La Bella Of Danville

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to return a credit balance and trust fund balance following discharge for one of three residents (R4) reviewed for billing in a sample list of 18. Findings include: The facility's Transactions Involving Resident Funds undated policy documents the Business Office Manager (BOM) is responsible for ensuring resident fund accounts are reconciled on a quarterly basis and statements will be provided in writing to the resident/resident's representative within 30 days after the end of the quarter. On 5/20/26 at 10:00 AM V28, R4's Family, stated the facility has at least two of R4's Social Security monthly benefits that were remitted following R4's discharge, first to the hospital and then to another skilled nursing facility, and the subsequent nursing facility has billed R4's estate. R4's census documents, stop billing on 10/20/25. This census and R4's electronic medical record profile documents Medicaid as R4's payor source.R4's Nursing Notes document R4…

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 and maintain fall interventions following falls with injury, accurately assess and document falls, timely notify physician and family of falls, and complete neurological assessments following fall with a head injury for 4 residents (R3, R4, R10, R8) of 6 residents reviewed for falls on a sample list of 19. These failures resulted in R3 sustaining an acute nondisplaced fracture at the medial and posterior malleoli. Findings include: 1. R3's Minimum Data Set, dated [DATE] documents R3's Brief Interview for Mental Status score as 15 out of 15, which indicates R3 is cognitively intact. R3's Fall Risk Evaluation Note dated 5/9/26 at 1:25 PM documents R3 has a fall risk score of 16, which indicates R3 is at a high risk for falling. A Fall list provided by facility documents R3 fell on 5/5/2026, 5/8/2026, and 5/9/2026. R3's care plan with an initiation date of 11/23/24 and revised on 4/22/2026 documents R3 is at high risk for falls…

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 upon interview, observation, and record review, the facility failed to promptly identify and intervene for an acute change in a resident's condition after a fall with a fracture; and failed to follow physician orders causing a delay in treatment that had the potential for harm for one (R4) of three residents reviewed on a sample list of seven residents.According to the Electronic Health Record (EHR) R4 has diagnoses including admission diagnosis of Urinary Tract Infection (UTI), Left Femur Fracture surgical aftercare, and repeated falls.R4's undated Care Plan documents R4 is high risk for falls with recent fall with fracture history (12/30/25); Interventions include adding scoop mattress on 1/26/26, offer to transfer R4 to wheelchair prior to dinner on 2/6/26, and non-skid strips placed by bed, and non-skid socks to replace slippers on 3/26/26. R4's Care Plan documents R4 is to ambulate with assistance and walker with left leg weight bearing as tolerated. R4 dependent on staff for ADL's, at risk for skin alterations, and has moderate cognitive impairment. 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 upon interview and record review the facility failed to maintain medical records on each resident in accordance with accepted professional standards and practices that are complete and accurately documented for two residents (R3, R4) on a sample list of seven residents. 1) According to the Electronic Health Record (EHR) R3 has diagnoses including Cerebral Vascular Accident, Epilepsy, Vascular Dementia, Obstructive Uropathy, Severe Protein Malnutrition, Anxiety, and Autonomic Nervous System Disorder.R3's undated Care Plan documents R3 is dependent on staff for all Activities of Daily Living (ADL's), has indwelling nephrostomy and foley tubes, cognitive impairment is severe, has a seizure disorder, has a communication deficit related to Aphasia, is at risk to develop clinically unavoidable skin breakdown related to Cerebrovascular disease, history of loss of weight, and muscle weakness.R3's progress notes dated 4/9/26 documents R3 out of facility for procedure. R3's progress notes do not document R3 returning from procedure, any new medical devices, status, and new orders…

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 a Registered Nurse (RN) providing services for at least eight consecutive hours a day, seven days a week. This failure has the potential to affect all 146 residents currently residing in the facility.Findings include:The Facility Assessment Tool dated 07/2025 through 04/2026 documents the following: Staffing Plan for licensed nurses: Refer to facility assessment and CMS minimum staffing rule. This same record further documents staffing should include one Registered Nurse (RN) each shift.The Daily Nurse Staffing Sheets dated 2/26/2026 through 3/31/2026 documents no RN coverage for at least 8 consecutive hours a day on 3/1/2026.On 4/1/26 at 11:54am, V27 Regional Nurse Consultant confirmed there was no RN coverage for 8 consecutive hours in the facility on 3/1/2026.The Facility's Midnight Census Report dated 3/20/2026 documents 146 residents reside in the facility.

Based on interview and record review, the facility staff failed to report an allegation of sexual abuse to the administrator. This failure has the potential to affect one resident (R4) out of six reviewed for sexual abuse on the sample list of fourteen.Findings include: On 2/5/26 at 12:18 PM, V1, Administrator, stated he is the facility's abuse coordinator. V1 stated all the facility staff know he is the abuse coordinator and to report all allegations to him. V1 stated he did not have an active investigation concerning an allegation of sexual abuse involving R5 touching R4. On 2/6/26 at 2:20 PM, V1 stated there had been a prior allegation on 5/7/25 that R5 was touching R4 on the breasts. V1 stated R5 seemed to gravitate towards R4. The facility's Initial Reportable Incident dated 5/7/25 documents an allegation of R5 sexually touching R4 on the breasts, an incident allegedly occurring 2 weeks prior to the reporting. The facility's Center for Medicare and Medicaid Services 2567 (statement of deficiencies) and associated Resident Numerical Reference dated 4/17/24 documents a cited…

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

Based on interview and record review, the facility failed to ensure sufficient licensed nursing staff were present for each shift in each building. This failure has the potential to affect all 54 residents residing in the South Building.Findings include:The Facility Assessment Tool dated 12/2024 through 12/2025 documents the following: Staffing Plan for licensed nurses including Registered Nurse (RN) and Licensed Practical Nurses (LPN): Refer to facility assessment and CMS minimum staffing rule. This same record further documents staffing should include one RN each shift and three LPN's for night shift.The Daily Nurse Staffing Sheets dated 1/1/2026 through 1/20/2026 documents no RN coverage for at least 8 consecutive hours a day on 1/3/2026, 1/4/2026, 1/11/2026, and 1/17/2026. This same record documents on 1/17/2026, the facility had no RN's and/or LPN's working the 11pm to 7am shift in the South Building. Further documents two LPN's working night shift in the north building.On 1/21/26 at 9:16am, V8 Assistant Director of Nursing confirmed there was no RN coverage for 8 consecutive…

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 a Registered Nurse (RN) providing services for at least eight consecutive hours a day, seven days a week. This failure has the potential to affect all 138 residents currently residing in the facility.Findings include:The Facility Assessment Tool dated 12/2024 through 12/2025 documents the following: Staffing Plan for licensed nurses including Registered Nurses (RN): Refer to facility assessment and CMS minimum staffing rule. This same record further documents staffing should include one RN per shift.The Daily Nurse Staffing Sheets dated 1/1/2026 through 1/20/2026 documents no RN coverage for at least 8 consecutive hours a day on 1/3/2026, 1/4/2026, 1/11/2026, and 1/17/2026.On 1/21/26 at 9:16am, V8 Assistant Director of Nursing confirmed there was no RN coverage for 8 consecutive hours in the facility on 1/3/2026, 1/4/2026, 1/11/2026, and 1/17/2026. V8 stated the nursing management staff are on-call on weekends if needed.Resident Council Meeting Minutes for October, November, and December 2025 document short staffing…

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 submit the results of abuse and misappropriation of resident property investigations to the State Agency within five working days for three (R1, R2 and R3) of four allegations reviewed in the sample of 11 residents.Findings include:On 12/21/25 at 9:00 AM, V2 Director of Nursing confirmed the facility did not submit a five-day final report to the Illinois Department of Public Health regarding R1's allegation of physical abuse on 4/10/25, R2's allegation of physical abuse on 4/15/25 or R3's allegation of Misappropriation of Property on 6/9/25. On 12/21/25 at 9:38 AM, V14 Previous Administrator stated V14 was informed of R1's allegation of physical abuse on 4/10/25, R2's allegation of physical abuse on 4/15/25, and R3's allegation of Misappropriation of Property on 6/9/25. V14 stated upon interviewing R1 regarding V17 Licensed Practical Nurse being physically abusive to R1, R1 recanted R1's allegation of abuse so V14 never completed a final report to Illinois Department of Public Health. V14 stated V14 interviewed 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.

Based on interview and record review, the facility failed to ensure all allegations of abuse/misappropriation of resident property were thoroughly investigated for three (R1, R2 and R3) of four allegations reviewed in the sample of 11 residents.Findings include:On 12/21/25 at 9:00 AM, V2 Director of Nursing stated V2 is unable to locate the investigation files for R1's allegation of physical abuse on 4/10/25, R2's allegation of physical abuse on 4/15/25 or R3's allegation of Misappropriation of Property on 6/9/25. V2 stated V2 cannot state that a thorough investigation was completed for these allegations, due to not having any documents to support that the investigations were conducted. On 12/21/25 at 9:38 AM, V14 Previous Administrator stated V14 was informed of R1's allegation of physical abuse on 4/10/25, R2's allegation of physical abuse on 4/15/25 and R3's allegation of Misappropriation of Property on 6/9/25. V14 stated upon interviewing R1 regarding V17 Licensed Practical Nurse being physically abusive to R1, R1 recanted R1's allegation of abuse so V14 never completed a final…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to identify, report and investigate a fall; and failed to implement post fall interventions for one of three residents (R5) reviewed for injuries/accidents in the sample list of 15. Findings include:R5's Minimum Data Set, dated [DATE] documents R5 has severe cognitive impairment, is always incontinent of bowel and bladder, requires substantial/maximal staff assistance with bed mobility and transfers, and dependence on staff for toileting hygiene. R5's Quarterly Assessments form dated 7/14/25 documents R5 has an unsteady gait, is confused, and is at high risk for falls. R5's active Care Plan documents a problem dated 9/24/25: R5 likes to sit on the floor. This care plan documents a problem, dated 9/14/24, is at high risk for falls related to history of falls and weakness, and interventions include room change to North building for increased observation/monitoring, attempt to anticipate needs, check/change offer frequent toileting, call light…

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 protect a resident's right (R2) to be free from physical abuse by another resident (R1). This failure affects two (R1, R2) of four residents reviewed for abuse in the sample list of four residents. Findings include: On 6/11/25 at 1:02 PM R2 was in her room. R2 was asked if anyone had hurt her recently. R2 stated yes, and pointed to the top of her left hand which had a scab and faded bruising. R2 stated, He (R1) started punching me (R2) while making a fist motion with both hands. R2 was unable to provide any additional information regarding this incident. R2's Brief Interview for Mental Status dated 3/24/25 documents R2 has severe cognitive impairment. The Long-Term Care Facility & IID - Serious Injury Incident Report dated 6/9/25 documents the following: On 6/2/25 at 3:45 PM V8 Certified Nursing Assistant (CNA) was sitting at the nurses' station. R1 was sitting in his wheelchair in front of the nurses' station facing the dining room. V8…

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 develop and implement person centered activities and interventions for dementia care for one (R1) of four residents reviewed for abuse in the sample list of four. Findings include: The facility's Dementia Clinical Protocol dated November 2018 documents, For the individual with confirmed dementia, the IDT will identify a resident-centered care plan to maximize remaining function and quality of life. Direct care staff will support the resident in initiating and completing activities and tasks of daily living. Bathing dressing, mealtimes, and therapeutic and recreational activities will be supervised and supported throughout the day as needed. The IDT (Interdisciplinary Team) will adjust interventions and the overall plan depending on the individual's responses to those interventions, progression of dementia, development of new acute medical conditions or complications, changes in resident or family wishes, and other relevant factors. 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 interview and record review the facility failed to protect resident's rights to be free from verbal and physical abuse from another resident. This failure affected three of five residents (R4, R5, R8) reviewed for abuse in the sample of eight. Findings Include: The facility's Abuse Prevention and Reporting- Illinois policy dated August 2023 documents the facility affirms the right of its residents to be free from abuse. The policy defines Abuse as the willful infliction of injury. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical Abuse as the infliction of injury on a resident. Physical abuse includes hitting, slapping, and other similar behaviors. The policy defines Mental Abuse as the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Verbal Abuse is defined as the use of oral, written, or…

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

Based on interview and record review, the facility failed to administer five consecutive doses of ordered intravenous antibiotic medication. This failure affects one resident (R3) of one reviewed for medication administration in the sample of eight. Findings Include: R3's diagnosis list (printed 5/7/2025) documents diagnoses including: Cutaneous Abscess of Buttock and Encounter for Change or Removal of Non-surgical Wound Dressing. R3's Care Plan (printed 5/7/2025) documents R3 has a history of wound infection requiring antibiotic treatment. R3's wound treatment timeline (undated) documents R3 was to start antibiotic treatment for a wound infection on the morning of 4/19/2025. R3's Order Entry (4/18/2025 at 6:44PM) documents a medical order for R3 to begin antibiotic treatment with Unasyn, 1.5 grams, intravenously every eight hours. R3's medication administration record (April, 2025) documents R3 did not receive the first dose of the above ordered antibiotic until 4:00PM on 4/20/2025. V13's handwritten note (5/7/2025) documents facility staff did not notify V5 (R3's wound care…

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 effectively supervise R3 to prevent falls. This failure resulted in R3 falling from R3's wheelchair to the floor in R3's room. This failure affects one resident (R3) of three reviewed for accidents in the sample of eight. Findings Include: R3's diagnosis list (printed 5/7/2025) documents R3's diagnoses include: Cerebral Infarction (stroke), Personal History of Transient Ischemic Attack (temporary disruption of blood flow to the brain causing stroke-like symptoms), and Alzheimer's Disease. R3's admission Assessment (3/13/2025) documents R3 has severe cognitive impairment, uses a wheelchair, and is dependent on staff for mobility and transfers from the wheelchair to other surfaces. The facility fall log (April, 2025) documents R3 experienced falls in the facility on 4/1/2025, 4/12/2025, and 4/13/2025. R3's Care Plan (printed 5/7/2025) documents R3 is at risk for falls and a new intervention starting on 4/1/2025 for staff to place R3 in bed after meals. The facility Post Fall Huddle (4/1/2025) documents R3 experienced 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 report an allegation of abuse involving two (R9, R10) residents out of four residents reviewed for abuse in a sample list of 11 residents. Findings include: The facility policy titled Abuse, Neglect, Exploitation and Misappropriation Program -Reporting and Investigating reviewed September 2024 documents residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This same documents if the Administrator cannot immediately refute the allegation relating to resident to resident abuse, neglect, exploitation, and/or misappropriation, the Administrator initiates a thorough investigation, completes and submits initial reports to the required agencies, and notifies local authorities. R10's Minimum Data Set (MDS) dated [DATE] documents R10 as severely cognitively impaired. This same MDS documents R10 requires supervision with eating, dependent on staff for toileting, dressing, personal hygiene, bed mobility…

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 in arranging a referral for an outside resource for one (R1) resident out of three residents reviewed for physician orders in a sample list of 11 residents. Findings include: R1's undated Face Sheet documents R1 admitted to the facility on [DATE] with a pre-existing Left Above the Knee (AKA) amputation. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as cognitively intact. This same MDS documents R1 requires supervision with eating, oral hygiene, toileting, bathing, dressing, personal hygiene, and bed mobility. R1's Physician Order Sheet (POS) dated April 2025 documents a physician order starting 12/26/25 for Carbohydrate Controlled Diet (CCD)/Renal, regular texture with regular/thin liquids consistency. This same POS documents a physician order dated 3/27/25 to refer R1 to a Prosthetic clinic. R1's Nurse Progress Note dated 3/27/25 at 11:28 AM documents R1 is to be referred to a prosthetic clinic. R1's Nurse Progress Notes…

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 146 residents in the facility. Findings include: On 4/9/2025 at 2:25PM, V10 (Dietary Manager) was actively supervising dietary operations in the facility kitchen. V10 reported being the full-time manager of the facility food service (person in charge) and reported not being a clinically qualified Certified Dietary Manager (also known as Certified Food Protection Professional) or having equivalent training. V10 denied meeting the State of Illinois standards to be a food service manager or dietary manager (required in states that have their own established standards to be a food service manager or dietary manager (483.60(a) (2) ii). V10 reported only completing a one-day course on food service sanitation (ServSafe) which did not include any instruction on clinical nutrition. V10's ServSafe certification (8/25/2022) documents V10 is a Certified Food Protection Manager. The same record does not…

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

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program by failing to exclude and prevent flying insects in the facility food service areas resulting in direct cross-contamination of resident dishes. This failure has the potential to affect all 146 residents in the facility. Findings include: On 4/8/2025 at 11:15AM, accumulations of decomposed food covered the underneath side of the facility kitchen dishwasher drainboards and surrounding wall, floor, and plumbing surfaces. The mechanical dishwasher drain pipe discharged into a floor-level receiving trough that was soiled with accumulations of food debris. A fetid odor was present in the area. A clear ten liter plastic container was positioned beneath the dishwasher drain screen and was half-full of yellow colored liquid and food debris. A second container was located beneath the drain pipe of an adjacent three-basin sink and partially full of opaque water. Three or more winged insects resembling fruit flies were present resting on and flying around the dishwasher 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 review the facility failed to honor the resident rights for one (R100) resident out of one resident reviewed for resident rights in a sample list of 47 residents. Findings include: R100's undated Face Sheet documents medical diagnoses as Muscle Wasting and Atrophy, Morbid Obesity, Acute Kidney Failure, Weakness, Contracture of Muscle, Difficulty in Walking, End Stage Renal Disease, Lymphedema and Moderate Protein Calorie Malnutrition. R100's Minimum Data Set (MDS) dated [DATE] documents R100 as cognitively intact. This same MDS documents R100 as being dependent on staff for toileting, dressing, bathing, transfers and requires maximum assistance for personal hygiene. R100's Care plan intervention dated 10/12/2022 instructs staff to provide resident with opportunities for choice during care provision. On 4/8/25 at 11:00 AM R100 was laying in his bed on his back. R100 stated, I want to get up. They (staff) told me I have to stay in bed until the (V39) Wound Physician sees…

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 notify a resident and their representative in writing about a hospital transfer and failed to provide a bed hold notice for one of two residents (R82) reviewed for hospitalizations on the sample list of 38. Findings Include: On 04/8/25 at 11:00am, R82 stated R82 went to the hospital 2 times in the last 2 weeks. R82 stated the facility did not talk with R82 about a Bed Hold Policy nor was R82 provided a Bed Hold Policy upon going to the hospital. On 4/9/25 at 12:21 pm, V35 [NAME] President of Clinical Operations stated Bed Holds are to be filled out by the nurses when a resident is sent to the hospital; a copy should be sent with the resident, and the facility keeps a copy. V35 confirmed that R82 was sent to the hospital on 3/25/25 and 3/28/25 and a Bed Hold Policy was not given to R82. R82's Progress Notes documents R82 was sent to the hospital on 3/25/25 and 3/28/25. R82's Medical Record does not contain a copy of the facility bed hold policy, or documentation that R82 or R82's representative was provided a copy 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 interview and record review, the facility failed to accurately complete a residents comprehensive assessment. This failure affects one (R119) of two residents reviewed for accuracy of assessments in the sample list of 47. Findings include: R119's Comprehensive assessment dated [DATE] documents R119 has been taking an antibiotic. R119's February 2025 Order Summary Report does not document R119 having any antibiotic orders. R119's Electronic Medical Record does not document R119 taking any antibiotics during the assessment period. On 4/11/25 at 12:53pm, V38 MDS Coordinator stated V38 completed the medication section of R119's 2/23/25 comprehensive assessment and marked R119 as taking an antibiotic. V38 confirmed R119 was not prescribed and/or administered any antibiotics during February 2025 (assessment look back period). The facility Resident Assessments Policy (revised March 2022) documents all persons who have completed any portion of the MDS resident assessment form must sign the document attesting to…

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

Based on observation, interview and record review the facility failed to enter in new wound dressing change orders and failed to provide wound care in accordance with professional standards. This failure affected one of three residents (R138) reviewed for wounds on the sample list of 47. Findings Include: The facility's Wound Care policy dated October 2010 documents staff should always verify the physician order and use the no-touch technique when cleaning a wound and if touching a wound is necessary, use sterile gloves. R138's Medical Diagnoses List dated April 2025 documents R138 is diagnosed with Idiopathic Aseptic Necrosis of the Right and Left foot and Peripheral Vascular Disease. On 4/11/25 at 10:25 AM V7 Wound Nurse performed R138's wound dressing changes. V7 sanitized her hands, placed new clean gloves on her hands, then preceded to cleanse R138's right lateral foot wound with gauze soaked in Betadine. V7 then picked the new clean dressing that covered both of R138's right foot wounds and placed it on R138's right foot with the same gloves she had worn to clean the wound. V7…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to prevent cross contamination during catheter care for one (R5) resident out of one resident reviewed for catheter care in a sample list of 47 residents. Findings include: R5's undated Face Sheet documents medical diagnoses as Hereditary Spastic Paraplegia, Morbid Obesity, Dependence on Wheelchair, Epilepsy, Cerebral Palsy, Neuromuscular Dysfunction of Bladder, Acquired Absence of Right and Left Above the Knee Amputations, Presence of Urogenital Implants, Scoliosis, Syringomyelia and Syringobulbia. R5's Minimum Data Set (MDS) dated [DATE] documents R5 as cognitively intact. This same MDS documents R5 as being dependent on staff for toileting and maximum assistance with bathing. R5's Physician Order Sheet (POS) dated April 2025 documents a physician order to cleanse Suprapubic catheter site with wound cleanser apply T-Drain dressing to site twice daily. On 4/9/25 at 2:05 PM V13 Licensed Practical Nurse (LPN) completed catheter care for R5's…

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

Based on interview and record review the facility failed to accurately transcribe a physician order which resulted in a resident receiving nine inaccurate doses of a psychotropic medication (antidepressant). This failure affected one of five residents (R79) reviewed for Unnecessary Medications on the sample list of 47. Findings Include: The facility's Adverse Consequences and Medication Errors dated February 2023 documents a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. Examples of medications errors include administering the wrong dose of a medication. R79's Medical Diagnoses List dated Major Depression Disorder, Vascular Dementia, Post Traumatic Stress Disorder, Insomnia, and General Anxiety. R79's Nurses Note dated 4/1/25 at 2:09 PM documents R138 returned from a Veteran's Administration appointment with written orders to increase his Sertraline (Antidepressant) 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 interview and record review the facility failed to offer, administer and/or obtain consent or declination of Influenza and Pneumococcal vaccinations for two (R57, R128) residents out of five residents reviewed for immunizations in a sample list of 47 residents. Findings include: 1. R57's undated Face Sheet documents R57 admitted to the facility on [DATE]. R57's Minimum Data Set (MDS) dated [DATE] documents R57 as severely cognitively impaired. R57's Electronic Medical Record (EMR) does not document consent, administration nor refusal of an Influenza vaccination and Pneumococcal vaccinations since admission to facility. 2. R128's undated Face Sheet documents R128 admitted to the facility on [DATE]. R128's Minimum Data Set (MDS) dated [DATE] documents R128 as severely cognitively impaired. R128's Electronic Medical Record (EMR) does not document a consent nor administration/refusal of an Influenza vaccination since admission. On 4/11/25 at 12:40 PM V41 Registered Nurse (RN)/Infection Preventionist (IP)…

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

Based on observation and interview, the facility failed to maintain a functional bathroom ventilation fan. This failure affects one resident (R128) of one two reviewed for environment on the sample list of 47. Findings include: On 4/8/2025 at 12:55PM, R128 reported R128's bathroom ventilation fan was inoperable and had not worked since R128 admitted to the facility in June of 2024. R128 reported wanting the fan to operate. When the ventilation fan switch was turned to the on position, the fan blades did not move. On 4/11/2025 at 11:16AM, the ventilation fan remained inoperable as above. R128 was present and reported previously asking several staff members (unidentified) over time to repair the fan, but nobody has done anything about it.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide a clean and comfortable environment for four (R1, R3, R10 and R11) of five residents reviewed for a safe, clean, comfortable, and home-like environment from a total sample list of 18 residents. Findings include: On 11/6/24 at 12:20 PM, R2 was sitting at a dining room table covered with napkins, tissues, condiments, and bags of personal items on the table. On top of these items laid mucous filled tissues. On 11/4/24 at 12:21 PM, R1 was eating in his room. When asked why he wasn't eating in the dining room, R1 stated that he doesn't like to eat with R2. R1 stated that (R2) is nice enough, but that her hacking and spitting up mucous causes him to lose his appetite. Additionally, R2 throws the tissues that she spits into, onto the floor. R1 said, It is just disgusting and hard to avoid seeing it or stepping in it. I won't even go to BINGO anymore because I just can't stand to see and hear her spit mucous everywhere. R1 stated that he…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to file a grievance for a known resident complaint for two (R1 and R3) of three residents reviewed for administration from a total sample list of 18 residents. Findings include: On 11/4/24 at 12:21PM, R1 was eating in his room. R1 stated that he doesn't like to eat in the dining room with R2 because R2 hacks and spits up mucous, causing him to lose his appetite. Additionally, R2 throws the tissues that she spits into, onto the floor. R1 said, It is just disgusting and hard to avoid seeing it or stepping in it. I won't even go to BINGO anymore because I just can't stand to see and hear her spit mucous everywhere. R1 stated that he has complained about this to all of the staff, including V5 Assistant Administrator, but they haven't done anything about it. On 11/4/24 at 7:20PM, R3 stated that he doesn't like it when R2 hacks and spits up mucous in the dining room and that he has seen her throw her tissues onto the floor. R3 stated that the staff know about…

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 medications were available to be given as ordered resulting in multiple missed doses of medications for three (R5, R6, R7) of six residents reviewed for medications in the sample list of 12. Findings include: 1.) On 10/24/24 at 12:13 PM R6 stated the facility has run out of R6's medications but was unable to state which medications. R6's Minimum Data Set (MDS) dated [DATE] documents R6 is cognitively intact. R6's August, September and October 2024 Medication Administration Records (MARs) document to give Duloxetine Hydrochloride (antidepressant) Delayed Release 60 milligrams (mg) by mouth one daily and Lorazepam (antianxiety) 0.5 mg twice daily. Duloxetine was not administered on 8/28/24, 9/12/24, 9/27/24, and 10/21/24. Lorazepam was not administered as ordered on 9/21/24, 9/23/24-10/3/24. R6's Nursing Notes document the following: On 8/28/2024 at 5:49 PM Duloxetine was unavailable. On 9/12/2024 at 4:36 PM Duloxetine was on order…

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 insulin timely resulting in repeated significant medication errors for one (R6) of six residents reviewed for medications in the sample of 12. Findings include: On 10/24/24 at 12:13 PM R6 stated R6 has not been getting her medications on time, and some medications that are scheduled to be given at noon are not given until later in the afternoon. R6 stated this includes insulin and R6's blood sugars have dropped because of it. R6's Minimum Data Set, dated [DATE] documents R6 is cognitively intact. R6's October 2024 Medication Administration Record (MAR) documents to administer Lispro (insulin) 36 units and additional dosing per blood glucose based sliding scale before meals three times daily at 7:30 AM, 11:00 AM, and 4:00 PM. R6's October 2024 Medication Administration Audit Report documents the following: Lispro scheduled at 7:30 AM was given on 10/6/24 at 1:30 PM, 10/9/24 at 9:23 AM, 10/16/24 at 9:01 AM, and 10/20/24 at 10:04 AM. Lispro…

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

Based on observation, interview, and record review the facility failed to administer medications as ordered for three (R4, R7, R5) of seven residents reviewed for medication administration in the sample list of 12. This failure resulted in three medication errors out of 25 opportunities, a 12 % medication error rate. Findings include: 1. R7's October 2024 Medication Administration Record (MAR) documents to administer Ferrous Sulfate 325 milligrams (mg) one tablet by mouth once daily scheduled as Lib B (Liberalized Breakfast). On 10/24/24 at 9:46 AM V9 Licensed Practical Nurse administered R7's morning medications Aspirin 81 milligrams (mg), Folic Acid 1 mg, Calcium Carbonate 600 mg, Vitamin D 1000 units. V9 had to locate a bottle of Thiamine 100 mg and administered one tablet at 10:10 AM. V9 did not administer Ferrous Sulfate 325 mg. At this time V9 confirmed R9's morning/breakfast medication administration was complete. At 10:13 AM V9 confirmed V9 had not administered R7's Ferrous Sulfate 325 mg. The facility's Med (Medication) Pass Times documents Liberalized Breakfast is…

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

Based on observation, interview and record review the facility failed to have an effective pest management program in place allowing flies to proliferate in the facility. This failure has the potential to affect all 141 residents who reside in the facility. Findings include: The Resident List Report dated 8/19/24 documents 141 residents reside in the facility. The facility Pest Control Policy dated 3/2024 documents the Environmental Services Director will be responsible for coordinating the facility pest control program. The pest control program will be conducted on a regular and as needed basis. Outside openings shall be protected against the entrance of insects by tight-fitting, self-closing doors, closed windows, screening, controlled air current or other means. All buildings will be tight-fitting and free of breaks. The facility contracted pest control program service reports from April 2024 to August 2024 do not document flies as an area of concern or attention. On 8/19/24 at 8:55AM, V3 Staffing Coordinator said there were usually a lot of flies near the front of the building.…

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 a diet as ordered for five (R1, R3, R6, R8 and R9) of five residents with diabetes reviewed for diabetic diet orders from a total sample list of nine residents reviewed. Findings include: The facility Physician Order Policy dated 11/2023 documents that after an order is received and confirmed, it will be completed as directed by the prescriber. The facility provided menu dated 8/20/24 documents one option for all residents for breakfast meal, lunch meal and dinner meal. The facility provided diet order report documents that R1, R3, R6, R8 and R9 all have orders for a low concentrated sweets diet. The facility provided undated menu cards document orders for a carbohydrate controlled diet/low concentrated sweet diet for R1, R3, R6, R8 and R9. On 8/20/24 at 8:45AM, ravioli and sauce was being made for lunch for the residents. V18 [NAME] confirmed that this was the only entree available for lunch. 1. R1's undated diagnoses list…

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 develop a comprehensive care plan for one of three residents (R1) reviewed for abuse on the sample list of nine. Findings Include: The facility's Identified Offender - admission Guidelines Policy dated May 2024 documents upon admission of an identified offender to a facility or a decision to retain an identified offender in the facility, the facility, in consultation with the medical doctor and law enforcement, must specifically address the resident's needs in an individualized plan of care that reflects the risk assessment of the individual. The care planning of identified offenders shall include a description of the security measures necessary to protect facility residents from the identified offender, including whether the identified offender should be segregated from other residents if the facility's risk assessment determines that an identified offender must have his or her own room, then all of the criteria below must be met: the room must be in…

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

Based on observation and interview the facility failed to honor R4's breakfast meal preferences. This failure affects one of (R4) three residents reviewed for meal preferences in the sample list of nine. On 6/11/24 at 7:28 AM R4 showed the surveyor a picture of R4's 6/9/24 breakfast tray, which showed one fried egg only on the plate. R4 stated that is what R4 was served on 6/9/24 and 6/10/24. R4 explained R4 prefers fried eggs and about one month ago, talked with V16 Dietary Manager and requested two fried eggs, two pieces of toast and two sausages every day for breakfast and that the facility did it a couple of days but since then, R4 is only getting one slice of toast and then the past two days, didn't even get that, R4 only got one fried egg. On 6/11/24 at 7:28AM R4's breakfast tray consisted of two fried eggs, one slice of toast, oatmeal and a four ounce drink. On 6/11/24 at 2:00 PM V16 confirmed R4 spoke with V16 awhile back and requested to receive two fried eggs and two pieces of toast for every breakfast so that is what R4 should be served. V16 stated V16 is not aware of R4…

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 a resident's right to be free from verbal abuse by staff. This failure affects one (R9) of three residents reviewed for verbal abuse on the sample list of nine residents. Findings include: The facility abuse policy dated 8/2023 documents the facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure the facility is doing all is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents has attempted to establish a resident sensitive and…

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

Based on interview and record review the facility failed to facilitate interdisciplinary care plan meetings including residents for one (R2) of three residents reviewed for care plan meetings from a total sample list of nine residents. Findings include: The facility Care Plan Meeting Procedure dated 3/2024 documents invitations will be extended to the resident or their representative, to participate in the resident's quarterly care plan meeting. Social Services, Nursing, Dietary, Activities, Restorative or Rehabilitation services will also be included to discuss any issues at the care plan meeting. R2's quarterly care plan dated 5/16/24 documents V8 Care Plan Coordinator was the only person in attendance for R2's care plan meeting. No documentation was recorded regarding falls, injuries or fall interventions. No documentation regarding behaviors, cares or weight loss was recorded. On 5/23/24 at 11:00AM, V8 Care Plan Coordinator said she did not know if R2's guardian had received her invitation to the care plan meetings and she held it on her own, without any other members 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 provide bathing, shaving and nail care for one (R2) of three residents reviewed for dependent activities of daily living from a total sample list of nine residents. Findings include: The facility Bathing policy dated 3/2024 documents ensuring a resident's cleanliness is done to maintain proper hygiene and dignity. The facility Nail Care policy dated 3/2024 documents nails should be assessed during bathing and addressed for cleanliness, length and uneven edges. The facility Certified Nursing Assistant (CNA) policy dated 7/2023 documents essential duties of the CNA include bathing, dressing, grooming, shaving, and feeding residents. R2's Minimum Data Set, dated [DATE] documents R2 is dependent for all care. R2's Minimum Data Set, dated [DATE] documents R2 is severely cognitively impaired. No documentation could be provided by the facility indicating when R2's last shower, shave or nail trim was most recently done. On 5/22/24 at 2:30PM, R2 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to protect a resident's (R206) right to be free from sexual abuse and failed to protect a resident's (R208) right to be free from physical abuse from another resident. R206 and R208 are two of four residents reviewed for abuse in the sample list of 36. Findings include: 1. R206's Diagnosis Sheet (current) includes the following diagnoses: Alzheimer's Disease, Difficulty in Walking and Fracture of the Left Femur. R206's Minimum Data Set (MDS) dated [DATE] documents R206 as being Severely Cognitively Impaired and uses a wheelchair for mobility. A facility report titled, Final Abuse Investigation, dated 4/5/24, documents an incident of alleged sexual abuse on 4/1/24 involving R206 with R205 as the alleged perpetrator. The Abuse Investigation Report documents that on 4/1/24 R205 and R206 were in the dining room eating. R205 self-propelled R205's wheelchair over to R206 and touched (R206's) chest over the top of (R206's) clothes. There was no…

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

Based on interview and record review, the facility failed to do complete a thorough investigation of an allegation of sexual abuse between two residents (R205) and (R206). R205 and R208 are two of four residents reviewed for abuse in the sample list of 36. Findings include: A facility report titled, Final Abuse Investigation, dated 4/5/24, documents an incident of alleged sexual abuse on 4/1/24 involving R206 with R205 as the alleged perpetrator. The Abuse Investigation Report documents that on 4/1/24 R205 and R206 were in the dining room eating. R205 self-propelled R205's wheelchair over to R206 and touched (R206's) chest over the top of (R206's) clothes. The above investigation in its entirety documents two statements from staff, V21 Dietary Aide as a witness that documents V21 seeing R205 grab R206's chest area and another staff member, Certified Nurse Assistant (V34) who was called for assistance to retrieve R205 and take R205 to a separate area. This investigation also documents V1 Administrator asked the (unidentified) Interdisciplinary Team if they had knowledge of R205's…

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

Based on interview and record review the facility failed to complete annual performance evaluations for three Certified Nursing Assistants (CNAs). This failure has the potential to affect all 139 residents residing in the facility. Findings include: V29's and V33's (CNAs) personnel files including performance evaluations were requested. The facility provided V29's Employee Job Performance Evaluation dated 2/10/22 and V33's Employee Job Performance Evaluation dated 11/11/22. There was no documentation provided that V29 and V33 had performance evaluations completed after 2022. The facility's daily staffing sheets dated 2/20/24-3/3/24 document V29 and V33 worked in the facility. On 3/5/24 at 3:37 PM V2 Director of Nursing stated CNA performance evaluations are completed annually. On 3/6/24 at 11:47 AM V2 confirmed V29 and V33 work in both buildings of the facility. On 3/6/24 at 11:02 AM V23 Human Resources (HR) confirmed there are no documented performance evaluations for V29 and V33 after 2022. V24 Regional HR stated the facility may have stopped doing annual evaluations for CNAS due…

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 139 residents in the facility. Findings include: On 3/3/2024 at 8:45AM, V14 (Dietary Manager) was actively supervising dietary operations in the facility kitchen. V14 reported being the full-time manager of the facility food service and reported not being a clinically qualified Certified Dietary Manager or having equivalent training. V14 reported the facility dietician only works in the facility one day per month. V14 denied meeting the State of Illinois standards to be a food service manager or dietary manager. V14 denied: -being a dietician; -being a certified dietary manager; -having an associate's or higher degree in food service management or in hospitality; -having 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting; -being a graduate of a dietetic and nutrition school or program authorized by the Accreditation Council for…

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

Based on observation, interview, and record review, the facility to prevent the potential for physical cross-contamination of residents' food. This failure has the potential to affect all 139 residents in the facility. Findings include: On 3/3/2024 at 8:45AM, a can opener was mounted on a food preparation table located in the main kitchen. The opener was soiled with accumulations of metal shavings where the cutting blade contacts canned food items being opened. V14 (Dietary Manager) was present and removed the opener from the table to be cleaned and sanitized. On 3/3/2024 at 10:05AM, a can opener was mounted on a food preparation table located in the facility satellite kitchen. The opener was soiled with accumulations of metal shavings and sticky food residue where the cutting blade contacts canned food items being opened. V25 was present and observed the can opener and stated, Oh yeah, they (dietary staff) probably need to wash that (the soiled can opener). V25 proceeded to remove the opener to be cleaned and sanitized. The facility Long-Term Care Facility Application for Medicare…

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

Based on interview and record review the facility failed to ensure the required Quality Assurance Performance Improvement (QAPI) meetings were being held quarterly and failed to ensure required members attended quarterly QAPI meetings. This failure has the potential to affect all 139 residents residing in the facility. Findings include: The facility Quality Assurance Performance Improvement Program Policy dated 10/2022 documents that the purpose of the QAPI committee is to ensure organized quality assessment and improvement including performance measurement, assessment, improvement and can address the care and services provided by the facility. The committee will meet at least quarterly to assure activities are performed and identified problems have corrective actions taken or an appropriate action plan is developed. The committee members include the Administrator, Medical Director, Director of Nursing, Infection Preventionist, Wound Care Nurse, Social Services Director, Activities Director, Dietary Manager, Housekeeping/Laundry Director, Maintenance Director, Human Resources…

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

Based on interview and record review the facility failed to ensure Certified Nursing Assistants (CNAs) received 12 hours of annual in-service training. This failure has the potential to affect all 139 residents residing in the facility. Findings include: The facility's Facility Assessment Tool dated 2/12/24 documents the facility will provide required in-service training for nurse aides to ensure continuing competence including: at least 12 hours annually, dementia management training, and abuse training. This policy documents additional training will be provided based on identified areas of weakness that is determined by the nurse aide's performance review. This policy documents to consider the following, but not all inclusive list of competencies, which includes person-centered care, activities of daily living, disaster planning, infection control, vital signs, caring for persons with Alzheimer's/Dementia, catheter care, and caring for persons with mental and psychosocial disorders and history of trauma. V30's, V31's, and V33's (CNAs) 12 hour annual in-service training was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility repeatedly failed to provide written notifications of bed hold for one (R79) of two residents reviewed for hospitalizations in the sample list of 54. Findings include: The facility's Bed Hold and Return to Facility policy revised October 2021 documents: The facility's bed-hold policies apply to all residents. The facility bed hold policy will be given to the resident and/or resident representative as follows: Upon admission to the facility. At the time of a transfer from the facility; In cases of emergency transfer, notice at the time of transfer means that the family, surrogate, or representative are provided with written notification within 24 hours of the transfer. The requirement is met if the resident's copy of the notice is sent with other papers accompanying the resident to the hospital. R79's on-going census log documents R79 was hospitalized on [DATE], 1/22/24, 2/10/24, 2/21/24 and 2/21/24. There is no documentation in R79's medical record that a written…

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 specific targeted behaviors/interventions and attempt nonpharmacological interventions for five residents (R8, R57, R62, R13, R79) of six residents reviewed for psychotropic medication in a sample list of 54. Findings include: The facility's policy Behavioral Health Services Program dated 2/2024 states, The facility will attempt to identify, to the extent possible, any previous history of mental illness, trauma, abuse, substance abuse, comorbidities, pattern of behaviors, preferences, interest, daily routines, medication use and effective behavior management interventions in developing an individual plan of care. The Care Plan should include well defined problem statement and should outline goals of care. It should include measurable objectives and timetables for individualized interventions. It should also identify the responsibilities of various staff to implement the approaches effectively. 1.) R8's Medication Administration Record MAR for…

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

Based on observation, interview and record review the facility failed to label insulin upon opening (R114, R30), failed to ensure insulin was labeled with resident's name, failed to secure medications, and failed to ensure that a resident's medication card had the correct label with the correct dosage of medication (R97) for three of three residents reviewed for medication storage in the sample list of 54. Findings include: The facility's Medication Administration Policy with a revised date of January/2015 documents, Labels that do not contain the correct order, correct name of the resident, and/or correct name of the resident's physician should be returned to the pharmacy for relabeling. The facility's Medication Storage policy with a revised date of July/2019 documents, Facility should ensure that medication and biologicals are stored in an orderly manner in cabinets, drawers, carts, refrigerators/freezers of sufficient size to prevent crowding. Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart of…

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 feeding assistance in a dignified manner for one (R113) of 28 residents reviewed for dignity in the sample list of 54. Findings include: The facility's Dignity policy revised 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. Staff shall carry out activities in a manner which assists the resident to maintain and enhance his/her self-esteem and self-worth. 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; staff interacting/conversing only with each other rather than with residents while…

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 a resident who is cognitively impaired was provided a health care surrogate. This failure affects one resident (R7) reviewed for resident representative in a sample list of 54. Findings Include: R7'2 Order Summary printed 3/6/24 includes the following diagnoses: Altered Mental Status, Pseudobulbar Affect, Moderate Intellectual Disability, Intermittent Explosive Disorder, Downs Syndrome, Generalized Anxiety Disorder, Restlessness, Agitation, Seizures, Conduct Disorder, and Dementia. This summary documents R7's admission date as 12/21/21. R7's Minimum Data Set (MDS) dated [DATE] documents R7 is severely cognitively impaired. R7's Care Plan revised 9/14/23 documents (R7) has explosive mood disorder & delusional disorder with behaviors of angry outburst & tearful episodes requiring meds. (R7) has impaired cognitive function or impaired thought processes related to altered mental status, moderate intellectual disability. (R7) has out…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to obtain the signature of resident representative for a cognitively impaired resident on a Do Not Resuscitate order for one resident (R7) of five residents reviewed for Physician's Orders for Life Sustaining Treatment (POLST) in a sample list of 54. Findings Include: R7'2 Order Summary printed [DATE] includes the following diagnoses: Altered Mental Status, Pseudobulbar Affect, Moderate Intellectual Disability, Intermittent Explosive Disorder, Downs Syndrome, Generalized Anxiety Disorder, Restlessness, Agitation, Seizures, Conduct Disorder, and Dementia. This summary documents R7's admission date as [DATE]. R7's Minimum Data Set (MDS) dated [DATE] documents R7 is severely cognitively impaired. R7's Care Plan documents, (R7) is a full code. Attempt resuscitation, CPR, including intubation and mechanical ventilation. Date Initiated: [DATE] R7's POLST form dated [DATE] documents R7 as Do Not Resuscitate Comfort focused treatment. The required…

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

Based on observation, interview and record review the facility failed to prevent misappropriation of resident's property for one of one resident (R138) reviewed for misappropriation of medication in the sample list of 54. Findings include: The facility's Medication Administration Policy with a revised date of January/2015 documents, Medications must be administered in accordance with a physician's order, e.g. (example), the right resident, right medication, right dosage, right route, and right time. Medications supplied to one resident may not be administered to another resident. R138's Physician's Orders document an order for Humalog Solution (Insulin Lispro) 100 units/ml (milliliters), inject per sliding scale with a start date of 2/16/24. On 3/4/24 at 8:18 AM, V9 Licensed Practical Nurse removed R138's vial of Humalog from the medication cart and withdrew 5 units of Humalog and administered those 5 units to R2. V9 stated that V9 noticed the insulin was not R2's insulin but used it anyway. V9 confirmed R2 did not have a vial of Humalog in the medication cart. On 3/6/24 at 11:47…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to prevent a decline in Activities of Daily Living (ADLs) for one of three residents (R19) reviewed for ADLs in the sample list of 54. Findings include: R19's Order Summary Report dated 3/4/24 documents diagnoses including Unilateral Osteoarthritis of the Right Knee, Presence of Left Artificial Knee Joint, Lymphedema, Weakness and Morbid Obesity and documents and admission date of 7/5/23. R19's Minimum Data Set (MDS) dated [DATE] documents assistance needed for transfers, dressing, toileting and personal hygiene as limited assistance of one person and locomotion as extensive assistance of one person and bathing as physical help of one person. This MDS documents R19 did not receive any therapy and was receiving restorative exercises for bed mobility and dressing. R19's MDS dated [DATE] documents R19 is dependent on staff for toileting, bathing, dressing and transfers and required substantial/maximal assistance (helper provides more than half of…

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 dressing and shaving assistance for three (R70, R113, R94) of four residents reviewed for activities of daily living in the sample list of 54. Findings include: 1.) On 3/3/24 at 9:46 AM and 12:10 PM, and on 3/5/24 at 10:25 AM R70 had long facial hair to cheeks, chin, lips and neck. R70's Minimum Data Set (MDS) dated [DATE] documents R70 has cognitive impairment and is dependent on staff for bathing and personal hygiene. R70's Care Plan revised 6/13/23 documents R70 requires assistance of two staff for personal hygiene. R70's Behavior Tracking with date range 2/5/24-3/5/24 documents R70 had no behaviors. R70's shower sheets dated 2/3/24, 2/5/24, 2/10/24, 2/14/24, 2/18/24, 2/22/24, 2/25/24, 2/26/24, 2/29/24, and 3/4/24 do not document shaving was provided as indicated on the form. On 3/4/24 at 4:11 PM V40 (R70's Family) stated staff were afraid to shave R70 with a razor and V40 was going to get an electric razor for R70. V40 stated…

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 transcribe hospital discharge orders and obtain laboratory results as ordered for two (R79, R60) of 28 residents reviewed for physician's orders in the sample list of 54. Findings include: The facility's Physician Orders-Entering and Processing policy revised January 2018 documents: Enter the order into the resident's chart under order tab and according to the instructions for the type of order that is received. Notify the resident's physician (if not the prescribing physician), for verification if applicable. Following a physician visit, a licensed nurse will check for any orders that require confirmation under Clinical>orders>pending orders. The orders will be confirmed by the nurse and the instructions for the order will be completed. Verbal and Telephone orders will be documented as such in the Electronic Medical Record. 1.) R79's Minimum Data Set, dated [DATE] documents R79 has cognitive impairment. R79's Nursing Note dated 2/21/2024 at 4:09 PM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to identify a pressure ulcer, implement pressure relieving interventions, develop a pressure ulcer care plan, report pressure ulcers to the physician upon identification and wound decline, and routinely assess pressure ulcers for one (R113) of five residents reviewed for pressure ulcers in the sample list of 54. Findings include: The facility's Pressure Ulcer Prevention policy dated January 2018 documents: Turn dependent resident approximately every two hours or as needed and position resident with pillow or pads protecting bony prominences as indicated. Specialty mattresses such as low air loss, alternating pressure, etc. (etcetera) may be used as determined clinically appropriate. Specialty mattresses are typically used for residents who have multiple Stage 2 wounds or one or more Stage 3 or Stage 4 wounds. Use pressure reducing pads in chairs (all types) to protect bony prominences for residents identified as Moderate/High/Severe Risk. The…

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

Based on interview and record review the facility failed to safely transfer one (R131) of three residents reviewed for accidents from a total sample list of 54 residents reviewed. Findings include: The facility Transfer policy dated 8/2023 documents that in order to protect the safety and well-being of the staff and residents and to promote quality care, this facility will use mechanical lifting devices for the lifting and movement of residents who require a two person assist and a gait belt will be used with all physical transfers. R131's undated diagnoses sheet documents: Contusion of Left Lower Leg (facility acquired), Weakness, Polymyositis, Acute Cholecystitis, Diabetes Mellitus, Malnutrition, Skin Cancer and Depression. R131's 1/11/24 Minimum Data Set documents that R131 is cognitively intact. 1.) R131's progress notes dated 10/9/23 document an injury to R131's left leg during a transfer on 10/6/24. R131's emergency room notes dated 10/11/23 document that on approximately 10/6/23, R131 was being transferred from a bed to a chair at the facility where an accident occurred, and…

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

Based on observation, interview, and record review the facility failed to maintain a suprapubic catheter in a safe sanitary manner for one resident (R92) of three residents reviewed for catheter care in a sample list of 54. Findings Include: R92's Care Plan revised 1/29/24 documents, (R92) has a suprapubic catheter and history of recurrent Urinary Tract Infections, (UTI) is at risk for infection (UTI) related to complex Catheterization/Rectourethral fistula with colostomy placement. (R92) empties own urine without telling staff. (R92) has a diagnosis of obstructive uropathy. (R92) has times of pulling out catheter. (R92) removes dignity bag at times. (R92) moves catheter himself above the level of the bladder, even after education. Date Initiated: 03/25/2021 On 3/3/24 at 10:05AM V37, Certified Nurse's Aide was changing R92's pants and incontinence brief. R92 was sitting on the edge of the bed. As V37 pulled up R92's brief the catheter tubing fell to the floor. Red fluid was noted in R92's catheter tubing. As V37 continued to pull up R92's brief, the catheter bag fell to the floor.…

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 placement, with gastric residual, of a Gastrostomy tube prior to medication administration and prior to restarting a Gastrostomy feeding for one of two residents (R97) reviewed for Gastrostomy tube in the sample list 54. Findings include: R97's electronic diagnosis list documents diagnoses including Unspecified Protein-Calorie Malnutrition, Dysphasia, Encephalopathy and Fibromyalgia. R97's Medication Administration Record (MAR) dated 3/1/24 through 3/31/24 documents orders for Enteral Feeding every shift for supplement related to Unspecified Protein Calorie Malnutrition, Glucerna 1.2 at 75 ml (milliliters)/hr. (hour) continuous with a start date of 12/27/23. This MAR documents an order to check residuals before beginning a feeding and before medication administration, if greater than 100 ml hold feeding for one hour and recheck, if not resolved contact the Physician with a start date of 9/14/23. This MAR also documents an order for every shift to check tube placement before feeding, flushes and…

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

Based on observation, interview and record review the facility failed to administer medications in accordance with Physician's Orders and manufacturer's recommendations for two of five residents (R2, R112) reviewed for medication administration in the sample list of 54. The facility had 2 medication errors out of 27 opportunities resulting in a 7.41% medication error rate. Findings include: The facility's Medication Administration Policy with a revised date of January/2015 documents, Medications must be administered in accordance with a physician's order, e.g. (example), the right resident, right medication, right dosage, right route, and right time. Medications supplied to one resident may not be administered to another resident. Labels that do not contain the correct order, correct name of the resident, and/or correct name of the resident's physician should be returned to the pharmacy for relabeling. 1.) R2's Physician's Orders document orders for Humalog Kwik Pen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro) Inject 5 units subcutaneously three times a day…

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 remove a roommate from an isolation room for two of two residents (R58, R60) reviewed for Infection Control in the sample list of 54. Findings include: The facility's Infection Precaution Guidelines policy with a revised date of January/2018 documents, Transmission-Based Precautions will be employed for known or suspected infections for which the route of transmission/prevention is known. The transmission-based categories are the following: Airborne, Droplet, Contact. Private room is preferred. When a private room is not available, place the resident in a room with another resident with the same infection, but with no other infection (cohorting). R60's Nurse's Notes dated 2/28/24 documents that a CNA (Certified Nursing Assistant) notified the nurse to assess a rash found on R60's body. This note documents the Nurse Practitioner was notified. R60's Nurse's Note dated 2/2/9/24 at 5:21 PM documents an order was received for Acyclovir HCL (hydrochloride) (antiviral) 500 mg (milligrams) three times a day for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to obtain signed refusal of Flu vaccine for two residents (R7 and R92) of five residents reviewed for immunizations in a sample list of 54. Findings include: R7's Minimum Data Set (MDS) dated [DATE] documents R7 has not received a flu immunization since 11/3/22. No rationale for omission of this immunization is documented. R7 electronic medical Immunizations record for 2023 flu season documents, Flu Consent refused No signed refusal is documented for R7. R92 's Minimum Data Set (MDS) dated [DATE] documents R92 has not received a flu immunization since 11/3/22. No rationale for omission of this immunization is documented. R92's electronic medical Immunizations record for 2023 flu season documents, Flu Consent refused. No signed refusal is documented for R92. On 3/6/24 at 2:30PM V3, Regional Nurse Consultant stated, I have looked through all the consent forms for this flu season and I cannot locate ones for (R7) or (R92). The Infection Control policy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident (R2) was not subjected to physical abuse by R3. This failure affects two (R2, R3) of 4 residents reviewed for abuse. Findings include: R2's Facility Census documents R2 was admitted to the facility on [DATE] and has the following medical diagnoses; Progressive Vascular Leukoencephalopathy, Protein-Calorie Malnutrition, HTN, Anemia, Local Infection of the Skin and Subcutaneous Tissue, Pure Hypercholesterolemia, Malignant Neoplasm of Right Female Breast, Sciatica, Arthritis, Neurofibromatosis, COVID-19, Gastritis with Bleeding, Difficulty in Walking, Anxiety Disorder, History in Falling and Vascular Dementia. R2's Minimum Data Set (MDS) dated [DATE] documents R2's Brief Interview for Mental Status (BIMS) score 0, severe cognitive impairment. R3's Facility Census documents R3 was admitted to the facility on [DATE] and has the following medical diagnoses; Alzheimer's Disease, Protein-Calorie Malnutrition, Non-Familial…

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 dietary support staff with the appropriate competencies to carry out the functions of the food and nutrition service. This failure has the potential to affect all 139 residents residing in the facility. Findings include: On 11/26/23 at 12:00 pm - 12:15 pm V15, Dietary Assistant plated residents meals off a steam table in the North building kitchen. V15 stated, (R7) is vegan. He won't get meat. V15 put six vegetable egg rolls on R7's plate, approximately a half cup (large serving spoon) of mashed potatoes, a small ladle of gravy and large serving spoon of cooked carrots. V15 stated, I had to look up what a vegan diet was. Just to be on the safe side. It is no-meat meals. I am not a cook; I just serve the food brought back here (north building) from the main kitchen on south (building). V15 then plated R6's meal. V15 stated, (R6) is a diabetic, he is on a special diabetic diet. I guess that means he can't have carrots today. They are the only sweet thing I am serving for lunch. I don't think there is any…

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 the supply of food to provide the quantity of food portions, according to the menu and resident preference. These failures have the potential to affect all 139 residents residing in the facility. Findings include: On 11/26/23 at 8:53 am V8, Certified Nursing Assistant stated residents get scrambled eggs every morning and residents complain the portions of scrambled eggs are not large enough. On 11/26/23 at 10:25 am V14 Activity Director stated she attends the resident council meetings each month. V14 stated the residents complain of food portions are too small. 1. R1's Minimum Data Set (MDS) dated [DATE] documents R1's Brief Interview of Mental Status (BIMS)score as 15 out of a possible 15 indicating no cognitive impairment. On 11/25/23 at 11:00 am R1 stated, Portions are small every morning. I don't think I got more than two forks of eggs this morning. 2. R13's MDS dated [DATE] documents R13's BIMS score as 15 out of a possible…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interview the facility failed to properly maintain essential laundry equipment which resulted in one facility washing machine functioning to provide clean linen and clean personal laundry for all 139 residents residing in the facility. Findings include: On 11/26/23 at 9:27 am V11, Laundry Assistant walked down to the south building laundry room. There were two commercial size clothes washers. One clothes washer was not operable. One commercial size clothes washer was actively washing clothes. V11 stated, This is the only washer that works. We are doing everything we can do with one washer, just to stay on top of the facility laundry, sheets, and stuff. The residents laundry has backed up. We are trying. V11 stated, It has been about a month since the one on north broke down, and this other one (south main laundry) has been broken since I started back in June. The one in the north building has not been working for over three weeks. We are told the owners have not approved…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review the facility failed to ensure residents had access to their personal clothing. This failure affected five of ten resident (R1, R6, R8, R13 and R14) reviewed for access to personal possession/laundry on the sample list of 19. Findings include: On 11/26/23 at 9:27 am, during tour of the facility south building, main laundry room V11, Laundry Assistant stated the resident laundry has backed up. There were six, 55-gallon wheeled barrels of residents soiled clothes and two 55-gallon, plastic barrel liners full of soiled clothes laying on the laundry room floor. V11 confirmed they were all soiled clothing. V11 stated, We are still behind on laundry. There is still more in the north building, that has not been brought down here. That is where the last washer is that broke (north building). That was the only washer in the north building. We are down to washing the whole facility laundry in one washer (points to a commercial clothes washer actively washing clothes). It…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure dignity was maintained by talking to a resident (R2) in a condescending manner during dining. The facility also failed to respond to a call light in a timely manner to meet a resident's (R9) toileting needs. R2 and R9 are two of 16 residents reviewed for dignity on the sample list of 19. Findings include: 1.) R2's Minimum Data Set (MDS) dated [DATE] documents R2's Brief Interview of Mental Status (BIMS) score of 15, out of a possible 15, indicating no cognitive impairment. On 11/26/23 at 12:40 pm R2's food tray had approximately one tablespoon of mashed potatoes and gravy on her lunch plate. R2's Lunch diet ticket was on R2's meal tray and documents no double entree but does not mention side items. On 11/26/23 at 12:45 pm, R2 requested a second portion of mashed potatoes. V19, Certified Nursing Assistant (CNA) raised R2's lunch plate cover. R2 had not eaten any of her meal. V19, CNA stated, You can't have more potatoes until you eat…

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 non-pressure wound dressings and failed to report new skin impairment for one of four residents (R16) reviewed for skin impairment on the sample list of 19. Findings include: R16's Minimum Data Set, dated [DATE] documents R16's Brief Interview of Mental Status (BIMS) score of 15 out of a possible 15. R16's same MDS documents R16 is at risk for pressure ulcers and at the time of the assessment look-back period had no pressure ulcers. R16's Physician Order Sheet (POS) dated 11/30/29 documents the following non-pressure treatment orders: Wound right upper posterior thigh, clean area with soap and water, dry then apply hydrocolloid to the area every day shift for wound healing. Active as of 11/22/2023. The same POS documents a second non-pressure wound treatment as follows: Wound left, posterior, upper thigh, clean area with soap and water, dry then apply hydrocolloid every day shift for wound healing. Active as of 11/23/2023. 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 a diabetic diet, as ordered by the physician, for one of 13 residents (R1) reviewed for meals on the sample list of 19. Findings include: R1's Physician Order Sheet dated 11/28/23 documents the following diagnosis and diet order: Type II Diabetes Mellitus Without Complications and LCS (low concentrated sweets) diet, regular texture, regular consistency. R1's Minimum Data Set, dated [DATE] documents R1's Brief Interview of Mental Status score as 15 out of a possible 15, indicating no cognitive impairment. On 11/25/23 at 11:00 am R1 stated his blood glucose level was 519 (could not verify) the other day, because the facility does not provide diabetic diets. R1's Medication Administration Record dated 11/01/23- 11/30/23 documents R1's blood glucose level on 11/23/23 at 11:00 am was recorded as 500 milligrams per deciliter indicating a high glucose concentration. R1 was administered Lispro insulin (100 units/per milliliter), 12 units…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect the resident's(R2) right to be free from physical abuse by another resident (R1). This failure affects two residents (R1, R2) of six residents reviewed for abuse. Findings include: On 10/24/23 at 10:40 am V4 Licensed Practical Nurse (LPN) said, on 10/9/23 at 2:47pm V4 was notified by V3 Certified Nursing Assistant (CNA) R1 had grabbed R2 by the left wrist in the common area. V4 said, V3 immediately removed R1 from the common area. V4 said, V4 conducted a skin assessment of R2 and observed redness around R2's left wrist. V4 said, R2 complained of slight pain. V4 said, V4 notified V1 Administrator, V5 R2's Physician and V6 R1's Power of Attorney. V4 said an ice pack was applied to R2's wrist. On 10/24/23 at 10:50am V3 Certified Nursing Assistant (CNA) said, on 10/9/23 at 2:45pm V3 was sitting at a table in the common area with R2. V3 said, R1 was walking around talking about bread or something, and R2 told R1 to be quiet. V3 said, R1 than came 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 record review and interview, the facility failed to notify a resident's guardian of an allegation of sexual abuse. This failure affects one resident (R2) out of three reviewed for notifications on a sample of three. Findings include: R2's Census dated 10/6/23 documents R2 was admitted to the facility 6/21/23. R2's Face Sheet dated 10/6/23 documents V5, R2's son, is R2's guardian and first emergency contact. R2 Diagnoses List dated 10/6/23 documents, R2 experiences medical diagnoses including Diffuse Traumatic Brain Injury with Loss of Consciousness, Encephalopathy, and Altered Mental Status. The facility's Initial Report to the Illinois Department of Public Health (IDPH) dated 9/17/23 documents an allegation of sexual abuse by another resident towards R2. The facility's Final Report to IDPH dated 9/22/23 documents the events leading to the allegation of sexual abuse had been witnessed by facility staff, V4, Certified Nursing Assistant. R2's Nurses Notes dated 9/18/23 at 3:34 PM and 10:35 PM, document follow-up nursing evaluations of R2 related to abuse. These Nurses Notes…

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 a resident was free from sexual abuse perpetrated by another resident. This failure affects one resident (R2) out of two reviewed for non-consensual sexual contact on a sample of three. Findings include: R2's Census dated 10/6/23 documents R2 was admitted to the facility 6/21/23. R2 Diagnoses List dated 10/6/23 documents R2 experiences medical diagnoses including Diffuse Traumatic Brain Injury with Loss of Consciousness, Encephalopathy, and Altered Mental Status. R2's Minimum Data Set (MDS) dated [DATE] documents R2 scored a 7 out of possible 15 during a Brief Interview for Mental Status (BIMS), rating R2 with severe cognitive impairment. R1's Census dated 10/6/23 documents R1 was admitted to the facility 8/11/14. R1's Diagnoses List dated 10/6/23 documents R1 experiences medical diagnoses including Dementia without Behavioral Disturbance and Schizoaffective Disorder. R1's MDS dated [DATE] documents R1 received a score of 9 out of a possible 15…

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

Based on interview and record review, the facility failed to follow their abuse prevention policy by failing to notify local law enforcement of sexual abuse and inform the resident's representative of an allegation of sexual abuse and the results of the facility investigation. This failure affects one resident (R2) out of two reviewed for sexual abuse on the sample of three. Findings include: The facility policy Abuse Prevention and Reporting- Illinois dated effective 8/2023 documents, External Reporting, Initial Reporting of Allegations: When an allegation of abuse, exploitation, neglect, mistreatment, or misappropriation of resident property has occurred, the resident's representative and the Department of Public Health's regional office shall be informed by telephone or fax. Informing Local Law Enforcement. The facility shall also contact local law enforcement authorities (i.e., telephoning 911 where available) in the following situations: Sexual abuse of a resident by a staff member, another resident, or visitor. When there is a reasonable suspicion that a crime has been…

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

Based on interview and record review, the facility failed to report an allegation of sexual abuse, and the final result of the facility investigation, to local law enforcement officials. This failure affects one resident (R2) out of two reviewed for sexual abuse on the sample of three. Findings include: The facility's Initial Report to the Illinois Department of Public Health (IDPH) dated 9/17/23 documents an allegation of sexual abuse by another resident towards R2. The facility's Final Report to IDPH dated 9/22/23 documents the events leading to the allegation of sexual abuse had been witnessed by facility staff, V4, Certified Nursing Assistant. On 10/10/23 at 10:48 AM, V1, Administrator, first stated, The police were notified about this incident between (R1 and R2), but I did not receive a case number at that time. I could check to see if any documentation could be obtained about the police reporting. At 11:19 am, V1 stated, For this incident, for notifying the police such as in the cases of what I would consider an actual assault, yes I would notify the police, but I considered…

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 complete pre-admission screening as required for a resident prior to admission to the to the Skilled Nursing part of the facility, when transferred to the Intermediate Care part of the facility, and when diagnosed with a new mental health diagnosis. This failure affects one resident (R1) out of three reviewed for pre-admission screening on the sample of three. Findings include: R1's Census dated 10/6/23 documents R1 was admitted to the Skilled Nursing part of the facility 8/11/14. This same Census documented R1 had been transferred back and forth between the Skilled Nursing part of the building and the Intermediate Care part of the facility 15 times during his residency at the facility. R1's Diagnoses List dated 10/6/23 documents R1 received a diagnosis of schizoaffective disorder on 9/1/2016. R1's Illinois Department of Healthcare and Family Services Interagency Certification of Screening Results (commonly referred to as an OBRA screen, Level 1 screening equivalent) dated 8/8/2014 documents R1's screening results…

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 complete required pre-admission screening to determine the appropriateness for a resident who was expected to stay at the facility less than 30 days. This failure affects one resident (R2) on the sample of three reviewed for pre-admission screening on the sample of three. Findings include: R2's Census dated 10/6/23 documents R2 was admitted to the facility 6/21/23. R2's Level 1 PASARR (Pre-admission Screening and Record Review) dated 3/13/23 (from prior nursing facility) documented R2 was deferred from the Level 1 PASARR due to being an exempted hospital discharge, and approving R2 for a 30 day stay at a nursing facility. This PASARR documents R2 was suspected of a medical condition of bipolar disorder. The Outcome Explanation portion of this PASARR documents if R2 stays in a nursing facility longer than 30 days, a request for a new Level 1 PASARR must be submitted. R2's comprehensive Electronic Medical Record did not include any other PASARR documents. On 10/10/23 at 1:24 PM, V11, Business Office Manager, confirmed, (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 interview and record review the facility failed to protect the residents right to be free from physical abuse from another resident. This failure affects four of four (R4, R5, R6, R7) of eight residents reviewed for abuse in a sample list of 14. Findings include: The facility abuse policy dated 10/2022 documents the facility affirms the right of their residents to be free from abuse. The policy documents physical abuse includes willful hitting, slapping, pinching, kicking and controlling behavior. R4's undated diagnosis sheet documents the following diagnoses including hypertensive crisis, vascular dementia with agitation, Alzheimer's dementia, mild developmental delay, and a history of drug use. R4's Minimum Data Set, dated [DATE] documents R4 has moderate cognitive impairment and is ambulatory. R4's care plan dated 8/21/23 documents R4 has a potential for aggressive behavior related to dementia. R4's August behavior sheet documents verbal and physical behaviors toward others. Facility 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.

Based on observation, interview and record review the facility failed to assist with activities of daily living for one (R4) of three residents reviewed for activities of daily living (ADL). Findings include: On 9/7/23 at 8:30AM, R4 was walking throughout the dementia unit with wet jeans around his lap area. V16 Certified Nursing Assistant (CNA) told R4 to go to his room and change his pants. R4 went into his room and came out in dry jeans, carrying his wet jeans. On 9/7/23 at 8:40AM, R4 took the wet jeans and placed them in a hallway laundry hamper. R4's care plan dated 6/8/23 documents R4 has an ADL self-care performance deficit related to dementia. R4 will maintain his current level of function with staff assistance for toileting and personal hygiene. On 9/7/23 at 8:45AM, V16 CNA said she was the only CNA in the dementia unit this particular morning and that, R4 will change himself. I don't know if he changed his brief or not.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review; the facility failed to identify, assess, and complete wound treatments as ordered for two (R3, R12) of four residents reviewed for wound care from the sample list of 14. Findings include: 1.) R3's undated Face Sheet, documents R3's diagnoses as: Type 2 Diabetes Mellitus with Periodontal Disease, Morbid Obesity due to excess calories, Dependence on other enabling machines and devices, Cerebral Infarction, Hemiplegia and Hemiparesis, Unspecified open wound right lower leg. R3's Minimum Data Set (MDS) dated [DATE], documents R3 has moderate cognitive impairment and is total dependence with two plus physical assist for bed mobility, transfers, toilet use, and personal hygiene and that R3 uses a wheelchair for locomotion. R3's Care Plan dated 8/28/23, documents R3 is at risk for skin impairment related to decreased mobility, diabetes, and incontinence. On 9/6/23 at 1:47 PM, V14 Registered Nurse (RN) was observed doing wound treatments on R3's left lower thigh and…

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

Based on observation, interview and record review the facility failed to administer medications according to physician orders for four (R9, R10, R16, R17) of four residents reviewed for medications in a sample list of 22 residents. Findings include: 1.) R9's Physician Order Sheet (POS) dated August 2023 documents physician orders for Clopidogrel Bisulfate 75 milligrams (mg) daily at lunch for Atherosclerotic Heart Disease, Furosemide 40 mg daily at lunch for Essential Hypertension, Humalog 100 units/milliliter (ml) give 4 units daily at breakfast for Type II Diabetes Mellitus, Humalog 100 units/milliliter (ml) give 8 units daily at lunch for Type II Diabetes Mellitus, Lantus Subcutaneous Solution 100 UNIT/ML give 37 units subcutaneously daily at lunch for TYPE 2 DIABETES MELLITUS, Norvasc 5 mg daily at breakfast for Essential Hypertension, Divalproex Sodium Delayed Release (DR) 500 mg daily at lunch for Schizoaffective Disorder, Metoprolol Tartrate 25 mg daily at breakfast for Essential Hypertension and obtain blood glucose levels before meals and at bedtime for Type II Diabetes…

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 food was not overcooked. This failure affects five of (R1, R2, R3, R5, R6) 12 residents reviewed for food palatability in the sample list of 22. Findings include: The Resident Council Meeting Minutes dated 7/25/23 documents, eggs are burnt. On 8/22/23 at 10:30 AM V6 (R2's Power of Attorney) stated the food is often overcooked, It is horrible. V6 stated last week the chicken was hard and V6 had to ask for R2's food to be pureed since R2 had difficulty chewing the food. On 8/22/23 at 12:00 PM R3 was eating lunch in R3's room. R3's meal tray included ravioli, broccoli, and bread. At 12:10 PM R3 stated the broccoli is overcooked and did not have much flavor. R3 ate R3's ravioli and a cup of broccoli remained on R3's meal tray. V6 was feeding R2 (R3's roommate). R2's meal tray included ravioli and broccoli. V6 stated the broccoli is overcooked. On 8/22/23 at 12:27 PM R6 stated R6 did not care very much for the broccoli. Broccoli was observed left on R6's meal tray and R6 had eaten all R6's ravioli. On…

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

Based on observation, interview and record review the facility failed to ensure staff had access to Personal Protective Equipment (PPE) while under COVID-19 outbreak status, failed to wear appropriate PPE while providing direct cares for COVID-19 positive residents (R1, R7, R9, R10, R18, R22), failed to post isolation signage for COVID-19 positive rooms, and failed to maintain current/accurate infection control logs. These failures affect eight residents (R1, R4, R6, R7, R9, R10, R18, R22) of 11 residents reviewed for infection control in the sample list of 22 residents. Findings include: 1.) R4's Concern/Compliment Form dated 8/17/23 documents staff were not wearing Personal Protective Equipment (PPE) when entering/exiting resident isolation rooms. The Reeducation Memo dated 8/17/23 with incident date of 8/16/23, documents a concern that V14 CNA was not wearing PPE in COVID-19 positive rooms and V14 was re-educated on the importance of PPE. On 8/22/23 at 11:29 AM R4 stated last Thursday R4 witnessed V14 CNA enter a COVID-19 positive room and V14 was not wearing a gown, gloves,…

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 failed to offer and administer COVID-19 vaccination boosters to four (R1, R3, R7, R8) residents of five residents reviewed for COVID-19 vaccinations in a sample list of 22 residents. Findings include: 1.) R1's undated face sheet documents diagnoses of Malignant Neoplasm of Lung, Pulmonary Embolism with Acute Cor Pulmonale, Reduced Mobility and History of COVID-19. This same face sheet documents R1's admission date of 7/1/23. R1's medical record does not document any education provided regarding COVID-19, nor does it document a bivalent COVID-19 booster being offered or administered. R1's medical record documents COVID-19 vaccinations were administered on 9/21/21, 10/14/21 and 8/1/22. No further COVID-19 vaccination boosters were documented as offered or administered. 2.) R3's undated face sheet documents a diagnosis of End Stage Renal Disease, Hypertension and Dependence on Renal Dialysis. This same face sheet documents R3's admission date of 6/19/23. R3's medical record does not document any education provided regarding COVID-19,…

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 that dignity was maintained by failing to respond to call light requests to provide a mechanical lift transfer for R11 and provide timely toileting assistance for R1. R1 and R11 are two of 10 residents reviewed for call lights/dignity on the sample list of 22. Findings include: The Resident Council Minutes dated 6/27/23 and 7/25/23 document concerns with call light response times. 1.) R11's Minimum Data Set (MDS) dated [DATE] documents R11 has a Brief Interview of Mental Status score of 15 out of a possible 15, indicates no cognitive impairment. The same MDS documents R11 is totally dependent on two physical staff assist for transfers. R11's Care Plan dated 6/12/23 documents the following: (R11) has an ADL (Activity of Daily Living), self- care performance deficit related to history of falls, incontinence of bowel and bladder, musculoskeletal impairment, pain chronic back and knee, and psychotropic medications. R11's same care plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to notify the physician and resident's representative of a significant weight loss for one (R2) of three residents reviewed for feeding assistance in the sample list of 22. Findings include: R2's MDS dated [DATE] documents R2 has severe cognitive impairment. R2's admission Record with admit date of 5/3/23 documents V6 as R2's Power of Attorney for Healthcare. R2's Weight Log documents R2's weights as follows 134.0 pounds (lbs.) on 5/3/23, 134.2 lbs. on 6/7/23, 133.4 lbs 7/17/23, and 112.8 lbs on 8/2/2023 (a significant weight loss of 15.4% in one month). R2's Nutritional assessment dated [DATE] completed by V32 Registered Dietitian documents R2 had a weight loss of 20.6 lbs (15.4%) and some of the weight loss was related to edema upon admission. V6 recommended adding ice cream to R2's meals to increase calories per day. There is no documentation in R2's medical record that V6 or V20 (R2's Physician) were notified of R2's significant weight loss. On 8/22/23…

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 interview and record review the facility failed to provide showers as scheduled for three (R1, R2, R3) of seven residents reviewed for showers in the sample list of 22. Findings include: The facility's Resident Council Meeting Minutes dated 6/27/23 documents concern with showers. 1.) On 8/22/23 at 12:57 PM R1 was in an isolation room. R1 stated R1's showers are supposed to be Monday and Thursday and R1 does not always get a shower twice per week. R1 stated R1 did not get a shower yesterday (Monday) because R1 has COVID-19 and staff don't want to come into R1's room to care for R1. On 8/23/23 at 9:20 AM R1 was no longer on isolation. R1 stated R1 hasn't had a shower since last Thursday. R1 stated, It has been a week and I (R1) smell like a skunk. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is cognitively intact and is totally dependent on one staff person for bathing assistance. The facility's shower schedules document R1's showers are scheduled twice per week and (based R1's Census) R1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide nutritional interventions as recommended by a dietitian, consistently document meal intakes, and have a significant weight loss evaluated by a physician for one (R2) of three residents reviewed for feeding assistance in the sample list of 22. Findings include: R2's MDS dated [DATE] documents R2 has severe cognitive impairment. R2's Care Plan dated 8/17/23 documents R2 has had a significant weight loss and includes a goal that R2 will eat 50% of 3 meals daily, and interventions to monitor weight and administer supplements as ordered. R2's Weight Log documents R2's weights as follows 134.0 pounds (lbs.) on 5/3/23, 134.2 lbs. on 6/7/23, 133.4 lbs 7/17/23, and 112.8 lbs on 8/2/2023 (a significant weight loss of 15.4% in one month). There are no documented weights after 8/2/23 in R2's medical record. R2's Meal Intakes dated 7/24/23-8/22/23 do not document recorded intakes for 16 meals. R2's Nutritional assessment dated [DATE] completed…

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 appropriate use of antibiotics for two (R1, R6) of three residents reviewed for wound infections in the sample list of 22. Findings include: 1.) R1's Care Plan revised 8/14/23 documents R1 is on antibiotics for a wound infection. This Care Plan documents R1's diagnoses include Left Artificial Knee Join and Aftercare Following Joint Replacement Surgery. R1's Order Summary Report dated 7/23/23-8/23/23 documents the following orders: Bactrim (antibiotic) DS (Double Strength) Oral Tablet 800-160 Mg (milligrams) give one tablet by mouth twice daily for 2 weeks for wound infection. There is no documentation that a wound culture was obtained or that the facility consulted with the physician to request a wound culture. On 8/22/23 at 12:57 PM R1 stated R1 admitted to the facility about a month ago after R1 was hospitalized for left knee replacement. R1 stated R1 has an infection in R1's left knee surgical wound due to staff not changing R1's dressing as ordered. At 2:16 PM V3 Licensed Practical Nurse (LPN)…

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 failed to offer and administer Pneumococcal vaccinations for three (R1, R2, R7) of five residents reviewed for immunizations in a sample list of 22 residents. Findings include: 1.) R1's undated face sheet documents diagnoses of Malignant Neoplasm of Lung, Pulmonary Embolism with Acute Cor Pulmonale, Reduced Mobility and History of COVID-19. This same face sheet documents R1's admission date of 7/1/23. R1's medical record does not document any education provided to R1 regarding Pneumococcal vaccinations, nor does it document a Pneumococcal vaccination being offered or administered. 2.) R2's undated face sheet documents a diagnosis of Cerebral Infarction, Essential Hypertension, Dementia and Anxiety. This same face sheet documents R2's admission date of 5/3/23. R2's medical record does not document any education provided regarding Pneumococcal vaccinations, nor does it document a Pneumococcal vaccination being offered or administered. R2's medical record documents R2's most recent Pneumonia vaccination was administered 8/1/96 with no…

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

Based on observation, interview, and record review the facility failed to act upon and respond to concerns made in the resident council monthly meetings. This failure has the potential to effect eight of eight residents (R26, R63, R112, R101, R33, R56, R27, and R74) reviewed for resident council on the sample list of 55 and all 116 residents residing in the facility. Findings include: The facility's Resident Council Minutes form dated 3/22/22 for the North building documents food is often cold when it is served. The facility's Resident Council Minutes form dated 3/29/22 documents concerns with call light response times and staff not returning after call light is shut off. This form documents concerns with staffing. The facility's Resident Council Minutes form dated 4/26/22 does not document old business or a follow-up to concerns made in March's resident council. This form documents concerns with call light response times and concerns with snack availability. The Resident Council Minutes for the North building dated 4/26/22 does not document old business or a follow-up to concerns…

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 promote a homelike environment by failing to ensure call light sounds levels were comfortable and by failing to ensure a non-institutional dining experience. This failure affected eight of eight (R26, R63, R112, R101, R33, R56, R27, and R74) residents reviewed for resident council and all 116 residents residing in the facility. Findings include: On 3/19/23 through 3/23/23 and on 3/21/23 from 9:00 AM to 3:00 PM, the call light system alarm could be heard throughout the facility. The sound was a high-pitched alarm sound that repeated over and over until the call light was answered. The call light alarm sounded repetitively throughout the day with infrequent breaks. The high pitch and constant sound level interrupted concentration and was pervasive. On 3/13/23 at 1:43 PM, a group meeting was held with R26, R63, R112, R101, R33, R56, and R27. All seven residents reported and concurred the following issues have not been addressed by the facility for several months: Call light noise level, call lights not being…

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 sufficiently staff Certified Nursing Assistants (CNAs). This failure affects four residents (R3, R5, R27, R55) on the sample list of 55. This failure has the potential to affect all 116 residents residing in the facility. Findings include: The facility's Resident Council Minutes document: On 1/13/23 residents had concerns with call light response times and residents not getting showers timely. On 2/28/23 residents voiced concerns with night shift not checking on them and answering call lights. On 3/12/23 at 9:50 AM R3 stated there are not enough staff, and R3 does not get help every day to get dressed and assisted out of bed. On 3/12/23 at 9:02 AM R5 stated they don't change R5 during the night, and R5's sheets are often wet with urine in the mornings. R5's Power of Attorney (V24) stated she comes to the facility in the mornings every day to assist R5 with morning care, and every morning R5's bed linens are soaked with urine. On 3/12/23 at 8:44 AM R27 stated: The facility is short staffed on CNAs. There are…

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 116 residents residing in the facility. Findings include: On 3/12/23 at 10:05am, V5 Dietary Manager was actively supervising dietary operations in the facility kitchen during resident meal preparations. V5 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 3/12/23 documents 116 residents reside in the facility.

Based on observation, interview, and record review, the facility failed to maintain sanitary food storage areas and failed to maintain sanitary kitchen floor surfaces. These failures have the potential to affect all 116 residents residing in the facility. Findings include: On 3/12/23 at 8:25am, the floor areas throughout the kitchen and adjacent dishwashing areas were soiled with accumulations of decomposing food and grease deposits. V6 Dietary Aide was present and stated the floors are cleaned once per shift. On 3/12/23 at 12pm, the kitchen refrigerator had water pooling on the bottom shelf. V5 Dietary Manager (DM) was present and stated this issue had been ongoing for a week or two. V5 stated V5 was not sure if it was a door seal issue or condenser issue V5 stated the condenser/evaporator had been blown out by V20 Maintenance Director and that seemed to help for a bit. V5 confirmed the kitchen and adjacent dishwashing area floors were dirty and stated staff are to clean the floors each shift. On 3/12/23 at 1:15pm, V20 Maintenance Director replaced refrigerator door seal. On…

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

Based on observation, interview and record review, the facility failed to ensure there is a Licensed Administrator managing the facility. This failure has the potential to affect all 116 residents residing in the facility. Findings include: On 3/12/23 at 11:17 AM, V1 acting Administrator was in the building. On 3/13/23, 3/14/23, 3/15/23 and 3/16/23 V1 was in the building as the acting Administrator. On 3/15/23 at 11:07 AM, V1 stated that V1 does not have an Administrator's license nor does V1 have a temporary Administrator's license. V1 stated that the owner's license is on the wall. V1 stated that the owner usually comes to the facility once every two weeks. V1 stated that V1 tried to apply for a temporary license and it was denied. The Resident Census and Conditions of Resident report dated 3/12/23 documents there are 116 residents reside in facility.

Based on interview and record review the facility failed to have required members attend the Quality Assurance Performance Improvement (QAPI) meetings. This failure has the potential affect all 116 residents residing in the facility. Findings include: On 3/13/23 at 3:19 PM the Quality Assurance meeting sign in sheets provided by V3 Psychiatric Rehabilitation Services Director, documents: The 4/20/22 meeting did not have a Medical Director or Director of Nursing in attendance. The undated meetings that reviewed April- September 2022 documents V1 Administrator was in attendance. V1 is not a Licensed Nursing Home Administrator. The undated meeting that reviewed October, November, and December documents there was no Medical Director or Administrator in attendance. On 3/15/23 at 11:07 AM V1 Administrator confirmed the facility's QAPI meeting sign in sheets are missing some of the required members and confirmed V1 is not a Licensed Nursing Home Administrator. Resident Census and Conditions of Residents dated 3/12/23 documents 116 residents reside in the facility.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program by failing to prevent cockroaches in the kitchen area. This failure has the potential to affect all 116 residents in the facility. Findings include: On 3/12/23 at 8:20am, the kitchen and pantry flooring was soiled throughout with accumulations of food debris. The legs of food preparation tables and dishwasher drain boards were also soiled with splattered food debris. Live German cockroaches were observed on the wall underneath of the mechanical dishwasher and the three compartment sink. Dead cockroaches were observed on the floor near the employee handwashing sink. On 3/12/23 at 10:35am, live German cockroaches were observed on the wall underneath of the mechanical dishwasher and the three compartment compartment sink. V5 Dietary Manager was present and confirmed the above insects were German cockroaches. V5 stated, They [pest control] come out monthly to treat for them [roaches] and not as bad as they used to be, but staff need to keep the floors cleaner. On 3/13/23…

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 interview and record review the facility failed to notify the resident's physician and representative of a change in condition and refusal of meals and poor food intake for four (R55, R27, R73, R114) of 32 residents reviewed for changes in condition in the sample list of 55. Findings include: The facility's Physician-Family Notification- Change in Condition dates as revised November 2018 documents the physician and resident representative will be notified of changes in a resident's condition and when there is a need to alter treatment. 1.) On 3/12/23 at 11:21 AM R55 stated, Finally after all these weeks I get to see a dermatologist Tuesday (3/14/23). R55 stated R55 last saw a dermatologist for R55's psoriasis a few months ago. On 3/13/23 at 12:03 PM R55 stated R55 can't sit up in R55's wheelchair for extended periods or attend activities as often as R55 did previously due to R55's pain/itching caused from R55's psoriasis. R55 described the pain as an ache rated as an 8 on a 1-10 scale. R55 stated R55…

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

Based on interview and record review the facility failed to timely report an allegation of verbal/mental abuse to the state survey agency for one resident (R55) of two residents reviewed for abuse in the sample list of 55. Findings include: On 3/12/23 at 9:08 AM R55 stated, (V18 Licensed Practical Nurse (LPN)) doesn't like me (R55). She chews me out about things. Chews my A (expletive). I haven't talked to anyone about her. She's kind of a little cross with me, tells me I should do things more. It gets to me sometimes. I don't think I deserve to feel that way. At 10:14 AM R55 stated V18 has yelled at R55. R55 stated, V1 Administrator spoke with R55 this morning about R55's concerns with V18. R55 told V1 what R55 previously reported about V18. On 3/12/23 at 9:35 AM V1 Administrator stated R55 has not reported concerns involving V18, and V18 is the only staff person employed by the facility with the name given by R55. At this time R55's allegation was reported to V1. V1 stated V1 was going to follow up with R55. On 3/13/23 at 11:49 AM V1 Administrator stated V1 filed a grievance…

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 observations, interview, and record review the facility failed to initiate an investigation for an allegation of verbal/mental abuse and remove an alleged perpetrator (employee) from further contact with residents to prevent potential further abuse. This failure has the potential to affect 20 residents (R55, R51, R212, R101, R104, R71, R33, R57, R27, R70, R68, R60, R15, R59, R35, R73, R62, R5, R13, R90). Findings include: On 3/12/23 at 9:08 AM R55 stated, (V18) Licensed Practical Nurse (LPN)) doesn't like me (R55). She chews me out about things. Chews my A (expletive). I haven't talked to anyone about her. She's kind of a little cross with me, tells me I should do things more. It gets to me sometimes. I don't think I deserve to feel that way. At 10:14 AM R55 stated: V18 has yelled at R55 before. R55 stated, V1 Administrator spoke with R55 this morning about R55's concerns with V18. R55 told V1 what R55 previously reported about V18. On 3/12/23 at 9:35 AM V1 Administrator stated R55 has not reported concerns involving V18, and V18 is the only staff person employed by the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide timely incontinence care and failed to provide assistance with shaving and nail care for four (R55, R5, R70, R73) of six residents reviewed for activities of daily living on the sample list of 55. Findings include: 1. On 3/13/23 at 12:18 PM R55 stated R55 calls for staff during the night, but they tell her that they're short staffed and can't assist her. Sometimes R55 must wait until 6:00 AM before R55 is provided incontinence care. On 3/12/23 at 9:08 AM R55 stated R55 was incontinent and was last changed at approximately 7:00/8:00 PM. At 10:14 AM R55 stated R55 told V15 Certified Nursing Assistant (CNA) that R55 needed to be changed. At 10:38 AM V15 answered R55's call light. V15 stated V15 was waiting for staff assistance to change R55. On 3/12/23 at 10:54 AM V15 and V16 Certified Nursing Assistants (CNAs) entered R55's room and provided incontinence care. R55's incontinence brief was saturated with urine and a large amount of…

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 change residents oxygen and nebulizer tubing. These failures affect four of five residents (R14, R43, R52, R110) reviewed for respiratory care on the sample list of 55. Findings include: The facility's Oxygen & Respiratory Equipment - Changing/Cleaning policy with a revised date of January 2019 documents, Purpose: 1. To provide guidelines to employees for changing all disposable respiratory supplies. 2. Nasal Cannula. a. Nasal cannulas are to be changed once a week and PRN (as needed). c. A clean plastic bag with a zip lock or draw string, etc. will be provided to store the cannula when it is not in use. It will be dated with the date the tubing was changed. 1. R14's Physician Order Sheet (POS) dated March 2023 documents R14 is diagnosed with Shortness of Breath, Chronic Obstructive Pulmonary Disease, and Dependence on Supplemental Oxygen. The same POS documents an order for Oxygen at two liters nasal cannula every shift as needed for Shortness of Breath. The same POS documents an order to change oxygen tubing…

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

Based on observation, interview, and record review the facility failed to administer medications in accordance with physician orders and manufacturer instructions and failed to administer gastrostomy tube medication separately for three (R20, R8, R54) of three residents reviewed for medication administration in the sample list of 55. The facility had 14 medication errors out of 31 opportunities resulting in a 45.16% medication error rate. Findings include: 1. R20's Physician's Orders dated 3/15/23 documents: Check blood glucose before meals and at bedtime. Novolog (Insulin Aspart) 100 units (u)/milliliter (ml) administer subcutaneous 15 units three times daily. Levothyroxine 100 micrograms (mcg) by mouth daily. Ferrous Sulfate (Iron) 325 mg by mouth daily. Atorvastatin Calcium 40 mg Metoprolol Succinate Extended Release 50 mg by mouth daily, hold if systolic blood pressure is less than 120 or diastolic blood pressure is less than 55. On 3/13/23 at 9:14 AM V13 Assistant Director of Nursing obtained R20's blood glucose level of 310. At 9:20 AM V13 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.

Based on observation, interview, and record review the facility failed to serve palatable food at an appetizing temperature. This failure affected 12 (R26, R63, R112, R101, R33, R56, R27, R17, R105, R99, R85, and R25) of 32 residents reviewed for food on the sample list of 55 and all 116 residents residing in the facility. Findings include: The facility's Resident Council Meeting minutes dated March of 2022 through February 2023 all documented concerns with the food temperatures and taste. 1. On 3/13/23 at 1:43 PM, a group meeting was held with R26, R63, R112, R101, R33, R56, and R27. All seven residents reported and concurred there are several issues with the quality, temperature, and palatability of the food. The residents also voiced concern they are not able to access food choice alternatives readily. At that time, R27 had a tray in front of her and stated, I just got back from Dialysis, and they had a tray ready when I got back but it was cold and it can't be reheated. 2. On 3/12/23 at 9:20 AM, R17 stated the food is terrible. On 3/12/23 at 12:00 PM, R17 stated the food 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 observation, interview, and record review the facility failed to ensure residents were treated with dignity and respect and provided privacy during care for three (R55, R27, R101) of 32 residents reviewed for resident rights in the sample list of 55. Findings include: 1.) R55's Minimum Data Set (MDS) dated [DATE] documents R55 is cognitively intact. On 3/13/23 at 12:03 PM R55 stated it bothers R55 that the staff do not always pull the curtain between R55 and R55's roommate during cares. On 3/12/23 at 10:54 AM R55 was lying in bed. V15 and V16 Certified Nursing Assistants entered R55's room and provided incontinence care. The privacy curtain was pulled between R55 and R55's roommate but was not pulled to block the view from R55's door. R55's perineal area was exposed and in view of the door when V18 entered and left R55's room on two occasions and when V13 Assistant Director of Nursing left R55's room. On 3/13/23 at 1:44 PM V2 Director of Nursing stated privacy curtains should be pulled between residents…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide routine foot care for one resident (R73) reviewed for foot care on the sample list of 55. Findings include: On 3/13/23 at 8:49 AM V19, R73's Power of Attorney, stated: R73's toenails are long, but the facility has never told V19 that R73 needs to see a podiatrist. V19 would schedule a podiatry appointment if R73 needed one. On 3/14/23 at 12:33 PM V17 Certified Nursing Assistant removed R73's socks and confirmed R73's toenails needed to be trimmed. R73's toenails were long and thick. Both great toenails were sticking up and approximately 1/2 past the tip of R73's toe. On 3/14/23 at 12:38 PM V1 Administrator stated the podiatrist rounds at the facility every 3 months. At 12:50 PM V4 Social Services Director stated We are not able to trim R73's toenails, and R73 toenails need to be trimmed by a podiatrist. R73 has refused to allow a podiatrist to trim R73's toenails previously. R73 is cooperative for V4, and V4 thought about assisting…

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

Based on interview and record review the facility failed to implement post fall interventions for two of six residents (R24, R81) reviewed for falls on the sample list of 55. Findings include: The facility's Fall Prevention Program with a revised date of May 2022 documents, Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Safety interventions will be implemented for each resident identified at risk. Accident/Incident Reports involving falls will be reviewed by the Interdisciplinary Team to ensure appropriate care and services were provided and determine possible safety interventions. Nursing personnel will be informed of residents who are at risk of falling. The fall risk interventions will be identified on the care plan. Foot wear will be monitored to ensure the resident has proper fitting shoes and/or…

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

Based on observation, interview, and record review, the facility failed to treat a resident's pain by failing to obtain and administer ordered narcotic pain medications for one of two residents (R8) reviewed for pain on the sample list of 55. Findings include: R8's Face Sheet dated 3/14/23 documents diagnoses including Spina Bifida, Spastic Paraplegia, Syringomyelia, Syringobulbia, Scoliosis, and Migraines. R8's Care Plan (current) documents: R8 is at risk for pain related to impaired mobility, urogenital implant, spastic paraplegia, and wound to buttock. Administer analgesic medications as ordered by physician. Monitor/document side effects and effectiveness each shift. R8's Physician Order Sheet dated 3/14/23 documents the following orders: Ultram (Tramadol/Opioid) 50 milligrams (mg), take 1 tablet by mouth two times a day for moderate pain; Acetaminophen (Tylenol/Analgesic) 650mg, take 1 tablet by mouth every 6 hours as needed for general discomfort; and document pain three times a day. R8's March 2023 Medication Administration Record (MAR) documents R8 did not receive R8's…

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

Based on observation, interview, and record review the facility failed to monitor and document fluid intake and obtain vitals per physician orders for one (R25) of two residents reviewed for Dialysis on the sample list of 55. Findings include: On 3/12/23 at 10:00 AM R25 stated they don't keep track of my fluids. R25 pointed to a water pitcher and stated, I never know if I am drinking enough or too much. R25's physician order with a revision date of 3/12/23 documents Fluid Restriction - Total: 1500 milliliters every 24 hours, 237 ml (8oz) beverage with meals, and Nursing to give 237 (8oz) per shift (3 shifts) for medication pass every shift. No Bedside water/drink. R25's Medication Administration Record (MAR) for 3/1/23 through 3/31/23 documents an order for 1500 milliliters/day fluid restriction every shift. This MAR does not specify how much R25 is supposed to receive per shift. R25's meal and fluid intakes documents R25's fluid intakes as the following: On 3/13/2023 there was no documentation of fluid intake for breakfast, 480 ml for lunch, and 840 ml for supper, on 3/14/2022 600…

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 for the use of side rails for one (R70) of two residents reviewed for side rails on the sample list of 55. Findings include: R70's Minimum Data Set, dated [DATE] documents R70 has moderate cognitive impairment. R70's Care Plan last revised 3/3/23 does not document the use of side rails. R70's 11/1/22 Quarterly Side Rail Assessment documents R70's bed does not contain side rails and side rails are not indicated at this time. There are no documented Side Rail Assessments after 11/1/22. On 3/12/23 at 10:04 AM R70 was lying in bed and R70's bed contained bilateral siderails. The siderail closest to the door was loose and moved side to side and back and forth. R70 stated R70 uses the siderails to turn in bed and during transfers. On 3/13/23 at 1:44 PM V2 Director of Nursing stated: V2 completes Side Rail Assessments quarterly. We have been behind in completing the assessments quarterly and correctly. R70 uses side rails for turning and…

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

Based on interview and record review the facility failed to administer medications as ordered resulting in significant medication errors for one resident (R27) of 34 residents reviewed for changes in condition in the sample list of 55. Findings include: R27's After Visit Summary dated 12/7/22 documents R27's discharge medications include Bumex (diuretic) 2 milligrams (mg) by mouth twice daily, Coreg 12.5 mg by mouth twice daily, Hydralazine 50 mg by mouth twice daily, and Imdur 60 mg by mouth daily. R27's December 2022 Medication Administration Record (MAR) documents Bumex, Coreg, Hydralazine, and Imdur were not administered as ordered/scheduled on 12/8/22, and documents to refer to a nursing note. There are no documented nursing notes explaining why the medications were not given or that the physician was notified. R27's weight log dated 3/14/23 documents R27's weighed 191.2 lbs (pounds) on 12/8/22 and 218.7 lbs on 12/10/22 (27.5 lb gain in 2 days). On 3/14/23 at 11:14 AM V2 Director of Nursing confirmed a check mark on the MAR indicates medication was given. V2 stated: A 9 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-up with a referral to an oral surgeon for one (R25) of two residents reviewed for dental on the sample list of 55. Findings include: On 3/12/23 at 10:00 AM, R25 stated R25 was supposed to have some teeth pulled and that was two years ago and I haven't gotten to go. R25's teeth had areas of decay. R15's Nursing Note dated 4/30/21 at 2:23 PM documents, (R25) stated that (R25's) tooth broke off a few days ago, (R25) showed (Registered Nurse) and tooth was cracked. (R25) stated that (R25's) mouth feels swollen and there is pain. (R25) is requesting to see a dentist. This note also documents a dentist appointment was scheduled for 5/27/21. On 3/14/23 at 10:38 AM, V3 Psychiatric Rehabilitation Service Director stated there is no documentation of R25 seeing the dentist on 5/27/21. V3 stated there is no documentation of R25 refusing to go to an appointment. V3 stated R25 did see the dentist in January and the dentist also made a referral for an oral surgeon. It has not been set up yet.

Based on observation, interview, and record review the facility failed to provide meals honoring food preferences for one (R17) of 32 residents reviewed for food preferences on the sample list of 55. Findings include: On 3/12/23 at 9:20 AM, R17 stated the food is terrible. R17 stated eating pork is against his religion but they continue to serve it to him. R17 stated he is allergic to bananas but gets bananas on the tray. R17 stated R17 does not like hot cereal but they serve him hot cereal. On 3/12/23 at 12:20 PM, V10 Certified Nursing Assistant took a tray over to R17, V10 took the lid off and walked away. V10 did not check the diet slip before providing the meal. R17 was served a pork chop with mashed potatoes and green beans. R17's diet card lying on the tray stated no pork. On 3/12/23 at 12:25 PM, V9 Dietary Aide stated R17 isn't supposed to receive pork.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure side rails were secure and assess side rails for the risk for entrapment for two (R70, R101) of two residents reviewed for side rails in the sample list of 55. Findings include: 1.) R70's Minimum Data Set, dated [DATE] documents R70 has moderate cognitive impairment. R70's Care Plan last revised 3/3/23 does not document the use of side rails. On 3/12/23 at 10:04 AM R70 was lying in bed and R70's bed contained bilateral siderails. The siderail closest to the door was loose and moved side to side and back and forth. R70 stated R70 uses the siderails to turn in bed and during transfers. 2.) On 3/12/23 at 10:13 AM R101 was lying in bed. R101's bed contained bilateral side rails. The side rail that was closest to the door was loose and moved back and forth. R101 stated R101 does not use the side rails. On 3/13/23 at 3:48 PM V20 Maintenance Director stated V20 inspects side rails annually for risk for entrapment and was last completed 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.