Fondulac Rehabilitation and Health Care Center

Based on record review and interview the facility failed to employ a licensed Administrator to ensure all residents were protected from abuse and all abuse allegations were investigated and reported to the police, State Agency, and residents' representatives, to ensure all staff received mandatory annual in-servicing, and to maintain positive staff feedback. These failures have the potential to affect all 79 residents residing within the facility. Findings include: The facility's Resident Listing dated 5-20-25 documents 79 residents currently reside within the facility. The facility's Job Description Manual (undated) documents, Job Title Variations: Acting Administrator. Position Description: Manages all business-related activity to achieve the company vision and supporting strategies and assures that the company image as an ethical and high-quality provider of health services is maintained. Assist in the overall operation of the facility in accordance with current applicable federal, state, and local standards, guidelines and regulations while completing the required training hours…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure all staff received annual QAPI (Quality Assurance and Performance Improvement) in-service training. This failure has the potential to affect all 79 residents residing within the facility. Findings include: The facility's Resident Listing dated 5-20-25 documents 79 residents currently reside within the facility. The facility's Annual In-Servicing Calendar Policy dated 09/2022 documents, March: QAPI All Staff. On 5/24/25 at 9:10 AM V2 (Director of Nursing) verified no staff received annual QAPI training.

Based on record review and interview the facility failed to ensure all staff received annual Infection Control and Prevention in-service training. This failure has the potential to affect all 79 residents residing within the facility. Findings include: The facility's Resident Listing dated 5-20-25 documents 79 residents currently reside within the facility. The facility's Annual In-Servicing Calendar dated 09/2022 documents, April: Infection Prevention and Control All Staff On 5/24/25 at 9:10 AM V2 (Director of Nursing) verified no staff received Infection Control and Prevention Training.

Based on record review and interview the facility failed to ensure all staff received annual Compliance and Ethics in-service training. This failure has the potential to affect all 79 residents residing within the facility. Findings include: The facility's Resident Listing dated 5-20-25 documents 79 residents currently reside within the facility. The facility's Annual In-Servicing Calendar dated 09/2022 documents, April: Ethics and Corporate Compliance All Staff. On 5/24/25 at 9:10 AM V2 (Director of Nursing) verified no staff received annual Compliance and Ethics training.

Based on record review and interview the facility failed to ensure all staff received annual Behavioral Health in-service training. This failure has the potential to affect all 79 residents residing within the facility. Findings include: The facility's Resident Listing dated 5-20-25 documents 79 residents currently reside within the facility. The facility's Annual In-Servicing Calendar dated 09/2022 documents, January: Behavioral Health All Staff. October: Behavioral Management All Staff. On 5/24/25 at 9:10 AM V2 (Director of Nursing) verified no staff received annual Behavioral Health training.

Based on interview and record review, the facility failed to have a Registered Nurse for eight consecutive hours in a 24 hour period on four of 31 days per the Facility's July Nursing Schedule. This has the potential to affect all 63 residents living in the facility. Findings. The Facility Assessment, dated 8/12/24, states, The facility's plan to ensure sufficient staff to meet the needs of the residents at any given time. The Facility's 2024 July Nurses Schedule shows there are no Registered Nurses working on four weekend days: 7/06/24, 7/07/24, 7/20/24, 7/21/24. On 8/21/24 at 12:05 PM, V3, Assistant Director of Nursing, stated, Yes, we did have gaps in the July schedule that we did not have Registered Nurse Coverage. The facility's Long-Term Care Facility Application for Medicare and Medicaid Form CMS (Centers for Medicare and Medicaid Services) 671 dated 8/18/24, signed by V1, Administrator, documents 63 residents currently reside within the facility.

Based on observation, interview and record review, the facility failed to serve foods as written on the menu. This has the potential to affect all 63 residents living in the facility. Findings: The Facility's Week at a Glance, dated 8/18/24, Week four, Luncheon Menu, states, Oven Fried Chicken Breast; Mashed Potatoes; Chicken Gravy; Mixed Vegetables; Roll/Margarine; Pie (menu does not specify what kind of pie as required). Residents were served: Plain Baked Chicken (no breading); Mashed Potatoes; Carrots; Bread; Strawberry Pie. On 8/18/24 at 12:35 PM, V5, Dietary Manager, stated, I don't know why the chicken was plain, carrots were served instead of mixed vegetables and bread was served instead of rolls. The frozen mixed vegetables didn't come in, but we do have canned mixed vegetables; there are frozen rolls in the freezer that could have been used. I'll talk to the cook. He's new and doesn't know things. On 8/19/24 at 10 AM, during the Group Interview with Resident Council, R3, R10, R11, R15, R29, R33, R38, all complained that often the menu will say one thing, and another will 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.

Based on observation, interview and record review, the facility failed to ensure use of a safe sanitation solution; place food on the steam table at the appropriate time; maintain clean appliances/fixtures in the kitchen; label, date and appropriately package all opened food; use only institutional approved storage containers; date, label and discard as required, all food items in the resident's floor refrigerator. This has the potential to affect all 63 residents living in the facility. Findings: The document Food from Outside Sources/Personal Food Storage, dated 4/2017, states, Food and beverages brought in from outside sources, that are to be stored in the facility refrigerators and freezers, will be checked by a dietary staff member. Any suspicious or obviously contaminated food or beverage will be discarded immediately. Food and beverages will be labeled with the resident's name, food item and date. These foods and or beverages will be placed on a designated tray/shelf. Facility storage procedures apply. On 8/18/24 at 11:15 AM, the floor refrigerator (for resident's use) had 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.

This failure resulted in two deficient practice statements. A. Based on observation, interview, and record review the facility failed to perform hand hygiene during medication administration for two residents (R22 and R35) of three reviewed for medication administration, in a sample of 47. B. Based on observation, interview and record review, the facility failed to implement Enhanced Barrier Precautions throughout the facility to protect vulnerable residents and prevent the spread of multi-drug resistant organisms (MDROs). This failure has the potential to affect all 63 residents residing in the facility. Findings include: A. The facility policy, Standard Precautions, dated (reviewed) 4/11/22 directs staff, Standard precautions will be instituted to prevent the spread and contamination of pathogenic microorganisms in a manner that voids transfer to residents, personnel and environment. Gloves: Wear gloves when touching blood, body fluids, secretions, and contaminated items. Remove gloves promptly after use, before touching noncontaminated items and environmental surfaces and before…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to notify the facility Ombudsman monthly of a resident transfer to the hospital and failed to provide the resident and resident representative with a written notice of transfer. This failure has the potential to affect all 47 facility residents. Findings Include: 1. R25's facility Census List, provided by V9/Business Office Manager on 8/19/24 documents that R25 was transferred to a local hospital on 2/9/24 and on 6/8/24. No evidence of a facility notification to R26 of a transfer/discharge was present on R25's chart. 2. R35's facility Census List, provided by V9/Business Office Manager on 8/19/24 documents that R35 was transferred to a local hospital on 4/24/24, 7/6/24 and 8/6/24. No evidence of a facility notification to R26 of a transfer/discharge was present on R35's chart. On 8/20/24 at 11:09 A.M., V7/Social Services Director verified that the facility did not provide R25, R35 or their representatives with a written notice of transfer. At that time,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide a copy of the bed hold policy for residents discharging to the hospital, for four of four residents (R25, R35, R45 and R70), reviewed for bed holds, in the sample of 47. Findings Include: The facility Bed Hold Guarantee Policy, dated (revised) 8/1/17 directs staff, The resident, resident family or legal representative will be given the appropriate 'Notice of Bed Hold Policy'' at the time of discharge or therapeutic leave, if possible, but notice will be given no longer than 24 hours after discharge or initiation of leave. 1. R25's medical record documents that R25 was hospitalized on [DATE] and 6/8/24. R25's medical record does not contain documentation of written notice to R25 or R25's resident representative, of the facility bed hold policy. 2. R35's medical record documents that R35 was hospitalized on [DATE], 7/6/24 and 8/6/24. R35's medical record does not contain documentation of written notice to R35 or R35's resident representative, of…

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

Based on interview and record review, the facility failed to develop a care plan addressing target behaviors exhibited, anticoagulant use, and psychotropic medication use for four of 19 residents (R4, R7, R12, and R49) reviewed for care plan accuracy in the sample of 47. Findings include: The facility's Comprehensive Care Planning, dated 11/1/17, documents, It is the policy of the facility to comprehensively assess and periodically reassess each resident admitted to this facility. The results of this resident assessment shall serve as the basis for determining each resident's strengths, needs, goals, life history and preferences to develop a person-centered comprehensive plan of care for each resident that will describe the services that are to be furnished to attain or maintaining the resident's highest practicable physical, mental, and psychosocial well-being. 1. R49's current Physician's Orders document the following medication order: Eliquis (anticoagulant) 5 milligrams (mg) take one tablet by mouth twice daily. R49's current care plan does not address the use of R49's Eliquis.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 perform the required nurse shift to shift controlled substance reconciliation for 19 of 19 residents, (R2, R3, R8-R10, R13, R17, R19, R22, R25, R34, R37, R43, R44, R47, R50, R52, R59 and R65) reviewed for controlled substances in a sample of 47. FINDINGS INCLUDE: The facility policy, Controlled Substances, dated (reviewed) 11/6/18 directs staff, It is the policy of the facility that all drugs listed as Schedule II drugs are subject to specified handling, storage, disposal and record keeping. The drugs in Schedule II will be counted and reconciled by the nurse coming on duty with the nurse that is going off duty. These records shall be retained for at least one (1) year. On 08/18/24 at 9:21 A.M., a review of the facility A Hall and C Hall narcotic Shift Change Accountability Record Sheet for Controlled Substances for August 2024, for residents residing in the facility A Hall and C Hall, shows missing, nursing documentation, to confirm facility nurses performed the required shift to shift controlled substance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff to resident mental abuse to the state agency for one of three residents (R23) reviewed for abuse in the sample of 47. Findings include: The facility's Abuse Prevention Program policy, dated 11/28/16, documents The facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. This includes but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. This facility therefore prohibits mistreatment, exploitation, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, exploitation, neglect or abuse of our residents. This policy also…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility failed to immediately remove an employee accused of mental abuse from resident care and complete an abuse investigation for alleged staff to resident abuse for one of three residents (R23) reviewed for Abuse in the sample of 47. Findings include: The facility's Abuse Prevention Program policy, dated 11/28/16, documents The facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. This includes but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. This facility therefore prohibits mistreatment, exploitation, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 PASARR (Preadmission Screening and Resident Review) was completed for three of four residents (R1, R44 and R58) reviewed for PASARR screenings in the sample of 47. Findings include: 1. R1's current Physician's Orders document R1's current diagnoses to include: Schizophrenia and Psychosis. R1's current medical record has no documentation of a PASARR Level I completed. On 08/20/24 at 10:05 AM, V3 (Assistant Director of Nursing/ADON) stated the facility has no record of R1 ever receiving a PASARR Level I. 2. R58's current Physician's Orders document R58 was admitted to the facility on [DATE] with a diagnoses of Schizophrenia. R58's Notice of PASARR Level I Screen Outcome (dated 01/23/24) documents the following: Your PASARR Level I screening is complete. Your Level I screen shows you may have a serious mental illness or intellectual/developmental disability. You meet the criteria for Convalescent Care, and you may stay for up to 60 calendar days…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 physician ordered daily skin checks and scheduled pressure ulcer treatments were completed and a pressure ulcer care plan was developed for three of three residents (R34, R35, R44) reviewed for pressure ulcers in the sample of 47. Findings include: The facility's Decubitus Care/ Pressure Areas policy, dated 1/2018, documents It is the policy of this facility to ensure a proper treatment program has been instituted and is being closely monitored to promote healing of any pressure ulcer. This policy also documents The pressure area will be assessed and documented on the Treatment Administration Record (TAR) or the Wound Documentation Record. Initiate physician order on treatment sheet. When a pressure ulcer is identified additional interventions must be established and noted on the care plan in an effort to prevent worsening or re-occurring pressure ulcers. The facility's Comprehensive Care Plan Planning policy, dated 11/1/17, documents It is the policy of (the facility) to comprehensively assess and…

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

Based on observation, interview and record review the facility failed to perform hand hygiene during suprapubic catheter care for one of two residents (R7) reviewed for urinary catheters in a sample of 47. Findings include: The facility's Standard Precautions policy, dated 4/11/22, documents Procedure: 1. Handwashing: wash hands after touching blood, body fluids, secretions, excretions and contaminated items, whether or not gloves are worn. Wash hands immediately after gloves are removed between resident contacts and when otherwise indicated to avoid transfer of microorganism to other residents or environments. It maybe necessary to wash hands between task and procedures on the same resident to prevent cross-contamination of different body sites. 3. Gloves: Wear gloves (clean , nonsterile gloves are adequate) when touching blood, body fluids, secretions, excretions and contaminated items. Put on clean gloves just before touching mucous membranes and nonintact skin. Change gloves between tasks and procedures on the same resident after contact with material that may contain a high…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a licensed pharmacist reviewed a resident's medication regimen monthly for six consecutive months for one of five residents (R57) reviewed for unnecessary medications in a sample of 47. Findings include: The Facility Psychotropic Medication Policy, dated 11/28/17, documents, Nursing Administration will meet with the consultant Pharmacist on a monthly basis to discuss any resident who may need or is due for a possible medication reduction. R57's current medical record, as of 8/20/24, has no documentation of R57 having any Medication Regimen Reviews completed by a licensed pharmacist for the months of March, April, May, June, July, and August 2024. On 8/20/2024 at 9AM, V2 (Director of Nursing) confirmed that for the time span of 2/2024-8/2024, R57 only had one medication regimen review completed by a licensed pharmacist in February 2024.

2. R49's current Diagnosis Report documents R49's diagnoses to include: Schizophrenia; Schizoaffective Disorder; Mood Disturbance and Anxiety; and Depression. R49's current Physician's Orders document the following medication order: Clozaril (antipsychotic, date of order 06/12/22) 1500 milligrams twice daily. R49's Monthly Behavior Tracking Records (dated February 2024 - August 2024) do not document any target behaviors or a consistent pattern of adverse behaviors displayed by R49. These same forms had multiple days throughout each month that were left blank, and R49's Behavior Tracking Record (dated May 2024) is completely blank for the entire month. R49's current care plan has no mention of any target behaviors displayed by R49 and has no documentation of any behavioral interventions in place. From 08/19/24 - 08/21/24, multiple observations of R49 were conducted, and no adverse behaviors were displayed by R49 during this time. R49's Consultation Report (dated 05/30/24) does not address the suggested gradual dose reduction for R49's Clozaril. On 08/21/24 at 08:40 AM, V3 (ADON)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 physician ordered laboratory tests for one of one resident (R67) reviewed for lab monitoring in a sample of 47. Findings Include: The facility policy, Laboratory Tests, dated (reviewed) 9/27/2017 directs staff, Appropriate laboratory monitoring of disease processes and medications requires consideration of many factors including concomitant disease(s) and medications(s), wishes of the resident and family and current standards of practice. Laboratory testing will be completed in collaboration with Medicare guidelines, pharmacy recommendations and physician orders. Obtain laboratory orders upon admission, readmission and PRN (as needed) for medication and condition monitoring per the physician's order. R67's admission Physician Order Sheet/POS, dated 7/16/24 includes the following diagnoses: Acute Hypoxic Respiratory Failure, Diabetic Ketoacidosis, Acute Kidney Injury, Diabetes Mellitus, Dizziness and Weakness. This same POS also includes the following physician orders for labs: CMP (Complete Metabolic Profile) and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a resident's schedule II narcotic was free from misappropriation for two of three residents (R1 and R3) reviewed for misappropriation of property in a sample of three. Findings include: The facility's Abuse Prevention Program, revised 11/28/16, documents that it is the right of the resident to be free from abuse, neglect, misappropriation of resident property, and exploitation. This form documents that misappropriation of resident property means deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. R1's current Physician Order Sheet, documents for R1 to take Hydrocodone (schedule II)-Acetaminophen 5mg (milligrams)325mg every six hours as needed. The facility's shipment details invoice details sheet documents that 30 tablets of Hydrocodone-Acetaminophen 5mg-325mg were delivered on 7/28/23 for R1. There is no Controlled Substance Proof of Use sheet in R1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility establish a system for the receipt and reconciliation of controlled drugs for two of three residents (R1 and R3) reviewed for controlled drugs in a sample of three. Findings include: The facility's Controlled Substances policy, revised 10/06, that all drugs listed as schedule II are subject to specified handling, storage, disposal, and record keeping. This form also documents that the drugs in Schedule II will be counted and reconciled by the nurse coming on duty with the nurse that is going off duty. The facility's shipment details invoice details sheet documents that 30 tablets of Hydrocodone-Acetaminophen 5mg-325mg were delivered on 7/28/23 for R1. There is no Controlled Substance Proof of Use sheet in R1's medical record. The facility's pharmacy shipment details sheet documents that on 8/2/23, 60 tablets of Hydrocodone-Acetaminophen 5mg-325mg were delivered to the facility for R3. R3's Controlled Substance Proof of Use, dated 8/2/23, documents that the…

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

Based on interview and record review the facility failed to ensure the privacy of medical records for two of three residents (R1, R3) reviewed for medical records in a sample of three. Findings include: The facility's Notice of Privacy Practices, undated, documents that the facility is required by law to maintain the privacy of your health information and to provide to you and your representative this notice of duties and privacy practices. R1's Controlled Substances Proof of Use form, documents R1's full name and place of residents. This form documents for R1 to take Hydrocodone-Acetaminophen 5mg (milligrams) 325mg tablets every six hours as needed for pain. R3's Controlled Substances Proof of Use form, documents R3's full name and place of residency. This form also documents for R3 to take Hydrocodone-Acetaminophen 5mg-325mg every six hours. On 8/14/23 at 10:45am, V4, Detective, verified that during the autopsy of V3, Licensed Practical Nurse, two cards of Hydrocodone-Acetaminophen 5-325mg, along with the reconciliation forms were found in V3's upper breast pocket of her scrubs.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 inform residents of their rights during their stay in the facility. This has the potential to affect all 62 residents residing in the facility. Findings include: Long Term Ombudsman Program Resident Rights for People in Long-term care Facilities, dated 12/04, documents Your rights as a citizen and a facility resident you do not lose your right as a citizen of Illinois and United States because you live in a long-term care facility. You have the right to vote. On 8/03/23 at 10:05 AM, a resident council meeting was conducted in the sunroom. During the resident council meeting, R39, R42, R33, and R11 were asked if they knew what the rules and their rights were at the facility, R39, R41, R33, and R11 were unaware of what the facility rules and rights were, and stated nothing has ever been gone over in resident council or posted in the facility that they knew of. R33 was unaware she could still vote while a resident of the facility. On 8/03/23 at 10:50 AM, a tour of the facility was taken, and no postings were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 deliver mail six days a week. This has the potential to affect all 62 residents residing in the facility. Findings include: Long Term Ombudsman Program Resident Rights for People in Long-term care Facilities, dated 12/04, documents Your facility must deliver your mail to you promptly. On 8/03/23 at 10:05 AM, a resident council meeting was conducted in the sunroom. During the resident council meeting, R39, R42, R33, and R11 were asked if they got mail delivered on Saturdays and during the week. R39, R42, R33, and R11 all stated they did not get mail delivered on weekends, and if a package was delivered on Saturday they had to wait until Monday when V13 Activity Director came back to work because V13 is who delivers the mail and packages and only works Monday through Friday. On 8/03/23 at 10:50 AM, a tour of the facility was taken, and a paper was posted in the clear glass display case at the nurse's desk that documents All mail that is available to be handed out will be given to activities by 1:00pm for…

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

Based on interview and record review, the facility failed to inform residents of their rights and where/whom to file a grievance. This has the potential to affect all 62 residents residing in the facility. Findings include: Facility Resident Grievances/Complaints, revised 11/1/17, documents It is the policy to actively encourage residents and their representatives to voice grievances and complaints on behalf of themselves or others. The facility shall provide contact information including: grievance official name, business address, business phone, a reasonable timeframe for completing the review of the grievance. On 8/03/23 at 10:05 AM, a resident council meeting was conducted in the sunroom. During the resident council meeting, R39, R42, R33, and R11 were asked if they knew who their grievance official was and how to file a grievance. R39, R41, R33, and R11 were unaware of who their grievance official was and stated there was no posting they were aware of on who to file a grievance to. On 8/03/23 at 10:50 AM, a tour of the facility was taken, and no postings were found on how to…

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

Based on record review and interview, the facility failed to ensure a Registered Nurse/RN was staffed eight hours per day, every day in July 2023. This failure has the potential to affect all residents residing in the facility on those days. FINDINGS INCLUDE: The facility's Nurse Staffing Schedule, for July 2023, document the facility failed to staff a Registered Nurse on July 8, 9, 25, and 28, 2023. On 8/4/2030, at 11:38 AM, V2/Director of Nursing confirmed the facility did not provide a RN for at least 8 hours on July 8, 9, 25, and 28, 2023. V2 confirmed resident census, on the aforementioned days, was 61, 61, 65, and 64, respectively. Resident Census and Conditions form, dated 8/2/23, documents 62 resident live in the facility.

Based on interview and record review, the facility failed to offer residents snacks outside of the scheduled meal service times. This has the potential to affect all 62 residents residing in the facility. Findings include: Facility Diet Listing, undated, documents 62 residents eat at the facility. Facility posted mealtimes documents Breakfast: 7:30am; Lunch: 12:00pm; and Dinner 5:30pm. Facility Evening Snacks, revised 10/15, documents It is the policy to offer each resident an evening snack and document whether the resident accepted or declined the evening snack. All residents will be offered a bedtime snack. On 8/03/23 at 10:05 AM, a resident council meeting was conducted in the sunroom. During the resident council meeting, R39, R42, R33, and R11 were asked if they were offered snacks throughout the day. R39, R41, R33, and R11 all stated they were not offered snacks and R41, R11, and R33 stated they were all diabetics and not offered a bedtime snack. On 8/03/23 11:40 AM, V7 Certified Nurse Aid/CNA stated There are no resident snacks passed by us, I just came to day shift off of PM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the Facility failed to accurately complete, document, systematically organize and have readily accessible medical records for all 62 Residents residing in the Facility. This failure has the potential to affect all 62 Residents residing in the Facility. Findings include: Resident Census and Condition Report, dated 8/2/23, document 62 residing in the Facility. Facility Administrator Job Summary, undated, documents: the Administrator is responsible for managing, planning, organizing, staffing, directing, coordinating, reporting, budgeting and the physical management of the Facility, Residents and equipment in a way that the purpose of the Facility shall be maintained in accordance with all established practices, policies, laws and applicable State Regulations; the Administrator will manage and conduct the business of the Facility in a manner that protects the Facility license and certification at all times; and the major goal of the Administrator is to provide an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. The facility's Medication Administration policy and procedure, Revised 11/18/17, documents 11. Avoid touching medication. If contact with medication is likely, prepare medication using gloves. 12. Appropriate hand washing is to be completed and/or alcohol based get rub or (cleansing agent) must be used, throughout the medication pass. This should occur: Before and after medication pass. After touching an oral medication during administration. It is acceptable to use an antiseptic gel type solution between residents. On 8/2/23 at 8:18 am V4 LPN (Licensed Practical Nurse) stepped up to the medication cart and did not perform hand hygiene prior to preparing medications for R15. V4 LPN noted to have a soiled protective adhesive bandage to her right thumb. V4 LPN reached into her uniform pocket, pulled out set of keys, unlocked the medication cart, and using keys unlocked the narcotic lock box. V4 LPN pulled out R15's Phenobarbital 64.8 mg bubble packed medication card and using her ungloved soiled right thumb…

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

Based on interview and record review, the facility failed to ensure the facility's designated Infection Control Preventionist (ICP) was scheduled to work at the facility in a manner that allowed the Infection Control Preventionist role to be fulfilled and failed to ensure the DON (Director of Nursing) who assists in the ICP role completed an approved ICP Certification. This failure has the potential to affect all 62 residents who currently reside in the facility. Findings Include: The facility's Infection Control Surveillance and Monitoring Policy, revised 4/11/22, states, It is the policy of the facility to do routine surveillance and monitoring of the facility to determine if compliance with infection control practices is maintained. The facility shall employ, at a minimum, a part time Infection Control Preventionist (ICP). These duties may be performed by the Director of Nursing (DON) with an approved Infection Control Certification. This same policy documents that the DON/ICP will: Investigate and implement controls to prevent infections in the facility; Direct the correct…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 person-centered plan of care for four of 16 residents (R23, R29, R37, R56) reviewed for care plans in the sample of 26. Findings include: The facility's Comprehensive Care Planning Policy, revised 7/20/22, states, 4. Comprehensive Care Plans shall strive to describe a. The resident's preferences, choices, and goals to the extent possible to assist in attaining or maintaining the resident's highest practicable quality of life. b. The resident's medical, nursing, physical, mental, and psychosocial needs and preferences. c. Person centered measurable objectives and timeframes for ease of evaluating resident progress toward achieving goals. 8. Communication of the Care Plan contents is paramount to the success of consistent care delivery. 1. R37's Face sheet documents R37 was admitted to the facility on [DATE]. R37's Cumulative Diagnosis Log documents R37 as a smoker. The facility's Smoking List documents R37 as a current smoker in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to review and revise a care plan for six (R29, R38, R68, R419, R43, and R56) of 26 residents reviewed for care plan revision in a sample of 26. Findings include: Facility policy, entitled Comprehensive Care Planning, revised [DATE], document, The following procedures shall be utilized in the development and maintenance of care plans: 1.b. The Care Plan shall be revised as necessary when the needs/problems and care and services specified in the plan of care no longer reflect those of the resident. 1. R29's Physician Order Sheet (POS), dated [DATE]-[DATE], documents Kidney Disease Stage Three. On [DATE] at 9:30 AM, R29 had was in bed with a right chest port in place with a dressing dated [DATE]. R29 stated she gets her Dialysis thru her right chest port on Tuesday, Thursday, and Saturday at a (local) Dialysis center, and has been on Dialysis for one year. On [DATE] at 9:30 AM, V6 Licensed Practical Nurse/LPN stated (R29) goes to Dialysis Tues,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 consents for residents on psychotropic medications, failed to provide clinical justification for the use of dual therapy, failed to identify and track behaviors that warranted the use of psychotropic medications, failed to ensure behavior tracking logs and resident care plans identified specific target behaviors, failed to document non-pharmacological interventions prior to the use of psychotropic medications, and failed to complete psychotropic medication assessments for five of six residents (R23, R37, R38, R43, R65) reviewed for unnecessary medications in the sample of 26. Findings include: The facility's Psychotropic Medication Policy revised 11/28/17, states, It is the policy of this facility that residents shall not be given unnecessary drugs. Unnecessary drugs is any drug used: 1. In an excessive dose, including in duplicative therapy. 2. For excessive duration. 3. Without adequate monitoring. 4. Without adequate indications…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a physician's order was obtained for code status (Do Not Resuscitate/DNR) for one resident (R419) of 26 residents, in a total sample of 26 residents reviewed for DNR Physician orders. FINDINGS INCLUDE: Facility policy, entitled Advance Directive, Revised [DATE], documents, 4. Any decision made by the resident shall be indicated in the chart in a manner easily understood by all staff. Advance directives specifying full code/attempt resuscitation/CPR [Cardio-Pulmonary Resuscitation] or the absence of determination shall be recorded as a Full Code. Those residents indicating Do Not Attempt Resuscitation/DNR shall be recorded as DNR. Staff must be aware of any requests for limited Medical Interventions shall be recorded appropriately on the care plan. DNR or requests for comfort measures only shall be recorded as signifying DNR-Comfort. Code status shall also be recorded on the resident's Physician Order Sheet. R419's IDPH [Illinois Department of…

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

Based on interview and record review, the facility failed to submit correct MDS (Minimum Data Set) assessments for two residents (R5 and R56) reviewed for MDS correctness in a sample of 26. Findings include: The facility's Comprehensive Assessment/MDS (Minimum Data Set) Policy, dated 11/1/17, documents: It is the policy of (facility) to comprehensively assess and periodically reassess each resident admitted to this facility. The results of this resident assessment shall serve as the basis of determining resident strengths, needs, goals, life history and preferences to develop a comprehensive plan of care for each resident with the goal of attaining or maintaining the resident's highest practicable physical, mental, and psychosocial well-being. 1. R5's current Physician Orders, dated 8/1/23, documents R5 has a diagnosis of Bipolar; R5's current Physician Orders does not document a diagnosis of Post Traumatic Stress Disorder/PTSD. R5's MDS (Minimum Data Set), dated 5/15/23 Section I Active Diagnoses, does not document R5's diagnosis of Bipolar but does document (with a checkmark 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.

Based on observation, interview and record review the Facility failed to document a completed admission Smoking Assessment in R219's Medical Chart for one Resident (R219) of 12 reviewed for Smoking in a sample of 26. Findings include: Facility Resident Smoking Policy, undated, documents that each Resident whom chooses to smoke will have a Smoking Assessment completed prior. Facility Smoking and Vaping Policy, revised 10/27/22, documents: the Facility works to provide appropriate care for Residents keeping safety and comfort in mind; implementation of the Smoking Safety Risk Assessment will be conducted once the Resident indicates they may want to smoke; and development of the Resident Smoking Contract will be completed by the Social Service Designee and the Resident. Facility Residents Who Smoke List, undated, documents R219 as a smoker. R219's admission Nursing Assessment, dated 7/19/23, documents that R219 is alert/oriented and has an orthopedic cast to the right wrist/forearm. R219's current Care Plan, documents R219 has chosen to continue smoking. On 8/2/23, during the hours of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the Facility failed to follow Physician Orders for Resident weights for one (R219) of 26 Residents reviewed for Weights in a sample of 26. Findings include: Facility Resident Weight Monitoring Policy, revised 9/2008, documents: it is the policy of the Facility that the Resident weights are recorded and monitored at least monthly; new admission weight is obtained within 24 hours of admit; weights and re-weigh results are recorded by nursing staff on the Report of Monthly Weight Form in the medical record; Residents who have been determined by the Weight Committee to be increased risk for weight loss will be put on weekly weights for at least four weeks; and all new admissions and re-admissions will be weighed weekly for at least four weeks. R219's Physician Order Sheet/POS, dated 7/19/23, documents that R219 admitted to the facility on [DATE]. The POS also documents an order, on 7/19/23, for daily weights for three days, then every week for four weeks. R219's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to meet the professional standards of quality care to ensure required care and services were provided for residents receiving enteral nutritional feedings for two (R29 and R56) of two residents and failed to implement a physician referral for a resident who is refusing gastrostomy tube cares, feedings, and flushes for one (R56) of two residents reviewed for gastrostomy tubes in the sample of 26. Findings include: The facility's Daily Cleansing of G/J/Peg Tube Site policy and procedure, dated 4/2007, documents It is the policy of (the facility) to provide care and services to the resident with a gastrostomy or Jejunostomy tube to maintain the site in clean and safe manner as to minimize the risk of infection. This policy documents the procedure for cleansing the tube site. The Facility Conformance with physician medication orders, reviewed 9/27/17, documents A complete and accurate listing of current medication orders will be maintained 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 have oxygen orders on one (R29) of one resident reviewed for oxygen in a sample of 26. Findings include: Facility Conformance with physician medication orders, reviewed 9/27/17, documents A complete and accurate listing of current medication orders will be maintained on the residents Physician Order Sheet. On 8/02/23 at 9:30 AM, R29 was in bed and had 4 liters of oxygen on via nasal cannula. R29 stated she has oxygen only because she had a hard time breathing due to excess fluid. R29 was able to answer questions but becomes short of breath with talking. R29's Physician Order Sheets (POS), dated 8/1-8/31/23, has no documentation R29 is on oxygen. On 8/03/23 at 9:30 AM, V6 Licensed Practical Nurse/LPN stated I don't see (R29's) oxygen orders on her physician order sheet and it should be. (R29) wears oxygen for comfort at night, and as she needs.

Based on observation, interview, and record review, the facility failed to have Dialysis orders, failed to obtain a daily weight, and failed to coordinate communication between the Dialysis facility and the nursing home on one (R29) of one resident reviewed for Dialysis in a sample of 26. Findings include: Facility Conformance with physician medication orders, reviewed 9/27/17, documents A complete and accurate listing of current medication orders will be maintained on the residents Physician Order Sheet. Facility Outpatient Dialysis Services Agreement, dated 3/17/07, documents The Nursing Facility shall ensure that all appropriate medical and administrative information accompanies all residents at the time of transfer to the Dialysis Unit. The parties will mutually develop a written protocol governing specific responsibility's, policies and procedures to be used in rendering Dialysis services to residents including the development and implementation of a resident's care plan relative to the provision of Dialysis services. The Nursing Facility will provide for the interchange of…

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

Based on observation, interview, and record review the facility failed to ensure a cooked pork roast was cooled to a safe temperature before storing in the refrigerator, open containers of food were covered to prevent contamination and labeled with the date opened, foods with expired dates were discarded, staff food was not stored in the refrigerator with residents' food, refrigerators were clean and without debris, and clean bowls in the kitchen were stored to prevent debris from falling into the eating surface. These failures have the potential to affect all 67 residents in the facility. Findings include: A Storage policy dated 10/2020 states, When using only part of a product, the remaining product should be in the original package or airtight container and labeled and dated. This policy also states, Do not leave serving utensils or tools in food containers. A Food from Outside Sources/Personal Food Storage policy dated 4/2017 states, All residents have the right to accept food brought to the facility by any visitor (s) and/or food from a facility garden, however, the food must…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure staff wore masks covering their noses and mouths while in the resident areas of the facility. This failure has the potential to affect all 57 residents in the facility. Findings include: A COVID-19 Control Measures policy dated as revised 2/21/22 states, Anyone entering the facility must wear a facemask. On 6/12/22 at 9:15a.m. V4 (Licensed Practical Nurse/LPN) walked from the residents' hallway through the facility's dining room to the side entrance of the building without wearing a face mask. V4 proceeded to talk with visitors who just entered the building before walking back through the dining room into the patient hallway where the nurses' desk was located. At 9:40a.m. V3 (LPN/Infection Preventionist) was standing behind the nurses' station which was centrally located between the three resident hallways. V3 was wearing a facemask which was placed under her chin and not covering her nose or mouth. V3 stated that staff are supposed to wear a facemask covering their noses and mouths while 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.

Based on interview and record review the facility failed to have documented efforts to obtain COVID-19 laboratory test results within 48 hours or that it attempted to contact its local and state health departments for assistance with timely COVID-19 laboratory testing. These failures have the potential to affect all 57 residents in the facility. Findings include: A COVID-19 Testing policy dated 6/4/20 gives as its purpose, To identify asymptomatic cases, to confirm infection symptomatic cases, to evaluate quality indicators, to follow-up on infection control programs and to support decision making. On 6/12/22 at 10:16a.m. and 6/14/22 at 2:00p.m. V2 (Director of Nurses) stated the facility recently had an outbreak of COVID-19 among its staff and residents. V2 stated that the facility's community transmission levels are high, and the facility was already testing unvaccinated staff two times weekly using a point of care (POC) rapid test. V2 stated that on 5/16/22 the facility had its first case of COVID-19 at which time they began a broad testing program for all residents and staff 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 provide Range of Motion exercises for limited range of motion, for seven of seven residents (R6, R9, R35, R40, R49, R55 and R57) reviewed for range of motion, in a sample of 27. Findings Include: The facility policy, Restorative ADL (Activities of Daily Living) Programs, dated (revised) 01/02 directs staff, Restorative programs shall be planned for any resident with a reasonable likelihood for improvement in their functioning levels or to prevent a loss of function. Documentation or program implementation, follow through and individual resident progress towards goals will be done as follows: The Nursing Assistant performing the program as part of the daily care will document and initial the daily flow sheet as indicated for each restorative program. 1. On 06/12/22 at 10:29 A.M., R9 was seated in a reclining wheelchair, in a resident room. R9's bilateral hands were in a contracture position. R9's Minimum Data Set assessment, dated 6/9/21,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reconcile controlled medications for 29 of 29 residents (R1, R5, R6, R9, R12, R14, R18, R19, R21, R22, R24, R26, R28, R29, R31, R32, R33, R35, R36, R37, R38, R47, R48, R49, R52, R54, R209, R308 and R309) reviewed for medications, in the sample of 29. FINDINGS INCLUDE: The facility policy, Controlled Substances, dated (revised) 11/6/18 directs staff, It is the policy of the facility that all drugs listed as Schedule II drugs are subject to specified handling, storage, disposal and record keeping. Schedule II drugs are to be kept under two separate locks requiring two separate keys. A permanently affixed locked cabinet within the locked medication cart may be used for safe keeping. The Schedule II cabinet must remain locked and the Charge Nurse shall have the key in her possession at all times. Only Licensed Nurses will have access to Controlled Substances. A control sheet for each prescription will be initiated. The control sheet will contain: Resident's Name, ordering physician name, Issuing Pharmacy, Name 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 perform daily skin checks and failed to follow dietary recommendations for the use of a high protein supplement for a resident with multiple pressure wounds for one of two residents (R57) reviewed for pressure wounds in a sample of 27. FINDINGS INCLUDE: The facility policy, Decubitus Care/ Pressure Areas, dated (revised) 01/18 directs staff, It is the policy of this facility to ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer. Nursing personnel are to notify dietary personnel of any pressure areas to seek nutritional support and monthly reviews by the Registered Dietician. When a pressure ulcer is identified additional interventions must be established and noted on the care plan in an effort to prevent worsening or re-occurring pressure ulcers. R57's current Physician Order Sheet, dated June 2022 documents that R57 was admitted to the facility on [DATE] 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 observation, interview and record review, facility staff failed to perform a resident bed to wheelchair transfer to minimize the risk of injury for one resident (R57) of three residents, reviewed for transfers, in a sample of 27. FINDINGS INCLUDE: The Facility's Fall Prevention policy (undated) documents, All staff must observe residents for safety. Interventions (fall) will be implemented for residents. New interventions will be written on the care plan. R57's current Physician Order Sheet, dated June 2022 documents that R57 was admitted to the facility on [DATE] with the following diagnoses: CVA (Cerebral Vascular Accident) with left sided weakness, Dementia, Aphasia and Delirium. R57's Minimum Data Set assessment, dated 5/26/22, documents R57 has functional limitation in range of motion impairments to one side of both upper and lower extremities. This same form documents that R57 is totally dependent on two staff members for bed to chair transfers. R57's current Care plan includes the following…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 minimize the risk of infection by keeping a urinary collection bag off of the floor and failed to place a urinary collection bag in a privacy bag for two of two residents (R13 and R57), reviewed for urinary catheters, in a sample of 27. FINDINGS INCLUDE: The facility policy, Urinary Drainage Collection Unit, dated (revised) 2/18 directs staff, To provide a sterile collection unit for urinary drainage to minimize entry of bacteria into the bladder. Hang the urinary drainage unit below the bladder level, not touching the floor. Keep urinary drainage bag in a catheter cover (dignity bag). 1. R57's current Physician Order Sheet, dated June 2022 includes the following diagnoses: Urinary Retention, Neurogenic Bladder, History of Urinary Tract Infection and Proteinuria. Also included are the following physician orders: Catheter change monthly with #16 Coude, 10 ML (Milliter) balloon and Supra Pubic Catheter Site Care every shift. On 06/12/22 at 9:15 A.M., R57 was lying in bed. A urinary catheter collection bag 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 observation, interview and record review the facility failed to provide behavioral health care services and develop individualized interventions/programs recommended in the PASRR (pre-admission screening and resident review) for one of one resident (R51) reviewed for behavioral health services in a sample of 27. Findings include: The Facility Assessment, dated March 2022, documents services and care we offer based on our Residents' need. Mental health and behavior to manage medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individual with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individual with depression, trauma/PTSD, other psychiatric diagnoses, intellectual or developmental disabilities. This form also documents that the facility must have sufficient staff who provide direct services to residents with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain…

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

Based on observation, interview and record review, the facility failed to follow manufacturer's warnings for administration of medications, for two residents (R36, R42) in the sample of twelve residents, reviewed for medication pass. This failure resulted in two medication errors out of thirty opportunities for error, for a 6.67% medication error rate. FINDINGS INCLUDE: The facility policy, Medication Administration (revised 11/18/17) directs staff, Medications must be identified by using the seven rights of administration: right resident, right drug, right dose, right consistency, right time, right route and right documentation. 1.) R36's current Physician Order Sheet, dated June 2022 includes the following diagnosis: Diabetes Mellitus. This same document includes the following medication: Lispro Insulin 18 Units subcutaneous after meals. On 6/12/22 at 11:47 A.M., V4/Licensed Practical Nurse (LPN) prepared to administer medications to R36. V4/LPN withdrew an Insulin pen from the top of the medication cart, applied a needle and without following the printed manufacturer's warning of…

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

Based on record review and interview the facility failed to do accuchecks (test for blood sugar levels) or give insulin to one resident (R36) of three residents reviewed for insulin in a sample of 27. Findings include: The facility Medication Administration policy revised 11/18/17, documents Drug administration shall be defined as an act in which a single dose of a prescribed drug or biological is given to a resident by an authorized person in accordance with all laws and regulations governing such acts. The complete act of administration entails removing an individual dose from a previously dispensed, properly labeled container (including a unit dose container), verifying it was the physicians order, giving the individual dose to the proper resident, and promptly recording the time and dose given. Medications must be prepared and administered within one hour of the designated time or as ordered. R36's current medical record documents R36 has a diagnosis of Diabetes Mellitus. R36's Physician Order dated 6/1/22 - 6/30/22 documents ACCUCHECK (before meals and bedtime) daily at 8:00…

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