Park View Rehab Center

Based on observations, interviews, and record reviews, the facility failed to provide hand splints for one resident (R31) out of a total sample of 25 residents.Findings include:R31's 'admission Record' documents a primary diagnosis of rheumatoid arthritis.On 9/09/2025 at 12:40 PM, R31 was sitting at the side of the bed. R31 was oriented to person, place, date, and situation. R31's left fingers were closed inward. R31 stated both hands had weakness, but it is worse on the left. R31 stated R31 is able to spread left fingers open with right hand. R31 stated the nurses and Certified Nurse Aides used to apply bilateral hand splints during the day, but not anymore. R31 stated the facility did a deep clean close to a year ago, and R31's hand splints disappeared. R31 suspected staff must have thrown them out by mistake. R31 informed staff, but they never replaced them. R31's 'Order Summary Report' documents R31 may wear splint to bilateral upper extremities as tolerated and as needed for comfort (active since 10/10/2023).R31's 'Care Plan Report' documents R31 has orthoses (brace/splint)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 notification of SNF - ABN (Skilled Nursing Facility - Advance Beneficiary Notice) and NOMNC (Notice of Medicare Non-Coverage) to 3 out of 3 residents (R19, R98 and R112). These failures affect 3 residents (R19, R98 and R112) in exercising their rights and options afforded by notification procedure.Findings include: On 09/10/2025 at 12:28 PM, the facility submitted the following information to residents discharged within the last six (6) months that includes R19, R98, and R122: R19 remained in the facility. Medicare Part A skilled services episode start date: 08/01/2025. Last covered day of Part A service: 08/29/2025. R98 remained in the facility. Medicare Part A skilled services episode start date: 06/03/2025. Last covered day of Part A service: 09/10/2025. R122 discharged to home. Medicare Part A skilled services episode start date: 03/30/2025. Last covered day of Part A service: 05/30/2025. R19's, R98's, and R122's SNF-ABN and NOMNC were not signed by residents for the same reason;…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 qualified personnel submit an accurate Level I PASRR (Pre-admission Screening and Resident Review) assessment for one resident (R7) out of a total sample of 25 residents.Findings include:R7's admission Record documents diagnoses of post-traumatic stress disorder (PTSD) (onset 9/04/2015), anxiety disorder (onset 11/03/2011), and alcohol dependence (onset 11/03/2011).R7's 4/14/2022 'Illinois PASRR Level I Form' does not include R7's diagnosis of PTSD. The 'Level I Attestation and Signature' box documents V17 (Office Tech / former Assistant Administrator) filled out the form. The 'Level I Attestation and Signature' box documents: By checking this box, I attest that I have reviewed all information contained herein and that I take responsibility for the completeness and accuracy of information reported throughout this submission. I attest that I am a health care professional working in a clinical capacity for this provider. I understand that approved submitters include clinical professionals such as nurses, [Licensed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 professional standards and administer medications in a timely manner for two (R11 and R31) out of a total sample of 10 residents reviewed for medication times.Findings include: 1.On 9/09/2025 at approximately 10:20 AM, V6 (Licensed Practical Nurse) prepared R11's morning medications. These included Hydroxyzine Pamoate (given for restless leg syndrome), Lamotrigine (antianxiety), Levetiracetam (anticonvulsant), Metoprolol Succinate Extended Release (for high blood pressure), and Potassium Chloride (for low potassium). At 10:32 AM, V6 stated V6 will not administer the Metoprolol because R11's blood pressure was low. R11 took the other morning medications at 10:32 AM. R11's 'Medication Administration Record (MAR)' documents R11's morning medications are to be given at 9:00 AM. R11's 'Medication Admin Audit Report' documents on 9/03/2025, R11's morning medications were also administered late. R11's received the 9:00 AM medications at 12:08 PM. On 9/04/2025, R11 received the morning medications at 10:57 AM.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow policy for self-urethral catheterization on obtaining physician order and failed to provide documentation a urinary catheter was being changed for 1 out of 1 resident (R5) for a total sample of 25 residents. R5 is [AGE] years old, initially admitted on [DATE]. R4 medical diagnosis includes paraplegia, flaccid neuropathic bladder, and neuromuscular dysfunction of the bladder. On 09/09/2025 at 11:28 AM, R5 was seen in his room sitting on his bed. In front was his wheelchair with the urinary catheter bag attached. R5 was alert and verbally able to express thoughts well. R5 has a BIMS (Brief Interview for Mental Status) score of 15 on last MDS review, dated 07/30/2025, which indicates resident cognition is intact. R5 said, I change my own catheter, somebody taught me when I was on the street. R5 pointed to the box full or urinary catheter supplies including urinary catheter. On 09/11/2025 at 10:54 AM, V2 (Director of Nursing) clarified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assess and provide a plan of care for the use of enteral feeding and failed to ensure a resident received enteral nutrition feedings via G-tube per physician orders for 3 out of 3 residents (R4, R60, R95) out of a total of 25 residents reviewed for enteral feeding. Findings include: 1.R4 [AGE] years old, initially admitted on [DATE]. R4 medical diagnosis includes encounter for attention to gastronomy as primary diagnosis, dated 11/30/2023. V23 dietary notes, dated 01/23/2025, documents R4 is consuming 76% of all meals per review. V23 recommend hold enteral feeding. Diet order: general/regular diet, regular texture, thin consistency. R4 feeds self with set up and occasional assistance. By mouth intake more than 76%. On 09/09/2025 at 10:53 AM, R4 was seen in her room. R4 showed her gastronomy tube. R4 said, Tube feeding needs to be cut off. I am tired of this thing. On 09/11/2025 at 09:46 AM, V2 (Director of Nursing) stated R4 does not use…

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

Based on interview and record review, the facility failed to report and investigate a misappropriation of property allegation for one (R2) of four residents reviewed for abuse in a sample of five. Findings include:On 08/24/2025 at 11:14 AM, R2 stated, I am the federal police. R2 stated he is missing a clock radio. R2 stated it was stolen, sold out in the street. R2 stated, I have no idea who stole it. R2 stated the police told R2 that they will recover it, but they didn't. R2 stated he informed the staff. R2 stated the police came here last week.On 08/24/2025 at 12:30 PM, R4 stated the police came to knock on R4's door and they asked R4 if any altercations or situations happened between R2 and R4. R4 stated he denied anything happened. R4 stated this happened last week, during the evening shift. On 08/24/2025 at 12:35 PM, V4 (Licensed Practical Nurse) stated R2 called the police last week because R2 was calling to complain about someone on the third floor. V4 stated the police officers went to the third floor, and they never asked V4 any questions, nor did they request R2's 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 interview and record review, the facility failed to ensure the resident has the right to be free of abuse in 3 of 5 residents (R1, R2 and R4) included in the sample reviewed for abuse. Findings include: 1. R1 is a [AGE] year old female with a diagnosis including Paranoid Schizophrenia, Diabetes 1, and Traumatic Amputation of right lower leg. R1 has a BIMS (Brief Interview for Mental Status) score of 15/15. R2 was first admitted to the facility on [DATE]. R2 is care planned for including moderate to intense anger, conflicts, difficult behavior with other persons. R2 is a [AGE] year old female with a diagnosis including Schizoaffective Disorder, Violent Behavior, Suicidal Ideations, Fibromyalgia and metabolic encephalopathy. R2 was first admitted to the facility on [DATE]. R2 has a BIMS (Brief Interview Of Mental Status ) Score of 15/15. Facility abuse investigation report, dated 2/21/25, shows R1 reported to administration she and R2 engaged in a physical altercation while on the elevator. Both 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure medication was administered as scheduled per physician order to 1 (R1) out of 3 residents reviewed for medication administration. Findings Include: R1's face sheet shows included diagnoses but not limited to insomnia and anxiety disorder. R1's Minimum Data Set, dated [DATE], shows R1 is cognitively intact with BIMS (Brief Interview for Mental Status) of 15. R1's Medication Admin Audit Report, printed on 2/11/25 at 11:21 AM, shows ]on 1/27/25, R1 had ordered and scheduled medication Zolpidem Tartrate (Ambien) 10 mg by mouth at bedtime for Insomnia, Seroquel 200 mg 1 tablet by mouth, and Tamsulosin 0.4 mg 1 capsule by mouth all to be administered at 9:00 PM, but were documented administered at 10:35 PM, more than one hour past the scheduled administration time. This Medication Admin Audit Report also revealed R1 had ordered and scheduled medications of Gabapentin 400 mg 1 capsule by mouth three times a day, Hydralazine 25 mg 1 tablet by mouth…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 availability of anti-anxiety medication as ordered by physician, andfailed to document medication ordered by physician as being administered as per policy. These failures involved 1 out of 1 resident (R1) for a total sample of 3 residents. Findings include: R1 is [AGE] years old, initially admitted in the facility on 05/08/2024. R1 diagnosis includes schizophrenia, paranoia, psychosis, anxiety, depressive disorder, and parkinsonism. R1's cognition has moderate impairment with BIMS (Brief Interview of Mental Status) of 12, dated 12/24/2024. Nursing notes, dated 12/09/2024 by V10 (Licensed Practical Nurse), documents R1 was very paranoid believing that other people are talking about him throughout the building. R1 thinks that a chair that was placed in hallway was used to spy on him. Physician was notified and gave order to transfer R1 to the hospital. Physician notes, dated 12/31/2024 by V11 (Medical Doctor), documents R1 was…

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

Based on observation, interview, and record review, the facility failed to date prepared food items in the refrigerator, and failed to ensure Dietary staff wear hair covering. These failures have the potential to affect all 119 residents receiving an oral diet in the facility. On 8/18/24 at 9:30 AM in the walk-in refrigerator, surveyor observed 4 green leaf salads, 5 cold cut sandwiches wrapped in plastic wrap, and a bowel of egg salad covered with plastic wrap, not dated. On 8/19/24 at 11:00 AM, V26 (Cook) was pureeing food with mask hanging at the chin level, and hair above upper lip not covered. On 8/18/24 at 9:35 AM V25 (Cook) stated, The salads, sandwiches, and egg salad in the refrigerator should have been dated. The staff know that their supposed to date open and prepared items. The cook from last night did not put a date on those items. On 8/20/24 at 10:20 AM, V20 (Dietary Manager) stated food that is in the refrigerator should be labeled and dated with the date it was prepared. V20 stated everyone working in the Dietary Department should have a hair net on. All hair should…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 enhanced barrier precautions (EBP) signs were placed on the resident's door, failed to don appropriate personal protective equipment while caring for a resident on EBP, failed to change gloves after touching dirty surfaces while providing incontinence care to a resident on EBP, failed to perform hand hygiene after doffing gloves during wound care, and failed to ensure linen was handled in a manner that prevents contamination. These failures affects 6 residents (R59, R68, R98, R96, R48 and R33), in a sample of 58, and has the potential to affect all residents within the facility. Findings include: 1. On 8/19/2024 at 11:00 AM,V23 (Housekeeper) opened the door to the area containing the laundry chute. There was a bag of visibly soiled linen sitting on the ground, and a cart containing bagged and unbagged articles of clothing (shirts, pants) and linen. V23 was asked if clothing items/linen needed to be bagged before entering the chute,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 conduct care plan conferences timely and involve the resident in the development of their plan of care. This failure affects 4 residents (R2, R27, R25, R59) in a sample of 58. Findings include: 1. R2's admission record documents in part the following diagnosis: schizoaffective disorder, bipolar type, acute combined systolic and diastolic heart failure, chronic obstructive pulmonary disease, and depression. R2's Minimum Data Set (dated 5/23/24) documents a Brief Interview for Mental Status (BIMS) summary score of 15, indicating R2 is cognitively intact. On 8/18/2024 at 10:58 AM, R2 stated R2 has not been invited to develop R2's plan of care or attend any care plan meeting regarding R2's care. R2 affirmed R2 would want to attend if there was any meeting about R2's care, and wants to be involved with R2's care. On 8/19/2024 at 12:21 PM, V24 (MDS Nurse/Restorative Nurse, Licensed Practical Nurse) could not recall having a care plan meeting for R2. On 8/19/24 at 1:36 PM, record review of R2's progress notes and care plan sign…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident's environment remained free of hazards for 1 resident (R82). This failure has the potential to affect all residents residing on the first floor. Findings include: On 8/18/2024 at 12:10PM, an uncovered cable box receptacle was observed with wires and cable cord connectors exposed. On 8/18/2024, R82 stated the box has been uncovered since he has been in that room, and he has been there for 8 months. On 8/19/2024 at 12:41 PM, V14 (Maintenance Director) stated, The cable box is supposed to be covered. On 8/20/2024 at 10:36 AM V16 ((Licensed Practical Nurse-LPN) said, No, I was not aware of a cable box receptacle was uncovered and a resident can get electrocuted if it does not have a cover. V16 stated damaged furniture or missing cable box receptacles or outlet cover should be reported to Maintenance and included on the Maintenance Log, and nothing is reported for that room. On 8/20/2024 at 10:40 AM, the Maintenance Log for the first floor was reviewed, and there was nothing reported for the…

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

Based on observation, interview, and record review, the facility failed to discard expired medication from the medication cart, and failed to ensure medication cart was free of loose pills. These failures have the potential to affect all 41 residents assigned to the 3rd floor medication cart. Findings include: On 08/19/24 at 11:16 AM, the 3rd floor medication cart had twenty-three loose pills in the medication drawers, Bisacodyl 5mg tablet bottle with expiration date unreadable and Ferrous Sulfate 325mg bottle with date unreadable. (V10) Licensed Practical Nurse (LPN) stated, The expiration dates on the pill bottles are faded. I cannot see them. It is important to know the expiration date because after the expiration date the medication is less effective. We (nurses) cannot pick pills from the bottom of the drawer; it is a medication error if we do. The pills are not clean. We won't be able to tell what each medication is if the medication is not in its original package. On 08/20/24 at 3:02 PM, V2, Director of Nursing (DON), stated, Expired medications should be removed from the…

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

Based on observation, interview, and record review, the facility failed to ensure a resident's urinary drainage bag was kept privately. Thais failure affects 1 resident (R59) in a sample of 58. Findings include: R59's admission record, documents the following diagnosis: paraplegia, flaccid neuropathic bladder, neuromuscular dysfunction of bladder, and obstructive and reflux uropathy. R59's Minimum Data Set (dated 6/20/2024) documents a Brief Interview of Mental Status summary score of 15, indicating R59 is cognitively intact, and R59 utilizes an indwelling urinary catheter. On 8/18/2024 at 10:32 AM, observed an exposed urinary drainage bag attached to the frame of R59's bed. R59 affirmed R59 wanted facility staff to keep R59's urinary drainage bag in a privacy bag. On 8/18/2024 at 10:40 AM, V11 (Certified Nursing Assistant) checked R59's bedframe and confirmed there was no privacy bag to put the urinary drainage bag in. V11 stated, sSmeone must have taken it off and not put it back on. V11 affirmed R59's urinary drainage bag should have been put into a privacy bag. On 8/20/2024 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 assess a resident the ability to safely self-administer medication. This failure affects 1 (R83) resident reviewed for self-administration of medications in the total sample of 58 residents. Findings include: R83's (08/08/2023) Minimum Data Set documented, in part Section C0500. BIMS (Brief Interview for mental status) Summary Score: 15. Indicating R83's mental status as cognitively intact. R83's (Active Order As Of: 08/19/2024) Order Summary Report documented, Diagnoses: (include but not limited to) Chronic Obstructive Pulmonary Disease with exacerbation. Pharmacy. Order Summary. Advair HFA Inhalation Aerosol 115-21 MCG/ACT (Fluticasone-Salmeterol) 2 puff inhale orally two times a day for COPD (chronic obstructive pulmonary disease)/Asthma. Order Status. Active. Order Date. 06/14/2024. Start Date. 06/15/2024. There was no order to may self-administer this medication. R83's (Revision on: 08/19/2024) care plan documented, (R83) is at respiratory risk r/t (related to) asthma. Respiratory risks will be minimized…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 light fixture has no missing fluorescent tube light and cover; failed to ensure the encasement of the air conditioning unit was appropriately sealed; and failed to ensure the dresser has no missing drawer/s in an effort to provide a homelike environment for 2 (R83 and R99) residents reviewed for homelike environment in the total sample of 58 residents. Findings include: 1. R83's (Active Order As Of: 08/19/2024) Order Summary Report documented Diagnoses of Chronic Obstructive Pulmonary Disease with exacerbation, chest pain and cerebral infarction. R83's (08/08/2023) Minimum Data Set documented, Section C0500. BIMS (Brief Interview for mental status) Summary Score: 15., indicating R83's mental status as cognitively intact. On 08/18/2024 at 11:19 AM, R83's light fixture was missing a fluorescent tube light and cover, and the air conditioning (AC) unit was mounted on a bigger encasement. There was a folded pillow on the right side of the AC unit. R83 stated, I informed (V3-Assistant Director of Nursing)…

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

Based on interview and record review, the facility failed to complete the MDS (Minimum Data Set) accurately. This failure affects 1 resident (R60) in the sample of 58. Findings include: Record review of R60's admission record documents the following diagnosis: schizophrenia, unspecified psychosis, and bipolar disorder. R60's MDS (Minimum Data Set), dated 7/3/2024, documents in section A1500 the resident is not currently considered by the state level II PASSR (Preadmission Screening and Resident Review) to have a serious mental illness and/or intellectual disability or a related condition. Record review of facility provided Notice of PASRR Level II Outcome for R60 (dated 9/02/2022) documents in part, .PASRR Determination Explanation You have a Level II PASRR Condition of Schizophrenia . On 8/19/2024 at 12:21 PM, V24 (MDS Nurse/Restorative Nurse, Licensed Practical Nurse) affirmed V24 completes MDS assessments for the residents. V24 stated A1500 should be coded as yes whenever a resident has a serious mental illness identified by the PASRR. On 8/20/2024 at 11:01 AM, V2 (Director of…

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

Based on observation, interview, and record review, the facility failed to ensure medications were signed out when administered for two residents (R71 and R91). This failure affected two residents in the sample of 58. Findings include: 1. R71 has diagnoses which includes: fracture of other specified skull and facial bones, right side, sequela, depression, asthma, personal history of traumatic brain injury, muscle weakness, chronic pain, essential hypertension, gastro-esophageal reflux disease without esophagitis, neuralgia and neuritis, prediabetes, acquired absence of eye, and anxiety disorders. R71's Brief Interview for Mental Status (BIMS), dated 06/6/24, shows R71's has a BIMS of 12, which indicates R71 has some cognitive impairments. On 08/18/24 at 10:45 AM, R71 stated, I did not receive my medications today. Surveyor asked V15, Registered Nurse/RN regarding R71's medication, and V15 stated, I gave (R71) all of her morning medications except for (R71's) clonazepam. Upon review of R71's eMar (Electronic Medication Administration Record), the following morning medications were…

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

Based on observation, interview, and record review, the facility failed to date the humidifier bottle for one resident (R36), in a sample reviewed for respiratory care. Findings include: R36 has diagnoses which include Seizures, Constipation, Essential Hypertension, Morbid Obesity, Lymphedema, Congestive Heart Failure, and Schizoaffective Disorder. R36 has a physician order, dated 11/02/23, which documents, O2 (oxygen) by nasal canula (n/c) for comfort and on excertion every 1 hours as needed. R36's care plan, dated 05/13/24, documents, (R36) has chest pain .Give oxygen as ordered by the physician. R36's Minimum Data Set (MDS) has a Brief Interview for Mental Status (BIMS) score of 15, which indicates R36 's cognition is intact. On 08/18/24 at 10:45 AM, R36 was lying in bed, well-groomed, receiving oxygen by nasal cannula. R36's oxygen cannula connected to humidifier bottle. R36's humidifier bottle observed with no date. On 08/18/24 at 10:53 AM, V15, Registered Nurse (RN), stated, There is no date on (R36's) humidifier bottle, but there should be a date on the humidifier bottle.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one resident (R100) the correct consistency diet. This failure affected one resident in a total sample size of 58 reviewed for diets. Findings include: R100 has medical diagnoses which include Acute ischemic heart disease, Dysphagia, Spinal stenosis, Dementia, Seizures, History of falling, and chronic kidney disease. R100's physicians order dated 2/14/24 documents, No added salt diet, mechanical soft, ground meat texture, thin liquids consistency. R100's care, plan dated 08/10/24, documents in part, I (R100) demonstrate some or high risk to potentially choke, aspire foods or liquids. This problem is related to diagnosis of Dysphagia .Provide diet as ordered NAS (no added salt), mechanical soft diet .At risk for aspiration related to diagnosis of dysphagia .Diet as order: Mechanical soft, thin liquids. R100's Minimum Data Set (MDS), dated [DATE], documents R100 has a Cognitive Skill for Daily Decision Making score of 3, which…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 personal refrigerators were kept at safe temperatures. This failure affects 1 resident (R59) in a sample of 58. Findings include: Record review of R59's admission record, documents the following diagnosis: paraplegia, flaccid neuropathic bladder, stage 4 pressure ulcer of sacral region, stage 4 pressure ulcer of the left lower back, stage 4 pressure ulcer of right lower back, major depressive disorder, neuromuscular dysfunction of bladder, and obstructive and reflux uropathy. R59's Minimum Data Set (dated 6/20/2024) documents a brief interview of mental status summary score of 15, indicating R59's is cognitively intact. On 8/18/2024 at 11:29 AM, R59's personal refrigerator in R59's room contained multiple containers of leftover food and beverages. The thermometer inside the refrigerator was at 44 degrees Fahrenheit. V12 (Certified Nursing Assistant) confirmed the thermometer inside the refrigerator indicated 44 degrees Fahrenheit. On 8/18/2024 at 11:36 AM, V10 (Licensed Practical Nurse) affirmed 44…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents with food and drinks that are palatable, attractive, and at a safe and appetizing temperature for two residents (R8, R7) of three residents reviewed for cold food being served. This deficiency has the potential to affect all residents on unit two. Findings include: On 3/26/2024 at 10:13am, R8 stated, I don't have any concerns regarding my care, they clean me and get me up when I'm ready. The problem I have, the food is always cold here. I must order my own food from a restaurant at times. On 3/26/2024 at 11:10am R7 stated, I ask for an extra tray when I'm hungry, and they don't want to give it to me. The food here is always cold. On 3/26/2024 at 11:35am, V12 (Dietary Cook) was preparing the tray line for lunch, which consist of baked chicken, pasta, steamed carrots, with mac and cheese. Substitute noted on side tray consist of turkey sandwiches, chef salad, and salami sandwiches. V12 was using the ice water method to check and recalibrate facility provided thermometer. Temperature 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 observation, interview, and record review, the facility failed to follow its policy on resident right to be free from any physical restraints for two (R10, R11) of three residents reviewed for restraints. Findings include: R11's MDS (Minimum Data Set) section GG (Functional Abilities and Goals), dated 2/26/2024, documents R11 is dependent with eating, he is substantial/maximal assist for Oral hygiene, Upper body dressing, personal hygiene; R11 is dependent for eating, toileting, showering/bathing, lower body dressing and putting on/off footwear. R11's MDS section C-Cognitive patterns is documented as not completed because R11 is rarely/never understood. R10's MDS (Minimum Data Set) section GG (Functional Abilities and Goals), dated 03/22/2024, documents R10 needs some help with self-care and indoor mobility. R10 is dependent on staff for eating, oral hygiene, toileting, showering/bathing, lower and upper dressing, personal hygiene and uses a manual wheelchair. R10's MDS section C-Cognitive patterns is documented as not completed because R10 is rarely/never understood. 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 interview and record review, the facility failed to failed to define resident to resident contact, failed to conclude physical abuse was substantiated when residents intentionally struck each other, and failed to report resident injury to IDPH (Illinois Department of Public Health) for one of four residents (R4) reviewed for abuse. These failures have the potential to affect 126 residents residing in the facility. Findings include: The facility census, dated 1/28/24, includes 126 residents. The Preliminary Incident Investigation Report, dated 11/11/23, states Nurse reported R3 and R4 engaged in a physical altercation. The resident has been assessed there are no injuries. R3's incident report, dated 11/11/23, states resident and co-resident were engaged in altercation. Resident R3 alleged that co-resident hit him. R4's incident report, dated 11/11/23, states resident and co-resident were engaged in altercation. Resident (R4) alleged that co-resident hit him. Injuries observed at time of incident: right eye abrasion. R3's BIMS (Brief Interview Mental Status), dated 11/9/23,…

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

Based upon interview and record review, the facility failed to ensure that care plans are individualized, and failed to review and/or revise comprehensive care plans with preventive interventions for four of four residents (R1, R2, R3, R4) reviewed for incidents/accidents. Findings include: 1. R1's functional assessment, dated 12/22/23, affirms substantial/maximal assistance is required for chair to bed transfer. R1's care plan, dated 11/2/23, includes ADL (Activities of Daily Living) Self Care Performance Deficit, Intervention: resident requires assistance when transferring. The Unusual Occurrence Report, dated 12/4/23, states, (R1) was transferred by 2 CNAS (Certified Nursing Assistants) from wheelchair to bed. (R1) was observed with blood on right lower leg. Nurse assessed (R1) immediately, laceration was observed on right lower leg. On 1/30/24 at 2:29 PM, V9 (Restorative Nurse) stated, I was aware that there was a screw on the bed that cause him to be injured, and affirmed he was made aware. Surveyor inquired how R1 transfers from the wheelchair to bed. V9 (Restorative Nurse)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure R6 was free from verbal abuse, which affected one resident (R6) in the sample of four residents (R2, R4, R5 and R6) reviewed for verbal abuse. Findings include: Facility document, dated 9/27/23 and titled Preliminary Incident Investigation Report Form, V1 (Administrator) documents the facility has an allegation of verbal or mental abuse with the individual(s) allegedly committing the offense is (are): (V3) with the alleged victim: (R6). The date and time of the alleged incident is documented as 9/27/23 at 12:20 pm, and the allegation was reported to V1 at 12:30 pm on 9/27/23. Circumstances of alleged incident are documented as On 9/27/23 it was reported to administration (V3) made an inappropriate comment to (R6). (V3) has (been) sent home and removed from the schedule pending the outcome of this investigation. (R6) has been placed on behavior monitoring. The police have been contacted. (R6's) physician and contacts have been notified. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to timely submit the final abuse investigation report to the State Agency within 5 business day, which affected one resident (R6) in the sample of four residents (R2, R4, R5 and R6) reviewed for verbal abuse. Findings include: Facility document, dated 9/27/23, and titled Preliminary Incident Investigation Report Form, V1 (Administrator) documents the facility has an allegation of verbal or mental abuse with the individual(s) allegedly committing the offense is (are): (V3) with the alleged victim: (R6). The date and time of the alleged incident is documented as 9/27/23 at 12:20 pm, and the allegation was reported to V1 at 12:30 pm on 9/27/23. Circumstances of alleged incident are documented as, On 9/27/23 it was reported to administration (V3) made an inappropriate comment to (R6). (V3) has (been) sent home and removed from the schedule pending the outcome of this investigation. (R6) has been placed on behavior monitoring. The police have been contacted.…

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

Based on interview and record review, the facility failed to provide sufficient nursing staff on a 24-hour basis to care for resident's needs. This failure has the potential to affect 123 residents that reside in the facility. Findings include: On 10/4/23 at 3:15 PM, V15 (Human Resource Director/Staffing Coordinator) stated V15 has been the Staffing Coordinator for two years. I do staffing for nurses and CNA's (Certified Nursing Assistants). The facility works eight-hour shifts. On the first and second shifts, first floor, I staff one nurse, one to two CNAs, third shift, I staff one nurse and one CNA. On the first and second shifts on the second floor, I staff one nurse and four to five CNAs, third shift I staff one nurse and three to four CNAs. On the first and second shifts on the third floor, I staff one nurse and two CNAs, third shift I staff one nurse and one to two CNAs. We do not use agency staff. We have enough staff to meet the needs of the residents. We may have an issue if there is a call-off. If there is a call-off, I ask staff to stay over or switch schedules. Usually…

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

Based on observation, interview, and record review, the facility failed to follow their policy and procedure on proper thawing of frozen meats and failed to ensure there was a functioning thermometer to measure adequate temperature control in the freezer where frozen foods are stored. These failures have the potential to affect 122 residents in the facility who are receiving oral diet. The Findings Include: On 10/03/23 at 9:45 AM, during the initial tour in the kitchen, the main freezer's external thermometer read 18 degrees Fahrenheit (F). V10 (Dietary Cook) stated they don't use the outside thermometer to check the temperature in the freezer because it does not work. V10 stated they use the thermometers inside. Surveyor entered the freezer with V10, and noted that both thermometers were broken. The thermometers' lines were cracked in half. Also three rolls of frozen boneless ham, and a bag of frozen chopped ham in a silver container were thawing under potable running warm water. V10 stated the ham will be served that day for lunch. On 10/4/23 at 10:42 AM, V23 (Registered…

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

Based on observation, interview, and record review, the facility failed to ensure garbage and refuse were disposed of properl,y by not closing the lids of the dumpsters outside the facility. This deficient sanitation practice has the potential to affect all 123 residents who reside in the facility. The Findings Include: On 10/3/23 at 10:09 AM, an observation of the outside garbage dumpster was conducted with V11 (Dietary Manager). The lid of the outside garbage dumpster fully opened. V11 stated, They leave it open because it's hard to close. At 10:14 AM, V12 (Maintenance Director) stated, The lids of the dumpster should be closed when not in used so no rodents get in there, and no debris would fly out. The lids should be closed for pest control, and if it's open the garbage would attract flies and rodents. It could cause pests in the building because all garbage from the building is being thrown there. If there are too many flies, the flies get in the building. On 10/4/23 at 10:59 AM, V11 stated the lids of the dumpster should be closed when not in use and that leaving the lids open…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accurate Minimum Data Set (MDS) Assessments for nine out of a total of 123 residents at the facility. Findings include: On 10/05/2023 at 9:50 AM, V24 (MDS Nurse) provided the survey team with the facility's Resident Matrix. It documents no resident with significant weight loss. On 10/05/2023 at 10:33 AM, V11 (Dietary Manager) stated, (V3, Director of Nursing) will notify (V11) if there are any residents with significant weight loss in the facility. (V11) will then reflect it on Section K-Swallowing/Nutrition Status of the resident's MDS Assessment. V11 stated there are currently no residents with significant weight loss. Surveyor reviewed R88's weights with V11. R88 weighed 200 lbs (pounds) on 5/02/2023 and 145 lbs on 7/20/2023. This was a severe weight loss of 27.5 %. V11 stated V1] was aware of the weight loss. When surveyor reviewed R88's 8/15/2023 Quarterly MDS, V11 marked no weight loss under Section K of the assessment. On 10/05/23 at 12:16 PM, V3 provided a list of residents with significant weight loss,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to revise 4 (R15, R56, R88, R84) out of 24 residents' comprehensive care plan to address their current condition, needs, and services in a sample of 24. The Findings Include: 1. R15's electronic medical records (EMR) show an initial admission date of 8/3/06, with listed diagnoses not limited to Encephalopathy, Essential Hypertension, Unsteadiness on Feet, and Weakness. R15's Quarterly Minimum Data Set (MDS), dated [DATE], shows R15 received restorative programs of active range of motion (AROM) and dressing/grooming. R15's Restorative Nursing Review, dated 8/16/23, shows R15 to continue dressing/grooming and AROM restorative programs. R15's comprehensive care plan shows Restorative care plan was last revised on 9/15/20, and R15's dressing/grooming restorative program is not addressed in the care plan. 2. R84's electronic medical records (EMR) show an initial admission date of 5/28/20, with listed diagnoses not limited to Other Specified Depressive…

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

Based on observation, interview, and record review, the facility failed to ensure medications were locked and secured while unattended, and failed to refrigerate an unopened insulin pen and label liquid medication that had been open in two of two medication storage rooms reviewed for medication labeling and storage. These failures have the potential to affect 45 residents residing in the facility (all residents on the third floor, and R21 on the first floor). Findings Include: On 10/04/2023 at 8:37AM, V19 (Registered Nurse/RN) was observed leaving medication cart (identified as 3rd floor medication cart) unlocked and unattended, with medication cart keys on top of the medication cart. V19 stated residents can potentially get access to the medications if the cart is left unlocked and unattended. V19 also stated it would be very dangerous to residents if they get access to the narcotics box with the keys that were left on top of the medication cart. On 10/04/2023 at 9:08AM, on the 3rd floor of the facility inside the medication storage room with V19 (RN), observed 2 liquid medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 treat residents with dignity and respect during meal assistance for two (R97, R118) out of a total sample of 24 residents. Findings include: On 10/03/2023 at 12:19 PM, R97 was sitting in a wheelchair in the dining room. V7 (Activity Aide) provided total assistance to R97 during lunch meal. V7 stood over R97 throughout the meal assistance. On 10/04/2023 at 11:59 AM, R118 was sitting in a geriatric chair in the dining room. V9 (Certified Nurse Aide) provided total assistance to R118 during lunch meal. V9 stood over R118 throughout the meal assistance. On 10/06/2023 at 10:39 AM, V26 (Nurse) stated when staff provide total assistance during meals, staff should sit with the residents to show respect. V26 stated if staff are standing over the resident, it will make the resident feel rushed. Facility's Feeding and Assisting Residents to Eat, dated 6/2014, documents: Nursing personnel assisting should be positioned/seated at eye level with the resident to provide a relaxed and comfortable environment, and to avoid 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policy and procedure to develop and implement a comprehensive person-centered care plan that includes measurable objectives with timeframes and interventions to address current conditions and medications use, for 2 (R14, R107) out of 24 residents in a final sample of 24. The Findings Include: 1. R107's electronic medical records (EMR) show R107 was initially admitted on [DATE], and has diagnoses not limited to Bipolar Disorder, Dementia, Depression, and Anemia. R107's October Medication Administration Record (MAR) shows R107 is receiving antidepressant and antipsychotic medication daily. R107's physician order sheet (POS) shows an order of Citalopram 20mg by mouth in the morning for antidepressant ordered on 6/21/22 and Risperidone 0.5mg by mouth two times a day ordered on 7/18/22. R107's Annual Minimum Data Set (MDS) assessment's reference date (ARD) was set to 4/13/23. R107's comprehensive care plan does not address R107's psychotropic…

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

Based on observation, interview, and record review, the facility failed to ensure a qualified staff member provide meal assistance to a resident with a diagnosis of dysphagia (swallowing disorder) for one (R97) out of a total sample of 24 residents. Findings include: R97's face sheet documents in part a medical diagnosis of dysphagia, oropharyngeal phase. R97's admission Minimum Data Set Assessment, dated 8/29/2023, documents during the assessment period, R97 exhibited the following behaviors: loss of liquids/solids from mouth when eating or drinking, holding food in mouth/cheeks or residual food in mouth after meals, coughing or choking during meals or when swallowing medications, and complaints of difficulty or pain when swallowing. On 10/03/2023 at 12:19 PM, R97 was sitting in a wheelchair in the dining room. V7 (Activity Aide) provided total assistance to R97 during the entire lunch meal. On 10/05/2023 at 11:02 AM, V14 (Speech Therapist) stated R97 is on a mechanical soft diet related to diagnosis of dysphagia due to swallowing issues. V14 stated the current recommendation for…

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

Based on observation, interview, and record review, the facility failed to provide meal setup assistance to a dependent resident for one (R14) out of a total sample of 24 residents. Findings include: R14's face sheet documents a medical diagnosis of weakness. R14's Annual Minimum Data Set Assessment, dated 6/09/2023, documents R14 requires supervision and setup help during meals. R14's Functional Abilities and Goals Assessment-OBRA document, dated 9/28/2023, documents R14 requires partial/moderate assistance while eating. On 10/03/2023 at 12:30 PM, R14's lunch tray was set on the bedside drawer behind R14's view, and not within reach. At 12:33 PM, R14 stated R14 did not know that staff brought in the lunch tray. R14 asked where R14's bedside table was located. R14 asked surveyor to call someone to feed R14. At 12:43 PM, lunch tray remained on the bedside drawer. R14 stated, I need someone to feed me. Out in the hallway, V8 (Certified Nurse Aide, CNA) and V9 (CNA) were collecting finished lunch trays from residents' rooms and the dining room. At 12:53 PM, R14 was still waiting 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 follow through the physician's recommendations to address a resident's (R84) weight loss. This failure had the potential to affect 1(R84) out of 1 resident reviewed for nutrition in a total sample of 24. The Findings Include: R84's electronic medical records (EMR) show R84 has listed diagnoses not limited to Paranoid Schizophrenia, Depressive Episodes, Gastroesophageal Reflux Disease Without Esophagitis, and Functional Dyspepsia. On 10/03/23 at 10:57 AM, R84 was lying in bed alert and able to verbalize needs. R84 stated R84 thinks R84 lost weight, and does not like the food in the facility. At 12:50 PM, R84 was eating lunch in R84's room. R84's main entrée consisted of chopped ham, mashed potatoes, and broccoli. R84 stated, I'm not going to eat that. I try not to eat pork. R84 only ate the mixed fruits. R84's weight records show the following: 9/1/2023 - 138.0 pounds (Lbs) 8/4/2023 - 140.0 Lbs 7/6/2023 - 146.0 Lbs 6/2/2023 - 148.0 Lbs 5/12/2023 - 150.0 Lbs 4/6/2023 - 143.0 Lbs 3/2/2023 - 147.0 Lbs R84's…

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

Based on observation, interview, and record review, the facility failed to ensure a resident received enteral nutrition feedings via G-tube per physician orders for one (R99) resident reviewed for tube feedings in a sample of 24 residents. Findings include: R99's physician order sheet/POS and medication administration record/MAR, documents: Jevity 1.5 @ 50cc/hr x 22hrs thru G-tube from 7AM to 5AM, with start dated of 08/27/2023. R99's care plan, dated 09/06/2023, documents, Infuse feeding as ordered on the POS. On 10/04/2023 at 11:10 AM, R99 was lying in bed in her room in a supine position, with head of bed elevated at 45 degrees. An enteral feeding pump was adjacent to R99's bed. Enteral feeding pump was turned off, there was no enteral tube feeding or tube feeding equipment. On 10/04/2023 at 11:14 AM, V5 (Registered Nurse/RN) was askedwhy R99's enteral feeding was not infusing. V5 stated R99's enteral feeding is scheduled to infuse at 12:00PM-8:00AM every day. V5 was asked to check R99's electronic medical record for R99's enteral feeding order. V5 stated R99's enteral feeding…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to acquire authorization/order from a medical professional for R126 to be outside of the facility without staff supervision. Findings include: R126 was viewed as a closed record. R126's 10/5/23 facesheet documents R126 diagnoses not limited to: Type 2 diabetes mellitus, anemia, schizophrenia, history of falling, and depression. R126 has a BIMS (Brief Interview for Mental Status) score of 15, indicating R126 was cognitively intact. R126's Community Survival Skills Assessment (SS), 7/5/23, documents: Recommendations: The resident does not appear to be capable of unsupervised outside pass privileges at this time. Comments: Residents Community Access Level is 2-patio only. R126's care plan, initiated 3/9/23, documents: The resident expresses the desire to receive an outside, independent pass. The resident requires the support of a long-term care facility secondary to a substance abuse disorder, compromised mental health status. Community Access level 2-patio…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 keep an accurate count of all narcotic medications for three (R9, R30, R116) residents reviewed for medications in a total sample of 24 residents. Findings include: On 10/03/2023 at 10:25AM, surveyor and V18 (Registered Nurse/RN) located on the 3rd floor of the facility performing a controlled substance count and record review. Surveyor observed the following: *A medication bingo card labeled (R30), Tramadol 50mg, observed there were 15 pills inside of the medication bingo card. R30's controlled drug receipt record documents a count of 16 pills. *A medication bingo card labeled (R30), Pregabalin 50mg; observed there were 25 pills inside of the medication bingo card. R30's controlled drug receipt record documents a count of 26 pills. *A medication bingo card labeled (R9), Tramadol 50mg; observed there were 14 pills inside of the medication bingo card. R9's controlled drug receipt record documents a count of 15 pills. *A medication pill bottle labeled (R116) Buprenorphine 8mg/2mg; surveyor observed there were 4 pills inside…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 obtain a consent for an antipsychotic medication prior to administering it to a resident (R14), and failed to ensure as needed (PRN) orders for anti-psychotic drugs were limited to fourteen days for 1 (R107) out of 5 residents reviewed for unnecessary medications in a total sample of 24. The Findings Include: 1. R107's electronic medical records (EMR) show R107 has diagnoses not limited to Bipolar Disorder, Dementia, Depression, and Anemia. R107's Physician Order Sheet (POS) shows R107 had the following orders: Haloperidol Lactate Injection Solution 5 MG/ML (Haloperidol Lactate) Inject 5 mg intramuscularly every 6 hours as needed for psychosis and Haloperidol Oral Tablet 5 MG (Haloperidol) Give 1 tablet by mouth every 6 hours as needed for psychosis. These PRN antipsychotic medications were ordered on 7/11/23. R107's October Medication Administration Record (MAR) shows R107's PRN antipsychotic medications were discontinued on 10/3/23. R107's EMR do not document R107's PRN antipsychotic medications needed to be extended…

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

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5% for two (R15, R32) of nine residents reviewed for medication administration resulting in a 7.41% error rate. Findings Include: 1. R32's electronic medication administration record (eMAR) documents: Loratadine tablet 10mg- Give 1 tablet by mouth one time a day scheduled at 9:00AM. On 10/04/2023 at 8:47AM, surveyor observed this medication was not given during the 9:00AM medication administration pass with V19 (Registered Nurse/RN). 2. R15's electronic medication administration record (eMAR) documents: Risperdal Oral Solution- Give 4 ml by mouth every 12 hours scheduled at 9:00AM. On 10/04/2023 at 9:21AM, V19 had R15's eMAR deployed on the computer, and was beginning to prepare R15's medication for administration. V19 gave R30 her inhaler medication as R30 passed by in her wheelchair in the hall. On 10/04/2023 at 9:22AM, V19 grabbed a clear medication cup with a clear liquid inside from the medication cart and stated, I am about to give (R15) his medication.…

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