Accolade Healthcare Danville

Based on observation, interview, and record review the facility failed to administer medications as ordered for three of nine residents (R24, R50, R78) reviewed for medication administration in the sample list of 38. This failure resulted in three medication errors out of 25 opportunities, a 12% medication error rate. Findings include: 1.) R24's May 2025 Medication Administration Record (MAR) documents to administer Novolin Regular Insulin per blood glucose (milligrams per deciliter) based sliding scale, with meals, scheduled at 8:00 AM, 12:00 PM, and 5:00 PM. On 5/19/25 at 12:06 PM R24 was in the main dining room eating lunch. On 5/19/25 at 12:30 PM R24 was in R24's room. V15 Registered Nurse (RN) administered 6 units of Novolin Regular Insulin into R24's abdomen. V15 stated V15 checked R24's blood sugar just a few minutes prior, which was 280. V15 confirmed R24 already ate lunch prior to R24's blood glucose check and insulin administration. On 5/20/25 at 1:50 PM V1 Administrator stated blood glucose should be checked prior to meals. V1 confirmed sliding scale insulin should 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 observation, interview and record review, the facility failed to appropriately label and store medications and account for controlled medications for five of 16 residents (R40, R61, R71, R192, R63) reviewed for medication storage in the sample list of 38. Findings include: The facility's pharmacy policy titled Administration Procedures for all Medications, dated 10/25/14, documents to check the expiration date on package and container prior to medication administration and to label an opened date on multi-dose containers. The facility's Narcotic Count policy dated 9/5/22 documents a physical count of narcotics will be done by the oncoming and off-going nurses at each change of shift to identify discrepancies and to ensure controlled medications are handled, stored, disposed of and accounted for properly. This policy documents the controlled medication record will accompany the controlled medication. The facility's Storage of Medications policy dated April 2025 documents all resident medications should…

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 initiate contact droplet precautions for two residents (R36, R69) and failed to sanitize a blood glucose meter following use to prevent cross contamination for one resident (R24) of 17 residents reviewed for infection control in a sample list of 38. Findings Include: The facility's Glucose Meter Cleaning policy dated July 2019 documents clean and disinfect the blood glucose meter after each use with an Environmental Protection Agency approved cleaner. The facility's policy Transmission Based Precautions revised April of 2025 documents In order to prevent the spread of communicable diseases isolation will be initiated according to CDC (Center for Disease Control) transmission based guidelines. Transmission based guidelines will be used in all cases in which standard precautions does not provide adequate barrier protection. Transmission based guidelines will be used to determine whether airborne, droplet, or contact isolation precautions…

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 maintain or improve range of motion and contractures following recommended restorative program for one (R76) of four residents reviewed in a sample size of 38. Findings include: The facility's policy titled Functional Maintenance Program dated April 2025 documents therapy will provide recommendations for maintenance programing based on therapy outcomes or screenings. Individual tasks will be documented in the Point of Care (POC) in the electronic health record (EHR). Measurable objectives, goals and interventions will be documented in the care plan. On 05/18/25 09:09 AM R76 was in bed and R76's right hand appeared contracted. On 5/20/25 at 9:22 AM R76 used hands and arms in the hallway. R76's left hand appeared contracted in a semi-fist position. R76 did not flex fingers on left hand. R76's face sheet dated 5/20/25 documents an admission date of 3/29/24 with a history of down syndrome, and adult failure to thrive. R76's MDS dated [DATE]…

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 check gastric residual volume during gastrostomy tube (g-tube) medication administration for one of two residents (R26) reviewed for g-tubes in the sample list of 38. Findings include: The facility's Tube Feeding (Administration of Medication) policy dated April 2025 documents to stop the feeding, disconnect the tubing, and check the tubing for placement before administering medications. R26's Care Plan dated 2/10/25 documents R26 has a g-tube and to monitor gastric residual volume prior to administering nutrition and medications. On 5/19/25 at 3:06 PM V17 Registered Nurse stopped R26's feeding, disconnected the tubing, and checked g-tube placement using air rush technique with syringe. V17 did not check gastric residual volume prior to administering water flushes, Tylenol, and Vitamin D3 into R26's g-tube. V17 confirmed V17 did not check gastric residual at this time. V17 stated V17 checked R26's gastric residual earlier, at the beginning of his shift. On 5/20/25 at 12:16 PM V11 Assistant Director of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to report an injury of unknown origin to the state agency (Illinois Department of Public Health) in the required two hour time frame. This failure affects one resident (R1) out of three reviewed for injuries on the sample list of three. Findings include: On 4/10/25 at 11:24 AM, R1 was lying in bed and did not make any verbal responses to a greeting by name and made no verbal responses to questions. R1's Census Detail dated 4/10/24 documents R1 was admitted to the facility 1/14/25, with a subsequent admission 3/7/25. R1's Diagnoses List dated 4/10/25 documents R1 had surgical repair of a right trochanter (hip) fracture which was present on R1's admission of 1/14/25, and surgical repair of a displaced spiral fracture of the right distal femur (knee area) present on R1's admission of 3/7/25. R1's Minimum Data Set, dated [DATE] documents R1 received a score of 4 out of a possible 15 during a brief interview for mental status, indicating severe…

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 fall prevention intervention according to a resident's care plan. This failure affects one resident (R1) out of three reviewed for fall prevention on the sample list of three. Findings include: On 4/10/25 at 11:24 AM, R1 was lying in bed and did not make any verbal responses to a greeting by name and made no verbal responses to questions. There was an alarm sensor pad underneath R1 with a wire cord leading towards the foot end of R1's bed, however the cord was not plugged in to anything. There was an alarm box module on top of a four drawer bureau across the room approximately eight feet away from R1's bed. On 4/10/25 at 11:29 AM, V5, Registered Nurse, confirmed the alarm sensor was not plugged into the module as it should be. V5 further stated he had knowledge of R1's Care Plan containing a fall prevention intervention that R1 was to have the bed alarm and it should be maintained in a functional condition. R1's Care Plan documents a fall prevention intervention dated as initiated on 3/28/25 for a…

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

Based on observation, interview, and record review the facility failed to ensure a dependent resident received repositioning for one (R2) of three residents reviewed for repositioning on a sample list of 4. Findings include: On 2/18/25 at 9:49 AM, 10:35 AM, 10:48 AM, 11:12 AM, 11:49 AM, 12:01 PM, and 12:30 PM, R2 was in his room sitting upright in a reclining geriatric chair. On 2/18/25 at 1:54, V8 Certified Nursing Assistant stated she did not lay R2 down this morning because he got up later than usual, around 9:30 AM to 9:45 AM and wasn't laid down until 1:15/1:30PM. V8 confirmed R2 was in reclining geriatric chair from around 9:30/9:45 AM to 1:15/1:30 PM. Resident/Family Concern Grievance Form documents that a grievance was made on 1/10/25 by V9 spouse of R2. V9 reported she had concerns that R2 was not being repositioned throughout the day. R2's Care Plan dated 1/17/25 documents R2 requires total assist from staff with transfers and requires repositioning every two hours and as needed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to identify and assess for significant weight loss and ensure nutrition/weight loss was evaluated by the physician and dietitian for one (R3) of three residents reviewed for weight loss in the sample list of four. Findings include: On 2/18/25 at 12:07 V24 Certified Nursing Assistant (CNA) was feeding R3's meal which consisted of creamed corn, mashed potatoes, ground country fried steak and cake. At 12:25 PM V24 brought R3's meal tray to the hall cart and stated R3 only ate about 10% of the meal and R3 didn't like the food. V24 stated V24 offered to order R3 alternative food, but R3 declined. R3's meal tray showed R3 ate a few bites of corn, meat and cake. On 2/19/25 at 9:30 AM V23 CNA assisted V3 Assistant Director of Nursing with R3's pressure ulcer treatment administration. R3 had one open, pink/yellow wound to the left buttock with two small superficial wounds next to it. R3 had a deep coccyx wound and the wound bed had pink and yellow…

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 Enhanced Barrier Precautions (EBP) for three (R1, R3, R4) of three residents reviewed for pressure ulcers in the sample list of four. Findings include: The facility's Enhanced Barrier Precautions policy dated 10/21/22 documents EBP expands the use of gloves and gowns to be worn during high-contact care activities that provides opportunities for Multidrug Resistant Organisms (MDROs) to be transferred between staff hands or clothing and between residents during these high-contact cares. This policy documents residents with wounds and indwelling medical devices are at high risk of acquisition and colonization of MDROs. This policy documents to wear gown and gloves when assisting residents on EBP with high-contact care activities, including dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, providing device care or wound care. The Centers for Disease Control and Prevention Consideration for Use of Enhanced Barrier Precautions 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide fingernail care for one of three residents (R3) reviewed for hygiene in the sample list of four. Findings include: R3's Minimum Data Set, dated [DATE] documents R3 has moderate cognitive impairment and requires substantial/maximal assistance from staff for bathing and personal hygiene. R3's Care Plan with reviewed date 7/26/24 documents R3's diagnoses include right sided Hemiplegia/Hemiparesis following Cerebral Infarction and Type 2 Diabetes Mellitus. On 7/29/24 at 9:45 AM V6 Certified Nursing Assistant entered R3's room, provided incontinence cares, and washed R3's face and under arms. R3's fingernails were long, past R3's fingertips, and a black substance was visible underneath. V6 did not offer or provide nail care for R3. On 7/29/24 at 10:04 AM R3 stated the staff trim/clean R3's fingernails about every three days and they have been this long/dirty for about two days. R3 stated R3 would like R3's fingernails cleaned and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement pressure relieving interventions to prevent the development of pressure ulcers, and failed to measure, assess, and report pressure ulcers for two of three residents (R2, R3) reviewed for wounds in the sample list of four. Findings include: 1.) On 7/29/24 at 8:47 AM R2 was lying in bed on R2's back. R2 stated staff change R2 once per day. R2 has a sore on R2's bottom that has been there for about a month, and the staff apply cream to the area. At 10:00 AM R2 was lying in bed. At 10:58 AM R2 was lying in bed on R2's back. R2 stated R2 is currently incontinent of urine, but no one has come in recently to check R2 or reposition R2. On 7/29/24 at 12:16 PM V17 and V10 Certified Nursing Assistants (CNAs) entered R2's room to provide incontinence cares. R2 was lying in bed on R2's back, and there were no pillows positioned underneath of R2 to offload pressure. R2's brief was wet with a moderate amount of urine. There was a small open…

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 timely notify the physician of newly developed, draining wounds for one (R1) of four resident reviewed for wounds in the sample list of six. Findings include: R1's ongoing census documents R1 readmitted from the hospital on 3/1/24. R1's Nurses Weekly Skin assessment dated [DATE] documents R1 had bruising to the groin and abdomen. There is no documentation that R1 had wounds to the abdomen when R1 readmitted on [DATE]. R1's Nursing Note dated 3/3/24 at 1:41 PM documents, CNA (Certified Nursing Assistant) found 3 new open areas just above resident's penis. [NAME] pus coming out of all 3 open areas. Cleaned and dressing placed. Wound nurse notified. R1's Nursing Note dated 03/04/2024 at 5:49 PM documents, Order received for Doxycycline (antibiotic) BID (twice daily) today r/t (related to) open areas on abdominal area. There is no documentation that R1's Physician (V11) was notified of R1's abdominal wounds found on 3/3/24 prior to 3/4/24 when antibiotics…

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 Failures at this level requires more than one deficient practice statement: A. Based on observation, interview, and record review the facility failed to culture a residents' draining wound prior to initiating antibiotics, assess a residents' surgical incision upon admission to include measurements/description of the surgical wound, and accurately transcribe wound treatment orders for three (R1, R2, R6) of four residents reviewed for wounds in the sample list of six. Findings include: A1.) R1's ongoing census documents R1 readmitted from the hospital on 3/1/24. R1's Nursing Weekly Skin assessment dated [DATE] documents R1 had bruising to the groin and abdomen and this note does not document open abdominal wounds. There is no documentation in R1's electronic medical record that R1 had abdominal wounds when R1 readmitted on [DATE]. R1's Nursing Note dated 3/3/24 at 1:41 PM documents, CNA (Certified Nursing Assistant) found 3 new open areas just above resident's penis. [NAME] pus coming out of all 3 open areas.…

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 the facility failed to assess and measure a pressure ulcer upon admission for one (R2) of four residents reviewed for wounds in the sample list of six. Findings include: R2's ongoing Census documents R2 readmitted from the hospital on 4/15/24. R2's Nurses Weekly Skin assessment dated [DATE] documents R2 has an unstageable coccyx wound. There are no measurements or description/characteristics of this wound documented in R2's medical record until 4/16/24. R2's Wound Summary with date range 4/16/24-4/24/24 documents on 4/16/24 R2's unstageable pressure ulcer was 75% non-granulating tissue and 25% deep maroon, had moderate drainage, and measured 6 centimeters (cm) by 4 cm with unknown depth. On 4/25/24 at 8:50 AM V4 Wound Nurse and V10 Wound Physician entered R2's room. V4 removed R2's coccyx wound dressing. The wound was pink with some dark tissue in the center of the wound. V10 measured the wound and stated it measured 4.8 cm by 2.1 cm. V4 cleansed the wound 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, record review and interview, the facility failed to employ a clinically, qualified Director of Food and Nutrition Services. This failure has the potential to affect all 96 residents residing in the facility. Findings include: On 4/16/24 at 10:10 am V8, Dietary Manager (DM) was actively supervising dietary operations in the facility kitchen. V8 stated the facility has had a lot of staff turnover in the kitchen and V8 has not had time to even compete the first module of the required DM education. On 4/16/24 at 10:15 am V8 assessed the commercial table top mixer and confirmed there is a buildup of rust, grease, and food debris on the under-plate directly over the multi-gallon commercial bowl. V8 stated, This will be addressed. It definitely needs attention. V8 confirmed the commercial can opener has a build-up on grease, metal fragments and rust in the gears, silver laminate coating peeling off the can opener blade and upper shaft of the can opener. The sleeve, that hold the table top commercial can opener shaft, has a build-up of brown and black grease-like…

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, record review and interview, the facility failed to maintain facility kitchen equipment in a clean, sanitary condition, to prevent potential cross-contamination and food-borne illness. This failure has the potential to affect all 96 residents residing in the facility. Findings include: On initial tour of the facility kitchen at 9:30 am. V9, [NAME] stated both the facility commercial sized, table top mixer and commercial table-top can opener were considered clean. 1. On 4/16/24 at 10:15 am V8, Dietary Manager joined the initial tour of the kitchen and assessed the commercial table top mixer. V8 confirmed there is a buildup of rust, grease, and food debris on the underplate directly over the multi-gallon commercial mixing bowl. V8 stated, This will be addressed. It definitely needs attention. 2. On 4/16/24 at 10:25 am V8, DM confirmed the commercial can opener has a build-up on grease, metal fragments and rust in the gears, silver laminate coating peeling off the can opener blade and upper shaft of the can opener. Rust was also present on both the can opener…

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 have required members attend Quarterly Quality Assurance (QAA) meetings. This failure has the potential to affect all 96 residents residing in the facility. Findings include: The Long-Term Care Facility Application for Medicare and Medicaid dated 4/16/24, documents 96 residents reside in the facility. The facility provided quarterly QAA meeting attendance forms dated 6/6/23 through 4/20/24, documents no Infection Preventionist present on 6/26/23, and verbal review only by the Medical Director on 11/21/23 and 4/20/24. On 4/17/24 at 11:47 AM, V1 Administrator stated V1 she did not know the Medical Director. The MD couldn't do a verbal review and did not know the MD had to be present in person or video. V1 confirmed the April QAA done 4/20/23, only had a verbal review from the medical director and the June 6/26/23 QAA did not have the Infection Preventionist present 11/21/23 and only had the MD's verbal review. On 4/19/24 at 1:00 PM, V1 Administrator stated the facility's QAA Committee list documents the following members need…

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 residents' rights to dignified activities of daily living. This failure affects six of six (R2, R38, R49, R72, R73, R77) residents reviewed for dignity on the sample list of 24. Findings include: The facility policy Resident Privacy and Dignity dated revised 3/2/24 documents the following: PURPOSE: To provide all residents with a home like environment that promotes dignity and respect to the residents of the facility. POLICY: To ensure that all residents are provided with dignity and privacy. RESPONSIBILITY: It is the responsibility of all staff to ensure that all residents have privacy and dignity. PROCEDURE: 1. All residents will be addressed and spoken to with dignity and respect at all times. All residents will be addressed by their preferred name during conversation. 2. Staff will knock on the resident's door prior to entering the resident's room. Staff will be invited into the resident's room if the resident is capable of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to accurately encode a resident's health status on the Resident Assessment Instrument (Minimum Data Set) regarding dialysis. This failure affects one of two residents (R92) reviewed for dialysis on the sample list of 24. Findings include: On 04/16/24 at 12:48 PM R92 had a dressing on R92's left upper arm. R92 stated the dressing is covering his dialysis port. R92 stated R92 goes to an outside facility for dialysis treatment three times per week. R92's Physician order Sheet dated 4/19/24 documents: Dialysis: Monday -Wednesday -Friday at (a local) Dialysis Center. R92's Minimum Data Set (MDS) dated [DATE] documents R92's Brief Interview of Mental Status score as 14 out of a possible 15, which indicates R92 has no cognitive impairment. The same MDS fails to document that R92 receives dialysis treatments. Dialysis coded incorrectly. On 4/19/24 at 1:12 pm V1, Administrator/ Registered Nurse acknowledged R92's MDS is not accurately encoded to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide PRN (as needed) dressing changes for a resident. This failure affects one resident (R7) reviewed for dressing changes in the sample list of 24. Findings include: R7's undated Medical Diagnoses Page documents R7's diagnoses as: Pyogenic Arthritis, unspecified, aftercare, following joint replacement surgery, Type 2 Diabetes Mellitus without complications, Morbid (severe) Obesity due to excess calories, Methicillin susceptible Staphylococcus Aureus Infection, Unspecified site, and presence of left artificial knee joint. R7's Physicians Order Sheet (POS) dated April 1, 2024 through April 30, 2024, documents R7's orders as: left knee: cleanse with wound cleanser, pat dry, then loosely pack with 1/4 inch iodoform packing strip, apply abdomen pad and wrap with gauze bandage roll, may secure dressing with elastic wrap daily and PRN if soiled or dislodged. R7's Minimum Data Set (MDS) dated [DATE], documents R7 is cognitively intact. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide and implement fall interventions to prevent falls for a resident. These failures affect one of one resident (R29) reviewed for accidents/supervision on the sample list of 24. Findings include: R29's Current (multiple dates) Diagnoses Sheet documents the following diagnoses: Malignant Neoplasm of the Head of the Pancreas, Secondary Malignant Neoplasm of Liver and Intrahepatic Bile Duct, Spinal Stenosis Lumbosacral Regions, Spinal Stenosis Cervical Region, Unspecified Abnormalities of Gait and Mobility, Other Abnormalities of Gait and Mobility. R29's Functional Assessment-Admission dated 02/29/24 documents R29 requires supervision and touching assistance with toileting and chair to bed transfers. 29's Minimum Data Set (MDS) dated [DATE] documents the following: R29's Brief Interview of Cognitive status score of 13 out of a possible 15, indicating no cognitive impairment. The same MDS documents: Supervision or touching assistance -…

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 administer two physician ordered intravenous antibiotic medications on two consecutive days resulting in a delay in treatment for one resident (R7) of one resident reviewed for significant medication errors in the sample list of 24. Findings include: R7's undated Medical Diagnoses Page documents R7's diagnoses as: Pyogenic Arthritis, unspecified, aftercare, following Joint Replacement surgery, Type 2 Diabetes Mellitus without complications, Morbid (severe) Obesity due to excess calories, Methicillin susceptible (resistant) Staphylococcus Aureus infection, Unspecified site, presence of left artificial knee joint. R7's Minimum Data Set (MDS) dated [DATE], documents R7 is cognitively intact. R7's Physicians Order Sheet (POS) dated April 1, 2024 through April 30, 2024, documents R7's orders as: Vancomycin Hydrochloride (HCl) Intravenous (IV) Solution, use 1000 milligrams (mg) intravenously one time a day related to Pyogenic Arthritis, unspecified aftercare…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to maintain complete and accurate medical records for one of two residents (R92) reviewed for dialysis/medical records on the sample list of 24. Findings include: R92's Minimum Data Set (MDS) dated [DATE] documents R92's Brief Interview of Mental Status score as 14, out of a possible 15, which indicates R92 has no cognitive impairment. On 04/16/24 at 12:48 pm, R92 had an undated gauze wound dressing on R92's left upper arm. R92 stated the dressing is covering his dialysis fistula port. R92 stated R92 goes to an outside facility for dialysis treatments, three times per week. R92 also stated the facility nurses do not assess R92's dialysis port fistula patency by thrill (feel for a vibration) and bruit (listen with a stethoscope). R92's Physician Order Sheet (POS) dated 4/19/24 documents: Dialysis: Monday -Wednesday -Friday at (a local) Dialysis Center R92's POS documents: Dialysis: Check Dialysis Site Q (every) Shift for s/s of infection, every…

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 wear a gown during high-contact resident wound care activities in accordance with the physician order, and the infection control enhanced barrier precaution policy. This failure affected one of three residents (R9) reviewed for pressure ulcers/wounds on the sample list of 24. Findings include: R9's Diagnosis Sheet dated 4/18/24 documents the following diagnoses: Type II Diabetes Mellitus with Diabetic Neuropathy, Type II Diabetes Mellitus with Diabetic with Polyneuropathy, Atherosclerosis of Native Artery with Intermittent Claudication, Bilateral Legs, Gangrene Not elsewhere Classified, Acquired Absence of Unspecified Finger(s), Acquired Absence of Unspecified Left Leg Below Knee, Acquired Absence of Right Leg Below Knee, and Phantom Limb Syndrome with Pain. R9's Physician Order Sheet (POS) dated 4/17/24 documents the following: Enhanced Barrier Precautions (EBP) in place during high-contact care activities that provides opportunities for transfer of MDROs (Multi-Resistant organisms that are resistant to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to maintain residents' dignity by failing to provide timely incontinence care for two of six residents (R9 and R10) reviewed for delay in treatment/abuse/dignity on the sample list of 11. Findings include: 1.) R9's Diagnoses Sheet last updated 11/15/23 document the following: Unspecified Urinary Incontinence, Type II Diabetes with Neuropathy, Morbid Obesity Due To Excess Calories and Mood Disorder due to Known Physiological Condition With Depressive Features. R9's Minimum Data Set (MDS) dated [DATE] documents R9's Brief Interview of Mental Status (BIMS) score as 13, out of a possible 15, indicating no cognitive impairment. The same MDS documents R9 is always incontinent of bowel and bladder. The same MDS documents: OBRA Interim section GG0130, Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing…

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

Based on record review and interview, the facility Administrator failed to recognize and timely report an allegation of staff to resident physical abuse to a law enforcement agency for one of six residents (R4) reviewed for abuse on the sample of 11 Findings include: The facility policy Abuse Prevention Program dated January 2022 directs the staff as follows: PURPOSE: This facility is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. This facility will not knowingly employ individuals who have been convicted of abusing, neglecting, or mistreating individuals. PROCEDURE: VIII. External Reporting of Potential Abuse 1. Initial Reporting of Allegations. If mistreatment has occurred, the resident's representative and Department of Public Health shall be informed as soon as possible of any allegation of abuse. In the events that cause the reasonable suspicion…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to maintain complete and accurate medical records by failing to document R10's history of abuse on R10's abuse risk assessment. These failures affected one of eight residents (R10) reviewed for accidents /abuse on the sample list of 11. Findings include: R10's (Private Company) Psychiatric note dated 12/28/23 documents: Childhood Trauma= Mom left them. She lived with her stepdad. Was raped by 2 (two) men. Later, she moved to live with her mom again. PTSD (Post-Traumatic Stress Disorder) = Stepdad used to beat her with a leather trap. She denies flashbacks. She occasionally has flashbacks of the rape by 2 (two) men. One of the men had a sexual intercourse with her. She said they were crazy men who thought she was their girlfriend in the past and broke their heart. Patients denies such accusations and said she didn't know those 2 strange men. (Private Company) note: F41.1: Generalized anxiety disorder, F43.10: Post traumatic stress disorder (PTSD), PLAN Med…

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 an order for pain medication as written by the pain specialist for one (R1) of three residents reviewed for pain in a sample of three residents. Findings include: The facility's Management of Pain policy last reviewed by the facility on August 2019 states, Resident and family are encouraged to report resident pain early so pain management can be more effective. Resident and family will be asked periodically measure satisfaction related to pain and it's management. This policy further states As a part of our approach to pain assessment and management, pain will be considered the fourth (sic) vital sign at the facility along with temperature, pulse, respirations, and blood pressure. For the purpose of this policy pain is defined as whatever the experiencing person says it is and existing whenever the existing person says it does. R1's Care Plan dated 8/1/23 includes the following diagnoses: Osteoporosis, Osteoarthritis, Morbid Obesity,…

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 have the required members of the Quality Assessment and Assurance Committee in attendance at its quarterly Quality Assurance meetings. This failure has the potential to affect all 88 residents residing in the facility. Findings include: The facility's Quality Assurance sign in sheets dated 3/15/22 has no documentation of the Director of Nursing, Infection Preventionist or Medical Director being in attendance, 7/28/22 has no documentation of the Infection Preventionist and Medical Director being in attendance, 9/19/22 has no documentation of the Infection Preventionist being in attendance, 12/22/22 has no documentation of the Director of Nursing and Medical Director being in attendance, and 1/23/23 has no documentation of the Director of Nursing and Medical Director being in attendance. On 3/1/23 at 9:55 AM, V1 Administrator stated there was not a Director of Nursing at the Quality Assurance meetings held on 4/21/22, 10/20/22 or 1/31/23. The facility's Resident Census and Conditions of Residents report dated 2/27/23 provided…

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 infection control practices to prevent the spread of disease to other residents. Failures include display of proper signage for COVID-19 (Human Coronavirus); wearing appropriate Personal Protective Equipment (PPE) into infectious resident rooms; wearing PPE as indicated during staff and resident testing for COVID-19; educate/encourage COVID-19 positive resident about measures to prevent infecting others, and pulling curtains during respiratory care in rooms with two residents. These failures affect 13 residents (R3, R9, R10, R16, R19, R30, R39, R66, R67, R79, R81, R142, R238) reviewed for infection control on the total sample of 55. These failures have the potential to affect all 88 residents residing in the facility. Findings include: R9's undated Face Sheet documents R9 admitted to the facility on [DATE]. The facility's undated room roster presented on 2/27/23, documents R9 as a COVID positive contact to R16 (they share a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to invite residents and their family members to care conferences for care planning purposes in four (R28, R53, R68, R74) of 24 residents reviewed for care plans from a total sample list of 55. Findings include: 1. R28's Minimum Data Set, dated [DATE] documents R28 as cognitively intact. R28's progress note dated 10/20/21 documents admission to the facility. On 2/27/23 at 2:48 PM, R28 stated that he had not been invited to care conferences, that he could recall. R28's progress notes document that R28's last quarterly care conference was held on 9/22/22. 2. R53's Minimum Data Set, dated [DATE] documents R53 as cognitively intact. R53's progress note dated 12/16/20 documents admission to the facility. On 2/27/23 at 2:31 PM, R53 stated that he had not been asked to a care conference. R53's progress notes document that R53's last quarterly care conference was held on 8/31/22. 3. R68's Minimum Data Set, dated [DATE] documents R68 as moderately cognitively…

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 assist with nail care for four (R11, R3, R18, and R37) of 24 residents reviewed for assistance with ADLs (Activities of Daily Living) on the sample list of 55. Findings include: 1. On 2/27/23 at 4:06 PM, R37 was lying in bed on right side, fingernails long, with dark substance underneath. On 2/28/23 at 9:10 AM, R37 was lying in bed on right side, fingernails long past fingertips, and dirty. On 2/28/23 at 12:19 PM, V39 Registered Nurse stated R37 currently has a fungus to his nails that he is receiving treatment for. V39 stated he is not diabetic and the CNAs should be trimming them. R37's 11/17/23 Quarterly Minimum Data Set (MDS) documents R37 is totally dependent for personal hygiene. 2. On 02/27/23 at 9:31 AM, R11 stated it would be nice if my fingernails were shorter, and the staff have only trimmed them once for me. R11's fingernails were one half inch past the fingertips. R11's 11/30/22 MDS documents R11 requires extensive assistance with personal hygiene. 3. On 2/27/23 at 11:04 AM, R3 was lying in bed.…

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 administer medications in accordance with Physician's Orders and failed to administer Gastrostomy tube medications separately for two of four residents (R47, R138) reviewed for medication administration in the sample list of 55. The facility had 4 medication errors out of 25 opportunities resulting in a 16% (percent) medication error rate. Findings include: The facility's Administration of Medications policy with a revised date of July 2022 documents, Purpose: To provide licensed personnel with guidelines for proper administration of medications. Policy: Residents shall receive their medications on a timely basis in accordance with state and federal guidelines, and within established facility policies. Procedure: 1. Drugs and biologicals may be administered only by licensed physicians, licensed registered or practical nursing personnel, and must be administered in accordance with the written orders of the attending physician. 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 store residents medications separately from food. This failure affects 10 residents (R338, R47, R6, R36, R43, R82, R53, R138, R76, R40) with medications in the medication room refrigerator in the sample list of 55. Findings include: On 3/1/23 at 1:35 PM, V38 Registered Nurse completed the medication storage room tour of the second-floor medication room. At this time there was yogurt, protein shakes and dill pickle bites in the medication refrigerator. In this same refrigerator there was medication for individual residents and stock medications for back up supply. On 3/1/23 at 2:52 PM, V2 Director of Nursing supplied a list of items in the medication refrigerator in the second-floor medication room. This list documents the refrigerator contains Lorazepam (antianxiety) concentrate for R338, R47 and R6, Insulin Glargine for R36, R43, R82 and R138, Lispro (insulin) for R43, R53, R138 and R76, Lantus (insulin) for R82 and R53, Humulin R (insulin) for R82 and Latanoprost eye drops for R40. This list documents that…

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 physician orders and weigh a resident at risk for rapid weight fluctuations due to dialysis treatment. This failure affects one (R40) of seven residents reviewed for weights from a total sample list of 55. Findings include: R40's progress notes document admission to the facility on [DATE]. R40s undated diagnosis sheet documents the following diagnoses: end stage renal disease, moderate calorie malnutrition, chronic obstructive pulmonary disease and anxiety. R40's physician orders dated 12/30/21 document R40 is to have renal dialysis three times a week. R40's progress notes document on 12/10/22 R40 was transferred to the hospital with fluid overload. R40's physician orders dated 12/13/22 document R40 to have daily weights recorded. The facility provided weight sheet and the dialysis weight sheets document weights are not recorded on 12/25/22, 12/27/22, 12/29/22, 1/3/23, 1/14/23, 1/28/23, 1/29/23, 1/31/23, 2/2/23, 2/4/23, 2/5/23, 2/7/23, 2/8/23,…

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 store respiratory equipment in a sanitary manner, obtain order for oxygen administration, and obtain an order for respiratory equipment changes for two of two residents (R5, R47) reviewed for respiratory equipment on the sample list of 55. Findings include: The facility's Oxygen Administration policy with a revision date of 01/23 documents under section B. that all orders must include the following: C. oxygen order. 1. R5's Care Plan dated 2/7/23 documents R5 has a diagnosis of Chronic Obstructive Pulmonary Disease, acute and chronic respiratory failure, history of COVID, sleep apnea with BIPAP (bilevel positive airway pressure), history of pleural effusion, and shortness of breath. On 2/27/23 at 10:55 AM, there were two BIPAP masks lying on the bedside table unbagged. There was oxygen tubing lying on the floor. The end of the oxygen tubing was unbagged and lying on the floor. On 2/27/23 at 2:06 PM, R5 stated the BIPAP masks continued 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.