Aperion Care Elgin

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to schedule neuropsychological testing for a resident as ordered by the neurology 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] with multiple diagnoses including convulsions, abnormal gait and mobility, cognitive communication deficit, diarrhea, chronic pain syndrome, nontraumatic intracerebral hemorrhage, cerebral infarction, generalized anxiety disorder, bipolar disorder, major depressive disorder, mild vascular dementia with agitation, violent behavior, and low back pain. R1's MDS (Minimum Data Set) dated December 23, 2024 shows R1 has severe cognitive impairment, requires setup assistance with eating, partial/moderate assistance with showering, and supervision with all other ADLs (Activities of Daily Living). R1 is occasionally incontinent of bowel and bladder. On March 3, 2025 at 11:55 AM,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 schedule an ophthalmology appointment for a resident as ordered by the neurologist. 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] with multiple diagnoses including convulsions, abnormal gait and mobility, cognitive communication deficit, diarrhea, chronic pain syndrome, nontraumatic intracerebral hemorrhage, cerebral infarction, generalized anxiety disorder, bipolar disorder, major depressive disorder, mild vascular dementia with agitation, violent behavior, and low back pain. R1's MDS (Minimum Data Set) dated December 23, 2024 shows R1 has severe cognitive impairment, requires setup assistance with eating, partial/moderate assistance with showering, and supervision with all other ADLs (Activities of Daily Living). R1 is occasionally incontinent of bowel and bladder. On March 3, 2025 at 11:55 AM, R1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an MRI (Magnetic Resonance Imaging) as ordered by the neurologist. 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] with multiple diagnoses including convulsions, abnormal gait and mobility, cognitive communication deficit, diarrhea, chronic pain syndrome, nontraumatic intracerebral hemorrhage, cerebral infarction, generalized anxiety disorder, bipolar disorder, major depressive disorder, mild vascular dementia with agitation, violent behavior, and low back pain. R1's MDS (Minimum Data Set) dated December 23, 2024 shows R1 has severe cognitive impairment, requires setup assistance with eating, partial/moderate assistance with showering, and supervision with all other ADLs (Activities of Daily Living). R1 is occasionally incontinent of bowel and bladder. On March 3, 2025 at 11:55…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 transportation arrangements were made for a resident with a scheduled physician follow-up appointment. 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] with multiple diagnoses including convulsions, abnormal gait and mobility, cognitive communication deficit, diarrhea, chronic pain syndrome, nontraumatic intracerebral hemorrhage, cerebral infarction, generalized anxiety disorder, bipolar disorder, major depressive disorder, mild vascular dementia with agitation, violent behavior, and low back pain. R1's MDS (Minimum Data Set) dated December 23, 2024 shows R1 has severe cognitive impairment, requires setup assistance with eating, partial/moderate assistance with showering, and supervision with all other ADLs (Activities of Daily Living). R1 is occasionally incontinent of bowel and bladder. On March…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 discard expired food items from the dry storage. The facility also failed to follow its dishwashing machine operation guidelines by not checking the dishwashing machine before its first use to ensure sanitization. This applies to all 87 residents consuming food from the kitchen. The Findings Include: On 4/30/24 at 10:12 AM, during an initial tour of the kitchen, the kitchen dry storage was observed with two one-gallon Worcestershire sauces used by the date of 12/13/2022. On 4/30/24 at 10:15 AM, V11 (Dietary Manager) stated that the expired sauce shouldn't be there and that he would discard it. The facility presented food storage guidelines and procedural Manual (2020) document: c. Discard food that has passed the expiration date, and discard food that has been prepared in the facility after seven days of storing it under proper refrigeration. On 5/1/24 at 9:48 AM, the kitchen was observed with V10 (Dietary Aide) running the dish machine after breakfast. As per the surveyor's request, V10 reran the machine…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess residents for self-administration and storage of medication, as well as notifying and ordering medications for residents who were self-administering. The facility also failed to ensure residents took their medications during medication pass. This applies to 4 of 4 residents (R12, R25, R34, R71) reviewed for administration and storage of medications in a sample of 26. The findings include: 1. On April 30, 2024 at 10:40 AM, R25 had a 245-milliliter bottle of generic day time severe cold and cough medicine which contained acetaminophen, dextromethorphan hydrobromide, and phenylephrine hydrochloride on the bedside table. R25's bottle of cough medicine appeared half empty. R25 was admitted to the facility with diagnoses including chronic obstructive pulmonary disease, abnormalities of gait and mobility, chronic respiratory failure, chronic pulmonary edema, hyperlipidemia, and muscle wasting. R25's MDS (Minimum Data Set) dated April 18,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess and care plan residents that smoke per facility policy. The facility also failed to ensure smoking materials were kept in the designated secure location. This applies to 5 of 9 residents (R46, R62, R71, R74, and R387) reviewed for safe smoking in the sample of 26. The Findings Include: 1. R46 is a [AGE] year-old male admitted on [DATE] with moderately impaired cognition as per the Minimum Data Set (MDS) dated [DATE]. R46 was observed on 4/30/24 at 10:45 AM in his room with an opened pack of cigarettes and matches on the bedside table. R46 stated, I have cigarettes and matches with me to go for smoking. I may go for a smoke after lunch. Record review on smoking safety risk assessment for R46 dated 1/15/24 document: All smoking materials will be kept locked in the facility designated area. A review of the care plan documents that R46 was care planned for smoking non-compliance with interventions, including smoking materials, 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 verify the counting logs accuracy for residents with controlled medications (R28, R47, and R52) and failed to dispose of controlled medications (R43) per facility policy. This applies to 4 out of 4 (R28, R47, R43, and R52) residents in a sample of 26. Findings include: 1. On 4/30/2024 at 2:45 PM, R28's Pregabalin 100 mg (milligrams) medication punch card was observed with #27 through #30 pill slots punched out with no medications. R28's Control Drug Administration Record sheet did not show any entries for medication removal. V4 (Licensed Practical Nurse/LPN) was present during the observation and said he was not sure why the medications removed were not logged in R28's sign-off sheet. R28's Medication Review Report (MRR) dated 5/01/2024 did not show an order for Pregabalin. 2. On 4/30/2024 at 2:46 PM, R43's Hydrocodone-APAP 5-325 mg medication punch card was observed with the #3 through #6 pill slots punched open, with tape over them with a pill inside each slot. V4 (LPN) was present during the observation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide timely incontinence care to a resident dependent on toileting and failed to keep indwelling catheter drainage bag off the floor. This applies to 2 out of 2 residents (R46 and R48) observed for incontinence care and indwelling catheter care in a sample of 26. 1. On 4/30/2024 at 11:29 PM, R48 had a strong smell of urine. On 4/30/2024 at 11:32 AM, skin check with V13 (CNA-Certified Nurse Assistant) showed R48's incontinent brief was soaked with urine. R48's shirt and bed pad were soaked with urine. R48's coccyx was observed to be red. V13 provided incontinence care but did not apply barrier cream. On 5/2/2024 at 11:22 AM, V2 (DON-Director of Nursing) said she expects staff to check for incontinence care frequently at least every two hours. She said she expects staff to provide timely incontinence care to prevent skin breakdown and infection. R48 was admitted to the facility on [DATE]. MDS (Minimum Data Sheet) dated 3/27/2024 documents…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 its oxygen and respiratory equipment changing/cleaning policy by not changing respiratory tubing and humidifier on weekly basis and not storing nasal cannula and nebulizer mask in a plastic bag with zip loc. This applies to 3 of 3 residents reviewed (R10, R40, R46) for respiratory care in a sample of 26. The Findings Include: 1. R46 is a [AGE] year-old male admitted on [DATE] with moderately impaired cognition as per the Minimum Data Set (MDS) dated [DATE]. On 4/30/24 at 10:45 AM, R46 was observed on his bed with his nasal cannula on the floor with no date/label. The humidifier was observed to be dirty and had no date/label. On 4/30/24 at 10:45 AM, R46 stated, They don't care about the tubing change. I filled the humidifier water chamber a couple of times. 04/30/24 at 10:51 AM, V4 (Licensed Practical Nurse/LPN), The night shift is supposed to change tubing, date, and label tubing, and fill the water reservoir. Oxygen tubing should…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to monitor and document behaviors; and failed to develop and update plan of cares with interventions for residents (R1 and R61) with known behaviors related to mental disorders. This applies to 2 out of 2 residents (R1, R61) reviewed for behaviors in a sample of 26. Findings include: 1. R61's Electronic Medical Record (EMR) showed R61 admitted to the facility on [DATE]. R61's EMR showed multiple diagnoses including psychosis, paranoid delusions, and dementia. R61's MDS (Minimum Data Set) dated 3/20/2024 showed R61 was cognitively intact. R61's MDS continued to show R61 did not show any behaviors of potential indicators of psychosis, including delusions. On 4/30/2024 at 10:34 AM, R61 was in his room and his privacy curtain was pulled. R61 had an untouched old meal tray with a ham sandwich, brussels sprouts, potatoes, a carton of milk, and a [NAME] Krispie treat on his bedside table. R61 said the facility staff was trying to poison him by…

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

Based on observation, interview, and record review, the facility failed to administer medications as ordered. There were 25 opportunities with 3 errors resulting in a 12% error rate. This applies to 2 out of 2 (R29, R77) residents in a sample of 26. Findings include: 1. On 5/01/2024 at 8:10 AM during medication administration, V5 (Licensed Practical Nurse/LPN) said R77 had scheduled 11 units of Aspart (insulin). V5 turned R77's Aspart FlexPen dose knob to 11 units then administered it on R77's right arm and quickly removed the pen from the injection area. R77's Medication Review Report (MRR) dated 5/01/2024 showed an order for Insulin Aspart FlexPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject 11 unit subcutaneously with meals for DM2. 2. On 5/01/2024 at 8:38 AM during medication administration, V5 said R29 had scheduled 12 units of Humalog (insulin). V5 turned R29's Humalog Kwikpen dose knob to 12 units then administered it to R29's right mid abdominal area and quickly removed the pen from the injection area. 3. Then V5 continued to say R29 had 2 units 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 administer the correct doses of insulin medications to residents (R29 and R77) and scheduled pain medication to a resident (R26). This applies to 3 out of 3 (R26, R29, R77) residents in a sample of 26. Findings include: 1. On 4/30/2024 at 2:46 PM during medication cart check, V4 (Licensed Practical Nurse/LPN) said he signed off R26's scheduled 9 AM Tramadol medication in the MAR (Medication Administration Record) but forgot to administer it that morning. R26's Tramadol 50 MG TAB medication punch card showed R26's 9 AM scheduled dose for 4/30/2024 was not removed. R26's Medication Review Report (MRR) dated 5/01/2024 showed an order for Tramadol HCI Oral Tablet 50 MG (Tramadol HCI) Give 1 tablet by mouth one time a day for Chronic pain. 2. On 5/01/2024 at 8:10 AM during medication administration, V5 (LPN) said R77 had scheduled 11 units of Aspart (insulin). V5 turned R77's Aspart FlexPen dose knob to 11 units then administered it on R77's right arm and quickly removed the pen from the injection area. R77's MRR…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dispose of expired medications. This applies to 2 of 2 (R34, R47) residents in a sample of 26. Findings include: 1. On 4/30/2024 at 3:12 PM, the medication storage task was done with V3 (Registered Nurse/RN) in the facility's [NAME] Hall medication room. The medication storage refrigerator had multiple medications stored including two bottles of R34's Vancomycin liquid solution with liquid solutions inside with expiration labels date of 4/01/2024. The Vancomycin bottle's labels said Use this bottle for dispensing after reconstitution. Contents MUST be used within 14 days, discard if hazy. R34's Medication Record Report (MRR) dated 5/01/2024 did not show an order for Vancomycin. 2. The medication storage refrigerator also had an opened hospice kit box with R47's medications. R47's box kit had one bottle of Lorazepam oral solution with liquid solution inside and an expiration label date of 3/02/2024, two needless syringes of Scopolamine gel with solution inside and they had an expiration label date 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 ensure a resident was free from physical abuse. This applies to 2 of 3 residents (R8 and R9) reviewed for abuse in the sample of 11 The findings include: 1. On 11/02/2023 at 11:23 AM, R8 was wheeling his wheelchair and showed where R7 hit him to his right arm. R8 did not provide details and said he was fine now. R8 said he entered R7's room, and he did not like it. On 11/02/2023 at 11:28 AM, R7 was sitting in his wheelchair and said he had a sign on by his door not to enter his room and R8 did anyway. R7 said he was wrong, apologized to R8, and it's all good now. On 11/03/2023 at 3:37 PM, V12 (Certified Nursing Assistant) said that on 10/21/23, she heard a call light in R8's room, and when she checked, he was not there, and at the same time, yelling was coming from R7's room. V12 said R7 was swinging his cane towards R8 who was by the door, and R8 had a skin tear in his right chin and discoloration in his arm. R8 said R7 was talking bad…

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

Based on observation, interview, and record review, the facility failed to serve palatable meals to the facility residents. This applies to all 91 residents residing in the facility. The findings include: Facility Resident Census and Conditions of Residents, dated 6/5/23, shows the facility census was 91 residents. On 6/6/23, V4 (Food Service Director) stated all residents in the facility were receiving oral diets and there were no residents with physician orders for NPO (Nothing by Mouth). On 6/05/23 at 12:21 PM during lunch service, a test tray of a regular diet was performed. The food was being served from the steam table in the main dining room onto room-temperature plates and the plated food was being covered with an insulated cover and placed on a tray rack for service to resident rooms. The room trays were delivered to the resident hallway and at 12:33 PM, the facility staff finished serving the room trays to the facility residents in the hallway. The food temperatures of the test tray were tested, and the pork entree measured 101.6 degrees F (Fahrenheit), the vegetables…

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

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in a sanitary manner. This applies to all 91 residents residing at the facility receiving oral diets. The findings include: 1. On 6/05/23 at 10:00 AM during initial tour of the kitchen the following concerns regarding sanitation were identified: There were dried food streaks down left side of fry top and down left side of stove top. V26 (Cook) was standing at the cook prep table utilizing the chemical sanitizing solution wiping cloth from the sanitizing bucket located at the cook station to wipe/sanitize the prep table in front of stove. V26 measured the chemical sanitation solution in the bucket at cook station measured 100 ppm (parts per million). V26 walked to the three-compartment sink and replaced the chemical sanitizing solution in the sanitizing bucket. V26 measured the concentration of the sanitizing solution which measured 100 ppm. Facility sanitizing chemical manufacturer information, dated 2018, shows the quaternary sanitizer test paper reading was expected to read…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 their water management program for prevention of legionella growth. The facility also failed to follow their policy for hand hygiene during R69 and R88's wound care. This applies to all 91 residents residing in the facility. The Resident Census and Conditions of Residents report dated June 5, 2023, shows the facility census as 91 residents. The findings include: 1. On June 5, 2023, at 4:05 PM, V1 (Administrator) said V15 (Maintenance Director) is in charge of the water management prevention program. On June 5, 2023, at 4:08 PM, V15 said, I do not do anything for the water management program for legionella. I do not believe we can have legionella here because it comes from water towers. On June 6, 2023, at 4:23 PM, V15 said, I check the hot water temperatures once a week. I do not keep a log of the water temperatures. The facility has an eye washing station in the kitchen, and monthly I turn them on to make sure the covers come off.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 nail, facial care and transfer for toilet needs to residents needing assistance with ADLs (Activities of Daily Living). This applies to 4 of 8 (R16, R25, R19 and R76) residents reviewed for ADL in the sample of 20. The findings include: 1. On 06/05/23 at 10:00 A.M., R16 was in her room. R16 was sitting in her reclining wheelchair. R16 was observed with long, jagged fingernails. There was black substance under R16's fingernails. During this observation, V11 (CNA/Certified Nurse Assistant) came in to R16's room and proceeded to take R16 to the dining room. On 06/06/23 at 11:42 A.M., R16 was in the main dining room. R16 was still observed with long, jagged edges fingernails and black substance under her nails. On 06/07/23 at 10:58 A.M., R16 was in the hallway being propelled by her brother-in-law. R16 was observed with same long fingernails. V18 (LPN/Licensed Practical Nurse) was present during this observation. V18 said that R16 is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon observation, interview, and record review, the facility failed to follow physician orders for wound treatment and failed to provide pressure redistribution wheelchair cushion for a facility acquired pressure ulcer per physician orders. This applies to 1 of 5 residents (R14) reviewed for pressure ulcer prevention and treatment in the sample of 20. The findings include: The EMR (Electronic Medical Record) shows that R14 was admitted to the facility on [DATE]. R14's diagnoses include heart failure, peripheral vascular disease, bipolar II disorder, fibromyalgia. The EMR also shows that on June 23, 2022, R14 acquired an unstageable pressure ulcer on the left posterior thigh at the facility. The MDS (Minimum Data Set) dated March 13, 2023, shows that R14 was cognitively intact, needed limited assistance for transfer from bed to wheelchair, and used a wheelchair for mobility. The MDS shows R14 independently propelled her wheelchair. Initial wound note, dated June 23, 2022, shows V22 (Wound Care 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 implement fall prevention interventions for R54 when providing personal care. This applies to 1 (R54) of 3 residents reviewed for accidents and supervision in the sample of 20. The Physician Order Sheet (POS), printed 6/7/23, shows R54's diagnoses included dysthymic disorder, dysarthria, anarthria, psychosis, depressive disorder, adjustment disorder, anxiety disorder, agoraphobia, osteoarthritis, and history of falling. Resident Fall Care Plan, initiated on 12/2021 and revised 2/28/23, shows R54 fell on [DATE] and interventions implemented at the time of his 12/16/22 fall included providing two staff to assist him with ADLs (Activities of Daily Living). The care plan shows R54 also fell on 2/23/23. Nursing progress note, dated 2/23/23, show R54 fell from bed when R54 began flailing arms and his CNA (Certified Nursing Assistant) stepped away from resident to avoid being hit. The progress note does not indicate two staff were assisting R54 at the time 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 provide physician-ordered weight loss prevention interventions for a resident who experienced significant weight losses. This applies to 1 of 2 residents (R54) reviewed for weight loss in the sample of 20. The findings include: POS (Physician Order Sheet), printed 6/7/23, shows R54's diagnoses included dysthymic disorder, dysarthria, anarthria, psychosis, depressive disorder, adjustment disorder, anxiety disorder, agoraphobia, osteoarthritis, and history of falling. The POS shows R54 had physician orders for pureed diet, whole milk with all meals, fortified mashed potatoes and ice cream with all meals, super cereal daily with breakfast, and house nutrition supplement four times a day for supplement. Nutrition care plan, revised 6/5/23, shows R54 experienced a 9.8% weight loss from March 2023 to May 2023. Nutrition interventions included monitoring oral nutrition intake, documenting intake every meal, and providing nutrition supplements as ordered. Review of resident diet tickets show R54 was to receive ice…

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