Paul House & Health Cr Ctr

Based on interview and record review, the facility failed to provide compliance and ethics training to the staff. This failure affects has the potential to affect all 93 residents that reside within the facility. Findings include: On 6/4/2025 at 10:39 AM, surveyor requested documentation for staff training on compliance and ethics. On 6/4/2025 at 1:39 PM, V1 (Administrator) provided surveyor with 2 binders labeled In-services 2025 and In-services 2024 and stated, all of our in-services are within that binder, if we in-serviced on it, it would be in there. Record review of in-servicing binders for 2024 and 2025 was completed and no training related to compliance/ethics was observed completed for staff. On 6/4/2025 at 3:37 PM, V1 (Administrator) affirmed there is no further documentation that the facility can produce related to compliance or ethics. V1 produced a binder labeled compliance and ethics program and affirmed that the facility does have a compliance and ethics program. V21 (Infection Preventionist, Registered Nurse, Nurse Consultant) stated that V21 is the nurse consultant…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care plan meetings were conducted and failed to ensure residents/resident's family members participated in the development of the comprehensive care plan. This failure affects 4 residents (R49, R65, R83, and R354) out of a sample of 55. Findings include: R65's minimum data set (5/16/2025) documents in part a brief interview of mental status summary score of 12, indicating that R65 has moderate cognitive impairment. On 6/2/2025 at 11:09 AM, R65 stated that R65 was not familiar with R65's plan of care and denied ever receiving a copy of R65's care plan. R65 denied that R65 has attended a plan of care meeting. R65 stated, I would want to go if there were meetings about me like that. R65's progress notes indicate that on 4/26/22, R65's was scheduled for a care plan meeting on 5/4/22. No further documentation of care plan meetings or care plan participation was observed in R65's medical record. R49's minimum data set (5/7/2025) documents in part 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 nasal cannula was labeled with the date changed for 1 (R26) resident; failed to follow the prescribed oxygen flow rate for 2 (R26 and R42) residents; and failed to ensure oxygen was delivered to 1 (R12) resident. These failures affected 3 (R12, R26, and R42) residents reviewed for oxygen therapy in the total sample of 55 residents. Findings include: On 06/02/2025 at 11:41am, R12 was using a nasal cannula, the tubing was connected to a humidifier bottle via an oxygen concentrator. The humidifier bottle was filled with water. No bubbles noted in the humidifier bottle. The concentrator regulator was set at 3liters per minute. This was pointed out to V6 (Agency LPN/Licensed Practical Nurse). V6 stated she (R12) is not assigned to me. V6 checked the humidifier bottle and stated there is no bubbles because the oxygen tubing is not screwed tightly to the humidifier bottle. V6 was then observed unscrewing and screwing the oxygen tubing to the humidifier bottle with multiple attempts until bubbles appeared…

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

Based upon observation, interview, and record review the facility failed to ensure that sufficient nursing staff were available to meet the needs for one residents (R504) in the sample of 55 residents. These failures have the potential to affect all 24 residents on 2 East. Findings include: On 6/3/2025 at 12:07PM, V12 (LPN/Licensed Practical Nurse), stated that current census for the 2 East unit is 24 residents. On 06/02/25 at 11:00am, R504 was observed, in his (R504) room, sitting on the side of bed with a walker in front of him, and R504's call light was wrapped on the bedside table behind R504 not within reach of R504. Surveyor observed urine on the floor below R504 with his (R504) foot lying in the puddle of urine. R504 stated, It has been over an hour that I (R504) have been waiting for help to get to chair and get cleaned up. A nurse came in, helped me sit on the side of the bed, and said that he (nurse) would be back once he (nurse) could find another nurse to help him (nurse). I'm sorry. This is humiliating. I'm (R504) so embarrassed. R504's face sheet documents diagnoses…

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

Based on observations, interviews, and record review, the facility failed to ensure incoming and outgoing nurses counted the controlled medications during shift change; failed to ensure administration of controlled medication was documented; failed to ensure that the medication refrigerator had a temperature log sheets; and failed to ensure that staff do not store personal food items inside the medication refrigerator used for residents medication storage. These failures affected two residents (R99 and R104) and have the potential to affect all 47 residents on the 2 [NAME] unit. Findings include: On 06/02/25 the V1(Administrator) provided a facility census of 47 residents on the 2 [NAME] unit. On 06/02/25 at 11:00 am, during the controlled medication count of R104's Pregabalin 150 mg (milligrams) 150 mg capsule, surveyor and V5 (Registered Nurse, RN) observed 52 tablets left in R104's Medication Dispensing Card however, R104's Controlled Drug Record/Disposition Form's last entry was on 06/01/25 at 5:00 pm and amount of Pregabalin 150 mg was observed with 53 capsules. V5 (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 the indwelling catheter drainage bag was covered for three residents (R18, R51 and R104) reviewed for dignity in the sample of 55 residents. Findings include: On 06/02/25 at 11:19 am, R51 was observed in bed with indwelling catheter bag hanging on the bottom of R51's bed, visible to the doorway and not covered in a privacy bag. R51 stated that R51 has been at the facility for several months and has never had a privacy bag for R51's indwelling catheter. On 06/02/25 at 11:22 am, V16 (Licensed Practical Nurse, LPN) stated that residents with indwelling catheters should have a privacy bag to cover the residents indwelling catheter. V16 stated that if a residents indwelling catheter bag is not covered then the facility is not protecting the residents privacy. On 06/04/25 at 9:35 am, V2 (Assistant Director of Nursing, ADON) stated that indwelling catheters should be in a privacy bag for the residents dignity. V2 explained if the indwelling catheter should be placed on the side of the bed not visible to the…

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

Based on observation, interview, and record review, the facility failed to ensure that the call lights of residents are accessible as stated in the care plans. This failure has the potential to affect 3 residents (R74, R94, and R504) reviewed for accommodation of needs in a sample of 55 residents. Findings include: On 06/02/25 at 11:27am, R74 was observed at the edge of the bed and the surveyor asked R74 to use the call light to ask staff for help. The call light could not be found and R74 did not know where to find the call light. The surveyor went to the Nursing Station and called V5 (RN/Registered Nurse). V5 came and stated I found it. It's here under the bed. Inquired from V5 why the call light should be within reach of the resident; V5 stated to allow the resident to get help and to prevent falling. V5 added that she will remind the CNAs (Certified Nurse Assistants). R74's records reviewed are as follows: Face sheet shows diagnoses which include but are not limited to Repeated Falls, Vascular Dementia, Unsteadiness on Feet, Abnormalities of Gait and Mobility, Lack of…

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

Based on interview and record review, the facility failed to transmit a minimum data set (MDS) assessment within required timeframes. This failure affects 1 resident (R354) in a sample of 55. Findings include: Review of R354's minimum data set (assessment reference date 4/7/2025) documents in part that the assessment was signed as complete as of 4/16/2025. No documentation could be found within R354's electronic health record. Review of R354's electronic health record does not document that R354's minimum data set (assessment reference date 4/7/2025) was transmitted to CMS. Review of R354's validation report related to the minimum data set (assessment reference date 4/7/2025) documents in part that the assessment was transmitted to CMS on 6/3/2025. On 6/4/2025 at 10:43 AM, V19 (Registered Nurse, MDS Coordinator) stated that the assessment was completed on 4/16/2025 and should have been transmitted within 14 days of completion. V19 explained that when the MDS was requested by the survey team, V19 noticed it was not submitted to CMS, which is why it was submitted yesterday (6/3/2025).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 follow physician orders for obtaining resident weights for a resident with known weight loss and congestive heart failure. This failure affects 1 resident (R80) in a sample of 55. Findings include: R80's face sheet documents in part a diagnosis of hypertensive heart disease and heart failure. R80's care plan identifies that R80 has a history of weight loss and is on diuretic medications that may cause weight fluctuations. R80's physician orders documents in part an active order (4/24/25) for Heart Failure Order Set- Weight every morning; Call MD if gain wt (weight) of 2 lbs (pounds)/1day and 5 lbs/1 week. one time a day every Tue and Thu Review of R80's weights for 5/2025 documents in part that R80's weight was collected on 5/5/2025. R80's weight was not documented again until 5/21/2025 (16 days later). On 6/4/2025 at 11:16 AM, V2 (Assistant Director of Nursing) affirmed that V2 is familiar with R80. V2 stated that R80 has a history of weight loss and heart failure. V2 reviewed R80's physician order for weights and…

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

Based on observation, interview, and record review, the facility failed to ensure the low air loss mattress was set appropriately for 1 resident (R66), failed to ensure the low air loss mattresses were not layered with multiple layers for 2 (R52 and R66) residents; and failed to ensure a resident's wheelchair has cushion for 1 (R74) resident. These failures affected 3 (R52, R66, and R74) residents reviewed for pressure ulcer prevention and treatment in the total sample of 55 residents. Findings include: On 06/02/25 at 11:10 AM, R52 was lying on a low air loss mattress. This surveyor requested V6 (Agency Licensed Practice Nurse) to check how many layers were between the low air loss mattress and R52. With assistance from V7 (Certified Nursing Assistant) V6 counted the layers and stated he (R52) was using an incontinence brief, there's a blanket that's twice folded making 4 layers of blanket plus the flat sheet. V6 stated we usually use the flat sheet and incontinence brief. V7 stated we use the blanket in case, the incontinence brief leaks. On 06/02/25 at 11:18 AM, V6 stated he (R52)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 containers of the piston syringe were labeled with the dates these were changed for 3 (R24, R55, and R66) residents and failed to ensure the containers of the distilled water used for flushing the g-tubes (gastrostomy tubes) were labeled with open date for 2 (R55 and R66) residents. These failures affected 3 (R24, R55, and R66) residents reviewed for tube feedings in the total sample of 55 residents. Findings include: On 06/02/25 at 11:48 AM, R66 had a G-Tube feeding on going with Jevity 1.5 rate of 50cc/hour. This surveyor requested V6 (Agency Licensed Practice Nurse) to check for the label on the container of the piston syringe. V6 stated it is not labeled. V6 stated the container should be labeled to know how old the piston syringe is for infection control. On 06/02/2025 at 11:49am, there was a gallon of [NAME] Choice distilled water at R66's nightstand. V6 stated we use it for flushing her g-tube. This surveyor requested V6…

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

Based upon observation, interview, and record review the facility failed to ensure that one resident (R504) reviewed for medication administration remained free from significant medication errors in a sample of 55 residents. Findings include: On 06/02/25 at 11:00am, R504 was observed, in his (R504) room, sitting on the side of bed with a walker in front of him. Also observed in R504's room, a full bag of IV (intravenous) Cefazolin Solution 2gm (gram) bag, on IV pole with primed tubing, not connected to resident. R504 stated that he (R504) is not sure if he (R504) received the antibiotic in the morning, he (R504) was sleeping. R504 stated that few times the nurses just come to connect IV antibiotic while he (R504) sleeps. Observed IV Access on right upper arm (PICC or Central Line) with gauze sleeve around the site. R504 stated that R504 did not refuse the antibiotic. R504's face sheet documents medical diagnoses that include but are not limited to infection and inflammatory reaction due to unspecified internal joint prosthesis. R504's active physician orders documents, in part, PICC…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 communication training to the staff. This failure affects 1 resident (R354) out of 55 residents in the sample. Findings include: Record review of facility census documentation provided on 6/2/2025 documents in part that 93 residents reside within the facility. Review of R354's minimum data set (4/7/25) documents in part that R354's primary language is Chinese and requires an interpreter for communication. On 6/2/2025 at 11:40 AM, V29 (R354's Family Member) stated that R354 has difficulty communicating and that English is not R354's first language. V29 explained that it is hard for the staff to communicate with (R354), so I have to be here-I am here every day as much as I can be. None of them speak the language, we speak Chinese. I am the interpreter to ensure (R354) gets the care (R354) needs. On 6/4/2025 at 10:39 AM, surveyor requested documentation for staff training on communication. On 6/4/2025 at 1:39 PM, V1 (Administrator) provided surveyor with 2 binders labeled In-services 2025 and In-services 2024 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 interview and record review, the facility failed to deliver mail and not open mail without permission for one (R1) of four residents reviewed for resident rights. R1's clinical record indicates: R1 is a sixty-six-year-old man admitted with chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, sleep apnea, type II diabetes, long term use of insulin, major depression, anxiety disorder, and essential hypertension. R1's minimum data set assessment section [C] indicates R1 is alert and oriented, able to make his needs known. On 4/12/25 at 10:58 AM, R1 stated, V2 (Director of Nursing/DON) opened up my mail, and she had no right opening up my personal mail. V2 opened my mail and took my pills, I don't know what the veteran pharmacy sent, how many, or nothing. On 4/13/25 at 2:00PM, V6 (R1's Family Member) stated, I have never been to the facility, but R1 calls me regarding all his concerns. R1 told me that V2 (DON) opened up R1's mail, and that was against the law. On 4/12/25 at 2:55 PM, V2 (DON) stated, one day the receptionist called me and said that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to answer a residents (R3) call light timely who is dependent for care. This failure affected 1 out 3 residents reviewed for call light response. Findings include: On 02/27/25 at 12:55 pm, R3 was observed sitting in a wheelchair in R3's room, awake, alert and able to communicate needs. When R3 was asked regarding staff responding to R3's call light. R3 stated that a few weeks ago R3 was in R3's bed, began to have chest pain, and activated R3's call device. R3 stated that no staff responded to R3's call light after 10 minutes so R3 phoned V2 (Director of Nursing, DON) on R3's cellular phone. R3 explained that V2 stated that V2 would send a nurse to R3's room. R3 explained once R3 hung up from speaking to V2 a few minutes later a nurse came into R3's room to assist R3. R3 then explained that R3 was sent to the local hospital and was treated for having a heart attack. Surveyor then requested to perform a call device response check with R3 and 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 observations, interviews, and record review, the facility failed to provide a functioning call device for a dependent resident (R3) who requires assistance from staff. This failure affected 1 out of 4 residents reviewed for resident call system. Findings include: On 03/03/25 at 12:10 pm, R3 was observed in R3's bathroom attempting to transfer from R3's wheelchair to the toilet. Surveyor questioned R3 regarding R3 asking staff to assist R3 to the toilet and R3 stated that R3 asked V12 (Licensed Practical Nurse, LPN) for help to the bathroom and V12 informed R3, that R3's CNA (Certified Nursing Assistant) was on break. R3 then stated that R3 asked R3's nurse V22 (LPN) (R3's assigned nurse) for assistance and V22 informed R3 that V22 would let R3's CNA know when R3's CNA return from break. R3 then stated that R3 had been waiting 20-30 minutes when R3 decided to transfer herself to the toilet. Surveyor then instructed R3 to activate R3's bathroom call light device for assistance at 12:13 pm. 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 interview and record review, the facility failed to ensure that an overbed table was maintained in good working condition for one of three residents (R2) reviewed for accidents in the sample of four. This failure resulted in R2 sustaining a fall after the overbed table top she was leaning on detached from the table base. R2's incident report of 1/1/2025, documents in part, resident was sitting in the hallway by the nurses' station in 2E. She was leaning on the bedside table in front of her when the table broke. R2 fell on the floor hitting her right side. 1/21/2025, at 3:20 PM, V4 (LPN-Licensed Practical Nurse) said I was in a resident room with a resident when R2 fell. After I got through with my patient, V3 (Assistant Director of Nursing) told me she (R2) fell; the fall was witnessed by a CNA (Certified Nursing Assistant) and physical therapy. V4 told me R2 was lying with her head down on an overbed table, the table gave way, and resident fell to floor. V4 added, I went to look at the overbed table and the tabletop was not connected to the base. 1/22/2025, at 9:45 AM, V6…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon record review and interview the facility failed to follow policy procedures, failed to ensure that care plans are accurate, and/or failed to ensure that comprehensive care plans include required problems/focus and/or approaches/interventions for four of four residents (R1, R2, R3, R4) in the sample. Findings include: 1. R1 was admitted to the facility on [DATE]. R1's diagnoses include obesity and generalized muscle weakness. R1's (12/22/23) risk assessment for skin integrity impairment determined a score of 12 (High Risk). R1's (9/13/24) functional assessment affirms resident is dependent on staff for toileting hygiene and requires substantial/maximal assistance for rolling left and right (turning/repositioning), sit to stand and toilet transfer were not applicable. On 10/29/24 at 12:11pm, surveyor inquired about R1's functional status, V11 (Assistant Director of Nursing) stated She is bedridden, we have to mechanical lift her. R1's comprehensive care plan (received 10/24/24) states (12/24/23)…

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 record review and interview the facility failed to ensure that competent nursing staff are available to meet the needs for four of four residents (R1, R2, R3, R4) reviewed for wound care. The facility failed to ensure that the Wound Care Nurse is certified, failed to ensure that wound assessments are accurate, failed to stage wounds correctly, failed to ensure that all Nursing staff are aware of LALM (Low Air Loss Mattress) use requirements, failed to in-service all Nursing staff for LALM use, failed to follow physician orders, failed to ensure that treatment administration is documented on the TAR (Treatment Administration Record), failed to administer treatments as ordered, and failed to follow policy procedures. Findings include: 1. R1 was transferred from the facility to the hospital on 9/21/24. On 10/28/24 at 1:05pm, surveyor inquired about R1's (facility acquired) skin integrity impairment, V2 (Director of Nursing) presented R1's (2/23/34) initial skin alteration record and (3/21/24) weekly skin alteration record and stated 2/23 is when the MASD (Moisture Associated…

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

Based upon record review and interview the facility failed to follow policy procedures and failed to ensure that the Physician, family and/or responsible parties were notified of change in condition for one of four residents (R1) reviewed for pressure ulcers. Findings include: On 10/18/24, IDPH (Illinois Department of Public Health) received allegations that the family was not notified of R1's infected (stage 4) sacral wound. R1's (9/16/24) progress notes state Nurse on duty observed changes in resident skin integrity, right away notified wound nurse. Head to toe skin assessment performed. Notably sacrum MASD (Moisture Associated Skin Damage) measured in (7 x 4.5 x 0). Family member at bedside. All responsible parties aware. On 10/23/24 at 1:14pm, surveyor inquired if V3 (Family) was notified by the facility of R1's skin integrity impairment V3 stated (R1) was sent to the hospital from the facility, I think like in September. The facility staff never even told me about the bed sores and affirmed an infected pressure ulcer was identified by hospital staff. R1's (9/21/24) progress…

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

Based on observation, interview, and record review the facility failed to ensure food was labeled, dated, and discarded after use by date and failed to ensure equipment has been immersed in the sanitizer sink for a full minute and then air-dried before use. These failures could potentially affect 100 residents who were to receive meals from the kitchen on 7/16/24. The findings include: On 7/16/24 at 9:34 AM, Surveyor toured kitchen with V12 (Dietary Manager), reach-in fridge checked and observed thickened water with open date on 7/3/24. V12 said thickened water is good for 7 days from date it was opened, and it should be discarded. V12 removed the opened thickened water from the fridge and tossed it. Thickened water container label showed after opening, may be kept up to 7 days under refrigeration. V12 said if food item is used beyond used by date there is a risk of making resident get sick, food / drink could be contaminated or spoiled. Surveyor inspected dry food storage room with V12, observed box of tea bags opened with no date labelled. V12 said once food item or product 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 dispose garbage properly in a contained dumpster; ensure garbage receptacles were covered and keep the dumpster area clean and free of garbage or waste to maintain a sanitary condition and to prevent harborage and feeding of pest. These failures could potentially affect all 102 residents that reside in the facility as of census 7/16/24. The findings include: On 7/16/24 at 10:15 AM, Surveyor inspected dumpster with V12 (Dietary Manager), observed dumpster with recycled items not closed, lid broken and/or bent. Another dumpster, with trash, had a lid not fully closed. V12 stated it was not fully closed because it is full of waste. V12 said the dumpster or garbage bin should be completely closed or covered to prevent flies or insects to come by. Surveyor also observed broken furniture and equipment around the dumpster area and garbage bins with waste inside, not covered. V27 (Maintenance Staff) interviewed and he stated the dumpster lid has bended and it does not close completely. He said another dumpster with…

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

Based on interview and record review, the facility failed to electronically transmit MDS (Minimum Data Set) records to CMS system using the CMS-specified Resident Assessment Instrument (RAI) process within the regulatory timeframes for 10 (R11, R16, R20, R32, R33, R39, R41, R49, R59, R90) of 10 residents reviewed for resident assessment in a sample of 24. The findings include: On 7/17/24 at 3:10 pm, V28 (MDS Regional Consultant, RN) stated she is covering the facility as there is no full time MDS coordinator currently working in the facility but there is a part time MDS coordinator who comes to the facility on weekends and working remotely on weekdays for few hours. She said the facility is in the process of hiring a full time MDS coordinator. She said facility is following CMS RAI guidelines in completing and transmitting MDS records. V28 said MDS assessment is completed for all residents, it is a snapshot of the resident's condition and how they should be taken care of. MDS includes resident's functional capabilities, it helps staff identify health problems or concerns and care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 refrigerate unopened insulin, discard loose tablets and expired medications, defrost medication refrigerators, and double-lock controlled medications from 2 of 2 medication rooms and 3 of 3 medications carts reviewed during medication storage observations. Findings include: On 7/16/2024 at 9:47 AM, surveyor reviewed the 1-East Team 1 medication cart with V4 (Nurse). In one of the top drawers, there was a bottle of Insulin Aspart 100 unit/milliliter vial for R154. The label on the bottle documents in part Refrigerate until open. V4 stated the vial was unopened. In the drawer with the house stock medications, there was a bottle of One-Daily Multivitamin 200 tabs. Written open date on the bottle was 5/27/2024. The best by date on the bottle was 3/2024. V4 started administering medications from the bottle that morning. At 9:52 AM, V4 stated the night shift nurses are supposed to check the medication carts for expired medications. On 7/16/2024 at 10:02 AM, surveyor reviewed the 2-West medication room with V5…

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

Based on observations, interviews and record reviews, the facility failed to follow their policy to ensure proper infection control guideline practices are followed related to personal protective equipment was not worn prior to entering a contact isolation room for 1 resident (R403), failed to use standard precautions during incontinence care and perform hand washing/hand hygiene for 2 residents (R10, R50), failed to follow their policy to ensure proper infection control guideline practice are followed related to the use of a nasal cannula that was picked up from the floor and was placed in the nostrils of 1 resident (R6) reviewed for infection control in a sample of 24. Findings Include: 1. On 07/17/2024 at 09:45 AM, surveyor observed R403's room had contact isolation sign on her door. On 07/17/2024 at 10:41 AM, V20 (Licensed Practical Nurse) stated that R403 is on isolation for Extended Spectrum Beta-Lactamase (ESBL). On 07/17/2024 at 11:45 AM, surveyor observed V22 (R403's daughter) sitting with R403 on the bed, hugging R403 without wearing any personal protective equipment. V22…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews the facility failed to offer, educate, and document the benefits and risks of Influenza and Pneumococcal vaccines to 4 (R80, R401, R403, R404) of 5 residents reviewed for vaccinations. Findings include: Per residents' vaccination record, R80, R401, R403, and R404 did not receive any of the following vaccines (influenza and pneumococcal ). Surveyor requested for all documentation related to vaccination including immunization record, consent forms, documentation of education and other documents that residents were offered and educated on before refusal. V2 (Director of Nursing / Infection Preventionist) was not able to provide any consent forms, and there was no documentation that any resident or representative of resident was educated and the reason for refusal. R401's consent for Influenza and Pneumonia vaccine documents in part: Yes to receiving influenza and pneumonia vaccine. R401's immunization record does not document any administration of vaccine. On 07/18/2024 at 10:24 PM, V2 (Director of Nursing / Infection Preventionist) reviewing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews the facility failed to offer, educate, and document the benefits and risks of the COVID-19 vaccines to 4 (R80, R401, R403, and R404) of 5 residents reviewed for vaccinations. Findings include: Per residents' vaccination record, R80, R401, R403, and R404 did not receive any vaccine (Covid-19). Surveyor requested for all documentation related to vaccination including immunization record, consent forms, documentation of education and other documents that residents were offered and educated before refusal. V2 (Director of Nursing / Infection Preventionist) was not able to provide any consent forms, and no documentation that any resident or representative of resident was educated and the reason for refusal. Reviewed R401, R403, R404 and R80's immunization record. No documentation of administering COVID-19 vaccine. On 07/18/2024 at 10:24 PM, V2 (Director of Nursing / Infection Preventionist) reviewed electronic health records and said, I cannot find any documentation that specific education was given, or if resident was able to understand education.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and interview, the facility failed to ensure that a resident's call light was within reach for one resident (R94), in the sample of 24. Findings include: R94's medical record (Face Sheet) documents R94 is an [AGE] year old admitted to the facility on [DATE] with diagnoses including but not limited to: Encephalopathy, Abnormalities of gait and mobility, Cognitive Communication Deficit, and Muscle weakness. R94's MDS (Minimum Data Set-6/29/2024) documents a BIMS score (Brief Interview for Mental Status) of 12 (moderately impaired). On 07/16/24 at 11:21 AM, R94 was observed sitting up in chair in resident's room. R94's call light was noted hanging over side of R94's nightstand, not within resident's reach. R94 said he did know where his call light was. On 07/16/24 at 11:23 AM, V9 (LPN-Licensed Practical Nurse) stated R94's call light was not within resident's reach. V9 added call lights should be within a resident's reach. On 07/18/24 at 10:15 AM, V3 (DON-Director of Nursing) stated call lights…

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

Based on interviews and record reviews, the facility failed to have an order for a code status for one resident (R153) out of a total sample of 24 residents reviewed for advanced directives. Findings include: On 7/16/2024 at 2:53 PM, R153 stated, wanting to be resuscitated (Full Code) if [R153] had a change in condition. On 7/16/2024 at 2:54 PM, V8 (Nurse) stated R153 is Full Code if there are no DNR (Do Not Resuscitate) papers in the paper chart. If there are no DNR papers in the chart, then V8 will check the computer. V8 stated I think [R153] is Full Code. R153's admission Record does not document a code status under the section Advance Directive. R153's Order Summary Report does not contain an order for a code status. R153's care plan did not contain a code status. R153's admission Summary progress note dated 7/12/2024 8:47 PM documents in part that R153 is Full Code. Surveyor reviewed R153's orders on 7/17/2024 at 10:09 AM and 11:42 AM. R153 remained without an order for a code status. On 7/17/2024 at 12:15 PM, V3 (Director of Nursing) stated staff assess a resident's 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 observation, interview and record review, the facility failed to ensure incontinence care was provided in a timely manner for 2 (R10 and R50) residents who needed assistance with toileting; and failed to ensure personal hygiene assistance was provided for 1 resident (R51) after returning from the hospital. This failure affected 3 residents (R10, R50, R51) reviewed for ADL (activities of daily living) care in a sample of 24. The findings include: 1. R10's face sheet showed admission date on 8/4/2023 with diagnoses not limited to Unilateral primary osteoarthritis right knee, Chronic systolic (congestive) heart failure, Hypothyroidism, Personal history of transient ischemic attack (tia), and cerebral infarction without residual deficits, Presence of cardiac pacemaker, Type 2 diabetes mellitus without complications, Other asthma, Muscle wasting and atrophy, Insomnia, Unspecified atrial fibrillation, Hyperlipidemia, Unspecified glaucoma, Carpal tunnel syndrome left upper limb, Unspecified fall, Cellulitis,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reviews, the facility failed to re-evaluate the necessity of a resident's (R83) enteral feeding for one out of a total sample of 24 residents reviewed for nutrition. Findings include: R83's admission Record documents in part medical diagnoses of adult failure to thrive (onset 3/05/2024), gastroparesis (onset 12/16/2023), unspecified protein-calorie malnutrition (onset 3/05/2024), and encounter for attention to gastrostomy (onset 3/05/2024). R83's Order Summary Report documents in part orders for Low concentrated sweets (LCS) diet Mechanical Soft texture, Thin Liquid consistency, No Added Salt, pleasure feed only (active since 3/29/2024). R83 also had an order for Enteral tube feeding Glucerna 1.2 at 65 [milliliter/hour] continuous [every] shift (active 6/10/2024) and Enteral tube [flush] 150 [milliliter] [three times] a day including medication administration three times a day for hydration (active 3/29/2024). R83's medications varied between oral and enteral feed administration. On 7/17/2024 at 8:55 AM, R83 received enteral feed of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure oxygen tubing and bubbler were dated and changed and failed to administer oxygen as ordered for 2 residents (R49 and R71) reviewed for respiratory care in a sample of 24. The findings include: 1. R49's face sheet showed admission date on 7/6/2021 with diagnoses not limited to End stage heart failure, Hypertensive heart disease with heart failure, Chronic obstructive pulmonary disease, Unspecified intestinal obstruction, Other asthma, Type 2 diabetes mellitus without complications, Unspecified abdominal pain, Peripheral vascular disease, Spinal stenosis cervical region, Other chronic pain, Nonrheumatic aortic (valve) stenosis with insufficiency, Unspecified atrial fibrillation, Primary insomnia, Zoster without complications, Unspecified abdominal hernia with obstruction without gangrene, Personal history of Covid-19, Presence of coronary angioplasty implant and graft, Coronary angioplasty status, Acute on chronic systolic…

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

Based on interviews and record reviews, the facility failed to ensure that one resident (R79) received medication as ordered out of a total sample of 24 residents. Findings include: R79's admission Record documents in part a diagnosis of major depressive disorder, recurrent, unspecified. R79's Order Summary Report documents in part an order for Wellbutrin SR (Sustained Release) oral tablet 150 milligram by mouth one time a day for depression. Order active on 5/06/2024. R79's care plan contains a focus for R79's use of antidepressant medication (last revised 8/10/2023). However, care plan is not updated to include R79's current antidepressant (Wellbutrin). Intervention for this focus includes to Administer ANTIDEPRESSANT medications as ordered by physician (initiated 8/10/2023). On 7/16/2024 at 11:10 AM, R79 was oriented to person, place, and year. R79 answered questions appropriately. R79 stated facility is not consistently providing medications. R79 stated facility did not provide Wellbutrin for six days a month or two ago. Random days when facility doesn't have Wellbutrin. R79…

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

Based on observations, interviews, and record reviews, the facility failed to ensure a medication error rate of less than 5% during medication administration observations. The facility had four medication errors out of 37 opportunities resulting in a 10.81% medication error rate. Findings include: On 7/16/2024 at 10:19 AM, V7 (Nurse) prepared medications for R9. V7 prepared Amlodipine, Buspirone, Lisinopril, Vitamin C and Vitamin D. At 10:26 AM, V7 stated [V7] needed to prepare MiraLAX (brand name) for R9. V7 pulled out a bottle of Polyethylene glycol 3350 (generic). V7 stated, did not have a spoon in the medication cart. V7 locked up the medication cart and went to the nurses' station. V7 retrieved plastic spoons and returned to medication cart. At 10:27 AM, V7 stated R9 needs one teaspoon of MiraLax. V7 took one spoonful of the Polyethylene Glycol 3350, put it in a clear, plastic cup, and mixed it with water. At 10:30 AM, R9 finished taking the medications and V7 returned to the medication cart to chart. V7 charted administering Aspirin 81 milligram but surveyor did not observe V7…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide requested medical records for one resident (R1) out of three residents reviewed for medical records request. R1 has a diagnosis which includes but not limited to: Alzheimer's disease, pressure ulcer of left heel stage 4, Alzheimer's disease with early, onset, dementia unspecified severity without behavioral. R1's Minimum Data Set (MDS) dated [DATE] shows no Brief Interview for Mental Status (BIMS) score for R1 which indicates that R1 has some memory impairments. On 01/16/23 at 1:41 pm, V10 (R1's Family Member) stated that R1's family requested R1's medical records from the facility in December 2023. V10 stated that V10 spoke with V1 (Administrator) regarding obtaining R1's medical records and V10 still has not received R1's medical records. V10 then explained that V10 received a call from the facility right before surveyor called V10 stating that R1's medical records were ready for V10 to pick up at the facility after V10 has been waiting 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 observations and interviews, the facility failed to provide sufficient staffing to ensure ADL (Activities of Daily Living) care was provided for dependent residents who required assistance with bladder and bowel incontinence for four of four residents (R1, R2, R3, R4) reviewed for ADL care. Findings include: On 10.21.2023 at 9:25 AM, the census on 2 [NAME] was 48. There were two nurses (V6 and V7, both Agency Licensed Practical Nurses) and CNAs. There was one call off, who was replaced by an agency CNA who had not arrived to the facility. 10.21.2023 at 9:31 AM, V3 (CNA-Certified Nursing Assistant) said when she starts work, at 7:00 AM, they're (the residents) are never clean and dry; they should be clean and dry. V3 said there is not enough help. I have 17 or 18 residents today; nine of those residents are complete and/or require assistance with their ADLs (Activities of Daily Living). R5 was soaked if they did their rounds (CNAs on 7p-7A shift), they (the residents) wouldn't be soaked (with urine). This is the busiest side. R5 demands constant attention. I'm constantly…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 four of four residents (R1, R2, R3, R4) reviewed for ADL care. Findings include: On 10.21.2023 at 11:33 AM, R1 was observed awake, alert, lying in bed. R1 said he was soiled. 1) R1's medical record (Face Sheet) documents R1 is a [AGE] year-old admitted to the facility on 2.20.2020 with diagnoses including but not limited to: Parkinson's Disease, Venous Insufficiency (Chronic) (Peripheral), Acute Kidney Failure, and Weakness. R1's MDS (Minimum Data Set of 7.23.2023) documents R1 is cognitively intact, requires extensive assistance/two + persons physical assist with bed mobility, transfers, and toilet use; R1 is frequently incontinent of urine and stool. 10.21.2023 at 11:33 AM, R1 was observed sitting up in bed. A blue brief was observed sticking out from the top of R1's yellow brief. R1 said…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not ensure proper sanitation and food handling practices to prevent the outbreak of foodborne illness. This failure has the potential to affect the 87 residents that are served food from the kitchen. Findings include: On 8/8/23 at 9:40 AM, surveyor toured the facility kitchen with V18 (Director of Dietary and Dining) and observed: -a staff lunch bag and a pan of roast beef (to be served at lunch) on the food prep counter/cooking area. -a bag of dry cereal not completely sealed. -7 bottles of thickened orange juice, nectar consistency with use by date 5/24/23. -a bag of dry pasta with no OPENED date. -a package of hotdog buns not sealed closed. On 8/8/23 at 10:40 AM, V21 (Cook) stated staff personal belongings are not supposed to be in the kitchen on cooking areas according to the rules. It is not sanitary. There is a potential for contamination and for residents to get bacteria. On 8/10/23 at 11:45 AM, V18 (Director of Dietary and Dining) stated because a staff person placed their lunch bag on the food prep…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 properly contain waste in the dumpsters. This failure has the potential to affect all 73 residents in the facility. Findings include: On 8/9/23 at 9:00 AM, toured the dumpster area with V18 (Director of Dietary and Dining). Observed three dumpsters, two recycle dumpsters with cardboard and plastic in them and one trash dumpster with bags of trash in it. The lids on all three dumpsters were open. On 8/9/23 at 9:20 AM, V22 (Maintenance) stated the dumpster lids should be closed. On 8/9/23 at 9:25 AM, V23 (Maintenance Director) stated the lids should be closed on the dumpsters. They should be closed because of the risk to attract rodents, and pests. On 8/10/23 at 11:45 AM, V18 (Director of Dietary and Dining) stated the dumpsters should be closed. There is a potential for odors and to attract cockroaches, flies, rodents. There is potential for pest infestations in the building. Facility Pest Control Physical Environment policy, date 4/1/2020, documents in part: Purpose: To ensure the facility is free of insects,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 liquid medications were properly labeled with an open date and ensure that one out of two medication carts reviewed were locked/secured while unattended. These failures have the potential to affect 27 residents residing in the facility. Findings Included: On 08/08/2023 at 9:39AM, an observation of the medication cart (Identified as 1 East Medication Cart) on the first floor of the facility with V4 (Registered Nurse/RN) present revealed the following medication to be opened and undated: Levetiracetam 100mg/ml with R66's name on it. V4 stated that she administered R66 the above medication this morning and that there should be an open date labeled on the medication. On 08/08/2023 at 9:53AM, an observation of the medication cart (Identified as 2 East Medication Cart) on the second floor of the facility with V5 (Licensed Practical Nurse/LPN) present revealed the following medication to be opened and undated: Albuterol Sulfate 2.5mg/3ml…

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

Based on observation, interview, and record review, the facility has the following failures related to infection prevention and control. The facility failed to clean and disinfect reusable equipment (blood pressure cuff device) used by four residents (R13, R51, R62, and R179). The facility also failed to follow appropriate infection control procedures after using a glucometer on one (R14) of one resident observed for a blood glucose reading in a total sample of 5 residents reviewed during medication administration. Facility also failed to provide access to perform hand hygiene for 1 out of 20 residents (R41) with multiple infections reviewed for facility infection control and prevention practices. Findings include: On 08/08/2023 at 11:55 AM, R41 was seen alert and verbally able to express his thoughts. R41 has 2 urinals hanging on the right-side rails of his bed. R41 said, I still have discomfort during urination, and frequently urinating during night. I cannot go to toilet by myself, and I also need to wash my hands in the toilet. I need to use the walker (pointing at the right…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow their policy to develop and implement a comprehensive person-centered care plan for one (R55) of five residents reviewed in a sample of 18. Findings include: R55 is a [AGE] year-old individual admitted to the facility on [DATE]. R55's medical diagnosis includes but not limited to: Cerebral Infarction due to embolism of left middle cerebral artery. R55's physician order sheet (POS) documents R55's orders to include but not limited to: Eliquis Oral Tablet 5 MG (Apixaban) Give 1 tablet via G-Tube two times a day for CVA (Cerebral Vascular Accident). Active (Start date for medication)7/1/2023. On 8/9/2023 at 2:54 pm, V16 (Minimum Data Set Coordinator -MDS) and surveyor reviewed R55's care plan. V16 said R55's anticoagulant medication, Eliquis Oral Tablet 5 MG, was not care planned and it should have been care planned after it was ordered so that R55's nurses can monitor for side effects including bleeding, bruising, blood clots, and…

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

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5% for two (R13, R179) out of five residents reviewed for medication administration resulting in a 12.12% error rate. Findings Include: R179's Facesheet documents that R179 has diagnoses not limited to major depressive disorder, Parkinson's disease, chronic systolic heart failure, and paroxysmal atrial fibrillation. R179's medication administration record (MAR) dated 08/01/2023 - 08/09/2023 documents: Co Q 10 (Ubidecarenone) 30mg- 1 tab by mouth one time a day. Sertraline 100mg- 1 tablet by mouth one time a day. Review of R179's MAR documents that V9 signed the MAR to indicate that the above medications were given. This documentation does not align with direct observation. On 08/09/2023 at 8:55AM, observed that these medications were not given during medication administration pass with V9 (Licensed Practical Nurse/LPN). R13's Facesheet documents that R13 has diagnoses not limited to: Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease, Chronic Heart…

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

Based on observation, interview, and record review, the facility failed to follow policy taking in to account preferences of food and beverages for 3 of 3 residents (R53, R52, and R11) during dining observations. These failures have the potential to affect 3 residents (R53, R52, and R11) meal preference and consumption of food and beverage during meals. Findings include: On 08/08/2023 at 12:21 PM, at the dining room during lunch, R53 and R52 who were seated on the same table were asked if they are enjoying their food. R53 said, Look what they gave me (holding grilled cheese sandwich), they did not give me my chocolate milk. They always fail to give me my chocolate milk. Then R52 said, Look what they gave me (holding a grilled cheese sandwich). I would like a Tuna Sandwich, but I always don't get what I asked. V17 (Dietary Staff) was informed but responded, I am not sure what they are getting. V18 (Director of Dietary and Dining Services) were informed and said, Let me talk to them. During conversation with R53 and R52, R53 said, I did not receive my chocolate milk. Then R52, when…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review of records, the facility failed to date and refrigerate food from outside source to 1 out of 1 resident (R41) reviewed for food on the bedside. These failures have the potential to affect 1 resident (R41) in consuming food that are not appropriate for consumption. Findings include: On 08/08/2023 at 11:45 AM, R41 was seen alert and verbally able to express his thoughts. R1 has a lot of food on the bedside table and drawer, including a sandwich dated 8/6/2023, milk in a carton, cucumber, peanuts on the bottle, crackers, Tortillas, Dreamies Raspberry, Donette's Danish, chips on a zip lock all not dated, and a banana with discoloration. R41 said, Some of this food is old, but I don't to know when I got them. On 08/10/2023 at 12:15 PM, V18 (Director of Dietary Services and Dining Services) said, Food on the bed side must be dated to know if it is still good to be consumed. Then it must be placed in resident's personal refrigerator that must be checked daily for temperature. If the resident does not have personal refrigerator, it will be…

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

Based on review of observation, interview, and record review, the facility failed to follow policy on Antibiotic Stewardship Program on tracking antibiotic use of all residents taking antibiotics and indication of antibiotic use by prescriber for 3 out of 5 residents (R41, R49, and R228) reviewed for antibiotic stewardship. These failures have the potential to affect 3 residents (R41, R49, and R228) with the risk of developing resistance with antibiotic. Findings include: Per review of facility's July 2023 Antibiotic Tracking, 3 residents (R41, R49, and R228) taking antibiotic were not included in the tracking log. R41 has multiple antibiotic use that includes: Levaquin 250 MG to give 1 tablet by mouth in the afternoon for ESBL (Extended-spectrum Beta-Lactamases) of urine for 1 week until 04/06/2023. Nitrofurantoin Macrocrystal Oral Capsule 100 MG Give 1 capsule by mouth two times a day for ESBL of urine until 04/06/2023. CefTRIAXone Sodium Injection Solution Reconstituted 1 GM Use 1 gram intravenously one time a day for antibiotic for 4 Weeks order date 5/2/2023 to 5/30/2023.…

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