Landmark of Lincoln Park Rehabilitation and Nursin

Based on observation, interview, and record review, the facility failed to refrigerate unopened insulin pens, label multi-dose medications, discard expired medications, and monitor refrigerator temperatures. These failures affected seven residents (R1, R50, R64, R67, R74, R97, R100) and has the potential to affect all 57 residents on the 3rd floor. Findings include: The (06/09/2025) 3rd floor census was 57 residents. On 06/09/2025 at 11:34 am, during the medication storage and labeling task with V6 (Registered Nurse) of the 3rd floor Team 1 cart with the following observations: 1. R67's Latanoprost has no open date. 2. R64's unopened Insulin Glargine in the med cart. R64's unopened Glargine has pharmacy auxiliary label which read Refrigerate. 3. R50's fluticasone nasal spray has no open date. On 06/09/2025 at 11:43 am, V6 stated her (R64) unopened Lantus (Insulin Glargine) should be stored in the refrigerator. Latanoprost and Fluticasone should have open dates, so V6 knows how long these have been opened to prevent giving expired medications to residents. On 06/09/2025 at 11:50 am,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide thermometers and maintain refrigerator logs for four residents' personal refrigerators. These failures affected four (R112, R120, R132, R550) of four residents reviewed for safe storage of personal food in a sample of 64. Findings include: On 6/09/2025 at 10:54am during observation of R120's personal refrigerator the following was observed: R120's Refrigerator Temperature Log Month/Year 3/2025 had missing initials and temperatures on 3/1/25, 3/2/25, 3/7/25, 3/8/25, 3/9/25, 3/10/25, 3/11/25, 3/13/25, 3/14/25, 3/15/25, 3/16/25, 3/17/25, 3/18/25, 3/19/25, 3/20/25, 3/21/25, 3/22/25, 3/23/25, 3/24/25, 3/25/25, 3/26/25, 3/27/25, 3/28/25, 3/29/25, 3/30/25, and 3/31/25. R120's Refrigerator Temperature Log Month/Year 6/2025 with missing initials and temperatures on 6/1/25, 6/2/25, 6/3/25, 6/4/25, 6/5/25, 6/6/25, 6/7/25, and 6/8/25. On 6/09/25 at 10:54 am, R120 said, Yes, this is my (R120) fridge. My friend brings me food in all the time.…

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

Based on observation, interview, and record review, the facility failed to ensure that the call lights were accessible as stated in the care plans. This failure affected two (R14 and R88) of two resident reviewed for accommodation of needs in a sample of 64. Findings include: 1. On 6/9/25 at 11:38 am, R88 was observed awake in bed trying to feel where his call light was located. R88 stated, Please, can you help find the call light? Do you know I'm blind? I think the staff that came to change me this morning did not put the call light back here. V4 (Assistant Director of Nursing) was notified at the nursing station. V4 came and got the call light from between the siderail and the floor and stated that staff will be reminded to always put resident's call light where he can reach it. R88's records reviewed are as follows: Face sheet shows diagnoses which include but are not limited to Encephalopathy, Weakness, Acquired Absence of Left Leg Below Knee, Osteomyelitis, And Reduced Mobility. Care plan dated 10/5/22 states in part that R88 have self-care deficits. Interventions states to be…

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

Based on record review and staff interview, the facility failed to provide clinical rationale or physician documentation justifying the increase in dosage of a psychotropic medication. This affected one of one resident (R102) reviewed for appropriate and necessary use of psychotropic medications in a sample of 64. Findings include: R102's Face Sheet dated 6/11/2025 documents in part a diagnosis of but not limited to Depression, Schizoaffective Disorder/Bipolar Type, Major Depressive Disorder, Alcoholism-Dependence/Withdrawal, and anxiety disorder. R102's Physician Order Sheet dated 6/11/2025 documents an active order dated 5/14/2025 with a start date of 5/15/2025, Venlafaxine HCL ER Oral Tablet Extended Release 24 Hour 150 MG Give 300 mg by mouth one time a day related to major depressive disorder, single episode, severe psychotic features. R102's Minimum Data Set-Section C dated April 15, 2025 documents a BIMS (Brief Interview Mental Status) of 15 which indicates R102 is cognitively intact. R102's Primary Physician: All Progress Note Type with an Effective date of 5/8/2025 authored…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide range of motion exercises and apply restorative devices, potentially contributing to the progression of contractures. This deficient practice affected three (R57, R73, and R74) of three residents reviewed for restorative care in a sample of 64. Findings include: 1. On 06/9/25 at 10:08 AM, R73 was observed in bed no hand protector/splint in place. On 6/11/2025 at 9:45 AM, R73 was observed in bed resting with contractures to R73's right and left hand. No hand splits, hand rolls or other restorative braces/services observed in place. V30 (Restorative Nurse, Licensed Practical Nurse) and V31 (Certified Nursing Assistant) entered the room, observed R73 and affirmed that no hand protectors, braces, or other restorative braces/services were in place. V30 stated R73 is on Passive range of motion programs for all extremities and is to receive two sets of 10 reps (repetitions) and wear bilateral splints for hands but can alternate with…

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

Based on observations, interviews, and record review, the facility failed to ensure controlled medications were stored in a double locked setting, failed to ensure completed controlled medications were returned to the pharmacy, and failed to ensure out going nurse signed the Narcotic/Controlled Substance Shift-to-Shift Count Sheet. These failures affected 3 (R14, R106, and R150) residents reviewed for controlled medications in the total sample of 64 residents. Findings include: On 06/09/2025 at 11:52 am, during the medication storage task with V7 (Licensed Practice Nurse). V7 opened the 3rd floor medication storage room using a key code. There was a small refrigerator inside the 3rd floor medication storage room. V7 opened the small refrigerator by unlatching the door. This surveyor inquired if the refrigerator was locked. V7 stated there is no lock, I just unlatched it. Requested V7 to check if the small refrigerator has controlled substances. V7 showed R14's two boxes of Lorazepam 2mg/ml. V7 stated the refrigerator should be locked because we have controlled medications in 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 document review the facility failed to ensure resident the right to be free from abuse in 2 of 4 residents included in a total sample of 8 residents. Findings include: R2 is a [AGE] year old female with a diagnosis including Emphysema, Hypothyroidism and Liver disease. R2 was first admitted to the facility on [DATE]. R2's BIMS (Brief Interview of Mental Status) score is 15/15. R2 care plans include conflictual, difficult behavior with other persons. Symptoms are manifested by covert/open conflict with of repeated criticism of staff. Behavior is manifested by unprovoked expressions of anger towards staff and peers. Behaviors of false allegations, initiates false reports and allegations of mistreatment perpetrated by others. History of aggression, accused of being inconsiderate to her roommates feelings as well as being discourteous. R2 is also care planned for being susceptible to abuse. R3 is a [AGE] year old male with a diagnosis including Vertebra fracture, Neurogenic bowel, 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 interview and record review, the facility failed to prevent and protect residents from resident-to-resident physical and verbal abuse. This failure affects two (R2, R4) residents out of five residents reviewed for abuse in a total sample of five. As a result of this failure, R1 pushed R2 on 04/6/25. R1 punched and yelled derogatory words to R4 on 04/29/25. Findings include: Facility reported incident/FRI dated 04/06/2025, documents the facility reported an altercation between R1 and R2. FRI documents R1 made alleged contact with R2. Staff intervened and separated R1 and R2. Facility reported incident/FRI dated 04/29/2025, documents the facility reported an altercation between R1 and R4. FRI documents R1 made alleged contact with R4. Staff intervened and separated R1 and R4. 1. On 05/07/2025, at 2:15 PM, R2 was laying on his bed, easily aroused, and in no apparent distress. R2 stated he got a minor scrape on his right elbow during the incident that had to do with R1. R2 reports he and R1 argued because…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 meet the needs of residents by not responding to the nurse call activation in a timely manner in 3 of 10 residents included in the sample. Findings include: Resident Council Meeting Minutes for January 2025 includes a statement that CNAs are not responding to call lights. They are constantly hiding, sleeping, and disappearing especially at meal time. Noted to have nasty dispositions. They are rude and hostile. Always talking on the phone. Concerns are listed every month no changes this far. Residents requesting for ice and water have to go find a CNA. Resident Council Meeting Minutes for February 2025 include statement Residents are not being changed on time. Call lights are on for a very long time. On 3/19/25 at 12:35AM R1 stated, There is a real problem with the CNAs here. They don't answer the nurse calls on any shift and it is worse on the night shift. Sometimes I activate the call and it can take two hours for a CNA to answer. Sometimes they never show up. This is ongoing and other residents are bringing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the right to be free of abuse in 2 (R1, R2) of 4 residents resulting in minor injury to R1 and R2. Findings include: R1 is a [AGE] year old female with a diagnosis including Diabetes 2, Anxiety Disorder, Heart Disease and Pyoderma Gangrenosum. R1 was first admitted to the facility on [DATE]. R1 has a BIMS (Brief Interview for Mental Status) score of 15/15. R2 is a [AGE] year old female with a diagnosis including Diabetes 2, Chronic Respiratory Failure, Peripheral Vascular Disease and Congestive Heart Failure. R2 was first admitted to the facility on [DATE]. R2 has a BIMS (Brief Interview for Mental Status) score of 15/15. Facility Resident Abuse Investigation dated 2/21/25 shows R1 made contact with R2. Staff intervened and separated R1 and R2. Body assessment completed with no pain noted from both parties. R1 and R2 placed on increased monitoring and transferred out of facility for a psych evaluation. Family and MD notification made. R1 and R2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policy to ensure a resident is free from abuse. This failure affected 1 (R2) out of 3 residents reviewed for abuse. The findings include: R2's admission record showed admission date on 10/16/2023 with diagnoses not limited to Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, Cerebral infarction, Chronic respiratory failure, Unspecified convulsions, Psychotic disorder with delusions due to known physiological condition, Alcohol abuse, Bipolar disorder, Major depressive disorder, Anxiety disorder, Essential (primary) hypertension. MDS (minimum data set) dated 9/25/2024 showed R2's cognition was moderately impaired. On 12/17/24 at 12:40 PM Surveyor observed R2 sitting up on the side of the bed, alert, and oriented x 3, verbally responsive. R2 stated he is ambulatory with walker / rollator. R2 was able to remember the incident that happened on 11/30/24 and stated he was coming…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent staff (V3-Former Receptionist) from verbally abusing one of three residents (R2), reviewed for abuse in a total sample of three residents. Findings include: R2's Face Sheet documents R2 is a [AGE] year-old admitted to the facility on 8.3.2021, with diagnoses including but not limited to: Diabetes Mellitus with Hyperglycemia, Venous Insufficiency (Chronic) (Peripheral), Lack of Coordination, and Morbid (Severe) Obesity Due to Excess Calories. R2's MDS (Minimum Data Set, dated 9.24.2024) documents R2's BIMS (Brief Interview for Mental Status) as 15 or cognitively intact. Facility's Final Incident Report of 9.13.2024, documents: Brief Description of Incident: Resident (R2) alleged that receptionist (V3-Former Receptionist) was verbally discourteous to her (R2). Immediate Action Taken: Body assessment completed with no findings. (R2) states she feels safe in the facility. (R2) declined (local police) involvement. (R2) was assessed for safety. No…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to provide a scheduled pain medication per doctor's order for effective pain management treatment for one (R1) resident out of four residents reviewed. Findings include: R1's Face sheet documents R1 is a [AGE] year-old female admitted to the facility on [DATE] who has diagnoses not limited to: limited to progressive systemic sclerosis, Raynaud's syndrome without gangrene, other abnormalities of gait and mobility, unspecified lack of coordination, weakness. 08/20/2024 10:23 AM observed V3 (Registered Nurse) standing by the nurse's medication cart. V3 stated she has been working for the facility for three months. V3 stated she has two more residents to give out morning medications to. V3 stated she will be passing out medications to R1 and R3. 08/20/2024 10:25 AM observed V3 take R1's blood pressure reading via wrist blood pressure monitor. R1 observed lying on her bed, wearing own clothes. Observed R1's blood pressure reading to be 108/78, pulse-121. V3…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide medication in compliance with standards of professional practice and facility policy for one resident (R5) out of a sample of two residents. Findings: On 7/9/2024 at 10 AM R5's rt knee was observed. A white patch with the word Lidocaine was observed rolled in a trifold on the right lateral knee with a handwritten date of 7/7/2024 on the patch. R5 stated, That pain patch has been on a few days. The left knee was observed to have a white patch with the word Lidocaine across the distal left knee. R5 stated, They put that pain patch on the other day. There was no date on left knee lidocaine patch. On 7/9/2024 at 10:30 AM V4 (Licensed Practical Nurse) stated, I am not sure how often we are changing the right knee lidocaine pain patch. The patch on the right knee is dated 7/7/2024. I will need to check on the left knee pain patch too. There is no date on the left knee patch. V4 reviewed R5's orders and stated that there is no order for Lidocaine patches. V4 stated, I didn't even know that she had lidocaine…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 perform criminal background checks for new residents within 24 hours of admission and failed to obtain fingerprint order within 72 hours of a hit on the preliminary criminal history search. These failures affected R44, R50, R114, R119, R123, R128, R134, R135, R292 and R293 in the sample of 59 residents reviewed for abuse and have the potential to affect all 137 residents residing in the facility. Findings include: The facility Midnight Census Report dated 5/20/24 documents, in part, that there are 137 active residents in the facility. On 5/22/24 at 12:12pm, V1 (Administrator) said, I (V1) am familiar with screening residents. If the facility is accepting a resident, we (facility) should put the resident in an isolated room until the CHIRP (Criminal History Information Response Process) results are received. I (V1) hope they are doing that here. This protects all residents in the facility. Admissions would know more about this. On 5/22/24 at 12:15pm, V33 (Admissions Director) stated, Social Services is mainly in charge 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 interview and record review, the facility failed to ensure Health Care Worker Background Checks were thoroughly complete and done in a timely manner in an effort to prevent abuse. This failure has the potential to affect all 137 residents residing in the facility. Findings include: The facility Midnight Census Report dated 5/20/24 documents, in part, that there are 137 active residents in the facility. On 5/22/24 at 11:30am, V34 (Regional Human Resource Director) said, The facility runs state and criminal background checks on employees to ensure the residents will be safe. We (facility) do a second check on abuse and neglect as well. Employees are checked within 10 days of hire. When we (facility) receive the results of the background check we (facility) look at whether the state says an employee is eligible for hire or not. On 5/22/24 at 11:41am, this surveyor and V34 (Regional Human Resource Director) discussed the Health Care Worker Background Check as follows: V26's (Cook) paper file was reviewed. V26's Illinois Department of Public Health: Health Care Worker Registry,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and failed to ensure the daily nursing staffing information was complete and accurate. These failures have the potential to affect all 137 residents residing in the facility. Findings include: On 5/20/24 at 9:00am, upon entrance to the facility, surveyor observed daily nursing staffing posted with a date of 5/17/24 near the receptionist area. On 5/20/2024 at 11:23am this surveyor observed the Daily Nursing Staffing posted with a date of 5/17/2024. This surveyor inquired with V2 (Director of Nursing) and V2 said, I will ensure an updated one is posted. On 5/20/24 at 11:24am, the 5/17/24 Daily Nursing Staffing was replaced with a current date of 5/20/24 and census of 138. On 5/20/24, V1 (Administrator) confirmed that the resident census is 137 active residents. On 5/21/2024 at 11:47am, V18 (receptionist) stated, I (V18) am responsible for entering the information for the Daily Nursing Staffing and posting it every day. I (V18) was not here on Monday (5/20/24). I (V18) am not sure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review and interview, the facility failed to maintain adequate monitoring of food storage temperatures. This failure has the potential to affect all residents (Census 137) of the facility. Findings include: On 05/20/24 at 10:05 AM Reviewed Milk Cooler refrigerator temperature log dated May 2024. Noted no temperature recordings on log for AM or PM shift on 5/13/24 and no recordings for the PM shift on 5/14/24 and 5/16/24. On 05/20/24 at 10:05 AM V24 (Dietary Manager) confirmed that the temperature log should have been completed two times a day. V24 stated that it is important to track the temperature of the cooler and if milk is not kept to an appropriate temperature, it can cause it to spoil. Facility policy titled Storage of Refrigerated/Frozen Foods, dated 4/2017, documents in part, .Monitoring of food temperatures and functioning of the refrigeration/freezer units will be in place.

Based on observations, interview, and record review, the facility failed to ensure staff dispose of used personnel protective equipment after sorting dirty linens and failed to ensure a sign was posted appropriately for a resident on enhanced barrier precaution in an effort to prevent spread of infectious microorganism. These failures affected R136 and has the potential to affect all the residents at the facility. Findings include: On 05/21/2024 at 12:17pm, there was a blue plastic gown hanging inside the 'Soiled Linen Room located in the Laundry room. V17 (Laundry Aide) stated, as translated by V16 (Laundry Aide), I (V17) use the gown (referring to the gown hanging inside the Soiled Linen room) throughout the shift. I (V17) hang the blue gown so I (V17) can wear it (used blue plastic gown) again when I (V17) sort soiled linens. I (V17) throw the blue plastic gown at the end of the shift. I (V17) work for 8 hours, and I (V17) sort dirty linens about 6times per shift. I (V17) use the same gown during the shift. I (V17) have been working at the facility for 6 years now. I (V17) was…

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

Based on observation, interview, and record review, the facility failed to ensure medication and/or treatment was not left inside the room of a resident whose ability to safely self-administer medications and/or treatments was not assessed. This failure affected 1 (R28) resident reviewed for self-administration of medication and/or treatment and has the potential to affect all 54 residents on the 3rd floor. Findings include: On 05/20/24 at 12:40PM, there was a small plastic bag with a tube inside on top of R28's bedside table. On the plastic bag were stickers with R28's identifier, name of medication, dated 04/04/2024 with instruction to 'apply to right thigh, perineal topically three times a day for skin condition for 10days. This observation was pointed out to V4 (Registered Nurse). V4 stated that is for her (R28) treatment. I (V4) don't have a knowledge of that. On 05/22/2024 at 2:39pm, V36 (MDS Coordinator/LPN) stated she (R28) did not have self-administration of medication careplan. On 05/22/2024 at 12:12pm, V2 (Director of Nursing) stated if a resident is 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 observations, interviews, and records reviewed, the facility failed to provide a home like environment for 5 (R8, R13 R42, R103, and R129) residents reviewed for home like environment in a total sample of 59 residents. Findings include: On 05/20/2024 at 11:30am, there were holes and cracks on the wall inside R8 and R13's room. These were pointed out to V4 (Registered Nurse). V4 stated maybe when the staff pushed the bed, hit the wall and put a dent on the wall. On 05/20/2024 at 11:36am, V6 (Maintenance Assistant) checked R8's and R13's room and stated there are holes, cracks and chipped paints on the wall and window. On 05/20/2024 at 11:38am, surveyor inquired if chipped paints and holes and cracks on the wall provided a home-like environment to residents. V6 stated to tell you honestly, we are not. R8's (05/21/2024) Order Summary Report documented, in part Diagnoses: (include but not limited to) cerebral palsy and spinal stenosis. R8's (03/22/2024) Minimum Data Set documented, in part Section C0500. BIMS (Brief Interview for mental status) Summary Score: 15. Indicating…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the low air loss mattresses were set on appropriate setting for 4 residents (R54, R72, R81, and R82) reviewed for pressure ulcer prevention in the total sample of 59 residents. Findings include: On 05/20/2024 at 11:46am, R72 was lying on a low air loss mattress set at 240lbs alternating every 5minutes. This was pointed out to V4 (Registered Nurse. V4 stated setting of her (R72) low air loss mattress is 240lbs alternating. At this time, surveyor requested V4 to check R72's weight on R72's electronic health record. On 05/20/2024 at 11:50am, V4 stated she (R72) weighs 168.4lbs on 05/08/2024. She (R72) had a pressure ulcer on her (R72) sacrum that has healed. The treatment nurse is responsible for the air mattress. On 05/20/2024 at 11:59am, R81 was lying on a low air loss mattress set at 250lbs, static off. This observations was pointed out to V4 and stated his (R81) mattress is set at 250lbs static off. On 05/20/24 at 12:23 PM, V2 (Director of Nursing) stated the purpose of the low air loss mattress is…

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

Based on observation, interview, and records reviewed, the facility failed to ensure resident information inside the resident's room were not in plain view of other residents and visitor. This failure affected 1 (R39) resident reviewed for dignity in the total sample of 59 residents: Findings include: On 05/20/2024 at 10:45am, there were signs posted 'Patient is now on Honey Thick Liquid. Thank you. Speech Therapy' and 'Aspiration Precautions - HOB (Head of Bed elevated/ EOB. - Tray Set up. - Distant Supervision. - Slow rate. - small cup sips. - No straw. - Alternate puree then cup sip honey thick liquids. - every few bites, clear throat' by R39 head of the bed bulletin board. On 05/20/2024 at 10:46am, V4 (Registered Nurse) stated maybe 'speech' put the signs there (pointing to the signs). On 05/20/2024 at 12:56pm, V10 (Speech Language Pathology/Rehab Manager) stated he (R39) is on honey thick liquid. He (R39) used to be on nectar thick liquid. (V11- SLP) was the one who posted the signs. I (V10) want to make sure the staff follow the signs. On 05/21/2023 at 2:32pm, V23 (Registered…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide communication devices identified on the resident's care plan. This failure affected 1 resident (R54) in a sample of 59 residents. Findings include: On 5/20/24 at 11:39, Observed R54 laying in fowlers position watching television in Spanish. R54 was unable to answer questions in English or Spanish and could only respond using hand gestures. When R54 was asked if he could communicate R54's needs, R54 shrugged R54's shoulder. No communication devices were observed within R54's room. On 5/21/24 at 12:13 PM, V38 (R54's family member) confirmed that R54's primary language is Spanish. V38 stated that the facility is unable to communicate with R54 without accommodations, such as a communication board and Spanish translation services. V38 stated that the facility staff have not utilized any interventions to improve R54's communication impairment. 05/22/24 10:53 AM V28 (Licensed Practical Nurse (LPN) stated that V28 is the nurse responsible…

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

Based on observation, interview and record review, the facility failed to follow facility policy of changing a midline catheter dressing. This applies to 1 (R54) resident reviewed for catheter care in the sample of 59. Findings include: R54's Order Summary Report documents in part an order was given to place midline catheter on 5/15/2024. R54's progress notes documents in part on 5/15/24 at 14:52, Note Text: Resident received midline to left arm, no infiltration noted, receiving 0.9 NSS 110ml/hr On 05/22/24 at 11:01 AM, Observed midline dressing to R54's right upper arm dated 05/15/2024. On observation of midline dressing, noted R54's reddened skin around the chlorohexidine patch under the transparent area of midline catheter dressing. V29 (Registered Nurse (RN) Stated that V29 is responsible for maintaining and administering intravenous (IV) fluids through R54's midline catheter. V29 confirmed that the date (5/15/24) was the date the dressing was applied and has not been changed since. V29 stated that redness near the chlorohexidine patch could be a sign of infection and should be…

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

Based on observation, interview, and record review the facility failed to ensure the nebulizer mask was secured when not in use for one resident (R10) and the oxygen tubing was changed weekly for one resident (R65). These failures affected 2 residents out of a sample of 59 residents. Findings include: On 5/20/2024 at 11:25am observed R10's nebulizer mask sitting on the bedside table which is covered with a white bath towel; the nebulizer mask was not contained in a plastic bag while not in use. On 05/21/2024 at 2:21pm surveyor brought the observation to V19's (LPN/Licensed Practical Nurse) attention; V19 stated the nebulizer mask should have a plastic bag containing the mask when the mask is not in use by the resident. V19 stated the mask is contained in a plastic bag to keep the germs off the mask. On 5/22/2024 at 9:25am V2(DON/Director of Nursing) stated when the nebulizer mask is not in use by the resident, the nebulizer mask is put into a plastic bag. V2 stated placing the nebulizer mask in a plastic bag when not in use by the resident is done for infection control purposes. 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 interview and record review the facility failed to follow their policy and procedure for resident assessment and documentation after a fall/incident for 1 resident (R1) of 3 residents reviewed for improper nursing care. The findings include: R1's health record documented admission date on 10/10/2023 with diagnoses not limited to Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right non-dominant side, Obstructive sleep apnea, End stage renal disease, Dependence on renal dialysis, Heart failure, Malignant neoplasm of bladder, Benign essential microscopic hematuria, Other abnormalities of gait and mobility, Weakness, History of falling, Unspecified sequelae of cerebral infarction, Personal history of transient ischemic attack, and cerebral infarction without residual deficits, Unspecified ptosis of left eyelid, Facial weakness, Dysarthria and anarthria, Conversion disorder with seizures or convulsions, Fistula, left shoulder, Anxiety disorder, Depression, Essential…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide adequate staffing to ensure that restorative services are provided for two residents (R8 and R9). This has the potential to affect all residents that reside in the facility. Findings include: 1. R8's quarterly MDS (Minimum Data Set) assessment dated [DATE] documents in part that R8 is cognitively intact. It also documents R8 has functional impairment/limitation in range of motion to one side of the upper extremity and both lower extremities. R8's comprehensive care plan contains a focus for passive range of motion and active range of motion (initiated 6/21/2022 and last revised 9/12/2022). On 3/26/2024 at 2:43 PM, R8 stated facility is not providing exercises and restorative program. On 3/26/2024 at 3:35 PM, V15 (Restorative Director) stated R8 is not on any restorative program. On 3/27/2024 at 10:15 AM, V25 (Restorative Aide) and V26 (Restorative [NAME]) stated R8 was not on any restorative program. 2. R9's quarterly MDS (Minimum Data Set)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to provide timely incontinence care for R8 out of seven residents reviewed for activities of daily living care. Findings include: R8's face sheet, physician order sheets, and comprehensive care plan document in part hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction (stroke) affecting the left non-dominant side, lack of coordination, abnormalities of gait and mobility, muscle weakness, and weakness. R8's comprehensive care plan contains a focus initiated 3/21/2022. It documents in part that R8 is frequently incontinent of bowel and bladder. Goal, last revised 7/10/2023, is for R8 to be clean, dry and odor free thought the next review date on 4/28/2024. R8's care plan also documents in part that R8 has a self-care deficit and requires assistance with activities of daily living to maintain the highest possible level of functioning (revised 9/12/2022). Intervention initiated 3/21/2022 documents in part that R8…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to follow their policy to conduct quarterly restorative assessments, follow therapy recommendations, follow residents' comprehensive care plan, and provide restorative services for two (R8 and R9) of nine residents reviewed for improper nursing care. Findings include: 1. R8's face sheet, physician order sheets, and comprehensive care plan document in part diagnoses of hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction (stroke) affecting the left non-dominant side, lack of coordination, abnormalities of gait and mobility, muscle weakness, and weakness. R8's quarterly MDS (Minimum Data Set) assessment dated [DATE] documents in part that R8 is cognitively intact. R8 has functional impairment/limitation in range of motion to one side of the upper extremity and both lower extremities. R8's comprehensive care plan contains a focus for passive range of motion initiated 6/21/2022 and last revised 9/12/2022. It…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of records and interviews, the facility failed to follow policy related to confidentiality of medical records and social media policy by using social media platform messages including names, symptoms, placements, smoking and out on pass status of 8 out of 8 residents (R19, R20, R21, R22, R23, R24, R26, and R27) reviewed for privacy and confidentiality. These failures resulted in 8 residents' (R19, R20, R21, R22, R23, R24, R26, R27) information being made available in a social media platform and potentially have their information shared during messaging and accessed by third party. Findings include: On 11/14/2023 at 9:29 AM, V9 (Attorney Representative) stated facility uses a messaging platform that is not safe in maintaining privacy and confidentiality of residents. At 10:10 AM, V9 via email sent documentation of exchanges by staff members in the facility with multiple dates (4/16/2018, 8/30/2021) which showed residents' complete names, symptoms, smoking status, placements, insurance status, and…

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

Based on observation, interview, and record review, the facility failed to follow their policy to administer medications in accordance with written orders of the attending physician. This failure could potentially affect 4 (R9, R12, R14 and R15) residents reviewed for medication administration. On 11/14/23 at 10:36 am Medication administration conducted with V3. Observed V3 prepared the following medications for R12: 1. Allopurinol 100mg 1 tablet. 2. Duloxetine 30mg 3 capsules. 3. Gabapentin 300mg 1 capsule. 4. Isosorbide ER 30mg 1 tablet. 5. Isosorbide ER 60mg 1 tablet. 6. Metoprolol ER 200mg 1 tablet. 7. Methocarbamol 750mg 1 tablet. 8. Pantoprazole 40mg 1 tablet. 9. Nifedipine ER 60mg 1 tablet. 10. Levetiracetam 500mg 1 tablet. 11. Valsartan 40mg 1 tablet. 12. Aspirin 81mg g1 tablet. 13. Artificial tears 1 drop to both eyes. 14. Oxycodone HCL 10mg 1tablet given per R12's request. Observed R12 took all prepared medications by mouth. R12's MAR (Medication Administration Record) and POS (Physician Order Sheet) reviewed with orders not limited to: 1. Allopurinol 100mg give 1 tablet…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and records review, the facility failed to report and initiate an investigation of an injury of unknown source in the time frame required and failed to report an alleged misappropriation of property. This failure affected 2 residents (R4,R1) out of 6 residents reviewed for reporting alleged violations. Findings include: 1. On 11/14/23 at 12:31 pm V43 (R4's Power of Attorney/niece) stated, (R4) fell on September 29th, Friday night. It was after dinner because the roommate, R7 told me. R7 said she heard the fall. I went to visit R4 just to make sure everything was okay with her. I arrived there on 9/30/23 around 3:30 pm and it was a normal visit. No one had called me. I found R4 distressed, she was showing pain in her facial expression, she was grimacing, about to cry, and she was saying that she was in pain 10 out of 10. R4 said in a shaky voice that she had fallen last night. When I asked where, she showed her knee, and it was black. I told V45 (Nurse) and he said, no, she didn't fall, 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 interviews and records review, the facility failed to thoroughly investigate an injury of unknown source/accident and failed to investigate an alleged violation of misappropriation of resident property for one resident (R4) out of 4 residents reviewed for abuse. Findings include: On interview R7 and R8, both R4's roommate said R4 had fallen on 6/29/23. On 11/14/23 at 12:31 pm V43 (R4's Power of Attorney/niece) stated, (R4) fell on September 29th, Friday night. It was after dinner because the roommate, R7 told me. R7 said she heard the fall. I went to visit R4 just to make sure everything was okay with her. I arrived there on 9/30/23 around 3:30 pm and it was a normal visit. No one had called me. I found R4 distressed, she was showing pain in her facial expression, she was grimacing, about to cry, and she was saying that she was in pain 10 out of 10. R4 said in a shaky voice that she had fallen last night. When I asked where, she showed her knee, and it was black. I told V45 (Nurse) and he said, no, 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 observation, interview and record review, the facility failed to follow policy and procedure for food temperature by not maintaining hot foods temperature at a minimum of 135F to prevent the risk of food borne illness. This failure can potentially affect 139 residents residing in the facility as of census dated 8/22/23. The findings include: R1's health record documented admission date of 7/14/23 with diagnoses not limited to Aortic aneurysm of unspecified site, Aneurysm of heart, Atherosclerotic heart disease of native coronary artery without angina pectoris, Other intervertebral disc degeneration lumbar region, Personal history of traumatic brain injury, Migraine without aura, Post-traumatic stress disorder chronic, Difficulty in walking, Unspecified lack of coordination, Schizoaffective disorder bipolar type, Mixed hyperlipidemia. On 8/22/23 at 10:50 am R1 observed sitting on the side of the bed, ambulatory with steady gait, alert and verbally responsive. Appears well groomed, no odor. Stated that breakfast today was dried powder egg, piece of toast, coffee. R1 stated…

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

Based on observation, interview and record review, the facility failed to a.) ensure food items were properly labeled with dates; b.) follow manufacturer guidelines for sanitizing and air-drying cooking equipment; c.) clean walk-in refrigerator and freezer door gaskets. These deficient practices have the potential to affect all 133 residents receiving food prepared in the facility's kitchen. Findings include: On 04/11/23 at 9:20 AM, during initial kitchen tour V21 (Food Service Manager) stated all items are labeled and dated with a delivery date, an open date, and a use by date. On 04/11/23 at 9:30 AM, observed the following items in the walk-in cooler: 1.) Yellow Mustard labeled with delivery date of 07/25/22. One gallon container was opened with 75% still in container. There was no open date or use by date on the yellow mustard container. 2.) Worcestershire Sauce labeled with delivery date of 01/22/22 and opened date 12/7/22. There was no use by date on the container. On 04/11/23 at 9:45 AM, V21 stated each of these items should be labeled with a delivery, an open date, and a use…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dumpster lids were fully closed to prevent the harborage of pests. This deficient sanitation practice has the potential to affect all 133 residents who reside in the facility. Findings include: On 04/11/23 at 12:15 PM, an observation of the outside garbage dumpster was conducted with V21 (Food Service Manager). Surveyor observed that the three lids on the dumpster were in the closed position however the lid on the right side did not lay flat leaving an approximate 4-inch open area. V21 stated the metal on the dumpster is bent upwards and therefore the plastic lid do not lay flat. V21 stated that because of this, animals could get inside the dumpster through this open area. V21 stated if animals were able to get inside the dumpster, they could eat food from the garbage, and this would attract more animals. On 04/13/23 at 11:06 AM, V13 (Housekeeping Director) stated that the housekeeping department uses the outside dumpster to throw garbage in and that V13 educates the housekeeping staff to make sure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 develop policies and procedures to ensure each resident and staff member is educated and offered the COVID-19 vaccine. The facility also failed to provide education regarding the benefits and potential risks associated with COVID-19 vaccine to a resident (R108) who refused vaccination. This failure has the potential to affect all residents in preventing COVID-19 infection. Findings include: On 04/11/2023 at 9:06 AM, survey team conducted the Entrance Conference with V1 (Administrator). Part of the Entrance Conference was to provide the survey team with COVID-19 Healthcare Staff and Resident Vaccination Policies and Procedures These documents are due within four hours of the entrance. Survey team requested these policies and procedures from V4 (Infection Preventionist) at 11:50 AM but did not receive them at the completion of the first survey day. Survey team set up a meeting with V4 on for the following day (04/12/2023) at 10:00 AM to go over the requested policies and procedures. On 04/12/2023 at 10:38 AM, surveyors…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 develop policies and procedures to ensure that all staff are fully vaccinated for COVID-19. This failure has the potential to affect all residents in preventing COVID-19 infection. Findings include: On 04/11/2023 at 9:06 AM, survey team conducted the Entrance Conference with V1 (Administrator). Part of the Entrance Conference was to provide the survey team with COVID-19 Healthcare Staff Vaccination Policies and Procedures and information on how the facility ensures contract staff are compliant with the vaccination requirement. These documents are due within four hours of the entrance. Second request for these documents was through V4 (Infection Preventionist) at 11:50 AM. At 03:27 PM, survey team did not receive the list of contract companies and the rest of the associated documents to ensure COVID-19 staff vaccination. Survey team set up a meeting with V4 on for the following day (04/12/2023) at 10:00 AM to go over the requested documents. On 04/12/2023 at 10:38 AM, surveyors interviewed V4 in private office. V4 stated…

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

Based on observations, interviews and record reviews the facility failed to follow their call light policy to always place the call light in an accessible location for 6 (R22, R45, R79, R110, R111, R123) residents in a sample of 27. Findings Include: On 04/11/23 at 10:20 AM R110 call light was observed connected to the light switch string out of reach over the head of R110. R110 was unaware where the call light was located when asked by the surveyor. R110 has diagnosis not limited to Lack of Coordination, Reduced Mobility, Dependence on Wheelchair and Weakness. R110 MDS (Minimum Data Set) Section C Cognitive Patterns BIMS (Brief Interview for Mental Status) score of 14 indicating cognitively intact. Care Plan document in part: Focus: R110 have a self-care deficit: Impaired Bed Mobility. Requires Extensive Assist for Bed Mobility, requires 1 person assist, General Weakness, Impaired balance and gait dysfunction, Impaired strength and endurance, Musculoskeletal Disorders - Polyarthritis, and COPD (Chronic Obstructive Pulmonary Disease). R110 has a Self-Care Deficit and R110 require…

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

Based on observation, interview, and record review the facility failed to ensure that medications 1 of 6 medication carts were locked while not in use or in view. These deficient practices have the potential to affect 30 residents residing on the first floor of the facility. Finding include, On 4/11/23 at 11:44 AM, Observed V9 [Registered Nurse] prepared the glucose machine to obtain R14's blood glucose level. V9 walked away, and down the hallway from medication cart into R14's room, without locking the medication cart. On 4/11/23 at 11:56 AM, V9 stated, I should have locked the medication cart, before walking down the hallway into R14's room. Residents or other staff could have gone into the medication cart. R14 medical record documents in part; R14 physician order dated 7/25/22-accu check [Blood Glucose] four times a day related to type 2 diabetes mellitus at 6:30 AM, 11:30 AM, 4:30 PM, and 8:30 PM. On 4/13/23 at 10:03 AM, V3 Assistant Director of Nursing] stated, My expectation for all the nurses is to lock the medication cart before walking away from the cart. Nurses should lock…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 menu spreadsheets and recipe for pureed bread for 12 residents receiving a pureed diet consistency in a total sample of 27 residents reviewed. Findings Include: On 04/11/23 at 9:40 AM, during initial kitchen tour observed large supply of fresh bread in dry storage area. On 04/11/23 at 1:03 PM, during lunch tray line service observed pureed diets receiving pureed fish, pureed stewed tomatoes, pureed rice, and pureed fruit. Pureed diets did not receive any pureed bread. Mechanical soft and regular diet consistency diets received baked fish, stewed tomatoes, rice, fruit cup, and a slice of bread. On 04/12/23, V1 provided surveyor with list of residents receiving pureed diets, copy of menu spreadsheets for 04/11/23 and recipe for pureed bread. On 04/12/23 at 11:09 AM, V22 (Cook) stated V22 did not prepare pureed bread yesterday for lunch service and therefore residents on pureed diet did not receive any pureed bread. On 04/13/23 at 11:29 AM, V34 (Registered Dietitian) stated the menus are signed off by…

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

Based on observation, interview, and record review the facility failed to a.) properly store respiratory supplies for one resident (R380); b.) ensure reusable equipment was cleaned after each resident use for seven (R8, R16, R18, R72, R117, R119, R120) residents observed during medication administration. These failures affected eight (R8, R16, R18, R72, R117, R119, R120, R380) of 15 residents reviewed for infection control in the survey sample of 27 residents. Findings include: On 04/11/23 at 09:47 AM V8 (Registered Nurse) was observed obtaining R16 blood pressure with a wrist blood pressure cuff while R16 was sitting in a wheelchair next to the third-floor nurse station with a reading of 113/73 pulse 67. V8 turned to and placed the wrist blood pressure cuff on top of the medication cart without cleaning it. V8 began preparing and administered R16 medications. On 04/11/23 at 09:55 AM V8 (Registered Nurse) returned to the medication cart, obtained the wrist blood pressure cuff then entered R18 room and stated, I am going to check your blood pressure. V8 obtained R18 blood pressure…

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

Based on interview and record reviews the facility failed to ensure that residents' vaccination status is tracked and to follow facility's policy and procedure for influenza and pneumococcal immunization to provide education regarding immunization for five (R50, R69, R74, R95 R108) residents reviewed for immunization in a sample of 27. The findings include: On 4/12/23 at 10:30 AM reviewed records of the following residents: 1. R74 initial admission was on 7/1/2022 with diagnosis not limited to Acute respiratory failure with hypoxia, Chronic obstructive pulmonary disease, Essential hypertension. R74 electronic health record (EHR) with no documentation regarding pneumococcal vaccine. No education regarding pneumococcal vaccine provided by facility. Reviewed pneumococcal immunization report of R74 no documentation found. 2. R108 initial admission was on 11/9/21 with diagnosis not limited to Unspecified protein calorie malnutrition, weakness, personal history of Covid-19. R108 Influenza immunization report documented in part: refused Influenza immunization (no date); Pneumovax 23 TBD…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 privacy and confidentiality for one [R14] resident's personal medication administration record. These deficient practices have the potential to affect 30 residents residing on the first floor of the facility. Finding include, On 4/11/23 at 11:44 AM, Observed V9 [Registered Nurse] prepared glucose machine to obtain R14's blood glucose level. V9 walked away from the medication cart and down the hallway into R14's room, with the computer screen unlocked exposing R14's mediation administration record on the open screen. On 4/11/23 at 11:56 AM, V9 stated, I should have locked the computer screen to provide privacy, so no one could see R14's information and medications. I forgot to lock the screen. R14 medical record documents in part; R14 physician order dated 7/25/22-accu check [Blood Glucose] four times a day related to type 2 diabetes mellitus at 6:30 AM, 11:30 AM, 4:30 PM, and 8:30 PM. On 4/13/23 at 10:30 AM, V3 [Assistant Director of Nursing] stated, The nurses should lock their computer screens before…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the comprehensive care plan was updated for 1 (R123) resident reviewed for accidents and hazards in a sample of 27. Findings Include: On 04/11/23 at 11:03 AM R123 was observed sitting in a recliner chair in R123 room unsupervised with the call light on the opposite side of the bed out of reach. Upon a physical assessment, R123 was observed to have an indented area to the left side of the head due to a craniotomy. R123 helmet was observed on the window seal. On 04/11/23 at 11:05 AM surveyor asked V8 (Registered Nurse) when does R123 wear the helmet. V8 stated they put on R123 helmet when he (R123) goes to the dining room. R123 was admitted on [DATE] with diagnosis not limited to Restlessness and Agitation, Nontraumatic Intracranial Hemorrhage, Lack of Coordination, Traumatic Brain Compression with Herniation, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Gastrostomy, Encephalopathy, Dysphagia,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 meet professional standards of care in pharmaceutical services for 2 [R72, R120] of 27 sampled residents reviewed. Finding include, On 4/11/23 at 9:54 AM, during medication administration surveyor observed V7 [Licensed Practical Nurse] prepare R72's medications; sertraline HCl Oral Tablet 100 MG, olanzapine Tablet 2.5 MG, Lisinopril Tablet 20 MG, metformin HCl ER Tablet Extended Release 24 Hour 500 MG, finasteride Tablet 5 MG, and cyanocobalamin Tablet 1000 MCG. V7 stated, R72 has a problem swallowing his medication, I will crush all of R72's medications. On 4/11/23 at 12:50 PM V7 [Licensed Practical Nurse] stated, I crushed all R72's morning medications. I usually work on the first floor, and I am not familiar with the residents on this floor [3rd] The nurse-to-nurse report that I received, the night nurse told me that R72 was crush all medications. I do not know the reason why. Metformin Extended release should have not been crushed. I will call R72's physician. 4/12/23 at 11:42 AM, V19 [Pharmacist]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to a.) ensure safety measures for a high fall risk resident were followed for supervision and b.) ensure recommended safety equipment was in use for 1 (R123) resident reviewed for safety in a sample of 27. Findings Include: On 04/11/23 at 11:03 AM R123 was observed sitting in a recliner chair in the room unsupervised with the call light on the opposite side of the bed out of reach. Upon a physical assessment, R123 was observed to have an indented area to the left side of the head due to a craniotomy. R123 helmet was observed on the window seal. On 04/11/23 at 11:05 AM surveyor asked V8 (Registered Nurse) when does R123 wear the helmet. V8 stated, They put on R123 helmet when he (R123) goes to the dining room. Surveyor asked V8 the position of R123 call light. V8 stated, They should put the call light where R123 can reach it. V8 proceed to the opposite side of the bed, unwrapped the call light from the side rail then attempted to place 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, interviews and record reviews the facility failed to follow policy and procedure on oxygen administration to check physician's order for accurate liter flow for one (R11) of 2 residents reviewed for Oxygen use in a sample of 26. The findings include: On 4/11/23 at 10:21 Observed R11 lying on bed, alert and verbally responsive. R11 observed with oxygen via nasal cannula at 5L. At 10:47am V6 stated that R11 is under hospice care and is using oxygen continuously via nasal cannula. On 4/13/23 at 10:35 AM V3 (Assistant Director of Nursing - ADON) and V25 (Regional Nurse Consultant) were interviewed and stated that oxygen administration should have a doctor's order. V25 stated that nurse should check MD's (medical doctor) order for oxygen liter flow and method of administration. V25 stated if there is no order of oxygen and was administered then the nurse is not following physician's order. R11's record reviewed and documented that R11 admission was on 3/8/22 with diagnosis not limited 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 follow their Medication Administration Guidelines for 2[R72, R120] of 5 residents observed during medication administration. Findings include, On 4/11/23 at 9:54 AM, during medication administration surveyor observed V7 [Licensed Practical Nurse] prepare R72's medications; sertraline HCl Oral Tablet 100 MG, olanzapine Tablet 2.5 MG, Lisinopril Tablet 20 MG, metformin HCl ER Tablet Extended Release 24 Hour 500 MG, finasteride Tablet 5 MG, and cyanocobalamin Tablet 1000 MCG. V7 stated, R72 has a problem swallowing his medication, I will crush all of R72's medications. On 4/11/23 at 12:50 PM V7 [Licensed Practical Nurse] stated, I crushed all R72's morning medications. I usually work on the first floor, and I am not familiar with the residents on this floor [3rd] The nurse-to-nurse report that I received, the night nurse told me that R72 was crush all medications. I do not know the reason why. Metformin Extended release should have not been…

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

Based on observations, interviews, and record reviews, the facility failed to maintain a medication error rate below 5% as evidence by 2 medication errors out of 25 opportunities, resulting in a medication error rate of 8% for 2 [R72, R120] of 5 residents observed during medication administration. Findings include, On 4/11/23 at 9:54 AM, during medication administration surveyor observed V7 [Licensed Practical Nurse] prepare R72's medications; sertraline HCl Oral Tablet 100 MG, olanzapine Tablet 2.5 MG, Lisinopril Tablet 20 MG, metformin HCl ER Tablet Extended Release 24 Hour 500 MG, finasteride Tablet 5 MG, and cyanocobalamin Tablet 1000 MCG. V7 stated, R72 has a problem swallowing his medication, I will crush all of R72's medications. On 4/11/23 at 12:50 PM V7 [Licensed Practical Nurse] stated, I crushed all R72's morning medications. I usually work on the first floor, and I am not familiar with the residents on this floor [3rd] The nurse-to-nurse report that I received, the night nurse told me that R72 was crush all medications. I do not know the reason why. Metformin Extended…

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

Based on interviews and record reviews the facility failed to (a) ensure that resident is free of any significant medication errors; (b) follow policy and procedure on medication administration to check physician order before administering medication. These failures apply to one (R55) resident in a sample of 27. The findings include: On 4/11/23 At 11:47am Placed a call to V29 (R55 Son) via phone and stated that he (V29) was informed by facility staff on 4/9/23 (Easter Sunday) that R55 was given Morphine that was not ordered for the R55. V29 stated that R55 was also given a Naloxone after doctor's order. R55 record reviewed and documented that R55 admission date was on 1/12/16 with diagnosis not limited to Hemiplegia and hemiparesis following Cerebral infarction; Type 2 Diabetes Mellitus; Chronic Kidney Disease; Asthma; Unspecified Atrial Fibrillation; Unspecified Dementia; Essential Hypertension. R55's progress notes dated 4/9/23 at 8:00 am documented in part: Per night nurse, the resident received a medication that was not ordered for him. Per nursing report, MD (Medical Doctor)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review of records the facility failed to maintain accurate resident record for a newly admitted resident (R281) with suspected Covid-19 to rule out Covid-19 infection for 1 out of 27 residents records reviewed out of 27 total residents. This failure has the potential to affect 1 resident (R281) in determining correct infection status of the resident. Findings include: On 04/11/2023 at 11:04 AM. R281 was seen in his room alert and verbally able to express his thoughts well during conversation. R281 said he has C. Diff infection when he came from the hospital. On 04/11/2023 at 01:06 PM. R281's discharge hospital records dated 04/07/2023 documented isolation order that reads: Contact precautions and special respiratory precautions due to suspected Covid-19 infection and Contact Plus precautions for Diarrhea. On 04/12/2023 at 11:10 AM. V3 (Assistant Director of Nursing) said, I don't know about infection control. I think V4 (Infection Preventionist) can answer your questions. On 04/12/2023 at 11:43 AM. V4 was informed about isolation orders from 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.