Morgan Park Healthcare

Based on observation, interview, and record review the facility failed to maintain clean kitchen and food storage room floors and walls, compromising safe and sanitary dietary conditions. This failure has the potential to affect 213 residents residing in the facility. On 2/13/2026 at 11:29, V22 (Dietary Manager) stated the dietary aides and cooks are responsible for cleaning the floors in their assigned stations; she (V22) is in the process of revising job descriptions; has not received complaints of bugs in food; has not observed bugs in the kitchen; and there is not a staffing issue in the kitchen. V22 stated the purpose of clean and sanitation in the kitchen practice good cleaning practices for the health of the residents. V22 verified the kitchen contained dirty floors with trash on the floors and debris along the walls throughout the kitchen. V22 verified mice and insect glue traps in the storage room under storage racks. On 2/13/2026 at 12:54 pm, V27 (Dietary Aide) stated all dietary staff are responsible for keeping the kitchen clean and sanitary; she (V27) mopped the kitchen…

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

Based on observation, interviews and record review, the facility failed to ensure that the dumpster was closed and free from trash. These failures have the potential to affect all 213 residents residing at the facility.Findings include: On 2/13/2026 at 10:01 am, Surveyor and V11 (Maintenance Assistant) observed the facility dumpster area with foul odor, two dumpsters that had four open lids, scattered debris and trash surrounding the perimeter on the ground around the dumpster area. V11 stated that he believes that the dumpster lids should be closed and that the housekeeping department is responsible for the dumpster area. V12 stated, I don't deal with that (referring to the dumpster area). V11 then explained if the dumpster lids are left open and trash is left around the dumpster area pest such as roaches and mice can come into the facility. On 2/13/2026 at 10:07 am, Surveyor and V12 (Housekeeping Supervisor) ) observed the facility dumpster area with foul odor, two dumpsters that had four open lids, scattered debris and trash surrounding the perimeter on the ground around the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide a safe, functional, clean and comfortable environment. This failure affects all 213 residents residing in the facility.Finding includes: On 2/13/2026 at 9:43am surveyor observed the base boards missing by room [ROOM NUMBER] and on the right side of the hallway on the first floor between rooms 111 & 113. Surveyor also observed missing floor panels in the center of the hallway floor. On 2/13/2026 at 9:59am surveyor observed the baseboard by medical equipment room missing with a hole in the wall, stained ceiling panels are not secured due to the holding rails being warped in the 1st floor dining room and missing parts of squares in the floor on the elevator (Elevator 3). At 10:10am on the second-floor surveyor observed the wall, in the shower room, behind the toilet with a brown substance splattered on the wall and the bottom of the toilet and floor with grayish black debri across from the nurse's station. On 2/13/2026 at 10:55am…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an effective pest control that eliminated roaches and mice in the facility. This failure has the potential to affect all 213 residents in the facility. Findings include: On 2/13/2026 at 10:30 AM, R18 stated bugs she identified as roaches are seen in the hallways and seldom in her room; no roaches in her food but have seen roaches in the dining room crawling on trays left over from lunch or dinner; mice seen in the hall running from one room to the next; and seen roaches in the shower room. On 2/13/2026 at 10:49 am, V21 (Certified Nurse Assistant-(CNA) stated she saw roaches on unit 2 North's hallway floors this week and have not seen any roaches in resident's food. On 2/13/2026 at 11:08 AM, R19 stated bugs in his room are roaches and are coming from the resident's room next door. On 2/13/2026 at 11:15 AM, R9 stated they saw bugs described as roaches crawling on his table and has seen mice in their room since he was admitted 8 months ago and no roaches in food. On 2/13/2026 at 10:01 am, Surveyor and…

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

Based on observation, interview and record review the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary and comfortable environment for seven residents (R3, R4, R5, R9, R19, R21, R22). Failed to provide functional furniture to store clothes for two residents R3 and R5. Failed to provide adequate window coverings for one resident (R3). Failed to ensure there were no holes in the walls of resident living areas for three (R4, R5, and R9). Failed to ensure the floors were clean and no garbage was on the floor for two residents (R3 and R19). This failure affected seven residents out of 22 residents reviewed for homelike environment.Findings include: On 02/13/26 at 10.25am surveyor entered R3's bedroom and observed multiple items on the floor that included dried food, multiple paper wrappings and disposable cups. Observed floor with dry black substance across multiple areas of the floor. Observed R3's window curtains with width too short to cover entire window, approximately 1/3 of window exposed. On 02/13/26 at 10:46am V9 (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.

Based on interview and record review, the facility failed to ensure that residents were free from physical abuse. This failure affected two residents (R14 and R15) of Four residents reviewed for resident-to-resident abuse.Findings Include:R2's admission record includes diagnoses of bipolar, depression, hypertension, delusional disorder, schizophrenia, heart failure, seizures and unspecified psychosis. R2's (2/3/26) Brief Interview Mental Status (BIMS) score is 12 which indicates that R12 has moderate impairment.R14's admission record includes diagnoses of chronic respiratory failure, COPD, congestive heart failure, pulmonary embolism, hemiplegia and hemiparesis.R14's (1-12-26) Brief Interview of Mental Status (BIMS) score is 12 which indicates that R12 has moderate impairment.R15's admission record includes diagnoses of anxiety, smoker, COPD (Coronary Obstructive Pulmonary Disease), asthma, hypertension, substance abuse, and left AKA (Above Knee Amputation).R15's (12/24/25) Brief Interview Mental Status (BIMS) score is 15 which indicates that R15 is cognitively intact.On 2/13/26 at…

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

Based on interviews and record review, the facility failed to investigate and report an allegation of resident-to-resident physical abuse to IDPH (Illinois Department of Public Heath) within the regulatory time requirement. This failure affected 2 residents (R14 and R15) in a sample of 3 residents reviewed for abuse. Findings include: On 2/13/26 at 10:45 am, R15 stated that R2 came into the room that they shared and knocked all R15's belongings on the floor and swung around R15 from behind and hit R15 on the right side in the jaw. I did tell the nurse what happened and R2 was sent out to the hospital that day.During surveyor's review of R15's EHR (Electronic Health Record) progress note, there was no documentation of R2 hitting R15.On 2/13/26 at 1:27 pm R14 stated that R2 came into his room and asked for two dollars, and he said no. R2 got mad and cursed R14 and threw the water pitcher that hit him on the side of his face, where water and ice went all over him. R14 reported the incident to the nurse on duty. R14's progress note dated 2/2/26 documented in part, Patient (R14) 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 observation, interview and record review the facility failed to assure that one resident (R9) had ceiling suspended curtains to create full visual privacy. This failure affected one resident out of 22 residents reviewed.Findings include:On 02/13/26 at 12:00pm observed R9 sitting in bed in a 4 person fully occupied room, with no privacy curtain observed around R9's bed.On 02/13/26 at 12:00pm R9 stated that on 08/03/25 his privacy curtain fell from the ceiling and the facility never replaced it. R9 stated that he has no privacy and cannot change his clothes at the bedside. R9 stated that he would like to have some privacy.R9's progress note dated 08/03/25 at 7:57pm documents in part, Resident was lying in bed watching television when the privacy curtain and attached track suddenly detached from the ceiling and fell. The resident immediately notified staff. Upon assessment the resident denied pulling on or laying against the curtain at any time prior to the incident. Work order request placed in maintenance log.On 02/13/26 at 1:09pm V1 (Administrator) stated that all residents…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 appropriate peri care supplies were available for two of three residents (R2, R4) reviewed for dignity in the sample of 11. Findings include:1.29.2026 at 5:22 PM, R4 said, they (staff) have used paper towels to clean me. That makes me feel bad, they should have towels or wipes to clean me.1.29.2026 at 6:09 PM, R2 said, they use paper towels to clean me. I don't like when they do that. It makes me mad.1.29.2026 at 6:27 PM, V9 (CNA) said, I have had to use paper towels to clean residents. I've ripped up shirts, blankets and sheets to use to clean residents.1.29.2026 at 6:38 PM, V10 (CNA) said, yes, I have used paper towels to clean residents when there was no linen.1.30.2026 at 11:25 AM, V14 (LPN) said, staff should not use paper towels to clean residents, they should use towels or wipes.Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities booklet (undated) documents, in part: Your rights to dignity and respect: Your facility must treat you with dignity and respect 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 review of records the facility failed to follow policy on providing Community Survival Skill Assessment. Failed to follow policy to involve responsible party/family to resident discharged against medical advice ([NAME]). Failed to follow policy in procuring physician order for independent pass and failed to follow community pass and care plan intervention on restriction of resident related to independent pass for 5 out of 11 residents (R1, R2, R3, R4, R11) reviewed for resident safety during community pass. These failures apply to 2 residents (R1 and R11) who was on independent pass and did not return to facility and applies to 3 residents (R2, R3 and R4) that were allowed to go out on independent community pass without physician orders and/or has care plan for restricted pass. Findings include: R1 is [AGE] years old, initially admitted in the facility on 01/06/2025. R1 diagnosis includes Schizophrenia, insomnia, auditory hallucinations, cocaine abuse, extrapyramidal and movement…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review of records the facility failed to follow their policy to ensure notification of proper parties are done related to discharging 1 out of 5 residents. These failures affected 1 resident (R1) who was discharged after going out of the facility on community pass without required documentation and notification to the proper parties. Findings include:On 11/12/2025 at 10:41 AM, V11 (Law Enforcement Detective) stated that R1 was reported by facility missing on 05/20/2025. V11 stated that she tried contacting facility multiple times via email and phone calls, but facility was not responsive to her communication or correspondence. Per V11 there was lack of cooperation on the part of facility and to do her job she needs cooperation from facility.On 11/12/2025 at 12:38 PM, V1 (Administrator) stated that R1 went out on pass on 05/19/2025 and did not came back in the facility. R1 has a history of not returning to the facility. V1 stated that she did not contact family members listed on the face…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review of records the facility failed to coordinate with law enforcement agency in providing information related to 1 out of 5 residents (R1) reviewed for independent out on pass. These failures affected 1 resident (R1) who left the facility during community pass did and not return. The facility is unable to report R1's whereabouts and status. Law enforcement agency unable to proceed in finding or knowing resident (R1) status due to lack of cooperation by facility.Findings include:R1 is [AGE] years old, initially admitted in the facility on 01/06/2025. R1'S diagnosis includes Schizophrenia, insomnia, auditory hallucinations, cocaine abuse, extrapyramidal and movement disorder, major depressive disorder and suicidal ideations. R1 cognition is intact has a BIMS score of 15 per MDS assessment dated [DATE].On 11/12/2025 at 10:41 AM, V11 (Law Enforcement Detective) stated that R1 was reported by facility missing on 05/20/2025. V11 stated that she tried contacting facility multiple times via…

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

Based on observation, interview, and record review, facility failed to follow their policy to accommodate resident's needs by ensuring call light is within reach for 4 (R2, R127, R156, R203) out of 8 residents reviewed for call lights as well as provide an adequately sized wheelchair for 1 (R92) resident out of 8 reviewed for appropriate wheelchairs in a sample of 37.R203 has diagnosis not limited to Unspecified Dementia, Severe Protein-Calorie Malnutrition, Encephalopathy, Adult Failure to Thrive, Alcohol Dependence with Unspecified Alcohol-Induced Disorder, Essential (Primary) Hypertension, Anemia, Muscle Wasting and Atrophy, Vitamin D Deficiency, Polyneuropathy, Abnormal Weight Gain, Restlessness and Agitation and Gastro-Esophageal Reflux Disease. R203’s MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 03 indicating severe cognitive impact. R203’s Care plan document in part: Focus: R203 is (low) risk for falls related to weakness. Interventions: Be sure R203’s call light is within reach and encourage the resident to us it for assistance as needed. Focus:…

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

Based on observation, interview and record review the facility failed to provide a resident's tube feeding in accordance with the physician's order for 1 of 1 resident (R44) reviewed for tube feeding in a sample of 37.Findings Include:R44 has diagnosis not limited to Gastrostomy, Asthma, Essential (Primary) Hypertension, Seizures, Encephalopathy, Chronic Pain, Tachycardia, Dysphagia, Cognitive Social or Emotional Deficit Following Unspecified Cerebrovascular Disease and Abdominal Pain, Vascular Dementia. MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 03 indicating severe cognitive impact. Care Plan document in part: Focus: The resident is receiving a tube feeding and it has been determined medically necessary. Focus: The resident may be at risk for weight loss related to NPO (Nothing by Mouth) diet. Interventions: Prepare/serve the resident's nutritional diet as ordered.On 07/30/25 at 11:24 R44 was observed in bed with a feeding pump at the bedside turned off. A bottle of Jevity 1.2 was hanging on the feeding pump with the tubing connected to R44.On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to keep a resident free of sexual abuse from a resident. This failure affects two of three residents (R1 and R2) in a total sample of three residents. Findings include:This Survey was conducted on-site in the facility from 7/18/25 to 7/20/25. R1 is [AGE] years old and admitted to the facility 10/1/2024 with a diagnosis of chronic kidney disease and is dependent on renal dialysis. Minimum Data Sets (MDS) reviewed on admission [DATE] and most recent of 4/18/2025 indicate that R1 has been assessed to be alert and oriented without cognitive deficit. The MDS also indicates that R1 has not been assessed to exhibit any behavioral or psychotic symptoms.R2 is [AGE] years old and has been a resident of the facility since 2/23/22. R2 has diagnoses that include but are not limited to schizoaffective disorder and Cognitive Communication Deficit. According to R2's MDS dated [DATE] R2 was assessed with mild cognitive impairment. On 7/18/2025 at 7:30pm, R1 was 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 interview and record review, the facility failed to follow their policy and procedure for reporting an allegation of resident-to-resident abuse. Findings include: This Survey was conducted on-site in the facility from 7/18/25 to 7/20/25. R1 is [AGE] years old and admitted to the facility 10/1/2024 with a diagnosis of chronic kidney disease and is dependent on renal dialysis. Minimum Data Sets (MDS) reviewed on admission [DATE] and most recent of 4/18/2025 indicate that R1 has been assessed to be alert and oriented without cognitive deficit. The MDS also indicates that R1 has not been assessed to exhibit any behavioral or psychotic symptoms.R2 is [AGE] years old and has been a resident of the facility since 2/23/22. R2 has diagnoses that include but are not limited to schizoaffective disorder and Cognitive Communication Deficit. According to R2's MDS dated [DATE] R2 was assessed with mild cognitive impairment. The electronic health record was reviewed for R1 and R2. Progress notes dated 4/27/25 for 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 the facility failed to investigate an incident involving a verbal argument and physical contact between a resident and employee to rule out abuse. This failure affected one resident (R1) of three residents reviewed for abuse in a total sample of five residents. Findings include: On 4/29/25, at 2:11 PM, R1 said the incident was on 2/26/25. R1 said R1 felt like V3 (Maintenance Director) was harassing R1 a little bit. R1 and V3 got into an argument. R1 and V3 got into a fight. V3 was calling R1 a fat ass. On the elevator, V3 told R1 to move. V3 got into R1's face downstairs after getting off the elevator. R1 and V3 started swinging on each other. V3 hit R1 a few times on the back of the head and on the right side. R1 was in pain on the right side. R1 said R1 has been on restriction two months for the incident. R1 said V3 does not bother R1. R1 and V3 talk to each other. V3 helped R1 with a fan. On 4/29/25, at 3:12 PM, V3 (Maintenance Director) stated on 2/26/25, I was on the third floor. I noticed and assisted a staff member move a bed onto 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 review the facility failed to ensure that two residents (R5 and R6) that receive supplemental oxygen in the facility had active Doctor's orders. This failure has the potential to affect 31 residents currently receiving oxygen in the facility. Findings include: R5 is [AGE] year old with diagnosis including but not limited to: chronic obstructive pulmonary disease, morbid obesity, anemia, congestive heart failure and nicotine dependence. R5 has a BIMS of 15, which indicates cognitively intact. R6 is [AGE] year old with diagnosis including but not limited to: chronic obstructive pulmonary disease, malignant neoplasm of unspecified part of left bronchus or lung, malignant neoplasm of upper respiratory tract, angina pectoris and muscle wasting. R6 has a BIMs of 14, which indicates cognitively intact. During investigation on 4/22/2025 at 12:05 PM, R6 was observed in bed receiving supplemental oxygen (O2) via nasal cannula at 4 LPM (Liters per minute). R6 stated that he had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 environment remains free of hazards and was a homelike environment. The facility failed ensure the wall paint in residents' rooms was not chipped and damaged exposing the drywall and failed to ensure ceiling and wall tiles in the shower room were repaired or replaced. This failure has the potential to affect 101 residents residing on the second floor. Findings include: On 04/08/25 at 01:12 PM Chipped paint was observed along the lower part of R1's south wall and along the side of R1's bed. On 04/08/25 at 02:26 PM Chipped paint was observed on the lower south wall in R6's room and at the head of R6's bed. R6 said it is probably due to them pushing my roommate in the wheelchair and bumping the wall. On 04/09/25 01:05 PM V2 (Director of Nursing) stated Plastered areas on the walls need to be painted. On 04/10/25 at 10:59 AM V5 (Maintenance) stated I have worked here for about a year. I started repairs from the first floor up everywhere there were holes in the walls. It is from residents and staff…

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

Based on record review and interview the facility failed to follow their abuse policy for two residents (R1, R2,) out of four residents reviewed for abuse. This failure resulted in staff members not immediately intervening in a situation before residents became abusive to each other. Staff did not intervene in time thus allowing R1 and R2 to put scratches on each other's face, neck and arms. Finding Include: Facility's abuse policy denotes residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. The facility prohibits abuse, neglect, misappropriation of property, and exploitation of its residents, including verbal, mental, sexual or physical abuse; corporal punishment; and involuntary seclusion. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical abuse and mental abuse. R1's 3/25/2025 21:40 Health Status/Progress Note Text reads: Upon…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record the fall incident of 1 (R1) out of 3 residents reviewed for incident record. This failure affected the accuracy of 1 resident's (R1) record, with inaccurate documentation of the chronological occurrence of the incident, impacting the credibility of facility staff documentation on resident's record. Findings include: R1 is a [AGE] year old resident in facility. R1 initially admitted in the facility on 02/14/2024. R1's diagnosis includes Alzheimer's disease, anxiety disorder, left below the knee amputation, and more recent sustained fracture of lower end of left femur/leg. R1 has an intact cognition with a score of 12 on her Brief Interview of Mental Status (BIMS) dated 02/10/2025. On 03/18/2025 at 12:01 PM, R1 was seen on her bed in her room. R1 able to express thoughts well within topic during conversation. R1 stated she had a fracture on her left leg. R1 took off the sheet that covers her left leg with below the knee amputation. 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 observation, interview, and record review, the facility failed to provide all 205 residents residing in the facility with needed supplies for activities of daily living such as towels and linen. Findings include: Observations made 3/11/25 and 3/12/25 of the utility closets and rolling linen carts where clean supplies are stored revealed very few linens and towels in them. Some had no gowns, pads, or linen. On 3/11/25, at 8:52 AM, V6 (Licensed Practical Nurse) stated sometimes there is not enough linen and towels. The CNAs (Certified Nursing Assistants) will complain there is no linen and towels so they cannot do their work. On 3/11/25, at 9:00 AM, V9 (Certified Nursing Assistant) stated V9 has worked at the facility 14 years. V9 stated we have not gotten any linen today. We should have linen and towels by now at 9:00 AM. We use wet wipes if there are no towels. We change linen daily and as needed. At 9:00 AM it's time to get residents cleaned, showered, dressed, out of bed, and change linen. Each shift gets towels and linen at the beginning of the shift. If there are 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.

Based on observation, interview, and record review, the facility failed to a.) ensure medications were administered as ordered by the residents' physician, b.) ensure medications were locked and secured while unattended, c.) provide sufficient nursing coverage to ensure adequate resident care and support, and d.) provide care and services that meet professional standards. These failures have the potential to affect 103 residents residing in the facility. The facility also failed to provide timely incontinence brief changing to a resident due to not providing linen to staff. This failure affects one of three residents (R17) reviewed for ADL care in a total sample of 17 residents. Findings include: On 3/01/2025, all the floors were reviewed for staffing. One nurse did not show up for the morning shift on 3/01/2025. On 3/01/2025, at 10:49 AM, V3 (Licensed Practical Nurse) stated, there was one nurse from the night shift that I reported to today. There was a nurse on duty for the night shift last night. At times, there are times I come in and there is no nurse for the night shift. It 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY On 1/28/25, at 2:03 PM, R7 said a CNA (Certified Nursing Assistant), V9, took R7 to the toilet. R7 said R7 had a incontience brief on and asked to get the brief off so R7 could go to the toilet. R7 said V9 was taking too long and R7 started peeing before R7 got onto the toilet. R7 said the pee got on V9's shoe. R7 said V9 slammed R7's back and R7's back hit the back of the toilet. R7 said this happened in the evening about a month ago. R7 said R7 was sent to the hospital. R7 told the hospital that R7 was abused. The hospital called the police. V9 has not worked with R7 since then. R7 has seen V9 in the building. On 1/28/25, at 2:20 PM, R5 said R5 pushed another resident (R6). R5 said R6 kept coming into R5's room. R6 is blind. R6 was in the room next to mine. R5 said R5 lost their temper. R5 was going into their room. R6 was blocking the way. R5 said R5 pushed R6 pretty hard. R5 got frustrated with the whole situation of R6 banging on the wall at 5:00 AM, coming out of the room butt naked, and coming into R5's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to a.) provide adequate supervision and monitoring for residents, and b.) revise a care plan for one (R8) out of three residents reviewed for resident injuries. These failures have the potential to affect 45 residents residing in the facility. Findings include: On 01/29/2025, at 1:20PM, R8 observed sleeping in his bed. R8 observed with a floor mat on the right side of his bed, bed in a low position, and a bolster underneath his legs. On 01/29/2025, at 1:22PM, V12 (Licensed Practical Nurse/LPN) states she was the nurse assigned to care for R8 on 01/14/2025. V12 states it was brought to her attention by the restorative team that R8 did not get up to walk when the restorative aides went in to weigh him. V12 states R8 usually ambulates in the facility without assistive devices so she went to assess R8. V12 states she also asked R8 to get up out of bed and R8 declined. V12 states R8 has a history of injuring himself and not reporting it to staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY On 1/28/25, at 2:03 PM, R7 said a CNA (Certified Nursing Assistant), V9, took R7 to the toilet. R7 said R7 had a brief on and asked to get the brief off so R7 could go to the toilet. R7 said V9 was taking too long and R7 started peeing before R7 got onto the toilet. R7 said the pee got on V9's shoe. R7 said V9 slammed R7 back and R7s back hit the back of the toilet. R7 said this happened in the evening about a month ago. R7 said R7 was sent to the hospital. R7 told the hospital that R7 was abused. The hospital called the police. V9 has not worked with R7 since then. R7 has seen V9 in the building. Record review of R7's Facesheet, MDS, and care plan provided by facility on 1/30/25 indicates R7 is [AGE] years of age with diagnoses that include but are not limited to chronic obstructive pulmonary disease, heart failure, paranoid schizophrenia, type 1 diabetes mellitus, dementia, schizoaffective disorder, bipolar disorder, major depressive disorder, generalized anxiety disorder, and spinal stenosis, thoracic region.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review the facility failed to ensure that a brown substance was not on the bathroom wall of three residents (R4, R5, and R10). This failure has affected three of four residents reviewed for homelike environment. Findings include: R4 is a [AGE] year old with diagnosis including but not limited to: Urinary tract infection, anxiety, epilepsy, insomnia and chronic kidney disease. R4 has a BIMS (Brief Interview of Mental Status) score of 15, which indicates cognitively impaired. R5 is a [AGE] year old with diagnosis including but not limited to: Type 2 diabetes mellitus, asthma, pain, acquired absence of right great toe and essential hypertension. R10 is a [AGE] year old with diagnosis including but not limited to: Heart failure, constipation, hypoglycemia, muscle weakness and edema. On 01/21/25 at 11:55 AM, R5 complained about brown stains on her bathroom wall and said that she believes the stains are feces from a previous roommate. Surveyor went to observe R5's bathroom,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure that one dependent resident (R7) received timely incontinent care. This failure resulted in R7 waiting an hour, sitting in her feces before being cleaned. Findings include: R7 is a [AGE] year old with diagnosis including but not limited to: acquired absence of right leg above knee, acquired absence of left leg above the knee, diarrhea, obesity, muscle wasting and atrophy. R7 has a BIMS (Brief Interview of Mental Status) score of 15, indicating cognitively intact. On 01/21/2025 at 12:30 PM, Surveyor observed R7 on the second floor in the hallway complaining that she was soiled with feces and had been waiting since 12:00 PM to be cleaned by her CNA (Certified Nurse Assistant). At that time, R7 said that V9 (CNA) told her (R7) that the mechanical lift was not charged and that R7 would have to wait until it charges to be transferred to the bed and cleaned. On 01/21/2025 at 12:45 PM, V7 (LPN/ Licensed Practical Nurse) said. R7 told me…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to ensure that one resident (R11) was free from abuse from another resident (R4.) This failure affected 2 residents (R4 and R11.) Findings include: R11 is [AGE] year old with diagnosis including but not limited to: Cognitive communication deficit, unspecified severe protein- calorie malnutrition, unspecified lack of coordination, essential hypertension, muscle wasting and atrophy. R4 is [AGE] year old with diagnosis including but limited to: Bipolar disorder, traumatic subdural hemorrhage without loss of consciousness, opioid abuse, insomnia and type 2 diabetes mellitus. On 12/09/2024 at 2:05 PM, R4 and R11 were observed sitting in the third floor dining room. At that time, R11 appeared upset and said, R4 pulled my hair and hit me in my face with a bag of cups. On 12/09/2024 at 2:10 PM, V8 (CNA/ Certified Nurse Assistant) said, R4 hit R11 earlier and I had to separate them. On 12/09/2024 at 2:10 PM, Surveyor asked if R4 had a history of physically…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review and interview the facility failed ensure that fall risk assessments were accurate for two of four residents (R2, R3) reviewed for falls. Findings include: The fall prevention and management policy states residents will be reassessed for fall risk at least quarterly or more frequently if there is a change in their condition. Reassessment will be conducted by the interdisciplinary care team. 1. R2's (11/14/24) functional assessment states upper and lower extremity functional limitation (on one side) was identified. R2's (11/18/24) incident report affirms resident stated that the CNA (Certified Nursing Assistant) was trying to help him get into the bed. When he stood up, he lost his balance and fell. R2's (11/18/24) post fall risk review determined a score of 9 (moderate risk) however the following concerns were identified: the Gait Analysis section includes Exhibits loss of balance while standing however it was not selected [R2 lost his balance when he fell]. Decrease in muscle coordination…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 community shower room on the third floor North-Wing is maintained in good repair and a sanitary manner. This failure has the potential to affect all 53 residents on the third floor North-Wing. Findings include: On 10/15/24 at 10am after the entrance conference, V1(Administrator) presented the census that shows that unit 3 North has 53 residents. On 10/15/24 at 10:40am, the following were observed in the 3-North community shower room: The hand-washing sink was leaking water and not properly affixed to the wall. Two visably soiled wet towels were on the floor of the shower stall. Missing Ceiling tiles. Broken soap dispenser by the sink and there was no soap available for handwashing. At this time, V8 (Housekeeper) was called to observe all the above. V8 stated that the lack of hot water, handwashing sink issue, missing ceiling tiles and broken soap dispenser are all maintenance issues. V8 stated If the soap dispenser was not broken, I would have put soap in there (pointing to the soap…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide an adequate amount of linen and towels to provide for resident care needs. This failure affects all 197 residents residing in the facility. Findings include: On 10/1/24, at 1:20 PM, V32 (Certified Nursing Assistant) stated there is no linen on the floor/unit (3 South) now. There is never enough linen. The beds should be changed daily on the morning shift. The Linen/Supplies closet holds the fitted, flat sheets, pillowcases, bath and face towels, gowns, and pads. Surveyor reviewed the contents of the supply closet for 3 South. Surveyor observed no flat or fitted sheets, 3 big towels, 2 small towels, 3 pillowcases, 7 gowns and 3 pads. Surveyor reviewed the two linen carts on 3 South with V32. Surveyor observed one cart was empty and the other cart had 2 pillowcases, 1 gown, 1 blanket, 1 flat sheet, 1 fitted sheet, 1 pad, 1 bath towel, 1 small towel that was stained with frayed edges and looked to be cut from a bigger towel. 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 secure Soiled Utility rooms that contained sharps and infectious waste materials. These deficient practices have the potential to affect all residents that reside in the facility. Findings include: On 10/2/24, at 8:59 AM, the door to the Soiled Utility room on 3 North was wide open. The door had a push button code entry lock on it. Inside the Soiled Utility room was a biohazard box with a red biohazard bag in it. There was clothes, or linen, inside the red bag. The room also had a hopper, an oxygen concentrator and five bins used for dirty laundry and trash. V42 (Floor Tech) stated the door is supposed to be closed at all times. V42 stated the door was already open when V42 arrived at the room. V42 did not know who opened the door. On 10/2/24, at 10:48 AM, surveyor opened the door of the Soiled Utility room on two South. The room did not have a lock on the door. The room had a cube size refrigerator (empty) that is used for urine and stool specimens. On the refrigerator was posted Do not refrigerate blood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 all fans and portable air conditioners used that circulate air in the kitchen in clean and sanitary condition; failed to ensure that testing strips were available to be used in the three-compartment sink that sanitizes equipment used for food preparation are not expired; failed to maintain the kitchen areas without stagnant water that attracts insects; failed to maintain all areas in the kitchen in a clean and hygienic status free from dirt and food wrappers including below the shelves, stoves, dishwasher, and three-sink compartment. These failures have the potential to affect all 196 residents with 1 resident not taking food by mouth. Findings include: On 10/01/2024, at 10:03 AM. With V18 (Food Service Director/Dietary Director): At the food preparation area, two fans were seen one on the floor and the other on the wall. There was also a portable air conditioner besides the fan on the floor. All equipment were seen to have dirt sticking on the grills. V18 stated that it should be clean because air…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 have functional and comfortable hot water for four (R90, R141, R154, R162,) residents and failed to have a safe environment for one (R443) resident. These deficient practices have the potential to affect all residents that reside in the facility. Findings include: On 10/01/2024, 12:52 PM R141 states that that the only concern she has is the hot water doesn't work and doesn't get hot. R141 states that she took a shower at 7:00 AM and the water was not hot. R141 states that the managers were made aware. On 10/01/2024, 12:58 PM R90 states that she does have an issue with the shower water not working and that she has showered with cold water. R90 states that the maintenance director has told her that he fixed it but R90 states that it is lukewarm and that she doesn't know if it works, and it has been like this for a long time. On 10/01/2024, 1:08 PM R162 states that the shower water is cold, and she would like to take a shower but not with cold water. R162 states that this has been going on for about 11 days or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to maintain an effective pest control program, failed to follow the pest control policy in maintaining the kitchen environment clean to prevent harborage of pests and failed to maintain areas free from pests for 2 residents (R8 and R94) rooms. These failures have the potential to affect all the facility residents. Findings include: On 10/01/2024, at 10:03 AM with V18 (Food Service Director/Dietary Director) underneath the dishwasher, three-compartment sink, and stove there were dirt and food wrappers. V18 was asked when was the last time staff cleaned the area? V18 stated I think it was last week but I am not sure if staff cleaned all areas. In a small room near the walk-in freezer, there were brooms and dustpans. A dustpan near the sink was full of dirty water that was grayish in color with a plastic cup floating and insects (similar to flies) flying over stagnant water. V18 was informed and took the dustpan filed with stagnant water out.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record reviews the facility failed to refer six (R21, R79, R97, R120, R127, R135) out of six residents reviewed with newly evident or a possible serious mental disorder to the appropriate state-designated authority for review, in a total sample of 35. Findings include: 10/02/2024, 11:29 AM V13 (Social Service Director) states that she handles the Pre-admission Screening and Resident Review (PASRR) level I and level II. V13 states that someone else from corporate takes care of the initial PASRR level I when a resident is newly admitted to the facility. She reviews the tracker, and it will let her know who is triggered for a level II. The tracker will show to refer a resident to level II screening. V13 states that a PASRR level II is for serious mental illness and is used to determine the need of level of the resident. V13 says that she waits for instructions on who is referred to PASRR level II. She was not aware that once a resident is given a new serious mental illness, they are 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide incontinence care for three (R56, R62, R94) residents and failed to provide scheduled showers for one (R87) resident. These failures affect four residents who are dependent for Activities of Daily Living/ADL care in a total sample of 35 residents reviewed. Findings include: On 10/01/2024, at 12:03PM, R87 states she has not received a shower in the facility for approximately 3 weeks. R87 states this is due to inconsistent water temperatures in the shower rooms in the facility. R87 states she has been requesting to have a shower but the water in the shower rooms are sometimes too cold to take a shower. R87 states she knows her body is not cleaned how it is supposed to be. On 10/02/2024, at 12:06PM, V6 (Certified Nursing Assistant/CNA) states the water on the second floor was cold when she checked it this morning and was not able to give R87 a shower today. On 10/02/2024, at 11:40AM, V7 (Licensed Practical Nurse/LPN) states she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to follow the tracheostomy care policy for maintaining a clean environment around a tracheostomy opening for 1 out of 1 resident (R49) and failed to label and date oxygen tubing for 3 out of 7 residents (R8, R96, R124) for a total sample of 35 residents reviewed for respiratory care. These failures have the potential to affect 4 residents (R8, R49, R96, R124) in avoiding respiratory health risk. Findings include: R49 is [AGE] years old, initially admitted on [DATE]. R49's medical diagnosis includes bacterial pneumonia and bacterial infections. On 10/01/2024, at 12:05 PM, R49 was found sleeping on his bed with his right hand holding a transparent tube. After calling his first name, R49 woke and can verbalize. R49 stated that he has something in his hand and inserted the transparent tube inside in his tracheostomy opening. On 10/02/2024, at 12:41 PM, after seeing R49's ability to take off the inner cannula of his tracheostomy and re-insert…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 monitor its call light system and answer call lights within a timely manner for two (R62, R182) residents in a total sample of 35 residents reviewed. Findings include: On 10/01/2024, at 12:25PM, R62's call light was illuminating above R62's room door. There was an audible sound heard from the call light. Housekeeping staff were seen passing by R62's room and did not answer R62's call light. On 10/01/2024, at 12:34PM, R62's call light was still illuminating above R62's room door. No audible sound was heard from the call light. On 10/01/2024, at 12:48PM, R62 states she had a bowel movement and urinated. She has been waiting for someone to change her incontinence brief for a long time. R62 states she is unable to go to the bathroom on her own and toilet herself. R62 states a CNA (Certified Nursing Assistant) staff member came into her room about 1 hour ago. CNA informed R62 that the CNA would be back to change R62. R62 states no one ever…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record reviews and interview the facility failed to follow the Pre-admission Screening and Resident Review (PASRR) policy for 2 of 8 residents (R12 and R49) in a total sample of 35 residents reviewed for PASRR assessment requirements. This failure has the potential to affect 2 residents (R12 and R49) in the correct determination of placement based on proper PASRR assessment. Findings include: R12 is [AGE] years old, initially admitted in the facility on 09/12/2024, with diagnosis that includes paranoid schizophrenia, dementia with behavioral disturbance, schizoaffective disorder, bipolar type, suicidal ideations. R12's psychotropic medication includes the following: Hydroxyzine Hydrochloride (antianxiety), Risperidone (antipsychotic), Trazodone (antidepressant). R12's care plan includes the following: R12 present signs and symptoms of depression, suicidal ideation (self-harmful behavior), and severe mental illness. R49 is [AGE] years old, initially admitted on [DATE]. R49's diagnosis includes bipolar…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 records review the facility failed to provide an individualized care plan to include an identified hygiene concern related to a tracheostomy of 1 (R49) of 35 residents in a total sample of 35 residents reviewed for planning of care. This failure has the potential to affect 1 resident (R49) in maintaining hygiene of the tracheostomy area. Findings include: On 10/01/2024, at 12:05 PM, R49 was found sleeping on his bed with his right hand holding a transparent tube. After calling his first name, R49 woke and can verbalize. R49 stated that he has something in his hand and inserted the transparent tube inside of his tracheostomy opening. On 10/02/2024, at 12:41 PM, upon seeing R49's ability to take off the inner cannula of his tracheostomy and re-insert the same; V23 (Licensed Practical Nurse) was asked if it is common for R49 to take off his tracheostomy inner cannula and reinsert it back? V23 stated that R49 takes off his tracheostomy inner tube often and sometimes sucks on it. On 10/03/2024, at 11:05 AM, V22 (Licensed Practical Nurse) stated that…

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

Based on observation, interview and record review, the facility failed to ensure an accurate count of narcotic medication for two residents (R3 and R141) in a sample of 35 reviewed for medication storage. Findings include: On 10/1/24, reviewed 3 North #2 medication cart with V11 (Licensed Practical Nurse). Observed six packages of buprenorphine and naloxone sublingual film 8mg/2mg for R3 in the narcotic box. According to the Controlled Drug Receipt/Record/Disposition Form, the amount left is 7. Observed eleven packages of buprenorphine and naloxone sublingual film 4mg/1mg for R141 in the narcotic box. According to the Controlled Drug Receipt/Record/Disposition Form, the amount left is 12. R3's physician order summary printed by facility 10/3/24, documents in part: suboxone sublingual film 8-2 MG (milligram) (buprenorphine HCL-naloxone HCL dihydrate) give 1 tablet sublingually three times a day. R141's physician order summary printed by facility 10/3/24, documents in part: suboxone sublingual film 4-1 MG (buprenorphine HCL-naloxone HCL dihydrate) give 1 film sublingually two times 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 observation, interview and record review, the facility failed to ensure the potency of insulin medications by not labeling the medications with the dates they were opened and the dates they were to be discarded for three residents (R21, R80 and R169) of 35 residents reviewed for medication storage. Findings include: On 10/1/24, reviewed 3 North #2 medication cart with V11 (Licensed Practical Nurse). -The cart was not locked, and the cart was not in V11's view. -observed insulin lispro injection vial for R21 not sealed, not labeled with opened and/or discard dates. -observed fiasp (insulin aspart) injection vial for R80 not sealed, not labeled with opened and/or discard dates. -observed Humalog (insulin lispro) injection vial for R21 not sealed, not labeled with opened and/or discard dates. -observed insulin lispro injection vial for R169 not sealed, not labeled with opened and/or discard dates. -observed basaglar kwik pen for R80 not sealed, not labeled with opened and/or discard dates. On 10/1/24, reviewed 3 North medication room with V11. -observed in the refrigerator,…

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

Based on record review and interview the facility failed to ensure that residents and staff are aware of the grievance process and failed to ensure that a grievance form and/or resolutions were provided to one of four residents (R1) in the sample. These failures have the potential to affect 198 residents. Findings include: On 9/6/24, IDPH (Illinois Department of Public Health) received allegations that staff were neglecting residents. The 9/24/24 census includes 198 residents. On 9/24/24 at 2:11pm, surveyor inquired about concerns at the facility, R1 stated I reported them (staff) for not doing their job. They had a resident sitting in feces for three and a half hours. Surveyor inquired who the concerns were reported to, R1 affirmed it was miss (V2's last name). [V2 is the DON/Director of Nursing]. On 9/25/24 at 9:54am, surveyor inquired about R1's reported allegations, V2 stated Making sure that staff was changing the patients in a timely fashion and answer the call lights. Surveyor inquired if a grievance form was provided to R1 and/or documented for R1's reported concerns, V2…

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

Based on record review and interview the facility failed to acknowledge resident rights and failed to comply with hospital transfer request (timely) for one of four residents (R1) in the sample. Findings include: On (6/11/24) IDPH (Illinois Department of Public Health) received allegations that R1 was not sent to the hospital as requested for pain and care is being delayed against her wishes. R1's progress notes state (6/9/24) resident expressed to writer (V5/Licensed Practical Nurse) that she has pain over entire body, and she would like to go to the hospital. Writer offered pain medication, but resident denied. Call placed to on call service for (Physician) and was made aware that NP (Nurse Practitioner) would return a call to the facility. [A return call from the NP was not documented]. (6/11/24) Resident complained of general malaise, pain, and a boil under the left arm. Writer contacted NP and new orders were given to send resident to the hospital for evaluation [2 days after initial request]. Patient was admitted for abdominal pain and UTI (Urinary Tract Infection). On 6/17/24…

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

Based on record review and interview the facility failed to follow policy procedures, failed to notify family of resident change in condition, and failed to document communication with the Nurse Practitioner regarding change in condition for one of four residents (R1) in the sample. Findings include: R1's face sheet includes emergency contact (V9/Family) and phone number. R1's progress notes state (6/9/24) resident expressed to writer (V5/Licensed Practical Nurse) that she has pain over entire body, and she would like to go to the hospital. Call placed to on call service for (Physician) and was made aware that NP (Nurse Practitioner) would return a call to the facility. [The NP return call and/or family notification were excluded]. On 6/17/24 at 2:53pm, surveyor inquired if the Physician and/or Nurse Practitioner were made aware of R1's (6/9/24) change in condition and/ or request to go to the hospital, V6 (Assistant Director of Nursing) accessed R1's electronic medical records and stated It says that a call was placed to the on-call doctor and the NP would call back. I (V6) see…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reviews, the facility failed to provide proper nursing care to one (R1) resident by failing to provide Indwelling Urinary Catheter care and Activities of Daily Living (ADL) Care in a sample of three reviewed. Finding include: R1's current face sheet documents R1 is a [AGE] year-old individual with medical diagnosis that include but not limited to: hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, hydronephrosis with ureteropelvic junction obstruction, other obstructive and reflux uropathy, disorder of kidney and ureter, unspecified. R1's BIMS (Brief Interview for Mental Status) dated [DATE], is documented as 15/15, indicating R1 has intact cognition, and documents R1 has an External catheter. R1's MDS section GG dated 3/13/2024 documents R1 needs Substantial/maximal assist with toileting hygiene, shower/bathe self, eating, oral hygiene, R1 needs Setup or clean-up assistance, upper body dressing. On 06/09/2024 at 09:47am, R1 was observed in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review that facility failed to ensure that one bedbound resident (R5), (with current deep tissue damage) had interventions in place to prevent further skin breakdown. This failure has affected one resident (R5) and has the potential to affect 14 other residents in the facility with pressure wounds. Findings include: R5 is a [AGE] year old with diagnosis including but not limited to: Pressure- Induced deep tissue damage, multiple sclerosis, unspecified protein-calorie malnutrition, difficulty in walking and anorexia. On 4/16/2024 at 11:45 AM, R5 was observed lying in bed with V11 (R5's mother) at the bedside. At that time, R5's heel protector/boot was observed soiled and lying in the bed, off of R5's foot. Surveyor noted sign at head of R5's bed which documented, Do not remove heel protector, if soiled or need replaced, please see wound care. On 4/16/2024 at 11:45 AM, V11 said, R5's wounds were acquired since he has been here. R5 did not have wounds when he first came…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review that facility failed to ensure that one resident (R4), received scheduled medication as prescribed by the doctor. This failure has affected one of four residents reviewed for medication. Findings include: R4 is a [AGE] year old with diagnosis including but not limited to: Muscle wasting and atrophy, muscle weakness, fracture of orbit and traumatic subdural hemorrhage with loss of consciousness of unspecified duration. R4 has a BIMS (Brief Interview for Mental Status) Score of 15, which indicates cognitively intact. On 4/15/2024 during investigation, V4 (Licensed Practical Nurse/LPN) was observed administering morning medication to R4. 04/15/2024 at 10:20 AM, V5 CNA (Certified Nurse Assistant) asked for permission and rolled R4 on his right side to check his back to observe a Lidocaine patch on R4's back with the date of 4/12/2023 written on it. At that time, V4 LPN (Licensed Practical Nurse) said, I wasn't aware that R4 did not have on his lidocaine patch…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure that one resident (R4), who requires hemodialysis three times per week, received his scheduled hemodialysis treatment on two different occasions. This failure has the potential to affect fifteen other residents who reside at the facility and receive dialysis. Findings include: R4 is [AGE] year old with diagnosis including but not limited to: End stage renal disease, chronic viral hepatitis C, unspecified kidney failure, anxiety disorder and essential hypertension. R4 has a BIMS (Brief Interview for Mental Status) score of 15, which indicates cognitively intact. On 03/04/2024 during investigation, R4 was observed lying in his bed. Surveyor inquired about R4's dialysis treatment. On 03/04/2024 at 11:20 AM R4 said, I've been here (the facility) since 02/09/2024 and I've missed dialysis a couple of times I think due to my insurance. I go to the dialysis center up the street in walking distance on Mondays, Wednesdays and Fridays. I'm not sure what…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure there were enough clean under pads and pillowcases readily available for residents use. This failure has the potential to affect all 199 residents residing in the facility. Findings Include: On 2/13/24 at 12:07 PM, V9 (Certified Nursing Assistant) stated sometimes the staff does not get enough under pads for the residents. At 12:54 PM, a phone interview conducted with V30 (Certified Nursing Assistant). V30 stated, They distribute linens to every floor each shift, but we don't get enough. We don't get any pillowcases for our residents. Some days they would only send two under pads and four bed sheets on our unit. We have around 50 residents on my unit. How am I supposed to take care of them and provide them clean linens if they only give us a few? What I do is I go downstairs to get my linens but most of the time they won't have any available. On 2/14/24 at 9:47 AM, V14 (Laundry/Housekeeping Supervisor) stated that the facility is…

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

Based on observation, interview and record review, the facility failed to ensure the kitchen floor was clean and equipment was in working order. These deficient practices have the potential to affect all 197 residents receiving food prepared in the facility's kitchen. Findings include: On 02/13/24 at 2:00 PM, during kitchen tour observed V16 (Dietary Aide) and V17 (Dietary Aide) working in the dish room scraping uneaten food from dishes into garbage cans. Observed garbage disposal leaking a large amount of water onto the tiled floor with large pools of water collecting on the floor around the dish room including where the staff was working, under the counters, behind the dish machine and extending to the far corner of the room away from the dish machine. This standing water appeared dirty with particles of food and dirt mixed in it and with pieces of brown and black material floating in the water. Observed large cotton blanket on the floor underneath the counter which was saturated in water and had particles of food stuck on the blanket. Observed food containers and wrappers on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to protect R7, R8, and R10' s right to be free from abuse by a resident (R2). This failure resulted in R2 becoming physically aggressive by slapping and spitting on the face of R10, and R2 inappropriately touching R7 and R8. Findings Include: R2' s clinical records show R2 was initially admitted to the facility on [DATE] with listed diagnoses not limited to Schizophrenia and Alzheimer' s Disease. R2' s Minimum Data Set (MDS) dated [DATE] shows R2 had moderately impaired cognition and independent with walking. R2' s progress notes dated 1/26/24 at 3:18 PM documented by V5 (Restorative Nurse Manager) revealed that R2 was noted attacking other residents pulling (R2' s) own hair out, biting and scratching self. It also documents that emergency ambulance was called and transferred R2 to the acute hospital. On 2/13/24 at 9:39 AM, a phone interview conducted with V3 (Insurance Case Manager). V3 stated that based on R2' s hospital records dated 1/30/24, R2 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to follow their policy and procedure to report an abuse immediately and no later than two hours to the State Survey Agency (SA) for 3 (R7, R8, R10) out of 7 residents reviewed for abuse. Findings Include: R2's clinical records show R2 was initially admitted to the facility on [DATE] with listed diagnoses not limited to Schizophrenia and Alzheimer's Disease. R2's Minimum Data Set (MDS) dated [DATE] shows R2 had moderately impaired cognition and independent with walking. R2's progress notes dated 1/26/24 at 3:18 PM documented by V5 (Restorative Nurse Manager) shows that R2 was noted attacking other residents and pulling (R2's) own hair out, biting and scratching self. It also documents that an emergency ambulance was called and transferred R2 to the acute hospital. At 10:22 AM, V5 (Restorative Nurse Manager) stated that on 1/26/24, V5 was the nurse in charge for the afternoon shift and was coming in at around 2:30 PM when V5 witnessed R2 started…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 thoroughly investigate an incident of abuse for 3 (R7, R8, R10) out of 7 residents reviewed for abuse. Findings Include: R2's clinical records show R2 was initially admitted to the facility on [DATE] with listed diagnoses not limited to Schizophrenia and Alzheimer's Disease. R2's Minimum Data Set (MDS) dated [DATE] shows R2 had moderately impaired cognition and is independent with walking. R2's progress notes dated 1/26/24 at 3:18 PM documented by V5 (Restorative Nurse Manager) shows that R2 was noted attacking other residents and pulling (R2's) own hair out, biting and scratching self. It also documents that an emergency ambulance was called and transferred R2 to the acute hospital. At 10:22 AM, V5 (Restorative Nurse Manager) stated that on 1/26/24, V5 was the nurse in charge for the afternoon shift and was coming in at around 2:30 PM when V5 witnessed R2 started screaming. V5 also stated witnessing R2 touching the private body parts of three male…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policies and procedures to administer a medication per physician's order for 1 (R6) out of 3 residents reviewed for pharmaceutical services with behavioral symptoms and who received an antipsychotic medication. R6's Medication Administration Record (MAR) was reviewed, it reflected that the medication had been unavailable for administration on multiple occasions. Findings Include: R6's Minimum Data Set, dated [DATE] shows R6 is cognitively intact. R6 Physician order Sheet (POS) with active orders as of 2/13/24 shows an order for Clonazepam 1 mg tablet, give 1 mg by mouth every 12 hours for anxiety related to anxiety disorder. Medication Administration Record (MAR) shows Clonazepam 1 mg tablet was not administered for ten days of admission. Note text dated 2/13/24 by V20 (LPN) reads in part: rejection (from the pharmacy) was e-mailed to the facility on the 10th (2/10/24) regarding non-coverage. On 2/13/24 V20 (License…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure that a cognitively impaired resident who was assessed to be in pain receives pain management as stated in the pain assessment and care plan. This failure affected one resident(R19) of two residents reviewed for pain management. Findings include: R19's face sheet shows diagnoses which include but are not limited to Disorder of Bone Density and Structure, Muscle Wasting and Atrophy, Alzheimer's Disease, and Dependence on Renal Dialysis. On 1/24/24 at 12:40pm, V22(R19's POA/Family) stated On that day, I went to see him(R19) at the nursing home, and he was across from the nursing station bent forward in a fetal position because of pain in his abdomen. We had to help him get in a wheelchair to take him back to his room, and the nurse did not give any pain medication. On 1/23/24 at 1:28pm, V18(Nurse Consultant) stated The Director of Nursing just started work today and I will be standing in for her. V18 was interviewed about R19's pain management.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure ADL (Activities of Daily Living) care was provided for dependent residents who required assistance with bladder and bowel incontinence for one of four residents (R5) reviewed for ADL care. Findings include: R5's medical record (Face Sheet) documents R5 is a [AGE] year-old admitted to the facility on 8.4.2020 with diagnoses including but not limited to: Unspecified Dementia, Type 2 Diabetes Mellitus, Metabolic Encephalopathy, and Unspecified Protein-Calorie Malnutrition. R5's MDS (Minimum Data Set, 9.12.2023) documents: -BIMS (Brief Interview for Mental Status) of 3 (severe cognitive impairment) -Bed Mobility/Transfer/Toilet Use: 3/2 (extensive assistance/One-person physical assist -Bladder/Bowel: 3/3 (always incontinent) Care plan (initiated 8.5.2020) documents in part, R5 is at risk for potential skin alteration related to comorbidities, impaired mobility, and incontinence. Keep linen clean, dry, and free from wrinkles. Keep skin,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 sufficient staffing to ensure ADL (Activities of Daily Living) care was provided for dependent residents who required assistance with bladder and bowel incontinence for one of three residents (R5) reviewed for ADL care. Findings include: On 12.6.2023 at 9:35 AM on 3 South, the census was 42, there were two nurses (V15-Licensed Practical Nurse and V23-Registered Nurse), and four Certified Nursing Assistants (V14, V19, V23, and V25). 12.6.2023 at 9:38 AM, R5 was observed awake, alert, lying on right side in bed. Call light activated by Surveyor; answered by V19 (CNA-Certified Nursing Assistant). V19 said he is not resident's CNA but would check resident for incontinence. Large soft BM was noted in brief and smeared on resident's buttocks. Incontinent pad was saturated with urine, a sheet, that had been placed between resident and incontinent pad, was saturated with urine as well. 12.6.2023 at 9:43 AM, V14 (CNA-Certified Nursing Assistant) said she is R5's assigned CNA today. V14 said she checked…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 schedule a Registered Nurse (RN) for at least eight consecutive hours a day for five of eight days reviewed for October 2023 (10.8, 10.21, 10.22, 10.28, 10.29) and two of eight days (11.5, 11.26) reviewed for November 2023. Findings include: 12.5.2023 at 2:59 PM, V3 (former Staffing Coordinator) said there is always an RN in the building for eight hours a day, seven days a week. 12.7.2023 at 1:09 PM, V3 (Former Staffing Coordinator) went through all available staffing assignment sheets for 10.5.23-12.5.23; not all sheets available for each day/each shift. No RN staffing worked on the following days: 10.8.23, 10.21.23, 10.22,23, 10.29.23, 11.26.23, 12.2.23, and 12.3.23. 12.8.2023 at 10:51 AM, V1 (Administrator) said there should be an RN (Registered Nurse) for eight hours a day seven days a week. Time Card Reports for October 2023 document there was no RN working in the facility on 10.8, 10.21, 10.22, 10.28, and 10.29. Time Card Reports for November 2023 document there was no RN working in the facility 11.5 and 11.26.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure that resident's rooms were free from peeling drywall and leaking water from the ceiling or bathroom sink. This failure has affected 5 residents (R10, R15, R16, R17 and R18) of 21 reviewed for homelike environment. Findings include: R10 is [AGE] year old with diagnosis including but not limited to: Acute Respiratory failure, Hypertensive emergency, Acute Respiratory distress, Pneumonitis and Acute Pulmonary edema. R15 is [AGE] year old with diagnosis including but not limited to: Difficulty walking, Lack of Coordination, Pulmonary embolism, Dyspnea, and Muscle wasting and Atrophy. R16 is [AGE] year old with diagnosis including but not limited to: Chronic pain, Hypertension, Dyspnea, Shortness of Breath, Chest pain, Muscle wasting and Atrophy. R17 is [AGE] year old with diagnosis including but not limited to: Chronic Obstructive Pulmonary Disease, Hypertension, Pressure ulcer of left ankle (stage 3), Insomnia, Dysphagia and Spinal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review the facility failed to ensure that residents had clean linen available. This deficiency has the potential to affect all 218 residents that reside in the facility. Findings include: R11 is [AGE] year old with diagnosis including but not limited to: Hypertension, Lack of coordination, Difficulty walking, Insomnia and Gout. R11 has a BIMS (Brief Interview for Mental Status) score of 15, which indicates cognitively intact. R10 is a [AGE] year old with diagnosis including but not limited to: Alcohol use, with intoxication, Hypertensive emergency, Opioid use, Acute Kidney failure, Acute Respiratory failure and Acute pulmonary edema. R10 has a BIMS (Brief Interview of Mental Status) score of 15, which indicates cognitively intact. On 10/3/23 at 9:42 AM, Surveyor observed one linen cart on 2N unit empty (without linen) and another linen cart with 2 flat sheets (no towels) and on 2S (2/ South) Surveyor observed one linen cart without linen or towels. On 10/03/23 at 11:16…

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

Based on observation, interviews and record review, the facility failed to ensure that the kitchen was free from pests and failed to ensure that food was covered in a storage container. This failure has the potential to affect 217 residents that receive meals from the kitchen. Findings include: On 10/4/23 during investigation, Surveyor conducted a tour of the kitchen with V26 (Dietary Manager). On 10/4/23 at 12:15 PM, Surveyor observed two black pests crawling on the wall by the dishwasher. Surveyor observed a brown pest crawling on the floor near the dishwasher. Flying pest where also observed in the kitchen. On 10/4/23 at 12:15 PM, V44 (Dietary Aide) said, These are roaches crawling. V42 (Dietary Aide) said, Roaches are always near the dishwasher. On 10/4/23 at 12:16 PM, Surveyor observed another brown pest crawling on the floor and pointed it out to V26 (Dietary Manager). V26 said, This is my 1st time seeing a roach here, the exterminators were just here the other day. Water was observed on the kitchen floor near the tray line and near the ice machine. A leakage was also 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.

Based on observation, interview, and record review the facility failed to ensure that a treatment cart was locked when not in visual proximity of the nurse and not in use to prevent tampering. This failure has the potential to affect all residents residing on the 1st and 2nd floor of the facility. Findings include: On 10/02/23 at 10:25am on the 1st floor south wing the floor treatment cart was observed by the south elevator unattended and not locked. Treatment cart not visible to the nurse. On 10/02/23 at 10:26am, V5 (Nurse) identified the cart as the treatment cart and stated in part that it (referring to the treatment cart) should be locked when not in use and not visible to the nurse because any of the residents can come and take medicated ointments (stored in the treatment cart). On 10/02/23 at 10:39am a treatment cart was observed on the 2nd floor north wing unattended to and not in view of the nurse. When shown to V7 LPN (Licensed Practical Nurse) and V7 was asked about the facility policy on medication/treatment cart storage; V7 stated that the cart should be placed visible…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 current standards of infection control and prevention in storing soiled linen after residents' care. This failure has the potential to affect all 45 residents residing on the 3rd floor. Findings include: On 10/02/23 at 10:57am, on the 3rd floor south wing hallway a yellow linen collection container was observed in the hallway with the lid unable to close due to over following soiled linens with the foul smell odor of urine in the hallway. V14 LPN (Licensed Practical Nurse) who was passing medication at the time of observation stated that the CNAs (Certified Nurse's Aides) know that it (referring to the soiled linen container) should not be this full and uncovered. On 10/02/23 at 2:25pm V2 DON (Director of Nursing) stated in part that all soiled linen should be placed in the soiled linen container and closed, to contain the odor and not touching the floor for infection control prevention and control. The facility nursing policy on Linen Handling dated 11/22 presented documented in part that the purpose…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure that the facility was free from urine and feces odor. The facility also failed to ensure that 2 elevators were in working condition. This failure has the ability to affect all 218 residents that reside in the facility. Findings include: On 10/3/23 during investigation, Surveyor observed 2 full barrels of laundry on unit 2N (2/ North) outside of room [ROOM NUMBER]. On 10/3/23 at 10:43 AM, Surveyor noted a strong odor on unit 2N. On 10/03/23 at 10:55 AM, Surveyor noted a strong odor on the 2S unit (2/South) near the nurse's station. Two garbage containers were observed outside of a resident's room. One container containing soiled linen and one with garbage. On 10/3/23 at 10:58 AM, V7 LPN (Licensed Practical Nurse) said, The unit usually smells like urine and feces when the CNAs (Certified Nurse Assistants) are doing patient care. When removing briefs and linen from the rooms, the smell travels. Sometimes the linen containers 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 interview and record review the facility failed to report to IDPH (Illinois Department of Public Health) incidents of illicit drug overdose for one resident (R3) in the sample reviewed for opiates overdose; and failed to report to IDPH within the required regulation time an allegation of abuse of R22 by facility staff members. Findings include: On 09/27/23 at 10:15am, R3 had a change in condition. R3 was found unresponsive and was transferred to the local hospital. Assessment showed that R3 has altered mental status secondary to opiates overdose. Emergency care rendered to R3 includes but not limited to intubation (Mechanical Ventilation) for adequate airway protection and was admitted to ICU (Intensive Care Unit) for further management of Hypercapnic Respiratory failure secondary to opiate abuse. R3's hospital record Encounter Summary showed reason for hospital visit includes Respiratory Distress, drug overdose. EMS (Emergency Medical Services) report showed documentation that according to the nurse, who called 911 this morning, patient was not taking any narcotic based…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 conduct a thorough investigation for one resident (R3) reviewed for substance abuse and failed to immediately initiate an investigation into the physical abuse of one resident (R22). These failures resulted in the alleged perpetrators continuing to have access to R22 and exposing R22 to the potential of further abuse and R3 to additional substance abuse. Findings include: R3's is a [AGE] year-old male resident that was admitted to the facility initially on 08/30/23 with diagnosis information list that includes but not limited to Schizophrenia unspecified, Major Depressive Disorder, recurrent, unspecified, Hyperlipidemia unspecified, Essential (Primary) Hypertension, Chronic Atrial Fibrillation unspecified, Chronic Obstructive Pulmonary Disease unspecified. R3's medical record Progress Note by V6 LPN (Licensed Practical Nurse) documented in part that at on 09/27/23 at 10:15am upon rounding, R3 was found unresponsive. Rapid Response (referring to code…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 revise and initiate a plan of care for one resident R3 reviewed for opiate overdose. This failure affected R3 who was found unresponsive on 09/27/23. R3 was transferred to the local hospital and was admitted with a diagnosis that includes R3 was intubated and admitted with diagnosis that include but not limited to Hypercapnic respiratory failure secondary to opiates overdose, altered mental status, secondary to opiate overdose and opiate abuse. Findings include: R3's is a [AGE] year-old male resident that was admitted to the facility initially on 08/30/23 with diagnosis information list of Schizophrenia unspecified, Major Depressive Disorder, recurrent, unspecified, Hyperlipidemia unspecified, Essential (Primary) Hypertension, Chronic Atrial Fibrillation unspecified, Chronic Obstructive Pulmonary Disease unspecified. R3's medical record Progress Note by V6 LPN (Licensed Practical Nurse) documented in part that on 09/27/23 at 10:15am upon rounding, R3…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to provide supervision and interventions for two residents (R10 and R13) with substance abuse. Findings include:On 10/3/23 during investigation, R9 was observed in her room. Surveyor inquired about R9's knowledge of residents consuming alcoholic beverages in the facility. On 10/3/23 at 10:45 AM, R9 said, I've seen residents getting drunk in the lobby quite frequently. When the nurses try to catch them, they (residents) hide the alcohol. A lot of the agency nurses may not even know what's going on with the drinking. R9 is [AGE] year old with diagnosis including but not limited to: Hypertension, Gastro- Esophageal Reflux disease, Generalized Edema, Acquired absence of lung and Endocarditis. R9's BIMS (Brief Interview for Mental Status) score is 15, which indicates cognitively intact. R13 is [AGE] year old with diagnosis including but not limited to: Alcohol Abuse, Cocaine abuse, Heart failure, Hypertension and Atherosclerotic Heart Disease. R13 ha a BIMS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow the facility policy to conduct resident criminal history background checks within 24 hours after admission of a new resident which affected R213, R216, R222, R223 and R225 in the total sample of 74 residents and has the potential to affect all 215 residents in the facility. Findings include: Facility document dated 9/10/23 and titled MDS (Minimum Data Set) Resident Matrix, documents, in part, that R213, R216, R222, R223 and R225 were new admissions to the facility. On 9/11/23, this surveyor requested criminal history background checks from V1 (Administrator) for R213, R216, R222, R223 and R225 along with their census reports and received the following: R213: Census report documents, in part, that R213 was admitted to the facility on [DATE] and is an active resident in the facility. R213's criminal history background check was performed on 9/11/23 with document reading: Registry search done on 9/11/23. R216: Census report documents, in part, that…

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

Based on observation, interview and record review, the facility failed to ensure the Daily Nurse Staffing was posted in a prominent place readily accessible to residents and visitors and failed to ensure the Daily Nurse Staffing was complete with the required information. This failure affected all 215 residents residing in the facility. Findings include: On 9/10/23 at 9:10 am, this surveyor entered the facility and did not observe the Daily Nurse Staffing posted in the lobby/reception area of the facility. On 9/11/23 at 9:00 am, this surveyor entered the facility and did not observe the Daily Nurse Staffing posted in the lobby/reception area of the facility. On 9/12/23 at 9:15 am, this surveyor entered the facility and did not observe the Daily Nurse Staffing posted in the lobby/reception area of the facility. On 9/12/23 at 9:34 am, V38 (Staffing Coordinator) stated, V38 is responsible for posting the nurse and CNA (Certified Nursing Assistant) schedule and posts it for employees to see in a locked bulletin board by the employee time clock in the back hallway. When asked if V38…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 proper labeling and dating of food items in the refrigerator and freezer and maintain sanitary conditions in the food preparation areas. This failure has the potential to affect all residents receiving oral nutrition. On 9/10/2023 at 9:40am surveyor observed in the refrigerator ½ loaf of yellow cheese with no label or date, 1/2 bag of shredded cheese with a sticker with no name of product name or dates, a long steel pan of Alfredo, written on the foil, that was not dated or covered properly. Surveyor further observed in the refrigerator a medium size steel container with 8 boiled eggs in it with no label or date, a medium size steel pan of peanut butter and jelly mixed with a date of 9/08/2023 and a medium sized steel pan of turkey slices with a date of 9/03/2023. On 9/10/2023 at 9:45am V3 (Cook) stated, food items should be labeled and have an in and use by date and the pan with the boiled eggs should have a use by date on it too. On 9/10/2023 at 9:49am surveyor observed 2 large round roasted turkeys…

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

Based on observation, interview and record review the facility failed to secure the lid on the outside garbage dumpster in an effort to prevent pest and rodents from entering into the facility. This failure has the potential to affect all residents residing in the facility. On 9/10/2023 at 8:31am surveyor observed the lid to one of the garbage dumpsters open from overflowing garbage bags. On 9/10/2023 at about 9:30am surveyor observed the lid to one of the garbage dumpsters open from overflowing garbage bags. On 9/13/2023 at 10:43am via email V21 (Maintenance Director) stated, dumpster lids should be closed when not in use to prevent and deter rodent activity. Housekeeping is responsible for ensuring the dumpster lids are closed after use. Policy titled Waste Management with a date of 5/14 documents, in part, to prevent the spread of infection, dumpster lid kept closed and maintenance and housekeeping personnel shall assure the dumpster area is kept clean and all trash bags are inside the dumpster, and dumpster lids closed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide a homelike environment by providing linens or pillows for resident beds; by ensuring that water was not leaking from the ceiling onto resident beds in room; by maintaining integrity of resident room walls, closet doors, baseboards, drawer covers, overhead lights, and wall air conditioner units; and by repairing or replacing damaged furniture. These failures affected R19, R31, R49, R50, R112, R126, R132, R134, R163, R165, R180, R181, R182 and R197 and has the potential to affect all 215 residents in the facility. Findings include: On 9/10/23 at 11:42 am, in the 2 South dining, this surveyor observed a chair with a light brown, plastic seat cushion that had 9 gaping tears in the plastic covering exposing the foam cushion underneath. The exposed foam cushion was discolored with black and brown stains. The edges of the plastic seating from the tears were frayed and elevated. On 9/11/23 at 10:07 am, in the 2 South dining, this surveyor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safe environment by correcting hazards from damaged furniture with an exposed nail and electrical outlets not covered. These failures affected R9, R64 and R112 and has the potential to affect the 47 residents residing on 2 South. Findings include: On 9/10/23 at 11:42 am, in the 2 South dining, this surveyor observed a brown wooden chair with a maroon and green flowered cloth seat cover with the left chair arm detached from the frame of the back of the chair. The chair arm is hanging down towards the floor exposing a gray screw approximately one inch with the sharp end of the exposed screw pointing outwards. On 9/11/23 at 10:07 am, in the 2 South dining, this surveyor observed the same chair with the chair arm hanging down exposing a gray screw approximately one inch with the sharp end of the exposed screw pointing outwards. On 9/11/23 at 12:22 pm, this surveyor and V21 (Maintenance Director) performed a brief environmental tour and walked into the 2 South dining room. This surveyor and V21 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 failed to complete the controlled drug count sheet which is utilized to count controlled substances for two residents (R67 and 216); and failed to complete a controlled drug receipt/record disposition form for three residents (R112, R149 and R204). This has the potential to affect all 47 residents on the 2-south unit and all 60 residents on the 2-north unit. Findings include: On 09/10/2023 V1 (Administrator) presented facility census report that documented the residents census of 47 residents on the 2-south unit and all 60 residents on the 2-north unit. On 09/11/23 at 9:12 am, Surveyor and V8 (Licensed Practical Nurse, LPN) performed a controlled substance audit of the 2-south team 2 medication cart. Surveyor did not observe a controlled drug receipt/record/disposition form for the following residents: R204 without a controlled drug receipt/record/disposition form for methadone 100 mg tablet. R149 without a controlled drug receipt/record/disposition…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that the call light was within a resident's reach for use to call for staff assistance and failed to promptly respond to a resident's call light which affected one resident (R182) in the total sample of 74 residents reviewed for accommodation of needs. Findings include: R182's admission Record documents, in part, diagnoses of cerebral infarction, hypertension, type 2 diabetes mellitus, cognitive communication deficit, dysphagia, weakness, muscle wasting and atrophy, lack of coordination, hemiplegia affecting right dominant side and gastrostomy status. R182's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview for Mental Status (BIMS) score of 3 which indicates that R182 has severe cognitive impairment. R182's Functional Status for ADL Assistance for bed mobility for self-performance is coded as extensive assistance with a support of two + (plus) persons physical assist. R182's Bladder and Bowel Status 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to acknowledge and comply with one resident's (R40's) meal preference. This failure has the potential to affect all residents in the sample of 74. Findings include: R40 has a diagnosis of but not limited Traumatic Subdural Hemorrhage, Bipolar Disorder, Dysphagia, Lack of Coordination, Type 2 Diabetes Mellitus, Hypertension, and Dysphagia. R40 has a Brief Interview of Mental Status score of 11 that indicates moderately impaired cognition. Minimum Data Set, dated [DATE] documents that R40 needs supervision and a one person assist with eating. Order Summary Report with active orders of 9/13/2023 documents that R40 has a General Diet Regular Texture, Regular thin liquids consistency, set up assistance and supervision. Resident Council Minutes dated 6/22/2023 states, in part, not reading the sub paper. On 9/10/2023 at 12:45pm surveyor observed R40 stating out loud and asking V17 (CNA) did he swap his lunch meal for a grill cheese. V17 did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain an advance directive for two residents (R9, R105) in the resident's electronic medical record (EMR). This failure affected two residents (R9 and 105) in a sample of 74 residents reviewed for advance directives. Findings include: R105's face sheet shows that R105 has a diagnosis which includes but not limited to nontraumatic intracerebral hemorrhage in hemisphere subcortical, schizophrenia, open -angle glaucoma, benign prostatic hyperplasia without lower urinary tract symptoms, unspecified dementia, seizures, essential hypertension, non-traumatic subdural hemorrhage, repeated falls, encounter for surgical aftercare following surgery on nervous system, presence of cerebrospinal fluid drainage device. R105's Advance Directive on the admission Record (profile section) was blank. R105's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview of Mental Status (BIMS) score of 03 which indicates that R105 is cognitively impaired.…

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

Based on observations, interviews, and record reviews, the facility failed to ensure a care plan for advance directive is updated for one (R126) resident reviewed for care planning in the total sample of 74 residents. Findings include: R126's (Active Order As Of: 09/12/2023) Order Summary Report documented, in part Diagnoses: (include but not limited to) muscle wasting, hypertension, and adult failure to thrive. Order Summary. Code Status: DNR (do-not-resuscitate). Active: 12/12/2022. R126's (06/16/2023) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating 126's mental status as cognitively intact. The (9/5/23) Facility DNR (do-not-resuscitate) LIST documented that R126 was on the list. The (9/5/23) Advanced Directives documented that R126's Code Status was DNR. R126's (date initiated: 08/22/2022) Care Plan documented, in part Focus: (R126) has NO advance directive. Goal: will communicate the absence of advance directive. Intervention: Resident is a FULL CODE - if resident becomes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide timely incontinence care for a dependent resident which affected one resident (R182) in the total sample of 74 residents reviewed for activities of daily living (ADL) care. Finding include: R182's admission Record documents, in part, diagnoses of cerebral infarction, hypertension, type 2 diabetes mellitus, cognitive communication deficit, dysphagia, weakness, muscle wasting and atrophy, lack of coordination, hemiplegia affecting right dominant side and gastrostomy status. R182's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview for Mental Status (BIMS) score of 3 which indicates that R182 has severe cognitive impairment. R182's Functional Status for ADL Assistance for bed mobility for self-performance is coded as extensive assistance with a support of two + (plus) persons physical assist. R182's Bladder and Bowel Status for urinary and bowel continence is coded as always incontinent. On 9/10/23 at 11:50…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain a resident's head of the bed elevated to at least 30 degrees when the resident is receiving enteral feedings (tube feedings) via a gastrostomy tube (G-tube) which affected one resident (R182) in the total sample of 74 residents reviewed for tube feedings. Findings include: R182's admission Record documents, in part, diagnoses of gastrostomy status, cerebral infarction, dysphagia, hypertension, type 2 diabetes mellitus, cognitive communication deficit, weakness, muscle wasting and atrophy, lack of coordination, and hemiplegia affecting right dominant side. R182's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview for Mental Status (BIMS) score of 3 which indicates that R182 has severe cognitive impairment. R182's Nutritional Status for the Nutritional Approaches indicates a feeding tube. On 9/10/23 at 11:50 am, R182 observed lying in bed with R182's head of the bed positioned at approximately 15 degrees…

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

Based on observation, interview and record review, the facility failed to label and date oxygen tubing and a tracheostomy mask. This failure affected two residents (R143 and R151) reviewed for oxygen equipment, in a total sample of 74 residents. Findings include: R151's Face Sheet documents R151 has the following diagnosis that include, but are not limited to, chronic respiratory failure with hypoxia, anemia, unspecified, chronic obstructive pulmonary disease, unspecified, hypoxemia, unspecified injury of head, initial encounter, methicillin resistant staphylococcus aureus infection as the cause of diseases classified elsewhere, coronavirus infection, unspecified, morbid (severe) obesity due to excess calories, muscle weakness (generalized), other pulmonary embolism without acute cor pulmonale, long term (current) use of anticoagulants, pressure ulcer of sacral region, stage 3, unspecified lack of coordination, muscle wasting and atrophy, not elsewhere classified, multiple sites, dependence on supplemental oxygen, essential (primary) hypertension, functional quadriplegia. R151's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to have a five percent (5%) or lower medication error rate. There were five medication errors out of 31 medication opportunities, resulting in a 16.13% medication error rate and affected six (R94 and R213) residents observed for medication pass. Findings include: On 09/11/23 at 8:33 am, V24 (Licensed Practical Nurse, LPN) was observed on the first-floor south medication cart. Surveyor observed V24 prepare and count 10 pills total that were administered to R94. Upon surveyor reconciling R94's medication for medications that were order for administration and medications that were observed as administered and documented by V24, the following medication error was identified: 1.) Not given during observation: Ascorbic Acid Oral tablet 500 milligram (mg) 1 tablet by mouth three times a day for dietary supplement; prophylaxis. 2.) Not given during observation: Cholecalciferol tablet 1000 unit (U) give 2 tablets by mouth one time a day 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that an eye drop medication was labeled with an open date and expiration date after opening the solution. This has the potential to affect one resident (R5) out of 74 residents in the sample. Findings include: On 09/11/23 at 10:21 am, Surveyor and V11 (Licensed Practical Nurse, LPN) inspected the 3-North Cart 2 and observed R5's Latanoprost solution 0.005% with no open date. V11 stated, eye drops expire 30 days after opening. V11 stated, eye drops are labeled with an open date in order to know when the eye drops expires. On 09/12/23 at 10:17 am, V2 (Director of Nursing, DON) stated, eye drop medications should be labeled with an open date once open. V2 stated, it is important for eye drop medication to be labeled with an open date after the medication is open, in order for the nurse to know when to discard and reorder the medication. V2 explained, if a medication does not have an open date there is a potential to give ineffective…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 check and document the temperatures of residents' personal refrigerators daily and failed to maintain an appropriate refrigerator temperature inside a residents' personal refrigerator which affected R21 and R47 in the total sample of 74 residents reviewed. Findings include: R21's admission Record documents, in part, diagnoses of type 2 diabetes mellitus, end stage renal disease, dependence on renal dialysis, hypertension, heart failure, idiopathic gout, cachexia, and muscle wasting and atrophy. R21's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview for Mental Status (BIMS) score of 10 which indicates that R21 has moderate cognitive impairment. On 9/10/23 at 12:43 pm, R21's personal refrigerator observed in room with a refrigerator temperature log posted on the front of R21's refrigerator with a date from June 2023. With R21's permission, this surveyor opened R21's refrigerator and observed the following items:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure that residents' call devices are functioning to allow residents to call for staff assistance. This failure affected 2 residents (R126 and R165) reviewed for functioning resident call devices in a total sample of 74 residents. Findings include: On 09/10/23 at 12:39PM, R126's call device was located at the right side of R126's bed. R126 stated, it doesn't work for a month now. R126's pressed the call light. This surveyor checked the overhead call device indicator outside of R126 room. The indicator was not lit. On 09/10/23 12:51 PM, V12 (Certified Nursing Assistant) stated, when the resident pressed the call light, the green light on the call light switch should be lit if it is working. It is not lit. (R126)'s call light is not working. On 09/11/2023 at 11:42am, V2 (Director of Nursing) stated, residents should have a working call light so they can call for assistance, and so we can address their need. On 09/11/2023 at 3:16pm, V21…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide a comfortable home like environment. This failure has the potential to affect all 215 residents in the facility. Findings Include: On 08/29/2023 at 9:50 am, R6 stated, The drawer from my dresser is missing and it has always been this way. Nothing was done about it. The paint in my room is old and chipped and the trim from the base boards is gone. It is like that in the entire facility. This place needs to be renovated. On 08/29/2023 at 10:01am, R8 stated, The facility is old looking and it really needs a lot of work. The residents feel depressed living in an old run-down building. On 08/30/2023 at 11:06pm, R9 stated, This place looks terrible. This place is so run down that it is depressing. On 08/31/2023 at 10:40am, R4 stated, The facility is very run down. It's a shame that we have to live like that. The entire facility is a dump. The sink in my room is loose and it needs to be replaced. The Maintenance Director said he will fix…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure adequate staffing for the 3-south unit of the facility on 08/20/2023. This failure resulted in R1 falling of the bed and sustaining a subdural hematoma as a result of the facility not having adequate staffing to provide resident care. Findings include: Review of the schedule 3 south 7am-3pm (dated 08/20/2023) indicated that there was only one certified nursing assistant working and one restorative aide. On 08/30/2023 at 11:37am, V5 (Staffing Coordinator) stated, On 08/20/2023, for the unit of 3 south, there were 5 Certified Nursing Assistants (CNAs) scheduled and we had 4 call offs. On that shift there was only a total of 1 CNA working the 3-south unit during the 7am-3pm shift. A restorative aide was pulled to work the 3-south unit. We are not utilizing a staffing agency. The new company that owns the building does not want to utilize a staffing agency. Sometimes a staffing agency is needed during times where there are a lot of call…

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

Based on observation, interview and record review, the facility failed to ensure food items were properly labeled, dated and stored; failed to practice safe hand washing and use of gloves; failed to clean kitchen equipment and failed to ensure that cook/service ware are sanitized. These deficient food sanitation practices have the potential to affect all 216 residents receiving food prepared in the facility's kitchen. Findings include: On 8/1/22 at 9:08 AM, during initial kitchen tour breakfast tray line was in progress. Surveyor observed V33 (Diet Aide) carrying 6-8 slices of toasted bread from the toaster with bare hands and put the toast into a large metal container on the tray line. Surveyor then observed V33 wash his (V33)'s hands for less than 5 seconds and put on gloves. Surveyor observed V34 (Diet Aide) using gloved hand to grab toast out of large metal container on tray line and place toast on individual resident trays. V34 observed alternating between touching different scoops to portion out food and touching toast directly with gloved hand. Surveyor did not observe any…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure the residents were treated with respect and dignity by not passing out meals to all residents sitting at a table at the same time. These failures affected 8 residents (R45, R54, R56, R73, R76, R95, R163, R215) reviewed during dining in a total sample of 104 residents. Findings include: On 8/1/22 at 1:17 PM, observed lunch cart delivered at 3rd floor dining room. Surveyor observed R45, R56, R76 sitting at the same table. At 1:19 PM, R76 was served lunch tray and began to eat. Surveyor observed R45 and R56 watching R76 eat. At 1:29 PM, R45's lunch tray was delivered. At 1:34 PM, R56 received her (R56)'s tray. On 8/3/22 at 12:50 PM, observed R56, R76, R95 sitting at the same table in 3rd floor dining room while R76 was eating lunch. R56 and R95 did not have a lunch tray in front of them. Surveyor heard R76 ask R56 are you hungry? At 1:02 PM, R56 received her (R56) lunch tray. At 1:04 PM, R95's lunch tray was delivered. On 8/3/22 at…

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

Based on observation, interview and record review the facility failed to ensure a clean and homelike environment by having loose or missing baseboards, walls damaged and not intact, broken or missing cabinets, window curtain not attached to curtain rod, and torn window screen. These failures affected residents (R5, R11, R21, R22, R25, R53, R56, R65, R74, R95, R104, R105, R122, R131, R157, R158, R162, R167, R186, R201, R210, R305) when reviewed for environment in the sample of 104 residents. Findings include: On 8/1/22 at 10:22 AM, observed R56, R158, R162's baseboards not attached to the wall behind R162's bed and on the opposite wall. Observed corner of wall near bathroom exposed to metal corner support approximately two feet from the floor extending up the wall. Surveyor observed brown rust-like color along the metal corner support and baseboard pulling away from the wall near the bathroom. Observed missing lower cabinet near the left side of closet. On 8/1/22 at 10:28 AM, observed R21, R95, R201's baseboards pulling away from the wall, exposing crumbling white wall with small…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assistive devices were properly maintained for two residents (R121 and R306) in the sample of 104 residents and failed to remove clutter from a restorative storage closet and ensure that the storage closet was locked, which has the potential to affect all 57 residents on the 3 North unit. Findings include: On 08/01/22 at 10:25 AM, R306 showed the surveyor the toilet safety rail in R306's bathroom. R306 grabbed the handle and demonstrated how the safety rail was loose and sliding off the toilet. The steel bracket securing the safety rail to the toilet was observed to be loose and not properly secured to the toilet seat. R306 stated that she (R306) has to steady herself (R306) with her (R306) hand on the toilet seat because it makes her (R306) feel like she's (R306) going to fall off the toilet when sitting down. On 08/01/2 at 12:00 PM, this observation was brought to the attention of V16 (RN/Registered Nurse) who stated that the loose toilet safety rail can be a Risk for injury or fall. V16 stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews the facility failed to provide oral supplements as recommended. This failure has the potential to affect 4 residents (R91, R95, R98, R162) reviewed for nutrition status in a total sample of 104. Findings include: On 8/1/22 at 1:40PM, observed R98 consuming lunch tray in 3rd floor dining room. R98 received mechanical soft meat, mashed potatoes, mixed vegetables, pineapple tidbits, and juice. There were no nutritional supplements on tray. Meal ticket documented nutritional treat with meals. On 8/1/22 at 1:46 PM, observed R91 consuming lunch tray in 3rd floor dining room. R91 received pureed meat, pureed vegetables, mashed potatoes, pureed bread and pureed pineapple. There were no nutritional supplements on tray. Meal ticket documented nutritional treat with meals. On 8/1/22 at 1:50 PM, observed R95 consuming lunch tray in 3rd floor dining room. R95 received meat, potatoes, mixed vegetables, bread, pineapple tidbits. There were no nutritional supplements on tray.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff donned the appropriate PPE (personal protective equipment) for PUI (persons under investigation) residents on contact and droplet isolation and failed to label and date oxygen equipment to prevent the spread of microorganisms including COVID-19 which affected R179, R205, R207, R211, R213, R558, R559, and R560 and had the potential to affect the 17 residents on the 1st floor of the facility. Findings include: Facility document, titled 1 S (South) 10 Day Quarantine and dated 8/1/22, documents, in part, that R205, R207, R211, R213, R558, R559 and R560 are documented as PUI for persons under investigation for COVID-19. On 8/1/22 at 10:22 am, a contact and droplet isolation sign was visibly observed posted on R559's room door. V14 (Certified Nursing Assistant, CNA) was observed entering R559's room with no gown or gloves on. Facility isolation sign (blue in color with a picture of a stop sign) documents, in part, Droplet/Contact Precautions: Health Care Workers Must Wear: N95 Respirator . Gloves,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that the call light was within a dependent resident's reach which affected one (R51) of 104 residents reviewed for accommodation of needs. Findings Include: R51's admission Record, documents, in part, that R51's diagnoses include schizophrenia, depression, muscle wasting and atrophy, idiopathic gout, osteoarthritis and cellulitis of left lower limb. R51's Minimum Data Set (MDS), dated [DATE], documents, in part, Section C. Brief Interview for Mental Status (BIMS) score: 15. which indicates that R51 is cognitively intact. Section G. Functional Status: self-performance for personal hygiene, and toilet use is coded as requiring extensive assistance, and support is coded as one-person physical assist. On 8/1/22 at 10:35 am R51's call light was observed not within R51's reach and was on the floor under R51's bed. On 8/2/22 at 10:05 am R51's call light was observed not within R51's reach and was on the floor under R51's bed. On 8/2/22 at…

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

Based on observation, interview and record review, the facility failed to ensure that a resident's low air loss mattress was placed at the recommended setting. This failure affected one resident (R39) of the four residents reviewed for pressure ulcer prevention interventions in a total sample of 104 residents. Findings include: On 08/01/2022 at 10:20am on the second floor, R39 was observed in the bed, laying on a low air loss mattress with a pink and white pad underneath R39. The reading observed on R39's control panel for the low air loss mattress was set at 175 lbs(pounds). On 08/01/2022 at 10:30am V13(LPN/Licensed Practical Nurse) stated, I'm(V13) not sure what the setting is for R39's low air loss mattress is supposed to be. V13 stated the machine is set at 175 lbs(pounds) now. On 08/01/2022 at 10:35am R39 stated the machine is supposed to be on 210 lbs(pounds). On 08/01/2022 at 10:40am V12(Wound Care Nurse/LPN (Licensed Practical Nurse) stated the setting on the control panel for R39's low air loss mattress is on 175 lbs(pounds) now, it should be on 210 lbs.(pounds). 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 observations, interviews and record reviews the facility failed to provide a specialized adaptive drinking cup for a resident (R98); failed to follow a physician order for a specialized adaptive drinking cup for a resident (R98); and failed to follow a physician order for specific feeding guidelines related to swallowing (R98). These failures have the potential to affect 1 (R98) of 6 residents reviewed for adaptive equipment usage in a total sample of 104. Findings include: On 8/1/22 at 11:32 AM, surveyor observed R98 feeding self in 3rd floor dining room. R98 was sitting at a table toward the back of the dining room and was facing the back wall of the dining room. This location was farthest away from the staff distributing meal trays. Surveyor did not observe any specialized cup on R98's lunch tray. Surveyor observed R98 drinking juice from regular plastic cup. This plastic cup was the same cup that the other residents in the dining room received. Surveyor observed 1-2 coughs noted while R98 drank…

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