La Bella At Clifton

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to care plan, identify targeted behaviors and develop/implement personalized interventions to address dementia related behaviors (R2). This failure affects two (R1, R2) of seven residents reviewed for abuse in the sample list of 14. Findings include: The facility's Dementia - Clinical Protocol dated November 2018 documents residents with dementia will have a resident-centered care plan to maximize remaining function and quality of life and the resident's needs will be communicated to direct care staff through care plan conferences, shift communication, and through written documentation such as nursing notes. This policy documents staff should report progressive or persistent worsening of symptoms and increased staff support to the Interdisciplinary Team (IDT), the physician will order appropriate interventions to address significant behavioral or psychiatric symptoms, and the IDT will adjust interventions on the care plan depending on the…

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

Based on observation, interview, and record review the facility failed to follow physician's orders and manufacturer's instructions for two (R9, R11) of nine residents reviewed for medication administration in the sample list of 14. This failure resulted in three medication errors out of 26 opportunities, an 11.5% medication error rate. Findings include: 1.) R9's April 2025 Medication Administration Record (MAR) documents to administer Albuterol Sulfate Hydrofluoroalkane Inhalation Aerosol Solution 108 (90 Base) micrograms (mcg) per actuation give two puffs orally twice daily. On 4/14/25 at 3:27 PM V17 Licensed Practical Nurse administered two puffs of Albuterol 108 mcg inhaler to R9. The inhaler box had a label to shake, and V17 did not shake the inhaler prior to administration. At 3:50 PM V17 confirmed R9's Albuterol inhaler box contained a label to shake and confirmed she did not shake the inhaler prior to administration. V17 stated V17 was not aware V17 needed to shake the inhaler prior to administration. The Highlights of Prescribing Information for Albuterol Sulfate 108 mcg…

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 the facility failed to ensure a wheelchair was in safe operating condition for one (R3) of three residents reviewed for falls on the sample list of 14. Findings include: R3's Nursing Note dated 4/1/25 at 8:38 AM R3 had a witnessed fall. R3 was on the floor by his chair with his legs extended out in front of him and the Certified Nursing Assistant (CNA) stated R3 unclamped the sling from the lift and was then lowered to floor without hitting his head. At 12:20PM on 4/14/2025 V6 CNA stated when V6 lowered R3 into his reclining chair, the wheelchair was broken and tilted forward, causing R3 to slide out of the wheelchair. V6 stated R3's wheelchair had been broken for awhile prior to this fall. On 4/15/2025 at 1:30PM V9 CNA stated that she switched out R3's chair on 4/2/2025 due to the wheelchair being broken and tilted in an upright position. V9 stated she felt that R3 couldn't be comfortable sitting in the forward tilted position of the broken wheelchair. V9 stated R3's reclining wheelchair had been broken for awhile. On 4/15/2025 at 140PM,…

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

Based on observation, interview, and record review, the facility failed to implement a plan of care to reduce resident intrusion of privacy and resulting in aggression. This failure has the potential to affect two residents (R1 and R2) out of three reviewed for allegations of abuse on the sample list of three. Findings include: On 3/25/25 at 11:05 AM, V1, Administrator, stated there had been an incident between R1 and R2 on 3/21/25 when R2 wandered into R1's room, R1 had gotten out of bed to redirect R2 out of his room, and both residents ended up falling to the floor with R2 landing on top of R1. R2's Nursing Progress Note dated 3/20/25 documents R2 had exited his bathroom in the wrong direction on this date, entering the adjoining room of R1 and upsetting R1. This same note documents an interdisciplinary team review of this incident and formulated a plan of care to place a sign in the bathroom to indicate to R2 which bathroom door to exit to go into his own room. On 3/25/25 at 2:30 PM, there was not any sign in the adjoining bathroom between R1's and R2's room to indicate to R2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to sufficiently staff Certified Nursing Assistants (CNAs). This failure affects five of seven residents (R1, R2, R3, R5, R7) reviewed for staffing in the sample list of seven. This failure has the potential to affect all 71 residents in the facility. Findings include: On 1/22/25 between 2:44 PM and 3:03 PM V18, V28, V29, V30, and V31 were the only CNAs working in the facility. 1.) On 1/22/25 at 7:55 AM R3 stated the facility doesn't have enough staff as the staff are constantly running. R3 stated if the CNAs are on their lunch break, then you must wait about 30 minutes for someone to answer your call light. R3 stated R3 is incontinent, uses the call light to be changed, and must wait for staff assistance. R3's Minimum Data Set (MDS) dated [DATE] documents R3 as cognitively intact and requires substantial/maximal staff assistance for toileting. 2.) On 1/22/25 at 8:06 AM R2 stated the facility is short staffed and it takes about 20-30 minutes…

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 sufficiently staff dietary support personnel resulting in delayed timeliness of meals for four of seven residents (R1, R2, R3, R4) reviewed for dietary services in the sample list of seven. This failure has the potential to affect all 71 residents in the facility. Findings include: On 1/22/25 between 6:50 AM and 12:20 PM V32 (Dietary Manager) worked as the dayshift cook during the breakfast and noon meals. V22 and V23 (Dietary Aides) were the only other kitchen staff working in the morning. All resident meals were served to resident rooms due to the facility experiencing gastrointestinal illnesses. On 1/22/25 at 10:55 AM V32 (Dietary Manager) was setting up the steam table to begin serving the noon meal. At 12:00 PM the A, B, and C Hall meal trays were delivered. At this time staff began delivering the D Hall trays to resident rooms, including R1 and R2. 1.) On 1/22/25 at 7:46 AM R4 stated there was a day about a week ago that breakfast…

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

Based on interview and record review the facility failed to maintain food ordering and supply to ensure the menus are followed and to log substitutes. This failure affects three of seven residents (R1, R2, R5) reviewed for dietary services in the sample list of seven and has the potential to affect all 71 residents in the facility. Findings include: On 1/22/25 at 8:06 AM R2 stated the facility runs out of food and doesn't always have substitutes available. On 1/22/25 at 8:17 AM R1 stated the facility has run out of milk, orange juice, and dinner rolls. On 1/22/25 at 11:46 Am R5 stated the facility has run out of certain foods and R5 is not always served yogurt with her meal. The facility's Week at A Glance Menu Week 2 documents cheeseburger on a bun as the main entree for the evening meal on Sunday (1/5/25) and sweet and sour pork as the main entree on Thursday (1/9/25) as sweet and sour pork. The facility's food order invoices dated 12/2/24, 12/23/24 and 12/30/24 document three boxes of 40 beef patties were ordered for each invoice. The facility's food order invoice dated 1/20/25…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to sufficiently staff housekeepers to maintain a clean and homelike environment for five of seven residents (R1, R2, R5, R6, R7) reviewed for housekeeping in the sample list of seven. Findings include: On 1/22/25 at 5:15 AM there was a white dusty substance on the floor outside of the B Hall Shower Room door. From 6:17 AM to 6:35 AM V8 (Housekeeper) cleaned the front entrance of the facility. V8 did not sweep prior to mopping the floor. At 6:41 AM V8 emptied the garbage cans at the nurses' station and mopped the floor. V8 did not sweep the floor prior to mopping. At 8:30 AM V8 cleaned and mopped resident rooms and bathrooms at the beginning of the C Hall. V8 used a broom to sweep up a pile of debris after V8 had finished mopping. V8 did not take a toilet brush into the bathroom to clean the toilet. At 8:43 AM V8 stated if there is only one housekeeper scheduled V8 only has time to clean V8's assigned two halls and then rotates and cleans the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure substitutes were available and failed to honor residents' food preferences for six of seven residents (R1, R2, R3, R5, R6, R7) reviewed for dietary services in the sample list of seven. Findings include: On 1/22/25 from 6:50 AM until 7:38 AM V32 (Dietary Manager) and V23 (Dietary Aide) served the breakfast meal on individual trays for each hall cart. V32 stated last week the facility was without yogurt for three days while they waited for the food order delivery. V32 stated peanut butter and toast was served in place of the yogurt while the facility was without. Yogurt was not served on R3's and R6's meal trays. On 1/22/25 at 12:20 PM there was no prepared egg salad readily available in the kitchen coolers. V32 stated there are hard boiled eggs that can quickly be made into egg salad if requested. V32 confirmed residents do not preselect meals. V32 stated the residents just let us know if they want something else once their meal 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 repeatedly failed to provide showers as scheduled for three of three dependent residents (R2, R3, R4) reviewed for showers in the sample list of five. Findings include: 1. R2's Facility Census documents R2 was admitted to the facility on [DATE] and has the following medical diagnoses; Atrial Fibrillation, Chronic Pulmonary Embolism, Abnormalities of Gait and Mobility, Unsteadiness on Feet, Weakness and Presence of Orthopedic Joint Implants. R2's Minimum Data Set (MDS) dated [DATE] documents R2's Brief Interview for Mental Status (BIMS) score 15, cognitively intact, needs substantial assistance with shower/bathe self, and Activities of Daily Living (ADL). R2's Care Plan dated 9/12/24 documents R2 will receive scheduled showers. Interventions: Staff will encourage resident to take showers per shower schedule. R2 has an Activities of Daily Living (ADL) self-care performance deficit related too decreased strength and mobility. R2's Shower Schedule documents R2 to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon observation, interview, and record review the facility failed to prevent the transmission of clostridium difficile (C-Diff) infections, failed to ensure shower rooms were disinfected to prevent the spread of infection, failed to obtain lab results, and failed to follow hand hygiene guidelines. This affected 8 (R1, R2, R7, R8, R9, R10, R11, R12) of 12 residents reviewed for infection with the potential to affect all 68 residents residing at facility. Findings include: Document identified as outbreak letter that is undated was provided by V2 (Director of Nursing) which documents facility is a 99-bed facility with a current census of 86 patients. 3 patient clostridium difficile (c-diff) positives identified on 7/30/2024. 20 symptomatic patients overall. All have been tested. 3 additional positives identified on 8/2/2024 for a total of 6 confirmed cases. Review of labs documented indicate that no two-step c-diff testing had been performed. Observation documents facility has 2 sets of jack and [NAME] style…

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 timely administer a resident's oral and intravenous antibiotic medication for an infected j-tube (jejunostomy tube) as prescribed to avoid a significant medication error. R2 received the first dose of IV antibiotics 10 days after it was ordered for the multi drug resistant organism in the J-tube site. This failure affects one of three residents (R2) reviewed for medications in the sample list of 12. Findings include: The facility's Medication Administration Policy with an effective date of March 2024 documents, Medications must be administered in accordance with a physician's order, e.g. (for example), the right resident, right medication, right dosage, right route and right time. The facility's Physician Orders -Entering and Processing policy with an effective date of November 2023 documents, Fax or call the orders to the appropriate pharmacy as needed. R2's Order Summary Report dated 8/20/24 documents diagnosis of Extended Spectrum Beta Lactamase (ESBL) Resistance, Gastrostomy Infection and Resistance to…

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

Based on interview and record review the facility failed to obtain informed consent prior to administering an antipsychotic medication to one of three residents (R5) reviewed for chemical restraints in the sample list of 12. Findings include: The facility's Behavioral Health Services Program policy with an effective date of February 2024 documents, The behavioral interventions outlined below are intended to be used only as suggested guidelines for behavior management. Each resident and situation should be considered on an individual basis depending on the nature of the behavior and risk of harm to self or others. Notify the family/resident representative of the change in condition and interventions implemented. Obtain consent for any new psychotropic medications prior to administration. R5's Order Summary dated 8/20/24 documents diagnoses including Anxiety Disorder Unspecified, Altered Mental Status Unspecified and Unspecified Dementia Unspecified Severity with Psychotic Disturbance. This Order Summary documents an order for Quetiapine Fumarate (antipsychotic) oral tablet 25 mg…

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 showers to two of three dependent residents (R2, R3) reviewed for showers in the sample list of 12. Findings include: The facility's Bathing - Shower and Tub Bath policy with an effective date of March 2024 documents, Purpose: To ensure resident's cleanliness to maintain proper hygiene and dignity. Guidelines: a shower, tub bath or bed/sponge bath will be offered according to resident's preference, no less than once per week or according to the resident's preferred frequency and as needed or requested. 1.) R2's Order Summary Report dated 8/20/24 documents diagnoses including Unsteadiness on Feet, Unspecified Abnormalities of Gait and Mobility and Weakness. R2's Minimum Data Set (MDS) dated [DATE] documents R2 is cognitively intact and documents R2 requires partial to moderate assistance to shower/bathe. On 8/19/24 at 10:31 AM, R2 stated that she does not always get her showers. R2's ADL (Activities of Daily Living) bathing task…

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 employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 69 residents residing in the facility. Findings include: On 5/20/24 at 8:23am, V9 (Dietary Manager) was actively supervising dietary operations in the facility kitchen during resident meal preparations. V9 reported being the full-time manager of the facility food service and reported not being a clinically qualified Certified Dietary Manager or having the equivalent training. The Resident Census and Conditions of Residents report dated 5/19/24 documents 69 residents reside in the facility. Facility Assessment Tool dated 12/13/2022 documents: Part 3: Facility Resources Needed to Provide Competent Support and Care for our resident Population Every Day and During Emergencies. Position Dietitian or other clinically qualified nutrition professional to serve as the director of food and nutrition services. 1 Full Time Food Service Manager.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to assess for the use of side rails, obtain consent for side rail use, and care plan side rail use for four (R7, R38, R41, R55) of four residents reviewed for side rails in the sample list of 36. Findings include: The facility's Side Rails/Bed Rails policy dated November 2023 documents bed rails are adjustable metal or plastic bars that range in a variety of types, shapes, and sizes. This policy documents the resident will be assessed for risk of entrapment and benefits of bed rails. This policy documents the assessment may consider the resident's medical diagnosis/conditions/symptoms/behaviors, size/weight, sleeping habits, medications, medical/surgical interventions, underlying medical conditions, existing delirium, self-toileting ability, cognition, communication, mobility, and risk for falls. This policies documents provide information such as the medical needs addressed, alternative interventions previously, and associated risk 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 maintain resident influenza and pneumococcal vaccination information and offer pneumococcal vaccines for four (R31, R7, R14, R54) of five residents reviewed for immunizations in the sample list of 36. Findings include: The facility's Influenza and Pneumococcal Immunization policy dated August 2023 documents education on the influenza will be given to the resident and resident representatives on admission and the vaccine will be administered once the consent for vaccination is signed. This policy documents residents and resident representatives will be given education on the pneumococcal vaccine and the vaccine will be offered in accordance with the CDC (Centers for Disease Control & Prevention) guidelines. This policy documents the influenza vaccine is offered October 1 through March 31. This policy documents influenza and pneumococcal vaccination refusals, education provided, and whether or not the vaccines were given will be documented in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to assess side rails for risk of entrapment for four (R7, R38, R41, R55) of four residents reviewed for side rails in the sample list of 36. Findings include: 1.) On 5/19/24 at 1:05 PM, R7 was lying in bed and there was an upright side rail on the left side of R7's bed. On 5/20/24 at 9:40 AM, V22 (Certified Nursing Assistant/CNA) entered R7's room and transferred R7 from the bed to the wheelchair. R7 used the side rail to sit up on the side of the bed. V22 stated R7 uses the side rail to assist with turning and transfers, and it has been there for at least three months. R7's Minimum Data Set (MDS) dated [DATE] documents R7 has severe cognitive impairment and requires substantial/maximal staff assistance for turning in bed and transferring. 2.) On 5/19/24 at 9:01 AM, R38 was lying in bed on an air mattress, and there were upright siderails on each side of R38's bed. R38's MDS dated [DATE] documents R38 has severe cognitive impairment and 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 accurately complete R15 and R54's comprehensive assessment. This failure affects two (R15, R54) of three residents reviewed for accuracy of assessments on the sample list of 36. Findings include: 1. R54's Minimum Data Set, dated [DATE], documents Section O0110 Special Treatments, Procedures and Programs. H1. Intravenous (IV) Medications R54 received while a resident. R54's Physician Order Sheet (POS) dated March, April, and May 2024 documents R54 has not been prescribed any Intravenous (IV) Medications. On 5/21/24 at 9:19AM, V2 (Director of Nursing) confirmed R54 has never received any Intravenous (IV) medications. V2 confirmed that the facility follows the Minimum Data Set (MDS) 3.0 User Resident Assessment Instrument (RAI) Manual for Long Term Care. 2. R15's MDS (Minimum Data Set) dated 3/13/24 documents R15 is receiving hospice services. R15's Physician Orders Sheet dated March 2024 documents an order for Palliative Care, not hospice. R15's untitled…

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 physician orders for laboratory results and withholding medication, and failed to assess, measure, and implement treatments for diabetic wounds for one (R31) of two residents reviewed for skin conditions in the sample list of 36. Findings include: On 5/19/24 at 9:37 AM, V7 (Licensed Practical Nurse/LPN) and V20 (LPN) administered treatments to R31's toe wounds. R31 had some toes that were previously amputated and there were dark black wounds to the left fourth toe and right second and third toes. On 5/19/24 at 9:55 AM, R31 stated R31 admitted with the toe wounds. R31's Care Plan dated 5/19/24 documents R31's diagnoses include Type 1 and Type 2 Diabetes Mellitus, Atherosclerosis of Coronary Artery Bypass Graft, Peripheral Vascular Disease, Chronic Kidney Disease, and Left Tibia Shaft Fracture. This care plan documents R31 has wounds to the left third and right fourth toes, and includes interventions to monitor for infection,…

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 complete a wound assessment for a pressure ulcer, follow physician orders for wound treatments, and monitor dressing to ensure they were intact for two of two residents (R15, R69) reviewed for pressure ulcers on the sample list of 36. Findings Include: 1. R69's Progress Notes dated 4/13/24 documents R69 was admitted to the facility from the hospital and has a stage 2 (pressure) wound to the coccyx. R69's medical record did not contain any wound assessments until 4/19/24, 6 days after admission. This wound assessment documents a stage 2 pressure ulcer to the sacrum measuring 2 cm (centimeters) by 0.5 cm by 0.1 cm. R69's May 2024 Physician Orders document the following Sacral Wound Treatment: apply a non-bordered foam dressing, cutting a donut out over wound, and secure it with tape twice a week. On 5/20/24 at 1:06 PM, V8 (Registered Nurse/RN) with V3 (Assistant Director of Nursing/ADON) entered R69's room to complete the wound treatment. V3…

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 initial and date oxygen, nebulizer, and humidification bottles, and failed to cover nebulizer for two (R41 and R70) of two residents reviewed for respiratory care on the sample list of 36. Findings Include: The facilities Oxygen and Respiratory Equipment-Changing/Cleaning Policy dated 3/2024 documents; Purpose: 1. Provide guidelines to employees for changing all disposable respiratory supplies. 2. To ensure the safety of residents by providing maintenance of all disposable respiratory supplies. 3. To minimize the risk of infection transmission. Procedure: 1. Handheld Nebulizer (HHN) and Mask, if applicable. A. The handheld nebulizer should be changed weekly and as needed (PRN). b. A clean plastic bag with zip loc or draw string, etc. will be provided with each new set up, and will be marked with the date the set up was changed. C. The aerosol machine will be cleaned monthly on the second shift using facility disinfectant and following manufacturer's directions. 2. Nasal Cannula. a. Nasal cannulas are to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to identify and care plan specific targeted behaviors and nonpharmacological interventions, and complete psychotropic medication assessments for one (R31) of five residents reviewed for unnecessary medications in the sample list of 36. Findings include: 1.) R31's Minimum Data Set, dated [DATE] documents R31 has severe cognitive impairment. R31's Care Plan revised 5/17/24 documents R31 admitted on [DATE] and is resistive to cares due to nursing home adjustment. This care plan does not identify what specific cares R31 is resistive to and does not identify any other behaviors. This care plan documents R31 takes antipsychotic medication for psychotic disorder, antianxiety medication for antianxiety, and an antidepressant for depression, but does not identify specific targeted behaviors for the use of these medications. R31's Physician Order dated 5/17/24-5/31/24 documents to give Lorazepam (antianxiety) 0.5 milligrams (mg) by mouth every eight hours as needed…

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

Based on observation, interview, and record review the facility failed to administer insulin per manufacturer's instructions and facility policy. There were 3 medication errors out of 33 opportunities, resulting in a 9.09% medication error rate. This failure affects three (R16, R32, R1) of six residents reviewed for medication administration in the sample list of 36. Findings include: The facility's Insulin Pen procedure dated March 2024 documents to apply a pen needle and prime the pen prior to each injection to remove air bubbles and ensure the needle is working. This procedure documents to prime the pen, turn the dial to 2 units and push the knob so that a drop of insulin appears, and this may need to be done more than once until a drop of insulin appears. 1.) The Fiasp (insulin) Highlights of Prescribing Information dated September 2017 documents Fiasp is a rapid acting insulin, to be given at the start of a meal or within 20 minutes of starting a meal, and it can cause hypoglycemia (low blood glucose). R16's Physician Order dated 4/18/24 documents to administer Fiasp FlexPen…

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 intravenous medications were accurately labeled for two (R22, R42) of six residents reviewed for medication administration in the sample list of 36. Findings include: The facility's Medication Administration Policy dated March 2024 documents medications must be administered as ordered including the right medication dosage, and labels that do not contain the correct order, resident name, or physician name need to be returned to the pharmacy for relabeling. The facility's Medication Storage policy dated March 2024 documents the medication name and quantity of additives should be included as part of the intravenous (IV) therapy label. 1.) R42's Physician Order dated 5/20/24 documents to administer a one-time IV micronutrient/hydration therapy of 500 milliliters (ml) 0.9% Normal Saline with vitamin/antioxidant additives (79 ml) including Glutamine 600 milligrams (mg), Arginine 300 mg, Lysine 150 mg, and Citrulline 250 mg to be given at a rate of 250 ml/hour (hr). On 5/20/24 at 11:51 AM, V24 (Registered…

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 employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 72 residents residing in the facility. Findings include: On 4/2/23 at 8:23am, V3 (Dietary Manager) was actively supervising dietary operations in the facility kitchen during resident meal preparations. V3 reported being the full-time manager of the facility food service and reported not being a clinically qualified Certified Dietary Manager or having the equivalent training. The Resident Census and Conditions of Residents report dated 4/2/23 documents 72 residents reside in the facility.

Based on interview and record review the facility failed to have the required members attend the Quality Assurance Performance Improvement (QAPI) meetings. This failure has the potential to affect all 72 residents residing in the facility. Findings include: The facility's Quarterly QAPI Meeting policy with a revised date of March 2022 documents, Purpose: The meeting is to review the results of the Quality Data the committee has reviewed for the previous quarter. When: quarterly meetings will be held 1 month after the end of the quarter. For example: The 1st quarter meeting will be held in April. Data to be reviewed will be from January, February & (and) March. Ideally the meeting is held on a designated same day to better facilitate attendance. Who Attends: Administrator, DON (Director of Nursing), Medical Director, Infection Preventionist, Social Services, Food Service Director, Activities Director, Maintenance Director, Human resources Director, Pharmacy Consultant, Dietary Consultant, Social Services Consultant, lab and Radiology support (call in to meeting if needed). On 4/2/23…

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 promote resident's dignity by failing to ensure staff did not stand over residents while providing feeding assistance and ensuring a resident's incontinence brief was not completely exposed in a public area for 2 of 18 residents (R8, R60) reviewed for dignity in the sample list of 26. Findings include: The facility's Dignity policy with a revised date of April 2018 documents, The facility shall promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. Maintaining a resident's dignity should include but is not limited to the following: Promoting resident independence and dignity while dining, such as avoiding: Daily use of disposable cutlery and dishware; Bibs or clothing protectors instead of napkins (except by resident choice); Staff standing over residents while assisting them to eat; 1.) R60's Order Summary Report dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a bed hold policy to one of one resident (R49) reviewed for hospitalizations on the sample list of 26. Findings Include: R49's ongoing census documents R49 was hospitalized from [DATE] - 12/23/22. On 4/02/23 at 8:41 AM, R49 stated R49 got sick pretty quick a few months back and with all R49's breathing issues, the facility sent R49 to the hospital but that R49 never received any paperwork about saving the bed. R49 also stated R49 has had previous hospitalization and didn't receive any bed hold policy then either. R49's medical record does not contain a bed hold policy for R49's 12/19/22 - 12/23/22 hospitalization. On 4/03/23 at 10:24 AM, V12 (Licensed Practical Nurse) stated when a resident goes out to the hospital, the standard of practice is for us to send the resident's face sheet, orders, the order to send to hospital, the transfer form, POLST (Physician Orders for Life Sustaining Treatment) and bed hold policy with the EMT's (Emergency…

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 transmit a resident's Minimum Data Set (MDS) assessment within 14 days of the completion date for one (R63) resident reviewed for discharge MDS assessments on the sample list of 26. Findings include: R63's Electronic Medical Record documents R63 discharged from the facility to home at R63's request on 12/5/22. R63's Census List documents and confirms R63 was discharged from the facility on 12/5/22. R63's discharge MDS dated [DATE], Section Z documents R63's discharge MDS was completed on 12/8/22. R63's MDS Summary dated 4/3/23 documents R63's discharge MDS was not transmitted until 4/3/23. On 4/3/23 at 9:45am, V10 (MDS Coordinator) stated there was no alert in R63's EMR stating R63's MDS was past due. V10 stated R63's discharge MDS was completed on 12/8/22. On 4/3/23 at 9:48am, V13 (Regional MDS Coordinator) stated R63's MDS should have been transmitted after it was completed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop a baseline care plan to address pain and risk of pressure ulcers for one of 26 residents (R172) reviewed for care plans on the sample list of 26. Findings Include: R172's ongoing census documents R172 was admitted to the facility on [DATE]. On 4/02/23 at 8:56 AM, R172 was heard yelling out, ouch from behind doors. Upon entering room, V33 (Certified Nursing Assistant) was in R172's room repositioning R172 onto R172's left side. R172 was lying in bed on a regular mattress. R172 stated R172's right leg hurts when being moved due to a fall at home, but nothing is broken. R172 explained the facility gives R172 pain medicine but they don't always help and it really only hurts when I move though so I stay in bed a lot. I did get up into the chair yesterday and it felt good though. Two disposable Hot packs were sitting in the windowsill. On 4/02/23 at 9:00 AM, V33 confirmed R172 has pain to the hip, likes to stay in bed because of the pain…

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 revise and update a resident's care plan for one of two residents (R32) reviewed for care plans in a sample list of 26. Findings include: R32's Physician's Order Sheet (POS) dated [DATE] documents R32's code status as Full Code-Cardiopulmonary Resuscitation (CPR). R32's Illinois Department of Public Health Uniform Practitioner Orders for Life-Sustaining Treatment (POLST) Form dated [DATE] documents R32 selected Yes Attempt Cardiopulmonary Resuscitation (CPR). Utilize all indicated modalities per standard medical protocols. Full treatment: Primary goals is attempting to prevent cardiac arrest by using all indicated treatments. Utilize Intubation mechanical ventilation, cardioversion, and all other treatments as indicated. R32's Social Service Note dated [DATE] at 10:13am documents the Interdisciplinary Team (IDT) met with V23 (R32's Power of Attorney/POA) and spoke about the care plan. The note documents R32 spoke about all R32's upcoming appointments…

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 provided hot packs for pain relief without a physician order for one of one resident (R172) reviewed for pain on the sample list of 26. Findings Include: On 4/02/23 at 8:56 AM, R172 was heard yelling out, ouch from behind doors. Upon entering R172's room, V33 (Certified Nursing Assistant/CNA) was in the room repositioning R172 onto R172's left side. R172 stated R172's right leg hurts when being moved due to a fall at home. R172 stated the facility gives R172 pain medications but they don't always help. Two used disposable Hot Packs were sitting in R172's windowsill. At 8:58 AM, V33 stated V33 had been putting hot packs on R172's groin area for the past three days for the pain as well as R172 is getting pain medications. R172's March and April 2023 Physician Orders do not contain an order for hot packs to the groin. On 4/03/23 at 9:50 AM, V12 (Licensed Practical Nurse) stated R172 has been asking for a hot pack but that R172 does not have an order for one. V12 stated V12 would need to call the physician to obtain an…

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

Based on observation, interview, and record review, the facility failed to ensure a pressure ulcer treatment was administered according to physician orders for one of three residents (R14) reviewed for pressure ulcers on the sample list of 26. Findings Include: R14's Wound Physician Notes dated 3/30/23 documents R14 has full thickness wounds to the left proximal medial foot and left medial first toe, full thickness caused by a cast on the opposite leg/foot rubbing on the foot. The left proximal medial wound measures 1.5 cm (centimeters) by 1 cm by 0 cm and the left medial first toe wound measures 1 cm by 1 cm by 0 cm. R14's April 2023 POS (Physician Order Sheet) documents an order to cleanse both the left medial first toe and left proximal medial foot with wound cleanser, apply honey to each wound and cover with a bordered gauze dressing three times a week on Monday, Thursday, and Saturday. R14's Care Plan dated 3/28/23 documents R14 is at risk for skin impairment of the left foot due to the cast on the right foot rubbing on it with an intervention to administer/monitor 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 a resident received the correct oxygen flow rate as ordered by the physician for one of one resident (R11) reviewed for oxygen administration in the sample list of 26. Findings Include: The facility's Oxygen Concentrator policy with a revised date of January 2013 documents, Purpose. To provide Oxygen for therapeutic use by utilizing a concentrator that converts ambient air to a high concentration level of oxygen. It is commonly used to provide oxygen therapy. Procedure. 1. Verify and understand the physician's order. 2. Know the flow rate and duration of use. 9. Adjust the flow meter control knob to the flow setting prescribed by the physician. The graduated line of the meter should be aligned with the center of the floating ball. R11's Order Summary dated 4/2/23 documents diagnoses including Essential Hypertension, Atherosclerotic Heart Disease, Peripheral Vascular Disease, Alzheimer's Disease, Chronic Obstructive Pulmonary Disease and Diabetes. R11's Order Listing Report dated 4/4/23 documents 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 interview and record review the facility failed to ensure the use of an as needed (PRN) antipsychotic medication was not administered beyond 14 days without clinical justification and evaluation for its use and failed to provide clinically pertinent explanation for concomitant use of two antipsychotic medications for one of five residents (R11) reviewed for unnecessary medications in the sample list of 26. Findings include: The facility's Psychotropic Medication - Gradual Dosage Reduction policy with a revised date of February 2018 documents, Purpose: To ensure that residents are not given psychotropic drugs unless psychotropic drug therapy is necessary to treat a specific or suspected condition as per current standards of practice and are prescribed at the lowest therapeutic dose to treat such conditions. Residents on anti-psychotic drug therapy will be monitored for tardive dyskinesia side effects every 6 months through the use of the AIMS (Abnormal Involuntary Movement Scale) scale. PRN (as needed)…

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.