Ryze At The Ridge

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: (a) properly date opened multi-dose medication solution, eye drops and inhalers; (b) properly store unopened multi-dose insulin vial and (c) properly discard expired house stock medication from 3 of 5 medication carts and 2 of 3 medication storage rooms inspected for medication storage and labeling. These failures affect 7 residents (R4, R16, R29, R34, R70, R75, R127) reviewed during medication storage observation. Findings include: On [DATE] at 10:23am Medication cart on 3rd floor inspected with V7 (Licensed Practical Nurse / LPN), stated has been working in the facility for 10 years. Observed the following inside the medication cart: 1. R16's Risperidone solution opened with no open date labelled. R16's POS (Physician Order Sheet) with order not limited to: risperidone Oral Solution 1 MG/ML (Risperidone) Give 2 ml by mouth two times a day. 2. R127's multi-dose Brimodine 0.2% solution with no open date. R127's POS showed order not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to assess eligibility and offer pneumococcal vaccinations, and failed to provide eligible residents and/or resident representatives education regarding the benefits and potential side effects of all available pneumococcal vaccinations to 4 (R1, R11, R128, R102) out of 6 residents reviewed for pneumococcal vaccinations in the sample of 26. Findings Include: On 8/20/24 at 10:54 AM, interviewed V14 (Infection Control Nurse) and stated that the facility sets up vaccination clinics for residents who need to receive the vaccines. V14 stated that the residents are educated about the vaccines. V14 stated that after the education is provided, consents are obtained from the resident or their representative. V14 stated that consents are uploaded right away in the resident's electronic health records (EHR) under the miscellaneous tab. V14 stated that V14 has no educational material that V14 provides to the residents about the vaccines. V14 stated V14 does it…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assess eligibility and offer COVID-19 vaccination for 4 residents (R11, R110, R231, R128), failed to ensure the residents medical records includes documentation if COVID-19 vaccinations were received or did not receive for 5 residents (R1, R11, R110, R231, R128), and failed to ensure the residents medical records includes documentation that education was provided to residents and/or resident representatives regarding the benefits and potential side effects of COVID-19 vaccination for 6 residents (R1, R11, R110, R231, R128, R102) out of 6 residents reviewed for COVID-19 vaccination in the sample of 26. Findings Include: On 8/20/24 at 10:54 AM, interviewed V14 (Infection Control Nurse) and stated that the facility sets up vaccination clinics for residents who need to receive the vaccines. V14 stated that the residents are educated about the vaccines. V14 stated that after the education is provided, consents are obtained from the resident or their…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complete a significant change in status Minimum Data Set (MDS) assessments using the CMS-specified Resident Assessment Instrument (RAI) process within the regulatory timeframes for one (R30) of seven residents reviewed for resident assessment in a sample of 26. Findings include: On 8/20/24, per review of R30's electronic health record (EHR) R30 was admitted to hospice on 06/26/24. Review of R30's Minimum Data Set (MDS) schedule indicates R30's last MDS assessment was completed 06/14/24 as a quarterly assessment and R30's next quarterly assessment is scheduled for 09/16/24. On 08/21/24 at 1:44 PM, V23 (MDS Coordinator) stated residents are reassessed every 90 days and/or if there is a significant change. V23 stated significant change assessments must be done if there is a change in one or two areas relate to functional ability or Activities of Daily Living, if the resident is admitted to hospice, and/or if the resident has had a fall with injuries, and/or readmitted from the hospital with a new diagnosis. V23 stated a…

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

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for a resident receiving hospice services for end-of-life support. This failure affects one resident (R30) out of one reviewed for hospice and comprehensive care plan in a sample of 26. Findings include: R30 has a diagnosis including but not limited to Chronic Respiratory Failure, Weakness, Unsteadiness On Feet, Dysphagia Following Cerebral Infarction, Lack of Coordination, Abnormal Posture, Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, Type 2 Diabetes Mellitus without Complications, Sequelae of Cerebral Infarction, Hydronephrosis, Shortness Of Breath, Long Term (Current) Use of Insulin, Cognitive Communication Deficit, Personal History of Traumatic Brain Injury, Hypertension, Personal History of Suicidal Behavior, Anemia, Gastro-Esophageal Reflux Disease without Esophagitis, Major Depressive Disorder, Schizophrenia, Hyperlipidemia, Bipolar Disorder, Current Episode Mixed, Severe, with Psychotic Features, Unspecified Dementia, Unspecified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policies and procedures to appropriately store oxygen tubing when not in use for 1 (R70) resident in a sample of 26. Findings Include: R70's Minimum Data Set (MDS) dated [DATE] shows R70 is cognitively intact. R70's Physician Order Sheet (POS) shows active order as of 8/20/24, Oxygen at 2Liters per nasal cannula continuous every shift related to acute and chronic respiratory failure with hypoxia. On 08/20/24 at 11:14 AM, surveyor with V10 (Certified Nursing Assistant/CNA) observed R70's oxygen nasal cannula tubing on the floor when not in use. V10 picked R70's oxygen nasal cannula tubing from the floor and placed the nasal cannula tubing on the oxygen tank. On 08/20/24 at 11:20 AM, surveyor and V8 (Registered Nurse/RN)) both entered R70's room. Surveyor asked V8 where should R70's oxygen nasal cannula tubing be stored when not in use? V8 stated R70's oxygen tubing should have been stored inside a plastic bag when not in use…

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

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5% for 2 (R27, R103) of 11 residents in the sample reviewed for medication administration. There were 31 opportunities and 4 errors resulting to 12.9% medication error rate. Findings include: R27's face sheet documented admission date on 8/25/2021 with diagnoses not limited to Type 2 diabetes mellitus, Chronic obstructive pulmonary disease, Personal history of covid-19, Schizoaffective disorder, Bipolar disorder, Major depressive disorder, Anxiety disorder, Gastro-esophageal reflux disease without esophagitis, Fibromyalgia. R103's face sheet documented admission date on 4/12/2023 with diagnoses not limited to Schizophrenia, Major depressive disorder. On 8/20/24 at 9:33AM Medication administration observation conducted with V6 (Registered Nurse / RN), checked R27's BP (blood pressure) =125/78 and PR (Pulse Rate) =101/min. V6 prepared and administered the following medications to R27: Saccharomyces Boulardi Probiotic 1 capsule, Omeprazole (Anti-reflux) 20mg…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and interviews the facility [A] failed to ensure housekeeping services were provided to maintain a clean and sanitary environment related to offensive odors, unclean floors, and bathrooms [B] failed to ensure the facility's furniture, equipment, plumbing, and over bed light fixtures were functioning properly for 8 [R1, R2, R5, R6, R7, R8, R9, R10] out of 10 residents in the sample reviewed for a homelike environment. Findings include: R2's clinical record indicates in part; R2 was admitted on [DATE] with medical diagnosis of acute bronchospasm, asthma, chronic obstructive pulmonary disease, schizoaffective disorder, auditory hallucinations, anxiety disorder, essential (primary) hypertension, and bipolar disorder. R2's Minimum Data set, Brief Interview dated 5/10/24, scored [02], indicates R2 is moderately impaired. During the facility tour dates of 7/9/24 thru 7/12/24, surveyor noted foul odors, missing drawers on R2, R5, R7, R8 bedside dressers, and noted one of the elevators was out 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 interviews and record reviews, the facility failed to maintain accurate and complete records of a resident's (R1) personal funds and provide R1's financial records quarterly and upon request for one out of four residents reviewed for trust fund. Findings include: R1's 4/16/2024 Quarterly Minimum Data Set assessment documents in part that R1 is cognitively intact with no signs and symptoms of delirium. R1's 6/20/2024 Behavioral Health Progress Note documents in part that R1 is alert and oriented to person, place, time, and situation. On 7/09/2024 at 11:53 AM, R1 was alert and oriented to person, place, time, and situation. R1 answered questions appropriately. R1 stated receiving a $10,000 check from V33's (R1's family member) estate at the beginning of the year. V34 (former Business Office Manager) went to R1's room and instructed R1 to sign the back of the check and hand it over to the facility. R1 requested multiple updates regarding the money but was told it was 'in process' due to the facility switching ownership. R1 started asking for billing statements in May. That'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 make prompt efforts to resolve a grievance and keep a resident updated on the progress of the investigation for one (R1) out of three residents who had spoken to staff regarding their concerns. Findings include: R1 was admitted to the facility on [DATE] with diagnosis not limited to Paraplegia, Low Back Pain, Psychosis, Bipolar Disorder and Anemia. R1's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response. Document titled Concern/Compliment Form date received: 05/09/24 document in part: Name of person voicing concern/compliment: R1. Concern/compliment reported to V4 (Psychiatric Rehabilitation Services Director): R1 had a check for $10,000 that was deposited at the end of February. R1 takes out money from her trust fund each week. The $10,000 was not reflecting in account. R1 was upset because it is her money. Documentation of Facility Follow-up: Date assigned: 05/09/24, Expected date 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 view the facility failed to report an allegation of misappropriation of a resident funds by failing to submit a report within the required time frame to the Illinois State agency for one (R1) of one resident reviewed for the abuse. Findings Include: R1 was admitted to the facility on [DATE] with diagnosis not limited to Paraplegia, Low Back Pain, Psychosis, Bipolar Disorder and Anemia. R1's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response. Document titled Concern/Compliment Form date received: 05/09/24 document in part: Name of person voicing concern/compliment: R1. Concern/compliment reported to V4 (Psychiatric Rehabilitation Services Director): R1 had a check for $10,000 that was deposited at the end of February. R1 takes out money from her trust fund each week. The $10,000 was not reflecting in account. R1 was upset because it is her money. Documentation of Facility Follow-up: Date assigned: 05/09/24, Expected date…

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

Based on interview and record review, the facility failed to report a serious fire incident that had the potential of causing serious bodily injury within 24 hours for 2 (R3, R4) of 4 residents sampled. This failure has the potential to affect all 123 residents residing in the facility at time of incident. Findings include: Review of resident progress notes and interview of V1 (Administrator) it was substantiated that on 1/21/24 at 11:30PM, R3 set R4's mattress on fire following an argument between both residents. Facility reportable incident logs were reviewed on 2/20/24. No incidents related to the 1/21/24 facility mattress fire was reported to the State Survey Agency. On 2/20/24 at 10:39 AM V1 (Administrator) stated we were considering discharge of R3 after the fire but after speaking with the guardian we did not. I did not file an incident with the mattress fire because nobody was hurt and no one was touched. R3 started the fire with a lighter. R3 stated he brought the lighter in from the community. He has behaviors when we restrict him from going into the community. We let him…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents right to be free of abuse for two (R1, R3) of four residents (R1, R2, R3, R4) reviewed for abuse on the sample list of eight residents. Findings include: 1. R1 is a [AGE] year old female resident with a diagnosis including Bipolar Disorder, Anxiety Disorder and Post - Traumatic Disorder. R1 was admitted to the facility on [DATE]. R1 has a BIMS (Brief Interview for Mental Status) score of 12/15. R1 Abuse/Neglect Screening Risk is 3 (Moderate). R2 is a [AGE] year old male resident with diagnoses including Chronic Obstructive Pulmonary Disease, Anxiety Disorder, Schizophrenia and Bi Polar Disorder. R2 BIMS (Brief Interview for Mental Status) is 11/15. R2 Social Service Abuse/Neglect Screening scored 3 Moderate Risk. Facility incident report dated 8/29/23 states that on 8/29/23 at 10AM, R1 alleged that R2 touched her inappropriately. Investigation was initiated, Residents separated, Police contacted, Family contacted and R2 was immediately…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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.) properly clean and sanitize tableware and cooking equipment, b.) ensure food items were properly label and dated, c.) properly store raw animal food separately from ready to eat foods, d.) follow hand washing and glove usage procedure. These deficient practices have the potential to affect all 126 residents residing in the facility. Findings include: On 07/09/23 at 9:14 AM, during initial kitchen tour with V4 (Dietary Manager) observed V5 (Dietary Aide) working in the dish room area alone in front of the dish machine rinsing off dirty plate ware (plastic bowls, plates, metal plate covers) and plastic meal trays. V5 placed them into the dishwasher racks. V5 was feeding the dirty items in the dishwater racks into the dishwasher, and then reaching around to the clean side of the dish machine to pull them out of the dishwasher without performing hand hygiene in between the two tasks. V5 did not perform any hand hygiene in between handling the dirty and clean items. On 07/09/23 at 9:16 AM, observed V5 still…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 call lights were within reach for four residents (R12, R21, R51, R56) and staff failed to respond in a timely manner to the call light for one resident (R51) of 7 residents reviewed for accommodation of needs in a total sample of 25. Findings include: 1) On 07/09/23 at 12:10 PM, observed R51 lying in bed with the call light cord wrapped tightly in a circle against the wall hanging from the call light box with the call light button dangling toward the floor out of R51's reach. R51 stated, there isn't a call light in here, I wish there was and I don't have a call light. R51 stated R51 tells R51's roommate when R51 needs help, and the roommate goes and gets a staff member. R51 stated if the roommate was not in the room when R51 needed help, I'd be in big trouble, and R51 would have to wait until the roommate returns. R51's roommate confirms R51 tells the roommate when R51 needs help. R51's roommate stated, I am not here all the time. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow smoking safety policy by not completing smoking safety assessment upon admission for one resident (R177) and on a quarterly basis for four residents (R20, R27, R47, R77) to determine the level of assistance and supervision needed during smoking, the ability to carry and store smoking materials, and if a smoking apron is indicated. The facility also failed to ensure that smoking care plan is initiated/ developed upon admission for one resident (R177). These failures can potentially affect five (R20, R27 R47, R77 and R177) of eight residents reviewed for smoking in the sample of 25. The findings include: 1) On 7/9/23 at 11:14 am R20 was ambulating with steady gait, alert and verbally responsive. R20 stated he is a smoker and smoking in designated area in the back patio. R20 stated that facility staff is keeping smoking materials. R20's health record documented admission date of 9/24/19 with diagnoses not limited to Chronic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow policy for psychotropic medication by failing to obtain or provide consent of psychotropic medication use for two (R20 and R53) residents, failed to monitor residents on antipsychotic drug therapy by not completing Abnormal Involuntary Movement Scale (AIMS) assessment timely for four (R20, R2, R35 and R53) residents, and failed to review drug regimen irregularities / recommendations for one (R53) five residents reviewed for unnecessary medications in a sample of 25. Findings include: 1) On 7/9/23 at 11:01 am R2 was alert and verbally responsive, up and about, ambulatory with steady gait. R2's health record documented admission date of 2/7/2019 with diagnoses not limited to Chronic obstructive pulmonary disease, Schizoaffective disorder, Type 2 diabetes mellitus, Essential hypertension, Hyperlipidemia, Major depressive disorder, Generalized anxiety disorder, Insomnia, Chronic pain, Gastro-esophageal reflux, Osteoarthritis,…

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

Based on observation, interview, and record review, the facility failed to follow policy and procedures for medication storage and labeling by failing to discard expired house-stock medications, failing to ensure personal items and floor cleaner chemicals were stored separately. The facility also failed to ensure that medications are labeled with open date for four (R24, R39, R41, R50) residents and failed to ensure that medication is stored in the container in which they were originally received for one resident (R78). These failures affect five residents (R24, R39, R41, R50, R78) in the sample of 25 residents. Findings include: On 7/10/23 at 9:18 AM 3rd floor medication room was inspected with V11 (Licensed Practical Nurse/LPN). This medication room had two white refrigerators. There was dust, paper and plastic in between the two refrigerators. The storage cabinet was unorganized with dust all over and house stock medications being stored with personal items including an umbrella, shoes, transparent plastic ware and a water bottle. There was a bottle of hard surface floor cleaner…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complete the quarterly Minimum Data Set (MDS) assessment using the CMS-specified Resident Assessment Instrument (RAI) process within the regulatory timeframe for one (R33) of four residents reviewed for quarterly resident assessment on the total sample list of 25. Findings Include: On 7/11/23 at 11:06 M, R33's electronic health record (EHR) reviewed. R33 was admitted on [DATE]. R33's Quarterly MDS assessment with assessment reference date (ARD) of 1/18/23 was completed on 2/6/23 past the 14 days regulatory timeframe. At 1:10 PM, interviewed V23 (MDS Coordinator/Care Plan Coordinator) and stated that Quarterly MDS assessments are signed and completed the day after the ARD. V23 stated that the facility follows the (Resident Assessment Instrument (RAI) manual to complete the MDS assessments. The facility's RAI Version 3.0 Manual dated October 2018 page 2-17 titled RAI OBRA-required Assessment Summary indicates that Quarterly (Non-Comprehensive) MDS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 develop a comprehensive resident centered care plan with goals and interventions for two residents (R24, R56) reviewed for care plans on the total sample list of 25. Findings include: R24 diagnoses include but are not limited to Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease, Atopic Dermatitis, Chronic Viral Hepatitis. R24 Braden Observation, dated 5/27/23, indicates R24 has moderate risk in developing pressure ulcers. R24's MDS (minimum data set) assessment, dated 6/1/23, documents, section M, (R24) is at risk of developing pressure ulcers/injuries. R24's comprehensive care plan does not address R24 is at risk for pressure ulcers/injury. R56 diagnoses include but are not limited to Schizophreniform, major Depressive Disorder, Mood Disorder due to known physiological condition, Psychotic Disorder. R56 has orders for the following psychotropic medications: Haloperidol tablet 2 milligrams, Mirtazapine tablet 15mg, Quetiapine Fumarate tablet 50mg. R56's comprehensive care plan does not address R56'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 current code status for one (R7) of one residents is correctly addressed in the comprehensive care plan in a sample of 25 reviewed for advance directives. Findings Include: On [DATE] at 11:24 AM, R7's face sheet and physician order sheet (POS) shows R7 is a Full Code. R7's Physician Orders for Life Sustaining Treatment (POLST) form shows R7 chose Cardiopulmonary Resuscitation (CPR) should be attempted in the event R7 is found with no pulse and is not breathing. R7's comprehensive care plan shows R7 selected Do Not Resuscitate (DNR) should R7 stops breathing and displays no pulse. At 12:34 PM, V18 (Social Service Director) stated that a resident's code status should be ordered in the POS and addressed in the care plan. V18 stated that care plan is updated right away when the code status is changed. V18 stated that DNR means if the heart stops, they don't perform CPR and Full code means if the heart stops staff has to perform CPR to the…

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

Based on observation, interview, and record review, the facility failed to follow routine catheter and infusion site care policy by not changing a midline dressing weekly for one (R5) of one residents reviewed for intravenous therapy in the sample of 25. The findings include: On 7/9/23 at 1:28 pm during Medication administration observation conducted with V10 (Registered Nurse / RN) R5 was lying in bed, alert and verbally responsive. V10 administered Zosyn 3.375 grams IV (Intravenous). R5 had a single lumen midline on right upper arm, R5's dressing was dated 6/30/23 and was peeling from R5 skin. V10 stated that IV antibiotic is for sacral wound infection. V10 stated that midline dressing should be changed weekly and as needed. V10 confirmed that midline dressing was dated 6/30/23 and should have been changed on 7/7/23. R5's health record documented admission date of 6/22/23 with diagnoses not limited to Infection of intervertebral disc, sacral and sacrococcygeal region; Type 2 diabetes mellitus; Major depressive disorder; Chronic pain; Ileostomy status; Neuromuscular dysfunction 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 follow policy for oxygen therapy for one (R53) of one residents reviewed for respiratory care in the sample of 25. Findings include: On 7/9/23 10:09 am R53 was up and about, ambulatory with steady gait, alert and verbally responsive. R53's oxygen tubing in R53's bed, oxygen machine/concentrator was off. R53 turned on oxygen machine / at 2Liter/minute 2L/min) and put on oxygen tubing via nasal cannula. R53's oxygen cannula was not dated. R53 had no door sign for oxygen in use. R53 had no bag to place oxygen tubing / cannula when not in use. Requested V11 (Licensed Practical Nurse / LPN) to R53's room, V11 confirmed that R53's oxygen is at 2L/min. V11 confirmed that there is no date on oxygen tubing. V11 stated R53 is removing oxygen tubing when R53 goes to smoke. R53's health record documented admission date of 2/14/19 with diagnoses not limited to Pneumonia, Asthma, Schizoaffective disorder, Restlessness and agitation, Major depressive…

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

Based on observation, interview, and record review, the facility failed to follow the meal ticket menu for 1 (R7) of 2 residents reviewed for nutrition in a total sample of 25 residents. Findings Include: On 07/09/23 at 12:30 PM, R7 was eating lunch in her room with V14 (Licensed Practical Nurse) supervising R7. R7's lunch tray consisted of pureed pork, pureed potatoes, pureed spinach, and a beverage. R7's meal ticket shows R7 was supposed to also receive pureed buttered dinner roll and pureed cinnamon diced pears, but these items were not on R7's lunch tray. At 12:45 PM, R7 ate 100% of R7's lunch and still did not receive the pureed cinnamon diced pears and pureed buttered dinner roll. On 7/11/23 at 11:29 AM, a phone interview conducted with V26 (Registered Dietitian). V26 stated that residents on mechanically altered diets can be at nutritional risks. V26 stated that these residents should be receiving the same food as regular diets on a mechanically altered textures. V26 stated that it is important to ensure the residents are getting correct nutrition and it's V26's expectation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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.) monitor the temperature of a resident's personal refrigerator, b.) label and date food items in a resident's personal refrigerator for 1 resident (R78) reviewed on the sample of 25 for safe personal food storage. Findings include: On 07/09/23 at 11:10 AM, observed inside R78's personal refrigerator 2% milk carton with use by date 06/26/23, a plastic bag containing American cheese wrapped in foil with no date on it and an open container of creamed cheese with no date on it. R78 did not know exactly how long those items had been in the refrigerator, estimating two-three weeks. There was no thermometer in R78's refrigerator. R78 stated that staff does not check R78's refrigerator. On 07/11/23 at 8:51 AM, V1 (Administrator) stated I thought we did away with the resident refrigerators and didn't realize they were not being monitored. V1 stated that now that it's been brought to my (V1) attention, I (V1) am addressing it. V1 stated V1 ordered thermometers yesterday for each resident's refrigerator and log sheets…

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

Based on observation, interview and record review, the facility failed to discard food items stored in the refrigerator on time, failed to label food, failed to perform hand hygiene and change gloves appropriately, and failed to follow proper food storage practices to prevent food borne illnesses. These failures have the potential to affect all 107 residents residing in the facility who are getting nutrition orally. Findings include: The (06/06/2022) facility census was 108. The (undated) List of residents on NPO (Nothing Per Orem) documented that there was 1 resident on NPO. On 06/06/2022 at 9:54am, inside the reach in cooler, there was a container of apple sauce with open date 5/28/22 and an open container of prune juice with open date 5/16/2022. V6 (Dietary Manager) stated that the apple sauce should be discarded yesterday and the prune juice should be discarded on 5/23/2022. On 06/06/2022 at 9:55am, surveyor inquired about the importance of discarding food accordingly. V6 stated, Resident may get sick eating it. On 6/06/2022 at 10:17am, there was a container of ground beef in a…

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

Based on observations, interview and record review, the facility failed to ensure the dumpster is fully closed at all times and failed to maintain an effective pest control program to ensure that the facility is free of insects. These failures have the potential to affect all 108 residents in the facility. Findings included: On 06/06/2022 at 11:18am, the lid of the outside dumpster was missing a piece. On 06/06/2022 at 11:19am, surveyor inquired about the dumpster lid. V8 (Housekeeping Director) stated, It is broken. We need to replace it. On 06/06/2022 at 11:20am, surveyor inquired about the importance of making sure the dumpster was fully closed. V8 stated, The dumpster needs to be closed at all times so the insects, rats and the squirrel will not be able to get inside the dumpster. On 06/08/2022 at 9:30am, in the skills training room, there was a black dead roach, approximately an inch long, on the mantle underneath the television. V8 was notified of this observation. V8 put a glove on and grabbed the dead insect with the gloved hand and proceeded to throw the insect into the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to enter a code status order in the electronic medical record (EMR) under the physician orders which affected two residents (R28 and R73); failed to ensure that a current and properly completed copy of the resident's IDPH (Illinois Department of Public Health) Uniform Practitioner Order Form for Life-Sustaining Treatment (POLST) was in the electronic medical record which affected three residents (R14, R36 and R95); and failed to ensure the care plan matched the current code status order for one resident (R14) in the sample of 51 residents reviewed for advance directives. Findings include: On [DATE] at 1:32 PM, during record review, R36's POLST form was noted to be scanned into the EMR (Electronic Medical Record), but no box was checked on the form indicating either full code or DNR (Do Not Resuscitate) status. On [DATE] at 1:40 PM, during record review, R95's POLST form scanned into the EMR also had no box checked indicating the code status. This finding…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 functional lights, and a clean wall and window. These failures affected 5 residents (R25, R26, R27, R43, R79) reviewed for safe, clean, comfortable, and homelike environment in the sample of 51 residents. Findings include: On 06/06/22 at 11:22 AM, during initial tour the following observations were made: R26's light behind the head of bed cover was missing, lightbulb tube was exposed, and light did not work. R26 stated that at night she does not want to turn on overhead light to prevent bothering her roommate. R26 stated that she (R26) uses light at night to read. R26 stated that she (R26) told staff about this problem. On 06/06/22 at 11:35 AM, observed a black substance located on the wall in R27's room under the window and observed paint bubbling and peeling on the inside window ledge. On 06/06/22 at 2:48 PM, surveyor and V10 (Licensed Practical Nurse/LPN) viewed R27's wall under the window. V10 stated there was a black substance coming from the window and that the window ledge had paint bubbling.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and interview the facility failed to provide and maintain a temperature log for the refrigerator that stores the resident's insulin on the second floor. This failure has the potential to affect all residents that reside on the 2nd floor. Findings: On 6/08/2022 at 12:49pm, surveyor did not see the temperature log for the small refrigerator in the medication room on the second floor. On 6/08/2022 at 12:49pm V11 (Licensed Practical Nurse/LPN) said, I don't know who took it down and the purpose of the temperature log is to make sure insulins are being stored at the correct temperature so that it doesn't freeze. On 6/08/2022 at 12:51pm, surveyor inquired about the temperature log for the small refrigerator that stores insulin and V3 (Assistant Director of Nursing/ADON) said, It is not here on the refrigerator; sorry, I will fix it right now. Policy titled Medication Storage with a revised date of 1/05/2022 states, in part, to ensure proper storage and facility should ensure that medications and biologicals are stored at their appropriate temperatures according to the…

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

Based on interview and record review, the facility failed to develop a smoking care plan for 1 (R68) resident reviewed for comprehensive care plan in the sample of 51 residents. Findings include: On 06/06/2022 at 11:11am, R68 stated, I smoke cigarette. R68's (Target Date: 04/19/2022) Care Plan was reviewed; no smoking care plan noted. On 06/08/2022 at 3:15pm, surveyor inquired about PRSC (Psychiatric Rehabilitation Service Coordinator) job description. V21 (Psychiatric Rehabilitation Service Coordinator/PSRC) stated, I (V21) complete community, aggression, smoking, and abuse assessments. I also do care plan for admission, insert advance directive, trauma history, communication issue, behavior. I also care plan if the resident smokes or not compliant with smoking policy. On 06/08/2022 at 3:19pm, surveyor inquired if R68 smokes, V21 stated, R68 smokes on and off. He should be care planned for smoking. On 06/08/2022 at 3:22pm, surveyor opened R68's electronic record on the surveyor's tablet and clicked the tab 'Care Plan' start date 4/15/2022, showed it to V21 and requested V21 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 observation, interview and record review, the facility failed to provide ADL (Activities of Daily Living) care related to nail care for one dependent resident (R42) in the sample of 51 residents when reviewed for ADL care. Findings include: On 06/06/22 at 11:52 AM, R42 was observed sitting in the dining area in a wheelchair. R42 was noted to have long fingernails about 1/2 inch beyond the tip of the finger. R42 stated that R42 would like to have R42's fingernails cut. This observation was brought to the attention of V4 (Certified Nursing Assistant/CNA) who stated, I know they are (fingernails) long and they need to be cut, but I have to ask the nurse. On 06/08/22 at 1:49 PM, during interview with V2 (Director of Nursing/DON), the surveyor asked who is responsible for providing nail care. V2 stated that the CNAs are supposed to trim resident's nails. The importance of nail care per V2 is that It's part of infection control because you don't want them to transfer bacteria that can be under the nails. R42's MDS (Minimum Data Set) dated 4/5/22 documents, in part, that R42…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 be free of medication error rate of 5% or more. There were a total of 8 medication errors out of 25 opportunities. The medication error rate was 32% that affected R42 and R44. Findings include: On 06/07/2021 at 9:27am, surveyor reviewed R42's EMAR (Electronic Medication Administration Record) screen that was pink for R42's scheduled 8:00am medications. V9 (License Practical Nurse/LPN) stated that pink means the meds are late and meds are supposed to be given between 8:00am and 9:00am. On 6/07/2022 at 9:37am, surveyor observed V9 give R42's 8:00am dose of Insulin Determir Solution 100 unit/ml. On 6/07/2022 at 9:49am, surveyor observed V9 give R42 her 8:00am meds. On 6/07/2022 at 9:49am, surveyor observed V9 give R42's Keppra 100mg/ml, Haloperidol 5mg, Bethanachol Chloride and Tamulosin HCL 0.4mg. On 06/07/2022 at 8:59am, surveyor observed V9 give R44's Oyster Shell Calcium and at 9:00 and give Ibuprofen for leg pain with a pain level of 8. V9 did not give R44 the 8:00am dose of Cholecalciferol Capsule 1000…

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