River View Rehab Center

Based on observation, interview, and record review, the facility failed to provide a safe and homelike environment. This applies to 1 of 1 resident (R179) reviewed for environment in a sample of 37. The findings include:On 9/03/2025 at 8:55 AM, R179 stated, My window is broken, the bottom half part. Do you see all the sharp pieces? R179 stated that the window has been broken for the past 2 years. He stated that he told everyone, but no one has done anything. R179 stated he used to feed the birds, but because of the broken glass he doesn't want to cut his hands. R179's MDS (Minimum Data Set) dated 8/20/25 shows that he is cognitively intact. R179's window had a broken bottom half with jagged and sharp edges where the damaged glass was exposed. There was a piece of cardboard on it.On 9/03/2025 at 11:57 AM, V4 (Maintenance Director) stated he has been working in the facility for two years. He stated he didn't see a work order for R179. V4 stated that R179 never told him anything about his window being broken. V4 stated, It might have been broken before I got here. On 9/3/25 at 12:10…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received oxygen therapy as ordered by physician.This applies to 2 of 3 residents (R130 and R69) reviewed for respiratory care in a sample of 37. The findings include: 1.R130's Face Sheet shows a primary admission diagnosis of Chronic Obstructive Pulmonary Disease. R130 also has diagnoses of dependence on supplemental oxygen and congestive heart failure. R130's MDS (Minimum Data Set) dated 8/6/25 shows her cognition is intact. On 9/2/25 at 10:51 AM, R130 was observed using 4 liters of oxygen per nasal cannula connected to oxygen concentrator. R130's oxygen concentrator had the humidifier water and canister, but it did not have any tubing connecting the humidifier to the oxygen. R130 said the staff have not given her the tubing for the humidifier and told her they do not have the tubing. On 9/3/25 at 3:01 PM, R130 was again observed wearing her 4 liters of oxygen, off the concentrator, without any humidity. It was noted 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 assist a resident in obtaining emergency dental services.This applies to 1 of 3 residents (R34) reviewed for dental services in a sample of 37.Findings include:On 9/02/2025 at 11:00 AM, R34 said he had ongoing right molar pain, 9 out of 10. R34 said he started to experience tooth problems in February 2025, when his tooth began to chip off. R34 said during his routine dental visit in February 2025, he was informed he needed a root canal extraction procedure to manage his tooth pain. R34 said his tooth was now more chipped and causing him more discomfort, especially when eating. R34 said he continuously tried to follow up with V6 (Social Worker) for assistance with his dental referral and was still waiting to receive an update.On 9/04/2025 at 11:00 AM, V6 (Social Worker) said he was responsible with assisting residents who required outside dental referral services, including for tooth extractions. V6 said he was informed in February 2025, regarding R34's needed dental procedure. V6 said based on R34's Medicaid insurance…

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

Based on observation, interview, and record review, the facility failed to remove expired food items from resident refrigerators and failed to provide a thermometer.This applies to 3 of 5 residents (R75, R110, and R181) reviewed in a sample of 37.The findings include: On 9/2/25 at 10:00 AM, initial tour of the first floor was conducted. The following observations were made: 1. On 9/2/25 at 10:57 AM, R75's fridge had two 15 oz cups of peach in his fridge. The peach cups expired on June 14, 2025. He said it is the cleaning lady who checks his fridge but is not done daily. 2. On 9/2/25 at 12:21 PM, R110's fridge had expired half consumed vegan cream cheese. The vegan cream cheese expired on 5/15/25. She said she has not seen any staff cleaning her fridge in days. On 09/3/25 at 12:21 PM, V5 (Housekeeping Director) said housekeepers are responsible for keeping the refrigerators clean. She said housekeepers should clean the refrigerators every day and dispose of expired foods. She said all expired foods should be thrown away for safety reasons. On 9/4/25 at 9:09 AM, V2 (DON-Director 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, direct care staff member failed to follow the facility's policy and procedures and immediately notify the nurse after a resident fall. This failure led to a delay of assessment by the nursing staff for the resident within the required time frame. This applies to 1of 3 residents (R1) reviewed for falls in a sample of 8. The findings include: On 4/16/25 at 10:13 AM, V4 (CNA-Certified Nursing Assistant) stated, On 4/7/25 between 10 AM to 10:15 AM, I brought (R1) to the shower room in his wheelchair. I put him on the shower chair. I had (R1) stand up and grab the handlebars. I scrubbed his back and butt with soap and a washcloth. Then I told (R1) to sit back down on his shower chair. Within 1 to 2 seconds, (R1) slides off. I picked him up and put him back on the chair. I asked (R1), does it hurt. He said no and that he has no pain. There were no injuries. I continued the shower. I asked (R1) if he wants me to tell anyone. (R1) said, Na, don't tell anyone right away. I dried him and put him in his gown and wheeled him back to his room. When I got to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to follow their abuse policy by not completing pre-admission screening of residents to ensure resident safety for 6 of 6 residents (R4, R10, R11, R12, R13, R1) reviewed in the sample of 14. The failure has the potential to affect all 179 residents in the facility. The findings include: The Facility Data Sheet form dated 3/27/25 showed a resident census of 179. 1. R4's admission Record showed R4 was admitted to the facility on [DATE]. R4's electronic medical records dated 2/19/25-3/31/25 showed no IDOC (Illinois Department of Corrections), Illinois Sex Offender Registry, or National Sex Offender Registry website checks had been completed on R4. 2. R10's admission Record showed R10 was admitted to the facility on [DATE]. R10's National Sex Offender Registry check was not completed until 3/31/25. 3. R11's admission Record showed R11 was admitted to the facility on [DATE]. R11's electronic medical records dated 3/17/25-3/31/25 showed no IDOC, Illinois Sex…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 initiate discharge planning for 1 of 3 residents (R1) reviewed for discharge planning in the sample of 14. The findings include: R1's admission Record showed R1 was admitted to the facility on [DATE] for rehabilitation therapy services due to his diagnosis of low back pain. R1's current care plan showed R1 was cognitively intact, ambulatory, and needed no staff assistance to complete his activities of daily living. R1's progress and nursing notes dated November 2024-March 2025 were reviewed. These notes showed multiple documented episodes of R1 having alcohol, drugs, and drug paraphernalia in the facility. The notes showed incidents of R1 being verbally aggressive and threatening towards residents and staff. The notes showed incidents of R1 repeatedly disobeying facility rules and leaving the facility despite his community pass privileges being revoked due to his behaviors. They showed multiple incidents of the local police being called to the facility…

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

Based on interview and record review, the facility failed to report and thoroughly investigate resident allegations of abuse per facility policy. This applies to 2 of 5 residents (R1 and R7) reviewed for abuse in a sample of 16. The findings include: 1. On 2/20/25 at 1:15 PM, R1 stated on 2/17/25 she told V23 (R1's Daughter) that on 2/16/25 V8 made verbal and written inappropriate comments regarding her body and also inappropriately washed her periarea and buttocks while showering R1. R1 stated V8 did not wash any other parts of her body and stated she should be washing herself. R1 stated she spoke with V26 (CNA) the next day about V8 washing her peri area and buttocks and R1 stated V26 told R1 did not require any staff to wash her body because R1 could do that independently. On 2/20/25, V23 (R1's Daughter) stated R1 reported to her on 2/17/25 that while in the shower, V8 allowed R1 to wash all of her body but when R1 began to wash her peri area and buttocks, V8 insisted on touching her and washing R1. V23 stated R1 told V23 that V8 also made several verbal comments regarding her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to permit a resident to return to the facility after he was transferred to the hospital. This applies to 1 of 3 residents (R5) reviewed for involuntary discharge in a sample of 16. The findings include: Face sheet, dated 2/22/25, shows R5's diagnoses included Huntington's disease and mood disorder. R5 was admitted to the facility on [DATE]. MDS, dated [DATE], shows R5 was cognitively intact and R5 was able to propel in a wheelchair once set up in the wheelchair. Care plan, dated 4/23/24, shows R5 was admitted to the facility on [DATE] with a criminal history of violating an order of protection and domestic battery. Approaches include, Review of my past behavior and evaluate the potential for me to engage in inappropriate / high risk behavior, provide R5 with supportive group intervention and/or 1:1 via a qualified provider, to promote safety intervene when I am observed to be engaging in inappropriate behavior, teach me impulse control strategies 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 it was free from physical abuse to 3 of 3 residents (R1, R2 and R3) reviewed for abuse in the sample of 3. The findings include 1. R1's face sheet printed on 2/4/25 show R1 has a diagnoses the include hypertension, morbid obesity, diabetes and cannabis use. R1's facility assessment dated [DATE] show R1 has no cognitive impairment. R2's face sheet printed on 2/4/25 show R2 has diagnoses that include stroke, diabetes and depression. R2's facility assessment dated [DATE] show R2 has no cognitive impairment The facility reported incident (FRI) sent to the state agency as final (date of incident 1/22/25) documents, upon investigation, it was discovered that [R2] was walking into the 2nd floor dining room to have dinner, when [R1] lifted her leg and hit R2 in the buttocks. R1 said she was playing around with R2 and the kick was not meant to be malicious but playful. Then when going to bingo. R2 states R1 backed up her wheelchair into her accidentally…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policy for grievance resolution and failed to ensure a grievance was resolved within 72 hours. This applies to 1 of 3 residents (R1) reviewed for grievances in the sample of 6. The findings include: The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. R1 has multiple diagnoses including, multiple sclerosis, dementia, osteopenia, depressive disorders, cerebral infarction, seborrheic dermatitis, history of falling, bipolar disorder, and convulsions. R1's MDS (Minimum Data Set) dated October 30, 2024 shows R1 has moderate cognitive impairment, requires supervision with eating, partial/moderate assistance with oral hygiene, personal hygiene, and bed mobility, and substantial/maximal assistance with toilet hygiene, showering, lower body dressing, and transfers between surfaces. R1 is frequently incontinent of bowel and bladder. On January 9, 2025 at 9:25 AM, R1 was lying in bed, covered 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, the facility failed to ensure a resident received assessment and treatment for a rash identified four months ago. 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]. R1 has multiple diagnoses including, multiple sclerosis, dementia, osteopenia, depressive disorders, cerebral infarction, seborrheic dermatitis, history of falling, bipolar disorder, and convulsions. R1's MDS (Minimum Data Set) dated October 30, 2024 shows R1 has moderate cognitive impairment, requires supervision with eating, partial/moderate assistance with oral hygiene, personal hygiene, and bed mobility, and substantial/maximal assistance with toilet hygiene, showering, lower body dressing, and transfers between surfaces. R1 is frequently incontinent of bowel and bladder. On January 9, 2025 at 9:25 AM, R1 was lying in bed, covered with multiple…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 foot care, including toenail clipping, and failed to ensure a resident was examined by a podiatrist as shown in the facility's foot care policy. This applies to 1 of 3 residents (R1) reviewed for foot care in the sample of 6. The findings include: The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. R1 has multiple diagnoses including, multiple sclerosis, dementia, osteopenia, depressive disorders, cerebral infarction, seborrheic dermatitis, history of falling, bipolar disorder, and convulsions. R1's MDS (Minimum Data Set) dated October 30, 2024 shows R1 has moderate cognitive impairment, requires supervision with eating, partial/moderate assistance with oral hygiene, personal hygiene, and bed mobility, and substantial/maximal assistance with toilet hygiene, showering, lower body dressing, and transfers between surfaces. R1 is frequently incontinent of bowel and bladder. On January 9, 2025 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a dependent residents fingernails were trimmed and hands cleaned for 1 of 1 residents (R20) reviewed for activities of daily living in the sample of 35. The findings include: R20's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include Chronic Obstructive Pulmonary Disease, Type 2 Diabetes, hypertension, hyperlipidemia, vascular dementia without behavioral disturbance, dysphagia, cerebral atherosclerosis, and paranoid schizophrenia. R20's facility assessment showed he has moderate cognitive impairment and requires substantial to maximum assistance with all cares. On 10/29/24 at 10:27 AM, R20 was lying in bed. R20's left hand was contracted. R20's fingernails on his left hand were very long and discolored from residue under his nails and his nails were pushing into the palm of his hand. On 10/29/24 at 10:34 AM, V5 (Wound Care Nurse) assessed R20's left hand. V5 said, This is not good, these finger nails…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 fluid restriction was in place for 1 of 2 residents (R30) reviewed for fluid restrictions in the sample of 35. The findings include: R30's face sheet showed he was admitted to the facility 7/2/2018 with diagnoses to include spina bifida, Type 2 Diabetes, iron deficiency anemia, hyperlipidemia, hypokalemia, neuromuscular dysfunction of bladder, Major Depressive Disorder, need for assistance with personal care, and hypo-osmolality and hyponatremia. R30's facility's assessment dated [DATE] showed he has no cognitive impairment and requires supervision through maximal assistance for cares. R30's 10/17/24 acute care hospital documents showed, . After Visit Summary . admission Diagnoses: . Hyponatremia; Cystitis . Fluid Restriction . 1800 ml . R30's physician order sheet showed an order dated 10/17/24 for Fluid Restriction: 1800 ml/day every shift for hyponatremia . On 10/29/24 at 9:43 AM, R30 said, Right now I got a limit on liquids…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pressure relieving interventions were in place for 2 of 6 residents (R57, R20) reviewed for pressure ulcers in the sample of 35. The findings include: 1. R57's face sheet printed on 10/31/24 showed diagnoses including but not limited to multiple sclerosis, diabetes mellitus, protein-calorie malnutrition, peripheral vascular disease, stage 4 pressure ulcer to the sacral region, left leg above the knee amputation, and history of osteomyelitis. R57's facility assessment dated [DATE] showed severe cognitive impairment and requiring total staff assistance with all activities of daily living. The same assessment showed the use of an indwelling catheter and R57 is always incontinent of bowel. The assessment showed the use of a feeding tube for nutrition. R57's physician order report showed she was admitted to hospice on 10/13/24. R57's wound evaluation report dated 10/17/24 showed stage four pressure ulcers to the sacrum, right hip, 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 accurately assess a resident with contractures and failed to ensure a hand splint was in place for a dependent resident with contractures for 1 of 1 residents (R20) reviewed for splints in the sample of 35. The findings include: R20's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include Chronic Obstructive Pulmonary Disease, Type 2 Diabetes, hypertension, hyperlipidemia, vascular dementia without behavioral disturbance, dysphagia, cerebral atherosclerosis, and paranoid schizophrenia. R20's facility assessment showed he has moderate cognitive impairment and requires substantial to maximum assistance with all cares. On 10/29/24 at 10:27 AM, R20 was lying in bed. R20's left hand was contracted. R20 had no splint on his left hand/wrist. On 10/29/24 at 10:34 AM, V5 (Wound Care Nurse) and V20 CNA (Certified Nursing Assistant) was assessing R20. When V5 was attempting to open R20's hand to clean dried up food from…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assess a resident for smoking safety, failed to implement safe smoking interventions, and failed to accurately assess a resident for community pass. This applies to 3 of 10 residents (R33, R90, R91) reviewed for safety in the sample of 35. The findings include: 1. R33's admission Record (Face Sheet) showed an admission date of 1/8/2020. The face sheet showed a diagnosis of paranoid schizophrenia. R33's 9/26/24 Quarterly Minimum Data Set (MDS) showed severe cognitive impairment with a Brief Interview for Mental status score of 5 out of 15. The MDS showed he had disorganized thinking, hallucinations, delusions, physical behavioral symptoms directed toward others (1 to 3 days a week), and verbal behavioral symptoms directed toward others (1 to 3 days a week). On 10/30/24 at 9:36 AM, the front desk sign-out sheet showed R33 had signed himself out on pass at 8:55 AM and returned at 9:27 AM. R33's 10/19/24 Nursing Note from 9:38 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 observation, interview, and record review the facility failed to provide catheter care for a resident with a suprapubic catheter for 1 of 3 residents (R30) reviewed for catheters in the sample of 35. The findings include: R30's face sheet showed he was admitted to the facility 7/2/2018 with diagnoses to include spina bifida, Type 2 Diabetes, iron deficiency anemia, hyperlipidemia, hypokalemia, neuromuscular dysfunction of bladder, Major Depressive Disorder, need for assistance with personal care, and hypo-osmolality and hyponatremia. R30's facility's assessment dated [DATE] showed he has no cognitive impairment and requires supervision through maximal assistance for cares. R30's care plan initiated 1/11/2019 showed, Indwelling Catheter . Interventions: (1/11/2019)Catheter care every shift during routine CNA care . 7/15/21 Educate resident on catheter care and maintenance . (4/15/2019 Monitor suprapubic site for drainage, redness, pain . (7/15/21) [R30] may change the foley rain bag per himself as per…

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

Based on observation, interview, and record review the facility failed to ensure the oxygen tubing was connected to the oxygen concentrator for the delivery of as needed oxygen to 1 of 1 resident (R48) reviewed for oxygen in the sample of 35. The findings include: On 10/29/24 at 10:13 AM R48 was sitting bed with the head of her bed elevated. R48 complained of being a little short of breath. R48's nasal cannula as hanging off the side of the bed and was not attached to the oxygen concentrator that was turned on. R48 stated she removed it to blow her nose. V3 RN (Registered Nurse) checked R48's oxygen saturation and it was 89% on room air. V3 placed the nasal cannula back in R48's nose and stated she would be back to check her oxygen saturation and left the room. V3 never checked R48's oxygen/concentrator to ensure the resident received the oxygen via nasal cannula. V3 was asked to check R48's oxygen; she returned to the resident's room. V3 was shown R48's nasal cannula and it not being attached to the oxygen concentrator. V3 stated the only way R48 would get any oxygen was if 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 the facility failed to ensure medications were not left at a residents bedside and medications were given on time for 3 of 7 residents (R133, R153, & R90) reviewed for medications in the sample of 35. The findings include: 1. On 10/29/24 at 9:44 AM, R133 was asleep on his right side in bed. There was a medication cup with 4 oblong pills in it sitting on the dresser at the end of his bed. On 10/29/24 at 9:50 AM, V3 stated she was going to give R133 his medications right now and has not given him any medications today. V3 stated they are to watch the resident take their medications to make sure they take the medication. V3 stated medications can't be left at the bedside. V3 stated the nurse needs to make sure the resident takes the medication and they take it at the right time. On 10/30/24 at 9:44 AM, V2 DON (Director of Nursing) stated medications should not be left at bedside because it is not safe, other residents could take it. V2 stated that also means the resident did not take the medication. The Face Sheet dated 10/31/24 for R133…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the interview and record review, the facility failed to report abuse allegations to the state agency. This applies to 2 of 5 residents (R5 and R6) reviewed for abuse in a sample of 5. The findings include: 1. On 9/25/24 at 2:55 PM, V21 (Certified Nursing Assistant/CNA) stated during evening shift in June 2024, V21 was on one-to-one supervision with R5 in the dining room. R2 entered the dining room and held up some sugar packets for R5. When R5 reached sugar packet, R2 grabbed R5's buttocks. V21 said he was about to eight feet away from the direct observation of this incident. V21 said he reported it to V17 (Registered Nurse/RN), and she said she would report it. On 9/26/24 at 12:34 PM, V17 stated she couldn't recall any incidents between R2 and R5 in June 2024. A review of facility reportable incidents failed to show that this incident was reported to the state agency. The Electronic Health Record (EHR) showed R5 had diagnoses including dementia and major depression. The Minimum Data Set (MDS) dated…

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

Based on interview and record review, the facility failed to protect residents from sexual abuse. This applies to 1 of 2 residents (R1) reviewed for abuse in a sample of 7. The findings include: The facility's initial incident report showed On 8/21/24 at 8:30 PM, (R1) reported to staff that (R2) came and grabbed her while she was sitting on the front porch. (R1) did not report the incident until this morning. The facility's final incident report showed The incident report was reported on August 22, 2024, at approximately 11:15 AM . (R1) stated that (R2) sexually assaulted her outside the building. The local police department was contacted and arrived on-site Based on the known facts from the medical record review and interviews, the following conclusions have been determined about the original allegation: abuse is substantiated as follows: The involved (R1) and (R2) outside the facility building. Upon thorough investigation, it was revealed that while (R1) was seated on her wheelchair outside, (R2) approached her and expressed his interest in her. (R1) informed him that she only…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 by a facility staff member. This applies to 1 of 3 residents (R1) reviewed for abuse in the sample of 3. The findings include: The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. The EMR continues to show R1 was sent to the local hospital on May 3, 2024 and returned to the facility on May 10, 2024. R1 has multiple diagnoses including, paraplegia, sepsis, UTI (Urinary Tract Infection), ESBL (Extended Spectrum Beta Lactamase) resistance, open wound of the scrotum and testes, multiple stage four pressure ulcers, PVD (Peripheral Vascular Disease), long-term use of antibiotics, urine retention, left leg above the knee amputation, and hypertension. R1's MDS (Minimum Data Set) dated May 17, 2024 shows R1 is cognitively intact, is able to eat independently, requires supervision with bed mobility, partial/moderate assistance with oral hygiene, toilet hygiene,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 1 of 2 residents (R1 and R2) reviewed for abuse in the sample of 5. The findings include: On 03/12/2024 at 12:10 PM, R1 was sitting in his wheelchair and showed where R2 poured hot water on his right hand. R1 said he placed a cup of water in the cafeteria's microwave, and R2 took the cup from the microwave and poured hot water onto his hand. R1 said he had a burn on his right hand and developed pain. R2 was out on pass and not available for the interview. A review of R2's nursing progress notes dated 02/14/2024 at 1:51 PM showed V5 (Social Worker) reported that R2 threw hot water at R1, and R2 was sent to the hospital for her behavioral evaluation. A review of nursing progress notes dated 02/14/2024 at 1:45 PM showed R1 told the nurse that R2 threw hot water on R1's right hand. R1 had slight redness and a small blister on the right hand. Progress notes showed the nurse…

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

Based on observation, interview, and record review, the facility failed to properly label and date food items and practice proper sanitation of ice machine scooper in the kitchen. This applies to all residents who receive oral nutrition and foods prepared in the facility kitchen and use ice from kitchen ice machine. Findings include: The Facility Resident Census and Condition of Residents (Form CMS--Centers for Medicare and Medicaid Services-672) dated 9/6/23 documents the total census was 147 residents. V10 said all 147 residents eat from the facility kitchen. On 9/5/23 starting at 10:10 AM, the facility kitchen was toured in the presence of V10 (Dietary Manager). At 10:21 AM, an opened, unlabeled, and undated bag of frozen breaded items (V10 stated the frozen items were fish sticks) were found inside the walk-in freezer. At 10:25 AM, an unlabeled and undated large frozen roast was found inside the walk-in freezer. The outside of the roast package had a reddish brown sticky substance on it. At 10:33 AM, an unlabeled and undated plastic pitcher with a thick reddish-orange liquid 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 assist residents with nail care and shaving. This applies to 6 of 32 residents (R14, R22, R33, R44, R125, R137) reviewed for ADL's (Activities of Daily Living) in a sample of 32. The findings include: 1. On 09/05/2023 at 10:05 AM, R125 was lying in bed. R125 had long fingernails with an accumulation of a black substance underneath them. His hair was not combed and he had a beard. R125 voiced that he would like his nails cut and would like to be shaved. R125's face sheet documents the following diagnoses: essential tremor, other recurrent depressive disorders, anxiety disorder, post traumatic stress disorder, muscle wasting and atrophy. R125's MDS (Minimum Data Set) dated 08/09/2023 showed he was cognitively intact and needs extensive assistance of one person for personal hygeine. R125's care plan dated 12/08/2021 show a focus of self-care deficit and requires assistance with ADL's to maintain the highest possible level of functioning.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 thermometers were in residents' personal refrigerators, to monitor and record temperatures daily, sanitize, and remove expired food items from resident refrigerators. This applies to 5 of 5 residents (R26, R33, R74, R83, R118) in a sample of 32. The findings include: On 9/5/23 at 10:00 AM, initial tour of the second floor was conducted. The following observations were made: 1. At 10:15 AM, inside R26's fridge, there were six (1/2 pint) cartons of milk that expired on 9/2/23 (three days earlier). There was no thermometer inside the fridge. R26's fridge was cluttered with different foods that were not labeled or dated and it was dirty inside. The freezer was full of ice build-up and food items. There were spilled food stains in the freezer. R26 stated, They (staff) don't check my fridge on a daily basis. 2. At 10:25 AM, inside of R74's fridge, there were 2 pieces of pie in container and a plastic container with a black substance that had a foul smell. It was not labeled or dated. 3. At 10:34 AM, inside…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safe handling and storage of an oxygen tank. This applies to 1 resident (R78) in a sample of 32. Findings include: On 09/05/23 at 10:21 AM, in R78's room three cylindrical oxygen tanks were in the corner of his room. One tank was standing upright directly on the floor not in a tank holder. On 09/07/23 at 02:28 PM, V2 DON (Director of Nursing) stated if the oxygen tank is in a residents room it needs to be in a holder because if it falls it could explode and cause injuries. R78's Face Sheet showed diagnoses of chronic obstructive pulmonary disease, heart failure, Parkinson's disease, alcohol dependence, major depressive disorder, generalized anxiety disorder, borderline personality disorder, polyneuropathy, convulsions, bipolar disorder, suicidal ideations and hypertension. R78's September 2023 Physician Orders include oxygen at 3 liters /minute via nasal cannula to keep O2 saturation greater than 92%. The Minimum Data Set, dated…

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

Based on observation, interview, and record review, the facility failed to ensure a resident with a malnutrition diagnosis and weight loss received his diet as ordered. This applies to 1 of 3 residents (R57) reviewed for portion sizes. The findings include: On 09/05/2023 at 11:44 AM, R57 was in his room, alert and interviewable. R57 appeared emaciated and weak. R57 said he does not get served what he wants. R57's face sheet showed diagnoses of unspecified severe protein-calorie malnutrition, anemia, type 1 diabetes mellites with diabetic nephropathy, chronic ulcer of left foot, chronic kidney disease, disorders of phosphorus metabolism, gastroesophageal reflux disease, depression, and bipolar disorders. R57's physician order dated 03/26/2023 showed double portions of all meals, skim milk with every meal, and banana with lunch on Mondays and Wednesdays. On 09/06/2023 (Wednesday), R57 was in line to receive his lunch tray. R57's Wednesday meal card read, Double Portion with skim milk and a banana. V9 (Dietary Aide) served a regular portion (three meatballs) with two extra meatballs,…

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