Pleasant Meadows Senior Living

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to report an allegation of verbal abuse to the state survey agency for one of 13 residents (R6) reviewed for staff behavior in the sample list of 21. Findings include:The facility's Abuse Prevention Program dated October 2022 documents visitors are encouraged to report suspected concerns of abuse immediately to the administrator or to an immediate supervisor who immediately reports to the administrator. This policy documents the facility will report allegations of abuse to the Illinois Department of Public Health (IDPH). On 3/16/26 at 11:31 AM R6 stated about a week or so ago a Certified Nursing Assistant (identified as V41 CNA) assisted R6 onto the bedpan during the night. R6 stated R6 told V41 that R6 couldn't decide if R6 was too hot or too cold and V41 told R6 that R6 better make up R6's mind because V41 was not going to keep coming into R6's room every five minutes as V41 is only required to come in every two hours. R6 stated R6 felt like this 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 appropriately label an insulin vial, insulin pens, and eye and ear drops with the date opened and failed to discard an insulin pen and ear drops for four (R11, R36, R69, R85) of seven residents reviewed for medication administration on a sample list of 41. Findings Include:On 1/13/2026 at 10:00 AM, the facility's Main Skilled Medication Cart located on the 200 Hall was inspected in the presence of V6 Licensed Practical Nurse (LPN). During the inspection, R11's Basaglar pen and Adelong pen were found without any documented date of opening. Additionally, R36's Novolog Flex Pen was labeled with an open date of November 26, 2025. Further review revealed that R69's Ofloxacin and R85's Latanoprost also lacked documented dates of opening.Review of R11's Medication Administration Record (MAR) dated January 2026 confirmed that R11 has an active physician's order and is currently receiving both Basaglar and Adelong.Review of R36's MAR dated January 2026 documents that R36 has an active physician's order and is currently…

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 implement proper hand hygiene during medication administration for three residents (R40, R43, R63) of seven reviewed for medication administration on a sample list of 41. Findings include: On 01/12/2026 at 8:57 AM, V5 Registered Nurse (RN) prepared R43's oral medications and inhaler, entered the R43's room, handed R43 the cup of medications and placed a cup of water on the bedside table. V5 RN then provided R43 with his inhaler, followed by a cup of water for swish and spit. After use, R43 returned the cup and inhaler to V5 RN. At no point before, during, or after medication administration did V5 RN perform hand hygiene.On 01/12/2026 at 9:10 AM, V5 RN prepared R40's oral medications, entered R43's room, handed R40 the cup of medications and placed a cup of water on the bedside table. Before leaving the room V5 RN disposed of R40's used cups. At no point before or after medication administration did V5 RN perform hand hygiene.On 01/12/2026 at 9:25 AM, V5 RN prepared R63's oral medications, entered 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 record review the facility failed to ensure resident rooms and equipment were clean and in good repair for two of three residents (R8 and R25) reviewed for homelike environment in the sample list of 41. Findings include:1) R25's minimum data set (MDS) dated [DATE] documents R25 is cognitively intact.On [DATE] at 8:45 AM, R25 stated she is embarrassed by how her room looks, stating, is this what I'm supposed to live with? The wall behind R25 was noted have cracked, fading paint and large nails placed in various spots. R25 stated she hangs pictures and a tee shirt to distract visitors from the condition of the walls. R25 stated she has expressed to staff about how bad her room looks. R25 stated she was ashamed when the doctor came in for a visit. R25 stated she spoke with her roommate stating, have we died, and this is where we ended up. R25 stated she is worried about her ceiling tiles being asbestos since they are so old.On [DATE] at 12:05 PM, R25's room and bathroom 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure one resident (R4) was free of a restraint which limited her ability to move about freely of one resident reviewed for restraints in a sample list of 41.Findings Include:R4's Care Plan dated 9/8/25 lists then following diagnoses: Osteomyelitis, Pressure Ulcer of the Sacrum, Neoplasm of the Spinal Cord, Type II Diabetes, Polyneuropathy, Unsteady on Feet, and Neurofibromatosis. R4's Minimum Data Set (MDS) dated [DATE] documents R4 is cognitively intact.On 1/11/26 R4 was seated in a (Geriatric) Chair in her room. This chair does not allow R4 to self-propel herself. R4's personal wheelchair was sitting on the other side of her room. R4 stated I want to sit in my chair R4 gestured to the wheelchair across the room with her name on it. I can't even move around in my room in this chair. I HATE it. I can't get my hairbrush, or my soda from my fridge or anything. It also makes my back and sores hurt. (R4 currently has two Stage IV Pressure…

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 receive proper treatment and assistive devices to maintain vision for one resident of one resident (R53) reviewed for vision and hearing out of a sample list of 41.Findings include:R53's care plan, dated 12/16/2025, documents an admission date as 08/22/2024 with the following diagnoses: Essential Hypertension, Hyperlipidemia, Fibromyalgia, Lumbago with Sciatica, left side and Diaphragmatic Hernia without Obstruction.R53's Care Plan, dated 12/16/2025, documents R53 wears reading glasses to assist with vision related to macular degeneration with an intervention documenting: Ensure that adaptive equipment that R53 needs is provided and is present and functional, eyeglasses.On 1/11/2026 at 9:30 AM R53 stated she has needed glasses, and her glasses have been broken for a long time.On 1/12/2025 at 1:25 PM V6 LPN (Licensed Practical Nurse) stated R53 does not currently have eyeglasses for use.On 1/12/2025 at 1:32 PM V7 CNA (Certified Nursing Aide) stated R53 does not have corrective eyeglasses 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 right to be free from verbal abuse of one (R1) resident from another resident (R2) out of four residents reviewed for abuse in a sample list of eight residents. Findings include:R1's Electronic Medical Record (EMR) documents medical diagnoses as Legal Blindness, Lack of Coordination, Disorders of Muscles, Dementia and Anxiety. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as moderately cognitively impaired. This same MDS documents R1 requires maximum assistance with bed mobility and is dependent on staff for bathing, toileting, dressing, personal hygiene and transfers. R2's MDS dated [DATE] documents R2 as severely cognitively impaired. This same MDS documents R2 requires moderate assistance with transfers and supervision with walking up to 50 feet. R2's Psychiatric Evaluation dated 10/21/25 documents R2 was admitted to a psychiatric hospital after threatening to kill his roommate (R1). This same report documents R2…

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 prevent cross contamination during wound care of one (R2) residents Right Ankle Arterial wounds out of three residents reviewed for wound care in a sample list of eight residents. Findings include:R2's MDS dated [DATE] documents R2 as severely cognitively impaired. This same MDS documents R2 requires moderate assistance with transfers and supervision with walking up to 50 feet. R2's Care Plan intervention dated 8/21/25 instructs staff to provide treatment to areas as ordered. R2's Physician Order Sheet (POS) dated December 2025 documents a physician order starting 11/26/25 to Clean R2's Right Ankle Arterial wound with wound cleanser, apply barrier ointment to the surrounding wound, apply Vaseline soaked gauze to the open wounds and cover with absorbent pad and gauze wrap daily and as needed. The facility daily staffing sheets show contract nurses were scheduled as R2's nurses from 10/16/25-10/20/25. R2's Hospital Record dated 10/20/25…

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 a resident's medical record included an elopement event for one of three residents (R1) reviewed for elopement in the sample list of five. R1's admission Record dated 9/23/25 documents R1 admitted to facility 8/28/2019. The admission Record documents R1's medical diagnoses include Congestive Heart Failure with presence of Cardiac Pacemaker, Age-Related Cognitive Decline, Major Depressive Disorder, Chronic Obstructive Pulmonary Disease, Abnormalities of Gait and Mobility, Lack of Coordination, Parkinson's Disease Without Dyskinesia, Need for Assistance with Personal Care, Unsteadiness on Feet, and Insomnia.R1's Minimum Data Sheet (MDS) Section C dated 8/15/25 documents R1 has moderate cognitive impairment.R1's undated Care Plan documents R1 has confusion and a cognitive communication deficit, R1 is high risk for falls, has a history of falls with major injury, and staff have observed R1 turning off safety alarms. The Care Plan documents R1 has psychosocial well-being issues with reported feelings of isolation, has…

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 protect a resident's right to be free from physical abuse by another resident. This failure affects two residents (R3, R4) of six reviewed for abuse in the sample of six. Findings include: The facility Abuse Prevention Program policy (10/2022) documents: a nursing home resident has the right to be free from verbal, sexual, physical, and mental abuse, exploitation, corporal punishment, and involuntary seclusion. The same record documents: Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention (77 ILL. Adm. Code 300.330). Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment (42CFR 483.13b Interpretive Guidelines). R4's diagnosis list (12/24/2024) documents diagnoses including: Dementia, Depression, and Muscle Weakness. R4's Resident Assessment (12/12/2024) documents R4 has severely impaired cognition, is completely dependent on or requires substantial staff assistance to perform…

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 notify a family representative of a change in resident condition for one of three residents (R6) reviewed for accidents/incidents on the sample list of 17. Findings include: R6's current medical diagnoses sheet documents the following: Unspecified Dementia, Alzheimer's Disease, Repeated Falls, and Muscle Weakness. On 11/27/24 at 2:32 pm R6 was seated in a wheelchair at the nursing station. R6 had a large yellow and green colored bruise on R6's left forehead. R6's bruise was approximately the size of a silver dollar, and incorporated R6's eye lid, eyebrow and front of R6's scalp. R6 also had a small, approximately one quarter inch long by one inch wide purple and yellow bruise under her left eye. On 12/3/24 at 1:20 pm V3, Licensed Practical Nurse (LPN)/Minimum Data Set (MDS) Coordinator stated V3 saw the bruise on R6 forehead Sunday 11/24/24, when V3, LPN came in to work as a floor nurse. V3 stated she was not R6's nurse but stopped and asked what happened. V3, LPN stated Certified Nursing Assistants…

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 resolve resident grievances of missing money. This failure affects two of five residents (R2 and R4) reviewed for missing personal belongings on the sample list of 17. Findings include: 1. The Facility Incident Report Form submitted as part of the investigation, includes R2's Minimum Data Set (MDS) dated [DATE], and therefore V1, Administrator/Abuse Prevention Coordinator was aware of R2's cognitive status. R2's MDS documents R2's Brief interview of Mental status score of 15 out of a possible 15, indicating R2 has no cognitive impairment. The facility facsimile to Illinois Department of Public Health Final (IDPH) report dated 11/06/24 documents the following: Summary: Resident (R2's) daughter (V42, POA) notified SSD (V4, Social Service Director) that resident was missing $33 on 10/28/24. The money was missing in the prior 2 (two) weeks of notifying SSD (V4). Administrator (V1, Administrator/Abuse Prevention Coordinator) was immediately…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to recognize and report a facial bruise of unknown origin to the Abuse Prevention Coordinator for one of three residents (R6) reviewed for incident/accidents on the sample list of 17. Findings include: R6's Current Diagnoses list documents the following:Repeated Falls, Difficulty Walking, Muscle Weakness, Generalized, Alzheimer's Disease and Unspecified Dementia, Unspecified Severity. R6's Minimum Data Set (MDS) dated [DATE] documents R6's Brief Interview of Mental Status score as 00 (zero) out of a possible 15, indicating severe cognitive impairment. The same MDS documents R6 uses a wheel chair for mobility and has not had any wandering behaviors or behaviors directed towards self or others. On 11/27/24 at 2:32 pm R6 was seated in a wheelchair at the nursing station. R6 had a large yellow and green colored bruise on R6's left forehead. R6's bruise was approximately the size of a silver dollar, and incorporated R6's eye lid, eyebrow and 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 record review the facility failed to follow physician orders and prevent cross contamination during wound care treatment administration. These failures affected one of three residents (R1) reviewed for accidents/skin impairment on the sample list of 17. Findings include: R1's Minimum Data Set (MDS) dated [DATE] documents the following: Brief Interview of Mental Status score of 05 (five), out of a possible 15, indicating R1 has severe cognitive impairment. R1's Skin/Issue note completed 11/13/2024 at 6:02 pm documented by V12, Facility Wound Licensed Practical Nurse documents the following: R1's Front right thigh. Issue type: Burn. Full thickness burn. Wound acquired in-house. Exact date:11/05/2024. The same Skin /Issue note documents R1's burn measured: Length (cm):4 Width (cm): 4 Depth (cm): 0.1. R1's right thigh burn is documented as having Exudate amount: Light. Exudate type: Serous: clear watery fluid, which is separated from solid elements (blisters that opened). R1'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 observation, interview and record review the facility repeatedly failed to maintain complete and accurate medical record for one of eight residents (R6) reviewed for medical records on the sample list of 17. Findings include: R6's current medical diagnoses sheet documents the following: Unspecified Dementia, Alzheimer's Disease, Repeated Falls, and Muscle Weakness. On 11/27/24 at 2:32 pm R6 was seated in a wheelchair at the nursing station. R6 had a large yellow and green colored bruise on R6's left forehead. R6's bruise was approximately the size of a silver dollar, and incorporated R6's eye lid, eyebrow and the front of R6's scalp. R6 also had a small, approximately one quarter inch long by one inch wide purple and yellow bruise under her left eye. There was no documented measurement of R6's bruise. There was no progress note documented on R6's chart to identify the cause of R6's left forehead bruise. There was no incident or accident on the facility log for R6 in November or December 2024. There was no documentation that vital signs were completed. There was 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to immediately report allegations of misappropriation to the facility's administrator and failed to report allegations of misappropriation to the State Agency (SA) and law enforcement for four residents (R13,R130,R25,R46) of five residents reviewed for misappropriation in a sample list of 46 residents. These failures have the potential to affect all 73 residents residing in the facility. Findings Include: The facility Abuse Prevention Program policy dated October 2022 documents Employees are required to report any incident, allegations or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the Administrator immediately, to an immediate supervisor who must then immediately report it to the Administrator or to a Compliance Hotline or Compliance Officer. Reports will be documented, and a record kept of the documentation. Supervisors shall immediately…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to investigate allegations of misappropriation of money and personal property and implement corrective action to prevent further incidents of misappropriation for four residents (R13,R130,R25,R46) of five residents reviewed for misappropriation in a sample list of 46 residents. These failures have the potential to affect all 73 residents residing in the facility. Findings Include: The facility Abuse Prevention Program policy dated October 2022 documents all incidents or allegations of abuse, neglect, exploitation, mistreatment or misappropriation of resident property occurred, that was alleged or suspected will be documented and result in an investigation. The appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interviewable. Any written statements that have been submitted will be reviewed, along with any pertinent…

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 prevent, investigate, and implement systemic interventions to address allegations of misappropriation. This failure affects four (R13, R25, R46, R130) residents and has the potential to affect all 73 residents who reside at the facility. Findings include: The facility's Midnight Census Report dated 10/26/24 documents 73 residents reside at the facility. The facility Abuse Prevention Program dated October 2022 documents all incidents or allegations of abuse, neglect, exploitation, mistreatment or misappropriation of resident property occurred, that was alleged or suspected will be documented and result in an investigation. The appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interviewable. Any written statements that have been submitted will be reviewed, along with any pertinent medical records or other documents. Residents to whom the accused has regularly provided care, and employees with whom…

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

Based on interview and record review, the facility failed to develop, implement, and maintain an effective, comprehensive, data-driven Quality Assurance Performance Improvement Program that demonstrates systematic identification of problematic areas within the facility along with reporting, investigation, and analysis of those areas to prevent adverse outcomes to the residents. This failure affects seven (R13, R25, R46, R130, R8, R44, and R52 ) residents and has the potential to affect all 73 residents who reside at the facility. Findings Include: The facility's ongoing Grievance Log dated September - October 2024 documents misappropriation of money for R13, R25, R46, and R130. Ongoing weight Logs for R8, R25, R44, and R52 document these residents have had a significant weight loss between August 2024 and September 2024, with no assessments completed by V19 RD (Registered Dietitian) or nutritional interventions implemented to try to prevent further weight loss. On 10/30/24 at 11:21 AM, V1 Administrator stated V1 has only been employed by the facility for three weeks, therefore has…

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 take actions aimed at performance improvement, implement those actions, measure its success and track performance. This failure has the potential to affect all 73 residents residing in the facility. Findings include: The facility's Quality Assurance Improvement Plan dated 10/1/18 documents, the purpose of QAPI (Quality Assurance Performance Improvement) in our organization is to take a proactive approach to continually improving the way we care for and engage with our residents, caregivers, and other partners so that we may realize our vision to set the standard in nursing and rehabilitative care; to provide excellent quality resident care and services. Quality is defined as meeting or exceeding the needs, expectations and requirements of the resident cost effectively while maintaining good resident outcomes and perceptions of care. To do this, all employees will participate in ongoing QAPI efforts which supports our mission to be a recognized leader in clinical quality and customer satisfaction in the market we serve. This…

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 hold quarterly Quality Assurance Performance Improvement meetings with all required attendees. This failure has the potential to affect all 73 residents who reside at the facility. Findings Include: The facility's Quality Assurance Performance Improvement (QAPI) sign in sheets dated 10/9/24 does not contain V39 (Former DON (Director of Nursing)/Infection Preventionist) signature as attending the meeting. The QAPI sign in dated 7/26/24 does not include V39 or V40's Medical Director signature as attending the meeting. The QAPI sign in dated 4/10/24 does not contain V40's signature as attending the meeting. On 10/30/24 at 11:21 AM, V1 Administrator stated V1 has only been employed at the facility for three weeks therefore has not attended a Quality Assurance Performance Improvement (QAPI) meeting. At this time, V24 Medical Records stated V24 takes the minutes for the meetings and explained that the last quarterly meeting was held on 10/9/24. V24 confirmed that V39 and V40 were not always at the meetings, their attendance 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.

Failures at this level required more than one deficient practice statement. A. Based on interview and record review, the facility failed to develop a water management plan that included the required risk assessment, control measures, and testing protocols to reduce the risk of growth of Legionella and other pathogens in the facility's water system. This failure has the potential to affect all 73 residents in the facility. B. Based on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions (EBPs) and provide hygienic wound care for three (R8, R32, R69) of five residents reviewed for EBP in the sample list of 46. Findings include: a. On 10/31/2024 at 11:00AM, the facility water management plan (undated) failed to document the required facility water system risk assessment where Legionella and other pathogens could grow and spread in the facility water system. The plan did not identify any specific testing protocols, acceptable ranges for control measures, or any corrective actions when control limits are not maintained to reduce the risk…

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 their influenza (flu) vaccination policy for five (R1, R8, R32, R63, R66) of five residents reviewed for immunizations in the sample list of 46. This failure has the potential to affect all 73 residents residing in the facility. The facility also failed to track and offer pneumococcal vaccinations to ensure residents are up to date for three (R32, R63, R66) of five residents reviewed for immunizations in the sample list of 46. Findings include: The facility's Vaccination of Residents policy dated August 2008 documents: Because long-term care residents are prone to developing serious complications when they contract the flu, all residents will be offered an influenza vaccine beginning in October of each year, unless medically contraindicated or the resident has already been vaccinate. The influenza vaccine will be available to all residents between October 1st and March 31st of each year. Residents admitted during this time period will be offered…

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 its Compliance and Ethics program by failing to have a committee that meets on a quarterly basis. This failure has the potential to affect all 73 residents residing in the facility. Findings include: The facility's Compliance Policies and Procedures dated 10/29/17 documents the organization is required to have written compliance and ethics standards including policies and procedures to reduce the prospect of criminal, civil, and administrative violations, management staff appointed to oversee compliance, steps to achieve compliance through monitoring and audits, reporting systems for reporting wrongful conduct within the facility, enforcement of standards through disciplinary action, and a response system after non-compliance is detected. This policy documents the facility's compliance committee meets at least quarterly and this committee includes, but is not limited to the facility's Administrator (who is the Compliance Liaison); the Director of Nursing (DON), Social Services Director (SSD) or Psychiatric…

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 prevent the potential for a fire hazard by failing to maintain facility laundry dryers in a safe operating condition. This failure has the potential to affect all 73 residents in the facility. Findings include: On 10/30/2024 at 1:25PM, the facility laundry dryers and surrounding floors, walls, ductwork, electric motors, and utility conduits were covered in lint appearing 0.25-1 in thickness. The entire floor area behind the dryers was covered with heavy accumulations of lint completely obscuring the floor surface below. The lint covered all portions of the rear dryer cabinets and also the electric motor casings of the dryers. The exterior sheet metal surfaces of the dryers were hot to the touch. V36 (Laundry Aide) was present and viewed the area behind the dryers and was asked if V36 thought the lint accumulations were a fire hazard. V36 stated to me, it would be. V36 reported the facility maintenance staff are supposed to clean the area behind the dryers, but V36 was unsure how often maintenance staff cleaned the area. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide fingernail care, bathing, and timely toileting/incontinence cares for five (R11, R30, R37, R131, R230) of 19 residents reviewed for Activities of Daily Living (ADLs) in the sample list of 46 residents. Findings include: 1. The facility Resident Council Group Concern Form (September, 2024) documents a group council complaint of facility staff not providing timely nursing care to residents. The facility grievance log (July and September, 2024) documents complaints of facility staff not answering call lights promptly, not providing showers timely, and not providing toileting care timely to residents. R37's diagnosis list (printed 10/29/2024) documents R37's diagnoses include: Need For Assistance With Personal Care, Reduced Mobility, Unsteadiness on Feet, and Osteoarthritis Of Hip. R37's quarterly assessment (8/14/2024) documents R37 is occasionally incontinent of bladder and requires substantial/maximal staff assistance for toileting…

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 the environment was free from hazards for seven of seven residents (R21, R53, R29, R39, R16, R61, R66) reviewed for safety and supervision in the sample list of 46. Findings include: The facility's Storage and Medications policy dated 10/27/14 documents, The medication supply is accessible only by licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. On 10/28/24 at 9:05 AM, there were two weekly pill organizers sitting on the entry way table, unattended and accessible to other residents. There were 28 days for the pills to be placed in. There were at least 27 unidentified pills visible in the cases. This table is at the front entry of the building which leads to the 100 hall and leads to the chapel/dining room area. On 10/28/24 at 9:10 AM, V2 Director of Nursing confirmed the pill organizers were sitting on the table and stated that the resident whose name is on the pill containers is not a long term care resident, but a resident 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 date and secure oxygen tubing, humidification bottle, and nebulizer tubing for one of three residents (R25) reviewed for oxygen on the sample list of 46. Findings include: R25's Care Plan updated 12/4/24, documents R25 is to receive nebulizer and oxygen therapies as ordered. R25's Physician Order Sheet dated 9/20/24 documents an order for oxygen per nasal cannula to maintain an oxygen saturation of 90% or above at bedtime. On 10/27/24 at 8:22 AM, R25's oxygen tubing (nasal cannula) was uncovered and draped over the knob of the oxygen concentrator with the nasal prongs of the nasal cannula on R25's floor. The tubing and humidifier bottle were not dated. At this time, a nebulizer machine sitting on R25's dresser had an uncovered nebulizer mask, reservoir and tubing connected to the nebulizer machine that was also not dated. On 10/27/24 at 8:44 AM, R25 was sitting on the side of R25's bed receiving oxygen via the tubing/nasal cannula that had been on the floor previously. On 10/27/24 at 9:58 AM, R25's undated…

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 regularly assess for the use of psychotropic medications for four (R1, R44, R8, R46) of five residents reviewed for psychotropic medication use in a sample list of 46 residents. Findings include: The facility's policy Psychotropic Medication Policy updated 11/2017 states Psychotropic medication shall not be prescribed without informed consent of the resident, the resident's guardian, or other authorized representative. Additional informed consent is not required for reductions in dosage level or deletion of a specific medication. The informed consent may provide for a medication administration program of sequentially increasing dosages or combination of medications to establish the lowest effective dose that will achieve the desired therapeutic outcome. Side effects of the medication will be described during the informed consent process. 1.) R1's Medication Administration Record for October 2024 includes the following current physician's orders for psychotropic medication: R1's Medication Administration Record for October…

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 consents for psychotropic medication use for two (R8, R37) of five residents reviewed for unnecessary medications in the sample list of 46. Findings include: The facility's Psychotropic Medication Policy revised November 2017 documents Psychotropic medication shall not be prescribed without the informed consent of the resident, the resident's guardian, or other authorized representative. Side effects of medications shall be described during the informed consent process. 1.) R8's October 2024 Medication Administration Record documents R8 received Depakote (anticonvulsant/mood stabilizer) Delayed Release 500 milligrams by mouth four times daily since 7/12/24. R8's Psychiatry Note dated 9/5/24 at 3:23 PM documents R8 receives Depakote for Bipolar Disorder. There is no documented consent for Depakote in R8's electronic medical record. On 10/30/24 at 1:05 PM V10 Restorative Nurse/Registered Nurse confirmed all of R8's psychotropic medication consents were provided, and there was no consent for Depakote. V10 was asked…

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 have a physician's order and care plan for restraint use for one (R8) of two residents reviewed for restraints in the sample list of 46. Findings include: The facility's Physical Restraint Policy dated February 2014 documents A physician order for a restraint will be valid for thirty (30) days. After 30 days, the Restraint Observation must be completed to determine if the restraint is required further. Physician orders for restraint shall be complete and specifically define the type, reason, duration, and justification for use. Residents who are restrained will be temporarily released from the restraint at least every two (2) hours and more often as necessary such as for ADL (Activities of Daily Living) care, activities, and meals. The care plan will reflect specific circumstances and medical symptoms for restraint use and time frames. The resident's response to the use of the restraint and goals identified in the plan of care will 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 interview and record review the facility failed to develop a comprehensive care plan for weight loss for one of 19 residents (R66) reviewed for care plans in the sample list of 46. Findings include: The Facility's Care Plan policy with a revised date of August, 2007 documents, Our facility develops a comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and psychological needs. R66's Care Plan dated 5/7/24 documents a diagnosis of Alzheimer's Disease. This Care Plan documents to encourage adequate nutrition and to offer small, frequent feedings. R66's weight record documents on 5/28/24 R66 weighed 143.2 pounds and on 9/2/24 R66 weighed 118 pounds. That is a 17.6% weight loss in a little over three months. V19 Dietician documents on 6/15/24 that R66 has had weight loss and recommended adding 60 cc (cubic centimeters) of (nutritional supplement) two times a day. V19 then documents on 9/13/24 that R66 has had continued weight loss and recommended increasing (nutritional supplement) to 90 cc two…

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 wound dressing changes were completed as ordered by the Physician for one of one resident (R59) reviewed for skin conditions in the sample list of 46. Findings include: R59's diagnosis list documents diagnoses including Congestive Heart Failure, Need for Assistance with Personal Care, Cellulitis of Right Lower Limb, Morbid Obesity and Mild Intellectual Disabilities. R59's Nurse's Notes dated 10/18/24 by V12 Wound Nurse documents R59 has bilateral lower leg edema and has an open area on her right lower leg measuring 2 cm (centimeters) x (by) 2 cm with some blood tinged drainage,and that the area is tender to touch. V12 documents that the Nurse Practitioner was notified and R59 was started on an antibiotic for cellulitis and a treatment order was obtained to clean the wound and apply a calcium alginate dressing and cover with a bordered foam dressing daily. R59's Treatment Administration Record dated 10/1/24-10/31/24 documents the order for the treatment to the right lower extremity to clean with normal…

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 administer medications according to Physician's Orders for one of four residents (R75) reviewed for medication administration in the sample list of 46. This failure resulted in two medication errors out of 33 opportunities resulting in a 6.06% error rate. Findings include: The facility's undated Medication Administration Policy documents, Drugs will be administered in accordance with orders of licensed medical practitioners in this State. Medications shall be administered within one (1) hour of the medication schedule unless specifically ordered otherwise (see Medication Administration Schedule). R75's Medication Administration Record dated 10/1/24-10/31/24 documents orders for Metoprolol Tartrate 25 mg (milligrams) give 0.5 tablet twice a day at 8:00 AM and at 5:00 PM and an order for Vitamin D give 50 mcg (micrograms) every day. On 10/27/24 at 12:41 PM, V14 Licensed Practical Nurse gave R75 one Metoprolol 25 mg half a tablet (12.5 mg), over 4 ½ hours late. V14 also administered R75 Vitamin D3 5,000 units one…

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

Based on observation and interview, the facility failed to serve palatable resident meals. This failure affects one resident (R37) of 10 reviewed for food palatability in the sample list of 46. Findings include: On 10/27/2024 at 9:45AM, R37 reported eating meals in R37's room and receiving cold food. On 10/29/2024 at 11:08AM, meal trays arrived in the 200 hallway and staff immediately began serving the trays to residents. All resident meals were served on ceramic plates. R37 received a meal tray of biscuits and sausage gravy. R37's food items measured 95 degrees Fahrenheit by Illinois Department of Public Health thermometer. R37 reported R37's food was not warm and R37 would like R37's meals to be warmer. On 10/29/2024 at 3:00PM, V28 (Cook) reported meals provided to residents eating in their rooms may not be arriving hot because hall trays are assembled in the main kitchen and placed onto a cart that is transported to the adjacent dining room where a drink station is located where staff then have to prepare each resident drink for each tray before taking the cart to the hall 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 Record Review and Interview the facility failed to provide an effective Infection prevention and control program. This failure has the potential to affect all 76 residents who reside at the facility. Findings Include: The facility's census dated [DATE] documents 76 residents reside at the facility. The facility's policy Infection Prevention and Control and Stewardship Program last reviewed [DATE] states Policy: To comply with system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual agreement. To comply with the core elements of antibiotic stewardship to reduce the unnecessary use of antibiotics. The facility has established an infection control program which addresses all phases of the organization's operation to reduce and prevent the risk of nosocomial infections in residents and healthcare workers. The designated Infection Control…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide residents intravenous therapy consistent with professional standards of practice. The facility failed to complete residents intravenous (IV) dressing changes, monitor document required measurements, specify type of intravenous (IV) access device (R1, R2 peripheral central venous catheter, and R3 implantable venous access device) including anatomical location of the residents device with an IV care plan for specific interventions. The facility also failed to obtain orders for residents IV dressing changes, device flushes, need to monitor for signs and symptoms of infection and infiltration. These failures affected three of three residents (R1, R2 and R3) reviewed for intravenous medication administration on the sample list of three. Findings include 1.) R1's progress note dated 6/26/24 at 6:42PM documents R1 was admitted to the facility following hospitalization (as documented on R1's Post Acute Care Transition Document dated…

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 protect the residents' right to be free from verbal abuse by another resident. This failure affected two of four residents (R5, R6) reviewed for abuse in the sample of nine. Findings Include: The facility's Abuse Prevention Program dated October 2022 documents the facility affirms the right of it's residents to be free from abuse or mistreatment. Verbal abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of an individuals' age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm or saying things to frighten a resident. The Abuse Investigation Summary dated 7/19/24 documents R5 and R6 were in a verbal altercation in their shared room. R5 began calling the staff name and telling them to get the F* (expletive) out of his room or he would shoot them. His roommate…

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 protect the resident's right to be free from abuse by failing to prevent misappropriation of a resident's physician prescribed medication. This failure affected one of three residents (R3) reviewed for abuse in the sample of nine. Findings Include: The Abuse Prevention Program dated October 2022 documents the term Abuse can include misappropriation of resident property. Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. The Incident Report for the incident of 7/22/24 documents R3's Semaglutide Injectable medication could not be found. R3's Physician Order Sheet dated July 2024 documents R3 is diagnosed with Diabetes. R3 is also prescribed Solution Pen-Injector 4 Milligrams/3 Milliliters (Semaglutide) - Inject 1 Milligram subcutaneous, once every Sunday related to Diabetes Mellitus. This medication order started…

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 safeguard four (R1-R4) of four residents' funds from potential funds mismanagement from a total sample list of four residents reviewed for protection of resident funds. Findings include: On 7/23/24 at 10:20AM, V4 Former Business Office Manager (FBOM) said that she hadn't worked for the facility in two years and yet she was still receiving new debit cards for the facility accounts and that she still had access to the resident trust because her name was still on the trust according to the local bank. On 7/23/24 at 10:30AM, V3 Business Office Manager (BOM) said that she had debit cards for petty cash and vending in the names of both V4 FBOM and V5 Former Administrator (FA) but didn't know what to do with them and had not asked anyone. V3 BOM said that she didn't know who was on the resident trust, but that she was responsible for the resident trust account. On 7/23/24 at 1:30PM, V1 Administrator said that he was not aware of who was able to sign on the resident trust. V1 confirmed that V4 FBOM, V5 FA, and V7 FSSD were 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide quarterly resident trust account statements for four (R1-R4) of four residents reviewed for resident funds from a total sample list of four. Findings include: The facility provided, undated Resident Personal Trust Fund Policy and Procedure documents that the quarterly statement of all transactions for the individual resident's account including withdrawals, direct charges, deposits and interest will be prepared and provided to the resident or legal representative. The resident or legal representative will be requested to sign a copy of the quarterly statement acknowledging receipt. The signing statement will be maintained in the business office file. Residents who are unable to acknowledge receipt of the quarterly statement will have the statement mailed to the responsible party. Account reports are to be provided to the resident within two weeks of being generated. On 7/23/24 at 2:51PM, V10, R1's Power of Attorney said that he receives billing…

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 inservicing to staff members on the facility Quality Assurance Performance Improvement (QAPI) program. This failure has the potential to affect all 81 residents residing in facility. Findings include: The facility Resident List Report dated 5/14/24 documents 81 residents residing in facility. The undated facility policy titled 'Quality Assurance Improvement Plan' documents Small group education sessions on QAPI are provided to all caregivers working in the building. The use of visual aide tools describing process improvement is utilized as reminders to keep staff members focuses on performance improvement techniques. Paycheck stuffers will contain 'Bits of QAPI' designed to provide ongoing information on the commitment to incorporate QAPI in the fabric of our culture and daily operations. QAPI is also part of the orientation for new staff members joining our team. On 5/21/24 between 1:30 PM-2:30 PM V4, V19, V29 and V32 Certified Nurse Aides (CNA) all stated they were unaware of a QAPI (Quality Assurance Performance…

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 document an initial wound assessment and weekly wound measurements, failed to document a months worth of wound treatments, and failed to obtain physician orders for wound treatments. These failures affected one of three residents (R1) reviewed for wound care. Findings Include: The facility's Pressure/Skin Breakdown Clinical Protocol dated January 2017 documents the facility is to document an individual's significant risk factors for pressures sores, document a complete admission assessment of skin conditions including location, stage, measurements, and current treatments, consult the physician to assist in defining the type of ulcer and to authorize pertinent orders for wound treatments and other related interventions. R1's Medical Diagnoses list dated February 2024 documents R1 is diagnosed with Fracture of Left lower leg, Alzheimer's Disease, Osteomyelitis, Peripheral Vascular Disease, Congestive Heart Failure, Occlusion and Stenosis of Carotid…

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 four Certified Nurse Aides (CNA) completed competency skills checks. This failure has the potential to affect all 77 residents residing in the facility. Findings include: The Daily Midnight Census Report dated 12/12/23 documents 77 residents residing in the facility. The Facility Assessment updated October 2023 documents Inservice training must be sufficient to ensure the continuing competence of nurse aides, must be no less than 12 hours per year. The Facility was not able to provide any documentation of competency of skills being demonstrated by V15, V20, V30 nor V31 CNAs. The facility provided documentation to show that V15's hire date was 2/10/15, V20's hire date was 10/24/22, V30's hire date was 5/29/2019 and V31's hire date was 3/28/2016. On 12/15/23 at 2:20 PM V1 Administrator stated all CNA's should complete competency skills review annually. V1 confirmed that CNA's (V15, V20, V30 and V31) did not complete the competency skills review return demonstrations for the past year. V1 stated the facility is going to…

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

Based on interview, and record review, the facility failed to employ a qualified Director of Food and Nutrition Services. This failure has the potential to affect all 77 residents residing in the facility. Findings include: On 12/12/23 at 9:51 am, V18, Registered Dietitian (RD) provided kitchen staff education certificates. There was no documentation/certificate of completion confirming that V5, Dietary Manager (DM) had met the education requirements to be employed by the facility as a Certified Dietary Manager (CDM). V18 (RD) stated V5, Dietary Manager has not met CDM certification requirement. On 12/12/23 at 2:05 PM, V5, Dietary Manager (DM) acknowledged V5, has been working in the facility as a dietary manager and has not met the education certification requirements to be certified. On 12/12/23 at 3:30 PM, V1, Administrator stated the facility corporate office has been aware V5, DM has not been enrolled in an education program to meet the requirements of certification. The Resident Census and Conditions of Residents report, dated 12/12/23, documents 77 residents reside in 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 prevent potential cross-contamination and food borne illness by failing to maintain the facility dishwashing machine at a safe chemical level, failing to maintain the facility ice machine in a clean sanitary manner, and failing to maintain a commercial food mixer free of paint chips, food-like build-up and rust. These failures have the potential to affect all 77 residents residing in the facility. Findings include: 1.) On 12/12/23 between 12:35 PM - 1:05 PM, and on 12/13/23 between 12:39 PM - 1:12 PM general meal observations were conducted in the main dining room. Meals were served on glass plates with metal utensils. On 12/14/23 at 10:30 am V26, Dishwasher confirmed the facility dishwasher was a low temp dishwasher and a chlorine solution was used as a sanitizer. V26, Dishwasher measured the chlorine concentration by using a test strip. The chlorine content in the dishwasher measured 10 parts per million (PPM) when tested during the sanitation cycle during dish washing. V26 stated The chlorine level 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.

Based on interview and record review the facility failed to ensure four Certified Nurse Aides (CNA) had a minimum of twelve hours of education annually. This failure has the potential to affect all 77 residents residing in the facility. Findings include: The Daily Midnight Census Report dated 12/12/23 documents 77 residents residing in the facility. The Facility Assessment updated October 2023 documents Inservice training must be sufficient to ensure the continuing competence of nurse aides, must be no less than 12 hours per year. The Facility Staff Inservice Binder documents V15 Certified Nurse Aide (CNA) and V31 CNA both completed nine hours of required training, V20 CNA completed eight hours of required training and V30 CNA did not complete any hours of required trainings in the past 12 months. The facility provided documentation to show that V15's hire date was 2/10/15, V20's hire date was 10/24/22, V30's hire date was 5/29/2019, and V31's hire date was 3/28/2016. On 12/15/23 at 11:30 AM V1 Administrator stated all CNA's should complete at least twelve hours of required training…

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 a surety bond in an amount sufficient to protect all resident personal trust funds. This failure affects 49 residents (R1, R3, R6, R8, R9, R10, R11, R12, R13, R15, R16, R17, R18, R19, R21, R22, R23, R25, R26, R27, R29, R32, R33, R34, R35, R39, R42, R43, R44, R45, R46, R47, R48, R49, R50, R51, R53, R54, R55, R56, R57, R58, R61, R63, R64, R70, R71, R72, and R77) out of 49 reviewed for resident trust funds on the sample list of 64. Findings include: The facility's surety bond (number 978), dated valid 11/12/23 to 11/12/24, documents the facility holds a surety for resident personal trust funds in the amount of $20,000.00. The facility's Balance Sheet dated 12/14/23 documents the resident personal trust funds are held by the facility in the amount of $26, 300.31. This same balance sheet documents R1, R3, R6, R8, R9, R10, R11, R12, R13, R15, R16, R17, R18, R19, R21, R22, R23, R25, R26, R27, R29, R32, R33, R34, R35, R39, R42, R43, R44, R45, R46, R47, R48, R49, R50, R51, R53, R54, R55, R56, R57, R58, R61, R63, R64,…

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 develop comprehensive care plans to include care categories including smoking, oxygen use, dialysis, and wounds. This failure affects four residents (R17, R30, R60, and R65) out of 19 reviewed for care plans on the sample of 64. Findings include: 1. On 12/12/23 at 10:08 AM, R17 stated, I go to dialysis 3 times per week on Monday, Wednesday, and Friday. On 12/14/23 at 11:05 AM, V12, Minimum Data Set and Care Plan Coordinator, stated, (R17) does get dialysis and he is diabetic. (R17) does go to the dialysis clinic 3 times per week. R17's Care Plan dated as created on 5/4/22 with revisions dated through 12/11/23 does not include dialysis as a focus care area, nor does the Care Plan include any monitoring of R17's arterial-venous fistula. 2.) R30's Minimum Data Set (MDS) dated [DATE] documents R30 as cognitively intact. R30's Care Plan initiated on 9/25/23 does not include a focus area, goal nor interventions for R30's Respiratory Diagnoses of Obstructive…

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 obtain physician orders for respiratory equipment use, failed to care plan respiratory care and interventions, repeatedly failed to maintain/clean and store respiratory equipment in a clean sanitary manner and off the floor, and failed to date and initial respiratory equipment when changed, as directed by the facility oxygen policy. These failures affect three (R30, R41, R54) residents of three residents reviewed for respiratory/oxygen on the sample list of 64. Findings include: The facility policy Oxygen Administration dated 2004 documents the following: The purpose of this procedure is to provide guidelines for safe oxygen administration. 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident. 3. Assemble the equipment and supplies as needed. 1. Oxygen therapy is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility repeatedly failed to follow their policy for receiving and disposing of controlled medications for one of five residents (R13) reviewed for unnecessary medications on the sample list of 64. Findings include: R13's Current Physician Order Sheet (POS) start date of 3/10/23 documents the following controlled substance orders and diagnosis: Lorazepam Tablet 0.5 milligrams, Give one tablet by mouth two times a day related to Generalized Anxiety Disorder, and Lorazepam oral Tablet 0.5 milligrams Give 0.25 mg by mouth one time a day for Generalized Anxiety Disorder. R13's Controlled Drug Receipt/Record/Disposition Form dated 10/6/23 - 11/08/23 documents 30 Lorazepam 0.5 milligrams whole tablets were delivered to the facility on [DATE]. The same form does not document signatures of the receiving nurse and a witness confirming the delivery of the controlled substance. R13's Controlled Drug Receipt/Record/Disposition Form dated 10/10/23 - 11/07/23 documents 30 Lorazepam…

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 prevent cross contamination during wound care for one (R60) resident and failed to perform hand hygiene and maintain a hygienic environment when assisting residents (R22, R23, R47, R49) with meals. These failures affected five residents out of six residents reviewed for Infection Control in a sample list of 64 residents. Findings include: 1.) R60's Minimum Data Set (MDS) dated [DATE] documents R60 as cognitively intact. This same MDS documents R60 requires maximum substantial assistance with toileting, bathing, dressing and moderate assistance with bed mobility. R60's Physician Order Sheet (POS) dated December 2023 documents a physician order starting 12/8/23 to cleanse Left Knee, apply collagen pad and foam dressing daily for Left Knee scrape. On 12/14/23 at 10:05 AM V25 Licensed Practical Nurse (LPN) completed R60's dressing change of Left Knee Trauma wound. V25 LPN did not provide clean field. V25 LPN placed wound dressing supplies…

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 homelike environment for one (R284) resident out of one resident reviewed for homelike environment in a sample list of 64 residents. Findings include: The facility Grievance Log Report dated 12/4/23 documents R284 wished to be moved due to roommate keeping heat up and television on all night. (R284) reports she was put in a bed with no sheet. This same report documents R284 was moved however the proper staff was not here over weekend to take her bed apart to move bed. (R284) was given a bed that was in a room with low air mattress that is unable to have a sheet on it. Mattress exchanged and sheet placed. R284's Nurse Progress Note dated 12/4/23 at 3:29 PM documents R284 was moved to a different room per her request. R284's Room Change Notice dated 12/3/23 documents R284 requested to change rooms. This same report documents R284 changed rooms on 12/3/23. On 12/13/23 at 1:15 PM R284 stated I couldn't get along with my other roommate. They wanted the room so hot I couldn't stand it. I asked to move and…

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

Based on interview and record review, the facility failed to timely transmit a resident's quarterly modified minimum data set. This failure affects one resident (R47) out of 20 reviewed for minimum data sets on the sample list of 64. Findings include: R47's Minimum Data Set (MDS) printed 12/12/23 documents this MDS was a (modified) quarterly assessment with an Assessment Reference date of 7/26/23, and was completed on 8/5/23. As of 12/12/23, this MDS had not been transmitted (submitted or accepted) as required. On 12/14/23 at 10:40 AM, V12, Minimum Data Set Coordinator, stated, I reached out to my corporate and was told that there must have been some kind of issue with a batch of transmissions because she found a number of other residents who had not been submitted from that time period.

Based on interview and record review, the facility failed to accurately complete a Pre-admission Screening and Record Review to determine the presence of mental illness. This failure affects one resident (R63) out of two reviewed for preadmission screening on the sample list of 64. Findings include: R63's Pre-admission Screening and Record Review (PASARR) dated 9/11/22 documents R63's suspected or confirmed PASARR conditions (mental illness): N/A (not applicable). This same PASARR documents, No mental health diagnosis is known or suspected. This PASARR documents, No Level 2 screening required, no MI (mental illness), ID (intellectual disability), RC (related condition). R63's Medical Diagnoses list dated 12/13/23 includes Bipolar 2 Disorder (severe mental illness) and was documented as diagnosed with this condition 1/14/21. On 12/13/23 at 2:46 PM, V21, Social Services Director, stated, I did go to the hospital prior to (R63's) admission here, but the hospital does the actual assessment for the PASARR. I did overlook the part where it has the no mental health diagnosis is known or…

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 new Pre-admission Screening and Record Review following the expiration of a temporary Pre-admission Screening and Record Review. This failure affects one resident (R17) out of two reviewed for pre--admission screenings on the sample list of 64. Findings include: R17's Level 1 Pre-admission Screening and Record Review dated 1/4/23 documents, Convalescence Categorical, Approval Period: 60 days. This same PASARR documents, Suspected or confirmed PASARR conditions: Mental Health Disability. As of 12/13/23, a new PASARR Level 1 screen had not been documented in R17's electronic medical record. R17's Medical Diagnosis List dated 12/13/23 includes Major Recurrent Depression, Chronic Post-Traumatic Stress Disorder, Agoraphobia with Panic Disorder, and Anxiety. On 12/14/23 at 11:50 AM, V21, Social Services Director, stated, After our discussion yesterday (reference F644) I started doing some audits and I did find (R17's) PASARR was over due. Unfortunately I know it is late but I did submit for a new Level 1 screen.

Based on observation, interview, and record review, the facility failed to revise a resident's care plan to reflect the actual health status of the resident. This failure affects one resident (R17) out of 19 reviewed for care plans on the sample list of 64. Findings include: On 12/12/23 at 10:08 AM, R17 was seated in his own room in a wheelchair. R17 was visibly a bilateral amputee with both right and left legs being absent below the knees. R17's Medical Diagnoses list (12/13/23) documents R17 experienced an Acquired Absence of the Left Leg Below the Knee dated 1/12/23. This same Medical Diagnoses list documents R17 experienced an Acquired Absence of the Right Leg Below the Knee dated 6/23/22. R17's Care Plan dated as created on 5/4/22 with revisions through 12/11/23 documents a focus care area for impaired skin integrity with nursing interventions including to monitor and change surgical dressing to right toes every shift and wound vac to right foot at all times, change 3 times per week on Mondays, Wednesdays, and Fridays, continuous suction. On 12/14/23 at 11:53 AM, V12, Minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to obtain Physician orders, complete weekly assessments and monitor a wound caused by trauma for one (R60) resident out of three residents reviewed for non-pressure skin conditions in a sample list of 64 residents. Findings include: R60's Minimum Data Set (MDS) dated [DATE] documents R60 as cognitively intact. This same MDS documents R60 requires maximum substantial assistance with toileting, bathing, dressing and moderate assistance with bed mobility. R60's Nurse Progress Note dated 6/20/23 at 10:19 AM documents Small scrape found on Left Knee during shower. R60's Certified Nurse Aide (CNA) Skin Attention Form dated 6/20/23 documents scrape on Left Knee under comments section. R60's Physician Order Sheet (POS) dated December 2023 documents a physician order starting 6/26/23 to cleanse Left Knee and apply foam dressing daily for scrape. R60's POS does not document a physician order for treatment of R60's Left Knee scrape from 6/20/23-6/25/23. R60's Initial…

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 2.) R33 fall risk assessment dated [DATE] documents R33 is a high risk for falls and has had 1-2 falls in the past 3 months. R33's Care Plan dated 09/14/23 documents the following interventions and dates the interventions were to be implemented post falls: Bed and chair alarm due to decreased safety awareness and impulsivity, date initiated: 04/20/2023. The same care plan documents (brand name, non-slip material) to the recliner date initiated: 09/22/2022. On 12/12/23 at 10:40 am V14, Restorative/Certified Nursing Assistant (CNA) stated R33 fell in the dining room a while back, and fractured R33's wrist. V14 stated She (R33) wore a splint on her wrist for awhile. Her wrist is healed now. R33 was seated in her bedside recliner, asleep. V20, CNA stated I believe (R33) is a high fall risk. She (R33) has an alarm on her bed and she sits on an alarm pad in her wheelchair. I (V20) am not sure if we are suppose to move it back and forth to her recliner or not. We usually just put it in her wheelchair. It makes sense to…

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

Based on observation, interview, and record review, the facility failed to provide services related to dialysis including obtaining a physician ordered diet, related monitoring of a dialysis fistula site, and obtaining daily weights. This failure affects one resident (R17) out of one reviewed for dialysis on the sample list of 64. Findings include: On 12/12/23 at 10:08 AM, R17 was seated in his own room in a wheelchair. R17 had a gauze dressing on his upper right arm. R17 stated, I have a fistula. I go to dialysis three times per week on Mondays, Wednesdays, and Fridays. R17 further stated, As far as I know I am supposed to get a diabetic diet and I am supposed to restrict my fluids but this facility doesn't do it. R17 then stated, I know I am supposed to stay away from foods like potatoes, bananas, and orange juice, but this kitchen doesn't adhere to that. R17 continued, The nurses here don't check my fistula with a stethoscope, only the nurses at the dialysis clinic do that. R17's current Physician Order Sheet (POS) dated for December 2023 does not include any physician orders 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.

Based on interview and record review the facility failed to obtain psychotropic medication consents for use, failed to complete quarterly psychotropic medication assessments, and failed to include psychotropic medication use in the resident's plan of care for three of five residents (R3, R54, R232) reviewed for unnecessary medications on the sample list of 64. Findings Include: The facility's Psychotropic Medication Policy dated February 2014 documents the policy is in place to establish a process for monitoring the use of and the reduction of doses of psychotropic medications without compromising the resident's health and safety, ability to function appropriately, or the safety of others. The policy documents psychotropic medication shall not be prescribed without the informed consent of the resident, the resident's guardian, or other authorized representative. The undated Psychopharmacological Drug Use Procedure documents Psychopharmacological drug usage must be addressed in the Care Plan and reassessed every 90 days. The undated Psychotropic Medication Use Management policy…

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 physician orders to obtain a blood Albumin (protein) level for one of four resident (R32) reviewed for wounds/pressure ulcers on the sample list of 64. Findings include: R32's (private wound company) Note dated 11/17/23, signed by V32, Wound Nurse Practitioner documents R32 has a Stage II pressure Ulcer on R32's Medial Right Buttocks. The same note documents an order to obtain a blood specimen to determine R32's Albumin level. On 12/14/23 at 2:05 PM, V25, Licensed Practical Nurse (LPN) entered R32's bathroom to complete R32's Pressure Ulcer treatment. R32 had a pencil eraser sized, Stage II pressure ulcer on her right medial buttocks. R32's Current Physician Order Sheet documents a STAT (immediately) physician order dated 12/15/23 to obtain the Albumin specimen to determine R32's blood level (28 days after the original order). On 12/14/23 at 2:00 PM V1, Administrator stated she was not able to find Albumin laboratory results for R32 (ordered 11/17/23). V1 stated she talked to V2, Director of Nursing by…

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 notify a resident, and the State Ombudsman, in writing of an involuntary facility-initiated discharge. This failure affects one resident (R1) out of 23 reviewed for transfers and discharges on the sample of 23. Findings include: On 11/21/23 and 11/22/23, R1 was not residing in the facility and R1's designated room was not occupied by R1. R1's room was void of personal belongings, and the bed was stripped of sheets. R1's Census Detail dated 11/21/23 documents R1 was discharged to the hospital on [DATE], with no return date documented. R1's Minimum Data Set, dated [DATE] documents R1 was discharged with a return anticipated. R1's Brief Interview for Mental Status dated 10/30/23 documents R1 as cognitively intact, receiving a score of 15 out of a possible 15. R1's Face Sheet dated 11/21/23 documents R1 is her own responsible party with no legal Power of Attorney. R1's Bed Hold and Transfer forms dated 11/11/23 document R1 was provided with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to allow a hospitalized resident to return to the facility. This failure affects one resident (R1) out of 23 reviewed for transfers and discharges on the sample of 23. Findings include: On 11/21/23 and 11/22/23, R1 was not residing in the facility and R1's designated room was not occupied by R1. R1's room was void of personal belongings, and the bed was stripped of sheets. R1's Census Detail documented R1 was discharged to the hospital on [DATE], with no return date documented. R1's Minimum Data Set, dated [DATE] documented R1 was discharged with a return anticipated. R1's Brief Interview for Mental Status dated 10/30/23 documents R1 as cognitively intact, receiving a score of 15 out of a possible 15. R1's Face Sheet documented R1 is her own responsible party with no legal Power of Attorney. On 11/21/23 at 8:50 AM, V1, Administrator, stated, I think I know what this is about, I have finally pulled the trigger to not accept (R1) back from the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to protect the residents' right to be free from physical abuse by another resident. This failure affected two of four residents (R3, R4) reviewed for abuse in the sample of four. Findings include: The facility's Abuse Prevention Program dated October 2022 documents the facility affirms the right of it's residents to be free from abuse or mistreatment. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means. Physical abuse includes hitting, slapping, pinching, and kicking. The Abuse Investigation Summary dated 8/17/23 documents on 8/17/23 R3 and R4 were involved in a physical altercation. V3 Certified Nurses Assistant (CNA) witnessed the incident. V3 stated she heard R3 yell, stop hitting me and when V3 came around the corner, she witnessed R4 hit R3 in the stomach and then R3 retaliated and hit R4 on the arm. R3's Medical Diagnoses sheet dated October 2023 documents R3 is diagnosed with Paranoid Personality…

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 staff failed to complete pressure ulcer risk assessments for residents with a known risk of pressure ulcers. This failure affects five residents (R10, R13, R15, R16, R17) out of 7 reviewed for pressure ulcers and risk assessments on the sample of 18. Findings include: 1. On 9/22/23 at 10:35 AM, R10 was laying in bed supine with a raised-edge air mattress on the bed. R10 had a pillow placed under both heels and dressings appearing as four inch square adhesive bandages on both heels R10's Census Detail (Undated) documents R10 was admitted to the facility on [DATE]. R10's Diagnosis List (undated) documents R10 experiences medical diagnoses including Acute Kidney Failure, Diabetes, Atrial Fibrillation, Hypertension, Adult Failure to Thrive, Severe Protein-Calorie Malnutrition, Need for Assistance with Personal Care, and Anemia. R10's current Physician Order Sheet (undated) documents R10 has current skin conditions and nursing treatments ordered by the…

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

Based on interview and record review, the facility failed to ensure that dignity was maintained by failing to respond to call lights in a timely manner for six of seven residents (R1, R2, R3, R5, R6, and R7) reviewed for call light response/dignity on the sample list of seven. Findings include: The Resident List Report provided by the facility, dated 8/25/23 documents R1-R3 and R5-R7 are all interview-able. The facility Resident Council concerns under Nursing category on May 1, 2023 documents the following: Resident feel that they are waiting to long at times to use the restroom. Issue is not resolved. The Response from Department also dated May 1,2023 documents: Management rounding units, CNA's completing rounds. Audit call lights. The facility Resident Council concerns under Nursing category on June 5, 2023, documents the same concern Resident feel that they are waiting to long at times to use the restroom. Issue is not resolved. The Response from Department documents: Call light audits continue. Staff educated on answering call lights as soon as they can. The facility Resident…

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 and interview the facility failed to provide a safe, sanitary, comfortable, homelike environment for seven of seven resident (R1-R7) reviewed for environment on the sample list of seven. Findings include: On 8/29/23 at 12:15 pm V17, Certified Nursing Assistant (CNA) stated V17, CNA rotates to work all units, and has worked for the facility 15 years. V17 stated several rooms have had rain leaking through the ceiling and the maintenance department is aware. The Resident List Report provided by the facility, dated 8/25/23 documents R1-R3 and R5-R7 are all interviewable. 1.) On 8/29/23 at 1:05 pm R1 was seated on R1's bed. All white ceiling tile panels, above R1's window, are stained with brown rings. R1 stated he had resided in the room occupied now by R2, prior to being moved to R1's current room. R1 stated R1 thought the sprinkler was malfunctioning in his previous room. It happened at about 1:00 am, one night (unidentified). The ceiling above R1's head was 'pouring water. R1 realized 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 observation, interview and record review the facility failed to ensure staff wore appropriate Personal Protective Equipment in transmission based - contact isolation room during blood glucose monitoring, and resident toileting care. The facility also failed to to perform hand hygiene, and failed to maintain a sanitary eating surface in the same contact isolation room. These repeated failures affect one of three resident (R1) reviewed for infection control on the sample list of seven. Findings include: R1's urine culture laboratory final report dated 8/18/23 documents R1 has ESBL (Extended Spectrum Beta-Lactamase) in his urine. R1's Physician Order Summary sheet dated 8/1/23-8/31/23 documents the following: Place on Contact Isolation for ESBL in urine. Active 8/18/2023. On 8/29/23 at 12:05 pm V15, Licensed Practical Nurse (LPN) entered R1's room, passing by the infection control transmission based-contact isolation cabinet set-up. The cabinet contained Personal Protective Equipment (PPE), just outside of R1's room. V15, LPN did not wash her hands, use hand sanitizer, don a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure that R3 was transferred in a safe manner, using a mechanical lift, and failed to implement fall intervention for R1. R1 and R3 are two of four residents reviewed for mechanical lift transfers/falls on the sample list of seven. Findings include: 1.) R3's Minimum Data Set, dated [DATE] documents R3 is totally dependent on two staff for transfers. R3's Care Plan dated 7/5/23 documents the following: R3 is at risk for falls related to gait/balance problems, Chronic Obstructive Pulmonary Disease, Cellulitis, a History of falls, Fibromyalgia, Weakness, Osteoarthritis of hip and knee, Chronic pain, Shortness of Breath and Insomnia. On 8/29/23 at 2:16 pm V16, and V20, Certified Nursing Assistants (CNA's) transferred R3 by using a full mechanical lift machine. R3 was seated in a wheelchair. V16 and V20 hooked loops of the mechanical lift sling to the mechanical lift. The mechanical lift base with roller wheels, was not opened to balance…

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 documentation that an allegation of physical abuse and an allegation of neglect were thoroughly investigated. This failure affects two residents (R1, R15) of five reviewed for abuse in the sample of 20. Findings include: The facility Abuse Prevention Program policy (10/2022) documents the appointed abuse investigator will attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident, and the resident, if interviewable. The same policy documents any employee who has regularly worked with the resident will also be interviewed. The policy documents the final investigation shall contain: the name, age, diagnosis and mental status of the resident allegedly abused, neglected, exploited, mistreated, or from whom property was misappropriated; the original allegation including the date, time, location, specific allegation, alleged perpetrator, witnessed to the occurrence, circumstances surrounding the occurrence and any noted injuries. 1. The Facility Incident Report Form…

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.