Pearl Of Montclare, The

Based on interview and record review the facility failed to notify a physician and resident representative of a significant change in condition/status (newly identified deep tissue pressure injury) for one resident (R5). This failure affected 1 resident in the total sample of 3 residents reviewed for notification of changes. Findings include: R5 has diagnosis which include but are not limited to: cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery, dysphagia oropharyngeal phase, other lack of coordination, other reduced mobility, polycythemia vera, elevated white blood cell count, cerebral edema, type 2 diabetes mellitus without complications, unspecified protein calorie malnutrition, acute respiratory R5's Brief Interview for Mental Status (BIMS) dated 1/21/26 shows a score of 12 which indicated that R1 has moderate cognitive deficits. R5's progress note dated 1/19/26 at 11:30 am authored by V7 (Licensed Practical Nurse, LPN, Wound Care Nurse) documents, in part: PT (Physical Therapy) notified WCN (Wound Care Nurse) of skin condition 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 on interview, and record reviewed the facility failed to ensure that a resident (R1) with a pressure ulcer received necessary treatment and services to promote healing. This failure affected one of three residents reviewed for wound care.Findings include:R5 has diagnosis which include but are not limited to: cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery, dysphagia oropharyngeal phase, other lack of coordination, other reduced mobility, polycythemia vera, elevated white blood cell count, cerebral edema, type 2 diabetes mellitus without complications, unspecified protein calorie malnutrition, acute respiratoryR5's Brief Interview for Mental Status (BIMS) dated 1/21/26 shows a score of 12 which indicated that R1 has moderate cognitive deficits.R5's Scale for Predicting Pressure Score Risk dated 12/10/25, 12/24/25, 1/1/26, and 1/6/26 shows that R5 is at risk for pressure ulcers. R5's progress note dated 1/19/26 at 11:30 am authored by V7 (Licensed Practical Nurse, LPN, Wound Care Nurse) documents, in part: PT (Physical Therapy)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 administration error rate of <5% for 2 (R2 and R5) residents of 4 (R2, R4, R5, and R6) residents reviewed for medication administration. There were 33 opportunities with 3 errors resulting in 9.09% medication administration error rate. Findings include: On 05/27/2025 at 11:15am, V5 (Licensed Practice Nurse) dispensed R2's medications including: Senna 8.6 mg/tab x 2 tablets - this is an error. R2's (Active Order as Of: 05/27/2025) Order Summary Report documented, in part Senna S Oral tablet 8.6-50mg (Sennosides-Docusate sodium) give 2 tablets by mouth two times a day. Folic Acid 800mcg x 1 tab - this is an error. R2's (Active Order as Of: 05/27/2025) Order Summary Report documented, in part Folic Acid Oral tablet 1 MG (1000mcg) 1 tablet by mouth one time a day. On 05/27/2025 at 2:52pm with V2 (Director Of Nursing), this surveyor requested V5 to show V2 the Over the Counter containers of Senna and Folic Acid that were administered to R2. V5 showed the containers to the surveyor and to V2.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an abuse allegation to Illinois Department of Public Health (IDPH) for one resident (R1) out of 4 residents reviewed for abuse. Finding include: R1's Face sheet documents that R1 was admitted to the facility on [DATE] with diagnoses not limited to: Toxic encephalopathy, unspecified abnormalities of gait and mobility, other reduced mobility, type 2 diabetes mellitus without complications, acute kidney failure. Essential (primary) hypertension. Minimum Data Set Section (MDS) section C (dated [DATE]) documents that R1 has a Brief Interview for Mental Status (BIMS) score of 5, indicating that R1 has a severe cognitive impairment. Care plan (dated 04/14/2025) documents that R1 is noted with potential communication deficits- may have difficulty completing her thoughts, trouble with word choices. On 04/15/2025 at 11:06AM, during a complaint investigation survey, surveyor inquired for V1 (administrator) to bring the surveyor the facility reportable…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policies and dispose of food items past their expiration/best buy/use by dates, label opened food item, store food and food related items away from cleaning solutions, perform hand hygiene during dishwashing, and cover prepared food to prevent contamination. This has the potential to affect all 108 residents that receive nutrition from the kitchen. Findings include: On 3/11/2025 at 9:03 AM, surveyor conducted an initial tour of the kitchen and food storage areas with V11 (Dietary Manager). During the tour of the facility's dry goods stock room on 3/11/2025 at 9:05 AM, there was a gallon of maraschino cherries that expired on 3/01/2025 in the bottom shelf. In the same bottom shelf, there was an opened jug of soy sauce with the 'best by' date of 11/30/2024. The label reads to refrigerate after opening. V11 did not know it had to be refrigerated. In the same bottom shelf, there was an additional jug of unopened soy sauce with a 'best by' date of 11/30/2024. There was also an unopened gallon 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 low air loss mattress devices were on the correct weights setting for residents (R28, R29) with current pressure ulcer and for residents (R6, 91) who are at risk in developing pressure ulcers. This failure has the potential to affect four (R6, R28, R29, R91) out of four residents reviewed for pressure ulcer care in a final sample of 22. Findings Include: On 3/11/2025 at 11:15 AM, R91 was lying in bed and noted on a low air loss mattress with the weight dial on the machine set to 400 pounds. R91's Minimum Data Set (MDS) dated [DATE] shows R91 requires staff assistance with positioning in bed. R91's BRADEN scale dated 2/20/25 shows R91 is at risk in developing skin breakdown. R91's weight records show R91 weighs 136.6 pounds dated 3/5/25. On 3/11/2025 at 11:20 AM, R6 was sleeping in bed and noted on a low air loss mattress with the weight dial on the machine set to 350 pounds. R6's MDS dated [DATE] shows R6 requires staff assistance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (a) oxygen and nebulization tubing were dated / changed; (b) BiPAP (Bilevel Positive Airway Pressure) and CPAP (Continuous Positive Airway Pressure) masks, oxygen and nebulization tubing were properly stored when not in used; and (c) obtain physician orders for use of BiPAP and CPAP. These failures affected four (R48, R61, R66, R86) out of four residents reviewed for respiratory care in a sample of 22. The findings include: R61's admission record showed admission date on 2/14/23 with diagnoses not limited to Unspecified atrial fibrillation, Acute on chronic systolic (congestive) heart failure, Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease. On 3/11/25 at 11:28 AM R61's room door signage indicated oxygen in use. Observed R61 lying in bed on moderate high back rest, alert and verbally responsive. Stated she has been residing in the facility for 2 years. Stated she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #37 Accidents PLEASE SEE F700 CITATION FOR DETAILS. Resident #41 Accidents F700 Based on observation, interview and record review, the facility failed to ensure the appropriate side rails were used, evaluate the use of side rails quarterly and develop plan of care for use of side rails for four (R37, R41, R61 and R63) out of four residents reviewed for accident / hazard in a sample of 22. The findings include: 1. On 3/11/25 at 11:11 AM Observed R63 Lying in bed, alert and verbally responsive, both upper bed / side rails were up. R63's admission record showed admission date on 2/21/2023 with diagnoses not limited to Alzheimer's disease, Essential (primary) hypertension, Heart failure, Obstructive sleep apnea (adult), Nonrheumatic aortic (valve) stenosis. No care plan found for bed / side rail use in R63's EHR (electronic health record). R63's last side rail assessment was dated 10/25/24 showed in part: 1/4 rails due to weakness. MDS dated [DATE] showed R63's cognition was severely impaired. She needed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide oral supplements on meal trays as part of the therapeutic diet prescribed by the physician for five (R15, R32, R40, R92, R106) residents reviewed for dining services in a total sample of 22. Finding include: R15, R32, R40, R92, R106's Order Summary Reports document in part dietary supplement order for High Calorie Frozen Dessert to be given at lunch. R15, R32, R40, R92, R106's lunch meal tickets document in part for Frozen Nutritional Treat to be served as a daily item. R15, R32, R40, R92, R106's nutrition care plan documents in part, provide and serve supplement as ordered and/or as needed. On 03/11/25 at 11:45 AM, observed R106 eating lunch in main dining room. R106 did not receive a High Calorie Frozen Dessert (Frozen Nutritional Treat) on her tray. R106 said, I didn't get it today and I don't get it every day, only sometimes. On 03/11/25 at 12:35 PM, V19 (R32's Guardian) stated she had fed R32 lunch and there was no Frozen Nutritional Treat on R32's lunch tray. V19 showed surveyor R32's lunch…

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

R16's Order Summary Report documents in part an active order for Enhance Barrier Precaution due to: wound every shift (order date 1/29/2025). R16's Care Plan Report documents in part that R16 is on Enhanced Barrier Precautions related to wound (initiated 1/29/2025). Intervention initiated 1/29/2025 documents in part for staff to clean/wash hands, including before entering and when leaving the room. Staff are to wear gloves and a gown for high contact resident care activities such as changing briefs or assisting with toileting. On 3/11/2025 at 10:40 AM, there was no Enhanced Barrier Precaution (EBP) sign outside of R16's room or on the door. There was no Personal Protective Equipment bin readily accessible near R16's room. After the surveyor interviewed R16, V37 (Certified Nurse Aide) provided incontinence care and dressing assistance to R16. V37 did not don a gown during the high touch care activities. R16's room remained without EBP signage and PPE bin during additional observations on 3/11/2025 at 2:58 PM and on 3/12/2025 at 9:34 AM. On 3/12/2025 at 9:36 AM, V23 (Nurse) stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to obtain a physician order and to determine if self-administration of medication was appropriate for one (R10) out of one resident observed with medications at bed side table in a sample of 22. Findings Include: On 3/11/25 at 11:32 AM, R10 received up in chair in bedroom alert and verbal on the phone. Surveyor observed one uncovered inhaler dispenser and nasal spray bottle on R10's bed side table. At 2:48 PM, R10 stated she has been having the inhaler and the nasal spray at her bed side for a long time since admitted to the facility. R10 stated that she uses the inhaler twice a day for wheezing and the nasal spray once a day for nasal congestion, and she uses the inhaler even when she does not have wheezing. At 2:50 PM, V4 (Licensed Practical Nurse/LPN) identified the medications as Ventolin HFA inhalation aerosol solution 108 (Albuterol Sulfate Inhaler 90 MCG/ACT) and Fluticasone propionate (nasal) bottle. V4 stated nurses should not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to refer a resident (R67) to the appropriate state-designated authority for a Preadmission Screening and Resident Review (PASRR) re-evaluation after new psychiatric diagnoses for one out of three residents reviewed for PASRRs. Findings include: R67's [DATE] Notice of PASRR Level I Screen Outcome documents in part that R67 did not require a Level II PASRR because R67 did not have severe mental illness, intellectual disabilities, or related conditions during the evaluation. It also documents in part that R67 did not have any antidepressants, mood stabilizers, antipsychotics, or other mental health medications prescribed during the evaluation. R67's admission Record now documents in part diagnoses of anxiety disorder (onset date [DATE]), unspecified psychosis not due to a substance or known physiological condition (onset date [DATE]), and major depressive disorder, single episode, unspecified (onset date [DATE]). R67's Order Summary Report also documents…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 nail care was provided for three (R14, R27, and R31) residents who are dependent in grooming reviewed for Activities of Daily Living (ADL) in a total sample of 22. Findings Include: On 3/11/25 at 12:27 PM, R27 observed lying in bed alert, legally blind, and with dirty long nail that overgrown the fingers tip. R27 stated, she would like her fingernails to be cut but she cannot remember the last time the staff cut her fingernails. On 3/11/25 at 12:30 PM, V6 (Certified Nursing Assistant/CNA) stated that R27's fingernails are dirty, nasty, and too long. V6 also stated that the CNAs should be providing nail clipping care during shower twice a week and as needed. V6 stated that failure to cut the long nail, could cause R27 to scratch herself. On 3/11/25 at 12:35 PM, R14 observed up in chair in the dining room with dirty, very long fingernails overgrown the tips of his fingers. R14 could not remember when last he had a nail cut. 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.

Resident #92 Unnecessary Meds, Psychotropic Meds, and Med Regimen Review Based on observations, interviews, and record reviews, the facility failed to update a resident's (R92) comprehensive care plan and limit R92's PRN (as needed) psychotropic drug to 14 days for one out of a total sample of 22 residents. Findings include: R92's admission Record documents in part medical diagnoses of dementia, anxiety disorder, major depressive disorder, and somnolence. R92's Order Summary Report (as of 3/11/2025 at 1:58 PM) documents in part an active order for Xanax (Alprazolam) 0.25 MG (milligram) one tablet by mouth every 24 hours as needed for anxiety. Order date was 2/24/2025 with no end date. R92's February Electronic Medication Administration Records (eMARs) document in part that facility administered one dose of the PRN Xanax to R92 on 2/26/2025. R92's February and March eMARs do not document in part any further PRN Xanax administration. As of 3/11/2025, R92's Care Plan Report did not include a focus on R92's use for Xanax. V2 (Director of Nursing) initiated the focus during time 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.

FACILITY Medication Administration F759 Based on observations, interviews, and record reviews, the facility failed to maintain a medication error rate of less than 5% for 1 (R51) of 3 residents reviewed for medication administration. There was a total of 32 opportunities with 2 errors observed, which resulted in a medication error rate of 6.25%. Findings Include: On 3/11/25 at 9:45 AM, after V8 (Registered Nurse) checked R51's blood pressure and heart rate, V8 started to prepare R51's morning medications. V8 started R51's nebulizer treatment Ipratropium-Albuterol and then prepared the oral pills Amlodipine 10 mg, Ferrous Sulfate 325 mg, Finasteride 5 mg, Fluoxetine 20 mg, Folic Acid 1 mg, Nebivolol 10 mg, Oxybutynin 5 mg, Senna 1 tablet, Sodium Bicarb 650 mg, and Vitamin B12 1000 mcg. At 9:56 AM, R51's nebulizer treatment was completed and took all his oral pills. At 9:57 AM, V8 stated she completed R51's medication pass and signed the Electronic Medication Administration Record (EMAR) indicating R51's medications were administered. R51's 3/11/25 Medication Administration Record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 menu and failed to follow cooking instructions. This affected all 108 residents receiving nutrition from the kitchen. Findings include: Surveyor conducted an initial kitchen tour with V11 (Dietary Manager) on 3/11/2025 at 9:03 AM. At 9:29 AM, there were multiple boxes of pies sitting on the kitchen counter. V11 stated the pies were frozen and are defrosting for lunch. Facility's Week at a glance menu documents in part that the facility was to serve lemon meringue pies for lunch on 3/11/2025. At 11:40 AM, V14 (Cook) began plating the lunch meal for the residents. Did not observe V14 slice or plate any pies. V11 stated the dessert for lunch was now a 4-ounce serving of pears. Later that day, V11 stated that the pies did not defrost in time for the lunch meal and the facility could not serve them. During a Resident Council meeting on 3/12/2025 at 1:24 PM, R67 and R88 stated that the facility does not follow the menus. R88 stated the menu will say one thing but the facility will serve a different…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 physician orders for nectar-thick liquids for one resident (R40) out of a total sample of 22 residents. Findings include: R40's Order Summary Report documents in part an active diet order for nectar-thick consistency for liquids (order date 2/26/2024). R40's Care Plan Report documents in part that R40 has swallowing/chewing difficulties and requires mechanically altered diet with thickened liquids (last revised 1/09/2025). Intervention initiated on 1/09/2025 documents in part to Provide and serve diet as ordered. On 3/11/2025 at 12:15 PM, V15 (Certified Nurse Aide) assisted R40 with lunch meal. R40 had a 114-milliliter carton of apple juice with lunch meal. V15 fed the apple juice thin and not nectar thick to R40. Facility's undated Accuracy of Quality of Tray Line Service policy documents in part: All meals will be checked for accuracy by the food and nutrition services staff, and by the service staff prior to serving the meal to the individual. The meal will be checked against the therapeutic diet…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure that one resident (R1) with a known history of falls did not have nine repeated falls. This failure affected one of four residents reviewed for falls. Findings include: R1 is [AGE] year old with diagnosis including but not limited to: Repeated falls, unspecified dementia, unspecified psychosis, muscle weakness and other specified disorders of the brain. R1's BIMS (Brief Interview of Mental Status) score is 4, indicating severe cognitive impairment. During investigation on 11/13/24 at 10:50 AM, Surveyor observed R1 sitting in a wheelchair in the dining room engaging in activities with peers and V3 activity aide. V3 (Activity Aide) said R1 usually sits near her (V3) because he often tries to get up from his chair and is a high fall risk. V3 (Activity Aide) said that R1's scar was a result of his fall on 09/28/24. Surveyor inquired about R1's fall on 9/28/24. R1 was unable to recall falling on 9/28/24 but said that he recalled hitting his head.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to a.) monitor call light system and answer call lights within a timely manner for four residents (R1, R3, R4, R7), b.) failed to provide incontinence care for five (R1, R3, R4, R5, R6) dependent residents, c.) failed to ensure medications were administered as ordered by the residents' physician for one (R1) resident, and d.) failed to provide sufficient nursing coverage to ensure adequate resident care and support. These failures have the potential to affect 20 residents residing in the facility. Findings include: On 06/01/2024 at 9:35AM, R1 stated he is having on-going issues with the staff's call light response time. R1 stated on 06/01/2024 at approximately 2:00AM, R1 pressed his call light to have his incontinence briefs changed because he was soaked and soiled. R1 stated he waited so long to have his call light answered that he fell back to sleep. R1 stated he woke up at approximately 6:00AM and his call light was still on, and no staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents who depend on staff assistance for their ADL (Activities of Daily Living) care received grooming care, showers, personal hygiene and feeding assistance. This affects three residents (R1, R2, R3) of three residents reviewed for ADL care. Findings include: 1. According to the Electronic Health Record (EHR) R1 had diagnoses including congestive heart failure, chronic obstructive pulmonary disease, coronary artery disease with history of stents, Parkinson's disease, depression, peripheral vascular disease, anxiety, gastro-esophageal reflux disease and urinary retention. The Minimum Data Set (MDS) dated [DATE], shows R1's cognition was intact with a fifteen out of fifteen points on the Brief Interview for Mental Status (BIMS). Section GG documents R1 requires partial/moderate assistance with oral hygiene; is dependent on staff for shower/bathing; and requires substantial/maximal assistance with personal hygiene. Care Plan…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 served at a palatable temperature, and an appetizing appearance and taste. This deficient practice has the potential to affect all 107 residents receiving food prepared in the facility's kitchen. Findings include: On 04/09/24, during lunch meal rounds observed meat lasagna being served. The appearance of the meat lasagna was not visually appealing because it looked very soft and mushy and was spreading across the plates. Some residents complained the lasagna tasted cold. No heated bases observed under the plates of food on lunch trays. On 04/10/24 at 10:09 AM, during interview with Resident Council participants R29, R64, R70, R75, and R87 complained of frequently receiving cold hot food and food that does not taste good. R64 stated the hot food is always cold and if I was at home, I wouldn't eat cold food and food tastes better when it's hot. On 04/10/24 at 10:23 AM, R87 stated R87 keeps a jar of peanut butter, jelly, and a loaf of bread in R87's room which R87 asked R87's son to bring because I…

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

Based on observations, interviews, and record reviews, the facility failed to a.) ensure food items were labeled and dated per facility policy, b.) discard expired and/or rotten foods, c.) follow manufacturer guidelines for storage, d.) keep food storage areas clean, e.) properly store uncooked meat, f.) clean ice machine, g.) do proper hand hygiene during meal preparation, h.) reheat pureed foods to 165 degrees before serving, i.) use tongs when serving bread to avoid direct hand contamination. These failures have the potential to affect all 107 residents receiving food prepared in the facility's kitchen. Findings include: On 04/09/24 at 9:00 AM, during initial kitchen tour V9 (Regional Food Service Manager) stated V9 has been in this position for three months and that prior to this V9 had been a Food Service Manager for 23 years. V9 stated that everything that goes in/out of the coolers/freezer must be labeled and dated. V9 stated all items should be labeled with a delivery date, an opened date, and a use by date. V9 stated the use by date is three days for prepared food with DAY…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 standards of professional practice and facility policy relative to infection prevention and control. This failure has the potential to impact every resident in the facility. The facility census of one hundred and nine residents. Findings: On 04/09/24 at 09:10 AM it was noted that R95 had a sign for contact precautions while R363 had signage on the door for enhanced barrier precautions (EBP) and contact precautions. During interview on 4/9/2024 at 9:11 AM, V4 (RN) stated that isolation requirements are different. For R95, staff did not have to gown or glove unless they are going to touch R95. During Interview with V2 (Director of Nursing and Infection Prevention Nurse) on 4/10/2024 at 1 PM, V2 was asked about the fact that some resident rooms have EBP signs, some rooms have contact precautions, and some rooms have both. V2 stated, I have told staff not to do that. I reeducated the staff again today because I saw it on the first floor too. On 04/09/24 at 09:17 AM R364 was observed to be on EBP 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 observations, interviews, and record reviews, the facility failed to treat five residents (R4, R37, R53, R65, R91) with respect and dignity by not serving all the residents sitting at the same table at the same time during dining observations. Findings include: On 04/09/2024 at 12:49 PM, R2, R37, and R91 sat at the same table in the dining room. At 12:50 PM, V21 (CNA-Certified Nurse Aide) provided R91's lunch tray. At 12:53 PM, V21 provided R2's lunch tray. At 1:02 PM, V44 (CNA) sat in between R2 and R91 to provide feeding assistance and cueing. R2 and R91 were eating but R37 did not receive lunch tray yet. V21 did not provide lunch tray and one-to-one feeding assistance to R37 until 1:16 PM. On 04/10/2024 at approximately 11:49 AM, staff started passing out lunch trays in the dining room and starting with the larger table set in front of the television. R65, R90, R37, R7, R60, R86, R63, R12, and R4 sat at the larger table set together. V22 provided R4's lunch tray first. R4 didn't want the main dish so V22 stated [V22] will get R4 a sandwich instead. At 12:02 PM, most of…

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

Based on observation, interview and record review, the facility failed to provide language support to non-English-speaking residents in accordance with professional standards of practice and facility policy. This failure impacts seven residents out of a total facility census of one hundred and nine residents. Findings: On 4/9/2024 at 10 AM, observed staff speaking English to R106. No communication board was at bedside. On 04/09/24 at 10:56 AM during interview V4 confirmed R106's primary/preferred language is Spanish. V4 stated that to communicate with R106, One of the CNAs speaks Spanish. Otherwise, she will touch the area of her body to tell us what is bothering her. On 04/10/24 at 9:20 AM during interview, V28 (CNA) stated she did not receive an orientation before providing resident care. R106 speaks Spanish but knows a little English. V29 (CNA) stated to speak with R106, staff find a coworker who speaks Spanish. There are no other services or resources available. On 04/10/24 at 9:30 AM V21 (CNA) stated there are 2 residents on the 2nd floor who speak Spanish. V21 stated that 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 on observations, interviews, and record reviews, the facility failed to ensure that a staff member supervised residents (R4, R7, R12, R26, R37, R53, R60, R63, R65, R86, R90, R91) sitting in the dining room. Findings include: On 04/09/2024 at 11:44 AM, V22 (CNA - Certified Nurse Aide) stated a CNA is supposed to watch the dining room when there are residents there, but it is difficult to do so if the CNAs also have their regular assignments involving residents' activities of daily living (ADL) care to carry out. On 04/10/2024 at 11:27 AM, multiple residents were in the dining room. Residents included R4, R7, R12, R26, R37, R53, R60, R63, R65, R86, R90, and R91. Residents R65, R90, R7, R37, R60, R86, R63, and R12 were sitting at the side with the television. R26 and R91 were talking in the middle of the room. In the smaller, activity side of the room, bingo concluded and V20 (Activity Aide) started cleaning up and assisting other residents back to their rooms. V20 left the room at 11:29 AM to take a resident to their room. No other staff in the dining room. Prior to leaving, V20…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to a.) provide thickened liquids as prescribed by physician affecting 1 resident (R71), b.) provide physician ordered oral nutritional supplements affecting 1 resident (R14), and c.) assess residents with a significant weight change and adjust nutrition interventions affecting 3 residents (R36, R71, R100) out of 6 residents reviewed for nutrition and weight loss in a final sample of 22. Findings include: 1. On 04/09/24 at 1:05 PM, observed R71 in room consuming lunch. R71 did not receive any liquids on R71's lunch tray. R71's lunch ticket read nectar thick liquids and had the following items listed on the meal ticket: nectar thick water, nectar thick juice, 4 ounces nectar thick dairy choice of milk, and nectar thick beverage of juice. V13 (Certified Nursing Assistant) stated the kitchen is supposed to send the thickened liquids on the tray because there are no thickened liquids available on the nursing unit. V13 stated this has happened…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide adequate staffing to ensure that nurses administer medications on time, staff supervise the dining rooms when fall-risk residents are present and provide residents' care needs. This has the potential to affect all the residents that reside on the second and third floors. Findings include: On 04/09/2024 at 11:44 AM, V22 (CNA - Certified Nurse Aide) stated the facility needs more staff. V22 stated a CNA is supposed to watch the dining room when there are residents there, but it is difficult to do so if the CNAs also have their regular room assignments and activities of daily living (ADL) care to carry out. V22 stated there are also a lot of residents on [V22's] assigned unit that requires total assistance and mechanical lifts for transfers. Two staff are required to do the mechanical transfers, so it is difficult to monitor the dining room if two are doing a transfer and the other CNA is rounding in the hall or doing ADL care. On 04/09/2024 at 1:32 PM, V45 (Family Member) stated the facility is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record reviews, the facility failed (a) to follow their policy and procedure to ensure consents were obtained prior to administering psychotropic medications to 3 residents (R27, R74, R76), (b) to ensure Abnormal Involuntary Scale (AIMS) were completed every six months for 2 residents (R14, R76), (c) to follow physician recommendation to attempt a gradual dose reduction (GDR) for 1 (R27) resident, and (d) to provide adequate documentation to support that a GDR was attempted or if contraindicated for 1 (R14) out 4 residents reviewed for psychotropic medications in a final sample of 22. Findings Include: On 4/10/24 at 2:47 PM, R27's electronic health record (EHR) reviewed. R27's physician orders show R27 is on antipsychotic medication Quetiapine 25 mg by mouth at bedtime related to diagnosis of Psychosis ordered on 11/15/21, on antidepressant medication Escitalopram 20 mg by mouth one time a day related to diagnosis of Major Depressive Disorder ordered on 4/27/20, and antianxiety medication…

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

Based on observations, interviews and record reviews, the facility (a) failed to properly discard multi-dose inhaler and insulins on expiration dates for 6 residents (R68, R362, R8, R56, R1, R89), (b) failed to date opened multi-dose insulins for 3 residents (R17, R34, R61), and (c) failed to follow their policy and procedure for medication storage and labeling to ensure medications were secured in a locked storage area from one out of three carts inspected for medication storage and labeling that could potentially affect all 53 residents residing on the second floor. Findings Include: On 4/09/24 at 9:03 AM, Surveyor observed a medication cart on the 2nd floor hallway left unattended and unlocked. There were house stocks medications sitting on top of the medication cart which include: Aspirin, Vitamin C, Vitamin B12, Cranberry, Calcium, Iron, Multivitamin, Stool Softener, Vitamin B1, Vitamin D, and Magnesium Oxide. At 9:07 AM, V7 (Agency Registered Nurse) came out of R88's room and stated that V7 was taking R88's blood pressure reading. At 9:15 AM, after preparing R88's medications,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident menus, individual food plan and preferences were followed affecting four residents (R29, R56, R75, R87), b.) provide menus that provide a variety of entrees which are not repetitive affecting three residents (R44, R70, R87), c.) communicate menu changes and/or food substitutions to residents affecting one resident (R70) out of 7 residents reviewed for menus in a final sample of 22. Findings Include: On 04/10/24 at 10:02 AM, during interview with Resident Council participants R29, R75, R87 all stated the kitchen was out of coffee this morning and no one received any coffee. R29 stated R29 did not receive any coffee this morning on R29's breakfast tray and when R29 asked the staff for a cup of coffee the staff told R29 there was no coffee to give her. R87 stated, I love coffee and want to get it at my meals and they run out of coffee all the time. On 04/10/24 at 10:10 AM, R87 stated, We always get pasta. There is too much pasta on the menu. R87 stated the menu repeats a lot. R44 stated, We…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 needed care or services by not ensuring compression stockings or compression wrap were applied, midline dressing was dated, educate, and assess residents who decided to apply compression wrap and develop a plan of care. These failures affected 3 (R20, R70 and R83) residents reviewed for quality of care in a final sample of 22. The findings include: R20's health record documented admission date on 12/20/2021 with diagnoses with not limited to Secondary parkinsonism, Chronic systolic (congestive) heart failure, Type 2 diabetes mellitus, Other asthma, Cardiomegaly, Hypertensive heart disease with heart failure, Atherosclerotic heart disease of native coronary artery without angina pectoris, Nonrheumatic aortic valve disorder, Spinal stenosis, Obstructive sleep apnea Vascular dementia, Anxiety disorder, Major depressive disorder, Hyperlipidemia, Obesity, Repeated falls, Pain in left knee, Other seborrheic dermatitis, Gastro-esophageal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 low air loss mattress was in the correct setting for 1 (R47) resident and failed to ensure the left heel boot protector was in place for 1 (R14) out of 2 dependent residents reviewed for pressure wound prevention in a final sample of 22. Findings Include: R47's clinical records show R47 has diagnoses not limited to hemiplegia following cerebral infarction affecting left non-dominant side, dementia, and type 2 diabetes mellitus. R47's minimum data set (MDS) dated [DATE] shows R47 requires substantia/maximal assistance with rolling left and right on the bed. R47's Risk assessment dated [DATE] shows R47 is at risk in developing pressure wounds. R47's weight records show R47 weighs 196.6 pounds dated 4/4/24. R14's clinical records show R14 has diagnoses not limited to dementia, type 2 diabetes mellitus, and hypertensive heart diseases with heart failure. R14's MDS dated [DATE] shows R14 is cognitively impaired and requires…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a resident receiving enteral feeding received appropriate care and services, enteral feeding was not administered as ordered and g-tube dressing was not changed daily for 1 (R1) resident reviewed for Tube feeding in a final sample of 22. The findings include: R1's health record documented admission date on 9/11/2021 with diagnoses with not limited to Dysphagia following cerebral infarction, Unspecified sequelae of cerebral infarction, Encephalopathy, Encounter for attention to gastrostomy, Type 2 diabetes mellitus with other circulatory complications, Gout due to renal impairment right hand, Other seizures, Vascular dementia, Heart disease, Atherosclerotic heart disease of native coronary artery without angina pectoris, Peripheral vascular disease, Hyperlipidemia, Chronic kidney disease, Hypothyroidism, Unspecified osteoarthritis, Personal history of covid-19, Essential (primary) hypertension. On 4/9/24 at 4:01pm Observed R1 lying in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that oxygen tubing and bubbler were dated, changed, and oxygen tubing was placed in a bag when not in use. These failures affected 2 (R65 and R106) residents reviewed for respiratory care in a final sample of 22. The findings include: R65' s health record documented admission date on 4/11/2023 with diagnoses with not limited to unspecified atrial fibrillation, Acute kidney failure, Retention of urine, Heart failure, Obstructive and reflux uropathy, Cardiomegaly, Atrioventricular block complete, Type 2 diabetes mellitus, Neurocognitive disorder with Lewy bodies, Polyarthritis, Gout, Tremor, Hyperlipidemia, Hypertensive heart disease with heart failure, Dementia in other diseases classified elsewhere, History of falling, Personal history of covid-19, Anemia, Insomnia. On 4/9/24 at 1:21pm Observed R65 sitting up on wheelchair in the dining room, alert and verbally responsive, with oxygen inhalation via nasal cannula at 3L/min, oxygen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assert the rights of the residents by not ensuring residents were afforded the opportunity to choose their own food menu items. This failure has the potential to affect 96 residents residing in the facility. Findings include: On 09/09/2023 at 11:15 AM, V10 (Food Service Manager) stated, Our menus are created on a monthly basis. I print the monthly menus and provide them to the Activity Department staff, who are responsible for passing out the menus to the residents. On 09/09/2023 at 12:24PM, V11 (Life Enrichment Director) stated, V10/Food Service Manager has never given me or any of my staff any of the menus to provide to the residents here at the facility. V10 began working here at the facility in July of this year. Prior to V10 working here, my staff and I used to pass out the menus to the residents. Since V10 has been working here, V10 has not provided menus for my department to give to the residents. I am unable to provide the menus to the residents if they are not provided to me by V10. I had a discussion with V10…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 their Involuntary Transfer and Discharge Process policy and failed to provide their bed hold policy upon discharge to hospital for one of one resident (R3), reviewed for involuntary discharge. Findings include: R3's medical record (Face Sheet, MDS-Minimum Data Set) documents R3 is a severely cognitively impaired [AGE] year-old admitted to the facility on 4.26.2023 with diagnoses including but not limited to: Vascular Dementia, unspecified severity, with agitation, restlessness and agitation, Major Depressive Disorder, single episode, unspecified, unspecified sequelae of cerebral infarction. R3's Petition for Involuntary/Judicial Admission dated 08.22.2023, completed and signed by V9 V14 (Social Services Director) documents in part: I assert that (R3) is a person with mental illness who: because of his or her illness is reasonably expected, unless treated on an inpatient basis, to engage in conduct placing such person or another in physical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 their bed hold policy, upon discharge to hospital, for one of one resident (R3), reviewed for discharge Findings include: R3's medical record (Face Sheet, MDS-Minimum Data Set) documents R3 is a severely cognitively impaired [AGE] year-old admitted to the facility on 4.26.2023 with diagnoses including but not limited to: Vascular Dementia, unspecified severity, with agitation, restlessness and agitation, Major Depressive Disorder, single episode, unspecified, unspecified sequelae of cerebral infarction. On 09.09.2023 at 9:57am V2 (Director of Nursing) said R3 had a behavior that was unsafe for him (R3) and other residents and was unable to be redirected. His psychiatrist was contacted, and another psychiatric evaluation was ordered. V2 stated the facility prepared IVD (Involuntary Discharge) and orders were given for R3 to be sent to the hospital. V2 said she does not know if R3 received 30-day notice to residents but will find out from social…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to permit a resident to return to the facility after hospitalization for one of one resident reviewed for discharge. Findings include: R3's medical record (Face Sheet, MDS-Minimum Data Set) documents R3 is a severely cognitively impaired [AGE] year-old admitted to the facility on 4.26.2023 with diagnoses including but not limited to: Vascular Dementia, unspecified severity, with agitation, restlessness and agitation, Major Depressive Disorder, single episode, unspecified, unspecified sequelae of cerebral infarction. On 09.09.2023 at 9:57am V2 (Director of Nursing) said R3 had a behavior that was unsafe for him (R3) and other residents and was unable to be redirected. His psychiatrist was contacted, and another psychiatric evaluation was ordered. V2 stated the facility prepared IVD (Involuntary Discharge) and orders were given for R3 to be sent to the hospital. V2 said she does not know if R3 received 30-day notice to residents but will find out from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow its policy on infection control and prevention to prevent the spread of COVID by not properly cohorting residents with confirmed COVID infections. This failure has the potential to affect two (R8, R11) residents out of four residents reviewed for infection control. Findings include: On 09/09/2023 at approximately 10:30 AM, V1 (Assistant Director of Nursing ADON/Infection Preventionist) confirmed there were COVID positive residents residing in the facility. V1 provided surveyor with a list of COVID positive residents. A total of two residents in the facility were positive for COVID. The two COVID positive residents resided in a room with another resident who were listed as PUI/Person Under Investigation. On 09/09/203 at 11:02 AM, V13 (Registered Nurse/RN) stated, R9 is on contact isolation for COVID. R8 has not tested positive for COVID and is a PUI for COVID exposure. R9 also reside in the same room as R8. On 09/09/2023 at 3:21 PM, R2 stated, I…

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