Warren Barr South Loop

Based on observation, interview and record review, the facility failed to ensure a low air loss mattress device was on the correct setting for 1 out of 2 residents (R4) for a total sample of 35 residents. This failure has potential to affect 1 resident (R4) at risk for a worsening pressure ulcer.Findings Include:On 4/21/26 at 1:23 PM, surveyor entered R4's room. R4 was observed lying in bed. R4 was on a low air loss mattress, setting noted below 80 pounds (lbs.).On 4/21/26 at1.28 pm, Surveyor and V8 (Registered Nurse) entered R4's room, V8 stated mattress not set to the right pressure, V8 changed the setting to 140lbs based on the current weight. V8 stated nurses can change the settings according to the current weight. The purpose of low air loss mattress is to offload pressure points. If it is not in the correct setting it can cause problems.On 04/21/2026 1:37 PM, V19 (Restorative) Stated primarily wound care nurse audits the setting and correct setting according to weight. Sometimes nurses also change the setting.On 04/23/2026 10:54 AM, V33 (Wound Care Nurse) stated that Residents…

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 proper tracheostomy care for one resident (R7) in a total sample of 35 residents reviewed.Findings Include:R7's face sheet documents that R7's diagnosis is not limited to cerebral infarction, Respiratory Disorder, Acute and Chronic Respiratory Failure, Myocardial Infarction, Emphysema and resident is on tracheostomy requiring continuous oxygen.R7's care plan with review date of 07/21/2025 documents in part, ensure that call light cord within easy reach, elevate head of bed, as needed, trach-suction secretions as needed, observe color, amount and consistency of sputum, provide over-bed table for positioning comfort while sleeping, remind to deep breath and cough.R7's MDS (minimum data set) dated 02/09/2026, documents that R7 does not score on the BIMS (brief interview for mental status), indicating that R7 is cognitively impaired.On 04/22/2026 at 11:29 AM, this surveyor observed R7 laying on his bed in a semi-flower position. R7's tracheostomy tubing was positioned to the right side of the neck, while…

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 proper pharmaceutical services to meet a resident's needs which includes acquiring and accurately administering a medication for one (R213) resident out of five residents reviewed in a total sample of 35. Findings include:On 04/22/2026 at 7:49 AM, V9 (Registered Nurse) crushed the following two medications and placed them in two separate medicine cups mixed with applesauce: Aspirin 81mg (milligram) 1 tablet via mouth, Diltiazem ER (Extended Release) 120 mg 1 capsule via mouth. When V9 crushed Diltiazem, V9 removed the purple hard part of the capsule, and the particles were released in a medicine cup and mixed with applesauce. V9 proceeded to administer the medication to R213. On 04/22/26 at 10:58 AM, this surveyor informed V9 that diltiazem hydrochloride extended-release capsule is not recommended to be crushed. V9 stated when I tried to change it from capsule, the pharmacy told me it does not come in any other form, it does not come in tablet or liquid. V9 stated that she notified the doctor last week…

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 three (R23, R199, and R213) of five residents reviewed for medication administration resulting in a 12% error rate.Findings include:On 04/22/2026 at 7:49 AM, V9 (Registered Nurse) administered Trelegy Ellipta 100mcg (microgram)/62.5 mcg/25 mcg via inhale 1 puff to R213. V9 instructed R213 to inhale and rinse only and did not instruct R213 to spit out. After R213 inhaled, R213 rinsed and swallowed the water provided. On 04/22/2026 at 8:30 AM, V9 stated that R199 was scheduled for a nebulizer treatment. V9 told R199 that she would set a timer on her phone for fifteen minutes. V9 administered the nebulizer treatment to R199 via a respiratory mask. V9 turned on R199's breathing treatment (lpratropium-Albuterol Inhalation Solution) at 9:02 AM. V9 left R199's room and moved the medication cart to the next room. This surveyor remained in the hallway in front of R199's room. This surveyor heard R199 coughing occasionally.On 04/22/2026 at 9:19 AM, R199 was still 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.

Based on observation, interview, and record review, the facility failed to provide a accessible functioning call light for one resident (R7) in a total sample of 35.Findings Include:R7's face sheet documents that R7 diagnosis is not limited to cerebral infarction, Respiratory Disorder, Acute and Chronic Respiratory Failure, Myocardial Infarction, Emphysema and resident is on tracheostomy.R7's care plan with review date of 07/21/2025 documents in part, ensure that call light cord within easy reach.R7's MDS (minimum data set) dated 02/09/2026 , documents that R7 does not score on the BIMS (brief interview for mental status), indicating that R7 is cognitively impaired.On 04/22/2026 at 11:29 AM, this surveyor observed R7 laying on his bed in a semi-flower position. R7's tracheostomy tubing was positioned to the right side of the neck, while the oxygen was on. Surveyor attempted to use the call light to ask for assistance, and the call light was pressed at 11:31 AM.On 4/22/2026 at 11:32 AM, V36 (Certified Nurse Aide/ CNA) was observed passing the room and did not answer the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and records review that facility failed to provide adequate supervision for one (R1) resident in a sample of four reviewed. This failure has the potential to affect all residents who need an escort while out of the facility on an appointment.R1's current face sheet documents R1 is a [AGE] year-old individual with medical diagnoses that include but not limited to: other encephalopathy, opioid abuse, uncomplicated, malignant neoplasm of overlapping sites of left female breast. MDS (Minimum Data Set) section C dated Sep 29, 2025, documents R1's Brief Interview for Mental Status (BIMS) as 12/15 indicating R1 has moderate cognitive impairment.On 09/30/2025 at 10:24 AM, V3 (Registered Nurse-RN) stated R1 needs an escort to appointments for safety because R1 gets confused and R1 can be in danger of getting lost or being abused if R1 goes to appointments alone.On 09/30/2025 at 12:19 PM, V5 (Work Clerk) stated he schedules appointments for residents and if a resident does not have intact cognitive…

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 wound care specialist's recommendation to treat a resident's pressure ulcer and failed to revise the comprehensive care plan addressing a resident's new skin alteration. These failures affected one (R1) out of three residents reviewed for wound care.Finding Include:R1's clinical records show an original admission date of 6/12/25 with included diagnoses but not limited to acute and chronic respiratory failure with hypoxia, anoxic brain damage, and encounter for attention to tracheostomy, and gastrostomy. R1's progress notes show R1 was discharged to hospital on 7/7/25, 7/11/25, 7/19/25, 8/9/25, 8/23/25, and 9/6/25. readmitted back to facility on 7/9/25, 7/15/25, 7/26/25, 8/20/25, and 8/31/25. R1's Quarterly Minimum Data Set assessment dated [DATE] shows R1 is cognitively impaired and is dependent on staff's assistance for his activities of daily living.R1's Wound Assessment Report dated 9/4/25 documented by V23 (Wound Care Nurse Practitioner)…

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, facility failed to follow their policy to ensure residents have a homelike environment for 3 (R1, R8, R9) out 5 residents reviewed for homelike environment in a sample of 11. Findings include:On 09/09/2025, surveyor observed R1's room had a broken thermostat with no temperatures indicating the temperature in the room. R1's dresser also had a missing handle with drawers that would not close. R1's dresser was also dirty with hardened paste all over it. R8's thermostat was also broken thermostat with no indication of the temperature. R9's thermostat had no temperatures marking on it. R1, R8 and R9's thermostat's analog dial did not have any markings on it to indicate if the thermostat was set to cool or hot.On 09/09/2025 at 10:30 AM, V7 (R1's POA) stated that R1's thermostat is broken and there is no way for us to know what temperature is being set in the room. V7 also pointed to R1's dresser and showed the hardened paste all over the dresser. V7 stated that some drawers would not even close.On 09/09/2025 at 1:14 PM, V3 (Maintenance…

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

Based on interview and record review, the facility failed to ensure hemodialysis services were provided 3 times weekly as ordered by physician to a resident (R5). This failure has the potential to affect 1 (R5) of 3 residents reviewed for Quality of Care /Treatment. The findings include: R5's admission record showed admit date on 02/18/2025 with diagnoses not limited to End stage renal disease, Dependence on renal dialysis, Arthritis due to other bacteria right knee, Acute and chronic respiratory failure with hypoxia, Gout, Benign prostatic hyperplasia, Type 2 diabetes mellitus, Chronic diastolic (congestive) heart failure, Unilateral primary osteoarthritis right knee, Essential (primary) hypertension. R5 was discharged to facility on 3/10/25. R5's order summary report dated 4/1/25 showed order not limited to: Hemodialysis MWF (Monday, Wednesday, Friday). On 4/1/25 at 2:22 PM V17 (LPN / Licensed Practical Nurse) stated she has been working in the facility for 2 years and is regularly assigned on the 1st floor. She said she had worked with R5 who was receiving HD (hemodialysis) 3x…

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 food items were properly labeled and dated, and failed to ensure kitchen staff wore appropriate hair covering. These failures have the potential to affect all 153 residents receiving food prepared in the facility's kitchen. Findings include: On 02/18/25 at 9:21 AM, upon entering the kitchen to conduct initial kitchen tour observed V11 (Food Service Director) walking around the kitchen without any hair coverings (no hairnet, no beard or mustache covering). When V11 saw surveyor, he immediately left the kitchen and reentered the kitchen at 9:25 AM wearing a beard protector covering his heard but not covering his mustache and he was not wearing a hairnet to cover the hair on his head. On 02/18/25 at 9:28 AM, V11 stated anyone who enters the kitchen must wear a hair net and any staff with facial hair should wear a beard guard. V11 stated the purpose of wearing hair coverings is to prevent hair from falling into the food being prepared for the residents. Surveyor brought to V11 attention that he was 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 observations, interviews and record reviews, the facility failed to follow their infection control policies and procedures by not having the correct transmission-based precaution signage for two residents (R151, R290), failed to place an isolation cart outside a resident's (R290) room who was on contact isolation, failed to ensure two residents (R16, R181) were placed on Enhanced Barrier Precautions (EBP), and failed to wear the appropriate personal protective equipment when entering a COVID-19 positive resident's (R151) room. The facility also failed to have policies and procedures for distributing information regarding the risks associated with shingles and how to protect the residents against the varicella-zoster virus, HIV, Hepatitis B, and Hepatitis C screening and (c) Hepatitis B immunization. These failures have the potential to affect all the residents that reside in the facility. Findings include: R151's Point of Care Test Results for SARs-CoV2 document in part that R151 tested positive for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the appropriate side rails were used for three residents (R16, R28, R144), and failed to follow their policy and evaluate the use of side rails at least quarterly for two (R132, R99) residents out of a total sample of 35 residents. Findings Include: 1. On 2/18/25 at 11:54 AM, R16 was lying in bed alert with some forgetfulness and noted with three half side rails up; 2 half upper rails and 1 half lower rail. Reviewed R16's side rail assessment dated [DATE] revealed R16 was assessed to only use 2 half-length rails for assistive device to turn and reposition and/or transfer. R16's Minimum Data Set (MDS) dated [DATE] shows R16 is cognitively impaired and needs staff assistance with activities of daily living (ADLs). 2. On 2/18/25 at 12:52 PM, R144 was sitting on the side of the bed trying to eat lunch with R144's both legs squeezed in between the two half side rails that were up on the right side of R144's bed. The other two half side…

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 safely secure medication in a locked storage area to limit access to unauthorized personnel for 1 (R442) resident. The facility also failed to properly date opened multi-dose inhalers for 1 resident (R46), failed to properly date opened multi-dose insulin pens for 3 residents (R16, R51, R129), and failed to ensure opened multi-dose insulin pens were stored to prevent the potential for cross contamination for 2 residents (R51, R129) from one of five medication carts and one of three medication rooms inspected for medication storage and labeling. Findings Include: On 2/18/25 at 10:46 AM, inspected first floor medication cart 2 with V6 (Agency Registered Nurse) and noted R46's Arnuity Ellipta inhaler without the date opened written on the label. R46's Arnuity inhaler shows on the label to discard 6 weeks after opening. On 2/18/25 at 12:42 PM, inspected fourth floor medication room with V47 (Licensed Practical Nurse) and noted the following:…

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 prepare pureed food in appropriate diet consistency form. This failure has the potential to affect 19 residents (R3, R11, R16, R17, R20, R28, R43, R55, R59, R65, R85, R88, R95, R130, R138, R144, R148, R175, R184) receiving pureed diets prepared in the facility kitchen based on list of residents receiving pureed diets dated 02/18/25. Findings Include: On 02/18/25 at 12:40 PM, observed R138 sitting in room eating lunch. Observed a pile of food particles on the side of R138's plate. R138's meal ticket list Cardiac-Pureed. Observed R138 put a spoon full of pureed ham into mouth and then take her fingers to pull out particles of food from her mouth and place them into the pile on the side of the plate. R138 stated there is skin and [NAME] in the ham which she cannot chew so that is why she has to remove them from her mouth. On 02/18/25 at 12:56 PM, V11 (Food Service Director) observed R138 still eating her lunch with pile of food particles on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to provide therapeutic diets and dietary interventions as prescribed by the physician and Registered Dietitian for four residents (R31, R138, R158, R391) reviewed in a total sample of 35. Finding include: On 02/18/25 at 12:33 PM, observed R158 eating lunch in room. R158's meal ticket read in part to give soup at lunch & dinner, mechanically altered/ground baked ham 6 ounces (Double Protein), 8-ounces 2% milk, 4-ounces fortified pudding, Mrs. Dash Seasoning. R158 did not receive double portion of ground ham, and tray was missing soup, fortified pudding, dessert (missing standard dessert), milk and Mrs. Dash Seasoning packet. R158 stated he likes milk with every meal, soup with lunch & dinner and some kind of dessert. R158 stated that he likes pudding and I didn't get any type of dessert today, see? R158 stated sometimes I get those things, but sometimes I don't get them, like today and I just eat what they give me. I don't complain. R158…

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 identify a resident's (R113) code status for one out of 35 residents reviewed for advanced directives. Findings include: R113's admission Record documents in part medical diagnoses of dementia and adult failure to thrive. On [DATE] at 1:08 PM, R113's Care Plan Report documents in part that R113 received education on advanced directives and end of life care options. Pursuant to resident rights, the advanced directive status of Full Code has been selected (initiated [DATE]). The goal was as follows: [R113] wishes for Full Code status as specified in advance directive documents will be honored and delineated in the medical record in compliance with state law through next review (initiated [DATE]). Interventions initiated on [DATE] include: As indicated, my advanced directives code status will be documented on my physician order sheet in the electronic medical system and be clearly identified on my electronic chart page so that the facility personnel…

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

Based on observation, interviews, and record reviews, the facility failed to follow their policy and assess a resident's (R99) need for restraints at least quarterly for one resident out of a total sample of 35 residents. Findings include: R99's admission Record documents in part diagnoses of acute respiratory failure with hypoxia, stiffness of the right hand, anxiety disorder, conversion disorder with seizures or convulsions, and contracture of the left hand. R99's Order Summary Report documents in part an active order to Apply Bilateral sheepskin restraint to avoid resident pulling trach (order date 1/28/2025). Prior to the sheepskin restraint, R99 also had an order to Apply Bilateral soft wrist restraint to avoid resident pulling trach (order date 8/19/2024). R99's Care Plan Report contains an update from 1/28/2025 regarding application of sheepskin wrist restraint. The listed goal did not reflect the sheepskin wrist restraint. It read [R99] will not have injury or complications related to bilateral soft wrist restraint use thru next review (Target Date 5/05/2025). On 2/18/2025…

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

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 a resident (R56) with current pressure ulcer and for a resident (R66) who is high risk in developing pressure ulcers. This failure has the potential to affect two (R56, R66) out of two residents reviewed for pressure ulcer care in a final sample of 35. Findings Include: On 2/18/25 at 12:16 PM and on 2/19/25 at 10:57 AM, R56 was noted lying in bed and noted on a low air loss mattress with the machine set to 120 pounds (lbs.). On 2/18/25 at 12:14 PM, R66 was sleeping in bed and noted on a low air loss mattress with the weight dial on the machine set to 180 lbs. On 2/19/25 at 10:49 AM, R66 was lying in bed alert and able to verbalize needs still noted on a low air loss mattress with the weight dial on the machine set to 180 lbs. R66 stated that [R66] feels like lying on a wood block because the mattress is too firm. On 2/19/25 at 11:19 AM, interviewed V29 (Wound Care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow the smoking policy and smoking assessment to ensure that smoking materials are not kept by the resident in their room. This failure has the potential to effect 2 (R110, R141) residents reviewed for smoking in a total sample of 35. Findings include: On 02/18/25 at 12:04 PM, observed red Oxygen in Use sign posted outside R110 and R141's room. R110 stated she smokes and is allowed to smoke independently meaning she can go outside to smoke whenever she wants unsupervised, and she is allowed to keep her cigarettes and lighter in her room. Observed R110 open her side table drawer, reach inside, and remove an opened pack of cigarettes and a lighter with fluid in it. On 02/18/25 at 12:06 PM, observed an oxygen tank on R141's side of the room in the corner next to R141's bed. Also observed a nebulizer machine on R141's bedside table. On 02/18/25 at 12:14 PM, V13 (Registered Nurse) looked in R141's electronic health record (EHR) orders 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 follow their policies and procedures to ensure a resident received medications according to the physician's order for 1 (R441) out of 8 residents reviewed for pharmaceutical services. The facility also failed to follow their policies and procedures to properly dispose of controlled substances dispensed to its residents due to discontinuance of the medication, and failed to account for and dispose of controlled medications in a manner that would decrease the possibility of loss or diversion. These failures were found for two residents (R35, R162) during narcotic reconciliation from two out of five inspected medication carts. Findings include: On 2/18/25 at 10:46 AM, surveyor reviewed the first-floor team two medication cart with V6 (Agency Registered Nurse). In the narcotics bin, there was a blister packet for R162's Oxycodone 5 mg capsule. There were thirteen capsules in the blister packet. The number six and number two slots were…

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 resident's food preference was followed for one (R81) out of 3 residents reviewed during dining observation in a final sample of 35. Findings Include: On 2/18/25 at 1:00 PM, Surveyor entered R81's room and observed R81's eating lunch in bed alert and able to verbalize needs. R81 stated, What is this on my plate? I don't see it listed on this menu (R81 pointed at her meal ticket). I don't want to eat it. I don't know what it is. I don't eat pork or beef. Do you know what type of meat this is? Surveyor observed R81's lunch tray with diced carrots, pudding, cornbread, diced sweet potato, and ham with gravy. R81 stated that [R81] cannot eat beef of pork because R81 gets indigestion. R81 stated that the kitchen staff knows that R81 does not eat beef or pork. On 2/19/25 at 2:46 PM, interviewed V31 (Registered Dietitian) and V31 stated that V31's progress notes on 9/26/24 for R81 indicate that R81 does not eat pork or beef. V31 stated, The meal tracker says [R81] dislikes pork or beef and [R81] should not be…

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

Based on interviews and record reviews, the facility failed to administer influenza and pneumococcal vaccines in a timely manner for three residents (R93, R118, R151) out of five residents reviewed for immunizations. Findings include: On 2/19/2025 at 12:29 PM, V2 (Director of Nursing) stated facility holds immunization clinics if there are enough people that consent to the vaccines. If there are only a few residents interested, then the facility will get the vaccines from the pharmacy. The facility will special order them and facility staff will then administer them. On 2/20/2025, facility provided sampled residents' influenza and pneumococcal consents. R93's Informed Consent for Vaccination - influenza was signed on 9/18/2024. There is no facility representative signature listed as a witness. R93 did not receive the vaccine until 11/15/2024. Facility's Immunization Monitoring - Current Residents also documents administration date of 11/15/2024. R118's Informed Consent for Vaccination - influenza was signed on 9/17/2024. R118 did not receive the vaccine until 10/25/2024. Facility'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 interviews and record reviews, the facility failed to administer a COVID-19 vaccination in a timely manner for one resident (R118) out of five residents reviewed for immunizations. Findings include: R118's admission Record documents in part diagnoses of cerebral infarction (stroke), muscle wasting, muscle atrophy, hypertension (high blood pressure), and seizures. R118's Informed Consent for COVID-19 Vaccine documents in part that it was signed on 10/22/2024. Facility did not administer the vaccine until 1/17/2025. The facility's Immunization Monitoring - Current Residents form also documents in part that R118 received the COVID-19 vaccine on 1/17/2025. On 2/19/2025 at 12:29 PM, V2 (Director of Nursing/acting Infection Preventionist) stated the facility does COVID-19 clinics when there are enough people that consent to it. If there are only a few residents interested, then the facility will get the vaccines from the pharmacy. The facility will special order them and facility staff will then administer them. On 2/20/2025 at 12:07 PM, V2 stated [V2] did not know why there 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure residents who are unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming for 2 (R1, R6) of 6 (R1,R2, R3, R4, R5, R6) residents reviewed for ADL care. This failure resulted in the facility failing to comb and shampoo hair for Resident's (R1, R6). Findings Include: R1 has a readmission date to the facility on [DATE] with diagnosis not limited to Wheezing, Conversion Disorder with Seizures or Convulsions, Secondary Hypertension, Gastrostomy, Dysphagia, Oropharyngeal Phase, Tracheostomy, Psychoactive Substance Abuse, Pulmonary Embolism, Encounter for Surgical Aftercare Following Surgery on The Respiratory System, Essential (Primary) Hypertension, Major Depressive Disorder, Anxiety Disorder, Contracture, Left Hand, Resistance to other Specified Beta Lactam Antibiotics, Gastro-Esophageal Reflux Disease, Encephalopathy, Acute Respiratory Failure with Hypoxia, Pressure Ulcer 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, facility failed to follow their policy to investigate an allegation of abuse for one of three residents (R4) in the sample of four. Findings include: On 11/17/2024, at 10:26 AM via telephone, V3 (R4's sister) said R4 was hit in the face in the morning of 11/6/2024, prior to R4's discharge from the facility. V3 said she reported the incident that day to a male ADON (V4-Assistant Director of Nursing) who said he would look into it. V3 said she also spoke with the V2 (Director of Nursing) who said she would look into it. V3 said I have not heard anything. On 11/17/2024, at 1:38 PM, V4 (Assistant Director of Nursing) said he was informed of alleged staff to resident abuse involving R4 and staff. V4 said I immediately reported it to the V1 (Administrator). V4 said I don't remember the details; I think I spoke with the resident's sister V3. On 11/17/2024, at 1:44 PM V2 (Director of Nursing) I never heard about any concern regarding R4. V2 said staff are supposed to notify the V1 (Administrator) immediately (of any allegation of abuse). On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to properly identify/assess a resident (R1) for the source of an injury in a timely manner and failed to recognize and/or assess risk factors placing the resident at risk for specific conditions and/or problems. This failure was for one (R1) resident out of three residents reviewed for injury of unknown origin in the sample of four. Findings include: R1's hospital record dated 11/13/2024, documents in part, multiple wounds/burns. pt-patient (R1) has significant burn marks/bruising on R (right) side, stated hot water was spilled on her at facility. APS (adult protective service) called. Wound care. On 11/17/2024, 12:45 PM, R1 stated that she accidentally spilled hot water on herself. R1 stated it happened during mealtime about 2-3 weeks ago. R1 is not able to remember the exact date. R1 stated that she denies reporting it to staff when it happened. R1 stated that she denies any staff hurting her and denies any staff spilling hot water on her. R1 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 interview and record review, the facility failed to notify resident's Responsible Party of pressure ulcer changes for 1 (R8) of 4 (R1, R2, R3) residents reviewed for pressure ulcers. Findings Include: R8 was admitted to the facility on [DATE] with diagnosis not limited to Cardiac Arrest due to Underlying Cardiac Condition, Encephalopathy, Tracheostomy, Gastrostomy, Anoxic Brain Damage, Essential (Primary) Hypertension, Retention of Urine, Chronic Kidney Disease, Stage 3, Hyperosmolality and Hypernatremia, Adult Failure to Thrive, Dysphagia, Oral Phase, Monoclonal Gammopathy, Type 2 Diabetes Mellitus with Hyperglycemia, Specified Anemias, Abdominal Aortic Aneurysm, Multiple Myeloma, Vascular Implants and Grafts, Acute on Chronic Diastolic (Congestive) Heart Failure, Acute and Chronic Respiratory Failure with Hypoxia, Contracture, Right Hand, Contracture, Left Hand, Muscle Wasting and Atrophy, Reduced Mobility, Restlessness and Agitation. R8's Care Plan documents in part: R8 has actual impairment to skin…

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 records review and interview the facility failed to provide an individualized or person-centered care plan for a resident who has an order for restraints due to pulling out of tracheostomy care. This failure applies to 1 out of 4 residents (R1) reviewed for plan of care. This failure has affected 1 resident (R1) by pulling his tracheostomy the second time. Findings include: R1 was initially admitted on [DATE] in the facility. Discharge record from the hospital dated 8/6/2024 documents that R1 uses tracheostomy that was providing oxygen at 28 percent. R1's medical diagnosis related to need for tracheostomy with 28 percent oxygen was respiratory failure. R1 had an order for soft restraints on both wrists dated 8/6/2024 upon admission due to pulling out his tracheostomy. On 8/7/2024 the day after R1 was admitted , V10 (RN/Supervisor) in her progress notes documented that she was notified by her Certified Nursing Assistant that R1 pulled out his tracheostomy. V11 (Respiratory Therapist) was notified. Per…

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 record reviews, interviews, and observation the facility fails as follows: to provide respiratory care as per physician's order; to provide interventions for plan of care that would help prevent tracheostomy dislodgement; to provide close monitoring of tracheostomy for a resident with history of multiple incidents of decannulation or dislodgement by following physician's order and/or plan of care. These failures apply to 1 out of 4 residents (R1) reviewed for respiratory care via tracheostomy. These failures that include not closely monitoring, not following physician orders and/or care plan interventions resulted in facility staff not being aware of decannulation or dislodgement of tracheostomy that provides oxygenation essential for 1 resident's (R1) airway. R1 was found expired with tracheotomy dislodgement. Findings include: R1 was initially admitted on [DATE] in the facility. The discharge record from the hospital dated [DATE] documents that R1 uses tracheostomy that was providing oxygen at 28…

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 review the risks and benefits of bed rails, failed to perform a bed rail assessment, and failed to obtain a physician order for bed rails for one of three residents (R11) reviewed for injury of unknown origin. Findings include: On 7/30/24 at 11:41am, R11 was observed lying in bed, on his back, with a soft cast placed on R11's left hand, and with the 2 upper bed rails secured in up position. R11 stated, I broke my left finger because I hit it on the rail (R11 pointed to the right upper bedrail that was secured in the up position). Man did it hurt! I called the nurse, and they sent me to the hospital. That's how I got this cast on my hand. I use the rails to help me get up and move. It's feeling better now. I was never shown how to use these rails. No one told me I could be injured on these rails. I cannot believe I broke my finger on this rail. On 7/31/24 at 9:15am, R11 was observed again, lying in bed, on his back, with a soft cast placed…

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 resident received enteral nutrition feedings via G-tube per physician orders for one (R2) resident out of three residents reviewed. Findings include: On 04/06/2024 at 10:52AM, surveyor located inside R2's room and observed R2 lying in bed in her room in a supine position with head of bed elevated at 45 degrees. Surveyor observed an enteral feeding pump adjacent to R2's bed. Surveyor observed R2's enteral feeding container labeled as follows: Nepro 1000ml dated 04/05/2024. R2's enteral feeding observed with approximately 500ml left in the container. R2's enteral feeding container and tube feeding equipment observed hanging on a pole next to R2's feeding pump. R2's enteral feeding pump observed turned off, feeding tube observed not connect to feeding pump and not infusing. On 04/06/2024 at 10:58AM, surveyor observed V5 (Agency LPN) sitting at a computer at the 5th floor nurses' station. Surveyor located at the nurses' station with V5 and asks V5 to deploy R2's electronic medical record on the computer.…

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 the following practices related to the kitchen: failed to follow the policy on maintaining a clean kitchen environment; failed to follow the policy on labeling and dating food stored in bins; failed to discard food beyond suggested date for consumption; failed to ensure the strip used for testing the 3-compartment sink was not expired; and failed to ensure a thermometer is available to monitor temperature of the freezers. These failures of practices have the potential to affect all 149 residents taking food by mouth. Findings include: On 02/27/2024 at 10:03 AM, with V11 (Food Services Director) providing tour of the kitchen. At the area where four (2) large plastic bins were stored: one (1) bin was filled with oatmeal and another bin has a large paper bag with bread crumbs(both bins have no labels and no dates.) V11 stated that there should be a date placed on every food item placed inside the bins. On 02/27/2024 at 10:10 AM, there are four large fans attached to the wall about seven (7) to eight (8) feet…

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 records review, the facility failed to label and store medications according to their policy for ten residents (R44, R49, R93, R98, R105, R110, R118, R158, R337, R338) in a sample of 36. Findings include: Observations: 2/27/24 at 9:30 AM, 1st floor, 2nd side medication cart (rooms 112-122) with V28 (Licensed Practical Nurse). -Latanoprost 0.005% ophthalmic solution -not labeled with open or discard dates -R93 -R118 -R44 -sealed, not refrigerated -R93 -Clear canal Earwax Softener Drops -expiration date 2023-06 -R105 -Insulin Glargine inject 3ml prefilled pen -not labeled with open or discard dates -R44 -Lantus (Insulin Glargine) 100u/ml vial -not labeled with open or discard dates -R118 -R110 -Lantus (Insulin Glargine) 100u/ml vial -labeled open 11/29/23 -R118 -Humalog (Insulin Lispro) 100u/ml vial -not labeled with open or discard dates -R98 -R110 2/28/24 at 11:45 AM, 2nd floor, 1st side medication cart with V29 (Registered Nurse). -Lantus (Insulin Glargine) 100u/ml vial -sealed, not refrigerated -R338 -R337 2/28/24 at 2:45 PM, 5th floor, 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 observations, interviews and records review, the facility failed to perform refrigerator checks for four residents (R14, R54, R92, R336) in a sample of 36 according to facility policy. Findings include: Observations: On 2/27/24 at 12:00 PM, no thermometer in R14's refrigerator, excess ice buildup in the freezer, bowl of fruit cocktail, not covered and not labeled. On 2/27/24 at 12:30 PM, R336's refrigerator thermometer reading approximately 50 degrees Fahrenheit. On 2/27/24 at 2:00 PM, R54's refrigerator thermometer reading approximately 52 degrees Fahrenheit. On 2/27/24 at 2:30 PM, R92's refrigerator noted with 1% milk carton with manufacturer sell by date 2/6/24. On 2/27/24 at 1:00 PM, V19 (Plant Operations Manager) stated housekeeping is over the refrigerators in the resident rooms. The refrigerators should have thermometers in them. R14's refrigerator does not have a thermometer in it. The thermometer is needed to make sure the temperature is adequate, between 35-41 degrees. Without the thermometer you don't know the temperature inside the refrigerator, don't know if…

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

Based on interview and record review, the facility failed to ensure bedtime snacks were offered to two of five residents (R158, R97) reviewed for bedtime snacks in the sample of 36. Findings include: 2.27.2024 at 1:20 PM, during the Resident Council Meeting, F158 and R97 said they have not received bedtime snacks in about a week. Both said they are diabetics. 2.29.2024 at 12:34 PM, V11 (FSD-Food Service Director) said, the facility does provide bedtime snacks to the residents. We send snacks up to each unit every night, however, it's been an issue especially on the 1st and 5th floors. It has been reported to me by R158 and R97, that the CNAs (Certified Nursing Assistants) have been taking the snacks for themselves and telling residents there are no snacks available. R97 told me she saw them (staff) put them in their bag. The Administrator is aware of the snack issue; he said he would look into it. The kitchen sends the trays (bedtime snacks) up to the units, the next morning the trays are returned to the kitchen; snacks are not passed out. I don't know which units. 2.29.2024 at 1:14…

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

Based on interview and record review, the facility failed to provide Notice of Medicare Non-Coverage for 3 (R387, R388, and R389) out of three residents reviewed for skilled nursing facility advance beneficiary notice of non-coverage in a sample of 36. Findings include: On 02/29/2024 at 11:03 AM, surveyor requested Notice of Medicare Non-Coverage for R387, R388 and R389 from V1 (Administrator). On 02/29/2024 at 3:30 PM, V1 provided Notice of Medicare Non-Coverage for R387, R388, and R389. Surveyor noticed R387, R388, and R389's notices were not signed but just stated verbal consent provided. On 02/29/2024 at 3:35 PM, V1 stated that we always get verbal approval by family members. V1 stated that the notification form does not necessarily need signatures. R387's Notice of Medicare Non-Coverage documents in part: For signature of patient or representative, it says 'Verbal consent by R387's daughter'. Dated, 12/27/2023. R387's Facesheet documents in part: date of discharge is 11/1/2023. Reviewed R387, R388 and R389's progress notes from 08/2023 to 12/2023. No documentation of residents…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and records review, the facility failed to provide proper medication by failing to administer medication as ordered to one (R286) of seven residents reviewed for medications. This deficiency has the potential to affect R286's healing from infection. Findings include: R286's current face sheet documents R286 is a [AGE] year old individual admitted to the facility on [DATE], and her medical diagnosis includes but is not limited to: acute and chronic respiratory failure with hypoxia, systemic inflammatory response syndrome (sirs) of non-infectious origin without acute organ dysfunction, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, dysphagia, oral phase, moderate protein-calorie malnutrition. R286's BIMS (Brief Interview of Mental Status) dated [DATE], does not score R286's BIMS, indicating R268's has Severe cognitive impairment. R286's POS (Physician Order Sheet) dated 10/12/2023…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to get consent for psychotropic medication before starting to administer medications for one (R127) out of seven residents reviewed for psychotropic medication administration in a sample of 36. Findings include: R127's current face sheet documents R127 is a [AGE] year-old individual admitted to the facility with the most current date of admission dated 02/22/2023, and current diagnosis including but not limited to: Anoxic Brain Damage, not elsewhere classified, Malignant (Primary) Neoplasm, unspecified, Anemia, Acute respiratory failure. 02/29/24 12:23 PM V24 (Fall & Psychotropic Nurse-LPN) said before a resident can be started on psychotropic medications, psychotropic education, and consent (signed and dated) are supposed to be completed/obtained before the resident can be started on psychotropic medications. Review of R127's psychotropic consent and medication administration record (MAR) with V24 documents R127 is compliant with her medications. V24…

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 implement education and ensure that its visitor demonstrates proper use of transmission-based precautions to prevent the spread of infections for 1 out of 2 residents (R44) for a total sample of 36 residents. 02/27/24 at 1:11 PM surveyor observed R144's wife at bedside, moving R144's leg and his indwelling foley catheter tubing and not wearing proper personal protective equipment/PPE. 02/27/24 at 1:14 PM, surveyor observed V9 (Infection Preventionist) wearing personal protective equipment/PPE (gown, mask, and gloves) in R144's room. 02/28/24 at 2:23 PM V9 (Infection Preventionist) said that the infection that R144 has is no longer in need to be under contact precautions but instead is on enhanced barrier based precautions. V9 stated that the infection that R144 has is transmitted by direct physical contact to the site. V9 said that enhanced barrier based precautions are like contact precautions. V9 said that the difference is that enhanced barrier based precautions means that if staff or visitors are 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 records review, the facility failed to administer/offer the pneumococcal vaccine to two (R30, R42) of five residents reviewed for vaccines. This deficiency has the potential to expose R20 and R42 to serious illness related to pneumococcal infections. Findings include: R30's current face sheet documents R30 is a [AGE] year-old individual admitted to the facility on [DATE], and her medical conditions include but not limited to: dysphagia, oropharyngeal phase, acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, chronic viral hepatitis C, chronic Obstructive Pulmonary Disease, unspecified, Tracheostomy and Gastrotomy status. R30's BIMS (Brief Interview for Mental Status) dated 10/19/2023 documents R30's BIMS as 99, indicating R30 has severed cognitive function. R30's Immunization Record documents R30 consented to the Pneumococcal vaccine on 12/15/2023, but to date, R30 has not receive the vaccine. R42's current face sheet documents R42 is a [AGE] year-old…

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

Based on observations, interviews and record review the facility failed to provide reasonable access to the use of a telephone to five (R7, R8, R9, R10, R11) residents reviewed for phone access. This deficiency has the potential to affect R7, R8, R9, R10, R11's ability to receive/ make calls without being overheard. Findings include: On 1/29/2024 at 10:58am, V18(Maintenance Director) with surveyor toured several residents room checking if their phones were working. V18 said it was important for residents to have working phones to communicate with their family and friends. V18 said if the residents don't have working phones, they cannot receive or make calls from their rooms. V18 tested R7, R8, R9, R10, R11's phones and stated they are not working, and there was no dialing tone. V18 used his phone to call the phones but the calls did not go through. V18 said staff should check every day to make sure residents phones are working and if they are not working, the staff should report to maintenance to come fix the phones. On 1/29/2024 at 11:20am, R10 said his phone does not work and R10…

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 record reviews and interviews, the facility failed to properly reconcile medication for a resident to the physician or nurse practitioner (NP) that includes diabetic care, failed to follow the diabetic management policy, failed to document, or record medications ordered to be administered on the MAR (medication administration record) for 1 out of 3 residents (R3) reviewed for improper nursing care. These failures have the potential to affect 1 resident in receiving care while in the facility. Findings include: R3 was [AGE] years old. R3's admission date to the facility was [DATE] with a medical diagnosis that includes intracerebral hemorrhage, type 2 diabetes mellitus with hyperglycemia, and an anoxic brain damage. R3 was dependent of all activities of daily living per the admission assessment. Per resident record, R3 stayed in the facility between [DATE] to [DATE] when the resident expired. Medication Administration Record (MAR) for the month of [DATE], reads that multiple medications including an…

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

Based on record reviews and interviews the facility failed to provide accurate progress notes, created new notes by separating single notes with different dates and putting additional notes after discharge of the resident. These failures have the potential to result in inaccurate documentation as to actual or factual events that happened as recorded. Findings include: Full progress notes of R3 were reviewed ranging from 11/21/2023 to 11/26/2023. On 11/28/2023 progress notes by V7 (Licensed Practical Nurse) dated 11/25/2023 and V8 (Respiratory Therapist) dated 11/25/2023 were in draft status. That means that it was not locked and can be modified. Later that day, these notes were locked, and additional notes were added to the progress notes dated 11/25/2023 by V8 (Respiratory Therapist). The original notes do not include (Last seen the resident (R3) around 12AM to suction, resident was stable). On 11/29/2023 at 11:53 AM, V8 was upset when asked about her progress notes dated 11/25/2023 and the additional notes placed on 11/28/2023. V8 stated that after 11/25/2023, she does not have…

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 to reposition a dependent resident in a timely manner to prevent worsening of a pressure ulcer for 1 (R20) out of three residents reviewed for pressure ulcer. This failure led to the resident's pressure ulcer worsening. Findings include: On 11/15/2023 at 10:45 AM, surveyor observed R20 lying on his back in his room. R20 is unable to talk to hold a conversation. V29 (Caretaker for R20) was seen in the room with him. V29 stated that the facility does not turn the resident frequently and that he developed a pressure ulcer here at the facility. On 11/15/2023 at 11:30 AM, surveyor observed R20 lying on his back. On 11/15/2023 at 12:30 PM, surveyor observed R20 lying on his back. On 11/15/2023 at 1:00 PM, surveyor observed R20 lying on his back. On 11/15/2023 at 1:42 PM, surveyor observed R20 lying on his back. On 11/15/2023 at 2:00 PM, V33 (Restorative Aide) stated that she has been helping V31 (Certified Nursing Assistant) with turning and repositioning. V33 stated that she just turned R20. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure residents who depend on staff for ADL (Activities of Daily Living) care received nail care, incontinence care and grooming care. This failure affected 4 residents (R2, R6, R12, and R14) reviewed for ADL care in the total sample of 23 residents. Findings include: On 09/25/2023 at 1:47pm, V9 (Certified Nursing Assistant) and V12 (Certified Nursing Assistant) checked R12. R12's green incontinence brief and chucks were wet. R12's fitted sheet was also wet with brown staining on the edge of the wet area. This observation was brought to the attention of V9. V9 stated yes, yes, I (V9) know. That happens when I (V9) have a lot of people. On 09/25/2023 at 2:08pm, I (R12) pushed the call light she (V9) came and she (V9) told me 'I'll be right back'. First time I (R12) used the call light was at 10:30am, because I (R12) am wet. I've been wet since 10:30 this morning. The only time she (V9) changed me (R12) was at 1:45pm. I (R12) feel bad…

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, interviews and record review the facility failed to ensure that staff knocks before entering the room of one resident R10. This failure has affected 1 of 23 residents reviewed for privacy. Findings include: R10 is [AGE] year old with diagnosis including but not limited to: Chronic Respiratory failure, Dependence on Supplemental oxygen, Dependence on Respirator status and Chronic Obstructive Pulmonary Disease. R10 has a BIMS (Brief Interview for Mental Status) score of 15, which indicates cognitively intact. On 9/25/23 at 1:54 PM R10 said, The staff does come in without knocking sometimes or introducing themselves. They also come in and out during the night making noise sometimes. You don't always know who's who because the staff don't always where name badges. On 9/25/23 at 2:03 PM, during interview with R10, V7 (Wound care nurse) walked into resident's rooms without knocking. V7 also did not have on a name badge. On 9/25/23 at 2:09 PM, V7 said, I usually knock on the resident's door but 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 ensure the call device is within reach for 1 (R12) resident reviewed for call device in a total sample of 23 residents. Findings include: On 09/25/2023 at 2:13pm, R12 asked this surveyor to get his (R12) sandwich from R12's drawer. Surveyor requested R12 to use the call device. R12 looked on the siderail close to him (R12) and stated it is not here. The call light is on the other siderail. I (R12) cannot reach it. On 09/25/2023 at 2:17pm, this observation was pointed out to V12 (Certified Nursing Assistant). V12 stated that is me. I (V12) forgot to put it back. It (call device) should be next to the resident so they can call whenever they need assistance. On 09/27/2023 at 1:51pm, V24 (Director of Nursing) stated call light should be placed on the stronger side so the resident will be able to use it. Best practice is to place the call light within reach of the resident. R12's admission Record documented that R12's diagnoses include but not limited to Parkinson's Disease, muscle wasting and atrophy,…

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 notify a family representative of a change in condition which affected one (R13) resident reviewed for policy and procedure in a total sample of 23 residents. Findings include: On 09/26/2023 at 12:27pm, V17 (R13's family member) stated I (V17) am the surrogate for Health. I (V17) come here 3 x a day for breakfast, lunch and dinner. I (V17) have concerns here. I (V17) was not notified when he (R13) fell last Wednesday, 09/20/2023. He (R13) fell around 3pm. When I (V17) came here for dinner at 5pm, the bed was empty. That's when I (V17) found out that he (R13) was sent to the hospital after I asked the staff. It is upsetting. Of course, I (V17) can't be happy about. They said it was an oversight. On 09/27/2023 at 1:08pm, V24 (Director of Nursing) stated it is best practice to notify the family. If unable to reach the family, then the next person can be contacted. Time frame is as soon as possible. Or instruct someone else to notify family. R13's admission Record documented that R 13's diagnoses include but not limited 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure that 1 resident was given scheduled medication. This deficiency affected 1 out of 3 residents reviewed for Physician orders. Findings include: R1 is [AGE] year old with diagnosis including but not limited to: Tracheostomy status, Gastrostomy status, Dysphagia, Malignant neoplasm of mandible, Abnormal posture and Reduced Mobility. R1 has been discharged from the facility. Surveyor called V40 (R1's wife) regarding complaint. V40 did not answer. On 9/27/23 at 2:10 PM, V24 DON (Director of Nursing) said, I am familiar with R1. He (R1) was only here from 8/16/23- 8/18/23. He was admitted and went out two days later to the hospital. Surveyor inquired about R1's medication and Nebulizer treatment orders for 8/17/23. On 9/27/23 at 2:10 PM, V24 said, I am not sure why R1's medication wasn't given on 8/17/23. Sometimes with new orders we have to wait for the Pharmacy, but we do use some house stock medication as well. Depending on the importance of 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 the Low Air Loss Mattress was not set to Static Mode and failed to ensure the Low Air Loss Mattress was layered per facility policy. These failures affected 1 (R2) resident reviewed for pressure ulcer/injury prevention and treatment in a total sample of 23 residents. Findings include: On 09/26/2023 at 11:31am, R2's low air loss mattress was set below 160lbs. Static light was on. V18 (Occupational Therapy) stated I (V18) will try to reposition her (R2) depending on how she (R2) would take it. On 09/26/2023 at 11:35am, V7 (Wound Care Director) checked R2's low air loss mattress setting and stated setting is below 160lbs and above 150lbs. The static light is on. It should not be on because we only use it if we are providing care or if we are about to transfer the resident from bed to chair. Staff can turn static button on. Static Mode makes the mattress firmer. On 09/26/2023 at 11:40am, V7 stated if the setting is not on static, the mattress will alternate the pressure on the resident's skin. V7 checked…

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, interviews and record review, the facility failed to prevent a colostomy bag from overflowing and spilling onto one resident (R19). This failure has the potential to affect 5 residents that reside in the facility with colostomies. Findings include: R19 is [AGE] year old with diagnosis including but not limited to: Colostomy status, Malignant neoplasm of colon, Diarrhea, Adult failure to thrive and Diverticulosis of Intestine. R19 has BIMS (Brief Interview of Mental Status) score of 13, which indicates cognitively intact. On 9/26/23 during investigation, R19 was observed in bed rubbing her abdominal area. At that time, R19 said, I feel like my colostomy bag is about to bust open. On 9/26/23 at 10:43 AM, V28 RN (Registered Nurse) removed brief from around R19's colostomy bag. R19's colostomy bag was inflamed with gas and feces. Tape was observed around the colostomy bag, on R19's skin. Feces was spilling from the colostomy bag onto R19's skin and gown. Surveyor inquired about R19s colostomy…

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, interviews, and record review the facility failed to ensure that one resident's (R8) humidifier bottle had the required amount of water for one resident (R8) from a sample of 23 residents reviewed for care. This failure has the potential to affect 22 other residents (besides R8) with tracheostomies. Findings include: R8 is [AGE] year old with diagnosis including but not limited to: Tracheostomy status, Gastrostomy status, Anoxic brain damage, Acute and Chronic Respiratory failure with hypoxia, and Epilepsy. On 9/25/23 at 12:35 PM, R8 was observed in bed. R8's humidifier bottle connected to the oxygen concentrator was empty (without water). On 9/25/23 at 1:10 PM, V24 (DON/ Director of Nursing) said, R8's humidification bottle is not supposed to be empty. If it's empty, it could dry out the patient's nose and could cause coughing. At that time, V24 filled R8's humidifier bottle with distilled water. On 9/25/23 at 1:45 PM, V26 (Respiratory Manager) said, We change the oxygen and trach tubing…

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

Based on interview and record review, the facility failed to ensure resident's allergies and intolerance were recorded on the resident electronic health record. This failure affected 1 (R3) resident reviewed for food allergies and intolerance in the total sample of 23 residents. Findings include: On 09/25/2023 at 12:08pm, R3 stated I (R3) am Lactose intolerant. I (R3) am allergic to tomatoes, raw or cooked. No cow's or goat's milk. I (R3) will throw up if I (R3) accidentally eat tomato or drink milk. On 09/26/2023 at 1:52pm, V3 (Dietician) stated when I (V3) interview the resident, I (V3) will confirm the allergies, restriction and intolerance. On 09/26/2023 at 2:06pm, V3 provided this surveyor the progress notes written by V3 for R3 and stated my (V3) note indicated I (V3) discussed my findings with nursing. I (V3) talked to the nurse after the interview that the resident (R3) is allergic to tomato. I (V3) did not see any update on the allergies. That is missing information that no one really responded to the information provided by the resident. It is not only not acceptable it 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.