The Pearl Of Downers Grove

Based on interview and record review, the facility failed to follow their policy for antibiotic stewardship. This applies to all 83 residents residing in the facility. The findings include: The facility's Long-Term Care Application for Medicare and Medicaid dated April 7, 2025, showed the facility's census was 83 residents. On April 8, 2025, at 1:04 PM, V2 (DON/Director of Nursing) said when a resident in the facility has an infection, McGeer's Criteria is supposed to be used. V2 continued to say she had not completed McGeer's Criteria since she started as the Infection Preventionist in November 2024. V2 reviewed antibiotic use for R79 in March 2025. V2 said she did not complete McGeer's criteria for R79 and reviewing McGeer's Criteria now, R79 did not meet criteria for an infection. V2 said R79 was prescribed antibiotics due to laboratory results and R79 did not have any symptoms. V2 said R79's urine culture results showed R79 had a growth of ESBL (Extended-Spectrum Beta-Lactamases) of 50,000 to 100,000 colonies. V2 said R79's laboratory results did not meet McGeer's Criteria. V2…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 each resident had a comprehensive care plan that outlined each residents' care needs accurately. This applies to 4 of 18 residents (R26, R27, R29, and R59) reviewed for care plans in the sample of 18. The Findings include: 1. R27's admission record showed R27 was admitted to the facility on [DATE], with multiple diagnosis including chronic atrial fibrillation, morbid obesity, sepsis unspecified organism, and benign prostatic hyperplasia with lower urinary tract symptoms. R27's MDS (Minimum Data Set) dated February 5, 2025, showed R27 was moderately cognitively impaired, and was dependent on staff assistance for toileting, bathing, dressing, bed mobility and transfer and had an indwelling urinary catheter and always incontinent of bowel. On April 7, 2025, at 11:03 AM, R27 was observed with urinary catheter tubing draining into a drainage bag. On April 9, 2025, V31 (Staffing Coordinator) provided a list of residents who needed 2 staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 refer a resident with a new mental health diagnosis for a level II PASRR (Preadmission Screening and Resident Review). This applies to 1 of 2 residents (R19) reviewed for PASRR in the sample of 18. The findings include: The EMR (Electronic Medical Record) showed R19 was admitted to the facility on [DATE], with admitting diagnoses including major depressive disorder, anxiety disorder, and seizures. The EMR continued to show R19 was diagnosed with unspecified psychosis not due to substance or known physiological condition on October 5, 2024. R19's Active Order Summary Report dated April 9, 2025, showed R19 had the following active medication orders: olanzapine (antipsychotic) oral tablet 10 mg (milligrams), give one tablet by mouth at bedtime related to major depressive disorder; and venlafaxine extended-release oral capsule 150 mg, give one capsule by mouth one time a day related to major depressive disorder. On April 9, 2025, at 8:50 AM, V26…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 timely revise the care plan with specific fall-prevention interventions for a cognitively impaired resident that required staff assistance. This applies to 1 of 1 resident (R34) reviewed for fall-related accidents in a sample of 18. The findings include: The EMR (Electronic Medical Record) shows that R34, a [AGE] year-old with diagnoses of dementia, psychosis, anxiety disorder, major depressive disorder, age related physical debility, repeated falls, unsteadiness of feet, difficulty walking, need of assistance with care, hyperlipidemia, Vitamin D deficiency, hypothyroidism, and chronic kidney disease. R1 was admitted to the facility on [DATE]. The MDS (Minimum Data Set) assessment dated [DATE] showed that R34's cognition was severely impaired with BIMS (Brief Interview Mental Status) score of 0/15. The MDS documents that R34 required substantial to maximum assistance from staff during wheelchair transport in the corridor or similar…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide restorative services to a resident per facility policy. This applies to 1 of 1 resident (R29) reviewed for restorative services in the sample of 18. The findings include: On April 7, 2025, R29 stated he did not receive restorative therapy and would like to be receiving it. On April 8, 2025, at 12:13 PM V10 (Licensed Practical Nurse) stated she had not seen R29 receiving any restorative therapy. On April 8, 2025, V11 (Rehabilitation Manager) stated R29 was not receiving skilled therapy services because during his initial assessment R29 was evaluated to be at his prior level of functioning. R11 stated the therapy department did recommend R29 receive restorative therapy to be provided by the facility. V11 stated a referral was provided to V2 (Director of Nursing) for R29 to receive restorative therapy. On April 8, 2025, at 3:16 PM, V2 (Director of Nursing) stated she was not aware R29 was provided a referral for restorative therapy and R29 was not receiving restorative therapy. V2 also stated when the facility did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide nail care to residents who are dependent on staff assistance with ADLs (Activities of Daily Living). This applies to 3 of 3 residents (R44, R47, R485) in the sample of 18. The findings include: 1. R485's admission record showed R485 was admitted to the facility on [DATE], with multiple diagnoses including hemiplegia and hemiparesis of left dominant side following cerebral infarction, cardiomegaly and dysphagia. R485's MDS (Minimum Data Set) showed R485 was moderately cognitively impaired and needed assistance with ADL's including supervision/light touch assistance with eating and oral hygiene, substantial assistance with bed mobility and dependent on staff for personal hygiene, bathing, toileting, dressing and transfer. R485 had mobility impairment to her left arm and left hand. On April 8, 2025, at 12:05 PM, R485's right hand was observed with all fingernails long and black/brown/yellow colored debris underneath the nails. R485 stated she would…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interventions, and failed to prevent further decrease in ROM (Range of Motion) and failed to provide positioning device for residents with hand contractures. This applies to 2 of 5 residents (R67 and R485) reviewed for limited range of motion in the sample of 18. The findings include: 1. R67 admission record showed R67 was admitted to the facility on [DATE], with multiple diagnoses including hemiplegia and hemiparesis following non traumatic intracerebral hemorrhage affecting the left non dominant side, dysphagia, unspecified mood disorder, neuralgia and neuritis, and gastrostomy status. R67's MDS (Minimum Data Set) dated January 7, 2025, showed that R67 was cognitively intact and was dependent on staff assistance for eating through a feeding tube, bathing, toileting, dressing, bed mobility and transfer. On April 8, 2025, at 1:27 PM, R67 was lying in bed and her left hand was contracted in flexion. R67 wrote on her paper with her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document justification for continued use of an indwelling urinary catheter for a resident who experienced a urinary tract infection. This applies to 1 of 4 residents (R27) reviewed for catheter use in the sample of 18. The findings include: 1.R27's admission record showed R27 was admitted to the facility on [DATE], with multiple diagnosis including chronic atrial fibrillation, morbid obesity, sepsis unspecified organism, and benign prostatic hyperplasia with lower urinary tract symptoms. R27's MDS (Minimum Data Set) dated February 5, 2025, showed R27 was moderately cognitively impaired, and was dependent on staff assistance for toileting, bathing, dressing, bed mobility and transfer and had an indwelling urinary catheter and was always incontinent of bowel. R27's admission assessment dated [DATE], under genitourinary section showed R27 was incontinent of urine and did not identify the use of an indwelling urinary catheter. R27's physician…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 develop a person-centered care plan to support a resident's dementia care needs. This applies to 1 of 2 residents (R26) reviewed for dementia care in the sample of 18. The findings include: The EMR (Electronic Medical Record) showed R26 was admitted to the facility on [DATE], with multiple diagnoses including Alzheimer's disease, ventricular tachycardia, and arthritis. R26's MDS (Minimum Data Set) dated March 7, 2025, showed R26 had moderate cognitive impairment. As of April 9, 2025, at 9:32 AM, R26's care plan did not include a care plan for Alzheimer's disease or dementia care including R26's dementia care needs or individualized interventions related to R26's symptomology. On April 9, 2025, at 9:36 AM, V24 (Social Services Director) said he conducts care plan meetings along with nursing and therapy. V24 said R26's comprehensive care plan was completed on March 14, 2025. V24 said R26's Alzheimer's disease diagnosis should have been discussed at the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policy to ensure a resident received psychotropic medications for a specific condition. This applies to 1 of 5 residents (R26) reviewed for unnecessary psychotropic medications in the sample of 18. The findings include: The EMR (Electronic Medical Record) showed R26 was admitted to the facility on [DATE], with the following diagnoses syncope and collapse, ventricular tachycardia, other Alzheimer's disease, other specified arthritis, benign prostatic hyperplasia with lower urinary tract symptoms, essential hypertension, pure hypercholesterolemia, long term use of insulin, and type 2 diabetes mellitus without complications. The EMR did not show R26 had any psychiatric diagnoses. R26's MDS (Minimum Data Set) dated March 7, 2025, showed R26 did not have any psychiatric/mood disorders. The MDS continued to show R26 was receiving antipsychotic, antianxiety, and antidepressant medications. R26's Order Summary Report dated April 14, 2025, showed…

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

Based on observation, interview, and record review the facility failed to ensure that a resident's non-pressure wounds received treatments as ordered by the wound physician for 1 of 3 residents (R2) reviewed for wounds in the sample of 7. The findings include: R2's Specialty Physician Wound Evaluation and Management Summary dated 1/14/25 shows that he has a non-pressure trauma wound to his left first toe measuring 0.9 cm (centimeters) x 0.6 cm. The dressing treatment plan is for xeroform gauze (gauze containing bismuth tribromophenate and petrolatum) and gauze roll once daily. This treatment plan is the same on the evaluations dated 1/20, 1/27, 2/3, 2/11 and 2/17. On 2/20/25 at 11:05 AM, R2 had a black scab on his left first toe. R2 did not have a dressing on his left first toe. R2's January and February Treatment Administration Record (TAR) shows a treatment order dated 1/1/25 for, Scattered scabs to L (left) dorsal foot and L great toe: Apply skin prep and leave open to air every day shift every Mon (Monday), Wed (Wednesday), Fri (Friday) for wound care. R2's January and February…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ordered pressure ulcer treatments were in place and failed to ensure pressure ulcer treatments from the Wound Physician were implemented for 3 of 3 residents (R1, R2 and R3) reviewed for pressure ulcers in the sample of 7. The findings include: 1. R2's Specialty Physician Wound Evaluation and Management Summary dated 1/14/25 shows he has a Stage 4 pressure ulcer on his left posterior heel measuring 3.0 cm (centimeters) x 2.9 cm x 0.1 cm. The dressing treatment plan is for xeroform gauze (gauze containing bismuth tribromophenate and petrolatum), and gauze roll once daily. This treatment plan is the same on the evaluations dated 1/20, 1/27, 2/3 and 2/11. R2's Specialty Physician Wound Evaluation and Management Summary dated 2/17/25 show that the same wound was now 9 cm x 6 cm x 0.1 cm and the treatment plan changed to silver sulfadiazine and gauze roll once daily. On 2/20/25 at 11:05 AM, V8 (Wound Licensed Practical Nurse) provide wound care to R2's left posterior heel wound. There was no dressing on 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 observation, interview and record review the facility failed to ensure a wound treatment cart was not brought into an isolation room to prevent cross-contamination and failed to remove gloves and perform hand hygiene during wound care to prevent the spread of infection for 1 of 3 residents (R2) reviewed for infection control in the sample of 7. The findings include: R2's Physician's Order Sheet shows an order dated 1/12/25 for: Strict contact isolation for MRSA (Methicillin-resistant Staphylococcus aureus) and C Striatum (Corynebacterium striatum) every shift for wound infection. On 2/20/25 at 11:05 AM, V8 (Wound Care Licensed Practical Nurse) brought the facility's treatment cart into R2's room to do his dressing changes. V8 cleansed R2's right leg wounds using saline and gauze and then with the same gloves on, reached into her treatment cart to get dressing supplies for R2's leg. V8 cleaned R2's right ankle and calf wounds, with the same gloves on, reached into her treatment cart to get additional dressing supplies. V8 removed R2's dressing from his sacrum and cleansed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure resident funds were managed by the resident/spouse per the resident/spouse wishes. This applies to 1 of 3 residents (R1) reviewed for representative payee in a sample of 15. The findings include: Face sheet, printed 9/26/24, shows R1 was admitted to the facility on [DATE] and R1's diagnoses included Alzheimer's disease, dementia, heart failure, severe protein-calorie malnutrition, major depression disorder, history of thyroid neoplasm, generalized muscle weakness, anemia, and history of pulmonary embolism. The face sheet shows V5 (Wife) listed as R1's Emergency Contact #1, POA (Power of Attorney) - Care/Medical, POA - Financial, Responsible Party, and Primary [NAME] Contact. On 9/16/24 at 1:55 PM, R1 stated his wife handled all of the finances and paperwork regarding the facility. On 9/16/24 at 10:27 AM, V5 (Wife) stated the facility told her she had to pay $1020.00 for R1's room and board and then applied to Social Security to become the payee…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident rooms were maintained in a clean and sanitary manner for 4 of 7 residents (R3, R6, R7, R8) reviewed for a clean, comfortable, homelike environment in the sample of 11. The findings include: On 4/24/24 at 8:39 AM, V10 (Family of R3) stated, This place is a nightmare. (R3) has only been here three days. Come look at the bathroom. V10 and this surveyor went into R3's bathroom. The garbage container, on the floor by the sink, was full of garbage. Stool was noted in the toilet and up to the bowl of the toilet. Soiled, damp washcloths hung from a towel bar and off the side of the sink. White, clumpy food debris was noted in the sink. Two toothbrushes laid on the sink by the faucet. A paper towel and two wadded tissues were on the bathroom floor. V10 stated, This place is dirty and unsanitary. The same stool was in the toilet yesterday. The food clumps in the sink were there yesterday. (R3) shares this bathroom with his neighbor so I assume all of these stains and things belong to him (neighbor)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ADL (activities of daily living) assistance to residents that required staff assistance for toileting/incontinence care for 2 of 3 residents (R2, R3) reviewed for activities of daily living in the sample of 11. The findings include: 1. R2's resident assessment dated [DATE] showed R2 was dependent on staff for toileting/incontinence care. The assessment showed R2 was incontinent of urine and stool. On 4/24/24 at 8:04 AM, R2 was in bed, dressed in a hospital gown. An odor of urine was noted in the room. R2 stated, I think I might be wet. I don't get up to the toilet. I just go in my brief. R2 stated her incontinence brief was last changed at 4:30 AM that morning. R2 complained of pain to her buttocks. At 8:25 AM, V8 Certified Nursing Assistant (CNA) and V9 Licensed Practical Nurse (LPN) entered R2's room to check R2's buttocks due to her complaint of pain to that area. V8 and V9 repositioned R2 on her side and pulled down R2's brief.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 supervise/monitor and provide a safe environment for residents by not having a front desk receptionist or locking facility doors during certain hours for one day (Sunday) of the week. This applies to all 76 residents in the facility. The findings include: On 3/23/24 at 9:55 AM, the Manager on Duty, V16 (Central Supply and Medical Records Coordinator), submitted a resident roster with 76 residents. On 3/23/24 at 10:28 AM, V2 (DON-Director of Nursing) stated, We don't have a front desk receptionist on Sundays. There is always a MOD (Manager on Duty) on the weekends, but they are not at the front desk. They are on the floors. Anyone can come in until 8 PM on Sundays. The evening nurse locks the front doors at 8 PM. There's a sign on the door that says visitors can come in through the unlocked doors on Sunday and they have to sign the visitor book. I talked to Corporate and the Administrator about this. It's not safe. I told them we need to hire another front desk receptionist. We need to make sure no one except…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 make prompt efforts to resolve a resident and their POA's concerns. This applies to 1 of 3 residents (R1) reviewed for grievances in a sample of 6. The findings include: On 3/23/24 at 9:58 AM, telephone interview was done with V2 (DON-Director of Nursing) regarding R1's medications who stated that after the care plan meeting, it was discussed in the stand down meeting that V15 (Business Office Manager) and V1 (Administrator) would reimburse the family. On 3/23/24 at 11:12 AM, telephone interview was conducted with V3 (Social Worker). V3 stated they had a care plan conference regarding R1 with V12 (R1's daughter/POA-Power of Attorney), V9 and V13 (Unit Manager/LPN). He said he couldn't remember exactly what was all discussed in the meeting, but he would try. He stated, (V12) had some concerns that she brought (R1's) medications at the time of admission and they were now missing. She wanted the nurse to use those medications first. She received a bill for the medications. (V13) was going to follow up on this.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 use resident's medications brought from home at the time of admission and verify and reconcile those medications with the physician and pharmacist. This caused R1 to be charged by the insurance company for medications that were ordered through the facility's pharmacy. The facility also failed to return the medications back to the responsible party. This applies to 1 of 3 residents (R1) reviewed for medications in sample of 6. The findings include: On 3/23/24 at 9:58 AM, telephone interview was conducted with V2 (DON-Director of Nursing). V2 stated the following: (V13-Unit Manager/LPN-Licensed Practical Nurse) is working on this issue. She attended (R1's) care plan meeting with (R1), (V3-Social worker), V9 (MDS/Minimum Data Set Coordinator/LPN), and (V12-R1's daughter) who lives out of state via phone. We did not know where R1's medications were. (V12) stated she gave it to the nurse at the time of admission. No one notified the management team that (R1's) medication was brought in. We tried to talk to (V12)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 personal ADL (Activities of daily living) care for 4 residents (R5, R19, R17, & R65) who are dependent on ADL care in a sample of 31. Findings include: 1. On 01/30/24 at 01:08 PM R5 was observed in her bed with long hair on her upper lip. R5 said that she did not like the hair on her lip and that staff never offer to shave her. R5's 1/9/24 care plan showed an ADL self-care deficit with interventions of physical assist with ADLs daily and as needed. R5's 1/15/24 MDS (minimum data set) section C showed that R5's mental cognition is intact. Section GG showed R5 needs setup or clean up assistance with personal hygiene. 2. On 01/30/24 at 12:21 PM, R17 was observed with long jagged fingernails with brown substances under the nails, hair on her chin, and her hair was observed oily. R17 said the last time her hair was washed was the previous week and that it bothers her very badly that her nails are not cut, she has hair on her chin and that her hair is dirty. R17 then told the surveyor that she needed her…

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

Based on interview and record review, the facility failed to obtain vital information regarding residents' pacemakers and ensure that it was readily available in the resident's medical record. This applies to 4 out of 4 residents (R13, R28, R34, R54) reviewed for pacemakers in a sample of 31. Findings include: 1. R13's face sheet documents an admission date of 10/28/2021. R13's face sheet shows diagnoses including hypertension, atrioventricular block, heart disease with heart failure, and presence of cardiac pacemaker. R13's medical record was reviewed. There was no physician order documenting the pacemaker and how often it should be checked prior to the start of the survey. R13's POS (Physician Order Sheet) showed an order on 01/31/24 (during the survey) for Pacemaker checks every 3 months and Pacemaker site monitoring: Inspect site. Notify physician of discomfort, redness, or discharge at site. Document condition of incision on Skin Integrity Report. R13's record did not show assessments in the progress notes, admission assessment or care plans that document the manufacturer,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors related to cardiac medications, insulin, and intravenous antibiotics. This applies to 4 residents (R15, R26, R36 and R63) reviewed for medications. The findings include: 1. On 1/31/24 at 9:25 AM, V14 (LPN/Licensed Practical Nurse) had finished removing and preparing medications for morning medication pass and was going into R15's room to give medications. Surveyor then counted the pills in R15's pill cup and noticed there were only 8 pills when there should have been 10 pills. The medication pass was stopped and V14 was told she was missing 2 pills. V14 then went back through each due medication again and realized she did not remove the Amiodarone 200 mg (milligram) tab or the Furosemide 20 mg tab from their pill cards and she would have missed giving them to R15. R15's Face sheet shows the following diagnoses: Atrial Fibrillation and Hypertension. R15's POS (Physician Order…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to properly label, contain, and store medications. This applies to 5 residents (R17, R15, R24, R16, and R49) reviewed for medication storage in a sample of 31. Findings include: 1. On 2/1/24 at 10:09 AM, the [NAME] back hall medication cart was checked with V13 (RN/Registered Nurse). When checking narcotics on this cart, R17's bingo card for Hydrocodone-APAP 5-325mg tablets was found with 13 pills in it, but the pill in the 13th slot/hole was different than the other 12 pills and the 13th slot/hole was punctured and taped closed. The pill in the 13th slot was an ovular white pill, scored on one side and 'G037' printed on the other side. The pills in slots 1-12 were not punctured, ovular with a slight pink shade, scored on one side and 'WES301' printed on the other side. V13 verified that it was a different pill in slot 13 and said he did not know anything about the pill being switched with another pill. It was verified the pill in the 13th…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 privacy to a resident during incontinence care. This applies to 1 resident (R15) reviewed for incontinence care in a sample of 31. The findings include: On 1/31/24 at 9:55 AM, V12 (CNA/Certified Nurse Assistant) provided incontinence care to R15. In the middle of incontinence care, when R15's brief was unfastened and pulled down, V12 opened the door to tell V14 (LPN/Licensed Practical Nurse) that R15 wanted powder for her skin folds. After speaking to V14, V12 returned to R15's bedside and left the door ajar and the privacy curtain open, exposing R15's vagina and perineal area to any person walking down the hallway. On 1/31/24 at 10:30 AM, R15 said she has to tell the staff to close her door often while they are providing incontinence care. R15 said when the door is left open during incontinence care and privacy is not provided it makes her feel violated. On 1/31/24 at 4:16 PM, V2 (DON/Director of Nursing) said when incontinence care is provided, the resident's door should be closed, or the curtain…

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

Based on observations, interviews and record reviews, the facility failed to prevent acquired pressure ulcers from worsening and new pressure ulcers from developing for 2 residents (R19 and R65) who were reviewed for wound care in a sample of 7. Findings include: 1. On 1/31/24 at 10:40am R19 was observed in her bed. On the floor in her room was an air mattress. V14 (Nurse) said that the air mattress is supposed to be on her bed and the staff brought it in today and will be putting it on her bed. No specialized mattress was observed on R19's bed the previous day, 1/30/24, only a standard mattress was observed. R19's nails were observed long and jagged. V14 (Nurse) started providing wound care for R19, and V8 ADON (Assistant Director of Nursing) assisted V14. R19 was observed with 2 new wounds to her right and left buttocks. Right buttock with open wound with bright red liquid in wound size 3.5cm X 3 cm. the left buttock with bright red liquid size 4cm X 3.5 cm. R19's brief was observed with bright red liquid in brief. The wound to the sacrum was 1.5 cm X 1 cm and open. After wound…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 services or treatment to prevent a decreased range of motion for a resident admitted with a limited range of motion. This applies 1 of 5 (R7) reviewed for range of motion in a sample of 31. The findings include: The EMR (Electronic Medical Record) showed R7 admitted to the facility on [DATE], with multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left dominant side, gout, muscle weakness, and fibromyalgia. The MDS (Minimum Data Set) dated 10/20/2023 showed R7 was severely cognitively impaired. The MDS continued to show R7 had upper extremity impairment on one side and was dependent on facility staff for self-care needs. R7's Nursing admission assessment dated [DATE] showed R7 had decreased left-hand grasp and left arm and leg weakness at the time of admission to the facility. The assessment continued to show that R7 had general weakness and a decline in functional…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 fall interventions for residents identified as high risk for falls. This applies to 3 of 5 (R28, R42, and R64) reviewed for falls in a sample of 31. The findings included: 1. The EMR (Electronic Medical Record) showed R28 was admitted to the facility on [DATE], with multiple diagnoses including dementia, muscle weakness, abnormalities of gait and mobility, and age-related physical debility. The MDS (Minimum Data Set) dated 12/31/2023 showed R28 was severely cognitively impaired. The MDS continued to show R28 required substantial to maximal physical assistance with bed mobility and transfers from facility staff. R28's Morse Fall Scale dated 1/26/2024, showed R28 was a high risk for falls. R28's fall incident reports from 12/15/2023 to 1/15/2024, showed R28 had a total of six unwitnessed falls in her room. R28's fall incident reports dated 1/07/2024 at 3:50 PM, 1/15/2024 at 8:00 AM, and 1/15/2024 at 10:08 PM, all showed R28 was…

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

Based on observation, interview, and record review, the facility failed to administer medications as ordered. There were 32 opportunities with 4 errors, resulting in a 12.5% error rate. This applies to 2 (R15 and R26) of the 5 residents observed in medication pass. 1. On 1/31/24 at 9:25 AM, V14 (LPN/Licensed Practical Nurse) had finished removing and preparing medications for morning medication pass and was going into R15's room to give medications. Surveyor then counted the pills in R15's pill cup and noticed there were only 8 pills when there should have been 10 pills. The medication pass was stopped and V14 was told she was missing 2 pills. V14 then went back through each due medication again and realized she did not remove the Amiodarone 200 mg (milligram) tab or the Furosemide 20 mg tab from their pill cards and she would have missed giving them to R15. This counts as two errors, for two missed medications. R15's Face sheet shows the following diagnoses: Atrial Fibrillation and Hypertension. R15's POS (Physician Order Sheet) shows the following orders: Amiodarone 200 mg tab…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assist residents identified as needing assistance with ADLs (Activities of Daily Living). This applies to 4 of 4 residents (R1, R2, R3, R4) reviewed for ADLs in the sample of 4. The findings include: 1. R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE]. R1's diagnoses included metabolic encephalopathy, major depression, diabetes type 2, cognitive communicative deficit, peripheral vascular disease, chronic kidney disease stage 3, and congestive heart failure. R1 was admitted under hospice care on January 11, 2024, for terminal protein calorie malnutrition. R1's change of condition MDS (Minimum Data Set) dated December 7, 2023 showed R1 had severely impaired cognition and required staff assistance for all ADLs (Activities of Daily Living). R1's care plan showed R1 has an ADL self-care performance deficit. Interventions included physical assist as needed with his ADLs, oral care routine, resident required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an injury of unknown origin was reported to the Administrator and the State Agency as shown in the facility's policy. This applies to 1 of 3 residents (R2) reviewed for injury of unknown origin in the sample of 6. The findings include: On August 17, 2023, at 2:33 PM, R2 was sitting up in a wheelchair in his room watching baseball on television. R2 was able to answer yes and no questions, but his degree of accuracy and understanding could not be determined due to his inability to speak and cognitive status. The EMR (Electronic Medical Record) shows R2 was admitted to the facility on [DATE]. R2 has multiple diagnoses including, displaced intertrochanteric fracture of the right femur, hemiplegia and hemiparesis affecting the right side, flaccid hemiplegia of the right side, dysphagia, aphasia, major depressive disorder, chronic atrial fibrillation, heart failure, dementia, chronic pain, urine retention, cognitive communication deficit, history of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to thoroughly investigate a resident's injury of unknown origin. This applies to 1 of 3 residents (R2) reviewed for injury of unknown origin in the sample of 6. The findings include: On August 17, 2023, at 2:33 PM, R2 was sitting up in a wheelchair in his room watching baseball on television. R2 was able to answer yes and no questions, but his degree of accuracy and understanding could not be determined due to his inability to speak and cognitive status. The EMR (Electronic Medical Record) shows R2 was admitted to the facility on [DATE]. R2 has multiple diagnoses including, displaced intertrochanteric fracture of the right femur, hemiplegia and hemiparesis affecting the right side, flaccid hemiplegia of the right side, dysphagia, aphasia, major depressive disorder, chronic atrial fibrillation, heart failure, dementia, chronic pain, urine retention, cognitive communication deficit, history of falling, and long-term use of anticoagulants. R2's MDS (Minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident received medication as ordered by the physician. This applies to 1 of 3 residents (R1) reviewed for improper nursing care in the sample of 6. The findings include: The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE], and transferred to the local hospital on August 6, 2023. R1 had multiple diagnoses including pneumonia, chronic respiratory failure, dysphagia, COPD (Chronic Obstructive Pulmonary Disease), heart failure, pleural effusion, chronic kidney disease, anemia, pulmonary hypertension, adult failure to thrive, pressure ulcer of the right and left heel, obstructive uropathy, muscle weakness, dysphagia, weakness, edema, and dementia. R1's MDS (Minimum Data Set) dated August 6, 2023, shows R1 had severe cognitive impairment, was totally dependent on facility staff for bathing, and required extensive assistance with all other ADLs (Activities of Daily Living). R1 had an indwelling urinary catheter and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow a dietitian's recommendation for residents with significant weight loss, failed to notify the dietitian of a resident with significant weight loss, and failed to monitor a resident's weight with significant weight loss. This applies to 4 of 9 residents (R41, R68, R17, and R67) reviewed for weight loss in the sample of 18. The findings include: 1. R41's Weights and Vitals Summary document showed R41 had significant weight loss of 10% in 6 months on 2/9/23. R41's 12/28/22 Nutrition/Dietary Note showed R41 triggered for significant weight loss of 6.7% on one month and the weight loss was undesirable. The same note showed the following recommendation was made, .to document [percentage] intake in [the electronic medical record] to better estimate if needs are being met. R41's Meal Intake documentation from 1/30/23 to 2/25/23 showed there were 13 missing meal intakes. On 02/28/23 at 10:38 AM, V3 (Dietitian) said that on 12/28/22 she…

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

Based on observation, interview and record review the facility failed to ensure staff wore recommended PPE (personal protective equipment) for residents positive with COVID-19. The facility also failed to ensure staff changed their gloves and washed their hands during incontinence care to prevent the spread of infection. This applies to 12 of 18 residents (R20, R31, R36, R28, R40, R44, R64, R71, R25, R332, R333, R334, & R335) reviewed for infection control in the sample of 18. The findings include: 1. The facility's COVID positive residents list (no date) shows, the following residents positive for COVID: R20, R31, R36, R28, R71, R25, R332, R333, R334, & R335. On February 28, 2023, at 9:43 AM, V8 Registered Nurse (RN) was working the COVID-19 unit. She was wearing a black KN95 mask. She was observed going in and out of COVID-19 positive rooms with the same KN95 mask all day. At 3:08 PM, (wearing the same black KN95 mask) she stated, she provides her own masks because she wants too, and she orders them from Amazon. She stated, it was a KN95. She did not have any particular reason 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 assist a resident in a dignified manner while providing assistance with feeding which included 1 of 18 residents (R10) reviewed for dignity in a sample of 18. The findings include: R10's Facility assessment dated [DATE] showed R10 to be a [AGE] year old female with severe cognitive impairment, needing extensive assistance with eating, and admitted with diagnoses which include: dementia, dysphagia, unspecified psychosis, and encounter for palliative care. On 2/27/23 at 12:20 PM, V16 Certified Nursing Assistant (CNA)/Central Supply was assisting R10 with eating the noon meal. V16 would be scrolling on her cell phone between giving R10 bites of food. On 2/28/23 at 9:00 AM, V13 Licensed Practical Nurse stated staff should not be on their cell phones while providing assistance with residents. When providing feeding assistance, it is important to interact with the resident and also make sure they are safe while they are being fed. On 2/28/23 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to implement orders for a resident with bilateral leg edema for 1 of 18 residents (R64) reviewed for quality of care in the sample of 18. The findings include: R64's Face Sheet shows that he was admitted to the facility on [DATE] with diagnoses of: heart failure, venous insufficiency and localized swelling of his bilateral lower limbs. R64's Physician's Order Sheet (POS) printed on 2/28/23 shows an order dated 2/3/23 for, ace wrap to bil (bilateral) LE (lower extremities) on in am and off at HS (nighttime) R64's POS also shows an order dated 1/30/23 for, tubigrip (compression bandage) to BLE in the morning for BLE edema/venous stasis. R64's Physician Note dated 2/23/23 shows, Patient was admitted to the hospital with chief complaint of b/l (bilateral) LE swelling Patient has +2 b/l LE edema .Plan: b/l LE edema. Continue Bumex. Continue Tubigrip and elevate b/l LE On 2/27/23 at 11:00 AM, R64 was sitting up in his wheelchair. R64's legs were not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review, the facility failed to ensure pressure reducing interventions were in place for residents at risk for pressure injuries for 2 of 3 residents (R7, R51) reviewed for pressure in a sample of 18. The findings include: 1. R7's Facility assessment dated [DATE] showed R7 is a [AGE] year old female, having severe cognitive impairment, is total dependent on staff for bed mobility, is at risk for developing pressure injuries, and having diagnoses which include: hemiplegia and hemiparesis (left), cerebral infarction (stroke), type 2 diabetes, aphasia, gastrostomy (feeding tube), and muscle weakness. During the survey, multiple observations of R7's heels were lying directly on the mattress. Observations were made on 2/27/23 at 9:15 AM and 12:10 PM, and on 2/28/23 at 10:00 AM and 11:45 AM. R7's Careplan printed on 2/28/23 showed R7 having a concern for potential skin integrity related to immobility, incontinence, and right sided weakness after a stroke. The Careplan has no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents with decreases in range of motion were assessed and interventions were implemented for 2 of 2 residents (R63 and R7) reviewed for range of motion in the sample of 18. The findings include: 1. R63's face sheet showed a diagnosis of hemiplegia and hemiparesis following a cerebral vascular accident affecting the right side and flaccid right side. A facility assessment done on 11/17/22 showed R63 had limited mobility on one side of his body. R63's doctor progress notes dated 2/15/23 showed R63 had a right shoulder subluxation (partial or incomplete shoulder dislocation). R63's Order Summary Report showed therapy recommended a right wrist/hand splint to be on during the day and a wheelchair trough for right arm support. The order had a start date of 9/20/22. On 2/28/23 at 9:45 AM, V4 (Physical Therapist) said R63 had a stroke that affected R63's right side. V4 said when R63's therapy ended on 9/20/22, it was recommended that…

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

Based on observation, interview, and record review the facility failed to have a fall prevention intervention in place for a resident at high risk for falls for 1 of 18 residents (R39) reviewed for safety in the sample of 18. The findings include: R39's face sheet showed R39 had a history of repeated falls. R39's fall risk assessment done on 12/22/22 showed R39 was at high risk for falls. R39's Progress Note dated 12/22/22 showed R39 had a fall and was found on the floor next to her bed. R39's Fall Prevention care plan showed as an intervention for a fall mat to be at bedside while R39 was in bed. On 02/27/23 at 9:49 AM and 1:30 PM, R39 was in bed. There was no fall mat in place. No fall mat was observed in R39's room including under R39's bed. On 02/28/23 at 8:55 AM and 10:00 AM, R39 was in bed. There was no fall mat in place. On 02/28/23 at 10:14 AM, V5 (Certified Nursing Assistant-CNA) said she was the CNA taking care of R39. V5 said R39 did not need a fall mat and confirmed there was no fall mat in R39's room. On 2/28/23 at 10:30 AM, V2 (Director of Nursing) said R39 should have…

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

Based on observation, interview and record review the facility failed to ensure a resident's indwelling urinary catheter bag was kept off of the floor to prevent infections for 1 of 1 resident (R74) reviewed for catheter care in the sample of 18. The findings include: On 2/27/23 10:20 AM, R74 was sitting up in his wheelchair in his room. R74 had an indwelling urinary catheter bag hanging under his wheelchair. R74 said that he currently has burning in his penis area. At 10:30 AM, R74 requested to go back to bed due to the pain. V10, Certified Nursing Assistant (CNA) assisted R74 back to bed. R74 stood up from the wheelchair and transferred to the bed. V10 unhooked the catheter back from under the wheelchair and placed it on the floor. V10 then assisted R74 to get into the bed. While V10 was assisting him, the catheter bag was still on the floor and moving across the floor as he was getting repositioned. At one point during the repositioning, V10 had stepped on the catheter bag. V10 then hung the bag on the bed frame and lowered the bed. V10 then placed a fall mat on the side of R74…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 had an order for oxygen administration and failed to ensure equipment was changed weekly for 1 of 1 resident (R179) reviewed for oxygen administration in the sample of 18. The findings include: On 2/27/23 at 9:59 AM, R179 had oxygen applied at 3 liters via an oxygen concentrator with a humidifier bottle attached. The humidifier bottle was dated 1/12/23. On 2/28/23 12:30 PM, R179 still had oxygen applied at 3 liters and the humidifier bottle was still dated 1/12/23. R179's Face Sheet shows that she was admitted to the facility on [DATE]. R179's Physician's Order Sheet printed on 2/28/23 does not show an order for oxygen. R179's Nursing Notes dated 2/24/23 at 7:07 AM shows, Remains on cont (continuous) O2 (oxygen) at 2LPM (liters per minute)/NC (nasal cannula). On 2/28/23 at 12:35 PM, V7 (Registered Nurse) said that if a resident is in need of oxygen, an order is received from the physician and put in the computer. V7 said…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 as needed (PRN) psychotropic medications had a stop/duration date for 3 of 5 residents (R29, R39, and R27) reviewed for psychotropic medication in the sample of 18. The findings include: 1. R29's Order Summary Report showed an order for lorazepam (psychotropic medication) to be given as needed. There was no stop/duration date associated with the order. 2. R39's Order Summary Report showed an order for lorazepam (psychotropic medication) to be given as needed. There was no stop/duration date associated with the order. 3. R27's Facesheet printed on 2/28/23 showed R27 is a [AGE] year-old female admitted to the facility with diagnoses which include: Palliative care, dementia, major depressive disorder, and adult failure to thrive. R27's Order Summary showed R27 having an order for Lorazepam 0.5 mg tablet as needed (PRN) every 4 hours as needed for terminal restlessness and agitation. The order's start date is 8/23/22 with no end/stop date. On 3/1/23…

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

Based on observation, interview and record review the facility failed to administer medications as ordered. There were 33 opportunities with 2 errors resulting in a 6.06% error rate. This applies to 1 of 4 residents (R130) observed in the medication pass. The findings include: On February 28, 2023, at 9:19 AM, V7 Registered Nurse (RN) was passing R130's morning medications. She gave R130 1 tablet of sodium bicarbonate (the physician order is for 2 tablets). V7 RN also stated, she could not give R130 her Veltassa (used for high potassium levels) because it was not available to be given. She stated, she called the pharmacy yesterday (February 27, 2023) and they said it would be delivered. The medication was still not there. R130's medication administration record (MAR) for February 2023 shows, Veltassa oral packet 8.4 mg (milligram) (Patiromer Sorbitex Calcium), give 1 packed by mouth one time day for routine . Sodium Bicarbonate Oral Tablet 650 mg (Sodium Bicarbonate (Antacid)), give 2 tablets by mouth two times a day for routine Take 2 tabs (1,300 mg total) PO BID (by mouth twice 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 administer medications as ordered. There were 33 opportunities with 2 errors resulting in a 6.06% error rate. This applies to 1 of 4 residents (R130) observed in the medication pass. The findings include: On February 28, 2023, at 9:19 AM, V7 Registered Nurse (RN) was passing R130's morning medications. She gave R130 1 tablet of sodium bicarbonate (the physician order is for 2 tablets). V7 RN also stated, she could not give R130 her Veltassa (used for high potassium levels) because it was not available to be given. She stated, she called the pharmacy yesterday (February 27, 2023) and they said it would be delivered. The medication was still not there. R130's medication administration record (MAR) for February 2023 shows, Veltassa oral packet 8.4 mg (milligram) (Patiromer Sorbitex Calcium), give 1 packed by mouth one time day for routine . Sodium Bicarbonate Oral Tablet 650 mg (Sodium Bicarbonate (Antacid)), give 2 tablets by mouth two times a day for routine Take 2 tabs (1,300 mg total) PO BID (by mouth twice 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 interview and record review, the facility failed to ensure residents were offered and/or received the influenza and/or pneumococcal immunizations to 2 of 5 residents (R44 and R129) reviewed for immunizations in the sample of 18. The findings include: The facility CMS 802 dated 2/28/23 shows R129 and R44 both currently reside in the facility. On 2/28/23 at 1:59 PM, V14, Infection Prevention Nurse, said as residents are being admitted , the nurse is offering pneumococcal and influenza vaccines. V14 said the Pneumococcal vaccine was done for all LTC (long term care) residents. R129's Immunization Report dated 3/1/23 has no date of administration and/or refusal for the Influenza vaccine. R44's Immunization Report dated 3/1/23 has no date of administration and/or refusal for the Influenza or Pneumococcal vaccines. The facility's Influenza Vaccination Policy (not dated) shows the following: All residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated 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.