Landmark of Cicero Rehabilitation and Nursing Cent

Based on interview and record review, the facility failed to develop and implement comprehensive, person-centered, and individualized fall care plans for four residents (R2, R8, R230, R253) with a history of falls. These failures have the potential to affect four residents (R2, R8, R230, and R253) reviewed for care plans in the total sample of 59 residents. Findings include: 1.R2's face sheet documents, diagnoses that include but are not limited to fracture of right hand, all on same level from slipping, tripping and stumbling without subsequent striking against object, and dementia.R2's BIMS (Brief Interview for Mental Status) score, dated 10/14/25, is 14, which indicates R2 is cognitively intact.R2's Fall Risk Review, dated 2/19/25, documents a score of 13, which indicates R2 was at high risk for falls, and also documents, Does the resident have a history of falls within the last 3 months? Yes. R2's progress note, dated 10/08/25, documents, Resident (R2) c/o (complain) pain on her right wrist. Writer asked resident (R2) what happened, resident (R2) stated that she (R2) had fallen…

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 activities that are appropriate for the season. This failure affected one resident (R71) and has the potential to affect all 32 residents that reside within the 3rd floor dementia unit.Findings include:Facility census (dated 1/5/2026) documents 32 residents reside within on the 3rd floor.R71's admission record documents the following diagnoses: epilepsy, schizophrenia, schizoaffective disorder, bipolar disorder, cataracts, major depressive disorder, and asthma.R71's Minimum Data Set (12/10/2025) documents a Brief Interview of Mental Status (BIMS) summary score of 10, indicating R71 has cognitive impairment. R71's comprehensive activity assessment (9/9/2025) documents R71 is only oriented to self and has an active interest in listening to music. R71's quarterly activity review (12/10/25) documents R71 prefers to participate in activities in R71 room/the day room (dining room) and enjoys sitting listening to music.R71's care plan…

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

Based on observation, interview, and record review, the facility failed to ensure medications were administered within regulatory requirements and failed to document medication administration timely for 8 of 59 residents (R24, R30, R88, R159, R245, R267, R276, R286) in the sample.Findings include:On (1/6/26) at 9:10am, surveyor stated the am medication administration will be observed. V27 (LPN/Licensed Practical Nurse) responded, I'm done already. V27 was asked how many residents V27 is currently assigned to. V27 replied, 31. EMAR (Electronic Medication Administration Record) was asked to be reviewed. V27 stated, I haven't signed it out yet. While reviewing the EMAR, R245 approached V27 and requested scheduled medications that were not received. R245's EMAR affirmed Aspirin, Folic Acid, and Divalproex Sodium were scheduled for 9am administration - none of which were documented as administered at this time. V27 was asked if R245's 9am medications were administered. V27 stated, No and proceeded to dispense R245's medications.On (1/6/26) at 9:30am, V30 (Registered Nurse) affirmed the…

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

Based on observation, interview, and record review, the facility failed to ensure medications were not accessible to unauthorized individuals, failed to ensure medication room doors were locked, failed to store medications in locked cabinets/refrigerators, failed to maintain the medication refrigerator temperature between 36F (Fahrenheit) to 46F, and failed to store refrigerated medications within the required temperature range. These failures have the potential to affect a total of 94 residents residing on 5th and 6th floors. Findings include:The 1/4/26 census includes 25 (5th floor) residents and 69 (6th floor) residents.On 1/7/26 at 1:58pm, the (5th floor) medication room was inspected with V31 (Licensed Practical Nurse). The medication room door was noted to be ajar. V31 was asked if the medication room door was locked. V31 stated, I thought I closed it; it normally slams. V31 entered the medication room without using a key. The 5th floor medication refrigerator was unlocked; a lock was not present. V31 was asked where the medication refrigerator lock was located. V31 responded,…

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 sufficient plates were available, failed to provide meals timely, failed to ensure hamburgers appeared palatable, failed to ensure steam table lids fit properly, and failed to maintain food temperatures within requirements to prevent food borne illness. These failures affect 54 (4th floor) residents. Findings include:The (1/4/26) facility census includes 54 (4th floor) residents. The facility meal-time schedule affirms the (4th floor) lunch is scheduled for 12:15pm-12:30pm.On (1/5/26) at 12:53pm, lunch (pot pie, mashed potato, rice, hamburgers, grilled cheese sandwich) was delivered to the 4th floor dining room via steam table. All the steamtable lids were notably bent on each corner and not insulating the food. On 1/5/26 at 1:00pm, the (4th floor) lunch had not yet been served but scattered clumps of pot pie and smeared mashed potatoes were noted atop of the steam table. The pot pie was still covered with plastic wrap, however, (3) serving scoops covered in clumped; pot pie, mashed potato, and rice…

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 conduct hand hygiene prior to passing meal trays for four (R7, R57, R181, R211) of 59 residents reviewed for infection control.Findings include: On 1/05/26 at 12:07pm, V14 (Rehab Aide) performed hand hygiene using hand sanitizer to both her hands, retrieved a tray of food from the steamtable, walked to the table R12 was sitting at, and served R12 the tray of food. V14 then walked back to the steamtable, did not perform hand hygiene, retrieved another tray of food from the steamtable, walked to the table R181 was sitting at and served R181 the tray of food. After serving R181 the tray of food, V14 went back to the steamtable, did not perform hand hygiene, retrieved another tray of food from the steamtable, walked to the table R7 was sitting at and served R7 the tray of food. After serving R7 the tray of food, V14 went back to the steamtable, did not perform hand hygiene, retrieved another tray of food from the steamtable, walked to the table R57 was sitting at and served R57 the tray of food. V14 then then…

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 sixth-floor men's resident shower room and the eighth floor east wing community shower room were maintained in a clean and sanitary condition; and failed to cover an open electric wire on the wall of the eighth floor. These failures have the potential to affect 71 residents on the sixth floor and 37 residents on the east wing of the eighth floor, reviewed for sanitary and safe environment. Findings include: On 1/5/26 at 10:30am, V1 (Administrator) presented the facility census which shows there are 37 residents on the east wing of the 8th floor. On 1/5/26 at 10:58am during observation of residents on the 8th floor with V33 (LPN/Licensed Practical Nurse), the east wing community shower room was observed with the following: The last toilet stall which V33 stated was the handicapped toilet had malodorous liquid on the floor surrounding the toilet commode. V33 stated she was not sure if the toilet commode was leaking or if it was urine on the floor. There was a pervasive urine odor in the shower…

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 secure handrails within hallways used by residents. This failure has the potential to affect all 32 residents that reside on the 3rd floor.Findings include: Facility census (1/5/2025) documents 32 residents reside on the 3rd floor. On 1/5/2026 at 10:15 am, the handrail next to the bathroom and across from room [ROOM NUMBER] was unsecured, loose and able to be displaced over approximately 3 inches up or down. V38 (Licensed Practical Nurse) observed the loose handrail, affirmed it was loose and stated, It needs to be tightened. I'll let maintenance know. V38 explained the purpose of handrails is for safety and to assist residents with gait abnormalities. On 1/7/2026 at 12:13 pm, V8, Maintenance Director, affirmed the facility expectation is that handrails are secured and promptly fixed if there are any repairs needed. V8 stated handrails are affixed to the walls in common areas for resident safety and to assist anyone that may need it. 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.

Based on observation, interview, and record review, the facility failed to accurately code Minimum Data Sets (MDS) in accordance with the Resident Assessment Instrument (RAI). This failure affected three residents (R9, R11, R71) reviewed for assessment accuracy in a sample of 59 residents. Findings include: 1.R71's MDS (Minimum Data Set), dated 9/10/2025 and 12/10/2025, item I6000, Schizophrenia, is coded No, indicating R71 does not have an active diagnosis of schizophrenia; R71 is taking antipsychotic medications on a routine basis; and S1200, Primary and Secondary SMI Diagnosis, 7-day look back period schizophrenia is indicated as a secondary diagnosis. R71's MDS (9/10/25) indicates R71 had hallucinations, delusions, Verbal behavioral symptoms directed towards others 1-3 days, Other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) occurred daily during the…

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

Based on observation, interview, and record review, the facility failed to ensure personal/hygiene care was provided to two of 59 dependent residents (R11, R40) in the sample reviewed for ADL care provided to dependent residents.Findings include: 1.R11's Minimum Data Set (11/5/2025) documents a Brief Interview of Mental Status (BIMS) interview should not be completed due to R11 being rarely/never understood, and R11 is dependent of staff for personal hygiene. On 1/5/2025 at 10:43 am, R11 was observed sitting in the dining room. R11's face/beard was covered with brown food particles, and food stains were observed on R11's shirt. R11's nails were long and R11's right thumb nail was approximately 1.5-2 cm long from the tip of the thumb, half the thumb nail was missing to the tip of the thumb and the nail appeared jagged and sharp. V38 (Licensed Practical Nurse) observed R11 and affirmedR11's nails needed to be trimmed and there was food on R11's face. V38 affirmed R11 needs assistance with activities of daily living. 2.R40's (12/22/20) care plan states resident has a self-care deficit.…

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 alarms were functioning properly, failed to implement fall prevention interventions, and failed to provide supervision for two of 59 residents (R17, R230) in the sample reviewed for safety.Findings include: 1.R17's diagnoses include autistic disorder, developmental disorder of motor function, and lack of coordination. R17's (11/7/25) functional assessment affirms partial to moderate assistance is required for sit to stand and chair/bed to chair transfers. R17's (4/21/25) care plan states resident had actual falls, interventions: self-releasing seat alarm belt. R17's (11/7/25) BIMS (Brief Interview Mental Status) determined a score of 15 (cognition intact). On (1/5/26) at 10:54am, R17 was seated in a wheelchair and an alarm box was observed behind the seat. V13 (Licensed Practical Nurse) asked R17 to stand up from the wheelchair; however, the alarm didn't sound. V13 was asked if R17's chair alarm was working. V13 stated, Nope, it'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 failed to dispense the correct medication and failed to dispense the correct medication dose. There were 2 medication errors out of 25 opportunities, resulting in a 8% medication error rate. 1 resident (R24) in the medication administration sample was affected. Findings include:R245's POS (Physician Order Sheets) include (7/19/25) Folic Acid 400mcg (micrograms) one time a day and (10/9/25) Aspirin 81mg (milligrams) one time day (scheduled for 9am administration). On 1/6/26 at 9:12am, V27 (LPN/Licensed Practical Nurse) dispensed (chewable) Aspirin 81mg and Folic Acid (1,000mcg) in a cup and affirmed she was prepared to administer them to R245. V27 was asked about the Aspirin discrepancy. V27 inspected the container and stated, The chewable tablet? V27 was asked if chewable Aspirin was prescribed for R245. V27 responded, No. V27 was asked about the Folic Acid discrepancy. V27 inspected the container and replied, This is 1,000. The (undated) drug administration policy states medications are administered as prescribed, in…

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 adequate seating was available for one of 59 residents (R213) in the sample. Findings include:On (1/5/26) at approximately 1:25pm, R213 was served lunch on a tray at the steam table. He proceeded to carry the tray throughout the (4th floor) dining room to find a seat however no chairs were available. R213 stood in the dining room while holding the meal/tray and proceeded to eat half a grilled cheese sandwich before staff provided a chair.On (1/7/26) at 12:20pm, V8, Maintenance Director, was asked if the facility has enough chairs in each dining room V8 (Maintenance Director) stated, I would say yes. V8 was asked why the 4th floor dining room did not have enough chairs available for all the residents (on 1/5/26). V8 responded, Ma'am I couldn't tell you. If anyone needs extra chairs, we just bring extra chairs to the floor. The order of meals served policy (revised April 2022) states dining rooms that have open dining will serve the resident in a timely manner (after) being seated.

Based on interview and record review, the facility failed to update one resident's falls care plan with new interventions to prevent or reduce the risk of further falls. This affected one of three residents (R1) reviewed for plan of care.Findings include: R1's falls care plan, initiated 3/18/25, notes R1 is not at risk for falls as evidenced by the following risk factors and potential contributing diagnosis: bipolar disorder with mood and/or behavioral disturbance. The only intervention noted: nursing staff will complete a fall risk assessment per facility fall protocol. This intervention was reviewed on 3/18, 6/23, and 9/22.There is not an at risk for falls care plan initiated prior to R1's fall or a high risk for falls due to actual fall care plan initiated post fall on 9/19/25.R1's falls report, dated 9/19/25, notes V4 (nurse) observed R1 on floor lying near table on stomach. R1 stated R1 moved away, another resident was going to touch R1, R1 took the other resident's coffee, and it spilled. Predisposing physiological factors include impaired memory, impulsive, agitated/anxious,…

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 effectively monitor/supervise residents in the dining room to prevent an avoidable accident. This affected one of three residents (R1) reviewed for supervision.Findings include:R1's medical record notes diagnoses including but not limited to generalized anxiety disorder, paranoid schizophrenia, drug induced secondary Parkinsonism, encephalopathy, psychoactive substance abuse with psychoactive substance-induced psychotic disorder with delusions, and strange and inexplicable behavior.R1's functional abilities assessment, dated 6/24/25, notes R1 requires supervision or touching assistance with walking 10 feet, 50 feet with two turns, and 150 feet.R1's fall risk review, dated 7/30/25, notes R1's fall risk score is 3; R1 is not at risk for falls.R1's fall risk review, dated 9/23/25, was completed for re-admission after hospitalization for a traumatic fall. R1's fall risk score is 3; R1 is not at risk for falls.R1's BIMS (Brief Interview of Mental Status) score, dated 7/2/25, notes R1's score is 10 out of 15. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain comfortable temperatures and failed to have a system in place to accurately take and record temperatures to ensure resident safety during extreme weather conditions. This failure has the potential to affect all 266 residents living in the facility.Findings include:On 7/1/2025, at 11:37 PM, temperature logs were reviewed for facility from April 7, 2025 - July 1, 2025. All temperatures recorded on logs ranged from 75 degrees Fahrenheit(F) - 81 degrees Fahrenheit in round numbers.On 7/1/2025, at 11:42 AM, V6, Assistant Maintenance Director, stated, We do daily temperatures in the morning and in evening. We have not had any temperatures out of range this year. The range is supposed to be 72-81 degrees. We had a town wide power outage I think it was last Sunday (6/22/2025). Temperatures were all good. It did not even last 10 minutes. Surveyor asked to accompany V6 to take temperatures on all floors. V6 took temperatures at various…

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 serve lunch to residents in the dining room at the same time as other residents seated at the same tables. This affected four of four residents (R192, R195, R258, and R260) reviewed for dignified dining experience in a sample of 63. Findings include: On 6/4/25 at 12:30PM, lunch service started on 8th floor common dining room. Resident names were called and lunch trays were provided. At the completion of the tray line, R258, R260, R192, R195 all were not given lunch trays. R258 and R260 were present in the dining room and names were not called by staff. R258 and R260 lunch trays were found on cart by staff and given to the residents. On 6/4/25 at 1:14PM, R260 was served a lunch tray. On 6/4/25 at 1:16PM, R192 was served a lunch tray. R192 did not have a diet ticket. On 6/4/25 1:24PM, R258 was served his lunch tray. On 6/4/25 at 1:25PM, R195 was served a lunch tray. R195 did not have a diet ticket. Facility's dignity policy, undated, documents: Trays must be served in order at each individual table- residents…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to obtain and document consent for participation in a pharmacy program, which included taking medication (descovy) for human immunodeficiency virus (HIV) pre exposure prophylaxis for four (R117, R129, R256, R258) of four residents reviewed for resident rights. Findings include: 1. R117 was admitted to the facility on [DATE], with diagnoses of hypertension, kidney disease, and schizoaffective disorder. R117's Brief Interview for Mental Status score, dated 5/14/25, documents a score of 15/15, which indicates cognitively intact. R117's physician orders, dated 5/28/25, documents Descovy Oral Tablet 200-25 MG. Give 1 tablet by mouth every day shift related to encounter for HIV pre-exposure prophylaxis. On 6/6/25, medication descovy was observed on medication cart with V10 (nurse). R117's medication administration record for June 2025 documents R117 received Descovy on 6/2/25, 6/3/25, and 6/4/25. On 6/5/25 at 4:15PM, R117, who was alert 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.

Deficiencies at this level require more than one deficient practice statement. A. Based on interview and record review, the facility failed to conduct care plan meetings with residents and/or resident representatives quartely, and failed provide residents with an opportunity to participate in the development, review, and revision of their care plans. This failure affected six of seven residents (R9, R15, R149, R161, R211, and R255) reviewed for care planning in a sample of 63 Findings include: 06/04/25 at 09:17 AM, V22 (Social Service Coordinator) stated a care plan conference with resident and/or resident's family is held quarterly. V22 stated he has not spoken with R15's family as of yet. V22 stated the previous Social Worker for the third floor nursing unit was gone prior to his start date. V22 stated he was not aware of R15's family member's request to have R15 transferred to a facility closer to them. 06/05/25 at 11:45 AM, V24 (Social Services Director) stated care plan meetings are held quarterly and annually for all residents. V24 stated the MDS (Minimum Data Set) staff send…

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 the lunch meal served from the steam table at a temperature of at least 125 degrees Fahrenheit. This failure affected the 10 of 10 ( R51, R79, R176, R186,R192,R195, R222, R256,R258, R260) residents on the eighth floor nursing unit. Findings include: According to the current resident census there are 10 resident residing on the eight floor nursing unit. ( R51, R79, R176, R186,R192,R195, R222, R256,R258, R260) On 6/4/25 at 12:30 PM, the lunch meal was observed on the eighth floor nursing unit. V23 (Dietary staff) was noted obtaining the following temperatures: regular diet: chuckwagon beef stroganoff at120 degrees, noodles were at 110 degrees, buttered cabbage at 120 degrees, hamburgers at 90 degrees. Mechanical soft diet: chuckwagon beef stroganoff at 110 degrees. After V23 checked the temperatures, V23 began serving the meal. V23 did not bring the food to the appropriate temperature prior to serving. 06/04/25 02:21 PM, V14 (Dietary Director) stated the food temperatures should be 125 degrees prior 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, this facility failed to ensure there was a call light cord attached to the call light switch on the wall for a dependent resident. This affected one of three residents R161 reviewed for call light accessibility in a sample of 63. Findings include: 06/03/25 11:40 AM, R161 was observed in bed. There was no call light cord attached to call light switch on wall. R161 stated she has to raise her bed up high and use her pillow to keep hitting the call light switch on wall behind R161's head of bed until it activates. R161 stated this has been going on for one month. On 6/3/25 at 12:45 PM, V34 (psychotherapist) stated today ,R161's BIMS (Brief Interview of Mental Status) score is 15 out of 15. V34 stated R161 has a good memory. On 6/3/25 at 11:55 AM, V3 (nurse) stated there is a binder kept at the nurse's station to document requests for maintenance. V3 held up the binder showing the last documented report to maintenance was June of 2024. V3 stated V3 called maintenance to notify of call light, but they must be busy because they have not…

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

Based on interview and record review, the facility failed to report an allegation of staff to resident abuse to the State Agency. This affected one (R170) of three residents reviewed for abuse policy and procedure. Findings include: On 6/5/25 at 9:30AM, the surveyor attempted to interview R170. R170 only said good morning, but would not answer any other questions. On 6/5/25 at 8:14 AM, V11, Registered Nurse/RN, said, The CNAs (Certified Nursing Assistants) told me (R170) was spitting and swearing at them. When I saw (R170), she was still agitated, and (R170) said the CNAs hit her. I asked the CNAs about it, and they said she does that, she make allegations about them. The next day, someone from administration called me to ask why I did not notify them, and I said it slipped my mind. V11 said he was aware the allegation needed to be reported to administration. On 6/5/25 at 9:13AM, V1, Administrator, said, These are all the abuse reportables for the facility. Upon review, the surveyor did not see a report for R170 dated 5/19/25. On 06/05/25 at 11:33 AM, V1 said, I did not report…

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, facility staff failed to accurately code a Minimum Data Set (MDS) for residents. This affected three of three residents (R98, R46, R269) reviewed for accurate assessment in the total sample of 63. Findings include: 1. R98's MDS (Minimum Data Set) section N medications denote high risk drug class, An X is documented denoting anticoagulant (warfarin, heparin, or low-molecular weight heparin). Number 2. Indication noted X noted for indication for all medications in drug class. Review of R98's physician order sheet showed there are no orders for warfarin, heparin, or low-molecular weight heparin. On 6/5/25 at 8:00 AM, V26 (MDS coordinator) said she coded section N incorrectly, she plans to submit a modification. 2. R46's diagnosis include Chronic Kidney Disease, stage 4, Dependence on Renal Dialysis. On 06/03/25 at 11:12AM R46 said, I have dialysis, I go there. R46's care plan identifies Diagnosis of renal failure and potential for complications related to dialysis. On 06/04/25…

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 observation, interview, and record review, the facility failed to effectively monitor/supervise a resident with known history of wandering into other residents' rooms. This affected one of three residents (R255) reviewed for monitoring/supervision in a sample of 63. Findings include: 06/03/25 at 11:00 AM, R255 was observed entering R211's room and taking a pair of blue sweat pants from R211's belongings. R255 exited R211's room, and brought clothing item into her room and put with her belongings. R255 then entered R71's room and took an orange tee shirt from R71's drawer and put it on over her clothing. There were no staff monitoring R255. On 06/03/25 at 11:15 AM, R71 stated, (R255) does this all the time; coming in her room and taking her belongings. On 06/05/25 at 11:15 AM V6, Director of Nursing/DON stated the resident's care plan is expected to contain information on medications, health conditions, behaviors, and refusal of care. V6 stated R255 has a behavior of wandering into other residents' rooms. V6 was informed staff developed a hoarding care plan related to R255…

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 serve double portions for one resident (R260) who was identified with a significant weight loss of 7.5 % in three months. This affected one of seven (R260) reviewed for significant unplanned weight loss This failure resulted in the R260 losing an additional unplanned five pounds in a month, and a total of 12.5% in six months. Findings include: R260 was admitted to the facility on [DATE], with diagnoses of major depression disorder, schizophrenia, autistic, anxiety, delusional disorder, and paranoid disorder. R260's weights: 5/5/25- 156.6 pounds 4/5/25 157.2 pounds 3/4/25- 161 pounds 2/5/25 168 pounds 1/28/25- 168.4 pounds 1/21/25- 169.8 pounds 1/14/25-170.4 pounds 1/5/25- 172.6 12/30/24- 172 pounds. R260's mini nutritional assessment, dated 4/7/25, documents malnourished. R260's progress note, dated 4/15/25, documents: NUTRITION: RD (Registered Dietician) WEIGHT REVIEW Value: 157.2 Vital Date: 2025-04-05; -7.5% change [ 8.9% , 15.4 ];…

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 the resident was free from unnecessary medications and with a diagnosis for the use of an anticoagulant. This affected one of one resident (R120) reviewed for unnecessary medications in the total sample of 63. Findings include: R120's face sheet shows diagnoses of unspecified dementia, bipolar disorder, schizoaffective disorder, zoster without complications, hyperlipidemia, tinea unguium, unspecified psychosis, dementia in other disease, screening for malignant neoplasm of prostate, fracture of orbital floor 5/8/2023), history of COVID 19, contact with and suspected exposure to COVID19, and acute kidney failure. On 6/3/25 and 6/4/25, R120 was alert; speech was not clear when attempt to interview about his medication. R120 was ambulating independently, transferring from bed independently, and transferring from surface to surface independently. R120's physician order sheet documents orders for heparin Heparin Sodium (Porcine) Injection Solution 5000 UNIT/ML(milliliter), Inject 1 milliliter subcutaneously every eight…

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 check a resident's food allergy prior to meal service. This affected one of one residents (R192) reviewed for food allergies. Findings include: R192 was admitted to the facility on [DATE], with diagnoses of type II diabetes, asthma, and multiple sclerosis. Under allergies documents mushrooms. On 6/4/25 at 1:16PM, R192 was served a plate of beef stroganoff at lunch. R192 observed mushrooms in the sauce, and informed staff he was allergic to mushrooms. R192s diet ticket for 6/5/25 documents lunch chuck wagon beef stroganoff, with no allergy listed. Facility recipe for chuck wagon beef stroganoff, dated 6/4/25, documents: 10.5 pounds of fresh mushrooms On 6/5/25 at 1:53PM, V14(Dietary Manager) confirmed R192's diet ticket did not indicate documented food allergy. V14 said any food allergy would be documented on the dietary ticket to alert staff of any concerns. Facility diet orders policy, dated 9/2023, documents: food allergies 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 maintain separation between clean and soiled equipment, and failed to ensure staff and residents were not sharing drinks to prevent cross-contamination. This failure affected three residents ( R68, R161, and R178) out of four reviewed for infection control in a sample of 63. Findings include: 1. R161's MDS (Minimum Data Set), dated 5/5/25, notes R161 is dependent on staff for toileting. R161 is frequently incontinent of bowel and bladder. On 6/3/25 at 10:50 AM, V18, CNA (Certified Nurse Aide), was observed providing incontinence care for R161. V18 donned gloves, provided bowel incontinence care, and with the same gloves, inserted four right fingers into a large multi-use container of petroleum jelly and scooped up some petroleum jelly and applied the petroleum jelly to R161's buttocks, then replaced lid on jar. Upon exiting room, V18 placed the jar in the clean linen cart with briefs and clean linen. On 6/5/25 at 12:45 PM, V35, CNA (Certified Nurse Aide) stated a barrier cream is applied to resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report a physical abuse allegation to the State Agency. This failure applied to one (R1) of three residents reviewed for abuse. Findings include: R1 is a [AGE] year-old female, who originally admitted to the facility on [DATE], and continues to reside in the facility. R1 has multiple diagnoses including but not limited to the following: COPD (Chronic Obstructive Pulmonary Disease), migraine, muscle spasms, anxiety, ADHD (Attention Deficit Hyperactivity Disorder), intervertebral disc degeneration, behavioral and emotional disorders, PTSD, insomnia, and dental restoration. R2 is a [AGE] year-old male, who originally admitted to the facility on [DATE], and continues to reside in the facility. R2 has multiple diagnoses including but not limited to the following: bipolar disorder, strange and inexplicable behavior, violent behavior, anxiety, brief psychotic disorder, and depression. On 4/30/2025 at 10:45AM, R1 said, One day last week, I was in the elevator…

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 thoroughly investigate an allegation of resident to resident physical abuse. This failure applied to one (R1) of three residents reviewed for abuse. Findings include: R1 is a [AGE] year-old female, who originally admitted to the facility on [DATE], and continues to reside in the facility. R1 has multiple diagnoses including but not limited to the following: COPD (Chronic Obstructive Pulmonary Disease), migraine, muscle spasms, anxiety, ADHD (Attention Deficity Hyperactivity Disorder), intervertebral disc degeneration, behavioral and emotional disorders, PTSD, insomnia, and dental restoration. R2 is a [AGE] year-old male, who originally admitted to the facility on [DATE], and continues to reside in the facility. R2 has multiple diagnoses including but not limited to the following: bipolar disorder, strange and inexplicable behavior, violent behavior, anxiety, brief psychotic disorder, and depression. On 4/30/2025 at 10:45AM, R1 said, One day last week,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to perform a blood glucose check on a diabetic resident that was reporting symptoms of a low blood sugar for 1 of 3 residents (R1) reviewed for quality of care in the sample of 3. The findings include: On 4/6/25 at 2:44 PM, R1 was seated in his wheelchair. R1 had bilateral above the knee amputations. R1 said he's had diabetes for a long time and knows when he feels off. R1 said usually his blood sugars run high, but on that morning (3/17/25) he felt weird. R1 described weird as feeling lightheaded and sweaty. R1 said he went to find the nurse and asked her to check his blood sugar because he thought it was low. R1 said the nurse (V9 - LPN) told him she was busy. R1 said he knew something was wrong, so he went to his room and called 911. R1 said he is a brittle diabetic meaning his blood sugar will be really high and then drop down really low. R1 said he didn't eat much dinner the night before and he thought that was why his blood sugar…

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 the treatment plans from an infectious disease practitioner and a dermatologist were implemented for a resident with a rash for 1 of 3 residents (R3) reviewed for quality of care in the sample of 13. The findings include: On 11/8/24 at 9:35 AM, R3 was sitting on the bed in his room. R3 lifted his shirt and he had multiple areas of small red spots on the front and back of his upper body. This surveyor was unable to visualize the rest of his body. R3 said that they itch at times. R3's Infectious Disease Consult Note from V21 (Infectious Disease Nurse Practitioner) dated 10/10/24 and 10/17/24 shows, Patient noted with disseminated, maculopapular rash on trunk and all 4 extremities Patient does report mild itching Discussed patient at length with ADON (Assistant Director of Nursing), discussed oral anti-fungal .Possible fungal in nature per my assessment Assessment/Plan: Disseminated Rash-recommend anti-fungal cream .Recommend Fluconazole (oral antifungal) 400 mg (milligrams) q (every) day x 14 days F/U (Follow-Up) 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.

Based on observation, interview and record review the facility failed to ensure a resident was served a no concentrated sweets diet as ordered by the physician for 1 of 3 residents (R3) reviewed for therapeutic diets in the sample of 13. The findings include: R3's Facesheet shows a diagnosis of: diabetes mellitus with hyperglycemia. R3's Physician's Order Sheet shows a diet order dated 8/4/22 for: No Concentrated Sweets diet. On 11/8/24 during the noon meal, R3 was served a dessert of mandarin orange fluff. R3 consumed the dessert. The facility provided Diet Spreadsheet for 11/8/24 shows that residents on a CCHO (LCS) (Consistent Carbohydrate, Limited Concentrated Sweets) diet should receive mandarin oranges instead of mandarin orange fluff. On 11/8/24 at 3:03 PM, V16 (Dietary Manager) said that all residents should receive what is on the spreadsheet for each meal based on their ordered diet. V16 said that residents on a CCHO (LCS) diet should have received mandarin oranges for the noon meal because the fluff part of the mandarin orange fluff contains a lot of sugar. The facility's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to reassess a resident's right and privileges to go out on pass. This applies to 1 of 9 residents (R3) reviewed for resident rights in the sample of 9. The findings include: R3's face sheet shows he is a [AGE] year-old male admitted on [DATE] and re-admitted on [DATE]. R3's diagnoses include bipolar disorder current episode depressed without psychotic features, mood disorder due to physiological disorder with mixed features, and psychoactive substance abuse. On 7/12/24 at 9:45 AM, R3 was observed in his room. He said he used to have a green pass and was able to leave the facility. There was an incident when he violated the of the rules and was placed on restrictions for months. There are other residents who get in trouble, and they are able to resume their privileges a week later. R3 said he has spoken to V12 (Psychiatric Rehabilitation Service Coordinator) about his pass privileges, and she said we are working on it. They keep putting me off.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure resident funds were refunded after discharge to 1 of 3 residents (R1) reviewed for personal funds in the sample of 9. The findings include: R1's admission Record dated 7/12/24 shows R1 was admitted to the facility on [DATE] and discharged on 4/22/24 under Medicaid/social security. R1 has an emergency contact listed as his sister. R1's diagnoses include, but are not limited to, Chronic Obstructive Pulmonary Disease (COPD), schizoaffective disorder, joint pain, depression, insomnia and anxiety. On 7/12/24 at 10:58 AM, V15, Business Office Manager, said R1 has a balance in his account of $518.39 of which he is owed. V15 said R1's family sent him a $20 check which is part of the balance he is owed. V15 said R1 does not owe the facility any money. V15 said R1's money is still sitting in his account because she does not know where to send his money. V15 said no one has called to inquire about R1's money. R1's Resident Account Trust History covering 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 observations, interview, and record review the facility failed to maintain an effective pest control program to support a sanitary environment and to enhance each residents' quality of life due to the continued presence of pests throughout the facility. This failure has the potential to impact all residents served by the dietary department. Findings include: On 01/29/2023 at 10:39 AM, entered kitchen for initial tour with V12 (Food Service Director) the following findings: At 10:41 AM, observed a large mechanical wooden (rat) trap near the inner entrance of the dry storage door beneath a shelving unit. Also observed a large opening to the lower portion of the wall to left of this wooden trap. At 10:43 AM, observed large rodent adhesive trap beneath a shelving unit on the opposite wall below a box of barbeque sauces and noted two small roaches adhered to this trap along with multiple small dark brown colored bugs adhered to all sides and throughout the adhesive trap with the presence of rodent feces 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 interviews and records reviewed the facility failed to follow their abuse policy to report an alleged resident to resident physical assault. This affected two of four residents (R3, R5) reviewed for reporting abuse. Findings include: R3 is [AGE] years old with diagnosis including but are not limited to Schizoaffective Disorder, Psychosis, and Anxiety. R5 is [AGE] years old with diagnoses including but are not limited to Schizoaffective Disorder, Bipolar type, Conduct Disorder, On 11/1/23 at 1:17PM V3, Security, said R3 was using both fists, throwing punches. V3 said R3 was hitting R5 on his face. V3 said R5 just said stop but didn't do anything else. V3 said I took R3 to the desk with the nurse. V3 said R3 got to swinging on the other guy. V3 said I saw R3 hit R5 like 4 hits before we intervened. V3 said V2 assisted him with R3. On 10/31/23 at 10:45AM V2, Security, said I used Crisis Prevention Intervention (CPI) on R3 on Thursday (10/26/23). On 11/1/23 at 10:59AM R3 seen in his room but R3 would not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and records reviewed the facility failed to follow their abuse policy and investigate an alleged resident to resident physical assault. This affected two of four residents (R3, R5) reviewed for investigating physical abuse. Findings Include: R3 is [AGE] years old with diagnosis including but are not limited to Schizoaffect Disorder, Psychosis, and Anxiety. R5 is [AGE] years old with diagnosis including but are not limited to Schizoaffective Disorder, Bipolar type, Conduct Disorder, On 11/1/23 at 1:17PM V3, Security, said R3 was using both fists, throwing punches. V3 said R3 was hitting R5 on his face. V3 said R5 just said stop but didn't do anything else. V3 said I took R3 to the desk with the nurse. V3 said R3 got to swinging on the other guy. V3 said I saw R3 hit R5 like 4 hits before we intervened. V3 said V2 assisted him with R3. On 10/31/23 at 10:45AM V2, Security, said I used Crisis Prevention Intervention (CPI) on R3 on Thursday (10/26/23). On 11/1/23 at 10:59AM R3 seen in his room but…

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 physician visits policy by not developing a treatment plan for a refusal of hernia surgery and the physician failed to document the resident refusal of treatment and services for a rectal bleed for approximately 8 months. This failure affected one of three residents (R2) reviewed for physician services. This failure resulted in R2 being sent to the hospital being diagnosed with 5.0 cm rectal tumor with metastasis to the regional lymph nodes, liver, and lungs. Findings include: On 11.1.23 at 2:38pm R2 observed in his room, resting in bed, R2 observed to be in good spirits, R2 said he had surgery, and he has staples in his stomach (abdomen). R2 said he has never refused to go for the surgery referral, he has never refused to have surgery for his hernia. R2 said he never refused to go to appointment to see why he had rectal bleeding. R2 said he wanted to know what was going on with him. R2 said he had blood coming from his rectum when he…

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 resident rights policy to provide safety and good care for 1 of 3 residents (R4) reviewed for dental care in a sample of 13. Findings include: R4's admission record indicates a diagnosis of schizophrenia, asthma, seizures, and hypertension. R4's order summary report indicates R4 had a dental appointment on 3/7/2023 and a scheduled appointment on 11/3/2023 at 2pm. R4's care-plan indicated intervention to report any unusual symptoms or change of condition to the physician for further medical interventions. A dental appointment schedule dated 3/10/2023 that indicates R4 last dental appointment was canceled by the provider and no further appointment was scheduled. On 10/24/2023 at 2:50pm R4 was observed sitting in bed alert and orient (person, place, time) times three, R4 said I have a cavity in my mouth and opened her mouth for this writer to observe a dark area on a right back bottom tooth. The dental appointment I had in March was canceled and I cannot get the nurse to schedule another appointment…

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 its' policy and procedure for Activities of Daily Living (ADL) Care by not giving residents routine daily and night care by a certified nursing assistant (CNA) for 1 of 3 residents (R6) reviewed for ADL care in a sample of 13. Findings include: On 10/24/2023 at 2:20pm R6 was observed with V8 (Nurse-LPN) in bed with his head laying on the bedside rails, without a gown on, and the smell of urine. V8 turned R6 to the side and observed R6 right side of head red from the bedside rails, bed pad wet and the bottom bed linen with yellow dried areas. On 10/24/2023 at 2:25pm V8 said R6 will reposition himself and lay on the rails, I don't know why he is wet he uses a urinal. The Bed linen should not be stained yellow, I'll have the certified nursing assistant to come and assist R6 now. On 10/24/2023 at 2:27pm V9 (Psychiatric Technician Monitor) said that R6 had not been assisted with care all shift. That her job is to monitor R6 to keep him from falling. On 10/24/2023 at 2:35pm V10 (Certified Nursing…

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

Based on interviews and record reviews, the facility failed to establish the rationale for transfers and discharges; failed to communicate and implement the discharge process accordingly for residents with mental illness and medical conditions. These failures affected 54 (R4, R7, R10 - R25, R28, R35 - R42, R45 - R54, R56 - R72) of 54 residents in the sample of 87 reviewed for transfers and discharges. Findings include: According to facility's admissions and discharge lists dated 07/14/23 to 09/14/23 and 06/29/23 to 09/21/23, the following residents were discharged to another long-term care facility: 07/24/23: R10, R50, R51 and R57. According to social service notes dated 07/24/23, R10, R50, R51 and R57 inquired about discharge to another facility. R10, R50, R51 and R57 were transferred to another facility the same day. During interview with R10 on 09/20/23 at 11:00 AM, he stated that he wanted to go home and not transferred to another facility. On 9/26/23 at 12:53 PM, V6, (Family Member) stated that she was notified of his (R57) discharge to another nursing facility. V6 continued,…

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 adequately notify the power of attorney and resident representative when transferring and/or discharging residents. This failure applied to eight (R11, R15, R16, R37, R54, R57, R58, and R61) of 87 residents reviewed for transfer and discharge. Findings include: Per facility census and resident face sheet, R11 was discharged from the facility on 8/30/23 to another long-term care facility and has a responsible party contact listed. On 9/20/23 at 10:58AM, R11 was interviewed regarding discharge. R11 said the facility asked me if I wanted to discharge to another nursing facility and within four hours I was discharged . It was so quick. I did not receive all my belongings and I would rather go back to the facility than be here. At 12:35PM, V10 (Responsible Party) was interviewed. V10 said I was told somehow that R11 was discharging to another facility. However, it was last minute, and I only found out when the discharge was taking place. I did not have a choice in the matter if R11 discharged . Per facility census and 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.

Based on interviews and record reviews, the facility failed to provide residents with sufficient preparation and orientation prior to transfer and/or discharge. This failure applied to eight (R10, R11, R15, R16, R18, R23, R36, and R37) of 54 residents in the sample of 87 reviewed for transfers and discharges. Findings include: According to facility's admissions and discharge lists dated 06/29/23 to 09/21/23 and 07/14/23 to 09/14/23, the following residents were discharged to another long-term care facility: According to social service notes dated 07/24/23, R10 inquired about discharge to another facility. R10 was transferred to another facility the same day. During interview with R10 on 09/20/23 at 11:00 AM, he stated that he wanted to go home and not transferred to another facility. Social Services notes dated 08/30/23 documented R11, R36 and R37 requested to be transferred to another facility; and were discharged the same day. On 09/20/23 at 10:58 AM, R11 stated during interview, They asked if anybody wants to go, and I raised my hand. Then they sent me here in four hours. I'd…

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

Based on interviews and record reviews, the facility failed to provide residents with required bed hold notice upon transfer to the hospital. This failure applied to nine (R31, R43, R73, R74, R75, R76, R78, R79 and R80) of 16 residents in the sample of 87 reviewed for bed-hold policy. Findings include: According to progress notes, the following residents were transferred to the hospital: 07/06/23: R78 was sent to the emergency room due to acute respiratory failure. Bed hold notice dated 01/4/23. 07/11/23: R75 was transferred to the hospital due to altered mental status. Bed hold policy dated 07/29/22. 07/19/23: R74 was sent to the hospital for psychiatric evaluation. Bed hold notice dated 06/15/23. 07/21/23: R80 was sent out due to aggressive behavior and Stage 4 sacral ulcer. Bed hold policy dated 05/19/23. 07/23/23: R76 was transferred to the hospital due to failure to thrive. Bed hold notice dated 10/30/22. 07/24/23: R79 was sent out to the hospital for evaluation of wound on foot. Bed hold notice dated 05/11/23. 07/25/23: R73 was ordered to be sent out to the hospital 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 interview and record review, the facility failed to provide a completed and accurate discharge summary for residents upon discharge from the facility. This failure applied to 50 (R4, R10, R11, R12, R13, R14, R15, R16, R17, R18, R21, R22, R28, R35, R36, R37, R38, R39, R40, R41, R42, R45, R46, R47, R48, R49, R50, R51, R52, R53, R54, R56, R57, R58, R59, R60, R61, R62, R63, R64, R65, R66, R67, R68, R69, R70, R71, R72, R85, R87) of 87 residents reviewed for proper discharge. Findings include: On 9/18/23 at 11:35AM, V3 (Assistant Director of Social Services) was interviewed regarding discharge summaries. V3 said a discharge summary is done for residents that are on the [NAME] Program. For residents that are not on the [NAME] Program, we complete a discharge assessment as well as a discharge summary in the progress notes. On 9/18/23 at 1:27PM, V2 (Director of Nursing) was interviewed regarding discharge summaries. V2 said we only complete discharge summaries for residents that are under the [NAME] program. If…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to ensure comfortable room temperatures in resident rooms and common areas with room temperatures above 80 degrees Fahrenheit. This failure has the potential to affect all residents in the facility. Findings include: On 8-22-23 at 12:00 PM, surveyor and V5 (Maintenance Director) toured throughout the facility to check room temperatures. The front lobby was 78 degrees Fahrenheit (12:16 PM), 2nd floor smoke room was 84.7 degrees Fahrenheit (12:22 PM), room [ROOM NUMBER] was 89.7 degrees Fahrenheit (12:23 PM), 3rd floor nursing station was 86.3 degrees Fahrenheit (12:24 PM), 3rd floor dining room was 81.6 degrees Fahrenheit (12:25 PM), room [ROOM NUMBER] was 91.4 degrees Fahrenheit (12:28 PM), room [ROOM NUMBER] was 90.6 degrees Fahrenheit (12:30 PM), 4th floor nursing station was 88.8 degrees Fahrenheit (12:31 PM), 4th floor dining room was 85.6 degrees Fahrenheit (12:33 PM), room [ROOM NUMBER] was 90.3 degrees Fahrenheit (12:34 PM), room [ROOM NUMBER] 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.