Decatur Rehab & Health Care Ct

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure equipment is in good working repair, and the environment is clean and free of debris for three (R25, R26, R6) of 12 residents reviewed for safe homelike environment out of a sample list of 34. Findings include: The facility's 11/2018 Resident Right's policy provided by V1 (Administrator) documents the facility must provide a safe, clean, comfortable and homelike environment. 1.) On 9/23/24 at 1:30 PM, R25 stated his dresser in his room is broken and missing the front of his top dresser drawer. R25 stated he made staff aware a week ago, but nobody has fixed his dresser yet. R25 stated since his dresser has been broken it has become harder to get to his items he needs. On 9/23/24 at 1:38 PM, the face to the top drawer of R25's dresser was missing. The floor of this drawer was broken in half. R25's clothes from the top drawer were falling out of the drawer and into the next dresser drawer. These clothes included socks and underwear. 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 report an allegation of physical abuse to the Abuse Coordinator for one of one resident (R4) reviewed for abuse in a sample list of 34 residents. Findings include: The facility policy titled 'Abuse Prevention Program' revised 11/28/2016 documents the facility affirms the right of the residents to be free from abuse, neglect, misappropriation of property and exploitation. Abuse is the willful injection of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. This same policy documents the facility must ensure all allegations of abuse are reported immediately to the Administrator of the facility. The report must be made to Illinois Department of Public Health (IDPH) within 24 hours after forming the suspicion. R4's undated Medical Diagnosis List documents medical diagnoses of Psychotic and Mood Disturbance, Anxiety, Congestive Heart Failure, Bipolar without psychotic features, Dementia with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to obtain a Level 2 Preadmission Screening and Resident Review (PASRR) after a new diagnosis of mental illness for one (R30) of three residents reviewed for PASRR in the sample list of 34. Findings include: R30's Face Sheet dated 8/26/24 comments R30 admitted to the facility on [DATE], a diagnosis of unspecified psychosis was added on 10/10/23, and a diagnosis of anxiety was added on 10/18/23. R30's Notice of PASRR Level 1 Screen Outcome dated 8/16/22 documents a Level 2 screening was not required since R30 did not have a mental illness diagnosis. There is no documentation that a Level 2 PASRR was completed after R30 was diagnosed with psychosis. On 9/23/24 at 10:47 AM V11 (Business Office Manager) confirmed V11 coordinates PASRRs. V11 reviewed R30's Level 1 PASRR and stated that a Level 2 was not required. V11 stated V11 has not had any residents with new diagnosis of mental illness after admission, so she was unaware that a Level 2 PASRR would be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop a comprehensive care plan for three (R35, R36, R37) of 12 residents reviewed for care plans in the sample list of 34. Findings include: The facility's Comprehensive Care Planning policy dated 11/1/17 documents the facility shall complete periodic assessments for each resident which is used to develop the resident's person centered comprehensive plan of care, and this care plan should reflect medical and nursing needs. 1.) R35's September 2024 Physician Order Summary (POS) documents R35 receives Lurasidone (antipsychotic) 60 milligrams (mg) every morning and 80 mg every evening and Xarelto (anticoagulant) 20 mg daily. R35's Nursing Notes document the following: On 6/23/24 at 9:00 AM R35's thumb was bleeding from R35 biting his hand due to anxiety. On 7/9/24 at 3:00 PM R35 was biting his fingers due to anxiety/nerves. On 8/12/24 at 8:45 PM R35 had a verbal outburst related to wanting his medications. On 9/15/24 at 6:30 AM R35 banged…

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 restorative care services for one of three residents (R7) reviewed for restorative services in the sample list of 34. Findings include: R7's Physician's Order Sheet dated 9/1/24 through 9/30/24 documents a diagnosis of Hemiparesis and documents an admission date of 4/12/24. R7's Minimum Data Set (MDS) dated [DATE] documents R7 had moderately impaired cognition and was not receiving any therapy or restorative services. R7's MDS dated [DATE] documents R7 is cognitively intact but did not receive any therapy and had 7 days of range of motion. On 9/22/24 at 9:35 AM, R7 was in his room and when asked if he had any concerns about his care he raised his left arm and tried to open his left hand. R7's left hand is contracted and he says that he thinks it just happened in the last couple months. R7 stated that he is not sure how it happened. R7 stated that he does not receive therapy or any exercises for his hand. R7's Restorative 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 obtain orders for Continuous Positive Airway Pressure (CPAP) settings and maintain hygienic care and storage of CPAP equipment for one (R36) of two residents reviewed for CPAP in the sample list of 34. Findings include: The facility's Bilevel Positive Airway Pressure/CPAP policy dated 3/8/13 documents CPAP and BiPAP use must have orders that includes the type of unit, pressure settings, inspiratory/expiratory positive airway pressure, frequency, oxygen if applicable, and humidification if applicable; and to clean the circuits weekly and as needed. 1.) On 9/22/24 at 8:19 AM R36's CPAP mask and tubing was uncovered and on top of the CPAP machine on R36's night stand. R36 stated the nurses clean it and fill it with water. On 9/23/24 at 10:04 AM R36's CPAP mask and tubing were uncovered and on top of the machine on R36's night stand. On 9/24/24 at 9:58 AM R36 stated R36 is not sure of the settings for R36's CPAP. R36 stated R36 uses the CPAP every night and just turns the machine on as the settings were previously…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to obtain consent, implement Gradual Dose Reductions, complete assessments, and track targeted behaviors for psychotropic medication use. These failures affect three (R21, R35, R37) of five residents reviewed for unnecessary medications in the sample list of 34. Findings include: The facility's Psychotropic Medication Policy dated 11/28/17 documents attempt to rule out causes of behaviors, attempt non-pharmacological interventions, initiate a Pre-Psychotropic Medication Assessment prior to starting a new psychotropic medication, complete Psychotropic Medication Assessments within 14 days of admission and at least quarterly, obtain informed consent, and document behaviors on the behavior tracking sheets. This policy documents residents receiving psychotropic medications will have either a psychiatric diagnosis or maladaptive behaviors that could be harmful to themselves/others, cause emotional distress, or destruction of property. This 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 observation, interview and record review the facility failed to provide palatable foods for two (R14, R22) residents out of two residents reviewed for palatable foods in a sample list of 34 residents. Findings include: 1. R14's Cognitive assessment dated [DATE] documents R14 as moderately cognitively impaired. On 9/22/24 at 11:43 AM V13 [NAME] pureed R14's pot roast with vegetables, placed R14's blended pot roast in his divided plate and sat it on the counter for 55 minutes with no cover. R14's food was not warmed prior to serving at 12:38 PM. On 9/22/24 at 11:50 AM The blended pot roast lacked flavor, was not appealing to look at and had multiple pieces of meat that required mechanical chewing to break down. On 9/22/24 at 11:54 AM V13 [NAME] blended R14's serving of beets to a watery, pourable consistency. V13 then placed the entire portion of blended beets in R14's divided plate with the blended pot roast and set it back on the counter with no lid. On 9/22/24 at 12:20 PM V13 [NAME] mixed two…

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 follow a physician order to provide a pureed diet by not providing the appropriate consistency of pureed foods for one (R14) out of one resident reviewed for diet consistency in a sample list of 34 residents. Findings include: R14's Cognitive assessment dated [DATE] documents R14 as moderately cognitively impaired. R14's Physician Order Sheet (POS) dated September 2024 documents R14's medical diagnoses of Hypertension, Dysarthria, Gastroesophageal Reflux Disorder (GERD) with Esophagitis, Cerebral Infarction, Hemiplegia and Hemiparesis. This same POS documents a physician ordered diet of Carbohydrate Controlled diet of pureed texture and thin liquids. R14's Careplan intervention dated 6/16/24 instructs staff to serve R14 his diet as ordered by Physician. The facility recipe for Pureed Pot Roast and Vegetables documents 2.0 servings of pot roast and vegetables should be mixed with one quarter cup of thickener. The facility recipe for Harvard…

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 to maintain documentation of influenza and pneumonia vaccination history and offer influenza and pneumonia vaccinations for two (R30, R35) of five residents reviewed for vaccinations in the sample list of 34. Findings include: The facility's Immunization of Residents policy dated 5/19/23 documents the facility will offer vaccinations to aid in the prevention of infectious diseases unless contraindicated by the physician or medically. This policy documents to obtain vaccination consents and obtain proof of vaccinations, and document vaccinations on the resident's Immunization Record. This policy documents to offer the pneumonia vaccine within 30 days of admission and offer the PCV13, PCV15, PCV20, or pneumococcal polysaccharide vaccine (PPSV23) according to the Pneumonia Vaccination Timing Guidelines. This policy documents to offer the influenza vaccine annually between September 1st and March 31st, and assess the resident's current influenza season immunization…

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

Based on observation, interview, and record review the facility failed to provide an accessible working call light for one (R25) of twelve residents reviewed for call lights out of a sample list of 34. Findings include: The facilities undated Maintenance and Preventative Service Policy documents to ensure all nurse call light systems are working properly. R25's care plan last revised 5/20/24 documents R25 needs supervision with Activities of daily Living (ADL's). The same care plan documents a revision on 8/9/24, the Interdisciplinary team documents a referral for Physical Therapy and Occupational therapy for an ADL decline and increased fall risk. On 09/23/24 at 1:38PM, R25 stated R25 does not have his own call light in his room. R25 stated at night if R25 needs help he must wake up R90 (roommate) to push the call light for him. R25 stated he made V5 (Maintenance Director) aware that he had no call light a month ago, but nobody has replaced it. On 9/23/24 at 1:45 PM, R25 did not have his call light within reach. There was one working call light plugged into the wall and that call…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to employ a Registered Nurse to serve as full time Director of Nurses (DON). This failure has the potential to affect all 39 residents in the facility. Findings Include: Upon survey entrance and throughout the survey (9/18/24) there was no Director of Nurses present and employed by the facility. On 9/20/24 at 2:58 PM, V1 (Administrator) confirmed the facility does not currently employ a full time DON. There has not been a full time DON employed by the facility since August 15, 2024. V1 confirmed the facility census is currently 39 residents. The Facility assessment dated [DATE] documents, a full time nursing supervisor (Director of Nurses) is required in order to meet the resident's needs and provide competent support and care for the facility's resident population.

Based on interview and record review the facility failed to treat one resident (R1) with respect of three residents reviewed for dignity in a sample list of three. Findings Include: R1's Progress Note documents R1 was admitted to the facility 8/7/24 at 4:00PM. On 8/19/24 at 10:19AM R1 stated I fell at home and broke my knee cap and my arm. Then I went to (the local hospital) and was sent to (the facility) The CNA's (Certified Nurses Assistant) here didn't know how much help I needed. There was once when a CNA on night shift (does not remember name) pulled my right arm. I told her I had broken that arm and the CNA stated 'no you didn't you just broke your left knee'. They were just generally uncaring and rude. R1's progress note dated 8/7/24 at 5:00PM documents (V9) Registered Nurse (RN) went back in (R1's room) and told (R1) once again how (R1) was going to transfer to the bed pan and that (V9) is in charge and we both (V9 and R1) have to go by the doctor's orders not what we want to do. (V9) told (R1) (V9) understood (R1) didn't want to be there. (R1) was asking the CNA's to go to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain a resident room in a clean sanitary manner for two residents (R1, R2) of three residents reviewed for housekeeping in a sample list of three. Findings include: On 8/19/24 at 10:19AM R1 stated (R2) was my roommate when I was at (the facility). (R2) urinated all over the bed, and it smelled bad. The facility did not clean the floor in our room and it was covered in urine. The shower also smelled like urine. I just couldn't live with that. R1's Progress Note documents R1 was admitted to the facility 8/7/24 at 4:00PM and left against medical advice on 8/13/24 at 3:00PM. R2's Minimum Data Set (MDS) dated [DATE] documents R2 is cognitively intact and frequently incontinent of urine. On 8/19/24 at 11:30AM R2's room was very cluttered with belongings and there was a strong ammonia like odor. The floor was so sticky the surveyor's shoes stuck to the floor when walking. The floor was stained with a yellow brown substance. At this time, 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 initiate a base line care plan and initiate resident centered interventions for one resident (R1) reviewed for Care Plans in a sample list of three. Findings Include: The facility's policy Baseline Care Planning revised 11/1/17 states It is the policy of (the facility) to promptly asses the plan (of) care for each resident admitted to the facility. Pending completion of the Comprehensive Resident Assessment and Care Plan, the interdisciplinary team shall asses each resident for potential needs. A Plan of Care (Baseline Care Plan) shall be developed to include instructions needed to provide effective person centered care to each resident, based on his/her initial assessment and professional standards of quality care, to serve as a functional guide in the delivery of care until such time as a comprehensive plan is developed. R1's Physician's Order Sheet (POS) for 8/7/24 to 8/31/24 includes the following diagnoses: Chronic Anemia, Chronic Depression, Frequent Falls, Closed Fracture of the Distal End of the Right Humerus, Open…

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

Based on observation and interview the facility failed to complete an admission Fall Risk Assessment for a resident with history of falls with injury. Ths failure affects one (R1) of three residents reviewed for falls in a sample list of three residents. Findings Include: The facility's policy Fall Prevention revised 11/10/18 states Policy: To provide for resident safety and to minimize injuries related to falls; decrease falls and still honor resident's wishes/desires for maximum independence and mobility. Procedure: Conduct fall assessments on day of admission, quarterly, and with a change in condition. Identify, on admission, the resident's risk for falls. Assessment of fall risk will be completed by the admission nurse at the time of admission. Appropriate interventions will be implemented for residents determined to be at high risk at the time of admission for up to 72 hours. The admitting nurse will assign a temporary category. R1's Physician's Order Sheet (POS) for 8/7/24 to 8/31/24 includes the following diagnoses: Chronic Anemia, Chronic Depression, Frequent Falls, Closed…

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 abuse allegations timely to the administrator and report abuse allegations to the State Survey Agency (SSA) for five (R1, R3, R4, R5, R6) of six residents reviewed for abuse in the sample list of six. Findings include: The facility's Abuse Prevention Program dated 11/11/11 documents: Sexual Abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. Employees are required to immediately report any occurrences of potential/alleged mistreatment, neglect, and abuse of residents and misappropriation of resident property they observe, hear about, or suspect to a supervisor and the administrator. The facility must ensure that all alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source, misappropriation of resident property, and reasonable suspicion of a crime, are reported immediately to the administrator of the facility and other officials in accordance with State Law through…

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 investigate an allegation of sexual abuse for four (R1, R3, R5, R6) of six residents reviewed for abuse in the sample list of six. Findings include: The facility's Abuse Prevention Program dated 11/11/11 documents employees are required to immediately report any occurrences or suspicions of potential/alleged instances of mistreatment and abuse that they observe or hear about to a supervisor and the facility's administrator, and an investigation will be initiated by the administrator or designee. R3's Minimum Data Set (MDS) dated [DATE] documents R3 is cognitively intact. R3's Psychiatry Progress Note documents R3 was evaluated due to reports of inappropriate sexual urges towards another male resident. This note documents R3 has been increasingly sexually inappropriate towards male residents and saying he has homosexual urges about R3's roommate (R5). This note documents R3's roommate (R5) was moved to another room and R3 reported having urges 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 interview and record review the facility failed to care plan resident behaviors, develop behavioral interventions, and monitor behaviors. These failures affect four (R1, R3, R5, R6) of six residents reviewed for abuse in the sample list of six. Findings include: The facility's undated Behavior Record Guide documents the Behavior Record form should include targeted behaviors and the care plan will include the goal for the targeted behavior. This guide documents to include behavioral interventions from the resident's care plan that have been found to be most effective to use as a response to the behavior. This guide documents to notify Social Service/Psychosocial Director or Minimum Data Set (MDS) Coordinator for additional behavioral interventions to be added to the Behavior Record and Care Plan, and the Social Services Director is responsible for documenting a behavioral monthly summary. 1.) R1's MDS dated [DATE] documents R1 has moderate cognitive impairment. The facility's Final Report for R1's abuse…

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 employee the services of a full time Director of Nursing. This failure has the potential to affect all 42 residents residing in the facility. Findings include: On 2/9/24 at 7:45 AM and at 2:00 PM during a tour of the facility, a Director of Nursing was not working in the facility. On 2/10/24 at 7:30 AM during a tour of the facility, a Director of Nursing was not working in the facility. The facility's Nurse's schedule for January 2024 and February 2024 does not document that a Director of Nursing was scheduled in the facility. On 2/9/24 at 2:42 PM, V1 Administrator stated the facility has not had a Director of Nursing since January 15, 2024. The facility's February 2024 Census sheet provided by V19 Regional Director of Operations documents there are 42 residents residing in the facility.

Based on observation and interview the facility failed to ensure the right to a safe, clean, and homelike environment for seven (R10, R11, R12, R13, R14, R15, and R16) of 20 residents reviewed for environment on the sample list of 20. Findings include: On 2/9/24 at 8:10 AM, the bathroom tile on R10 and R11's bathroom floor was broken around the toilet and multiple tiles on the floor were cracked. The floor was stained, and dirt and debris were accumulated along the base. The tiles on R12 and R13's floor was stained and there was dirt and debris accumulated along the base. R14, R15, and R16's toilet was not secured and moved when V2 Maintenance Director pushed it. The floor around this toilet was stained with a dark orange, brown residue all around the toilet. At that time, R14 stated the toilet moves when I sit on it. On 2/9/24 at 8:30 AM, V2 Maintenance Director confirmed that R10, R11, R12, R13, R14, R15, and R16's bathroom tiles were broken and stained, and that dirt and debris was accumulated along the cove base.

Based on observation, interview, and record review the facility failed to ensure a room was equipped with a working toilet for seven (R4, R5, R6, R7, R8, R9, and R18) of twenty residents reviewed for toilets on the sample list of 20. Findings include: On 2/9/24 at 8:10 AM, an out of order sign was taped to R4, R5, R6, R7, R8, R9, and R18's bathroom doors. At that time, V2 Maintenance Director stated the toilets clog up and he will unclog them but the next day it will happen again. V2 stated a plumber has not been called. V2 stated the piping to these rooms meet in the middle under the hallway. V2 stated he has had problems with these toilets for a couple months. On 2/9/23 at 11:24 AM, R9 stated R9's bathroom has been out of order for a month and a half. R9 stated R9 will have to go to the shower room to use the toilet. R9 stated when another resident is getting a shower, R9 will have to go and ask other residents to use their restrooms. Maintenance Work Order dated 1/12/24 documents R7, R8, R9 and R18's toilet was leaking. Hand written list dated 1/16/24 provided by V2 documents R7,…

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 pressure ulcer plans of care for three of three (R1, R2, and R3) residents reviewed for care plans on the sample list of 20. Findings include: 1. On 2/10/24 at 8:25 AM, a dime sized necrotic pressure area was on the heel of R1's right foot. R1 also had sheared areas to the coccyx. R1's medical record did not contain a care plan for R1's pressure ulcers. On 2/9/24 at 1:20 PM, V1 Administrator stated R1's medical record did not contain a care plan for R1's pressure ulcers. 2. On 2/10/24 at 8:15 AM, R2 was sitting up in the wheelchair. A half dollar sized necrotic pressure area was on R2's left heel. R2's medical record did not contain a care plan for R2's pressure ulcer. On 2/9/24 at 1:20 PM, V1 Administrator stated R2's medical record did not contain a care plan for R2's pressure ulcers. 3. On 2/10/24 at 9:00 AM a dressing dated 2/10/24 was present to R3's coccyx. R3's wound assessment dated [DATE] documents R3 has an unstageable…

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 residents right to be free from verbal mental abuse by staff. This failure affects two (R1, R3) residents out of three residents reviewed for abuse in a sample list of four residents. Findings include: The facility policy titled 'Abuse Prevention Program' revised 11/28/2016 documents the facility affirms the right of the residents to be free from abuse, neglect, misappropriation of property and exploitation. Abuse is the willful injection of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Verbal abuse is the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or families or within their hearing distance regardless of their age, ability to comprehend or disability. R1's Medical Diagnosis List includes medical diagnoses of Cerebral Vascular Accident (CVA), Aphasia, Hemiplegia affecting Right side due to CVA, Dementia with…

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

Based on record review and interview the facility failed to follow residents' rights by not allowing residents to receive their mail which is to be delivered unopened on Saturdays. This failure affects all 42 residents which reside in the facility. Findings include: Resident Council meeting held on 8/16/23 at 10:00 AM consisted of R144, R23, R24 and R29 (Resident Council President). All four residents stated individually, No we do not receive our mail on Saturdays. R24 stated she received mail opened at one time and stated this upset her immensely and R24 told them not to every open her mail again. V18, Transport/Medical Records person stated at 12:40 pm on 8/17/23, When the Business Office Manager was here, she delivered the mail to the residents. I went yesterday (8/16/23) to the mail box and retrieved Saturday thru Wednesday mail and gave it to (V1 Administrator). I don't know who will be getting the mail and passing it out to the residents. V1, Administrator confirmed on 8/18/23 at 12:35 PM, The residents will be receiving their mail on Saturday. The charge nurse will get 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 employ a Full Time Director of Nurses. This failure has the potential to affect all 42 residents residing in facility. Findings include: The facility daily census report dated 8/15/23 documents 42 residents residing in facility. On 8/15/23-8/22/23 Director of Nurses (DON) was not observed on site at various times during first and second shifts. On 8/15/23 at 10:00 AM V1 Administrator stated the facility has not had a full time Director of Nurses since January 2023. V1 stated (V2) Assistant Director of Nurses (ADON)/Licensed Practical Nurse (LPN) has been the go-to person for all the DON questions and programs. V1 Administrator stated, We (facility) have had a couple of leads but DON's are very hard to find.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide at least 80 square feet of floor space per resident bed in 28 of 30 resident rooms on 2 of 2 resident living corridors. 25 of these rooms were occupied by residents. This failure affects all 42 residents residing in the facility. Findings include: Historical room size documentation and actual measurements demonstrate that the double occupancy resident bedrooms do not meet the minimum required square footage of 80 square feet per resident bed (160 total square feet). room [ROOM NUMBER] measured 77.9 square feet per bed. room [ROOM NUMBER] measured 76.5 square feet per bed. Rooms 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14 (current Nursing Director Office), 16 (current therapy room), 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, and 28 measured 74.3 square feet per bed. room [ROOM NUMBER] measured 68.5 square feet per bed. room [ROOM NUMBER] (current Minimum Data Set office) measured 77.5 square feet per bed. room [ROOM NUMBER] (current…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to transmit minimum data set assessments in the required timeframe within 14 days after the assessment reference date. This failure affects six residents (R8, R15, R24, R30, R31, and R41) out of six reviewed for minimum data set transmission on the sample list of 44. Findings include: 1. On 8/16/23 at 1:23 PM, V4, Minimum Data Set (MDS) Coordinator, reviewed the minimum data set information on the facility's computer screen and stated, For R8, he had an annual (MDS) dated [DATE] which was submitted (transmitted) 12/8/22, a quarterly dated 1/6/23 submitted 4/13/23, a quarterly dated 4/6/23 submitted 6/22/23, and his current quarterly is dated 7/5/23 has not been submitted yet. 2. V4, Minimum Data Set Coordinator reviewed the computer screen and stated, (R15) had a quarterly (MDS) dated [DATE] submitted 6/22/23, this one was submitted late. (R15) has a current quarterly dated 7/5/23 which has not yet been submitted, this one should have been submitted by…

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 certify the accuracy and completion of resident assessments by obtaining required Assessor and Coordinator signatures. These failures affect four residents (R8, R15, R30, R41) of six reviewed for resident assessments in the sample list of 44. Findings include: 1. On 8/18/2023 at 2:47PM, R30's 4/5/2023 and 7/6/2023 resident assessments do not document the required assessment Coordinator signatures verifying assessment completion. On 8/17/2023 at 3:25PM, V1 (Administrator) reported R30's assessment was not completed due to staff turnover. 2. R8's Minimum Data Set (MDS) assessment dated [DATE] did not include the signatures of the staff members who participated in the completion of this assessment, nor did it include the signature of the Registered Nurse certifying the completion. 3. R15's MDS dated [DATE] did not include the signatures of the staff members who participated in the completion of this assessment, nor did it include the signature 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 Failures at this level required more than one deficient practice statement. A. Based on observation, interview, and record review, the facility failed to maintain safe water temperatures to prevent the potential for scalding injuries on the facility's South Hall. This failure has the potential to affect 17 residents (R1, R4, R10, R11, R12, R13, R16, R22, R23, R24, R26, R31, R33, R34, R93, R243, and R244) residing on the South Hall from the sample list of 44. B. Based on interview and record review the facility failed to ensure a severely cognitively impaired resident (R245) was monitored to prevent elopement from the building. This failure affects one resident out of one resident (R245) reviewed for elopement in a sample list of 44 residents. C. Based on observation, interview, and record review, the facility failed to install and maintain a handrail in the North Hall with an adequate gap between the wall and the handrail to prevent a risk of an entrapment incident. This failure affects eight ambulatory…

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 complete Psychotropic Assessments and failed to obtain an end date for a Psychotropic medication. These failures affect four residents out of four residents (R4, R20, R24, R243) reviewed for unnecessary Psychotropic medications in a sample list of 42 residents. Findings include: 1.) R4's Undated Medical Diagnosis list documents medical diagnoses of Depression, Psychosis and Generalized Anxiety Disorder. R4's Physician Order Sheet (POS) dated August 2023 documents physician orders for Risperidone (antipsychotic) 3 milligrams (mg) twice daily starting 11/10/21, Buspirone Hydrochloride (HCL) (anxiolytic) 5 mg twice daily starting 11/12/21. R4's medical record documents the last psychotropic assessment was completed 12/21/22. There is no other psychotropic assessment completed. R4's Medication Administration Record (MAR) dated August 2023 documents R4 has been administered Risperdal 3 mg twice daily and Buspirone HCL twice daily from 8/1/23-8/18/23. On 8/16/23 at 3:08 PM Observed V17 Registered Nurse administer…

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 bread as planned on the menu. This failure affected four residents (R12, R14, R15, R17) of 42 reviewed for diets in the sample list of 42 residents. Findings include: On 8/15/2023 at 12:25PM, no puree bread/margarine was noted on the food service line during the lunch meal and no residents who receive pureed diets received a portion of pureed bread/margarine. V21 (Cook) was present and reported no pureed bread/margarine was prepared for the lunch meal on 8/15/2023. The facility dietary menu for 8/15/2023 documents residents receiving pureed diets should be served a #20 scoop of pureed bread/margarine during the lunch meal service. The facility Diet Listing (7/28/2023) documents R12, R14, R15, and R17 all received puree diets.

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 medication administration for three (R2, R4, R24) out of six residents reviewed for medication administration in a sample list of 42 residents. Findings include: 1.) R2's Physician Order Sheet (POS) dated August 2023 documents a physician order for Lactulose 10 grams (gm)/15 milliliter (ml). Give 30 ml daily. This same POS documents a physician order for Divalproex sprinkles 500 mg daily. On 8/16/23 at 3:25 PM Observed V15 Licensed Practical Nurse (LPN) open a new bottle of R2's Lactulose using bare thumbnail to break foil seal. V15 LPN did not use hand hygiene nor wear gloves prior to opening new Lactulose bottle. On 8/16/23 at 3:26 PM Observed V15 Licensed Practical Nurse (LPN) use V15's bare hands to open R2's Divalproex capsules emptying the sprinkles into a medicine cup. V15 LPN did not use hand hygiene nor wear gloves prior to opening R2's Divalproex capsules. On 8/16/23 at 3:30 PM V15 Licensed…

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 handrail in the facility's North Hall in a manner securely attached to the wall. This failure had the potential to affect eight ambulatory residents (R5, R19, R25, R27, R28, R29, R144, and R145) residing on the North Hall from the sample list of 44. Findings include: On 8/15/23 at 10:10 AM, the section of handrail between on the facility's North Hall was loose and easily moveable more than 1 inch up and down. There was a hole 2 inches in diameter in the drywall behind the section of handrail where the securing bolt penetrated the wall. On 8/17/23 at 12:40 PM, V20, Certified Nursing Assistant noted the loose handrail and stated, Did you see that, I don't think it's supposed to do that. On 8/17/23 at 12:50 PM, V3, Maintenance Director, stated, It looks like the bolt is loose behind the wall. I can see if I can tighten it up. The North Hall Resident Roster provided by V11, Licensed Practical Nurse, documents R5, R19, R25, R27, R28, R29, R144, and R145 are ambulatory residents residing on the North…

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 right to be free from verbal abuse by another resident and a staff member. These failures affect four residents (R26, R30, R244, R22) out of four residents reviewed for abuse in a sample list of 42 residents. Findings include: 1.) R26's Physician Order Sheet (POS) dated August 2023 documents medical diagnoses of Schizophrenia, Right Knee Total Arthroplasty, Major Depression, Morbid Obesity, Bipolar Disorder and Anxiety. R26's Cognitive assessment dated [DATE] documents R26 as cognitively intact. R26's Minimum Data Set (MDS) dated [DATE] documents R26 requires total dependence of two staff using a total body mechanical lift for transfers, extensive assistance of two people for bed mobility, dressing, and toileting, extensive assistance of one person for personal hygiene, limited assistance of one person for locomotion, and supervision for eating. R26's Nurse Progress Note dated 5/31/23 at 1:15 PM documents, (R26) continues to yell…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to follow their Abuse Prevention Policy by failing to promptly report allegations of verbal abuse to the Abuse Coordinator and by failing to suspend a staff member after an allegation of staff to resident verbal abuse. This failure affects three (R26, R30, R22) out of three residents reviewed for abuse in a sample list of 42 residents. Findings include: The facility policy titled 'Abuse Prevention Policy' revised 10/14/2016 documents the facility must ensure all allegations of abuse are reported immediately to the Administrator of the facility. The report must be made to Illinois Department of Public Health (IDPH) within 24 hours after forming the suspicion. This same policy documents the facility will remove the staff member from the property pending investigation of allegation of abuse. 1.) R26's Physician Order Sheet (POS) dated August 2023 documents medical diagnoses of Schizophrenia, Right Knee Total Arthroplasty, Major Depression, Morbid Obesity,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to follow their Abuse Prevention Policy by not reporting allegations of verbal abuse to the State Agency. This failure affects three (R26, R30, R22) out of three residents reviewed for abuse in a sample list of 42 residents. Findings include: The facility policy titled 'Abuse Prevention Policy' revised 10/14/2016 documents the facility must ensure all allegations of abuse are reported immediately to the Administrator of the facility. The report must be made to Illinois Department of Public Health (IDPH) within 24 hours after forming the suspicion. 1.) R26's Physician Order Sheet (POS) dated August 2023 documents medical diagnoses of Schizophrenia, Right Knee Total Arthroplasty, Major Depression, Morbid Obesity, Bipolar Disorder and Anxiety. R26's Cognitive assessment dated [DATE] documents R26 as cognitively intact. R26's Nurse Progress Note dated 5/31/23 at 1:15 PM documents, (R26) continues to yell using profanity. Can hear (R26) from her room to 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 interview and record review, the facility failed to conduct comprehensive annual and initial minimum data set assessments according to the required timeframe within 366 days. This failure affects three residents (R8, R30, and R41) out of six reviewed for annual assessments on the sample list of 44. Findings include: 1. R8's annual comprehensive Minimum Data Set was dated with an Assessment Reference Date (ARD) of 10/6/22. On 8/16/23 at 1:23 PM, V4, Minimum Data Set (MDS) Coordinator stated, For (R8), he had an annual dated 10/6/22 which was incomplete. Our corporate MDS specialist has been coming in to try to help us get everything up to date, so a lot of the sections did not get completed. All of this has been going on longer than I have been working here. We have had a lot of staff turnover with this position which has created problems all around. 2. R41's comprehensive initial Minimum Data Set was dated with an ARD of 5/22/23. Sections C for cognitive status, D for mood state, and F for personal preferences were incomplete. The facility provided Manual instructions dated…

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

Based on interview and record review, the facility failed to complete a Level 2 PASARR (Preadmission Screening and Resident Review) within 40 days of admission for a resident admitted to the facility as an exempted hospital discharge. This failure affects one resident (R18) of one reviewed for admission screening in the sample list of 44. Findings include: 08/16/23 at 10:40AM, R18's PASARR Level 1 screen (6/8/2022) documents R18 was screened for mental disorders and intellectual disabilities upon admission to the facility on 6/7/2022. The same record documents R18's admission to the facility was approved for only a 30 day or less stay and the facility must re-screen (complete a Level 2 PASARR) for R18 by or before the 30th day if R18 remained in the facility beyond the authorized timeframe. On 8/17/2023 at 2:34PM, V1 (Administrator) reported a Level 2 PASARR was not completed for R18.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to document any care plan focus area or non-pharmacological therapeutic interventions for a resident with diagnosed and exhibited symptoms of depression. This failure affects one resident (R41) out of two reviewed for behavioral and emotional indicators on the sample list of 44. Findings include: On 8/15/23 at 9:54 am, R41 was in bed with the blanket pulled over his face, the lights were out in the room, and the blinds were pulled shut. R41 stated, I do have some depression. I do take an antidepressant. I don't know if there is a social service person I can talk to if I need to. R41's current Face Sheet documents R41 was admitted to the facility 5/11/23. R41's Physician Order Sheet documents R41 has medical diagnoses including Major Depressive Disorder and was prescribed Sertraline (antidepressant) 100 milligrams daily. R41's Minimum Data Set assessment dated [DATE] was incomplete with section C for cognitive status assessment, section D 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 observation, interview and record review the facility failed to properly date and store oxygen tubing for three (R33, R34, R243) residents out of three residents reviewed for respiratory care in a sample list of 42 residents. Findings include: During the facility tour on 8/15/23 at 10:30 AM R34 was sitting on her bed with her nasal cannula in her nose and the oxygen concentrator was sitting next to her bed. R34's oxygen tubing was checked for dates and the date on the tubing was 7/23/23. In checking the humidifier on the concentrator for a date there was no date. Continuing with facility tour R33's oxygen tubing, humidifier and CPAP (Continuous Positive Airway Pressure) tubing did not have any dates on 8/15/23 at 10:45 AM. R33 stated she only uses her oxygen tubing at night along with her CPAP. Follow up checks on oxygen tubing, humidifier and CPAP tubing were done on 8/16/23 and 8/17/23 at 2:30 PM both days. There were no changes in the oxygen tubing, humidifier or CPAP tubing. R34's tubing still had…

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 conduct a social service assessment upon admission and conduct any therapeutic interventions for a resident with diagnosed and exhibited symptoms of depression. This failure affects one resident (R41) out of two reviewed for behavioral and emotional indicators on the sample list of 44. Findings include: On 8/15/23 at 9:54 am, R41 was in bed with the blanket pulled over his face, the lights were out in the room, and the blinds were pulled shut. R41 stated, I do have some depression. I do take an antidepressant. I don't know if there is a social service person I can talk to if I need to. R41's Face Sheet documents R41 was admitted to the facility 5/11/23. R41's Physician Order Sheet documents R41 has medical diagnoses including Major Depressive Disorder and was prescribed Sertraline (antidepressant) 100 milligrams daily. R41's medical record did not include a social service initial evaluation or assessment, and there were no social service…

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 the services of a full time Director of Nursing. This failure has the potential to affect all 29 residents residing in the facility. Findings include: On 7/24/22 from 8:00 AM to 4:00 PM and on 7/25/22, 7/26/22, and 7/27/22 from 7:30 AM to 4:30 PM there was not a Director of Nursing working in the facility. On 7/26/22 at 12:00 PM, V1 Administrator stated that the facility has not had a Director of Nursing since the end of May 2022. The facility's Census and Condition report dated 7/24/22 documents that there are 29 residents residing in the facility.

Based on observation, and interview the facility failed to prevent the potential for cross-contamination and foodborne illness by failing to close and seal stored food, failing to dispose of expired refrigerated food, failing to maintain a can opener in a sanitary operable condition, failing to maintain mixer blades, failing to maintain sanitary food preparation areas from grease, debris and dust, and failing to maintain a three-well sink free of paint chips, caulking, and dust. These failures have the potential to affect all 29 residents residing in the facility. Findings include: 1. On 07/24/22 at 08:15 am, during the initial tour of the facility kitchen, V24, [NAME] , confirmed upright three door refrigerator contained opened food items, unwrapped exposed and undated. The food items included the following: Two opened, exposed to air, undated one pound packages of turkey breast sliced sandwich meat, one opened five-pound container of cottage cheese dated as opened 5/16/22, two, five-pound plastic bags of opened, exposed to air, shredded mozzarella cheese with no opened date, 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 hold quarterly Quality Assurance meetings and failed to ensure a Director of Nursing was present at these meetings. This failure has the potential to affect all 29 residents residing in the facility. Findings include: The facility's Quality Assurance sign in sheets provided by V1 Administrator documents that a Quality Assurance meeting was held on 6/8/21, 7/12/21, and 5/17/22. These sheets do not document that a Director of Nursing was present at the 6/8/21 or 5/17/22 meeting. On 7/26/22 at 12:00 PM, V1 Administrator stated that the facility had three Quality Assurance meetings in the last year. V1 stated the 6/8/21 was for the first quarter of 2021, 7/12/21 was held for the second quarter. V1 stated there was not a third or fourth quarter meeting. V1 stated they just had their first quarter meeting for 2022 on 5/17/22. V1 stated the Director of Nursing was not present for the meetings held on 6/8/21 or 5/17/22. The facility's Census and Condition report dated 7/24/22 documents that there are 29 residents residing in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to designate a qualified and trained person to serve as Infection Preventionist. This failure has the potential to effect all 29 residents residing in the facility. Findings include: On 7/24/22 at 8:00 AM, there was no one in the the facility designated as the Infection Preventionist. The Facility assessment dated [DATE] documents in order to provide competent support and care for the resident population, the facility will employ an Infection Preventionist. On 7/24/22 at 8:30 AM V1 Administrator stated the facility did not currently have anyone designated as the Infection Preventionist. V1 confirmed there was no one available that was qualified and trained as an Infection Preventionist. V1 confirmed the facility's census was 29 residents.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to inform a resident (R2) on seven different occasions of missed administration of medications to prevent chest pain and failed to obtain informed psychotropic medication consent for R6. These failures had the potential to affect two of six residents (R2 and R6) reviewed for psychotropic/medications on the sample list of 21. Findings include: 1. R2's Physician Order Sheet (POS) dated 7/1/22-7/31/22 documents the following diagnoses and medication order: Pericardial Effusion (extra fluid collects between the heart and pericardium that causes pressure on the heart), and Hypertension. Isosorbide Mononitrate 20 milligrams (mg) tablet, take one tablet by mouth once daily, at least 30 minutes before meal. R2's Minimum Data Set (MDS) dated [DATE] documents R2's Brief Interview of Mental Status score of 14 out of a possible 15, indicating R2 has no cognitive impairment. On 7/25 at 8:20 am V12, Licensed Practical Nurse (LPN) administered all of R2'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 record review and interview, the facility failed to notify a resident's (R2) physician, on seven separate occasions, of missed administration of medication used for heart-related chest pain. The facility also failed to notify resident's (R3) physician of significant weight loss. R2 and R3 are two of two residents reviewed for physician notification of change in condition on the sample list of 21. Findings include: R2's Physician Order Sheet (POS) dated 7/1/22-7/31/22 documents the following diagnoses and medication order: Pericardial Effusion (extra fluid collects between the heart and pericardium and causes pressure on the heart), and Hypertension. Isosorbide Mononitrate 20 milligrams (mg) tablet, take one tablet by mouth once daily, at least 30 minutes before meal. R2's Medication Administration Record (MAR) dated July 1-31, 2022 documents the following: On July 19 - July 25, 2022 (seven doses) R2 did not receive Isosorbide Mononitrate (circled to indicate not given). There is no documentation in R2's chart that documents V17, Medical Director was notified R2 had missed…

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 a comprehensive care plan for four (R3, R9, R15 and R25) of 21 residents reviewed for care plans on the sample list of 21. Findings include: 1. R3's Physician Order Sheet (POS) dated July 2022 documents R3 is diagnosed with Dementia and Depression. R3's Report of Monthly Weights and Vitals dated 2022 documents R3 weighed 191.2 pounds in January 2022 and 168.5 pounds in February 2022. This is a significant weight loss of 11.87% in one month's time. The undated Resident Weight Monitoring policy documents if a resident has a significant weight change, it is documented in the care plan with goals and approaches/intervention listed. On 7/27/22 at 1:00 PM V1 Administrator confirmed there was no documentation in R3's care plan of R3's significant weight loss, goals, or interventions to address it. 2. R9's face sheet documents R9 was admitted to the facility on [DATE]. On 7/25/22 at 12:00 PM, R9 was lying in bed on an air mattress. The air…

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, repeatedly that one resident (R14) had physician ordered, narcotic pain medication available to treat pain post a fall with fracture. R14 is one of one resident reviewed for pain on the sample list of 21. Findings include: R14's Minimum Data Set (MDS) dated [DATE] documents R14's Brief Interview of Mental Status score of 15 out of a possible 15, indicating no cognitive impairment. On 07/24/22 at 10:20 am R14 was lying in bed with R14's left arm in a sling. R14 stated About three weeks ago (7/02/22), I (R14) was walking down the hall as I (R14) usually does with no problem. I got to the main dining room corridor, tripped and fell. My arm was in severe pain. The facility finally got strong pain medication (Hydrocodone/ Acetaminophen) ordered from the doctor (unidentified). The strong pain medication was working well until a couple days ago. The facility ran out of the strong (narcotic) pain meds (medication) and all I get 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 record review, observation and interview the facility failed to provide prescribed medication on seven separate occasions, for one (R2) of four residents reviewed for medication administration on the sample list of 21. Findings include: R2's Physician Order Sheet (POS) dated 7/1/22-7/31/22 documents the following diagnoses and medication order: Pericardial Effusion (extra fluid collects between the heart and pericardium and causes pressure on the heart), and Hypertension. Isosorbide Mononitrate 20 milligrams (mg) tablet, take one tablet by mouth once daily, at least 30 minutes before meal. On 7/25 at 8:20 am V12, Licensed Practical Nurse (LPN) administered all of R2's medications scheduled at 8:00 am except Isosorbide Mononitrate 20 milligrams tablet. V12, LPN stated, We are out of that (Isosorbide Mononitrate), I don't know why. I will have to re-order this. Nobody (unidentified staff) else did. I can see on the MAR (Medication Administration Record) he (R2) has missed several doses. They are circled (nurses initials circled to indicate the medication was not given) off. I…

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, observation and interview the facility failed to prevent a significant medication error. The facility failed to administer a medication used for heart-related chest pain, as ordered by the physician. This failure was repeated on seven separate occasions for one (R2) of four residents reviewed during medication administration observation on the sample list of 21. Findings include: R2's Physician Order Sheet (POS) dated 7/1/22-7/31/22 documents the following diagnoses and medication order: Pericardial Effusion (extra fluid collects between the heart and pericardium and causes pressure on the heart), and Hypertension. Isosorbide Mononitrate 20 milligrams (mg) tablet, take one tablet by mouth once daily, at least 30 minutes before meal. On 7/25 at 8:20 am V12, Licensed Practical Nurse (LPN) administered all of R2's medications scheduled at 8:00 am except Isosorbide Mononitrate 20 milligrams tablet. V12, LPN stated, We are out of that (Isosorbide Mononitrate), I don't know why. I will have to re-order this. Nobody (unidentified staff) else did. I can see 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 properly secure residents' medications. This failure has the potential to effect eight (R1, R3, R6, R13, R16, R21, R29, R130) of eight residents reviewed for medication storage on the sample list of 21. Findings include: On 7/24/22 at 11:10 AM V2 Registered Nurse was passing medications. The medications were divided up into medication cups on top of a tray. Each medication cup had multiple medications in it and each one was labeled with a resident's initials. V22 (Certified Nurse Assistant) was standing by the tray 'keeping watch' over the medications for V2 RN while V2, RN took one medication cup into a resident's room and then came back for another one. On 7/24/22 at 11:15 AM V2 stated he had pulled up all the medications for the eight residents on isolation at the same time. V2 RN stated while he took the medications for an isolation resident into their room to them, he had V22 CNA watch over the other resident's (unsecured) medications in the medication cups. V2 RN admitted that he knew this wasn't per…

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 resident dignity was maintained during dining. This failure affected one (R10) of one resident reviewed for dignity on the sample list of 21. Findings include: R10's Physician Order Sheet dated 7/1/22-7/31/22 documents the following diagnoses: Dementia, Severe Front Temporal Type, with Behavioral Problems Unimproved, and Picks Disease. R10's Minimum Data Set, dated [DATE] documents R10 has severe cognitive impairment and requires extensive physical staff assistance with dining. On 07/24/22 at 12:10 pm R10 was seated at a dining table, adjacent to the television lounge with other unidentified residents. R10 was eating with R10's fingers. R10's hands were thickly covered in food. R10 was eating barbeque meatballs, au gratin potatoes, green beans and diced peaches in syrup with her fingers. Food debris was scattered around R10's plate, and on R10's chest. R10 had a table spoon size metal spoon and a plastic spoon on the table across 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 prevent the physical abuse of one resident (R25) by another resident (R7) for two (R25, R7) of three residents reviewed for abuse on the sample list of 21. Findings include: R7's nurse's note dated 7/7/22 at 7:00 AM, written by V3 Licensed Practical Nurse documents, (R7) was yelling at another (R25) and hit him on the arm. Writer separated them and brought (R7) to the desk. Notified (doctor) and Administrator (V1). On 7/25/22 at 8:39 AM, V3 stated on 7/7/22 at 7:00 AM that, I was passing meds and I don't know what was said but I heard a smack and (R25) said, Don't you smack me. I separated them (R7 and R25) and called the Administrator. The facility's final abuse investigation report form dated 7/11/22 written by V1 Administrator documents an allegation of physical abuse was reported on 7/7/22 at 7:00 AM. This form documents that R7 hit R25 on the arm. On 7/27/22 at 10:16 AM, V1 Administrator stated R7 is alert and oriented and knows what R1 is doing. V1 stated R7 did hit R25 on the arm on 7/7/22 at 7:00 AM.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to request a re-screening of a Preadmission Screening and Resident Review (PASRR) after the current PASRR expired for one (R25) of three residents reviewed for PASRR on the sample list of 21. Findings include: R25's Face Sheet documents R25 was admitted to the facility on [DATE]. R25's PASRR dated [DATE] documents, Review Date: [DATE] Level I Outcome: Exempted Hospital Discharge Rationale: Exempted Hospital Discharge 30 Day Approval-A 30 day or less stay in the NF (nursing facility) is authorized. Re-screening must occur by or before the 30th day if the individual is expected to remain in the NF beyond the authorization timeframe. As the individual was medically admitted and is currently psychiatrically stable, they meet criteria for a 30 day EHD (Exempted Hospital Discharge) approval. Should their stay require more than the 30 days, or they develop any signs of psychiatric decompensation, please submit a Conclusion of a Time Limited approval Level l and a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to complete a discharge summary prior to discharge for one (R30) of one resident reviewed for discharge on the sample list of 21. Findings include: R30's Nursing Notes dated 4/12/22 at 9:50 AM, documents R30 was admitted to the facility on [DATE]. R30's nursing notes documents R30 was discharged on 5/25/22 at 9:30 AM. R30's medical record does not contain an Discharge summary. On 7/25/22 at10:39 AM, V13 Medical Records stated R30 was discharged went to a different facility. V13 stated there is not a discharge summary for R30.

Based on observation, interview, and record review the facility failed to assist with nail care for one (R9) of 16 residents reviewed for activities of daily living on the sample list of 21. Findings include: On 7/25/22 at 1:20 PM, R9 was laying in bed. R9's toenails were long and past the tips of the toes. R9 stated she can not trim them herself and doesn't like them that long. R9 stated no one in the facility has assisted her with nail care. At that time, V4 Certified Nursing Assistant (CNA) stated that R9's toenails were needing trimmed and that R9 could not trim them herself. On 7/27/22 at 9:26 AM, R9 stated no one has trimmed her toenails yet. R9 stated she needs them trimmed because they drag across the sheet and it is uncomfortable. At that time V4 CNA stated they had not trimmed R9's nails yet. R9's baseline care plan dated 5/17/22 documents R9 has poor mobility.

Based on observation, interview, and record review the facility failed to apply an orthotic boot to help correct foot drop for one (R9) of one residents reviewed for range of motion on the sample list of 21. Findings include: On 7/25/22 at 1:20 PM, R9 was lying in bed. R9's right foot was noted to be dropping forward towards the mattress. A boot was not on R9's right foot. R9 stated the boot is in the closet and the staff has never applied it. R9 stated it is used for foot drop. At that time, the boot was lying on the top shelf of the closet 07/25/22 01:25 PM Physician order date 5/16/22 documents an order for an orthotic boot while in bed. On 7/25/22 at 2:17 PM, V17 (R9's Physician) stated the orthotic boot should be worn while R9 is lying in bed.

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, failed to perform incontinence care in a manner to prevent cross contamination and potential infection for R28, and failed to maintain R25's urinary indwelling catheter tubing off the floor to prevent cross contamination. R25 and R28 are two of four residents reviewed for bowel and bladder/catheter care on the sample list of 21. Findings include: 1. R28's Physician Order Sheet (POS) dated 7/1/22- 7/31/22 documents the following diagnoses: Dementia, and CVA (Cerebrovascular Accident/ Stroke). R28's Minimum Data Set (MDS) dated [DATE] documents the following: R28's Brief Interview of Mental status score was 10 out of a possible 15, indicating moderate cognitive impairment. The same MDS documents R28 is always incontinent of bladder and frequently incontinent of bowel and has had no behaviors of rejecting care. The same MDS documents R28 is dependent on total physical assistant of two staff for hygiene needs…

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 that a resident maintained a usual body weight and when weight loss continued, the facility failed to implement any new interventions to prevent, address, or treat the underlying cause of the weight loss which resulted in the resident experiencing a significant weight loss. This failure effected one (R6) of two residents reviewed for nutrition on the sample list of 21. Findings include: R6's Physician Order Sheet dated July 2022 documents R6 is diagnosed with Dementia with Psychoses, Mood Affective Disorder, Depression, Cerebral Vascular Accident, Muscle Weakness, and Insomnia. R6's Minimum Data Set (MDS) dated [DATE] documents R6 is moderately cognitively impaired and requires limited assistance of one person for eating. The same MDS documents R6 lost 5% or more in the last month or 10% or more in the last six months and is not on a physician weight loss program. R6's Report of Monthly Weights and Vitals dated 2022 documents R6 weighed 156…

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 utilize a continuous airway pressure machine for one (R9) of one resident reviewed for sleep apnea on the sample list of 21. Findings include: On 7/25/22 at 1:20 PM, R9 stated that she has a continuous airway pressure machine (C-PAP) machine in the bedside table and the staff have never taken it out and applied it. R9 stated she has Sleep Apnea and she has a hard time sleeping at night and feels that the C-PAP would help. A C-PAP machine was in the bedside table in a box. On 7/25/22 at 2:17 PM, V17 (R9's Physician) stated he evaluated R9 on 5/19/22. V17 stated R9 has a diagnosis of Sleep Apnea and that he wrote orders for R9 to have the C-PAP. V17 stated he expects that the facility would be using the C-PAP while she is sleeping. R9's physician progress dated 5/19/22 written by V17 documents R9 has Obstructive Sleep Apnea and requires a C-PAP.

Based on interview and record review the facility failed to redirect a resident (R7) from the dining room when an escalation of behaviors occurred for one (R7) of one resident reviewed for behaviors on the sample list of 21. This failure resulted in an escalation from verbal to physical behaviors in the dining room in which R7 slapped R25 on the arm. Findings include: R7's nurse's note dated 7/7/22 at 6:00 AM, written by V3 Licensed Practical Nurse documents, (R7) up in dining room wheelchair out in the dining room. Yelling out inappropriate comments at times. Cussing other residents and calling them names. 1:1 with (R7) ineffective. R7's nurse's note dated 7/7/22 at 6:30 AM, written by V3 Licensed Practical Nurse documents, Writer gave (R7) his medicine. (R7) states, I like that. Then threw the water and the medicine. Continues to yell out. R7's nurse's note dated 7/7/22 at 7:00 AM, written by V3 Licensed Practical Nurse documents, (R7) was yelling at another (R25) and hit him on the arm. Writer separated them and brought (R7) to the desk. Notified (doctor) and Administrator (V1).…

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 justify the use of an antibiotic for one (R25) of two residents reviewed for catheters on the sample list of 21. Findings include: R25's Physician Order sheet documents an order dated 7/12/22 for Keflex 500 milligrams two times a day for one week. R25's urine culture results dated 7/12/22 documents a result as not indicative of a UTI (Urinary Tract Infection). R25's medical record does not contain documentation that R25's physician was notified that R25's urine culture did not indicate a UTI. R25's Nurse's Note dated 7/13/22 at 3:30 AM documents, T 98.5 (Temperature 98.5 degrees). Resting quietly in bed with eyes closed. (Continues) on (antibiotic) therapy for UTI. No adverse reactions noted. (Indwelling catheter) patent with light amber urine. On 7/27/22 at 11:00 AM, V1 Administrator stated there are no assessments or documentation in R25's medical record to justify the use of the antibiotic. V1 stated there was no documentation in R25's medical record that indicated R25 had an Urinary Tract infection.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to assess the need for psychotropic medications, complete quarterly psychotropic medication assessments, attempt gradual dose reductions, and failed to complete an abnormal involuntary movements scale. This failure effected two (R6, R15) of five residents reviewed for unnecessary medications on the sample list of 21. Findings include: 1. R6's Physician Order Sheet dated July 2022 documents R6 is diagnosed with Dementia with Psychosis, Mood Affective Disorder, Depression, and Insomnia. R6 is prescribed Citalopram (Antidepressant) 40 milligrams once per day, Risperidone (Antipsychotic) 0.125 milligrams every morning and 0.25 milligrams every evening, and Trazodone (Sedative) 100 milligrams at bedtime. R6's undated Face Sheet documents R6 is under the care of a Legal Guardian. R6's Minimum Data Set, dated [DATE] documents R6 is moderately cognitively impaired. R6's Citalopram, Risperidone, and Trazodone Psychotropic Medication Quarterly Evaluations dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure a resident was provided assistive dining devices, according to the physician order. This failure affected one of four resident (R10) reviewed for dining/dignity on the sample list of 21. Findings include: R10's Physician Order Sheet (POS) dated 7/1/22-7/31/22 documents the following diagnoses: Dementia, Severe Front Temporal Type, with Behavioral Problems Unimproved, and Picks Disease. The same POS documents the following Diet Order and assistive devices: Mechanical Soft Solids; With 1 (one) on 1 (one) supervision, thin liquids, patient (R10) is to use (a) divided plate, regular spoon, and her (R10's) cup with lid, and removable straw all (for all) meals. R10's Minimum Data Set, dated [DATE] documents R10 has severe cognitive impairment and requires extensive physical staff assistance with dining. On 07/24/22 at 12:10 pm R10 was seated at a dining table alone, with no staff assistance. There was a large tablespoon/serving spoon and a…

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

Based on observation, interview, and record review the facility failed to ensure a bedroom door had the ability to open and close appropriately for one (R9) of 16 residents reviewed for environment on the sample list of 21. Findings include: On 7/24/22 at 10:00 AM, the door to R9's room would not close. R9 stated, You have to lift up on it to get it to close. It is always broken. The top hinge to the door at the frame was loose and the screw were not screwed in all the way. To close the door the door had to be lifted and pushed closed. The door was stuck closed and had to be pulled forcefully to open it. On 7/25/22 at 8:51 AM, V4 Certified Nurse's Assistant stated she told V8, Maintenance Director about the door a week ago and it still is not working right. V4 stated the door won't open or close correctly. On 7/25/22 at 9:45 AM, V8 stated he fixed the door yesterday. V8 stated they requested that it be fixed last week. V8 stated it has been fixed before and that he put some screws in it but it keeps coming loose because it's hollowed out. V8 stated the door frame needs replaced.