Little Village Nrsg & Rhb Ctr

Based on interview, and record review, the facility failed to protect the resident's right to be free from abuse for two (R51, R92) in a sample of 21 residents. Findings include: Facilities incident report form (11/11/2025 at 5:45 PM) documents in part: R51 and R92 had an altercation in their room. R51 stated R92 hit him in the stomach. R92 stated R51 took his belongings, placed his profile picture on his television, and was blowing kisses at him. R51 has a medical history of schizoaffective disorder, bipolar disorder, and a brief interview for mental status (BIMS) score of 14, which means R51 is cognitively intact. R92 has a medical history of bipolar disorder, and schizophrenia and a BIMS score of 12, which means R92 is moderately impaired. On 12/15/2025 at 11:12 AM, Surveyor observed R92 laying on his bed while watching television. R92 seems comfortable and free of pain. R92 stated he had an altercation with his roommate R51. R92 stated the altercation started because he caught his roommate stealing his clothes. R92 stated he got into a physical and verbal altercation due to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a baseline care plan was developed within 48 hours of admission for one (R109) resident reviewed for baseline care plans in a sample of 21.Findings Include:R109 was admitted to the facility on [DATE] with diagnosis not limited to Fracture of Unspecified Part of Neck of Left Femur, Asthma, Low Back Pain, Chronic Pain, Schizoaffective Disorder, Presence of other Bone and Tendon Implants.Progress note dated 12/10/25 12:57 PM document in part: Progress Note R109 arrived at 12:03 pm. R109 was admitted to the hospital for a fall where he (R109) sustained a left hip fracture and has 3 sutures intact and open to air. R109 is alert to name, place and time. R109 has a hx (history) of Asthma, Chronic lower back pain and Schizophrenia. R109 is continent with use of urinal and bed pan, uses a wheelchair for locomotion and is weight bearing as tolerated. R109 has an abrasion to his left knee and bruising to left thigh post fall. R109 is an active smoker. 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 provide scheduled showers for a resident that requires partial/moderate assistance with Activities of Daily Living/ADL care. This failure affects one (R71) resident in a total sample of 21 residents reviewed for ADL care. Findings include:On 12/15/2025 at 12:53PM, R71 observed sitting on his bed with a red walking stick lying next to him. R71 states he is blind and is unable to see. R71 states he has concerns with getting his scheduled showers in the facility. R71 states he is scheduled to receive a shower in the facility twice a week on Mondays and Thursdays. R71 states on his shower days, the staff does not always come to get him and take him for his shower. R71 states when he asks staff about his shower, they tell him they will return, but no one returns to give him his scheduled shower. R71 states he did not receive a shower this past Thursday on 12/11/2025. R71's Facesheet documents that R71 has diagnoses not limited to: Legal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure the narcotic count was completed at the beginning and end of each shift and failed to sign the controlled drug count record at the beginning and end of each shift for 1 of 2 medication cart narcotic logs reviewed.Findings Include:On 12/15/25 at 11:01 AM medication cart B was reviewed with V14 (Licensed Practical Nurse). During review of the Controlled Substances, November 2025 and December 2025 Controlled Substance Check Form there were observed with multiple blank boxes. V14 stated, there were no narcotics before 2 days ago and we did not have any narcotics before that because the doctor does not prescribe narcotics. On 12/15/25 at 01:18 PM the medication cart A was reviewed with V12 (Licensed Practical Nurse). On 12/17/25 at 09:13 AM V3 (Assistant Director of Nursing) stated The Controlled Substance Check Form should be done and signed shift to shift, nurse to nurse every day. The nurse should check to see if any new narcotics have come, and the sheet should still 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 a medication error rate of less than 5%, by making 2 errors out of 31 attempts with an error rate of 6.45%. This deficient practice was identified for 2 (R11, R58) of 4 residents observed for medication administration.Findings Include:R11 was admitted to the facility with diagnosis not limited to Hypertensive Heart Disease with Heart Failure, Biventricular Heart Failure, Congestive Heart Failure, Dementia, Unspecified Severity, with Moo Disturbance, Bradycardia and Presence of Cardiac Pacemaker.R11's Care Plan document in part: Problem: Category: Cognitive Loss/Dementia. R11 has memory/recall problems, forgetting vital information towards her plan of care. BIMS (Brief Interview of Mental Status) score 3, indicating cognitively impaired.On 12/15/25 at 09:07 AM V12 (Licensed Practical Nurse) stated said to first I am going to take your blood pressure. V12 entered R11's room and placed the blood pressure cuff on R11's right arm and checked R11's oxygen saturation with the pulse oximeter. V12 exited R11's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to protect the rights of the resident and allow one (R2) resident to go out on a community pass after a ninety-day restriction without performing a reassessment. R2's Minimum Data Set (MDS) dated [DATE] shows R2 is cognitively intact.R2's was admitted to the facility on [DATE] with diagnoses including but not limited to other bipolar, major depressive disorder recurrent, severe with psychotic symptoms, generalized anxiety disorder, and other psychoactive substance abuse. On 8/19/25 at 10:58 AM, R2 received in room, stated he has been in the facility since October 2023. He went out to the community on independent pass on 2/28/25, he came back to the facility intoxicated with drug-marijuana, and he was given a ninety-day community pass restriction on 3/3/25. His ninety-day community restriction officially ended in June 2025, but he is still not being allowed to leave the facility despite multiple requests voiced to the facility V7 (Social…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an allegation of mental abuse (bullying) to the state survey agency. This failure affects 1 resident (R1) sampled for abuse reporting. Findings include: On 5/20/2025 at 11:00 AM, V1 (Administrator) explained that when R1 was admitted to the hospital, V1 was notified by V9 (Licensed Practical Nurse) that the hospital told V9 that R1 was being bullied by R1's roommate (R4). V1 could not recall the actual date of the allegation. V1 stated that V1 investigated the allegation by interviewing other staff and R4. V1 said that the facility could not substantiate the bullying allegation but kept R1 and R4 separated after the allegation was made. V1 denied that the allegation was reported to the state survey agency. V1 affirmed that bullying can be mental abuse and that the allegation should have been reported. On 5/21/2025 at 12:11 PM, V9 (Licensed Practical Nurse) could not recall the exact date, but could recall that during R1's last hospitalization, a social worker from the hospital had called and asked to speak with a…

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

Based on interview and record review, the facility failed to complete a thorough investigation of verbal/mental abuse after an allegation of bullying was made. This failure affects 1 resident (R1) sampled for abuse. Findings include: R1's Minimum Data Set (3/20/25) documents in part a brief interview of mental status (BIMS) summary score of 15, indicating R1 is cognitively intact. On 5/20/2025 at 10:32 AM, R1 stated that R1 was being bullied/harrased by R2 and R3. R1 did not name R4 as a resident that was harassing R1. R1 stated that R2 and R3 have formed a clique and call R1 a dirty pol whenever R1 walks past R2/R3. R1 explained that R2/R3 calling him names makes him feel worthless and that the harassment had been going on for over a year. R1 affirmed R1 told the hospital about the bullying during R1's last hospital stay in April. On 5/20/2025 at 11:00 AM, V1 (Administrator) explained that when R1 was admitted to the hospital, V1 was notified by V9 (Licensed Practical Nurse) that the hospital called and told V9 that R1 was being bullied by R1's roommate (R4). V1 could not recall…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document in the medical records the reason for one residents' (R1) transfer and discharge to the hospital out of three residents reviewed for transfer/discharge. The facility failed to check the correct box that they could not meet R1's needs on the Involuntary Discharge form, instead they checked the box that the safety of individuals in the facility were endangered. Finding Include: R1 progress note dated 12/25/2024 08:43 PM reads Ambulance arrived to facility. Resident became aggressive yelling and screaming that she does not have to leave because she got drunk while on pass. Resident stated she will call state and that she has the right to drink when she is not at facility. Resident left facility on stretcher to Hospital. R1's emergency room note dated 12/25/24 reads: patient arrived by ambulance from nursing home with petition. Per EMS (Emergency Medical Support) staff said she was aggressive earlier. On arrival patient is cooperative and calm. She is upset admission to psych unit. Diagnosis Depression and Intoxication. R1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 give a resident an involuntary discharge notice 30 days prior to the resident's discharge. This applies to one resident (R1) out of three residents reviewed for transfers and discharges. Finding Include: R1 progress note dated 12/25/2024 08:43 PM reads: Ambulance arrived to facility. Resident became aggressive yelling and screaming that she does not have to leave because she got drunk while on pass. Resident stated she will call state and that she has the right to drink when she is not at facility. Resident left facility on stretcher to Hospital. R1's emergency room note dated 12/25/24 reads: patient arrived by ambulance from nursing home with petition. Per Emergency Medical Support staff said she was aggressive earlier. On arrival patient is cooperative and calm. She is upset admission to psych unit. Diagnosis Depression and Intoxication R1 progress note dated 12/31/2024 03:58 PM reads: Writer talks to resident psychiatrist and the psych NP of resident behaviors at this facility. Resident has been non-compliance to go to an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review facility failed to follow their bed hold policy for one resident (R3) out of three residents reviewed for discharges/transfer. This failure resulted in the facility not holding R1's bed for 10 days and subsequently R1 was discharged to the community instead of being allowed to return to the facility Findings Include: Facility's bed hold and readmission policy denotes it is the policy of this facility to readmit residents after hospitalization or temporary therapeutic leave when the resident requires services which can be provided by the facility. Residents, or their designated representative, shall be informed of this policy at the time of admission and at the time of transfer to a hospital, or for therapeutic leave which extends beyond 24 hours. A specific bed may be held for ten (10) days recipients of Medicaid benefits in accordance with the State Plan unless the resident has indicated a desire not to return to this facility or physician has indicated the services provided…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 let one resident (R1) return out of three residents reviewed transfers and discharges. This failure resulted in R1 not returning to the facility after hospitalization and was subsequently discharged to the community. Finding Include: R1 progress note dated 12/25/2024 08:43 PM reads: Ambulance arrived to facility. Resident became aggressive yelling and screaming that she does not have to leave because she got drunk while on pass. Resident stated she will call state and that she has the right to drink when she is not at facility. Resident left facility on stretcher to Hospital. R1's emergency room note dated 12/25/24 reads: patient arrived by ambulance from nursing home with petition. Per Emergency Medical Support staff said she was aggressive earlier. On arrival patient is cooperative and calm. She is upset admission to psych unit. Diagnosis Depression and Intoxication. R1's Hospital record dated 1/2/25 reads: patient scheduled for discharge by attending psychiatrist. Patient denied auditory hallucinations, denied…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Registered Nurse (RN) coverage for 8 consecutive hours in a 24-hour period on Mondays, Wednesdays, Thursdays, Fridays and every other Saturday and Sunday during 3 of 3 months reviewed. This failure has the potential to affect all 105 residents residing in the facility. Findings include: During the facility tour 12/03/24 -12/05/24 there were no Registered Nurse assigned to provide care to the facility residents. The Third Quarter PBJ (Payroll Based Journal) indicate V19 (Nurse Manager/Registered Nurse) worked 07/06/24. 07/07/24, 07/20/24, 07/21/224, 08/01/24, 08/02/08/03/24. 08/04/24, 08/17/24. 08/18/24, 08/31/24, 09/01/24, 09/02/24, 09/28/24 and 09/29/24. V20 (Registered Nurse) worked 07/02/24, 07/09/24, 07/16/24, 07/23/24, 07/30/24, 08/06/24, 08/13/24, 08/20/24, 08/27/24, 09/3/24, 09/10/24, 09/17/24 and 09/24/24. There are no documented hours for V21 (Registered Nurse) during the third quarter (PBJ). On 12/03/24 at 09:48AM V1 (Administrator) stated there are no nursing staff waivers. On 12/05/24 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and review of records the facility failed to follow handling of clothes inside a net-like bag by leaving on the floor exposed to unclean surfaces per their policy. These failures have the potential to affect 5 residents (R17, R10, R73, R22, and R100). Facility also failed to follow Water Management Program that have the potential to affect all 105 residents living in the facility in ensuring water supply in the facility are free from water borne diseases. Findings include: On 12/03/2024 at 11:33 AM, a total of 3 rooms were seen with net-like (mesh) full of clothing laying on the floor. V11 (Certified Nursing Assistant) was informed, then identified as follows: Red bag is R17's clothing, blue and black bags is R10's clothing, and yellow bag is R73's clothing. V11 stated that bags that contains clothes need to be taken off the floor. V11 also said that the facility uses these net-like (mesh) bags to place resident's clothing to be laundered. V11 was asked if clothes that are…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 discard medications not in their original packaging, label and date a used insulin pen, store unused insulin in the refrigerator, check medication fridge temperatures daily, store mediations in a clean fridge, and store refrigerated medications away from food. This has the potential to affect all 48 residents receiving medications from Medication Cart A and those residents on insulin. Findings include: On 12/03/2024 at 9:36 AM, surveyor reviewed facility's Medication Cart B with V4 (Nurse). V4 stated the cart contained medications for about 48 residents. On the first fourth slot in the first drawer, there was one loose, pink capsule not in its original packaging. On the first slot of the second drawer, there was a round, orange pill and an oval white pill not in their original packaging. In the fourth slot of the second drawer, there was a white oval pill not in its original packaging. In the second slot on the third drawer, there were five loose pills not in their original packaging (two circular, white…

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

Based on review of records and interviews the facility failed to educate 2 residents (R73 and R250) on influenza vaccination and 4 residents (R45, R73, R90 and R250) on pneumococcal immunization per their policy on documentation of influenza and pneumococcal immunization. These failures have the potential to affect 4 residents (R45, R73, R90 and R250) on informed decision on the risk and benefits of influenza and pneumococcal vaccinations in a sample of 46 residents. Findings include: Per preventative health care of the sampled residents, it documents as follow: R45 has no record of pneumococcal vaccination. Informed consent form under for pneumococcal immunization reads that R45 request to received immunization on 9/11/2024 no record provided that R45 received immunization. R73 has no record of influenza and pneumococcal vaccination. Informed consent for influenza and pneumococcal vaccinations are both declined with reasons are left blank. R90 has no pneumococcal vaccination. Informed consent form under pneumococcal immunization reads that R90 request to received immunization 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 review of records and interviews the facility failed to provide the right of every resident to formulate advance directives for 2 out of 22 residents (R90 and R250) per their policy. Failures includes providing written information on advance directives and addressing advance directives as part of planning of care. These failures have the potential to affect 2 residents (R90 and R250) out of 46 residents in the sample. Findings include: During review of R90 and R250 resident's record, no documentation related advance directives were included. V8 (Director of Social Service) was informed and stated to check for clarification. On [DATE] at 09:33 AM, V8 stated that R90 and R250 does not have any documentation on his record related to discussing advance directives. Per V8 as per policy advance directives should be discussed on admission, after which it needs to be followed up within 72-hour period. V8 stated that advance directives is very important to make sure that residents have been educated on their…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 include urinary catheter use in R85's comprehensive care plan, have urinary catheter care orders, and maintain R85's dignity by not failing to provide a urinary catheter privacy bag for one (R85) out of a total sample of 46 residents. Findings include: R85's Face Sheet documents in part diagnoses of infection in the urine, presence of urogenital implants and attention to other artificial openings of urinary tract. It documents in part urinary catheter use. R85's Physician Order Report from 11/03/2024 - 12/03/2024 does not document in part urinary catheter care orders. R85's Care Plan does not contain a focus for urinary catheter use, goals, or interventions. On 12/03/2024 at 9:33 AM, R85's room was in front of the main entrance to the facility. R85's room door was open and R85 was lying in bed. Urinary catheter tubing and bag was in plain sight. On 12/05/2024 at 9:21 AM, V2 (Director of Nursing) stated R85 has had the urinary catheter for weeks. V2 stated the expectation when it comes to urinary catheters 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 interviews and record reviews, the facility failed to transcribe hospital orders upon initial admission for one (R96) out of a total sample of 46 residents. Findings include: R96's Face Sheet documents in part diagnoses of seizures, hypertensive heart disease, neuralgia and neuritis, alcohol dependence, insomnia, and mood disorder. On 12/03/2024 at 11:02 AM and during a follow-up interview at 12:38 PM, R96 stated when [R96] discharged from the hospital, the hospital staff instructed R96 to take Magnesium pills. R96 stated [R96] had a bottle of Magnesium pills but facility staff took it during admission. R96 asked staff about the Magnesium pills but they have not added it to R96's treatment. R96's Patient Discharge Instructions dated 11/01/2024 documents in part printed prescription for Magnesium Oxide 250 mg (milligrams) 2 tablets orally every day for 30 days. Reason for the prescription was for supplement. Surveyor reviewed R96's Progress Notes. V22's (Nurse) 11/01/2024 6:52 PM admission note for R96 documents in part: [V23 (Physician)] made aware of resident's admission…

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

Based on observation, interview, and record review the facility failed to a.) ensure the portable oxygen tank was on the correct setting, b.) ensure the oxygen tubing was stored to prevent contamination, and c.) ensure the oxygen tubing was labeled and dated when changed. This failure has the potential to affect 1 (R37) of 2 residents reviewed for oxygen therapy. Findings Include: R37 has diagnosis not limited to Respiratory Failure, Unspecified with Hypoxia, Chronic Kidney Disease, Stage 4, Permanent Atrial Fibrillation, Pleural Effusion, Shortness of Breath, Unilateral Primary Osteoarthritis, Left Knee, and Hypertensive Heart Disease. R37 MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 12 indicating moderately impaired. Physician Order Report dated 11/03/24 - 12/03/24 document in part: Oxygen: Change tubing and mask weekly and prn (as needed) (Label). Start date 11/11/24. Oxygen: Nasal Cannula. Rate 3L/Min (Liters/Minute) Continuous. Every shift: Days, Evenings, Nights. Start date 11/11/24. Care Plan Problem start date 11/16/24 document in part: Problem:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 have resident's medications readily available for administration, administer medications on time, and ensure accurate reconciliation of a resident's controlled medication for three residents (R43, R74, R78) observed during medication administration and during medication storage and labeling task. Findings include: R78's Face Sheet documents in part diagnoses of seizures, schizophrenia, bipolar disorder, insomnia, and delusional disorders. R78's Physician Order Report from 11/03/2024 - 12/03/2024 documents in part an order for Phenobarbital (Schedule IV controlled substance) 16.2 mg (milligram) tablets, take two tablets three times daily. On 12/03/2024 at 9:36 AM, surveyor reviewed Medication Cart B with V4 (Nurse). At 9:57 AM, V4 stated outgoing and oncoming nurse are supposed to count the controlled medications at the beginning of the shift. During review of the narcotic bin, surveyor and V4 reviewed R78's Controlled Drug Receipt/Record/Disposition Form for Phenobarbital 32.4 mg. Instruction was to take…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 obtain written informed consent prior to prescribing and administering psychotropic medications for 3 residents (R15, R90 and R96) out of a total sample of 46 residents per facility's policy. Findings include: R15 is [AGE] years old, with primary medical diagnosis of COPD (Chronic Obstructive Pulmonary Disease), Schizophrenia disorder, bipolar type. Per R15's MAR (Medication Administration Record) resident has 3 psychotropic medications signed as given are as follows: Aripiprazole (antipsychotic) 10 MG signed as being administered daily, Depakote 250 MG (anticonvulsant) used for major depression signed as being administered 3 times a day, and Trazodone (antidepressant) 100 MG signed as being administered daily at night. R90 is [AGE] years old, with primary diagnosis of osteoarthritis on left knee, malignant neoplasm right breast, dementia, depressive episodes, and delirium. Per R90's MAR (Medication Administration Record) resident has 3 psychotropic…

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

Based on review of records and interviews the facility failed to educate 2 residents (R73 and R250) on Covid- 19 vaccination per their policy on documentation of Covid-19 immunization. These failures have the potential to affect 2 residents (R73, and R250) on informed decision on the risk and benefits of Covid-19 vaccinations in a sample of 46. Findings include: Per preventative health care of the sampled residents, it documents as follow: R73 has no record of Covid-19 vaccination for 2024. Informed consent was not provided. R250 no vaccination on record and no informed consent. On 12/04/2024 at 01:11 PM with V3 (Assistant Director of Nursing / Infection Control Preventionist) stated, all resident's immunization should be documented under preventative health care and progress notes. Vaccinations including Covid-19, influenza and pneumococcal are located under preventative health care. V3 stated I need to make sure that I document all immunization under preventative health care. I know I failed to document. V3 stated that informed consent were provided to resident 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 observation, interviews, and review of records the facility failed to ensure that resident room environment was in a safe condition for 1 (R73) out of 46 residents . Failure includes detached vinyl flooring and tiles located at entry door from the bed going to the restroom. Findings include: R73 is [AGE] years old with primary medical diagnosis of Parkinson's disease, schizoaffective disorder, bipolar type, difficulty in walking, lack of coordination, and dementia. On 12/05/2024 at 11:34 AM, R73 was seen sitting on the right side of the bed with walker. R73 stated she now uses the walker going to the toilet. In front of R73 about 4 to 5 feet was the door entrance to the restroom/toilet. Upon looking at the flooring of the entrance to the restroom and toilet, a thin vinyl that was detached around ¾ of the square remaining. When stepped by feet it easily slides on the floor. V11 (Certified Nursing Assistant) was informed. And upon seeing the flooring stated that it is a problem because R73 may slip 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 ensure that a resident was free of physical and verbal abuse from staff. This failure affected one of three residents reviewed for abuse. Findings include: On 10/21/24 at 11:35am, R3 was asked what happened between him and the staff V11(CNA/Certified Nurse Assistant). R3 stated It was at nighttime, and I couldn't sleep. I asked him(V11) to give me some ice, he yelled at me and then he hit me on the cheek and said he would beat me to death. Inquired from R3 about any emotional effect this had on him(R3) and if anyone witnessed what happened. R3 responded that he(R3) felt okay and felt safe in the facility because the staff was fired immediately and never came back to work. R3 added that no staff witnessed the incident, and no staff has ever hit him before at the facility, and he did not have any fears that it could happen again. V11's employee records show that V11 was suspended first and later terminated, after investigation. R3 has a BIMS (basic interview for mental status) score of 14(cognitively intact). 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 that residents have privacy curtains which extend around the bed. This failure affected Four residents (R8, R9, R10, and R14) reviewed for residents' privacy. Findings include: On 9/30/24 at 10:59 am, Surveyor observed that the privacy curtains that are supposed to extend around the beds for R8, R9, R10, and R14 were not there. On 10/2/24 at 11:15am, the surveyor observed again that the privacy curtains were still missing. At this time, the surveyor called the attention of V10(CNA/Certified Nurse Assistant). V10 stated that each resident usually has a curtain around the bed for when they need privacy. On 10/2/24 at 11:30 am, V7 (Maintenance Director) stated All residents have privacy curtains. The surveyor then toured around with V7 and found that the privacy curtains for all of the 4 residents were missing. V7 stated I will put up the privacy curtains when they are available. The facility's policy titled Quality of Life - Dignity with revision date August 2009 states: each resident shall be cared 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 that residents' call lights are functional and in good working order. This failure has the potential to affect 5 residents, R2, R7, R11, R12, and R13, reviewed for functioning call lights. Findings include: On 9/30/24 at 10:40am, the surveyor observed that the rooms of R2, R7, R11, R12, and R13 did not have functioning call lights for residents to ask staff for assistance. On 10/2/24 at 10:45am call lights situations were still the same. On 10/2/24 at 11:30 am, V7 (Maintenance Director) was shown around and V7 noted the rooms/residents that needed their call lights fixed. V7 stated I will start working on them right away. V7 presented the facility's Maintenance logbook which did not contain any documentation of the call lights issues. Facility's policy on call lights dated 05/17 states in part: Objective - To respond to residents' requests and needs. #5 states: when the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident. #7 states: Report all…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 large community shower room on the A-Wing is maintained in a sanitary manner free of patches black substance. This failure has the potential to affect all 13 residents on the A-Wing and other residents who use this shower room. Findings include: On 9/30/24 at 10:59 am, Surveyor observed the A-Wing Community shower room with wet towels and blankets on the floor and patches of black substances all over most areas of the ceiling. Also, there was an open area of the ceiling, and the ceiling air-vent was broken and had accumulated dust. The surveyor asked V2(Director of Nursing) if the black substance is mold. V2 stated I cannot tell what it is; let me call Maintenance. V7(Maintenance Director) came and said It's black stuff from the moisture on the ceiling. I will clean it. Regarding the open area of the ceiling, and the broken ceiling vent with accumulated dust, V7 stated that the Contractor will come to do it. On 9/30/24 at 11:22am, with V7, the Surveyor observed the air vent behind the Ice…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility failed to affirm the right of the resident to be free from verbal abuse. This deficient practice affects one (R1) of three residents reviewed for abuse. Findings Include: On 08/25/2024 at 9:34AM, R1 was not observed inside of his room. On 08/25/2024 at 9:36AM, V7 (Licensed Practical Nurse/LPN) states she is the nurse responsible for caring for R1 but R1 is not currently in the facility. V7 states R1 was petitioned to be sent out to the hospital for a psychiatric evaluation on 08/22/2024 due to verbal aggression and resistance to redirection. On 08/25/2024 at 2:18PM, V6 (Maintenance Director) states he has been working at the facility for 6.5 years. V6 states V4 (Former Floor Technician) is a former floor technician who was responsible for mopping the facility floors. V6 states he was first made aware of the altercation between R1 and V4 when V6 walked onto the first floor unit and saw V4 huffing and puffing. V6 states V4 looked very angry so he inquired to V4 about…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to revise a care plan for one (R1) of three residents reviewed for care plans. Findings include: On 08/25/2024 at 3:42PM, V14 (Licensed Practical Nurse (LPN)/Former Care Plan Coordinator) states she is the former care plan coordinator and is knowledgeable about the care plan process. V14 states the social services department are responsible for entering abuse care plans for the residents. V14 states an abuse care plan should be documented in the resident's medical record for a resident who is at risk for abuse, is vulnerable, or has actually experienced abuse. On 08/25/2024 at 3:46PM, R1's electronic medical record is deployed on the computer. V14 reviews R1's care plan and states she does not see an abuse care plan documented for R1. V14 states she is vaguely familiar with R1's altercation involving allegations of abuse and R1 should have an abuse care plan. Nursing Progress Note dated 06/03/2024 written by V2 (Director of Nursing) documents, R1 reported…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a.) ensure food items were properly labeled, dated, and stored, b.) air dry the blender after being washed in the three-compartment sink before being used for meal preparation. These failures have the potential to affect all 89 residents receiving food prepared in the facility's kitchen. Findings include: On 11/05/23 at 9:38 AM, during initial kitchen tour V6 (Cook) stated anything that goes into the refrigerator cooler must be labeled and dated. V6 stated the items should be labeled with a delivery date, an opened date and use by date. On 11/05/23 at 9:40 AM, V6 opened the 1st Reach-In Refrigerator Cooler and surveyor observed a disposable plate containing hotdogs and slices of ham covered in plastic wrap. The plate was not labeled or dated. V6 stated the hotdogs and ham should have been labeled and dated and that the items would be thrown out right away. On 11/05/23 at 9:55 AM, observed opened 1 gallon jug container of Teriyaki Marinade and Sauce on the storage rack near the food preparation area labeled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dumpster was covered to prevent the harborage and feeding of pests, insects, and rodents. This deficient sanitation practice has the potential to affect all 89 residents who reside in the facility. Findings include: On 11/05/23 at 10:04 AM, V6 (Cook) accompanied surveyor outside the building to tour the dumpster area. Observed large dumpster with one of lids wide open and the dumpster filled with garbage. V6 stated the lids to the dumpster should be closed so animals cannot get inside the dumpster because having the lid of the dumpster open can attract pests close to the building and we already have bad rats out here. On 11/05/23 at 3:04 PM, observed one of the lids to the dumpster wide open. On 11/06/23 at 1:05 PM, V5 (Dietary Manager) stated the lids to the dumpster should be kept closed at all times to prevent trash from blowing out of the dumpster and to keep pests from climbing inside the dumpster. V5 stated we don't want to attract animals close to the building. On 11/07/23 at 8:45 AM, 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 observation, interview, and record review, the facility (a.) failed to properly discard a multi-dose insulin 28 days after opening for 3 residents (R14, R22, R54); (b.) failed to properly date opened multi-dose insulin vials for 3 residents (R1, R6, R75); (c.) failed to properly store multi dose insulin vials that require refrigeration for 3 residents (R6, R19, R54); (d.) failed to ensure that medication cart was locked when not attended; (e.) failed to separate medications from food items from one of one medication storage room and one of two medication carts inspected for medication storage and labeling. Findings include: On 11/5/23 at 10:10 am, Medication cart B inspected with V4 (Assistant Director of Nursing / ADON) and observed the following inside the medication cart: 1. R14's Humulin R multi dose insulin vial with open date 10/1/23, discard date 10/29/23. Pharmacy label indicated: discard after 28 days. Lantus [NAME] dose insulin vial with open date 10/1/23, discard date 10/29/23. Pharmacy label…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 to ensure that resident on hemodialysis was placed on Enhanced Barrier Precautions and failed to ensure that proper use of PPE (Personal Protective Equipment) including gowns and gloves were implemented and available at the point of care for 1 resident (R12). These failures could potentially affect 17 residents residing on unit D wing for facility's census dated 11/5/23. Findings include: R12's health record documented admit date of 3/17/23 with diagnoses not limited to Chronic obstructive pulmonary disease, Other schizophrenia, End stage renal disease, Anemia in chronic kidney disease, Unspecified viral hepatitis C without hepatic coma, Encounter for adjustment and management of vascular access device, Dependence on renal dialysis, Type 2 diabetes mellitus with other specified complication, Other specified arthritis multiple sites, Other hyperlipidemia, Other allergic rhinitis, Depression, Acute 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 record reviews, the facility failed to accurately document advanced directives code status for 1 resident (R75) out of 18 residents reviewed for advance directives. Findings include: R75 admitted to the facility on [DATE]. R75's diagnosis included but not limited to Idiopathic Gout, Raynaud Syndrome, Unspecified Opened Wound, Type 2 Diabetes Mellitus, Hyperlipidemia, Cataract, Hypertensive Heart Disease without Heart Failure, Personal History of Other Venous Thrombosis and Embolism. R75's MDS (Minimum Data Set) dated [DATE] BIMS (Brief Interview for Mental Status) score is 15/15 indicating intact cognition. On [DATE] at 2:00 PM, surveyor reviewed R75's Health Care Power of Attorney signed by R75, dated [DATE] and documents in part regarding end-of-life matters I (R75) do not want my life to be prolonged if, to a reasonable degree of medical certainty, my situation is hopeless. On [DATE] at 2:04 PM, surveyor reviewed R75's Face Sheet which documented in part, there are no Advance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medications were given as ordered by the physician for 2 residents [R57, R83] reviewed for medications in a sample of 18. Findings include: 1. On 11/5/23 at 10:38 AM, R83 stated, I have not received my 9AM medications at this time. On 11/5/23 at 1:30 PM, V3 [Agency Licensed Practical Nurse] stated, I gave R83 her 9AM medications around 9AM. On 11/5/23 at 3:00 PM, R83 stated, I have not received my medication from V3. When there is an agency nurse, I get my medications very late. On 11/5/23 at 3:05 PM, surveyor observed R83's paper medication administration record, for 11/5/23 9AM medication was not signed out. On 11/5/23 at 3:10 PM, V3 stated, I told you earlier that I gave R83 her medication, I am not going to change my answer. I did not sign out the medication, I will sign her medication out when I sit at the nursing station. Reviewed R83's clinical record documents in part R83 was admitted to the facility on [DATE] with the following…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain a medication error rate below 5% as evidenced by 3 medication errors out of 28 opportunities, resulting in a medication error rate of 10.71% for 3 (R8, R63, R75) of 10 residents observed during medication administration. Findings include: On 11/05/23 At 1:04 pm, Medication administration observation conducted with V3 (Licensed Practical Nurse / LPN Agency). R8 sitting up on wheelchair approached V3 complaining of right hip pain. Observed V3 prepared Acetaminophen 500mg 2 tablets and administered to R8. Observed R8 took medications by mouth. R8's MAR (Medication Administration Record) and POS (Physician Order Sheet) reviewed and showed order: Acetaminophen 325mg 2 tablets; oral every 6 hours PRN (as needed). On 11/6/23 at 8:52 am, Medication administration observation conducted with V16 (Licensed Practical Nurse / LPN). Observed V16 prepared and administered R63 Fluticasone nasal spray 1 puff each nostril. R63's MAR and POS showed order not limited to: Fluticasone propionate spray suspension…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 serve food as planned on the cycle menu, and failed to ensure standardized recipes were followed during food preparation. This failure has the potential to affect all 92 residents receiving food prepared in the facility's kitchen. Findings include: On 9/2/2023 at 9:50 AM, V8 (Morning Cook) stated residents would be served lemon pepper chicken (3-ounce portion), roasted potatoes, peas & carrots, and fruit cocktail for lunch. Residents on mechanical diets would receive mechanical chicken. Residents on pureed diets would receive pureed chicken. V8 stated the facility only has two residents on a pureed diet and five residents on mechanical diet. V8 said pureed chicken would be prepared at 11:30 AM, tray line would start at 11:30 AM. Menu for lunch meal dated 9/2/2023 listed the following items to be served: Grecian Chicken, Roasted Potatoes, Peas & Carrots, Bread & Butter, and Mixed Fruit and Spreadsheet (Saturday SS 2017 Week 3) for lunch meal listed the following items to be served: Grecian Baked Chicken,…

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