Alden Town Manor Rehab & Hcc

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide appropriate services, equipment, and assistance to maintain or improve mobility with maximum practicable independence. This failure affected two (R1, R2) residents out of four residents who were reviewed for services and equipment. Findings include: R1 [AGE] year-old resident admitted to the facility on [DATE] to 2/26/2025 with diagnoses including but not limited to: enterocolitis to clostridium difficile, urinary tract infection, benign prostatic hyperplasia, hyperlipidemia, hypertension, epilepsy, Cerebral vascular accident with left hemiparesis, and dysphagia. R1's Minimum Data Set (MDS), dated [DATE], documents that R1 has a Brief Interview for Mental Status (BIMS) score of 6/15, which suggests that R1 is cognitively impaired. R2 [AGE] year-old resident admitted to the facility on [DATE] with diagnoses including but not limited to: tracheostomy, chronic kidney disease, encephalopathy, adrenal insufficiency, pituitary mass,…

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

Based on interviews and records reviewed the facility failed to submit accurate and complete data on the Payroll Based Journal. This failure has the potential to affect all 184 residents in the facility. The findings include: On 03/19/25 at 12:55 PM V1, Administrator, said we have no staffing waivers. On 03/20/25 at 09:35 AM V14, Nurse Consultant, said the Interim Director of Nursing, is here at least 5 days, for at least 8 hours. V14 said the DON clocks in (the surveyor requested time cards for 14 days). On 3/20/21 at 10:21AM V1 said Payroll Based Journal (PBJ) data is submitted quarterly and resident census is not included. On 03/20/25 at 12:08 PM V1, Administrator, provided January - March 2025 PBJ Reports. V1 reported unfortunately, for the date of July 2024, August 2024, and September 2024 - there was an error in submission with the integrated file. Therefore, no data was shown for 4th Quarter of 2024. CMS and IDPH were notified of the submission error. On follow up interview, of the same day, V1 was asked by the surveyor for evidence of Director of Nursing included in PBJ and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately code the minimum data set (MDS) assessment for four (R9, R34, R48 and R160) of eight residents reviewed for hospice. In addition, the facility failed to accurately code the weight assessment for one resident (R70) who was identified to have a greater than 10 percent weight loss in 6 months but not identified on the MDS for one of thirteen reviewed for nutrition in a total sample of 54. Findings Include: R160 R160 was admitted to the facility on [DATE] with a diagnosis of cerebrovascular accident. R160's Minimum data set (MDS) dated [DATE] under section J1400 prognosis (Does the resident have a condition or chronic disease that may result in a life expectancy of documents a code 0 which indicates No. R160 hospice admission orders dated 8/29/24 terminal diagnosis of senile degeneration of the brain with 6 months or less to live. On 3/21/25 at 10:15AM, V6(minimum data set, MDS nurse) said a resident receiving hospice services on their 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.

Based on interviews and records reviewed the facility failed to meet residents' needs when they utilize the call lights for assistance. This failure affected 5 ( R283; R75; R121; R115; and R16 ) residents reviewed for call light concerns out of a sample of 54 residents. Findings include: A.During Resident Council interview on 03/18/25 at 11:21 AM R19, Resident Council President gave consent for the surveyor to review the council meeting notes. R283 said If I pull the light they come when they want. I call and sometimes I might wait up to an hour. R283 said yesterday I requested an oatmeal that my sister brought me at 4:00am, I used to work nights so that is when I eat. R283 said they didn't bring it in until 8:00AM with breakfast. R283 said I can hear them talking, laughing, and carrying on in the hallway. R283 said why can't they just bring me what I ask and then they can carry on and I'll be taken care of? On 03/19/25 at 11:04 AM R75 and R121 said the staff will turn the call light off and say I will be back in a minute and they don't come back. R75 said it feels like the call…

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 keep residents free from physical restraints for two (R2 and R10) out three residents reviewed for restraints in a total sample of 54. Findings Include: R2 is a [AGE] year old with the following diagnosis: cerebrovascular disease, neuromuscular dysfunction of the bladder, and acquired absence of bilateral legs above the knee. On 03/18/25 at 9:35am R2 was observed sitting across from the nurse's station in a manual wheelchair with back rest not reclined. A tan/gray canvas strap device tied in a knot to left and right arm rest of wheelchair. Blanket was over chest/abdominal area so the front of R2 was not able to be seen. On 03/18/25 02:43 PM, R2 was lying in bed. Lap belt strap noted tied to each arm rest on the wheelchair. On 03/19/25 12:40 PM, R2 was sitting in a manual wheelchair straight up. The lap belt was tied to each side of the wheelchair and velcroed around R2's waist. V19 (CNA) stated R2 wears this strap while up in a wheelchair…

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 coordinate getting residents (R16, R156, R76 and R84) a level II PASRR assessment for residents with severe mental illness diagnosis for four out of five residents reviewed for PASRR screening in a total sample of 54. Findings Include: R16 is a [AGE] year old with the following diagnosis: major depressive disorder and post traumatic stress disorder (PTSD). R156 is a [AGE] year old with the following diagnosis: bipolar disorder. R76 admitted in the facility on 5/31/2017 with diagnoses but not limited to: Dementia, Bipolar Disorder and Major Depressive Disorder. R84 admitted in the facility on 6/20/23 with diagnoses of but not limited to: Dementia with other behavior disturbance, schizoaffective disorder, and anxiety. R156 was unable to be interviewed due to mental status. On 3/19/25 at 12:28PM, R16 stated R16 is diagnosed with depression and PTSD. R16 confirmed R16 receives medication daily for managing symptoms. R16 reported R16 also attends…

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 doctor's orders for one resident(R89) with a diagnosis of lymphedema by not following physician recommendations of elevating bilateral legs for one of three residents reviewed for quality of care. Findings Includes: R89 has diagnosis of Dementia, Pulmonary Hypertension, Lymphedema and Atherosclerotic Heart Disease. During the survey, (3/18-/3/21/25) R89 was observed with legs flat in the bed in her room. There were no additional pillows available for use to place under her legs. On 3/21/25 at 11:48AM, V23(restorative nurse) said he was not aware of any recommendations to elevate R89's legs. On 3/21/25 at 11:53AM, V22(memory care director) said she was not aware of any recommendations to elevate On 3/21/25 at 11:59AM, V21(nurse practitioner) said she would expect any doctor recommendations to be followed as ordered. V21 said if any resident refuses, she would expect to be notified and the behavior to be documented. V21 said R89 was recommended to keep her legs elevated to help with circulation 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 observation, interview and record review, the facility failed to date oxygen tubing and to properly store nebulizer mask while not in use for one of three (R13) residents reviewed in a total sample size of 54. Findings Include: R13' physician order sheet dated 3/18/25 documents: respiratory: oxygen per nasal cannula at two to four liters per minute continuous .order dated (3/13/25). Albuterol sulfate nebulization solution 1.5milliliter inhale orally via nebulizer every six hours as needed for respiratory symptoms order dated (3/13/25) On 3/18/25 at 10:48am, R13 was observed with a nasal cannula on with oxygen running. R13's oxygen tubing was not dated. R13's nebulizer mask was observed laying in R13's second night stand drawer which was partially opened without a bag. V6 (nurse) said, R13 was re-admitted last night. R13's oxygen tubing should be dated and R13's nebulizer mask should be stored in a plastic bag to prevent contamination. On 3/20/25 at 3:59pm, V14 (regional nurse consultant) said, the oxygen tubing should be dated so that staff will know when to change it.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to implement their policy to ensure reporting of an allegation of resident-to-resident inappropriate touching, and an allegation of being physically restrained by a family member. This affected three of three residents. (R1-R3) reviewed for abuse policy and procedure. Findings include: a.R1's diagnosis include but are not limited to Dementia, Bilateral Cataracts, and Hearing Loss. R1 is identified in his care plan to have mild cognitive deficits and impaired decision making. R1 was transferred to another facility on 1/16/25. R2's diagnosis include but are not limited to Depression, Multiple Sclerosis, Dysphagia, Cerebrovascular Disease, Colostomy, and Bilateral above the knee amputation. R2's cognitive assessment dated [DATE] identifies R2 is rarely/never understood, cognition is severely impaired. According to R2's assessment she is dependent on staff for all cares and Activities of Daily Living. On 3/12/25 between 2:15PM-2:30PM R2 sitting in a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and records reviewed the facility failed to provide evidence that all alleged abuse violations are thoroughly investigated. This failure affected three of three residents (R1-R3) reviewed for abuse policy and procedue. The findings include: a.R1's diagnosis include but are not limited to Dementia, Bilateral Cataracts, and Hearing Loss. R1 is identified in his care plan to have mild cognitive deficits and impaired decision making. R1 was transferred to another facility on 1/16/25. R2's diagnosis include but are not limited to Depression, Multiple Sclerosis, Dysphagia, Cerebrovascular Disease, Colostomy, and Bilateral above the knee amputation. R2's cognitive assessment dated [DATE] identifies R2 is rarely/never understood, cognition is severely impaired. According to R2's assessment she is dependent on staff for all cares and Activities of Daily Living. On 3/12/25 between 2:15PM-2:30PM R2 sitting in a wheelchair across from the nurses' station. R1 alert, awake, looking around. Surveyor greeted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify resident's representative of a hospital transfer for one of three (R1) residents reviewed for transfer policy in the sample of three. Findings include: R1 is a [AGE] year old female admitted to the facility on [DATE] with diagnosis including but not limited to Multiple Sclerosis; Quadriplegia; Neuromuscular Dysfunction of Bladder; Peripheral Vascular Disease; Intervertebral Disc Disorders with Myelopathy, Thoracic Region; Adjustment Disorder with Mixed Anxiety and Depressed Mood; Pressure Ulcer of Sacral Region, Stage 2; and Spinal Stenosis, Lumbar Region with Neurogenic Claudication. On 01/10/2025 at 1:16 PM V9 (Social Service Director) said, Upon admission to the facility, R1 had told me that V20 (Family Member) was her POA (Power of Attorney). R1 said she will reach out and arrange the document to be delivered to the facility. Around the time of R1 hospitalization (12/19/2024), the floor nurse didn't have V20's phone number which was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to implement fall prevention interventions for a resident with a history of and at risk for falls. This failure affects one of three (R2) residents reviewed for falls. Findings include: R2 is a [AGE] year old female admitted to the facility on [DATE] with diagnosis including but not limited to Diffuse Large B-Cell Carcinoma, Lymph Nodes of Head, Face, and Neck; Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Dominant Side; Aphasia following Cerebral Infarction; Muscle Weakness; Difficulty in Walking; Type 2 Diabetes Mellitus with Hyperglycemia; Unspecified Dementia; Psychotic Disorder with Delusions due to known Physiological Condition; and Hallucinations. According to R2's MDS (Minimum Data Set) assessment dated [DATE] (post fall) documents the following: Section C, R2 has BIMS (Brief Minimum Data Set) score of 2 indicating severely impaired cognition. In additional, R2 displays inattention and disorganized…

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 implement interventions to manage behaviors for residents with a diagnosis of Dementia. This failure applies to three of three residents (R1, R2, R3) reviewed for Dementia Care in the sample of three. Findings include: On 12/6/24 at 10:00 AM R2 was lying in her bed in her room. R2 was able to answer simple questions but when asked about the incidents on 9/7/24 and 10/6/24 R2 stated she did not remember. At 12:00 PM R1 was seated in her geri chair in the common area by the nurse's station. R1 called out for Surveyor and wanted Surveyor to bend her 2 fingers. Surveyor spoke to R1 and asked if she was hungry and R1 stated no. Surveyor then told R1 it was almost lunch time and R1 started yelling out, can you bring me some food. At 12:30 PM R1 was moved to the dining room for lunch and she continued to call out, Miss, can I have my food, please!, over and over again until staff were able to bring her her food and sit down to assist her. At…

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 abuse policy by not reporting an injury of unknown origin to include bruising and acute displaced fracture of distal tibia to the State regulatory agency. This affected one of three residents (R1) reviewed for reporting injury of unknown origin. Findings Include: R1 had the diagnosis of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominate side and peripheral vascular disease. On 10/15/24 at 12:37PM, V21 (Illinois department of public health regional office staff) reported that there was no facility report incident or reportable incident for R1. On 10/16/24 at 10:50AM, V5 (regional consultant) said, she does not have and could not find a facsimile or email conformation that R1's reportable incident was sent to Illinois Department of Public Health. On 10/16/24 at 12:24PM, V3 (adon) said, injuries of unknown origins should be reported to Illinois Department of Public Health. On 10/16/24 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and records review, the facility failed to follow physician's orders for Oxygen for one (R4) of three residents reviewed for Oxygen use. Findings include: R4 was admitted to the facility on [DATE] with diagnosis of nephrotic syndrome, hypertensive heart disease with heart failure, heart failure, and kidney disease. On 10/15/24 at 1:55PM, R4 was observed in bed with nasal cannula attached to a green Oxygen tank. V9(nurse) said R4's oxygen was set to one liter. V9 confirmed R4's oxygen tank was empty and needed to be replaced. R4's physician order dated 2/1/24 documents Oxygen per nasal cannula at two liters per minute continuous every shift. On 10/16/24 at 12:14PM, V3 Assistant Director of Nursing (ADON) said all residents with Oxygen should have Oxygen applied according to the physician orders. The Oxygen tanks should never be empty. R4's Oxygen care plan dated 2/21/24 documents: administer Oxygen per physician orders; elevate the head of the bed while napping or sleeping to avoid…

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 timely incontinence care for one of three residents (R3) reviewed for incontinence care on the sample list of 18. Findings Include: R3's diagnoses include Dementia. R3's Minimum Data Set (MDS) section H (bowel and bladder) dated 2/8/24 documents: Urinary continence: always incontinent. R3's care plan initiated 8/4/23 documents: activities of daily living (ADL) self care performance deficit related to weakness and assist with toileting needs as necessary. On 05/02/24 at 2:20pm, R3 was sitting on the side of the bed, with her gown pulled up exposing her incontinence brief. (Initials) 6:20AM was written on R3's brief with a black marker. R3 was alert and oriented to person, place and time and said she needed to be cleaned. R3 said, she has not been provided incontinence care today. R3 was saturated with urine. R3 also had a wet incontinence pad with a strong smell of urine. V10 (cna) said, she has not provided any care to R3. R3 was her last resident. V10 said, R3 was wet, the bed pad was wet and there is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to supervise one of three residents (R4) reviewed for risk for falls. This failure resulted in R4 falling from her wheelchair and having to be transferred to local hospital with a contusion to the bridge of her nose. Findings include: R4 was admitted to the facility 6/6/23 with a diagnosis end stage renal disease, type II diabetes, major depression, Alzheimer's disease, anxiety disorder, dementia and hypertension. R4's Minimum Data Set, dated [DATE] documents R4's brief interview for mental status score 4/15 which indicates severe cognitive impairment. R4's fall risk assessment dated [DATE] documents resident is at risk for falls. Under mobility unsteady gait; under mentation: confused. R4's progress note dated 5/1/24 documents: Writer down the hall doing rounds and assessing patients that were in their rooms when staff hollered out to me and informed me that resident was on floor while in dining room with other residents. Assessed patient and noted…

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 was free from resident to resident physical abuse. This applies to 1 of 3 residents (R2) reviewed for abuse on the sample list of 7. The findings include: R2's face sheet shows she has diagnoses including Dementia, and Alzheimer's Disease. R1's 1/17/24 Minimum Data Set (MDS) assessment shows her memory are cognition are impaired. R3's face sheet shows he has diagnoses including Dementia, Encephalopathy and Alzheimer's Disease. R2's 1/16/24 MDS shows his memory and cognition are severely impaired. R3's Care Plan initiated on 12/29/23 shows he exhibits aggression towards staff and peers. Interventions include calmly and firmly redirect R3. On 3/15/24 at 9:56 AM, V1 (Administrator) said there was a physical altercation between R2 and R3 that was witnessed by V8 (Memory Care Director). V1 said V8 is out on leave and unavailable for interview. V1 said she investigated the incident and did substantiate physical aggression because R3 hit R2 in the head with an open hand. On 3/14/24 at 12:01 PM, V17 (Certified…

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

Based on observation, interviews, and record reviews, the facility failed to administer medications as ordered; failed to ensure medication is available during medication administration; and failed to follow policy in the administration of eyedrops and insulin pen. There were 25 opportunities with five errors resulting in a 20% medication error rate. The errors involved four (R119, R137, R170 and R184) of 16 residents in the sample of 71 reviewed for medications. Findings include: On 02/05/24, the following were observed during medication pass: 11:00 AM: V9 (Registered Nurse, RN) was about to give Humalog on R170, however, the medication was not currently available. V9 stated, His Humalog is not available; there is nothing in the convenient box, nothing in the main medication box and even in the insulin boxes. I will order it now. R170's POS (Physician Order Sheet) recorded: Humalog KwikPen SQ (subcutaneously) 100 units per milliliter (u/ml) inject 8 units before meals. At 12:27 PM, V10 (Licensed Practical Nurse, LPN) was observed preparing R119's eyedrop medication. R119 has an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed implement transmission-based precautions in a timely manner for residents who tested positive for RSV (Respiratory Syncytial Virus) and failed to follow their infection control policy by not wearing appropriate Personal Protective Equipment in an RSV isolation room. These failures applied to two of two residents (R8, R139) reviewed for infection control and has the potential to affect 23 residents being cared for by staff. Findings include: On day one of survey 02/05/2024 between 10:00 AM and 12:30 PM no isolation precautions were observed to be in place for R8 and R139. During observations on the unit, multiple staff were noted to provide care and enter the room without personal protective equipment such as gowns, gloves and face shields. On the following day 02/06/2024 at 12:19 PM contact and droplet isolation sign observed to be in place for R8 and R139 room. At 1:33 PM V37 (Registered Nurse) was interviewed and said that she collected…

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 implement their abuse prevention policy by failing to thoroughly investigate allegations of resident sexual abuse and injury of unknown origin for three (R136, R585, R536) of five residents reviewed for abuse on the sample list of 71. Findings include: 1. On 02/05/2024 at 11:30 AM V1 (Administrator) presented Facility Reported Incident pertaining to R136 and R585 with investigation documents. The investigation consisted of: an Initial and Final copy of a Facility Reported Incident and seven staff interviews. On 02/06/24 at 04:23 PM V1 (Administrator) related the following in summary: There is no police report or hospital record pertaining to incident involving R136 and R585 on 10/22/2023. We called V17 (R136's family) and gave details of the incident, we asked if they would want police to be involved or if they wanted R136 go to the hospital, but V17 refused. V17 was mostly concerned about R585 being removed from the facility which R585 was on 10/23/2023. On 02/07/2024 at 10:32 AM V16 (Agency Registered Nurse) related 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 follow their discharge policy by improperly discharging a resident without permission of the resident or responsible party. This failure affected one (R585) of two residents reviewed for unplanned discharge. Findings include: R585 was admitted to the facility 1/13/23 with diagnoses that included Alzheimer's Dementia. According to R89's electronic health record, R89 was alert and oriented, however experienced periods of confusion and occasionally presented with inappropriate behavior towards staff and residents. Facility reported incident dated 10/22/23 indicated that R585 was involved in an abuse allegation with another resident (R136). In an interview with V15 CNA (Certified Nursing Assistant) on 2/7/24 at 10:02AM, V15 said that the incident occurred at approximately 2:30AM. Progress note written by V19 LPN (Licensed Practical Nurse) on 10/22/23 stated that R585 was being sent out to the hospital via an involuntary petition for inappropriate behavior. R585 left the facility at 12:29PM and did not return. Progress note…

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 resident and/or responsible party with notification of 10 day bed hold and 30 day discharge. This failure applied to one (R585) of two residents who were reviewed for unplanned discharge. Findings include: R585 was admitted to the facility 1/13/23 with diagnoses that included Alzheimer's Dementia. According to R89's electronic health record, R89 was alert and oriented, however experienced periods of confusion and occasionally presented with inappropriate behavior towards staff and residents. Facility reported incident dated 10/22/23 indicated that R585 was involved in an abuse allegation with another resident (R136). In an interview with V15 CNA (Certified Nursing Assistant) on 2/7/24 at 10:02AM, V15 said that the incident occurred at approximately 2:30AM. Progress note written by V19 LPN (Licensed Practical Nurse) on 10/22/23 stated that R585 was being sent out to the hospital via an involuntary petition for inappropriate behavior. R585 left the facility at 12:29PM and did not return. On 2/7/24 at 5:20PM, V27…

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 restorative services after skilled therapy was completed. This failure applied to one of one (R181) resident reviewed for rehabilitation services on the sample list of 71. Findings include: According to electronic medical records, R181, is a [AGE] year-old female admitted on [DATE], with medical diagnosis that include but are not limited to: muscle weakness generalized, unsteadiness on feet, and lack of coordination. On 02/05/2024 at 11:15am, R181 said I came here after surgery. I started receiving physical therapy on 01/11/2024, and I was discharged on 02/01/2024. I am waiting to start with restorative services. On 02/06/2024 at 11:42am, R181 said, I have wanted to walk and move about the facility since my physical therapy ended, but no one from restorative therapy has ever come to assist me with walking. I fear losing all my gains obtained from physical therapy since I am inactive. My goal is to be able to go home walking out of the facility.…

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 identify fall prevention measures as a restraint for 2 of 3 residents (R3,R6) reviewed for fall prevention in the sample of 6. The findings include: 1) R3's electronic face sheet printed on 8/27/23 showed R3 has diagnoses including but not limited to Alzheimer's Disease, dementia without behaviors, functional quadriplegia, and history of falling. R3's facility assessment dated [DATE] showed R3 has severe cognitive impairment and does not utilize restraints. R3's nursing care plan dated 12/18/21 showed, (R3) is at risk for falls related to dementia, syncope/collapse, pacemaker, and requires assistance with activities of daily living. Encourage appropriate use of wheelchair, encourage resident to call, keep bed in lowest position, promote placement of call light within reach, and provide an environment clear of clutter. On 8/27/23 at 10:20AM, R3 was in her reclining wheelchair with the back laid down to an approximate 45 degree angle, the…

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

Based on observation, interview, and record review, the facility failed to follow their medication storage policy by 1. Failing to ensure medication carts were able to be locked and secure when not in use; 2. Failing to store insulin, eye drops, inhalers and creams in individual containers and separately from other medications or items; 3. Failed to sign narcotic medications out of the control book immediately after administering; and 4. Failed to maintain the medication room free of food items. These failures applied to six of seven medication carts and two of three medication rooms that were reviewed for Medication Storage and Labeling. Findings include: On 03/28/23 01:38 PM Surveyor observed Pharmacy personnel installing new locks on medication carts and facility nursing staff telling them that the medication carts were not locking properly, and the drawers were not secure or would come open after walking away. On 03/29/23 at 09:34 AM V4 Director of Nursing said, 'A nurse brought to my attention yesterday that the [medication] cart was not locking. They demonstrated this and it…

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

Based on observation, interviews, and record reviews, the facility failed to clean/disinfect the blood glucose monitoring device per policy and procedure and failed to perform hand hygiene during lunch service. This deficiency affected eight (R1, R11, R83, R88, R98, R113, R126, and R152) residents reviewed for infection control and has the potential to affect 72 residents currently residing on the third floor in the facility. Findings include: On 03/27/23 at 11:30 AM during medication administration observation, V8 (Licensed Practical Nurse, LPN) took R126's blood glucose level read as 387mg/dl (milligrams per deciliter) as seen on the glucometer. Subsequently, after V8 administered R126's insulin, she put back the glucometer inside cart without cleaning or disinfection. At 12:03 PM, she (V8) took the unclean glucometer from the cart and used it on R113. After the blood sugar monitoring, she did not clean glucometer and put it back in the cart. On 03/28/23 at 3:38 PM, V4 (Director of Nursing) was asked regarding expectations on staff during medication administration. V4 replied,…

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 comprehensive, resident-centered care plan in place to address the hearing assistance needs of a resident with significant hearing loss that impacts everyday communication. This failure applied to one (R70) of one resident reviewed for hearing services. Findings include: R70 is an [AGE] year-old female with a diagnoses history of Depressive Episodes, Macular Degeneration, and Age Related Cataracts who was admitted to the facility 12/17/2014. On 03/27/23 at 11:21 AM Observed R70 to be hard of hearing while speaking with surveyor. On 03/27/23 at 02:41 PM Observed R70 having a difficult time hearing while speaking with surveyor and repeatedly pointed to her left ear explaining that she was unable to hear the surveyor well. R70 stated the hearing aid she received was so big and lousy and she can't hear clearly with them. R70 stated the hearing aids also kept making a noise. R70 stated they kept trying to clean them, but nothing helped…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to follow their policy and procedures for maintaining a resident's quality of hearing by not ensuring a resident with impaired hearing who requires a hearing aid was adequately assessed for an effective hearing aid device and not ensuring an adequate hearing aid device was available. This failure applied to one (R70) of one resident reviewed for hearing and vision. Findings include: R70 is an [AGE] year-old female with a diagnoses history of Depressive Episodes, Macular Degeneration, and Age-Related Cataracts who was admitted to the facility 12/17/2014. On 03/27/23 at 11:21 AM Observed R70 to be hard of hearing while speaking with surveyor. On 03/27/23 at 02:41 PM Observed R70 having a difficult time hearing while speaking with surveyor and repeatedly pointed to her left ear explaining that she was unable to hear the surveyor well. R70 stated the hearing aid she received was so big and lousy and she can't hear clearly with them. R70…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews, the facility failed to monitor that a tube feeding is securely connected and is prevented from leaking while feeding a resident with severe impaired cognition and contracted hands and knees. This deficiency affects one (R138) of four residents in a sample of 53 reviewed for tube feeding. Findings include: R138 is a [AGE] year-old female, admitted in the facility on 10/15/2021 with diagnoses of Anoxic Brain Damage, Not Elsewhere Classified; Chronic Respiratory Failure, Unspecified Whether with Hypoxia or Hypercapnia; Encounter for Attention to Gastrostomy; Persistent Vegetative State and Dysphasia Following Cerebral Infarction. Physician Order Sheet (POS) dated 07/12/2022 documented: Diabetisource to infuse 1200 ml/day (milliliters per day) 60ml/hr (milliliters per hour) starts at 1600. On 03/27/23 at 10:30 AM, R138 was observed in bed in a supine position. Head of bed elevated at a 30 degree-angle. There is an ongoing enteral feeding of Diabetisource at 60 ml…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to follow their policy and procedures for providing consistent pain management for residents by not ensuring prescribed pain medication was available and by not following physician's orders for scheduled pain medication administration for a resident with chronic knee pain and arthritis. This failure applies to one (R70) of two residents reviewed for pain. Findings include: R70 is an [AGE] year-old female with a diagnoses history of Spinal Stenosis, Primary Generalized Osteoarthritis, and Difficulty in Walking who was admitted to the facility 12/17/2014. On 03/27/23 at 02:36 PM R70 stated her knee is swollen and really hurts. R70 stated a few weeks ago they didn't have any pain pills for her. R70 stated pharmacy didn't deliver her pain medication or something like that was going on. R70 stated one night she was in such horrible pain she was ready to call 911. R70 stated during that time her opioid pain medication didn't come in or wasn't available. R70's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews, the facility failed to administer medications as ordered. There were 25 opportunities with 3 errors resulting in a 12% medication error rate. The errors involved two residents (R11 and R126) in the sample of 53 reviewed for medications. Findings include: On 03/27/23 at 11:30 AM during medication administration observation, V8 (Licensed Practical Nurse, LPN) was observed preparing insulin for R126. R126's POS (Physician Order Sheet) documented: 07/17/22 - Humalog solution (Insulin Lispro) Inject 6 units subcutaneously with meals. Hold if blood glucose less than 12. 10/25/22 - Humalog solution (Insulin Lispro) Inject as per sliding scale: If 201-250 = 2 units; 251-300 = 3 units; 301-350 = 4 units; 351-450 = 6 units, subcutaneously with meals. V8 took R126's blood glucose level, read as 387mg/dl (milligrams per decilitre) as seen on the glucometer. Sliding scale order is 351-450 = 6 units V8 took R126's Humalog pen, put the needle and turned dose knob to 6…

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.