional assessment affirms substantial/maximal assistance is required for toileting hygiene, and chair/bed to chair transfers are dependent on staff. R1's comprehensive care plan (received 10/15/24) excludes toileting and transfer assistance. On 10/15/24 at 12:27pm, V4 (CNA/Certified Nursing Assistant) was observed feeding R1 in the dining room, R1 ate 100% of the meal. Surveyor inquired if R1 can…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 bed linen and bath towels for four (R1, R2, R3, R4) out of four residents and failed to ensure the facility's washing machines was functioning properly. This failure has the potential to affect all 150 residents residing in the facility. Findings Include, On 9/10/24 at 10:00 AM, R1 stated, I never have clean face towels to clean myself up in the morning. The nurses tell me I have to wait for the clean laundry to come up, sometimes the laundry does not come up until 1 PM. I should not have to take my own money to buy face towels. R2's clinical record indicates in part; R2's medical diagnosis was muscle wasting, paraplegia, and major depressive disorder. Minimum Data set [MDS] Section [C] dated 8/6/24, Brief interview mental status scored [15], indicates R2 is cognitively intact. MDS section GG dated 8/6/24 indicates R2 is dependent for activities of daily living [ADL] care, toileting, bathing, and transferring. On 9/11/24 at 8:10 AM, R2 stated, I have not been changed all night. I am soaked with urine…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 waste containers were properly contained and covered. This failure has the potential to affect all 156 residents residing in the facility. Findings include: On 7/16/24 at 10:19 AM, Surveyor and V40 (Maintenance Director) observed the facility dumpster area and noted one of the dumpsters uncovered. V40 stated that the dumpster was for recyclable items but that it should still be covered. V40 then covered the dumpster with the lid. On 7/16/24 at 10:21 AM, Surveyor and V40 observed the additional dumpster and garbage can located in the back parking lot. The dumpster was observed with no cover and the trash can lid was unable to be closed from the amount of trash inside (which included food and drink waste). V40 stated that the additional trash cans and dumpster were for the construction being done at the facility and that the city must have forgotten to pick them (the garbage cans and dumpster) up. V40 affirmed that the trash gets picked up by the city weekly and that not covering trash/waste containers…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 obtained/consumed alcohol, failed to ensure alcoholic beverages and razors were stored in a safe manner. This failure effected 2 residents (R149 and R410) and has the potential to affect all 67 residents on the second floor and 31 residents on the first floor of the facility. Findings include: R149's face sheet documents in part a diagnosis of alcohol abuse. R149's Minimum Data Set (MDS) dated [DATE] documents in part a brief interview of mental status (BIMS) summary score of 15, indicating that R149 is cognitively intact. R149's care plan (dated 5/16/2024) identifies that R149 has a history of hoarding items related to R149's alcohol abuse. R149's hospital records and discharge instructions dated (12/6/23) states, Avoid alcohol while on narcotic pain medication. R149's physician orders indicate R149 has an order for HYDROcodoneAcetaminophen Oral Tablet 5-325 MG (HydrocodoneAcetaminophen) Give 1 tablet by mouth every 6…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review the facility failed to ensure oxygen tubing, humidifier bottle, and nebulizer mask were dated, failed to ensure that a resident receiving oxygen have oxygen orders, and failed to ensure respiratory equipment (incentive spirometer, peak flow meter, and nebulizer mask) were contained. These failures affected 4 residents (R49, R59, R360 and R410) reviewed for oxygen in a sample size of 71. Findings include: R59's admission diagnoses include but not limited to acute and chronic respiratory failure with hypoxia or hypercapnia, and congestive heart failure. On 7/14/24 at 10:30 am, observed R59 in room lying in bed with nebulizer mask and tubing lying on the bedside table not dated, concealed, or contained in a bag. On 7/16/24 at 3:22 pm, Surveyor inquired to V2 DON (Director of Nursing) if oxygen tubing and mask should be dated and contained in a bag. V2 stated that oxygen tubing and mask should be dated and contained in a bag. R59's POS (Physician Order Set) documents in part, Albuterol Sulfate Nebulization Solution 0.83 mg/3ml…

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

Based on observation, interview and record review, the facility failed to post the daily nursing staffing. This failure has the potential to affect all 156 residents residing in the facility. Findings include: On 07/14/24 V2 (Director of Nursing) present facility's census of 156 residents. On 07/14/2024 at 9:00am, upon entrance to the facility, the facility's daily staff posting was observed posted at the receptionist desk dated 07/04/24. On 7/14/2024 at 910am V45 (Receptionist) stated that she just started this position a couple of days ago and she does not know you post it for display and acknowledged that she did not post it (Daily Nurse Staffing Form) dated 7/04/2024 On 7/15/2024 at 9:39am V22 (Staffing Coordinator) stated the Nurse Staffing is posted daily and in her absence V20 (Transportation Coordinator) whose assist with scheduling or the DON (Director of Nursing) will post the Daily Nurse Staffing.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY On 07/14/24 at 10:31 AM, R113 was cleaning up her (R113) personal refrigerator. This surveyor requested to see what was inside R113's refrigerator. R113 opened her (R113) personal refrigerator and stated I (R113) have different kind of food, (pointing to each food) R113 stated I (R113) cottage cheese, yogurt, egg salad, and avocado; food that regular people eat. I (R113) buy my (R113) own food. This surveyor requested to see R113's temperature log. R113 stated it is on the side. R113's (07/2024) personal refrigerator temperature log has no entry from 07/02/2024 through 07/13/2024. On 07/14/24 at 10:34 AM, V12 (Housekeeping Aide) stated the Guardian Angels are in charge of checking the personal refrigerator temperature. On 07/14/24 at 10:38 AM, this surveyor showed V6 (Licensed Practice Nurse) R113's 07/2024 personal refrigerator temperature log and stated the only entry I (V6) see is the temperature on July 1st. the nurses are in charge of checking the refrigerator every shift. On 07/16/2024 at 11:48am, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to perform hand hygiene before performing direct care to resident; failed to perform hand hygiene in between assisting residents during dining service; and facility failed to post an Enhanced Barrier Precautions (EBP) isolation sign and place Personal Protective Equipment (PPE) directly outside a resident's isolation room in an effort to prevent the spread of infectious microorganisms. These failures affected R36, R42, R79, and R120 in the sample of 71 residents and has the potential to affect all 89 residents residing on 1st and 3rd floors when reviewed for infection control. Findings include: On 07/15/24 at 11:36 AM Observed V6 apply gloves to hands without using hand sanitizer to do blood glucose on R120. V6 observed stepping away from R120, remove gloves then open medication cart without sanitizing hands. On 07/15/24 at 11:40 AM V6 Licensed Practical Nurse (LPN) stated, I (V6) should have used hand sanitizer before applying the gloves. 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 observation, interview and record review, the facility failed to maintain a resident's dignity by covering a resident's indwelling catheter urinary bag from public view and failed to maintain a resident's dignity during one-to-one feeding by a staff member by sitting eye level with the resident and engaging with only one resident during one-to-one feeding. These failures affected R2 and R36 in the total sample of 71 residents when reviewed for resident rights. Findings include: On 7/14/24 at 12:40 pm, R36 observed in reclining wheelchair in dining room sitting at a larger circular table. V16 (Certified Nursing Assistant, CNA) lifts up R36's reclining wheelchair to an upright position. V16 observed cutting up R36's meatloaf patty with gravy into smaller pieces while standing on R36's right side. V16 remains standing and begins feeding R36 the meatloaf patty pieces with the fork. V16 then lifts up R36's cup filled with apple juice and gives R36 a drink from the cup. V16 continues standing while feeding…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 call devices were within residents' reach for use to call for staff assistance. This failure affected 3 residents (R18,R41 and R155) reviewed for accommodation of needs in a total sample of 71 residents. Findings include: On 07/14/24 at 11:31 AM, R155 was seated on a wheelchair by the window. There were floor mats on each side of R155's bed. R155's call device was on the floor between the two beds inside the room. This surveyor requested R155 to use the call light. R155 stated I (R155) can use it, but I (R155) can't reach it. It is hard for me (R155) to go there, myself (R155), on a wheelchair because of the floor mats. On 07/14/24 at 11:37 AM, this observation was pointed out with V6 (Licensed Practice Nurse). V6 picked the call light on the floor and clipped it on R155's pillow, within reach of R155. V6 stated it was on the floor and she (R155) could not reach it. The call light (device) is the best way to communicate that a resident needs help. On 07/16/2024 at 11:38am, V2 (Director Of Nursing)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 for assessed resident's to exercise their right to engage in an intimate sexual relationship. This failure affected 2 residents R8 and R65 in a total sample of 70. Finding include: On 07/14/24 at 10:58 AM R65 stated The facility doesn't allow us to adult things. When the staff catch us having sex, they stop us. The facility gave us condoms. The staff caught us having sex around 15 times and they stopped us each time. I don't understand why as two consenting adults they continue to prevent us from having sex. On 07/15/24 at 10:11 AM (V11) PRSD stated, Once the residents come to the staff and let the staff know that they want to have sex I (V11) do an assessment. The facility provides condoms. The facility also lets the residents know that if they (residents) have a roommate then they (residents) must make sure the curtain is closed. There is no form that the residents must sign. We care plan the resident giving consent to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to list the code status for one resident (R133) on the electronic medical record. This failure has the potential to affect one resident (R133) out of a sample of 71 residents. Findings: R133's has a diagnosis of but not limited to Nontraumatic Intracerebral Hemorrhage, Epilepsy, Lack of Coordination, Convulsions, Schizoaffective Disorder, Difficulty in Walking and Hypertension. R133's Minimum Data Set (MDS), dated [DATE], does not documents Brief Interview of Mental Status (BIMS) score but documents No (resident is rarely/never understood. R133's Order Summary Report (POS) with active orders as of 7/16/24, documents that no physician's order for advance directives (full code or DNR status) for R133. R133's admission Record Form for Advance Directive section is blank. R133's Care plan dated 6/06/2023 documents, in part, dated Pursuant to R133's rights & the individual's desire to retain control & autonomy over his/her health care decisions,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 nail care for two residents (R18, R41). This failure affected two residents (R18, R41) and has the potential to affect all residents in the sample of 71 residents. Findings include: R18 has a diagnosis of but not limited to Hemiplegia And Hemiparesis Following Unspecified Cerebrovascular Disease Affecting Right Dominant Side, Type 2 Diabetes Mellitus, Dementia, and Contracture, Right Hand. R18 has a Brief Interview of Mental Status Score of 05. R41 has a diagnosis of but not limited to Cerebrovascular Disease, Hemiplegia And Hemiparesis Following Unspecified Cerebrovascular Disease Affecting Unspecified Side, Weakness and Contracture, Left Elbow. R41 has a Brief Interview of Mental Status Score of 12. On 7/14/2024 at 11:27am surveyor observed R18's hands with long fingernails with a brownish gray substance under the nails. On 7/14/2024 at 11:31am V14 (Licensed Practical Nurse-LPN) stated nail care is provided daily, on shower days and as needed and the nurse will cut the fingernails of diabetic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 apply a hand splint to a resident with contracture, failed to ensure a hand splint was applied on correct hand, and failed to ensure the resident was appropriately care planned for a hand splint in an effort to prevent further contracture of the hand and functional decline of the resident. These failures affected 1 (R83) resident reviewed for limited range of motion in a total sample of 71 residents. Findings include: On 07/14/24 at 10:44 AM, there was bedside table on R83 left side by the wall and a call device was on R83's right side, within reach. R83's both hands have contractures, more to the left hand than the right hand. R83 stated I (R83) use my right hand to press the call light if I (R83) need the staff to give me (R83) a sip of water. The staff applies splint on my left hand every morning if there are people downstair, if no one is there, then no one will put it on me. I (R83) did not remove my splint, it was not applied to me. R83 was instructed to close his left hand. R83 stated I (R83) can't.…

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

Based on observations, interviews, and record review, the facility failed to ensure incoming and outgoing nurses counted the controlled medications during shift change; and failed to ensure administration of controlled medication was documented. These failures affected three residents (R53, R62 and R87) reviewed for pharmacy services and records in a total sample of 71 residents. Findings include: On 07/15/24 at 10:30 am, Controlled Substances Check form for 3rd floor Team 1's medication cart was observed with missing signatures on 07/12/24, 07/13/24 and 07/15/24. This observation was pointed out to V27 (Registered Nurse, RN) and V27 stated, I (V27) don't know why it's not signed. I (V27) am from the agency. I (V27) should have signed it (referring to the controlled substance accountability record) after I (V27) counted. My (V27) pen ran out of ink. On 07/15/24 at 10:36 am, during the controlled medication count of R53's Tramadol HCL (Hydrogen Chloride) tab 50 milligrams (mg) with surveyor and V27, there were 12 tablets left in R53's Medication Dispensing Card. R53's Controlled Drug…

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

Based on observation, interviews, and record review, the facility failed to ensure washcloths were changed in between dirty body surface areas, failed to ensure a sign is posted for a resident on enhanced barrier precautions and failed to ensure staff appropriately don and doff personal protective equipment during high contact care for a resident on enhanced barrier precautions in an effort to prevent the spread on Multidrug Resistant Organism. This failure affected 1 (R3) resident reviewed for infection control and has the potential to affect all the residents on the first floor. Findings include: On 07/01/2024 at 1:16pm, there was a sign posted by R3's outside wall sequence of donning and doffing of PPE. A PPE bin was outside of R3's room with gown, gloves, and mask. There was no enhanced barrier precautions sign posted by R3's room or door. V12 (Certified Nursing Assistant) knocked at R3's room and entered wearing a mask and gloves only. V12 put down a basin with one washcloth by R3's foot of bed. R3 was turned on her (R3) left side. There was a minimal bleeding noted on R3'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 interview and record review, the facility failed to develop a plan of care for Foley catheter use. This failure affects 1 resident (R4) sampled for Foley catheter care. Findings include: On 7/1/24 at 10:35 AM, R4 affirmed that R4 has had a Foley catheter since before entering the facility. R4's admission records documents in part the following diagnosis: acute on chronic heart failure, retention of urine, and presence of urogenital implants. R4's MDS (Minimum Data Set), dated 5/15/24, documents in part a BIMS (Brief Interview for Mental Status) summary score of 15, indicating that R4 is cognitively intact and that R4 utilizes an indwelling catheter. Record review of R4's IL- URINARY CATHETER REVIEW dated 6/19/24, indicates R4 had a urinary catheter placed approximately 6/17/24 and does not identify R4's medical diagnosis/clinical condition that demonstrates catheterization was unavoidable. Record review of R4's CAA (care area assessment) worksheet dated 5/15/24, identified that R4 has a Foley catheter, and that R4's indwelling catheter will be addressed in the care plan for…

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

Based on observation, interview and record review, the facility failed to ensure physician orders are in place for residents utilizing Foley catheters and provide care for residents with Foley catheters. This failure affects 1 resident (R4) sampled for Foley catheter care. Findings include: R4's admission records documents in part the following diagnosis: acute on chronic heart failure, retention of urine, and presence of urogenital implants. R4's MDS (Minimum Data Set), dated 5/15/24, documents in part a BIMS (Brief Interview for Mental Status) summary score of 15, indicating that R4 is cognitively intact and that R4 utilizes an indwelling catheter. On 7/1/24 at 10:35 AM, R4 affirmed that R4 has had a Foley catheter since before entering the facility. R4 stated that facility staff do not care for R4's foley catheter or the drainage bag. R4 showed the drainage bag to surveyor which appeared to be bulging and contained 1000-1200 mL of straw-colored urine. R4 stated no one empties it, so I have to do it myself. On 7/1/24 at 10:37 AM, V6 (Licensed Practical Nurse) affirmed V6 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 interview and record review, the facility failed to provide as needed medication for pain prior resulting with one resident suffering from excruciating pain and refusing to be touched during therapy and restorative sessions. This failure affected 1 (R3) resident reviewed for pain management in the total sample of 11 residents. Findings include: On 07/02/2024 at 11:35am, V20 (Physical Therapy) stated I (V20) saw her (R3) between 4/1/2024 - 4/10/2024. Her (R3) PT was discontinued because she (R3) reached her (R3) maximum potential. (R3) is not progressing; repeatedly showing no improvement. When I (V20) assessed her (R3) on 4/1 she (R3) was dependent with bed mobility, transfers, and the gait was not assessed because she (R3) cannot really sit at the bed, her (R3) pain was 10/10. She (R3) refused to be touched. I (V20) continued to see her (R3) and provide what she (R3) can tolerate. On 4/5/2024, she (R3) basically had 15 minutes of PT session because she (R3) cannot tolerate the exercises. She (R3) had an excruciating pain. She (R3) had a big wound on the left side of the…

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

Based on observation, interview and record review facility failed to follow professional standards of practice and facility policy to (a) ensure incontinence care were provided timely for two residents (R4, R6), and (b) to ensure provider orders were followed in preventing alterations in skin integrity for one resident (R4). These failures have the potential to affect 2 (R4, R6) out of 3 residents reviewed for skin preventive measures. Findings Include: On 5/7/2024 at 9:55 AM V10 (Certified Nursing Assistant/CNA) entered and then exited R4's room and stated R4 is normally wet so I need to get her up and get her cleaned up before she eats. On 5/7/2025 at 10:07 AM V10 (CNA) started to get R4 to a sitting position in bed and diaper observed by surveyor to appear wet. Surveyor asked if R4 was wet or soiled. V10 (CNA) stated Yeah, just a little bit. V10 (CNA) removed wet diaper and got R4 up to wheelchair. R4 was wheeled to the bathroom. Bed pad was observed to be saturated with pale yellow liquid and smelled like urine. When bed pad was lifted, sheet was also wet. R4 was taken to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed accurately assess and supervise one resident's (R4) out of three residents reviewed for falls. Findings include: Review of Medical Record includes date of admission of 11/3/2023 and falls by R4 dated 10/23/2023, 12/18/2023, 1/31/2024 and 5/3/2024. Review of Fall Risk Assessment completed 11/3/2023 at 7:27 PM has the answer no to the question: Does the resident have a history of falls within the last 3 months? Review of Nursing Progress Note by V38 (Licensed Practical Nurse/LPN) created 11/3/2023 at 21:26 stated in part that R4 is diagnosed with falls. R4's Care Plan initiated 11/4/2023 relative to fall risk was reviewed and reflects R4 is at risk for falls as evidenced by the following risk factors and potential contributing diagnosis: general weakness, impaired coordination, impaired gait and balance. Goal: R4 will have fall interventions in place that will help reduce my risk for falls and injury through the next review. Review of Progress…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 failed to follow a resident's care plan to ensure a resident received the correct oxygen flow rate as ordered by the physician for 1 (R3) out of 3 residents receiving supplemental oxygen. Findings Include: R3's clinical records show R3 was admitted in the facility on 3/29/24 with diagnoses not limited to Chronic Obstructive Pulmonary Disease (COPD) and Hypoxemia. R3's Minimum Data Set (MDS) dated [DATE] shows R3 is cognitively intact. R3's order summary report with active orders as of 5/7/24 reads in part: Oxygen @ 2 Liters/Min via nasal cannula continuous every day and night shift for COPD ordered on 4/23/24. R3's care plan shows R3 has Oxygen Therapy related to insufficient gas exchange with one intervention that reads: OXYGEN SETTINGS: The resident has O2 via nasal canula as ordered by physician. On 5/7/24 at 11:14 AM, R3's sitting up on a chair in R3's room alert and able to verbalize needs. R3…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record reviews the facility failed to ensure one [R1] of three sampled residents was free of verbal abuse from an employee. R1's clinical record documented in part: R1 was admitted on [DATE] with the following medical diagnosis of abnormalities of gait and mobility, pulmonary embolism, heart failure, anemia, type ll diabetic, acute embolism of deep veins of lower extremity, ulcer of right/left lower leg, muscle weakness, and essential hypertension. R1's Minimum Data Set Brief Interview for Mental Illness indicated R1 was cognitively intact. R1's care plane dated 1/21/24 documents in part: -R1 assessment reveals a history of suspected abuse and neglect or other factors that may increase my susceptibility to abuse and neglect. -R1 has a self-care deficit with impaired transfer abilities due to general weakness. -R1 has impaired coordination, gait, and balance. On 3/12/24 at 2:40 PM, R1 stated, I was in the bed, and dropped some of my items on the floor by accident. I am too weak to walk,…

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

Based on observation, interview, and record review, the facility failed to assess/monitor one resident (R1) for self-administration of medication out of three residents reviewed for medication administration. Findings include: On 1/30/24 at approximately at 10:15am a medication administration observation was conducted with V12(Licensed Practical nurse/LPN). V12 was observed administering medication to R4 on the second floor of the facility outside of R4 room. V12 prepared Iron 325mg 1 tablet, aspirin 81mg 1 tablet, vitaminD3 1000mg 1 tablet. An unlabeled white pill was noted on medication cart inside a clear plastic medication cup. Surveyor inquired about the unlabeled white pill and V12 stated, the unlabeled white pill was not for R4. V12 stated she found the pill in the cart unlabeled and unpackaged and states she don't know who it is for. V12 reposition her medication cart at the nursing station. At approximately 10:30am V12 walked away from medication cart leaving the unlabeled white pill in the clear plastic cup unattended on top of the medication cart. On 1/30/2024 at 1:00pm…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, facility failed to affirm the right of the resident to be free from verbal abuse. This deficient practice affected two (R3, R5) out of three residents reviewed for abuse. Findings Include: On 01/30/2024 at 10:37AM, R3 observed lying in bed with a gown on inside of R3's room. R3 states approximately around thanksgiving time, she pulled her called light because R3 needed staff to assist R3 with having her incontinence briefs changed. R3 states V9 (Former Certified Nursing Assistant/CNA) came into R3's room and yelled What do you want? R3 states after she told V9 her reason for pulling the call light, V9 stated I'm going to change you so you can't let the men staff play with your p*y, because that's all you want anyway. R3 states V9 then told R3 that V9 was not going to change R3's incontinence briefs and V9 left R3's room. R3 states V9's eyes were red and V9 smelled like marijuana. R3 states she informed V6 (Social Services Director) of what happened. R3 states V9 is the only staff member in the facility who has verbally abused R3. R3 states she…

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

Based on interview and record review, the facility failed to report and investigate verbal abuse for one (R5) of three residents reviewed for abuse. Findings include: On 02/01/2024 at 10:25AM, V2 (DON) states she has been the DON at the facility for approximately three months. V2 states she took V10's statement pertaining to when V10 witnessed V9 being verbally abusive to another resident (identified as R5). V2 states V10 witnessed R5 ask V9 for something and V9 responded to R5 stating I'm not getting your fat a nothing. V2 states that V10 asked V9 why did V9 talk to R5 this way and V10 stated to V9 that V9 could not speak to R5 that way. V2 states that V9 asked the nurses to sign V9's time card so that V9 could leave the facility. V2 states that both nurses declined to sign V9's time card but allowed V9 to the leave the facility. V2 states V9 was then suspended from the facility and ultimately terminated from the facility. Surveyor asked V2 did she report this incident of verbal abuse involving V9 (Former CNA) and R5. V2 stated she just took V10's statement and V1 (Administrator)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to accommodate the needs of one (R1) resident by failing to ensure call light was within reach for R1 to use it if desired, in a sample of three residents reviewed. Findings include: R1's current face sheet documents R1 was first admitted to the facility on [DATE] and re-entered the facility on 11/21/2023 and lists R1 medical diagnosis to include but not limited to: Cerebral infarction, unspecified, malignant neoplasm of endometrium, other lack of coordination. R1's MDS (Minimum Data Set) section C -Cognitive functions dated [DATE], Document R1's BIMS (Brief Interview for Mental Status) as 2/15, indicating R1 has severe cognitive impairment. R1's MDS section GG (Functional Abilities and Goals) with assessment reference date of 11/01/2023 documents R1 is dependent for toilet transfer, Shower/bathe self, Oral hygiene, Upper/lower body dressing, putting on/taking off footwear. On 11/28/2023 at 12pm, V11(Licensed Practical Nurse-LPN) 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 interview and record review, the facility failed to ensure resident to resident physical abuse did not occur for two of three residents (R12, R13) reviewed for abuse. Findings include: Facility's final incident report (9.29.2023) documents in part: Facility received report of a peer-to-peer incident in which resident (R12) and resident (R13) were involved in a physical altercation. Both residents were immediately separated and placed on 1:1 monitoring. Residents were assessed by nursing and both residents MD(s) (were) notified. Both residents care plans were reviewed and will be updated as needed. After review of statements, and resident interview, resident(s) (R12) and (R13) were involved in a peer-to-peer incident in which both residents made physical contact with each other in the corridor of the first-floor dining room. During the incident (R13) attempted to his position from his wheelchair and slipped down to the floor as staff intervened and separated both residents. (R13) was assessed by nursing and noted with a laceration to his forehead. (R13) was transferred to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide sufficient staffing to ensure ADL (Activities of Daily Living) care was provided for dependent residents who required assistance with bladder and bowel incontinence for one(R1) of three residents reviewed for ADL care. Findings include: R1's MDS (Minimum Data Set) section C -Cognitive functions dated [DATE], Document R1's BIMS (Brief Interview for Mental Status) as 2/15, indicating R1 has severe cognitive impairment. R1's MDS section GG (Functional Abilities and Goals) with assessment reference date of 11/01/2023 documents R1 is dependent for toilet transfer, Shower/bathe self, Oral hygiene, Upper/lower body dressing, putting on/taking off footwear. R1's current face sheet documents R1 was first admitted to the facility on [DATE] and re-entered the facility on 11/21/2023 and lists R1 medical diagnosis to include but not limited to: Cerebral infarction, unspecified, malignant neoplasm of endometrium, other lack of coordination. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to follow their policy to identify residents at risk for impaired nutritional status, adjust nutritional interventions and notify the family of persistent decline in appetite and food intake. This failure affected 1 resident (R8) of 3 residents reviewed for nutrition. Findings include: On 11/28/23 at 12:06 PM, R8 stated R8 did not eat any breakfast this morning. R8 stated, I eat what I want, when I want and I buy snacks from the vending machine and order out for food a couple of times per week. I don't really eat the food here. On 11/28/23 at 1:10 PM, V19 (Certified Nursing Assistant) stated R8 routinely refuses meals. V19 stated on occasion R8 will pick at one food item on the tray but that R8 usually only drinks the coffee off the tray, refusing everything else most of the time. V19 stated R8 eats a lot of snacks from the vending machine and will eat food from outside the facility. V19 stated R8 refused breakfast and lunch tray today. V19…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and interviews, the facility failed to provide sufficient staffing to ensure ADL (Activities of Daily Living) care was provided for dependent residents who required assistance with bladder and bowel incontinence for one of three residents (R1) reviewed for ADL care. Findings include: R1's MDS (Minimum Data Set) section C -Cognitive functions dated [DATE], Document R1's BIMS (Brief Interview for Mental Status) as 2/15, indicating R1 has severe cognitive impairment. R1's MDS section GG (Functional Abilities and Goals) with assessment reference date of 11/01/2023 documents R1 is dependent for toilet transfer, Shower/bathe self, Oral hygiene, Upper/lower body dressing, putting on/taking off footwear. R1's current face sheet documents R1 was first admitted to the facility on [DATE] and re-entered the facility on 11/21/2023 and lists R1 medical diagnosis to include but not limited to: Cerebral infarction, unspecified, malignant neoplasm of endometrium, other lack of coordination. On 11/28/2023 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 record review and interview the facility failed to protect residents from being abused and failed to immediately intervene in situations before residents became physically aggressive towards their peers for four (4) of six (6) residents (R4, R5, R6, R7) reviewed abuse. Findings Include: Facility's abuse report dated 8/27/23 denotes brief description of Incident: Facility received report that R4 and R5 were involved in an unwitnessed peer to peer incident. R4 was interviewed and stated R5 came into his room and was going through his belongings. R4 was yelling for her to leave his room and a staff member then escorted R5 from his room. R4 appeared agitated and was sent out for behavior per physician order. R4's 8/23/2023 15:09 Social Service Note Text reads: Behavior Note: Per staff's report, resident was inappropriate towards staff. Resident was counseled and educated on refraining from inappropriate behaviors towards staff. Resident was educated and advised to bring issues or concerns to staff for immediate intervention. Staff will continue to monitor and follow up on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon observation, interview and record review the facility failed to ensure that R3's activities care plan was accurate, complete and/or had attainable goals, failed to provide 1:1 activities to one of three residents (R3) reviewed for accommodation of needs, failed to follow the activities program policy and failed to ensure that staff have access to resident electronic medical records to document activities participation/attendance. Findings include: On (6/9/23) IDPH (Illinois Department of Public Health) received allegations that the facility is not involving R3 in activities like painting and/or art. R3's diagnoses include pseudobulbar affect and aphasia. R3's (6/14/23) BIMS (Brief Interview Mental Status) determined a score of 1 (severely impaired). R3's (6/14/23) functional assessment affirms (1-2 person) physical assist is required for ADL's (Activities of Daily Living) care. R3's (6/14/23) preferences for activities assessment includes listening to music: yes however additional activity preferences…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 shift change accountability records for controlled substances that enables periodic reconciliation and accounting for residents'controlled medications and failed to ensure that controlled medications are placed into a secured storage area and double locked. These failures have the potential to affect all 180 residents residing in the facility as of census dated 6/6/23. The findings include: On 6/7/23 at 11:07am Second floor medication storage room was inspected with V19 (Nursing Manager). Observed with white refrigerator inside the medication room, lock is broken. V19 confirmed that refrigerator locked was broken and maintenance was informed. Observed a box with no lock with the following medications: Lorazepam oral solution 2mg/ml; Morphine sulfate solution 20mg/ml R190. V19 stated that those medications came from hospice company. V19 stated that controlled medications such as morphine and lorazepam should be kept in double locked. At 12:15 PM First floor medication storage room was inspected…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policy and procedures for medication storage and labeling to: Discard expired house-stock medications and supplements as well as an expired resident-specific medication for one resident (R20). Discard expired medications from the convenience box inside the refrigerator. Ensure personal food items were not stored in medication carts. Ensure that food is not stored in the refrigerator where medications are stored. Ensure that medications are stored in an orderly manner in refrigerator of sufficient size to prevent crowding. Label a multi-dose insulin pen and inhalers with an open date for four residents (R18, R27, R45, R84). These failures affected R18, R27, R45 AND R84 in the sample of 35 residents and have the potential to affect all 180 residents residing in the facility to facilitate precautions and safe administration of medications reviewed for medication storage and labeling in 2 of 3 medication storage rooms and 3 of 6 medication carts inspected in each floor or unit. The findings include: On…

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

Based on observation, interview and record review, the facility failed to ensure a.) food items were properly labeled, dated, and stored, b.) proper use of hair restraints worn by staff, c.) hand washing policy followed, d.) cook/service ware sanitized according to manufacturer guidelines. These deficient practices have the potential to affect all 173 residents receiving food prepared in the facility's kitchen. Findings include: On 06/06/23 at 9:20 AM, during initial kitchen tour observed V6 (Cook) working in the kitchen prep-area without wearing a hairnet. When surveyor inquired about V6's hairnet V6 said, I just took it off. I'm about to go on break soon. V6 stated the purpose of wearing a hairnet is so that V6's hair does not fall into resident food. On 06/06/23 at 9:24 AM, V5 (Assistant Dietary Manager) stated all food items are labeled with a delivery date, an open date and a use by date unless labeled with manufacturers use by date. V5 stated any food item over five days is discarded. On 06/06/23 at 9:25 AM, observed in the walk-in refrigerator the following items: 1.) Opened…

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

Based on interviews and record reviews, the facility failed to provide a policy for COVID-19 Immunization for staff and residents and failed to provide documentation for two residents (R59, R80) who declined the vaccine. This has the potential to affect all180 residents that reside in the facility. Findings include: On 06/06/2023 at 09:11 AM, survey team conducted the facility entrance and requested the infection control policies from V1 (Administrator). These documents included the facility's COVID-19 Immunization Policy and Procedures. The facility was to provide this document within four hours of the entrance. At 10:35 AM, surveyor emailed V1 and V2 (Director of Nursing) a list of documents needed to review the facility's infection control practices. These included the COVID-19 Immunization Policy and Procedures and their mechanism of choice for tracking residents' COVID-19 immunization statuses. On 06/07/2023 at 11:54 AM, V3 (Infection Preventionist) provided facility's COVID-19 immunization tracker for the residents. The tracker was incomplete and did not include all the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to properly assess and provide specific services needed based on diagnosis when failing to initiate a level II Pre-admission Screening and Resident Review (PASARR) for 7 (R2, R3, R59, R78, R81, R82, R94) residents reviewed for PASARR in a sample of 35. Findings included: A review of the medical record revealed R2 was admitted to the facility on [DATE] with diagnosis not limited to Major Depressive Disorder, Schizophrenia. On 10/01/22 R2 primary diagnosis was documented as Psychotic Disturbance, Mood Disturbance and Anxiety. A review of R2 care plan dated 06/14/22 document in part: R2 requires psychotic medication for Major Depression and Schizophrenia. Interventions: Complete psychotropic evaluation and assessment consistent with protocol. The Order Summary Report dated 06/08/23 document in part: Quetiapine 100 MG (Milligram) daily, Quetiapine 200 MG (Milligram) at bedtime for Behavior Disturbance and Vistaril 25 MG twice a day for Agitation and Anxiety.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure that wound dressing was in place for one (R25) resident and maintain appropriate setting for low air loss mattress for three (R2, R35, R124) residents. These failures have the potential to affect four (R2, R25, R35, R124) of five residents reviewed for pressure ulcer in a sample of 35. The findings include: R2 admission date documented 2/14/23 with diagnoses not limited to Unspecified dementia, Major depressive disorder, Primary generalized osteoarthritis, Seizures, Muscle wasting, Type 2 diabetes mellitus, Generalized muscle weakness, Dysphagia, Insomnia, Hypothyroidism, Schizophrenia, Essential hypertension, Immunodeficiency. R25 admission date documented 1/28/23 with diagnoses not limited to Pathological hip fracture, Type 2 diabetes mellitus, Unspecified dementia, Metabolic encephalopathy, Gastro-esophageal reflux disease. R124 admission date documented 3/3/23 with diagnoses not limited to Metabolic encephalopathy,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 'Oxygen Administration' policy by not labeling oxygen equipment and replacing oxygen tubing, humidifier bottles and nebulizer equipment weekly and failed to follow infection control measures to properly store oxygen tubing when not in use. This affected 4 (R93, R110, R111, R181) out of a total sample of 35 residents. Findings include: R181 is a resident of the facility. Face sheet documents in part medical diagnoses of tracheostomy status, acute and chronic respiratory failure with hypoxia, and chronic obstructive disease. R181's comprehensive care plan contains a focus, initiated 06/02/2023, that documents in part that R181's has altered respiratory function secondary to chronic obstructive pulmonary disease. R181's physician order sheets document in part: Oxygen at 6 liters/minute via trach collar continuously. Physician order sheets also document in part: Change trach collar and tubing as needed for infection control AND every day shift every 7 day(s) for infection control. On 06/06/2023 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 follow pureed menu and recipes and failed to give adequate portion sizes of pureed food to 11 residents (R2, R25, R35, R36, R74, R78, R79, R97, R101, R159 and R241) out of 8 residents reviewed for menus and nutritional adequacy in a sample of 35. Findings include: On 06/06/23 at 11:46 AM, observed V6 (Cook) use a numbered 16 scoop (blue) and counted out 12 portions of pieces of breaded fish and placed in blender to pureed. V6 stated the blue scoop was equivalent to 2 ounces. V6 added water to the pureed fish but did not measure out the amount of water before adding to the fish. Surveyor observed that V6 did not follow any recipe. V6 stated, the recipes are in those binders over there somewhere. On 06/06/23 at 12:05 PM, after puree fish preparation V6 stated now I put the pureed fish in a pan and put it on the steam table for tray line service. At 12:23 PM, the lunch tray line started, and surveyor did not observe V6, or any other staff take the temperatures of the pureed foods on the tray line. At 12:30 PM, 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.

Based on observations, interviews, and record reviews, the facility failed to contain and transport soiled linen in a manner that prevents or limits the spread of infection and don personal protective equipment (PPE) during patient care for a resident (R125). This has the potential to affect all 48 residents that reside on the first floor. Findings include: R80 is a resident at the facility. R80's physician order sheets read an active order as of 06/04/2023 to maintain contact isolation related to an infection in the urine. R80's comprehensive care plan contains a focus initiated on 06/06/2023 that documents in part that R80 is on isolation related to an infection. On 06/06/2023 at 11:53 AM, surveyor observed a contact isolation sign posted on R80's door. A PPE bin was outside the door in the hallway. Next to the PPE bin was a blue geriatric chair. There were soiled linens and an incontinence pad on the chair. Incontinence pad had brown stains. No staff in the immediate vicinity. At 12:28 PM, the dirty linen remained on the geriatric chair outside of R80's room. At 12:32 PM,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 vaccinations to five (R38, R37, R52, R59, and R80) of five residents reviewed for pneumococcal and influenza vaccinations. Findings Include: 1.Review of R38's electronic medical record (EMR) revealed R38 was admitted to the facility on [DATE] and is [AGE] years of age with diagnoses that included but were not limited to: stage 3 chronic kidney disease, anemia, and heart failure. Review of R38's current physician orders with active orders as of 6/8/23 revealed R38 had no orders to receive pneumococcal and influenza vaccinations. Further review of R38's EMR revealed no documentation indicating the facility assessed R38's eligibility to receive the pneumococcal and influenza vaccinations and/or that R38 was provided education related to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY FACILITY Based on interview and record review, the facility failed to complete the quarterly Minimum Data Set (MDS) assessment using the CMS-specified Resident Assessment Instrument (RAI) process within the regulatory timeframe for 1 (R149) of 1 resident reviewed for quarterly resident assessment in a sample of 35. Findings Include: On 6/7/23 at 3:09 PM, R149's electronic health record (EHR) reviewed. R149 was admitted on [DATE]. R149's Quarterly MDS assessment with assessment reference date (ARD) of 10/7/22 was completed on 10/24/22 past the 14 days regulatory timeframe. At 3:24 PM, interviewed V28 (MDS Director) and stated that Quarterly MDS assessment's ARD is set 92 days from the last ARD MDS assessment and should be completed within 7 days from the ARD. V28 stated that scheduling and completion timing of the MDS assessments are based on the RAI manual. The facility's RAI Version 3.0 Manual dated October 2018 page 2-17 titled RAI OBRA-required Assessment Summary indicates that Quarterly (Non-Comprehensive)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 by not following physician orders for a resident's (R181) enteral feeding for 1 out of 4 residents reviewed in a total sample of 35 residents. Findings include: R181 is a resident of the facility. R181's face sheet documents in part diagnoses of gastrostomy status and dysphagia-oropharyngeal phase. R181's comprehensive care plan contains focuses, dated 06/02/2023, that documents in part that R181 demonstrates some risk to potentially choke or aspirate food or liquids relating to dysphagia. R181 requires tube feeding related to dysphagia. Intervention dated 06/02/2023 documents in part: Provide diet, as ordered. On 06/06/2023 at 11:10 AM, R181 was lying in bed. R181's enteral feeding was running at 65 milliliters per hour (ml/hr). At 2:45 PM, surveyor reviewed R181's physician orders. There were two orders for the enteral feeding. Both orders dated 06/05/2023 document in part to run the feeding at 75 ml/hr. At 2:58 PM, surveyor went to R181's room to verify the enteral feeding. Enteral…

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

Based on interviews and record reviews, the facility failed to ensure that as needed (PRN) psychotropic medication be evaluated if medication is to be extended longer than 14 days for continued use. This failure has the potential to affect one (R78) of five residents reviewed for unnecessary medications in a sample of 35. The findings include: R78 admission date documented 5/10/23 with diagnoses not limited to Parkinson's disease, Type 2 diabetes mellitus, Dysphagia, Unspecified psychosis, Major depressive disorder, Insomnia, Anxiety disorder, Dementia, Hyperlipidemia, Anemia, Heart failure, Essential hypertension, Overactive bladder. R78 order summary report documented in part: Lorazepam Oral Tablet 0.5 MG (Lorazepam) Give 0.5 mg by mouth every 8 hours as needed for anxiety order date 5/10/23. R78 Psychiatric progress notes dated 5/14/2023 documented in part: Patient seen for routine evaluation with no complaints noted. Assessment/Plan: Dementia/ Major Depressive Disorder 1. Stable on Lexapro and PRN Ativan regimen. 2. Per Staff no agitation, no aggressive behavior or resistance 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 observations, interviews, and record reviews the facility failed to ensure a medication error rate of less than 5% for one (R176) of four residents in the sample reviewed for medication administration. There were 25 opportunities and 2 errors resulting in 8% medication error rate. The findings include: R176 admission date was on 5/5/23 with diagnoses not limited to Chronic obstructive pulmonary disease, Type 2 diabetes mellitus, Heart failure, Atherosclerotic heart disease, Chronic bronchitis, Bilateral primary osteoarthritis of hip, Essential hypertension. On 6/6/23 at 11:10am Medication administration observation done with V20 (Licensed Practical Nurse - LPN). Observed V20 checked R176's Blood pressure (BP) = 104/67; Pulse rate = 86/min. Observed R176 lying in bed, on moderate high back rest, alert and verbally responsive. V20 prepared the following medications: Bumetanide 1mg (milligram) 1 tablet; Loratadine 10mg 1 tablet; Carvedilol 6.25mg 1 tablet. V20 poured Polyethylene glycol powder in medication cup about 8ml (milliliter). V20 transferred 8ml Polyethylene glycol…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a functioning call light for 1 (R38) resident out of a total sample of 35 residents. Findings include: R38 is a resident of the facility. R38's comprehensive care plan contains a focus dated 05/19/2023 that documents in part that R38 requires total assistance with two staff members for transfers. On 06/06/2023 at 12:11 PM, R38 stated [R38's] call light does not work. R38 stated needs staff assistance to transfer in and out of bed. R38 pressed the call light button repeatedly. Surveyor checked the call light outside of R38's room. The two light indicators above R38's door were not on. R38 pressed the call light button again. R38 stated you can't get anybody in here. At 12:14 PM, V14 (CNA, Certified Nurse Aide) passed by R38's room. Did not take note of R38's room or call light. At 12:15 PM, surveyor went to the nurses' station to see if R38's call light reflected at the station. No beeping/buzzing heard. Call light panel with room numbers was not lit up for R38's room. No indication at nurses'…

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