Pearl Of Elk Grove, The

Based on observation, interview, and record review the facility failed to ensure patient care equipment was maintained to ensure residents were able to get out of bed for 4 of 4 residents (R1,R2,R3,R6) reviewed for full body mechanical sling lifts in the sample of 4. The findings include: On 01/15/2025 at 9:10AM, the #2 full body mechanical sling lift inspection sticker showed inspection was performed October 2024 and is due for re-inspection January 2025. On the lift arm that supported the resident there was exposed wires and what looked like part of a broken cover. At 9:30AM, there was a sign on lift #2 that showed, OUT of ORDER. The #8 full body mechanical sling lift inspection sticker showed, Preventative Maintenance 05/31/19. On 01/15/2025 at 9:20AM, V3 Maintenance said, I have not received any reports from the Nursing Staff on the need for mechanical lift maintenance or repair. There is a portal in our computer system that generates a workorder, that would be the proper way to request maintenance. Usually staff just call me, leave a voice mail, email, or report directly to me,…

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 resolve resident grievances for 5 of 6 residents (R1, R3, R4, R5 R6) reviewed for grievances in the sample of 6. The findings include: On 12/17/24 at 9:55 AM, R1 stated he has seen R2 standing at the lunch time steam cart in the hall. R1 said R2 continually touches the trays and removes plate lids with his bare hands. R1 said it is unsanitary and spreads germs. R1 said it has been discussed at group meetings when staff members are present. Nothing is being done about it. On 12/17/24 at 12:37 PM, R4 stated she has seen R2 pick food off resident trays and hovers over the steam carts to find his tray. R4 said she has seen R2 pick food off used trays and then touch fresh food trays. R4 said R2 touches the warming covers with his dirty hands. R4 said it was discussed at the last food focus meeting and staff know about the issue. R4 said no one is doing anything about it. On 12/17/24 at 11:21 AM, V3 (Registered Nurse) said R2 does touch the food trays at mealtimes. R2 is alert and has OCD (obsessive compulsive disorder). Timing…

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 a sufficient amount of nursing staff/providers to notify family of change in condition, provide grooming needs, and distribute meals in a timely manner. This applies to 7 of 11 residents (R2-R8) reviewed for nursing care. Findings include: 1.R3's Electronic Medical Records (EMR) showed R3's diagnoses include paraplegia, congenital hydrocephalus, heart failure, and palliative care. R3's Minimum Data Set (MDS) dated [DATE] showed R3 was cognitively moderately impaired and dependent on one to two staff assistants for daily care activities. During the observation on 11/02/2024 at 1:35 PM, R3 was in bed sleeping with noisy breathing, and the meal tray was by his bedside untouched. V15 (Agency- Certified Nursing Assistant) said he didn't know about R3. Since morning, he has had noisy breathing and didn't even eat breakfast. V15 said V6(Agency Registered Nurse) is aware of R3's condition. Around 1:45 PM, R6 said he had been having the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the observation, interview, and record review, the facility failed to notify the family, physician, and hospice provider in a timely manner about the change of conditions for a resident. This applies to 1 of 1 resident (R3) who was reviewed for significant change in condition in a sample of 12. Findings include: During the observation on 11/02/2024 at 1:35 PM, R3 was in bed sleeping with noisy breathing, and the meal tray was by his bedside untouched. V15 (Agency- -Certified Nursing Assistant) said he is from the agency and does not know about R3. V15 said that since morning, he has had noisy breathing sounds and hasn't even eaten breakfast. V15 said that V6(Agency Registered Nurse) knows R3's condition. Around 1:45 PM, R6 said they did not feed him to avoid R3 from aspirating on food. When the writer asked R6 whether the family and provider knew about the change in conditions of R3, V6 said she did not get a chance and would notify them soon. On 11/04/2024 at 10:54 AM, V18 (R3's family member) said…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide nail care for residents' dependent on staff. This applies to 3 of 8 residents (R2, R4, and R8) reviewed for Activities of Daily Living (ADL) care in a sample of 12. The findings include: 1. R2's EMR showed R2's diagnoses include morbid obesity, acute kidney failure, h/o fracture, osteoarthritis, bipolar, anxiety, and mood disorder. R2's Minimum Data Set (MDS) dated [DATE] showed that R2 was cognitively intact and required one to two extensive assists for most of his daily activities. R2 had quarter inch-long right-hand fingers with blackish dirt under the nails and said that only once the staff cut his nails and they don't care. 2. On 11/02/2024 at noon, observed R4 with about an inch-long nails on both hands, with sharp edges and brownish dirt under the nails. R4 said no one cuts her nails. R4's EMR showed R4 had diagnoses including hypertensive heart disease, acute kidney disease, palliative care, dementia, and cerebrovascular…

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 food was served at palatable temperatures. This applies to 3 of 5 residents (R5-R7) reviewed for meal service. Finding includes: Observation of the lunch meal on 11/02/2024 between 12:10 PM and 1:15 PM at the 100 halls, where the residents were served meals to rooms. A random temperature check of R5, R6, and R7 trays showed that sweet potatoes and beans delivered to residents were below 100 degrees Fahrenheit. On 11/04/2024 at 1:15 PM, V3 (Food Service Director) said the temperature of the meal tray should not be going below 135 degrees Fahrenheit. V3 said she addressed the concerns about cold food due to staff distributing it on time with management several times before the new administrator started, and it continues to be a problem. On 11/02/2024, between 12:15 PM and 1:00 PM, V5(Cook) recorded the temperature of random residents' meal trays and said that during lunchtime meal trays are sent with hot plates, but they sit 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 implement a fluid restriction for a resident with congestive heart failure (CHF) and failed to do daily weights for residents with CHF. This applies to 3 of 29 residents (R6, R13, and R82) reviewed for quality of care in the sample of 29. The findings include: 1. R6's Face Sheet printed on 10/22/24 showed R6 had a diagnosis of CHF. R6's Order Summary report showed an order for a fluid restriction of 2-2.5 liters per day. The order had a start date of 10/10/24. On 10/22/24 at 10:27 AM, V2 (Director of Nursing) said R6 was on a fluid restriction for CHF. On 10/22/24 at 11:15 AM, R6 said she was not aware if she was on a fluid restriction. On 10/21/24 at 12:18 PM, on R6's bedside table was a large disposable foam cup, two plastic cups, a dietary supplement drink (in its original container), and a container of milk. The large disposable foam cup appeared to be full. One plastic cup was half full. The other plastic cup was three quarters full. The dietary supplement drink appeared full. The container of milk was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident's arm was supported by a sling during a transfer and while up in the wheelchair for 1 of 6 residents (R105) reviewed for range of motion in the sample of 29. The findings include: On 10/21/24 at 10:30 AM , R105 was in bed. R105's left arm was resting on her stomach. R105 said she had a stroke and was unable to move her left arm or hand. There was a sign on the wall above R105's bed that read Must wear sling when being transported. At 10:32 AM, V15 (Certified Nursing Assistant) and V16 (Occupational Therapy) came into the room and provided incontinence care. V15 and V16 then rolled R105 from side to side to place a mechanical lift sling underneath her. R105 held her left wrist with her right hand while being rolled. V15 and V16 connected the mechanical lift sling the the lift machine and began raising R105 in the air. V16 told R105 to hold her arm. R105 was transferred via the mechanical lift to her wheelchair. R105 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident with a diagnosis of dysphagia (difficulty swallowing) was cued/followed safe swallowing strategies, failed to transfer a resident in a safe manner, and failed to have a fall intervention in place for a resident at risk for falling. This applies to 3 of 29 residents (R3, R73, and R92) reviewed for safety in the sample of 29. The findings include: 1. R3's Face Sheet printed on 10/21/24 showed R3 was diagnosed with adult failure to thrive and dysphagia. On 10/21/24 at 1:10 PM, R3 was eating in her room with no staff present. R3 fed herself three consecutive spoonfuls of mechanical soft chicken. The spoonfuls appeared full with food falling off of the spoon as R3 moved the spoon towards her mouth. R3 did not alternate between food/solids and liquids. On 10/21/24 at 1:18 PM, R3 said she was done eating. Food was falling out of R3's mouth as she was talking. R3 had a cup of water and juice sitting on the meal tray. The cups…

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 PRN (as needed) anti-anxiety (psychotropic) medications had a duration/end date for 4 of 8 residents (R66, R40, R299, R106) reviewed for unnecessary medications in the sample of 29. 1. R66's Order Summary Report dated 10/22/24 shows an active order for Lorazepam (an anti-anxiety medication) 2mg (milligram)/mL (milliliter) give 0.5mL by mouth every 2 hours as needed for severe anxiety/nausea started on 5/31/24 with no duration listed. On 10/23/24 at 11:04 AM, V2 (Director of Nursing/DON) said PRN (as needed) antipsychotic and psychotropic medications should have a stop date or duration. 2. R40's Physician Orders for October 2024 shows an order dated 9/19/24 for Lorazepam Oral Tablet 0.5mg tablet by mouth every 8 hours as needed for restlessness related to anxiety disorder. There is no stop date listed for this order. 3. R299's Order Summary Report printed on 10/22/24 showed an order for Lorazepam (anti-anxiety psychotropic medication) to be given every 2 hours as needed starting on 10/20/24. There was no stop…

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 in the medication refrigerator for 2 of 29 residents (R120, R89) reviewed for medications in the sample of 29. The findings include: On 10/23/24 at 10:17 AM, V7 (Registered Nurse/Infection Preventionist) with this surveyor reviewed the medication room refrigerator. The refrigerator contained R120's used insulin pen with an opened date of 9/3/24 and an expiration date of 10/1/24 (22 days ago). The same refrigerator contained a bottle of liquid medicated mouthwash for R89 with an opened date of 7/12/24 written on the pharmacy sticker. The same pharmacy sticker shows discard after 14 days. V7 said those medications should have been thrown away since they are expired and she will dispose of them. The facility's Storage of Medications Policy dated 10/17/24 shows All expired medications will be removed from the active supply and destroyed in the facility,regardless of amount remaining.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff wore gowns when providing direct patient care to 1 of 29 residents (R73) on Enhanced Barrier Precautions (EBP) in the sample of 29 reviewed for infection control. The findings include: On 10/21/24 at 9:51 AM, V18, (Certified Nursing Assistant/CNA), changed R73's shirt and adjusted his neck pillow, wiped saliva from his mouth, and adjusted him in his wheelchair. V18 was not wearing a gown when providing R73's care. R73's room had PPE (personal protective equipment) in a container outside of his room and a sign on his door showing he is on EBP. On 10/22/24 at 1:40 PM, V7, (Registered Nurse/Infection Preventionist), said the staff is expected to wear a gown and gloves when providing high contact care (transferring, repositioning, toileting) a resident on EBP. R73's admission Record dated 10/22/24 shows R73 is a [AGE] year-old man, and his diagnoses include, but are not limited to, hemiplegia and hemiparesis following cerebral…

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 update a resident's care plan when a resident exhibited sexual behaviors and public displays of affection and required a room change. This applies to 1 of 5 residents (R2) reviewed for resident-to-resident sexual assault in the sample of 5. The findings include: On September 18, 2024 at 1:39 PM, and on September 23, 2024 at 2:09 PM, V3 (CNA-Certified Nursing Assistant) said on September 10, 2024 she was walking up and down the corridor, picking up dinner trays. V3 noticed R2 was out of his room. V3 said she approached R1's room and the privacy curtain was closed. V3 said she was surprised by this because the staff never leave R1's privacy curtain closed when they are not in the room because R1 is a high fall risk and requires frequent observation. V3 said she went to pull the privacy curtain back and found R2 standing at R1's bedside with one knee on R1's bed. R2's khaki shorts and belt were down around R2's ankles. V3 could see R2's bare buttocks. V3…

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 was seen by their attending physician as shown in the facility's policy. This applies to 1 of 5 residents (R2) reviewed for physician visits in the sample of 5. The findings include: The EMR (Electronic Medical Record) shows R2 was admitted to the facility on [DATE]. R2 has multiple diagnoses including, Parkinson's Disease, dementia with behaviors, anxiety, falls, psychotic disorder with delusions, insomnia, and depression. R2's MDS (Minimum Data Set) dated July 24, 2024 shows R2 is cognitively intact, requires setup assistance with eating, supervision with oral hygiene, partial/moderate assistance with personal hygiene, bed mobility, and transfers between surfaces, substantial/maximal assistance with toilet hygiene, showers, and lower body dressing, and is occasionally incontinent of bowel and bladder. The EMR shows V8 (Physician) is R2's primary care physician. On May 23, 2024 at 12:30 PM, V8 (Physician) documented 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident was not administered a medication that was not prescribed for them, and failed to notify the Director of Nursing, or a nurse manager, regarding a medication error in a timely manner for 1 of 3 residents reviewed for medication error in the sample of 8. The findings include: R1's admission Record, printed by the facility on 8/15/24, showed she had diagnoses including Charcot's Joint, left ankle and foot, Covid-19, Type II diabetes mellitus, Methicillin Susceptible Staphylococcus Aureus infection (MRSA), and displaced comminuted fractures of shafts of left fibula and left tibia. R1's facility assessment dated [DATE] showed she is cognitively intact. R1's care plan initiated on 5/14/24 showed she is on diuretic therapy related to hypertensive heart disease. The care plan showed R1 was on Lasix and hydralazine. The care plan also showed that many other medications may interact with antihypertensive medications to potentiate their effect,…

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 was permitted to return to the facility following a behavioral hospitalization for 1 of 3 residents (R2) reviewed for involuntary discharge in the sample of 3. The findings include: R2's electronic medical record accessed on 8/9/24 show R2 was admitted to the facility on [DATE]. R2's diagnoses include Alzheimer disease, schizoaffective disorder, diabetes and cognitive communication deficits. R2's facility assessment dated [DATE] show R2 has moderately impaired cognition. R2's progress notes dated 7/15/24 show R2 was sent out to the emergency room due to aggressive behaviors towards staff via involuntary petition. Daughter was informed A progress notes dated 7/16/24 show R2 was transferred to a behavioral health (in Indiana) A progress noted dated 7/23/24 by V7 (Social Services) show V8 (R2's daughter) reports that the hospital behavioral health is ready to discharge R2. Writer advised daughter to contact social worker at the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide incontinence care to a resident who is dependent on staff for activities of daily living (ADL's) to 1 of 3 residents (R1) reviewed for ADLs in the sample of 4. The findings include: R1's facility assessment dated [DATE] show R1 has no cognitive impairment. The same assessment show R1 is dependent on staff for toileting and R1 is always incontinent for bladder functions. On 8/9/24 at 9:45 AM, R1 was in bed alert and pleasant R1 said, an agency CNA (Certified Nursing Assistant) was assigned to him on day shift last 8/2/24 and 8/3/24. R2 1 said he did not get changed. R1 said last 7/31/24 on PM shift, he again had an agency CNA and he waited long to be changed. R1 said he had to sit on a wet diaper. R1 said he has some redness on his bottom that is why he wanted to be changed sooner. R1 said he already reported his concerns to V2 (Director of Nursing-DON.) that he did not get the care he needed on those three days. On 8/9/24 at 10:10 AM, V2 (DON)…

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 neurological assessments were completed accurately for a resident who fell and hit her head, and failed to complete post-fall documentation and include it in the resident's medical record. This applies to 1 out of 5 (R1) residents reviewed for falls. The finding includes: R1's EMR (Electronic Medical Record) showed an admission date of 6/03/2024 with diagnoses including cerebral ischemia, refractory anemia, malignant neoplasm of left breast, secondary neoplasm of the bone marrow, antineoplastic chemotherapy-induced pancytopenia, slurred speech, and weakness. R1's admission Minimum Data Set showed R1 was severely cognitively impaired. R1's admission Fall Assessment risk form dated 6/03/2024 showed R1 was at low risk for falls. On 6/07/2024 at 1:00 PM, V2 (Director of Nursing/DON) said R1 had an unwitnessed fall on 6/04/2024 around 10 PM. V2 said the facility staff notified her after the incident and reported R1 was observed on the floor in her room trying to reach for something. V2 said R1 had sustained a small…

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 resident grievances were documented and timely resolutions were provided. This applies to all 151 residents residing in the facility. The findings include: Daily Census, dated 6/2/24, shows the facility census was 151 residents. 1. On 6/3/24 at 2:00 PM, R2 stated he was the Resident Council President and he canceled the resident council meeting last week because he did not want to participate in another meeting listening to the same complaints from residents, the facility promising to address the problems and then doing nothing. R2 stated the issues of poor quality of food, residents not receiving what they ordered, palatability, the food service not serving the planned menus, the hot food being served cold came up frequently at resident council meetings. R2 stated the complaints of food service were so numerous the facility decided to have a separate food council to discuss the concerns. R2 stated he was tired of discussing the concerns with administration including poor quality food services, lack of activities,…

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 ADL (Activities of Daily Living) care to residents who required staff assistance with toileting hygiene. This applies to 6 of 6 residents (R1, R2, R4, R5, R6, and R13) reviewed for ADLs (Activities of Daily Living) in a sample of 22. The findings include: 1. MDS (Minimum Data Set), dated 3/8/24, shows R1 was dependent on staff for toileting hygiene and was always incontinent of bowel and bladder. On 6/3/24 at 2:32 PM with V9 (LPN - Licensed Practical Nurse), and V2 (Director of Nursing) in the library, R1 was sitting in his wheelchair smelled of very strong urine and his red shorts were soaked in urine. V2 and V9 observed R1's urine-soaked shorts and stated R1 should be checked and changed every 2 hours. R1 stated his incontinence brief had not been checked/changed since approximately 9:30 AM that morning. R1 stated he can not feel that he urinates in his brief unless he has a very large rush of urine. R1 stated he never…

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 medications were reordered in a timely fashion to be available for medication administration. This applies to 2 of 3 residents (R1 and R4) reviewed for medications in the sample of 22. The findings include: 1. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. The MDS(Minimum Data Set) Assessment, dated 3/8/24, shows R1 was cognitively intact. MAR (Medication Administration Record), dated 6/2024, shows R1 had physician orders for the following eye medications: 1. Refresh Lacri-Lube Ophthalmic Ointment instill 1 application in both eyes every 8 yours as needed for dry eyes (3/2/24) 2. Refresh Tears Solution instill 1 drop in both eyes every 4 hours as needed for dry eyes (3/13/24) 3. Systane Balance Ophthalmic Solution 0.6% instill 2 drops in both eyes two times a day for dry eyes. (3/29/24) On 6/3/24 during initial tour of the facility, R1 stated he brought eye drops from his eye physician office…

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 properly store resident diabetic medication resulting in a delay of the medication administration. This applies to 1 of 3 residents (R5) reviewed for medications in a sample of 22. The findings include: Face sheet, dated 6/4/24, shows R5's was admitted to the facility on [DATE] and her diagnoses included type 2 diabetes, hypertension, chronic kidney disease, chronic obstructive pulmonary disease, and humerus fracture. MAR (Medication Administration Record) report, dated 4/2024, shows R5 had a physician order (dated 4/9/24) for Ozempic (2mg (milligrams)/dose) once a day every Tuesday for diabetes. The MAR report shows R5 received her scheduled Ozempic dose on 4/30/24. On 6/3/24 during initial tour of the facility, R5 stated the facility lost the Ozempic pen she personally bought and provided to a nurse at the facility. R5 stated she received one of the four doses from the pen at the facility and when the next dose was due the pen was missing. R5 stated…

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 that state survey results were available to residents and visitors. This applies to 2 of 4 residents (R1 and R3) reviewed for accessing survey results in the sample of 14. On 12/12/2023 at 1:16PM, V11(R1's family) said he asked for survey results after he had some concerns about R1's care, and the last survey result available to review was dated 12/12/2022. On 12/12/2023 at 1:45PM, R3 and V12 (R3's family) said he was not aware of the availability of the survey reports. A review of the list of surveys for the facility showed the Department of Health initiated an annual survey on 09/12/2023 and complaints surveys on 01/24/2023, 02/03/2023, 03/16/2023, 04/11/2023, 05/03/2023, 05/30/2023, 06/01/2023, 06/05/2023, 06/20/2023, 06/27/2023, 07/14/2023, 09/29/2023,10/20/2023, and 11/29/2023. On 11/12/2023 at 3:00 PM, V1 (Administrator) indicated she updated the survey binder with the 2023 survey result after V11 (R1's family) called her and asked for it. V1 said she was responsible for ensuring results were posted/updated…

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 toileting, bathing/showering and transfer help to residents who required staff assistance for ADLs. (Activities of Daily Living). This applies to 10 of 12 residents (R1-R3 and R6-R12) reviewed for ADL assistance in a sample of 12. The findings include: 1. MDS (Minimum Data Set), dated 8/25/23, shows R1 required modified independence for cognitive skills for daily decision making. The MDS shows R1 required extensive assistance from staff for toileting and personal hygiene, was totally dependent on staff for transfers and bathing, and was always incontinent of bowel. MDS, dated [DATE], shows R2 was cognitively intact, was totally dependent on staff for toileting, bathing/showering, and transfers, and was frequently incontinent of bowel. On 11/9/23 at 1:30 PM, R1 and R2 were in their room lying in their beds. R1 stated he had only had two showers during the month of 11/2023. R1 stated he and R2 were told by staff that there were not enough people…

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 sufficient staffing to assist residents who require help to perform ADLs. (Activities of Daily Living). This applies to 10 of 12 residents (R1-R3 and R6-R12) reviewed for ADL assistance in a sample of 12. The findings include: 1. MDS (Minimum Data Set), dated 8/25/23, shows R1 required modified independence for cognitive skills for daily decision making. The MDS shows R1 required extensive assistance from staff for toileting and personal hygiene, was totally dependent on staff for transfers and bathing, and was always incontinent of bowel. MDS, dated [DATE], shows R2 was cognitively intact, was totally dependent on staff for toileting, bathing/showering, and transfers, and was frequently incontinent of bowel. On 11/9/23 at 1:30 PM, R1 and R2 were in their room lying in their beds. R1 stated he had only had two showers during the month of 10/2023 and they were told by staff that there were not enough staff to give showers. R1 and R2 stated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to attend to call lights in a timely manner as per facility policy. This applies to 4 of 4 residents (R1-R3, R8) reviewed for improper nursing care in the sample of 10. The findings include: Facility Resident Council meeting minutes for July, August and September 2023 recorded resident concerns with call light response. R8 was the President of the Resident Council. 1.R8's diagnoses on face sheet included MS (Multiple Sclerosis), spastic hemiplegia affecting right dominant side, paraplegia, unspecified, functional quadriplegia, central pain syndrome, personal history of urinary (tract) infections. R8's quarterly MDS (minimum data set) dated 9/13/23 showed that R8 was cognitively intact and required extensive 2 person assist for transfer and toilet use. On 9/29/23 at 9:44 AM, R8 verified the residents concerns about call light response voiced at the Resident Council. R8 stated The aides from the agency turn the call lights off and disappear. It…

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/trimming facial hair. This applies to 5 of 32 residents (R43, R52, R54, R106, R99) reviewed for ADL's (Activities of Daily Living) in a sample of 32. The findings include: 1. On 9/12/23 at 10:32 AM, R52 was lying in bed talking about random topics that did not make sense. R52 was very confused and was unable to be interviewed. R52's fingernails were long and yellow with an accumulation of a black substance. R52's face sheet documents the following diagnoses: spinal stenosis, lumbosacral region, need for assistance with personal care, other signs and symptoms involving the musculoskeletal system, unspecified osteoarthritis, and idiopathic chronic gout, unspecified shoulder without tophus. R52's MDS (Minimum Data Set) dated 7/20/23 documents a BIMS (Brief Interview for Mental Status) summary score of 2, which means he is severely cognitively impaired. For personal hygiene, he was assessed as 3/2,…

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.

4. On 9/12/23 at 10:29 AM, R34 was lying in bed and eating her breakfast. Next to her tray was a medication cup with 7 oral pills. Surveyor asked R34 who gave her these medications. R34 replied, The girl outside gave it to me in the morning. It was like 15 minutes ago. On 9/12/23 at 10:32 AM, V14 (RN-Registered Nurse) stated, Yes, I am (R34's) nurse this morning. I brought (R34's medications) to her, but she said she would be nauseated if she didn't take it after breakfast. So, I left it there because I thought she would take it after breakfast. It's still there? Review of R34's EMAR (Electronic Medication Administration Record shows the following medications were in R34's medication cup: Sertraline HCL Oral tablet 50 MG (Milligrams), Theragran-M Oral Tablet (Multivitamins with minerals), Vitamin C 500 MG, Vitamin D3 25 MCG (Micrograms), Apixaban 5 MG, Glimepiride 2 MG, and Metformin HCL 1000 MG. 5. On 9/12/23 at 11:10 AM, R23 was not in her room. On top of her end table, there was 2.5 OZ (Ounces) antifungal powder (Miconzale Nitrate 2%) and 5 OZ Inzo antifungal cream (Miconzaole…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to perform hand hygiene while administering medications, while providing incontinence care, before putting on gloves and removing gloves, failed to properly sanitize a glucometer, failed to provide a resident with a clean, unused mechanical lift sling, failed to empty and store a resident's urinal, and failed to properly dispose of biohazard waste. This effects 12 residents (R6, R12, R32, R80, R106, R110, R125, R88, R11, R24, R66, & R127) in a sample of 32. Findings: 1. On 9/12/23 at 11:53 AM, a paper towel with blood on it was observed in R11 and R24's shared bathroom sink. 2. on 9/12/23 at 1:02 PM V6 (CNA/Certified Nurse Aide) provided incontinence care for R66. V6 put on gloves and provided perineal care, removed soiled brief, applied cream to perineal area, applied clean brief, and repositioned R66 and adjusted R66's bed and never changed her gloves or cleaned her hands. On 9/12/23 at 1:18 PM, V6 said, I forgot to clean my hands, I…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to have call lights accessible to dependent resident. This applies to 1 of 1 resident (R57) reviewed for accommodation of needs in a sample of 32. The findings include: On 9/12/23 at 11:35 AM, R57 was observed sitting in wheelchair in her room by the window. R57's call light was on the bedside table close to the bed. R57 said she could not reach the call light and would like the call light placed within her reach. R57's face sheet (9/13/23) showed that R57 had the following diagnoses of encounter for orthopedic after care following surgical amputation, cognitive communication deficit, need for assistance with personal care and fall. R57's Minimum Data Set (MDS) dated [DATE] shows R57's cognition is intact, R57 needs extensive assistance with two or more person physical assist with toilet use and extensive assistance with one person physical assist with personal hygiene. R57's care plan (initiated 8/12/23) shows that R57 is at risk for falls…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to effectively communicate with 1 resident (R53) that did not speak English, in a sample of 32. The findings include: R53 is a [AGE] year old female admitted to the facility on [DATE], who's primary language is Italian. R53's diagnoses include heart failure, stage 4 kidney disease, pain of joints and lower back, and depression. On 9/12/23 at 2:19 PM R53 was in bed watching TV. The surveyor asked R53 how was the service that she was receiving at the facility, but the surveyor was unable to understand her reply because R53 replied in a foreign language. On 9/14/23 at 9:00 - 9:19 AM, R53 was in bed eating her breakfast. The surveyor asked R53 what she ate for breakfast, V7 (Nurse) was present, R53 replied in her native language. The surveyor asked V7 what R53's reply was, and the nurse said she did not know, but she thought she wanted something. V7 then asked R53, What do you want? V7 showed R53 a piece of paper that had pictures on it…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain vital information regarding residents' pacemakers and ensure that it was readily available in the resident's medical record. This applies to 3 out of 3 residents (R4, R34, R52) reviewed for pacemakers in a sample of 32. Findings include: 1. R4's face sheet documents an admission date of 8/28/2017. R4's face sheet documents the following diagnoses: unspecified diastolic congestive heart failure, anemia, presence of cardiac pacemaker, hyperlipidemia, atherosclerotic heart disease of native coronary artery without angina pectoris, type 2 diabetes mellitus without complications. On 9/13/23 at 2:24 PM, R4's medical record was reviewed with V2 (DON-Director of Nursing). There was no physician order on the POS (Physician Order Sheet) documenting the pacemaker and how often it should be checked. There was nothing in the progress notes, admission assessment or care plans that document the manufacturer, model, and serial number of the pacemaker. It was…

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

Based on observation, interview, and record review, the facility failed to administer and monitor a resident on intravenous fluid therapy. This applies to 1 of 1 resident (R119) reviewed for intravenous therapy in a sample of 32. The findings include: On 9/14/23 at 09:02 AM, R119 was observed in bed with IV (Intravenous) fluids hung on an IV pole and the tubing attached to an IV on the resident's right hand. R119 was sleeping. R119's IV fluid bag was full and the IV chamber was not dripping or administering the IV fluid therapy to R119. R119's IV fluid bag and tubing also did not have labels on them. At 09:30 AM, the IV fluids were still attached to R119, and the fluids were still not infusing into R119's IV and he was not receiving the IV therapy. At 10:25 AM, R119's IV fluids were still not infusing into R119's IV. At 10:25 AM, V4 entered R119's room and said R119 had not received any fluids from the bag hanging and there was something wrong with R119's IV. R119's EMR (Electronic Medical Record) shows R119 was admitted to the facility with diagnoses including dementia, malignant…

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 contain reusable nebulizer treatment masks, and incentive spirometers. This effects 3 residents (R3, R11, and R68) in a sample of 32. Findings: 1. On 9/12/23 at 1:45 PM, R3's nebulizer mask was observed on her bedside table not covered. R3's diagnoses included Chronic Obstructive Pulmonary disease and asthma. 2. On 9/12/23 at 11:53 AM, R11's nebulizer mask was observed uncovered in her opened drawer of her bedside table. R11 said, The last time I used it was a week ago. R11's diagnosis included asthma. 3. On 9/12/23 01:27 PM, R68's incentive spirometer was observed uncovered on his bedside table. R68's diagnosis include Chronic Obstructive Pulmonary disease and dementia. On 9/13/23 at 2:52 PM, V2 (Director of Nursing) said incentive spirometer and respiratory equipment including masks should be covered for infection control. The facility Nebulizer therapy policy dated 4/1/23 showed that masks should be stored in a plastic bag.