Warren Barr Lincoln Park

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to date and label insulins and eye drops per policy; failed to maintain medication carts free from insulin that were expired; failed to store controlled substances inside a double locked storage; and failed to maintain medication storage area free from controlled substance that was discontinued. These failures affect 6 residents (R19, R30, R2, R1, R53, and R3) reviewed for drug storage. Findings include: On [DATE] at 10:25 AM, with V10 (Registered Nurse / Agency), the following insulins were found: R19's Insulins Lispro had no date and Fiasp insulin had written as follows: date opened [DATE], and date expired was [DATE]. V10 stated it should not be in the medication cart because it was already expired. R30's insulins Lispro and Fiasp both had no date written. V10 stated, All of insulins are being used because it is inside the medication cart. It should have been dated when opened and the expiration date is 28 days after opening. R2's…

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

Based on interview and record review, the facility failed to maintain medical records on each resident in accordance with accepted professional standards and practices that are accurately documented for eight (R8, R16, R26, R33, R53, R61, R127, R277) out of eight residents reviewed for resident records. Findings include: On 10/29/2024 at 11:30 AM, V14 (Certified Nursing Assistant/CNA) stated, I believe there are 10 residents I am responsible for. Surveyor questioned V14 what room numbers she was responsible for. V14 voiced the room numbers she was assigned to. V14 stated she works from 7:00 AM until 3:00 PM. Surveyor questioned V14 on what her next duties/tasks she was going to carry out. V14 stated, I was waiting on the other lady to come in, so she can chart under my name, lunch is about to come, she doesn't have a log in. V14 reported she is just helping the lady out with the charting. Surveyor questioned V14 for the name of the person that doesn't have log in. V14 stated the other CNA is V15 (CNA). V14 stated, If the resident received care and it is documented, that is what…

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 accurately complete one residents (R29) comprehensive annual assessment. Findings include: On 10/30/24 at 3:58 PM, V24 (Regional Director of Clinical Data Quality and Performance Audits) stated, Someone is covering MDS (Minimum Data Set) from another facility. On 10/30/24 at 4:25 PM, V1 (Administrator) stated, We do not have a current MDS Coordinator. On 10/31/24 at 9:10 AM, V19 (MDS Consultant) stated, (R29's) Census, 5/18/2024, is an error. (R29) went to the hospital and was admitted and returned with qualifying nights at the hospital. (R29) came back to the facility as dual (Medicaid and Medicare payor). MDS is scheduled in sequence. The census line has an error. The submitted MDS on 10/17/24, was a quarterly assessment, modified to be inactivated. MDS annual created it to be finalized on 10/31/24, with the same ARD (Assessment Reference Date) of the submitted MDS (10/17/24). Census drives the MDS. Assessments are in sequence. A quarterly was sent. The type of assessment was an error. We inactivated the quarterly and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to initiate a new Level I screen for one (R70) resident reviewed for Pre-admission Screening and Record Review (PASARR) in a total sample of 21. Findings include: R70's Facesheet documents R70 was admitted to the facility on [DATE]. R70's Level I PASARR outcome documents R70 has an exempted hospital discharge, with a 30-day length of stay that expired on [DATE]. On [DATE], at 2:19 PM, V1 (Administrator) states the facility checks to see if a resident has a PASARR screening upon admission. V1 states the PASARR indicates the determination of needs/DON score for the individual resident. V1 states based on the DON score, it is determined if a resident is appropriate for the nursing home setting or not. V1 states she is unaware of the DON score ranges or what the different DON score ranges are indicative of. V1 states a PASARR Level II is needed for a resident if it is determined that the resident has an SMI/severe mental illness. V1 states the determination…

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 address a high blood sugar result for 1 out of 3 residents (R75) reviewed for blood sugar testing. Findings include: R75 was [AGE] years old, initially admitted on [DATE], in the facility with medical diagnosis that includes diabetes mellitus. V25 (Registered Nurse) progress notes, dated [DATE], reads R75 expired in the facility pronounced expired by EMS (Emergency Medical Service) at 3:15 PM. Also on the same progress notes, at 2:31 PM, R75's blood sugar was obtained, with 397 result. Per physician order, R75 was receiving Paxlovid medication for Covid-19 from [DATE] to [DATE]. There was an order to check R75's blood sugar before meals and at bedtime, and to call the MD (Medical Doctor) if blood sugar result is below 60 or above 300. R75's MAR (Medication Administration Record), dated [DATE], R75's blood sugar result was scheduled at 11:00 AM. R75's result was 33,3 which was above 300 that per physician order to call physician. Review of all…

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 pressure ulcer preventative measures were accurately applied for two residents (R4 and R62) in a sample of 18 residents reviewed for pressure ulcer. Findings include: 1. R4's POS (Physician Order Summary) has active order, Patient to be on low air loss mattress at all times daily, afterrnoon, and every shift for pressure reduction, order date 8/27/24. On 10/29/24 at 12:40 PM, R62 was lying in bed on a low air loss. A fitted sheet was on the mattress, and a flat sheet folded two times was between R62 and the mattress. On 10/29/24 at 12:45 PM, V2 verified there was a fitted sheet, a flat sheet folded two times, and R62 was wearing a brief. 2. R62's POS has active order, Patient on LAL (Low Air Loss) mattress at all times every shift for pressure reduction. Order date 9/23/24. On 10/29/24 at 1:00 PM, R4 was lying in bed on a low air loss mattress. A fitted sheet was on the mattress. On 10/29/24 at 1:05 PM, V22 verified there was a fitted sheet, a flat sheet folded two times used as a draw sheet, and R4…

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

Based on observation, interview, and record review, the facility failed to follow their policy on resident food preferences for one (R70) resident in a total sample of 21 residents reviewed. Findings include: R70's Nutrition Progress Note, dated 10/20/2024, documents in part, Review of diet tolerance, PO (by mouth) intakes, appetite changes, weights, labs, medications, skin conditions. Recommend: Continue current diet, provide food preferences, provide foods from alternative menu, provide assistance with meals as needed, closely monitor diet tolerance, PO intakes, labs, and weights. Continue Pro Stat three times daily to maintain skin integrity. Will continue to monitor and make changes as necessary. Facility menu documents eggs were served in the facility for breakfast on 10/27/24, and 10/28/24. On 10/29/2024, at 11:50 AM, R70 stated the facility staff continues to serve her eggs on her meal trays for breakfast although she has informed the facility that she does not like eggs to eat. R70 states she has informed the Dietary Manager (identified as V8) of her dislike for eggs, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure appropriate use of personal protective equipment (PPE) worn by staff caring for a resident with a known infectious disease (R50), and failed to ensure staff maintains clean technique/infection control practice while performing a bed bath (R3) for one resident. These failures affect 2 residents (R3 and R50) reviewed for infection prevention and control in a total sample of 21 residents reviewed. Findings include: 1. R50's physician order sheet/POS, dated 10/21/2024, documents R50 is on contact isolation precautions for shingles. On 10/29/2024, at 11:41 AM, V5 (Registered Nurse/RN) stated R50 is on contact isolation in the facility due to R50 being diagnosed with shingles. On 10/29/2024, at 11:48 PM, surveyor observed a sign posted on R50's door that reads, Contact Precautions Everyone Must: clean their hands, including before entering and when leaving the room. Providers and Staff must also: Put on gloves before room entry. Discard…

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

Based on observation, interview, and record review, the facility failed to ensure that medication was locked up safely when not in visual proximity of the licensed nurses and not in use to prevent tampering and accidental hazard. This failure has the potential to affect all the residents residing on the 2nd and 3rd floor of the facility. Findings include: On 07/10/24 at 11:29am, the treatment cart was observed in the hallway on the 3rd floor, not in visual proximity of the nurse, and was unlocked. V16, RN (Registered Nurse) was asked about the facility policy/protocol on treatment carts storage and medication storage. V16 stated the medications are to be locked in a cart when not in use and not in visual proximity of a nurse. V16 stated, I did not put it there so I was not watching to see whether it is locked or not. You will have to ask the treatment nurse (referring to V18 (Wound Care Nurse) why the cart was left unlocked. On 7/10/24 at 11:31am, V18, LPN (Licensed Practical Nurse) Wound Care Nurse, stated, The wound care cart (treatment cart) should be locked because the treatment…

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 immediately report to IDPH (Illinois Department of Public Health) within required time, the allegation of abuse of one of four residents (R1) reviewed for abuse. This failure affected R1 who was handled roughly and was hit on the arm and back by a facility staff as an attempt to redirect R1. Findings include: R1's medical record documented R1 was admitted on [DATE], with diagnoses that includes but not limited to Dementia in other diseases classified elsewhere mild with agitation, insomnia due to medical condition, essential hypertension, and chronic obstructive pulmonary disease. On 07/10/24 at 3:00pm, V20, CNA (Certified Nursing Assistant), stated, I will tell you the truth, it happened about two weeks ago, and the whole thing was in the hallway where the video camera can pick it up (see it). V20 checked the calendar of the day she worked and stated the incident happened on 06/30/24. V20 stated, (R1) was trying to sit on the floor. (R1) usually does…

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 immediately initiate an investigation into an alleged physical abuse for one of four residents (R1) in the sample reviewed for physical abuse. This failure affected R1 who was handled roughly and was physically hit in the arm and back by a staff to redirect R1. Findings include: R1's medical record documented R1 was admitted [DATE], with diagnoses that includes but not limited to dementia in other diseases classified elsewhere mild with agitation, insomnia due to medical condition, essential hypertension, and chronic obstructive pulmonary disease. On 07/10/24 at 2:50pm, V20, CNA (Certified Nursing Assistant), stated, I will tell you the truth. It happened about two weeks ago, and the whole thing was in the hallway where the video camera can pick it up (see it). V20 checked the calendar for the day she worked and stated the incident happened on 06/30/24. (R1) was trying to sit on the floor. (R1) usually does this, and when I was trying to grab (R1)…

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 medication is administered as ordered for one resident (R3) for residents reviewed for medication administration. Findings include: R3's MAR (Medication Administration Record) and POS (Physician Order Sheet) showed an order for Potassium chloride crys ER 20 meq tablet extended release give 20 [NAME] by mouth one time a day every Monday, Wednesday, Friday for supplement. The MAR showed R3 was administered this medication on 07/10/24, a Wednesday, and should not have been given any potassium on 07/11/24. On 07/11/24 at 11:45am, R3 was observed in bed, with two plastic medication cups on the over bed table. One had a big whitish pill and the second cup had six medications. R3 asked the surveyor to identify the pills. R3 stated, I am stressed because I have been calling the nurse and the nurse will not help me. I don't know what this big pill is. V16, RN (Registered Nurse) stated they were R3's morning scheduled medications, and was…

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

Based on observation, interview, and record review, the facility failed to follow their policy on enteral tube feeding care by failing to label the date and time the feeding was started for two (R2, R3) residents of three residents reviewed for enteral feedings. Findings include: 1. R2's medical diagnoses in current face sheet includes: cerebral infarction due to embolism of bilateral posterior cerebral arteries, encounter for attention to gastrostomy, and cognitive communication deficit. R2's Diet: NPO (Nothing by Mouth) diet, NPO texture, NPO consistency and her Brief Interview for Mental Status (BIMS) dated 5/3/24 is documented as 6/15, indicating R2 has severe cognitive impairment. R2's Physician's orders, dated 04/26/2024, document: Enteral Feed Order every shift Enteral feeding G-Tube feeds with Jevity1.5 at 75ml/hour. Start at 17:00 and infuse until 1575ml is reached per day. On 5/6/2024 at 10:20am, R2 was observed sleeping with head of bed elevated to about 75 degrees, and R2's nutritional supplement was observed running at a rate of 75mL/hour. The pump showed R2 had…

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.) food items were properly stored per manufacturer guidelines, b.) expired foods were discarded, and c.) proper hand washing was done in between handling dirty and clean plate ware. These failures have the potential to affect all 77 residents receiving food prepared in the facility's kitchen. Findings include: On 12/12/23 at 9:15 AM, during initial kitchen tour, V10 (Food Service Manager) stated all food items in the refrigerator should be labeled with a delivery date, an open data, and an expiration date or use by date. V10 stated all items should be discarded after labeled use by date. On 12/12/23 at 9:20 AM, walk-in refrigerator had a container of opened package of French Toast labeled, with preparation date 12/08/23, and use by date 12/10/23. V10 stated this item would not be served to a resident because it is past its use by date. V10 stated I'll throw it out now. On 12/12/23 at 9:32 AM, V11 (Dietary Aide) was handling dirty plate ware, and placing dirty items into a dish rack before feeding the…

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

Based on observation, interview, and record review, the facility failed to ensure medications were properly labeled and stored in 2 of 2 medication carts reviewed. This affects 4 residents (R54, R3, R64, and R68) reviewed for medication storage. Findings Include: 1. R54 has diagnoses of Asthma and Essential (Primary) Hypertension. R54's Order Summary Report, dated 12/13/23, documents: Budesonide-Formoterol Fumarate Inhalation Aerosol 160-4.5 MCG/ACT 2 puff inhale orally every 12 hours. R54's Care Plan documents: Focus: R54 has Asthma. Intervention: Give medications as ordered (Budesonide Inhaler). Monitor/document side effects and effectiveness. 2. R3 has diagnoses not limited to Type 2 Diabetes Mellitus with Diabetic Neuropathy, Chronic Diastolic (Congestive) Heart Failure, Chronic Obstructive Pulmonary Disease, Disorders of Electrolyte and Fluid Balance, and Urinary Tract Infection. R3's Order Review Report, dated 12/12/23, documents: Insulin Glargine Solution 100 UNIT/ML 25 unit subcutaneously at bedtime for diabetes. Humalog Injection Solution 100 UNIT/ML (Insulin Lispro) 3 unit…

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

Based on observation, interview, and record review, the facility failed to follow their policy and procedures for infection prevention and control by: 1. Failed to ensure that proper PPE (Personal Protective Equipment) such as N95 mask is worn by staff during COVID outbreak in the affected area. 2. Failed to ensure that a sign will be provided outside the room for residents on transmission-based precautions indicating the type of the precaution for 5 residents (R9, R14, R60, R68, R274). 3. Failed to follow enhanced barrier precaution policy and procedures for resident (R68) with PICC (peripherally inserted central catheter) line. These failures affect 5 residents (R9, F14, R68, R274, and R60), and could potentially affect 23 residents residing on 3rd floor for facility's census, dated 12/12/23, reviewed for infection control. The findings include: 1. R9's health record documented admission, dated 3/9/2020, with diagnoses not limited to Covid-19, Spinal stenosis, lumbar region with neurogenic claudication, Mixed hyperlipidemia, Personal history of covid-19, Generalized anxiety…

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: (1) provide eligible residents and/or resident representatives education regarding the benefits and potential side effects of all available pneumococcal and Influenza vaccinations; (2) assess eligibility and offer Influenza vaccination to 2 (R9, R68) residents; and (3) assess eligibility and offer pneumococcal vaccinations to 4 (R9, R60, R68 and R274) residents. These failures affect 4 (R9, R60, R68 and R274) of 5 residents reviewed for pneumococcal / influenza vaccinations. The findings include: 1. R9's health record documented admission date of 3/9/2020, with diagnoses not limited to Covid-19, Spinal stenosis, lumbar region with neurogenic claudication, Mixed hyperlipidemia, Personal history of covid-19, Generalized anxiety disorder, Major depressive disorder, single episode, Chronic kidney disease stage 3b, Unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Essential (primary) hypertension,…

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

Based on observation, interview, and record review, the facility failed to ensure the residents were treated with respect and dignity by not passing out meals to residents sitting at a table at the same time. These failures affected 1 resident (R70) reviewed during dining in a total sample of 19 residents. Findings include: R70's diagnosis which includes but not limited to End Stage Renal Disease, Type 2 Diabetes Mellitus Without Complications, Hypertension, Chronic Diastolic Congestive Heart Failure, Dependence on Renal Dialysis, Anemia In Chronic Kidney Disease, Malignant Neoplasm Of Sigmoid, History Of Falling, Unspecified Protein Calorie Malnutrition, and Pressure Ulcer Of Sacral Region, Stage 3. R70's Physician Orders, dated 12/12/23, documents Regular diet, ordered 12/08/23, and resident sent out to ER (Emergency Room) for evaluation of aggressive behavior, dated 11/30/23. R70's MDS (Minimum Data Set) from 11/17/23 BIMS (Brief Interview for Mental Status) was 13 out of 15, indicating intact cognition. R70's nutrition care plan, dated 12/11/23, documents, (R70) is at high…

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

Based on observation, interview, and record review, the facility failed to ensure the call light was within reach for 1 (R60) resident reviewed for accommodation of needs in a sample of 19. Findings Include: R60 has diagnoses not limited to Extended Spectrum Beta Lactamase (ESBL) Resistance, Major Depressive Disorder, Insomnia, Hallucinations, Dementia in other Diseases Classified Elsewhere, Mild, with other Behavioral Disturbance, Acute on Chronic Diastolic (Congestive) Heart Failure, Essential (Primary) Hypertension, Chronic Kidney Disease, Stage 3, Anemia in Chronic Kidney Disease, Cognitive Communication Deficit, Lobar Pneumonia, and Acute Cough. R60's Care Plan documents: Intervention: Keep call light within reach when in bedroom or bathroom Date Initiated: 12/08/23. Focus: (R60) has an ADL (Activities of Daily Living) self-care deficits r/t (related/to) decline in ADL functions. Resident needs staff assistance to safely complete ADL task r/t cognitive impairment, confusions, poor balance, limited mobility and decrease activity endurance. Intervention: CALL LIGHT: Call light…

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

Based on interview and record review, the facility failed to obtain a Physician's order with the code status for 2 (R14, R66) of 2 residents reviewed for Advance Directives in a sample of 19. Findings Include: 1. R66 has diagnosis not limited to Acute on Chronic Systolic (Congestive) Heart Failure, Paroxysmal Atrial Fibrilelation, Acute Embolism and Thrombosis of Right Axillary Vein, Essential (Primary) Hypertension, Acute and Chronic Postprocedural Respiratory Failure, Personal History of Pneumonia, Cardiomyopathies, and Cognitive Communication Deficit. R66's Care Plan documents: Focus: (R66) Advance Directive Status (Code Status: Full Code) Pursuant to resident rights, personal choices, and the individual's desire to retain control and autonomy over his health care decisions, the individual (or representative) has been educated on Advance Health Care (including end of life care) options. Date Initiated: 11/25/23. Intervention: As indicated, document the code status on the Physician's Order Sheet (POS) in the EMR system Date Initiated: 11/25/23. Order Summary Report has no…

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 physician ordered oral nutritional supplements. This failure affected 2 residents (R23, R34) of 6 residents reviewed for nutrition. Findings include: On 12/12/23 during initial kitchen tour conducted between 9:15-9:56 AM, observed cases of Magic Cup supplement stored in the reach-in freezer. 1. R34's diagnosis includes but not limited to Unspecified Protein Calorie Malnutrition, Alzheimer's Disease, Major Depressive Disorder with Severe Psychotic Symptoms, Schizophrenia, and Unspecified Bipolar Disorder. R34's Order Review Report, dated 12/12/23, documents in part Magic Cup three times per day, ordered on 10/11/22. R34's MDS (Minimum Data Set) from 12/07/23 indicates BIMS (Brief Interview for Mental Status) was not conducted. R34 is rarely/never understood. R34's nutrition care plan, dated 12/05/23, documents R34 is at risk for compromised nutritional status related to diagnosis of Alzheimer's Disease and R34 has experienced weight loss. Interventions include but not limited to Magic Cup three times…

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 received the correct oxygen flow rate as ordered for 2 (R4, R66) of 2 residents reviewed for respiratory care in a sample of 19. Findings Include: 1. R66 has diagnoses not limited to Acute on Chronic Systolic (Congestive) Heart Failure, Paroxysmal Atrial Fibrillation, Acute Embolism and Thrombosis of Right Axillary Vein, Essential (Primary) Hypertension, Acute and Chronic Postprocedural Respiratory Failure, Personal History of Pneumonia, Cardiomyopathies, and Cognitive Communication Deficit. Order Review Report, dated 12/12/23, documents: Oxygen 2L (Liters)/min (Minute) via nasal cannula to maintain Oxygen Saturation level equal or above 92% as needed for SOB (Shortness of Breath). R66's Care Plan documents Focus: R66 is at risk for alteration in respiratory functioning related to CHF (Congestive Heart Failure), Acute on Chronic respiratory failure, Hx (History) of pneumonia and Hx of R (Right) Hydropneumothorax s/p…

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

Based on interview and record review, the facility failed to follow their fall policy and R5's comprehensive care plan to prevent further falls for 1 of 6 residents reviewed for falls. Findings include: R5's face sheet documents medical diagnoses of lack of coordination and abnormalities of gait and mobility. R5's Fall Risk Evaluation, dated 7/29/2023, documents R5 is at high risk for falls. R5's Significant Change MDS (Minimum Data Set) Assessment, dated 10/28/2023, documents R5 requires partial/moderate assistance with toileting hygiene and toilet transfer. R5's comprehensive care plan contains a focus that documents R5 is at high risk for falls related to history of falls, Parkinson's Disease, poor safety awareness, poor balance, coordination, limited mobility, and decreased activity endurance. R5 also continues to over-estimate functional limitation. Intervention initiated on 8/23/2022 documents in part: Staff to address [R5's] needs with a prompt response to all requests for assistance. V8's (Nurse) progress note, dated 11/05/2023 at 1:53 PM, documents: The resident fell on 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 observation, interview, and records review, the facility failed to follow their policy on resident food preferences for one (R6) of four residents reviewed. Findings include: R6 is a [AGE] year-old individual, admitted to the facility on [DATE]. R6's medical diagnoes include but are not limited to Type 2 Diabetes Mellitus with Diabetic Neuropathy, unspecified, and mixed hyperlipidemia. R6's BIMS (Brief Interview for Mental Status) Score, dated [DATE], documents R6's score as 15/15, indicating R6's cognation is intact. On 10/05/2023 on 10:00am, R6 said she does not get her boiled egg each morning, which she prefers, despite requesting for it each day. R6 further stated she has received the boiled egg only once, and even today she did not receive one. On 10/05/2023 10:55am, V5(Food Services Director) said she met R6 about two weeks ago, and R6 told her of her food preferences, including boiled egg/s for breakfast, no sweeteners, no canned foods. V5 said today's breakfast was baked egg with cheese and…

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