Pavilion Of Logan Square, The

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of records and interview the facility failed to maintain accurate resident record, ensure resident records are readily accessible related to psychotropic medication use for 1 out of 4 residents (R1) reviewed for improper nursing care. These failures can affect 1 resident (R1) who uses psychotropic medication related to correct medical diagnosis and consent documentations. Findings include: R1 is [AGE] years old, initially admitted on [DATE] discharged on 8/20/2020, re-admitted on [DATE] and discharged to hospital 3/25/2025. R1 medical diagnosis includes dementia with behavioral disturbance, brief psychotic disorder, and mood affective disorder. Per R1's physician order documents that R1 has an order for the following psychotropic medications: Haloperidol Tablet 5 MG, as needed for aggression for 14 days, Haldol Injection Solution 5 MG/ML (Haloperidol Lactate) inject 5 mg/ml intramuscularly every 6 hours as needed for aggression for 14 days, Olanzapine Oral Tablet 2.5 MG give 1 tablet by mouth in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to implement fall prevention interventions for one (R1) of three residents reviewed for falls. This failure resulted in R1 falling on 02/08/2025 and R1 is hospitalized at the time of this survey. Findings include: R1's face sheet dated 09/15/2024, documents that R1 is a [AGE] year-old resident with diagnoses not limited to: unspecified intellectual disabilities, down syndrome, unspecified, type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema, nontraumatic subarachnoid hemorrhage, unspecified, traumatic subdural hemorrhage without loss of consciousness. R1's MDS/Minimum Data Set, dated [DATE] documents that R1 has a BIMS/Brief Interview for Mental Status score of 04/15, indicating that R1 has severely impaired cognition. On 02/08/25, 10:37 AM, V3 (Registered Nurse) states that R1 fell this morning at approximately 9:50 AM. V3 continues to state my CNA (certified nursing assistant) was in the room with her. R1 was walking…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, review of records, and interviews the facility failed to safeguard resident rights to properly account and correctly charge resident funds for 7 out of 9 residents (R2, R4, R5, R7, R8, R9, and R10. These failures does not conform with their policy that mandate the facility to hold, safeguard, manage and account resident funds. Four (4) residents (R2, R4, R7, and R8) personal funds accounts were affected and charged dental insurance premiums that should have been included in care cost. 5 residents (R2, R5, R8, R9, and R10) were charged haircuts on their resident funds without proper documentation of consent, residents unable to give consent due to impaired cognition, and/or service date discrepancies. Findings include: On 01/14/2025, at 1:07 PM, V3 (Assistant Administrator) stated that dental insurance premiums were charge by increasing resident's allowance (care cost) credit to accommodate dental insurance premiums. Per V3, dental insurance premiums is part of care cost and not to be charged differently. V3 stated that starting January 2024 there was an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and records review, the facility failed to provide flu vaccine and education to two (R1, R11) residents of four reviewed. Findings include: R11 is a [AGE] year-old individual admitted to the facility on [DATE]. R11's medical diagnosis includes but not limited to influenza due to identified novel influenza a virus with other respiratory manifestations, type 2 diabetes mellitus with diabetic chronic kidney disease, acute respiratory failure with hypoxia, cognitive communication deficit. R11's MDS (Minimum Data Set) section C dated [DATE], documents R11's Brief Interview for Mental Status (BIMS) as 15/15 indicating R11 has intact cognitive function. MDS section GG (Functional Abilities) documents R11 requires setup or cleaning assistance with eating and oral hygiene, partial to moderate assistance with toileting and is dependent for shower/bathing, upper and lower body dressing. Hospital records dated [DATE] document R11 presented to the hospital with two-day history of coughing and dyspnea, now…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, facility failed to follow their policy to investigate an allegation of abuse for one of three residents (R2) reviewed for abuse in the sample of six. Findings include: 11/12/2024, at 11:31 AM via telephone, V3 (Emergency Department Physician) said R2 has a known fall risk history. Injury allegedly occurred during resident care at the facility; resident rolled out of bed onto floor. V3 said per facility, R2 was already in a low bed. V3 said R2's injuries were consistent with being punched in the face, not fall from low bed. V3 added R2's eyelid laceration was too complex (involved tear duct, resident crying bloody tears) to be treated at original hospital, R2 was transferred to another local hospital for laceration repair. 11/13/2024, at 11:02 AM, V5 (Certified Nursing Assistant) via telephone, said I helped V7 (Certified Nursing Assistant) transfer R2 from shower chair to bed using a gait belt. I asked V7 if she needed help with R2, V7 said no, I left the room. 11/13/2024, at 11:34 AM, V7 (Certified Nursing Assistant) said I gave R2 his shower…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record reviews, the facility failed to ensure one [R2] of 3 residents were free from physical abuse. R1 clinical record indicates in part; R1 was admitted on [DATE] with the medical diagnosis of bipolar disorder with manic severe, psychotic features, restlessness, agitation, disorientation, Parkinson's Disease with dyskinesia, cognitive communication deficit, weakness, and essential hypertension. Minimum data set brief interview dated 9/4/24 scored [7] indicates R1 is moderately cognitively impaired. R1's care plan indicates in part: Abuse and Neglect 8/25/24- R1 became physically aggressive toward female peer. R1 was sent to the hospital for combative behavior, and was diagnosed with urinary tract infection, and treated with antibiotics. R1 needs verbal reminders to engage in activities due to memory deficit. R1 Progress note- 8/25/2024 11:05 Nurses Note Note Text: R1 was sitting by her room in the hallway, when writer was informed by staff that resident smack another resident [R2] that…

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

Based on observations, interview, and record review, the facility failed to ensure employees' personal food items were not stored in the Kitchen's walk-in cooler; failed to ensure the ceiling is not leaking and the drainage pipe is not clogged at the dishwashing area inside the kitchen in an effort to prevent food borne illnesses. These failures have the potential to affect all residents taking oral nutrition at the facility. Findings include: The (09/08/2024) census report documented that there were 204 residents at the facility. The (09/09/2024) Diet Type Report documented that there were 3 residents not taking oral nutrition at the facility. On 09/08/2024 at 9:21am, there were 4 small food baskets inside the walk-in cooler with V9's (Cook), V11's (Dishwasher), V12's (Dietary Aide), and V14's (Cook) names. V9 stated these (small food baskets) are for the Kitchen staff. They (facility) let us (Kitchen staff) keep our food in the walk-in cooler because we (Kitchen staff) don't have a place to keep our food. On 09/09/2024 at 9:43am, there was a puddle of water by the dishwashing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a resident's ability to safely self-administer medications which affected one resident (R63) when reviewed for self-administration of medications in the total sample of 76 residents and has the potential to affect all 52 residents on the 4th floor in the facility. Findings include: On 9/8/24 at 10:13 am, V22 (Registered Nurse, RN) stated that the residents on the 4th floor are primarily residents with dementia. On 9/8/24 at 11:21 am, this surveyor entered R63's room via an open door and observed R63 laying in bed. This surveyor observed a clear medicine cup containing 5 medication pills on top of the nightstand (3 drawers) near R63's bed. The clear medication cup (30 milliliters) contained the following: one round light pink pill, one round dark pink pill, 2 round brown pills, and one red capsule. This surveyor went to the doorway to the hall and requested that V24 (Certified Nursing Assistant, CNA) who was walking by to enter R63's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to assure that emergency medical equipment stored to be used in emergency basic life support was checked daily. This deficient practice has the potential to affect all Fifty seven residents that reside on the 3rd floor of the facility. Findings include: On [DATE] at 10:50am crash cart checklist observed with daily checks only for [DATE], [DATE], and [DATE]. Observed missing crash cart daily checks for [DATE], [DATE], [DATE], [DATE] and [DATE]. On [DATE] at 11:01am V4 Licensed Practical Nurse (LPN) stated, The crash cart should be checked every day. The crash cart should be checked every day to make sure we (staff) have supplies in case of an emergency. When the crash cart is not checked and it's an emergency the resident could be in danger. On [DATE] at 10:46am V2 Director of Nursing (DON) stated, The crash carts have basic things for emergencies. The crash carts have oxygen tubing, IV (intravenous) starter kits, IV fluids, the suction machine…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide a safe environment with unsecured shaving razors left in the unlocked shower room; failed to provide a safe environment with liquid body soap left unsecured in a drinking cup in a resident's room and in the unlocked shower room; failed to provide a safe environment with the laundry chute left unlocked accessible to residents; failed to implement care planned fall precaution interventions; failed to update a care plan with an observed fall intervention in place; and failed to follow the facility's fall prevention policy and procedure. These failures affected two residents (R14, R146) and have the potential to affect 57 residents on the 2nd floor, 57 residents on the 3rd floor and 52 residents on the 4th floor. Findings include: On 9/8/24 at 10:49 am, this surveyor observed R146's door closed, and a contact isolation sign posted outside R146's closed door. This surveyor donned appropriate personal protective equipment (PPE) 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 observations, interviews, and record reviews, the facility failed to ensure the nebulizer mask was contained, failed to ensure the oxygen tubings and humidifier bottles were labeled with dates when changed, and failed to ensure oxygen tubings and humidifier bottles were changed per facility policy. These failures affected 4 (R36, R142, R163, and R303) residents reviewed for respiratory care in the total sample of 76 residents. Findings include: On 09/08/24 at 11:14 AM, R142's nebulizer mask was on top of R142's night stand, not contained. On 09/08/24 at 11:16 AM, this observation was pointed out to V15 (Registered Nurse). V15 stated her (R142)'s nebulizer mask is not in plastic container. On 09/10/2024 at 2:53pm, V2 (Director of Nursing) stated the nebulizer mask should be in a plastic container when not in use to prevent cross contamination. It is an infection control issue if not contained. R142's (Active Orders as of: 09/09/2024) Order summary Report documented, in part Diagnoses: (include but not limited to) chest pain, COPD (chronic Obstructive Pulmonary disease), 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 monitor personal refrigerator temperature logs for five residents; and failed to ensure that personal refrigerators had a refrigerator thermometer for three residents. These failures affected five residents (R17, R36, R101, R110, and R117) out of 76 residents in the total sample. Findings include: R101 has a diagnosis which includes but not limited to unspecified dementia, gastrostomy status, unsteadiness on feet, supraventricular tachycardia, generalized anxiety, post covid condition, and gastritis. R101 Brief Interview for Mental Status (BIMS) dated 07/19/24 documents that R101 does not have a BIMS score and indicates that R101 has memory problems. On 9/08/2024 at 10:25am surveyor observed R36's personal refrigerator without a thermometer and a temperature log. On 9/08/2024 at 10:33am surveyor observed R17's personal refrigerator without a thermometer and a temperature log. On 9/08/2024 at 10:35am V5 (Certified Nursing Assistant-CNA) stated resident's personal refrigerators are supposed to have a temperature…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 cigarette butts were contained and not blown towards the generator's fuel tank in an effort to prevent fire. This failure has the potential to affect all residents residing at the facility. Findings include: On 09/09/2024 at 9:36am with V9 (Cook) at the facility's docking area, noted a big red tank with signs posted FLAMMABLE. KEEP FIRE AWAY and '270GHL'. Cigarette butts were noted inside the trash can adjacent to the fuel tank, under the fuel tank, on the drain cover, and on the surrounding of the docking area. These observations were pointed out to V9. V9 stated that's Maintenance's job. This surveyor called for the maintenance. On 09/08/2024 at 9:47am with V10 (Dishwasher) translating for V13 (Maintenance). This surveyor pointed out to V13 the cigarette butts under the fuel tank, inside the plastic trash can, drain cover, and on the surrounding of the docking area. V13 stated staff are smoking close to the docking area and the wind blows the cigarette butts towards the fuel tank. I (V13) don't know…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain residents' call lights within reach of residents to use for staff assistance which affected two residents (R63, R303) in the total sample of 76 residents when reviewed for accommodation of needs. Findings include: On 9/8/24 at 11:21 am, this surveyor entered R63's room and observed R63 laying in bed. R63's red call light string is observed attached to the call light activator (on the wall) and is looped through hook on the wall to extend the red call light string towards R63 in bed; however, R63's red call light string is observed hanging on the opposite side of R63's nightstand table (3 drawers) which is clearly out of R63's reach in bed. This surveyor went to the doorway to the hall and requested that V24 (Certified Nursing Assistant, CNA) who was walking by to enter R63's room. When asked V24 where is R63's call light, V24 retrieves the red call light string from the behind R63's nightstand table and clipped it to R63's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that a resident has a physician's order for a code status (Full Code or DNR, Do Not Resuscitate) in the resident's electronic medical record (EMR) which affected one resident (R196) in the total sample of 76 residents reviewed for advanced directives. Findings include: On [DATE] at 2:11 pm, V19 (Licensed Practical Nurse, LPN) and V37 (LPN) were observed sitting at the nurse's station on R196's floor. This surveyor asked V37 how does V37 know the code status of V37's assigned residents, and V37 stated, We (nurses) know from here. It comes from here, as V37 is pointing to the computer screen with the electronic medical record (EMR) system is visible. V37 stated that the resident's code status for full code (life-sustaining treatments) or DNR (not providing certain treatments and/or allow natural death) is listed on the profile screen for each resident which is the first screen the nurse sees when viewing each resident's EMR. V37 stated, There is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to complete sections of a resident's minimum data set accurately to reflect the resident's health status. This failure has the potential to affect 1 resident (R153) in a sample size of 76. Findings include: Record review of R153's admission Record documents in part the following diagnosis: hemiplegia and hemiparesis following cerebral infarction affecting the left-non dominant side, dementia in other diseases classified elsewhere, unspecified psychosis. Record review of R153's Minimum Data Set (MDS) dated [DATE] documents in part that R153 has clear speech (distinct intelligible words), is able to be understood, and able to express ideas and wants. Additionally, R153's MDS dated [DATE] documents that the Brief Interview for Mental Status (BIMS) should not be completed, resident is rarely/never understood (incongruent data). On 9/8/2024 at 10:59 AM, V6 (Registered Nurse Supervisor) stated that R153 is hard to understand when speaking and can't…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 refer one resident R170 to the appropriate state designated authority for a Level II PASARR (Preadmission Screening and Annual Resident Review) evaluation and determination after R170 was diagnosed with a new mental disorder. This deficient practice affected one resident (R170) in a total sample size of 76 residents. Findings include: R170's PASARR dated 03/03/23 documents in part, PASRR Level I Determination: No Level II Required - No SMI (Serious Mental Illness)/ID (Intellectual Disability)/RC (Related Condition). R170's admission date to the facility is 03/04/2023. R170's medical diagnosis with dates include but are not limited to Chronic Obstructive Pulmonary disease (03/09/23), Other Asthma (03/04/23, Schizoaffective Disorder (03/09/23), Paranoid Schizophrenia (04/18/23), Other Schizophrenia (04/18/23), Bipolar Disorder Current Episode Mixed Severe Without Psychotic Features (04/18/23), Major Depressive Disorder (04/18/23), Anxiety Disorder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain a pre-admission screening and resident review (PASARR). This failure affects 1 resident (R153) in a sample of 76. Findings include: Record review of R153's admission Record documents in part the following diagnosis: major depressive disorder, unspecified psychosis not due to a substance or known physiological condition. R153' Face Sheet documents R153 was admitted to the facility on [DATE]. Record review of R153's electronic medical record does not indicate a PASARR was completed. On 9/10/24 at 9:53 AM, V27 (Assistant Administrator) affirmed that there was not a Level I PASARR completed for R153 prior to the start of the survey. V27 provided a Level I PASARR that documents in part a submission date of 9/9/2024 and determination outcome for R153 dated 9/10/24. Record review of facility provided policy titled, PASARR Guideline (Revised 12/2022) documents in part, The PASARR process consists of the completion of a Level I screen per State 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 invite and conduct care plan conferences to include the resident in development of their plan of care. This failure affects 1 resident (R136) in a sample of 76. Findings include: Record review of R136's admission record documents in part, the following diagnosis: hemiplegia and hemiparesis following cerebral infarction affective left-non dominant side, unspecified dementia without behavioral disturbance, protein calorie malnutrition, and osteoarthritis of the left hip. Record review of R136's minimum data set (dated 8/16/24), documents in part a brief interview of mental status score of 11, indicating that R136 is cognitively impaired. On 9/8/2024 at 10:19 AM, R136 stated that R136 has never been invited to participate in the development of R136's plan of care. R136 denied ever participating in a plan of care meeting (care conference). R136 affirmed that if there was a meeting held to discuss R136's plan of care, R136 would want to participate. Record review of R136's progress notes (care conference notes) document in part…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that two residents (R40 and R199) who depend on staff's assistance for their ADL (Activities of Daily Living) care received shaving. This failure affected two out of 76 residents reviewed for ADL care. Findings include: R40's Brief Interview for Mental Status (BIMS) dated 08/22/24 shows that R40 has a BIMS score of 08 which indicates that R40 has moderate cognitive impairments. R40 has a diagnosis which includes but not limited to: unspecified dementia, major depressive disorder, and bipolar. R199's Brief Interview for Mental Status (BIMS) dated 08/22/24 shows a BIMS score of 6 which indicates that R199 has some cognitive impairments. Surveyor interviewed with R199, and R199 was alert but not able to answer questions appropriately. R199 has a diagnosis which includes but not limited to: need for assistance with personal care, muscle weakness and dementia. On 09/08/24 at 10:16 am, R40 was observed in bed awake, and alert ungroomed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 follow policy procedures, failed to timely document a skin integrity impairment, failed to document an accurate skin integrity impairment, and failed to follow physician orders for one of four residents (R3) reviewed for incidents/accidents. Findings include: R3's (3/1/24) BIMS (Brief Interview Mental Status) determined a score of 12 (cognition intact). R3's (5/24/24) physician orders include left knee: cover with foam silicon dressing for skin protection. Change every 3 days and as needed. On 5/28/24 at 1:32pm, R3 was observed lying in bed (in high position). Surveyor inquired about the current height of R3's bed V6 (Restorative CNA/Certified Nursing Assistant) stated in part It's kind of high right now and proceeded to lower the bed. As V6 lowered R3's bed, the over bed table (above R3's knees) fell and hit the side rail. Surveyor inquired about R3's (malfunctioning) over bed table V6 responded The tray table got caught underneath there. R3 replied Down in room (prior room number) that happened 3 times and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon observation, interview, and record review the facility failed to follow policy procedures, failed to implement fall prevention interventions and/or failed to provide supervision for one of four residents (R1) in the sample. Findings include: R1 was admitted [DATE] and discharged [DATE]. R1's diagnoses include but not limited to encephalopathy and (5/12/24) wedge compression fracture of first lumbar vertebra. R1's (3/31/24) BIMS determined a score of 11 (moderate impairment). R1's (3/31/24) functional assessment affirms supervision or touching assistance is required for chair/bed to chair transfer and walking. Partial/moderate assistance is required for toileting. R1's (4/12/24) fall risk assessment determined a score of 11 (at risk). The facility fall log affirms R1 fell on 5/6/24 and 5/12/24. R1's (5/6/24) incident report states patient verbalized she was walking towards the door lost balance and fell. Sent to hospital for evaluation. No witnesses found. R1's (5/7/24) progress notes state returned to…

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

Based upon observation, interview and record review the facility failed to ensure that the call light was within reach, failed to provide a clean urinal, and failed to ensure that clothing was available for one of three residents (R4) reviewed for accommodation of needs. The facility also failed to provide sufficient towels and/or washcloths this failure affects 207 residents. Findings include: On 11/2/23, IDPH (Illinois Department of Public Health) received allegations that resident call lights are left out of reach and staff are using gowns and/or pillowcases to clean residents due to lack of towels and washcloths. The 12/11/23 facility census includes 207 residents. On 12/11/23 at 11:55am, R4 was lying in bed however the call light was on the floor and out of reach. Surveyor inquired about the location of R4's call light. V6 (CNA/Certified Nursing Assistant) stated, It's by the bed on the floor. Surveyor inquired if R4 could reach the call light. V6 responded, Not from this angle he couldn't. R4 was somewhat covered with a sheet and completely naked. Surveyor inquired if R4 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 upon observation, interview and record review the facility failed to ensure that adequate nursing staff were scheduled on the (4th floor) dementia unit, failed to ensure that sufficient nursing staff were available to meet the needs for two of three dependent residents (R3, R4) reviewed for ADL (Activities of Daily Living) care, failed to ensure that staff were aware of required frequency to check and/or change dependent residents, failed to provide (R4) clothing, failed to ensure (R4's) call light was within reach, failed to provide (R4) a clean urinal, failed to timely identify/report/investigate (R4's) injury of unknown origin, failed to ensure staff use proper transfer techniques to prevent falls/injury, failed to revise (R3's) care plan with appropriate transfer interventions (post rib fractures), failed to offload (R1's) wound as directed, failed to follow (R1's) treatment orders, and failed to provide (R1) timely incontinence care to prevent MASD (Moisture Associated Skin Damage). These failures have the potential to affect 55 (4th floor) residents. Findings include: On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility to provide a safe environment for residents, staff and the public by blocking an egress door on the 4th floor stairwell. This failure affects 55 residents living on the 4th floor. Findings include: On 12/11/23 at 10:45AM The 4th floor stairwell exit door (next to RM [ROOM NUMBER]) was observed closed and blocked with a soiled linen cart. Surveyor was unable to open the door from the stairwell side. The door was forced open. On 12/11/23 at 10:50AM V1 (Administrator) stated, the staff are not supposed to block the stairwell doors. They probably do that to prevent the confused residents from trying to exit the door. I will address that issue. Facility policy titled Exits or Means of Egress states including: 3. All personal shall keep exits clear at all times. Exit doors should never me blocked , even briefly. 4. Whoever discovers a blocked exit shall clear the exit, if possible, and report the finding to his or her Immediate Supervisor or to 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 upon interview and record review the facility failed to implement the grievance policy and failed to investigate reported allegations for one of three residents (R1) reviewed for concerns. Findings include: The 12/11/23 facility census includes 207 residents. On 11/13/23, IDPH (Illinois Department of Public Health) received allegations that R1 is not provided appropriate wound care and bed sores are deteriorating. The facility Social Worker is unavailable and not following up after several messages were left. On 12/12/23 at 1:09pm, the complainant stated A few weeks ago (mid-November 2023) he (R1) was complaining about having sores on his bottom, so I tried to call the facility to try to coordinate with the Social Worker there (facility) and wasn't able to get a hold of anyone. On 12/13/23 at 1:42pm, surveyor reviewed R1's (November 2023) social service progress notes however concerns were excluded. V18 (Social Service Director) affirmed a message was received from the complaint (regarding R1's care) and V2 (Director of Nursing) was allegedly informed however V2 affirmed that…

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

Based upon observation, interview and record review the facility failed to provide ADL (Activities of Daily Living) care to two of three dependent residents (R3, R4) reviewed for ADL care. Findings include: R4's diagnoses include dementia, lack of coordination, abnormalities of gait/mobility, and need for assistance with personal care. R4's (10/30.23) functional assessment affirms moderate assistance is required for dressing and maximal assistance is required for toileting. On 12/11/23 at 11:55am, R4 was somewhat covered with a sheet and completely naked. Surveyor inquired if R4 was dressed. V6 (CNA/Certified Nursing Assistant) removed R4's sheet and replied, He doesn't have on any clothes, he doesn't have nothing on. Surveyor inquired why R4 was not dressed. V6 stated, He says it be hot, so he doesn't wear them, he takes the clothes off however there were no clothes present. Surveyor observed a large bruise on R4's right arm and requested the assigned Nurse. V6 left the room (without assisting R4) and did not return. R4 sat up, put a pull-up on and walked to the doorway…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 for labeling, dating, and storing food item to ensure that food is labeled, dated and discarded after use by date; failed to ensure that resident's dishes and utensils were sanitized at a safe water temperature required for operating dishwashing machine. These failures have the potential to affect 190 residents living in the facility with 3 residents on Nothing by Mouth (NPO) for a total facility's census of 193 dated 10/29/23. The findings include: On 10/29/23 at 9:05 am Toured Kitchen with V12 (1st cook) stated that he has been working in the facility for 13 years. Observed with 2 garbage containers by the entrance with no lids / cover. Observed another garbage container by the refrigerator that was not covered with garbage / waste in it. Walk in freezer with open ice cream that was not dated, mixed vegetables not labeled or not dated, box of empanadas with use by date of 9/10/23. V12 stated that food items should be dated, labelled, and discarded after use by date. Walk in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure a resident (R100) received the correct oxygen flow rate as ordered by the physician and to properly label oxygen tubing for 4 (R20, R100, R120, R172) out of 4 residents reviewed for oxygen use in a sample of 35. Findings Include: R100's clinical records show R100 has listed diagnoses not limited to Dementia, Emphysema, Chronic Obstructive Pulmonary Disease, and Anemia. R100's physician order sheet (POS) reads in part: May give oxygen (O2) at 2 liters per minute (LPM) ordered on 10/26/23. R100's Minimum Data Set (MDS) dated [DATE] shows R100 is cognitively impaired and requires extensive with two staff assistance with bed mobility, transfer, and personal hygiene. On 10/29/23 at 11:20 AM, Surveyor entered R100's room with V10 (Licensed Practical Nurse). R100 was receiving supplemental O2 via nasal cannula at 1 LPM. R100's oxygen tubing had no label with the date when it was last changed. V10 stated that R100 should be getting 2…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a.) ensure controlled substances were counted, and documented, at the beginning and end of each shift for 13 out of 88 shifts and b.) keep an accurate count of all narcotic medications. These failures have the potential to affect 64 residents. Findings include: On 10/29/2023 at approximately 10:50AM, surveyor located on the 3rd floor of the facility with V6 (LPN/Licensed Practical Nurse). V6 stated that he did not perform a narcotic drug count. V6 was responsible for the 3rd floor short side medication cart (Rooms 301-329). On 10/29/2023 at approximately 10:50AM, review of the Shift Change Accountability Record for Controlled Substances sheet for the month of October 2023 for cart identified as short side medication cart located on the 3rd floor of the facility indicated for 11 shifts in October 2023, nurses had not counted and documented the controlled substances. The following dates were missing signatures: On 10/21/23, 3rd shift (11pm-7am) On 10/22/23, 1st shift (7am-3pm) On 10/24/23, 2nd shift (3pm-11pm) and 3rd shift…

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

Based on observation, interview, and record review the facility failed to a.) ensure medications were locked and secured while unattended, b.) refrigerate an unopened insulin pen and label liquid medication that had been open in two of four medication storage rooms reviewed for medication labeling and storage and c.) ensure expired medications in supply for use were discarded. These failures have the potential to affect 78 residents residing in the facility. Findings Include: On 10/29/2023 at 9:34AM, surveyor located on the fourth floor of the facility. V10 (Licensed Practical Nurse/LPN) observed leaving medication cart (identified as 4th floor short side medication cart) unlocked and unattended. V10 states that she does not have an excuse for leaving the medication cart unlocked and unattended and it should be locked at all times when not in attended. V10 states that residents can potentially get access to the medications and there could be lots of consequences if the cart is left unlocked and unattended. The following was observed on the 4th floor short side medication cart:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 clean and disinfect reusable equipment (blood pressure cuff device) used by two residents (R14, R197). The facility also failed to follow their policy and procedure for Enhanced Barrier Protection to ensure that PPE (Personal Protective Equipment), including gowns and gloves available in the hallways between resident's rooms for 2 (R103 and R153) residents. This failure could potentially affect 38 residents residing on 1st floor for facility's census dated 10/29/23. The findings include: R103's health record documented admission date of 10/1/23 with diagnoses including but not limited to Osteomyelitis, Type 2 diabetes mellitus with other specified complication, Cellulitis of left lower limb, Non-pressure chronic ulcer of skin of other sites with unspecified severity, Type 2 diabetes mellitus with foot ulcer, Encounter for surgical aftercare following surgery on the skin and subcutaneous tissue, Morbid (severe) obesity due to excess calories, Other asthma, Muscle weakness (generalized), Other abnormalities 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 interview and record reviews, the facility failed to provide eligible residents and/or resident representatives education regarding the benefits and potential side effects of all available pneumococcal vaccinations and assess eligibility and offer pneumococcal vaccinations to 4 (R141, R192, R193, R195) of 5 residents reviewed for pneumococcal vaccinations. Findings Include: 1. R141's Electronic Health Records (EHR) show R141 was admitted to the facility on [DATE] and is [AGE] years of age with diagnoses that included but were not limited to: acute pyelonephritis, hyperlipidemia, essential hypertension, and muscle weakness. R141's current physician orders with active orders as of 10/30/23 revealed R141 had no orders to receive pneumococcal vaccination. Further review of R141's EHR revealed no documentation indicating the facility assessed R141's eligibility to receive the pneumococcal vaccination and/or that R141 or R141's representative was provided education related to the pneumococcal vaccination. 2.…

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

Based on interview and record reviews, the facility failed to document the information on the residents' COVID-19 vaccine and failed to document if education was provided regarding the benefits and potential risks associated with the COVID-19 vaccine to 4 (R141, R192, R193, R195) out of 5 residents reviewed for COVID-19 immunizations. Findings Include: On 10/30/23 at 10:41 AM, R141, R192, R193, and R195's electronic health records (EHR) were reviewed and revealed no documentation regarding each dose of COVID-19 vaccine administered to R141, R192, R193, and R195 or if they did not receive the COVID-19 vaccine due to medical contraindications or refusal. R141, R192, R193, and R195's EHR also do not have documentation if education was provided to them or their representatives regarding the benefits and potential risks associated with the COVID-19 vaccine. There were no COVID-19 consents found in R141, R192, R193, and R195's EHR. The facility's spreadsheet for all residents' COVID-19 vaccination status provided by V3 (Assistant Director of Nursing/Infection Preventionist) shows R141,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 records review, the facility failed to assist two residents with activities of daily living by failing to (a) assist in feeding one resident (R138) who requires extensive assistance with eating, (b) failing to elevate the head of the bed to 90 degrees for one resident (R48) while eating. This deficienct practice has the potential for R48 to experience aspiration while eating and subject R138 to malnourishment. Findings include: a) On 10/30/23 at approximately 9:00 AM, surveyor observed R138 lying in bed. Observed substantial tremor in R138's right arm/hand. R138 was arousable to hearing R138's name. R138's breakfast tray was sitting on the sink/face bowl in R138's room, intact/not served. On 10/30/23 at 9:12 AM, V32 (Restorative) was observed in R138's room applying a splint to R138's right hand. V32 stated V32 was only in the room to apply R138's splint. On 10/30/23 at 9:32 AM, V31 (Certified Nursing Assistant) stated V31 had not fed R138 because R138 was sleeping and 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 failed to ensure that PICC (Peripherally Inserted Central Catheter) line dressing was dated once changed. The facility also failed to ensure that arm circumference and PICC line catheter were measured as ordered. This failure can potentially affect 1 (R103) resident in a sample of 35. The findings include: R103's health record documented admission date of 10/1/23 with diagnoses including but not limited to Osteomyelitis, Type 2 diabetes mellitus with other specified complication, Cellulitis of left lower limb, Non-pressure chronic ulcer of skin of other sites with unspecified severity, Type 2 diabetes mellitus with foot ulcer, Encounter for surgical aftercare following surgery on the skin and subcutaneous tissue, Morbid (severe) obesity due to excess calories, Other asthma, Muscle weakness (generalized), Other abnormalities of gait and mobility, Skin graft infection, Essential (primary) hypertension, Other symptoms and signs involving cognitive functions and awareness, Hypo-osmolality and hyponatremia, Post…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure the proper amount of fabric layers were used for one resident (R63) using a low air loss mattress device, and failed to ensure low air loss mattress devices were in the correct settings for 3 (R63, R100, R152) out of 3 dependent residents with current pressure ulcers in a sample of 35 reviewed for pressure ulcer care. Findings Include: On 10/29/23 at 11:20 AM, Surveyor entered R100's room with V10 (Licensed Practical Nurse). R100 was resting in bed. R100's low air loss mattress weight control knob was set to 350 pounds (lbs.). V10 stated that R100 has a sacral wound. At 1:13 PM, R152 was resting in bed. Surveyor checked R152's low air loss mattress with V10 and the weight was set to 120 lbs. At 1:16 PM, V10 stated that the low air loss mattress setting should be based on the resident's weight. On 10/30/23 at 9:43 AM, V15 (Wound Care Nurse) stated that R100 has two unstageable pressure ulcers acquired from the hospital. V15…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to follow their policy and procedure to ensure that resident is not keeping smoking materials for health, safety, and security reasons. This failure could potentially affect 1 (R173) of 1 resident reviewed for smoking in the sample of 35. The findings include: R173's health record documented admission date of 4/19/22 with diagnoses not limited to Chronic obstructive pulmonary disease, Atrial fibrillation, Peripheral vascular disease, Elevated prostate specific antigen, Benign prostatic hyperplasia without lower urinary tract symptoms, Retention of urine, Hyperlipidemia, Essential (primary) hypertension, Personal history of covid-19. On 10/29/23 at 10:42 am Observed R173 sitting up on the side of the bed, alert and verbally responsive. Stated that he is ambulatory. Observed with smoking materials - cigarette and lighter at bedside table. Stated that he is a smoker. On 10/31/23 at 9:41 V25 (Social Service Director) stated that she has been…

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