Bria Of Elmwood Park

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide care and services in accordance with professional standards of nursing practice by failing to ensure effective communication of clinical information during the resident's transfer to the acute care hospital. This failure applied to two (R3, R5) of three residents reviewed for hospital transfer procedures.Findings include:1. R3 is a [AGE] year-old male with medical diagnoses that include: acute and chronic respiratory failure with hypoxia, dependence on respirator [ventilator] status, anoxic brain damage, epilepsy, and history of cardiac arrest.R3 was transferred to local hospital for change in condition on 12/17/25 and on 1/2/26.Nurse Progress note, Effective Date: 12/17/2025 03:08:00 written by V12 (Registered Nurse/RN) reads: Note Text: Client was sent to (local hospital) emergency room for GI Bleed per Dr order. Director of Nursing and family notified.Nurse Progress note, Effective Date: 12/17/2025 03:17:00 written by V12 (RN) reads: Note…

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 review, the facility failed to follow its fall prevention policy as evidenced by:Failure to complete fall risk evaluations/assessments prior to and following resident falls.Failure to document a resident's fall.This deficient practice affected two residents (R2 and R4) out of five residents reviewed. The findings include:1. R2 is a [AGE] year-old male originally admitted on [DATE] with medical diagnoses that include and are not limited to: acute respiratory failure, tracheostomy, schizoaffective disorder, and epilepsy. According to the Minimum Data Set (MDS) dated [DATE], R2 has a Brief Interview for Mental Status (BIMS) score of 10/15. R2 fall assessment dated : 5-17-2025 reads score of 15 (high risk for falls). Per R2 progress note dated: 12-25-2025 at 5:50 AM reads: R2's was noted on the floor. On 2/8/2026 at 12:20 PM, V2 (Director of Nursing) said, any fall assessment score greater than 10 indicates a patient is at risk for falls. R2's fall assessments all resulted in scores…

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 coordination and integration of hospice services into the resident's plan of care by not incorporating resident request for hospice enrollment into the resident's active physician orders, failing to ensure nursing staff were aware of the resident's hospice status, and failing to communicate hospice enrollment during a hospital transfer. This failure applied to one (R3) of three residents reviewed for hospice services.Findings include:R3 is a [AGE] year-old male with diagnoses including acute and chronic respiratory failure with hypoxia, ventilator dependence, anoxic brain damage, epilepsy, and history of cardiac arrest.Review of the medical record revealed a hospice consent signed on 12/27/25 initiating hospice services.Review of R3's most current POS (physician order sheet) does not include any physician orders for hospice and there is no documentation on R3's face sheet indicating hospice status.R3 was transferred to the hospital on [DATE] 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 residents were able to receive visitors of their choosing at the time of their choosing by limiting visitors after 8pm. This failure applied to two (R1, R5) of three residents reviewed for resident rights and has the potential to affect other residents in the building.Findings include:Facility provided current census of 158 residents.R1 is a [AGE] year-old resident admitted in March of 2025 with diagnoses including but not limited to: anoxic brain damage, acute and chronic respiratory failure, unspecified severe protein-calorie malnutrition, pressure ulcer of sacral region, stage 4, tracheostomy status, anemia, and gastrostomy status. R1 is nonverbal and unable to self-advocate and fully dependent on staff for care.1/9/26 at 12:09PM, V11 (R1 Family Member) said, I went yesterday and the tube feeding was off again -- I got there at like 6pm, that's the time I usually go between 5:45-6pm .last night they told me it was 8pm and it was time for 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents who were unable to maintain adequate nutrition independently received enteral nutrition as ordered and failed to maintain accurate records of daily enteral intake for residents. This failure affected three of three (R1, R4, R5) residents reviewed for enteral feeding.Findings include:R1 is a [AGE] year-old resident admitted in March of 2025 with diagnoses including but not limited to: anoxic brain damage, acute and chronic respiratory failure, unspecified severe protein-calorie malnutrition, pressure ulcer of sacral region, stage 4, tracheostomy status, anemia, and gastrostomy status.R1 is nonverbal and unable to self-advocate and fully dependent on staff for care.01/09/26 at 4:18PM, V4 (Social Services Director) said, I know we had a care plan meeting with R1's family. We can give the family a narrative if they want a resolution to the concern. The concern forms are internal but if they request a concern form, they…

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 standard infection prevention and control regarding hand hygiene and use of gloves during care for two residents (R12 and R13) in the sample reviewed for infection control. As a result, R12 ADLs (Activities of Daily Living) bed bath was done with staff assistance with gloved hands not performing any hand hygiene or removing soiled gloves and touching R13 belongings and the clean linen cart with soiled gloves. This failure affected R12, R13 and has the potential to affect all 37-residents residing on the 1st floor.Findings include: R12's admission Record documented that R12 was admitted to the facility on [DATE] with listed diagnosis information that includes but not limited to Urinary tract infection site unspecified, other lack of coordination, type 2 diabetes mellitus without complications, muscle weakness, unspecified abnormalities of gait and mobility, peripheral vascular disease, pressure induced deep tissue damage of right…

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 discharge policy and Against Medical Advice (AMA) policy when discharging a resident. This failure affected one resident (R4) of three residents reviewed for discharge. R4 was discharged from the facility to an unknown location and the facility does not know resident's current location or condition.Findings include:R4 is [AGE] years old admitted to the facility on [DATE], face sheet listed the following medical diagnosis among others: Localization-related (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, not intractable with status epilepticus, dysphagia unspecified, generalized abdominal pain, prolonged grief disorder, anxiety disorder, unspecified psychosis not due to substance or known physiological condition, depression, acute pancreatitis without necrosis or infection, alcohol use unspecified with withdrawal , uncomplicated, etc.On 12/08/2025 at 10:36AM and 1:01PM, surveyor attempted to contact…

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

Based on observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that staff report/document maintenance issues/broken equipment, and failed to ensure that broken equipment was not in use. These failures have the potential to affect 169 residents.Findings include:The 11/19/25 census includes 169 residents.On 9/26/25, IDPH (Illinois Department of Public Health) received the following allegations: A shower chair broke on 9/21 and nobody repaired, replaced, or otherwise prevented R4 from using it on 9/23 resulting in it breaking on R4. R5 entered the bathroom while R4 was showering.R4's progress notes state (9/18/25) Writer was called to shower room by staff. Writer noted the resident in the shower room on the floor. Resident lost balance while attempting to transfer to shower chair and fell to the floor. (9/24/25) Resident told writer she would like to file a complaint against another resident because she felt violated when (R5) entered the community bathroom while she was in the shower room despite her telling (R5) not to enter 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 record review and interview the facility failed to follow policy procedures, failed to document a grievance form, failed to investigate reported theft of funds, and failed to report a theft allegation to IDPH (Illinois Department of Public Health) for one of three residents (R4) reviewed for misappropriation of funds. Findings include:On 9/26/25, IDPH (Illinois Department of Public Health) received allegations that roughly $500 of R4's SNAP (Supplemental Nutrition Assistance Program) benefits were stolen. The complainant feels it had to have been facility staff who had access to R4's social security number. The issue was reported but nothing was done by the facility. R4 was admitted to the facility on [DATE]. On 11/20/25 at 10:38am, surveyor inquired about R4's stolen SNAP benefits V5 (Social Service Director) stated, She (R4) reported it to me (V5) over a year ago when she first admitted , it did not happen here (facility). Surveyor inquired what was implemented when the allegation was received. V5…

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 adequate staffing of certified nursing aides and implement an effective system in place for call-offs on the night shift. This failure has the potential to affect all residents residing on the first floor.Findings Include:Based on Facility Census Report dated 9/30/2025, there were 38 residents residing on the first floor.Facility Assessment Tool dated 8/1/2025 with review date of 10/1/2025 shows the facility will staff 10 CNAs in total on the night shift.Facility Staffing Sheets dated 9/9/2025-9/28/2025, showed 6 night shifts out of 20 reviewed, were staffed with less than 10 CNA's.On 9/29/2025 at 11:45AM, R3 said at nighttime he has to wait a long time for his call light to be answered.At 11:50AM, V5 (Registered Nurse) said she works both night and day shift. V5 said on the night shift there are sometimes not enough CNA's, and there are times where they work on the first floor with only two CNA's. V5 said she feels as if that is not enough staff to adequately care for all the residents. Staff have expressed concern…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow its Activities of Daily Living (ADL) policy by not providing ADL care assistance to dependent residents. This applies to 2 of 3 residents (R4 and R5) reviewed for ADL care in a sample of 5.The Findings include:1. R4 is a [AGE] year-old male admitted on [DATE] having severe cognitive impairment as per the MDS (Minimum Data Set) dated 5/22/25. On 7/8/25 at 10:05 AM, R4 was observed on his low bed, confused with an unkempt and dirty beard with discolored facial hair around his mouth and food debris on the beard. R2 was also observed with long dirty-looking discolored fingernails on both hands.The MDS dated [DATE] documents that R4 requires substantial/maximal assistance to personal hygiene. A review of the R4's ADL care plan document to assist resident with ADLs.2. R5 is a [AGE] year-old male admitted on [DATE] having cognition intact as per the MDS dated [DATE]. On 7/8/25 at 9:30 AM, R5 was observed on his bed with long facial hair…

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 adequate supervision to one (R1) out of three residents reviewed for falls (R1, R2, and R3) and failed to follow their fall policy and procedure after R1 experienced a fall on 5/14/2025. Findings include: R1 is a [AGE] year-old female who originally admitted to the facility on [DATE] and continues to reside in the facility. R1 has multiple diagnoses including but not limited to the following: paraplegia, PTSD, conversion disorder with seizures, depression, UTI, and osteoporosis. Minimum Data Set (MDS) dated [DATE] shows R1 has a Brief Interview of Mental Status (BIMS) of 15, meaning R1 is cognitively intact. MDS dated [DATE] shows R1 needs maximal assistance during transferring and toileting. On 5/15/2025 at 11:05AM, R1 stated the staff at night never want to assist me. I cannot walk or use my legs. I need help doing certain things. R1 said I had a procedure on 5/13/2025 and I after couldn't transfer myself like I normally do. I was in pain and…

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

Based on interview and record review the facility failed to revise and update Abuse/Neglect Care Plan affecting 1 of 3 (R1) residents reviewed for Abuse Care Plan. Findings Include: On 4/24/2025 at 9:27 AM, V6 (Social Service Director) stated Social Service Department is responsible for updating resident Abuse Comprehensive Care plan. Care plan is updated quarterly, annual, and significant change such as grievance/concern related to allegation. V6 said sexual abuse allegation is considered a concern. V6 stated R1's abuse/neglect comprehensive care plan was last updated/revised on 3/28/2024. V6's abuse care plan should have been updated on 4/22/2025 when a sexual abuse allegation was reported to IDPH. On 4/24/2025 at 10:24 AM, V9 (MDS Coordinator) said she oversee the overall care plan like a gate keeper. V9 said comprehensive care plan should be updated whenever there is an allegation of abuse. On 4/24/2025 at 11:00 AM, V10 (Social Service Coordinator) said care plan is updated as needed. Care plan is reviewed quarterly (during ARD), any significant changes in behavior and care.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to report immediately resident to resident sexual abuse allegation to Illinois Department of Public Health and Local Law Enforcement affecting 1 of 3 (R1) residents reviewed for Abuse. Findings Include: On 4/22/2025 at 9:15 AM during initial interview, V1 (Administrator) stated that the facility was aware of the sexual assault allegation by R1. V1 stated R1 was upset because of room change and allegation about roommate was told to V11 (Licensed Practical Nurse/LPN) who was the nurse on duty. V1 stated the sexual allegation that R1 stated was he was touched inappropriately and penetrated by his roommate. V1 stated R1's roommate has been discharged from facility. V1 stated he did not report the sexual assault allegation, nor did facility called police on 3/28/2025 (alleged date of event) because V1 stated after interviewing R1 and staff he concluded that R1's sexual assault allegation was fabricated. On 4/22/2025 at 9:30 AM V2 (Director of Nursing) 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement a grievance council that addresses residents' complaints to voice and resolve concerns of food quality. This failure affected four residents (R71, R81, R99 and R107) out of a total sample size of 30 and has the potential to affect 128 of 150 residents residing in the facility. Findings include: R71 is a [AGE] year-old male resident with diagnoses including but not limited to major depressive disorder, recurrent, mild; other sequalae of cerebral infarct and memory deficit following cerebral infarction. Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status (BIMS) score of 15 which indicates R71's cognition is intact. R81 is a [AGE] year-old female resident with diagnoses including but not limited to chronic respiratory failure, unspecified whether with hypoxia or hypercapnia; schizoaffective disorder, unspecified; anxiety disorder, unspecified; tracheostomy status. Minimum Data Set (MDS) dated [DATE] has a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide a credentialed certified respiratory staff, as required by state law, to perform respiratory assessment, treatment, and monitoring for residents requiring respiratory care. This failure has a potential to affect all residents requiring respiratory care. Findings include: On 01/27/25 at 11:43 AM V4 (Respiratory Therapy Director) said, It's me and another staff, she's a student, working today (on the respiratory unit). There are 20 residents, 19 have been assessed as needing respiratory therapist attention. V5 (Respiratory Technician/Student) is not a student, but she is not certified yet. Some of our tasks, respiratory therapist, include suctioning, tracheostomy care, ventilator checks, assessments, responding to respiratory emergencies, and transporting tracheostomy dependent residents to the dialysis. On 01/27/25 at 12:07 PM Surveyor observed V5 (Respiratory Technician/Student) independently providing tracheostomy care to R149.…

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 review, the facility failed to adequately protect its residents by failing to supply individuals entering the facility with appropriate masks during an influenza outbreak. This failure had the potential to adversely affect the facility's entire resident population of 150. Findings include: On 01/28/2025 at 1:05 PM, V3 (Infection Preventionist) said presently the facility had implemented contact and droplet precautions due to an influenza outbreak. V3 said she recommended that her staff wear a face-shield and N95 mask for contact and droplet precautions. V3 said that the non-medical masks the facility was providing staff and residents were not appropriate, and acknowledged some of the staff were wearing them. V3 said she had to be repetitive with staff, and remind them not to use the non-medical masks. V3 said she told V2 (DON) about not using the non-medical masks, adding she felt V2 needed to back her up on the issue. V3 said she also alerted V1 (Administrator) a couple of weeks ago about the non-medical masks, and even argued with a…

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

Based on observation, interview, and record review, the facility failed to follow their policy by 1. Failing to ensure staff properly document medication administration of medication on the controlled substance record for three (R14, R17, and R256) residents, and 2. Failed to follow their policy by failing to ensure a newly admitted resident's Oxycodone controlled medication was initially documented on an individual controlled substance form for one (R257) resident. These failures affected four (R14, R17, R256, and R257) residents reviewed for pharmacy services. Findings include: On 1/28/25 at 11:39 AM, the controlled substances were reviewed with V12 LPN. Findings include: 1. Review of the individual controlled substance record for R256's Oxycodone HCl (Hydrochloride) Oral Tablet 5 mg (milligram) *Controlled Drug*, give 1 tablet via G-Tube (gastrostomy/stomach tube) two times a day related to Fractures is blank. The scheduled dose for 8:00 AM has not been documented as administered to R256. The medication administration record documents V12 LPN administered the Oxycodone at 8:00…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure licensed staff administered medicated breathing treatment for 1 of 6 (R67) residents reviewed for medication administration in the final sample of 58. Findings include: R67 is a [AGE] year old female admitted to the facility on [DATE] with diagnosis including but not limited to Chronic Respiratory Failure, Nontraumatic Intracranial Hemorrhage, Dysphasia following Nontraumatic Intracerebral Hemorrhage, Neurocognitive Disorder with Lewy Body; Encounter for Attention to Tracheostomy, and Quadriplegia. On 01/27/25 at 01:37 PM Surveyor observed V5 (Respiratory Technician/Student) gathering tracheostomy care supplies and independently going into resident's room. Shortly after, upon leaving resident's room, V5 said, I just finish the resident's tracheostomy care and will be giving medications, breathing treatment, to R67 next. On 01/27/25 at 01:40 PM V5 (Respiratory Technician/Student) said in the follow up interview, I've been working…

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 by 1. Failing to ensure medication without a resident name and medication discontinued by the physician was removed from the active medications in the medication cart for one (R15) resident, 2. Failed to follow their policy by failing to ensure expired insulin and insulin without a resident's name was removed from the active medications in the medication cart for one (R75) resident, 3. Failed to follow their policy by failing to ensure new unopened insulin was refrigerated per the facility policy to retain purity and potency for one (R256) resident. These failures affected three (R15, R75, and R256) residents reviewed during medication storage and labeling. The facility failed to follow their policy by failing to remove two vials of expired Tuberculin testing solution from the medication refrigerator in the medication storage room. This failure has the potential to affect all newly admitted residents to the first…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report allegations of physical abuse for one (R1) resident out of three residents reviewed for physical abuse. Findings include: On 12/14/2024, at 10:03AM, R1 states there was an altercation that took place, and he was sent out to the hospital. R1 states he told another resident to turn their television/TV down and then the other resident attacked him. R1 states he does not know the other residents' name and forgot which room number the incident occurred in. R1 states himself and the other resident were not roommates. R1 states he was inside of his own room, which was separate from the other residents' room. R1 states he went to the other residents' room to tell him to turn the TV down and the other resident attacked him from the back. R1 then states the event occurred so long ago that he can't remember what happened and maybe the other resident was his former roommate. R1 states he is unable to describe the resident who attacked him but states he is a…

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

Based on interview and record review the facility failed to ensure a resident recieved the correct dose of medication as prescribed, Oxycodone 5 milligrams every eight hours as needed. This affected one of three residents (R1) reviewed for professional standards of care for medication administration. Findings include: On 11/21/24 at 8:15am, R1 observed alert to person, place, time and situation. R1 said his pain is being managed. R1 said he doesn't take Oxycodone 5 mg like that, R1 said he doesn't take Oxycodone every four hours. R1 said he takes other medications to reduce his pain also. R1 said he might take Oxycodone 5 mg after returning to the facility from being out on pass, R1 said when he's out on pass he's moving around more and that increases his pain. R1 said he last took Oxycodone last night (11/20) when he returned to the facility. R1 said he went out on pass on Monday 11/18/24, R1 said it was later in the day. R1 said he does not know what time he requested Oxycodone 5 milligrams on Monday 11/18/24. Review of facility resident sign out log with V2 (Social Services…

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 follow their narcotic medication policy to ensure control medication Oxycodone 5 milligrams are documented and accounted for. This affected one of three resident (R1) reviewed for controlled medications. Findings include: On 11/21/24 at 8:15am, R1 observed alert to person, place, time and situation. R1 said his pain is being managed. R1 said he doesn't take Oxycodone 5 mg like that, R1 said he doesn't take Oxycodone every four hours. R1 said he takes other medications to reduce his pain also. R1 said he might take Oxycodone 5 mg after returning to the facility from being out on pass, R1 said when he's out on pass he's moving around more and that increases his pain. R1 said he last took Oxycodone last night (11/20) when he returned to the facility. R1 said he went out on pass on Monday 11/18/24, R1 said it was later in the day. R1 said he does not know what time he requested Oxycodone 5 milligrams on Monday 11/18/24. Review of facility resident sign out log with V2 (Social Services Director), V2 said he reviewed the record…

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 serve palatable resident meals. This failure affects six ( R3, R6, R7, R8, R9 and R10) residents reviewed for food palatability. Findings include: R3 is a [AGE] year-old female originally admitted on [DATE] with medical diagnoses that includes and are not limited to: malignant neoplasm of the breast, spondylosis of lumbar region and obesity. Based on MDS (Minimum Data Set) dated: [DATE], BIMS (Brief interview for mental status) reads results of 15/15 intact cognition. On 11-16-2024 at 9:00 am R3 said, I am very unhappy with the dietary services here, the food does not have any flavor, is undercooked or overcooked. I have to buy food and keep as you see I have cans of food and chips just in case I do not like what I am getting on the tray I can supplement with what I have in the room. R6 is a [AGE] year-old female, originally admitted on [DATE] with medical diagnosis that includes and are not limited to: diabetes, malignant neoplasm of the vulva 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 provide residents with dinner meal at the facility's designated mealtimes. This failure affected 14 (R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19) residents review for frequency of meals. Findings include: R3 is a [AGE] year-old female originally admitted on [DATE] with a medical diagnosis that includes and is not limited to malignant neoplasm of the breast, spondylosis of the lumbar region, and obesity. Based on MDS (Minimum Data Set) dated: [DATE], BIMS (Brief interview for mental status) reads results of 15/15 intact cognition. On 11-16-2024 at 9:00 am, R3 said, on Wednesday 11-13-2024 many of the patients did not eat until 10:00 pm. My roommate (R10) received her dinner tray at 10:00 pm, the chicken that came on the tray was all overcooked and hard. R6 is a [AGE] year-old female, originally admitted on [DATE] with medical diagnoses that include and are not limited to: diabetes, malignant neoplasm of the vulva, and depression.…

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 make transportation arrangements that took into account the resident's physical and mental needs, in order to avoid a missed appointment with the resident's oncologist. This failure applied to one (R1) of four residents reviewed for assistance with transportation arrangements. Findings include: R1 is the subject of this complaint and is no longer in the facility. R1 is a [AGE] year-old male with a history of Acute Respiratory Failure, Emphysema, Malignant Neoplasm of Larynx, COPD, Severe Protein-Calorie Malnutrition, and documented behavioral disturbances. Nursing Progress Note with Created Date : 10/10/2024 15:20:47, reads: Resident is supposed to have appointment with oncologist today but d/t no escort it is deemed unsafe for patient to go alone with only the transport guy d/t his behavior. Family is aware. The clinic called writer and they will call us back to reschedule. Endorsed to nnod. [sic] 11/16/24 at 10:19AM, V3 (Transportation) stated that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their narcotic and medication administration policy by not documenting in the electronic medical record (EMR), that narcotic medication was administered. This failure applied to one (R11) of four residents reviewed for medication administration. Findings include: R11 is an [AGE] year-old male who was admitted to the facility 08/22/24 with the diagnoses history of left perinephric hematoma, intervertebral disc degeneration, hypertension, Atrial fibrillation, Benign prostatic hyperplasia, chronic myelomonocytic leukemia, monoclonal gammopathy, idiopathic gout, multiple sites, non-Hodgkin lymphoma, b-cell lymphoma, and chronic kidney disease. R11's physician orders for September 2024 reads: Hydrocodone-Acetaminophen Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 6 hours as needed for Moderate Pain (4-7). On record review R11 had 5 doses of Hydrocodone-Acetaminophen Oral 1 Tablet 5-325 MG controlled…

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 that all healthcare personnel have current basic life support cardiopulmonary resuscitation training and certification. Ten certified Nursing Aides 10 of 10 (V27, V28, V29, V30, V31, V32, V33, V34, V35, V36) reviewed for current CPR. Findings include: [DATE] at 1:39 pm, V7 (Administrator) said the facility does not require that all the Certified Nursing Assistants have a cardiopulmonary resuscitation training and certification, she only encourages the aides to have the training. V11 (Human Resource Staff) presented a list of Certified Nursing Aides that do not have current CPR certification and are currently working at the facility. V11 said all the certified nursing aides do not need to be CPR trained. [DATE] at 2:13 pm, V8 (Director of Nursing) said some of the aides that currently work at the facility do not have CPR training and certification. V8 said they do not have to have CPR training and certification. Facility CPR policy reviewed with…

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

Based on observation, interview, and record review the facility failed to have a licensed respiratory therapist on duty on 8/8/24 for the entire duration of the shift. This affected 11 of 11 residents (R13-R23) reviewed for respiratory care. Findings include: On 8/8/24 at 6:40 am, V19 (Respiratory Aide/respiratory therapy student) was observed going from resident room to resident room, administering respiratory care and treatments, working unsupervised by a licensed respiratory therapist on the trach/vent unit. V19 said the Licensed Respiratory Therapist left at 6:30 am, V19 said he always leaves early. V19 said she was a student, and she does not graduate school until December 2024. R13-R23 was assigned to V19 on 8-8-24. On 8/9/24 at 9:59 am, V25 (Respiratory Therapy Supervisor/ Director) said respiratory therapy students should not be working alone, unsupervised, and they should be working with a licensed respiratory therapist. V25 said she was not aware that V25 was working without a licensed therapist. V25 said she was not aware that the licensed therapist left early. V25 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 interviews and records reviewed the facility failed to notify the attending physician of an acute change in condition to include loose stools and weakness. This affected one of three residents (R1) reviewed for notification of a change. The findings include: Ambulance record dated [DATE] documents called to location for patient in cardiac arrest. RN says this patient was last checked on by CNA around 2:00AM, however she had come on at 11:00PM and not seen this patient. Patient is pale cold to the touch. Patient is laying in fluids that have dried to the linens. Crew takes over compressions and places patient on monitor. Rhythm check confirms asystole and no pulse. Crew removes CPR board and notes the patient's neck remains in position without being held. Crew notes severe stiffness to the mandible and neck. Crew contact hospital and received orders to terminate resuscitation. Reason rescue stopped: Obvious signs of death. On [DATE] at 11:02AM, V16, Certified Nursing Assistant (CNA), said I started 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 interviews and records reviewed the facility failed to conduct a comprehensive assessment of one resident who developed new loose stools. This affected one of three residents (R1) reviewed for quality of nursing care and assessments. This failure resulted in R1's loose stools being left untreated. The findings include: Ambulance record dated [DATE] documents called to location for patient in cardiac arrest. RN says this patient was last checked on by CNA around 2:00AM, however she had come on at 11:00PM and not seen this patient. Patient is pale cold to the touch. Patient is laying in fluids that have dried to the linens. On [DATE] at 11:02 AM, V16 Certified Nursing Assistant (CNA), said I started at 3:00 PM on Sunday [DATE] and remained until 7:00 AM on [DATE]. V16 said I started with rounds around 11:00 PM. V16 said I saw R1 he was sleeping, I did not wake him up. V16 said R1 is usually sleeping on night shift and he had his eyes closed. V16 said on night shift R1 is incontinent of urine and bowel and…

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

Based on interview and record review, the facility failed to provide care in accordance with professional standards of quality by 1. Failing to provide timely respiratory tracheostomy care; 2. Failed to respond to request from resident for respiratory suctioning to clear airway; 3. Failed to have staff who had the necessary skills to adequately meet the needs of the resident in respiratory distress; 4. Failed to provide adequate supervision and monitoring of tracheostomy patients to avoid life-threatening situations. These failures affect 1 (R2) of 3 residents reviewed for respiratory care in the sample of 4 and have the potential to affect 12 residents in the facility. Findings include: On 03/11/2024 at 2:54 PM, V1 (Administrator) presented surveyor the facility tracheostomy status resident list showing 12 residents with tracheostomy status. On 03/04/2024 at 12:31 PM, Surveyor interviewed V4 (Respiratory Therapist) who stated in summary: My respiratory therapy duties are to: check vital signs for residents with tracheostomies, make sure all residents with tracheostomy status are…

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 nursing staff failed to respond to a resident requiring respiratory care and the nursing staff failed to provide needed suctioning for a resident in potential hypoxia (lack of oxygen); for one (R2) of three residents reviewed for respiratory care in the sample of four. Findings include: R2 is a [AGE] year old male admitted to the facility on [DATE] with diagnosis including but not limited to Acute and Chronic Respiratory Failure with Hypoxia or Hypercapnia; Dysphagia; Chronic Obstructive Pulmonary Disease; Systolic (Congestive) Heart Failure; Hypertension; and Gastrostomy and Tracheostomy Status. According to R2's face sheet, R2's code status: Full Code. According to R2's MDS (Minimum Data Set) assessment dated [DATE] and [DATE] under section E, R2 had no behaviors that impacted care. R2's care plan dated [DATE] (revised on [DATE]) reads in part, (R2) is Ventilator dependent related to Respiratory Failure. Patient is refusing to turn to ventilator at night.…

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 follow the facility abuse policy to conduct criminal background checks within 24 hours after admission of a new resident for 11 (R14, R35, R45, R48, R52, R56, R68, R70, R95, R106, R122) of 11 residents reviewed for criminal background check. This failure has the potential to affect the 153 residents currently residing in the facility. Findings include: Per census report, there are 153 residents currently residing in the facility. Per facility list, there are 11 identified offenders currently residing in the facility. According to face sheets, the following identified offenders were admitted on the following dates, along with the dates their criminal history records were checked from the state law enforcement agency: R14, admitted on [DATE]; records checked on 04/19/13, which was 144 hours post admission R35 was admitted on [DATE]; records checked on 03/13/23 R45, admitted on [DATE]; records checked on 02/23/19 R48 was admitted on [DATE]; records…

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 two resident shower rooms on the first floor were in working order. This failure affected R25 and has the potential to affect all 28 residents residing on the first floor. Findings Include: On 3/11/24 at 11:40AM, R25 stated, I do not like receiving showers because the water temperature in the shower is too cold. The CNA's will turn the hot water all the way up and it is still freezing cold. I request for bed baths instead of showers because the hot water in the shower does not work. On 3/11/2024 at 12:35PM, this surveyor observed two shower rooms on the first floor. One of the shower rooms was observed to be missing a handle and not in working order. The second shower room temperature was noted to not reach an acceptable hot water temperature. On 3/12/24 at 10:55AM, V9 (Maintenance Director) was interviewed regarding first floor shower rooms. V9 and this surveyor went to first floor to observe shower rooms. V9 checked water…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide ADL (Activities of Daily Living) care to 4 (R89, R92, R95, R154) of 8 residents reviewed for residents dependent on staff to provide ADLs in the sample of 74. Findings include: 1. R92 is a [AGE] year old with diagnosis including chronic respiratory failure with hypoxia, tracheostomy, paraplegia and gastrostomy. R92's care plan reads in part, ADL: requires assist with daily care needs related to weakness/ discomfort when moving/ spasm of affected area/ poor motivation/ inactivity resulting from impaired cognition/neurological deficit. Staff will anticipate and meet all of residents needs on a daily basis through next review. Interventions: clean, dry, groomed, turned and positioned. Assist resident with ADLs. Encourage/ Assist with turning and repositioning every two hours and as needed. Mechanical lift with two assist for transfers. Keep clean and dry after each incontinent episode. Monitor for changes with daily care abilities and…

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

Based on observation, interview and record review, the facility failed to have a five percent (5%) or lower medication error rate. There were 3 medication errors out of 25 medication opportunities resulting in a 12% medication error rate. This failure affected one resident (R43) and has the potential to affect all 53 residents on the 4th floor. Findings include: On 03/11/24 at 11:45 AM, surveyor observed medication administration on the 4th floor with V3 (RN). V3 administered medication to R43, who received among other medications, Lorazepam 2mg 1 tablet by mouth three times a day, and Buspirone 10mg, 1 tablet by mouth three times a day. Surveyor documented 11 medications during the medication preparation for R43, but V3 had a total of 12 pills in her medication cup. Surveyor presented this observation to V3. V3 stated that resident gets 2 tablets of Vitamin D, that's why she has 12 pills. She also added that she is an agency nurse and must locate the residents, that's why she is still passing morning at this time. Per medication reconciliation, review of physician order for 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 ensure that staff accommodate a resident's need to utilize a wheelchair for mobility as assessed and according to resident's care plan. This failure affected one resident (R89) of 3 residents review for mobility/limited range of motion. Findings include: R89 is a [AGE] year-old female she has resided at the facility since 6/4/2022 with past medical history including but not limited to type 2 diabetes with diabetic neuropathy, morbid (severe) obesity due to excess calories, hyperlipidemia, essential primary hypertension, end stage renal disease, etc. On 03/12/24 at 11:40 AM, R89 was observed in her room, awake, alert and oriented and stated, she has been in the facility for a couple of years. R89 stated, she has an electric wheelchair but had only used it twice, when a man came from outside and trained her on how to use it and then one more time. R89 further stated, staff always tell her (R89) that they do not have enough staff to get her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide one resident (R54) with existing pressure ulcers with necessary treatment and services consistent with professional standards of practice to promote wound healing and prevent infection and failed to provide psychological services for a resident with a history of refusing pressure ulcer treatments. These failures affected one resident (R54) of 5 residents reviewed for pressure ulcers. Findings include: R54 is a [AGE] year-old male admitted to the facility on [DATE], past medical history includes, but not limited to cellulitis, need for assistance with personal care, chronic embolism, and thrombosis of deep veins of bilateral lower extremity, pressure ulcer of sacral region stage 4, osteomyelitis, etc. On 03/11/24 at 12:10PM, R54 was observed in his room, awake and alert, unkempt with long matted hair and very long overgrown beard. R54 stated, he came to the facility for wound care and would like to go home, resident stated that he…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement fall interventions for one (R112) of 5 residents reviewed for falls in the sample of 74. Findings include: On 3/11/24 at 10:15 AM, V2 (DON-Director of Nursing) was asked to provide a fall log showing all the incidents involving falls in the facility. This log presented showed 73 total falls in the last 90 days. On 3/11/24 V31 (Corporate Nurse Consultant) was asked which staff member oversees fall prevention, V31 stated, V5 (Restorative Nurse) is the fall prevention nurse but the DON V2 helps, so they both are. On 3/11/24 at 11:10 AM, V5 affirmed she was the restorative director in charge of restorative nursing but was not the fall prevention nurse. V5 indicated that her duties were to update the care plans and interventions for residents who had fallen but she was not the dedicated fall nurse. On 3/11/24 at 11:30 AM, V2 (DON) indicated that she did not have a fall prevention nurse at the time. V2 stated, I'm not sure why V31 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 maintain infection control practice during incontinence care. This failure affected 1 (R124) of 9 residents reviewed for bowel and bladder care. Findings include: R124 is [AGE] years of age. Current diagnoses include but are not limited to Type 2 Diabetes Mellitus, Schizoaffective Disorder, and Hypertension. R124's comprehensive assessment dated [DATE] documents a brief interview for mental status score of 15 out of 15. A score of 13-15 indicates the person is cognitively intact. On 03/11/24 at 12:37 PM, V34 CNA (Certified Nurse Assistant) came in room to provide incontinence care. V34 CNA was observed putting on gloves, turning R124, and opening her incontinent brief. V34 stated, R124 is wet, and she had a bowel movement. V34 proceeded to clean R124's buttocks of feces with disposable wipes. V34 then applied a clean incontinent brief while wearing the same gloves used to clean the feces. V34 continued to put on R124's pants and adjust…

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 facility assessment tool for staffing by not having two nurses on the first floor morning shift on 2/2/24. This failure resulted in R2, R14, R15 and R16 receiving their medication over one hour late. In addition, the facility failed to have enough staff to provide direct care on the night shift for 12/05/23. This failure resulted in R2 not being provided incontinence care and R3 who was diagnosed as dependence on renal dialysis missing her scheduled in-house dialysis treatment as prescribed. This failure affects five of five residents reviewed for staffing. Findings include: On 2/2/24 there was only one nurse observed on the first floor. On 2/2/24 at 10:00AM, R2 who was alert and oriented at time of interview, R2 said the facility is always short staffed and he has to wait for incontinence care and medications. R2 said he receives his medications late most days. When asked how does he know its late, R2 said he watches the View…

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 interviews and record reviews, the facility failed to report and investigate an allegation of injury of unknown origin. This deficient practice affects one resident (R5) of three residents reviewed for abuse. R5 was noted to have bruising on right shoulder, reported to the facility by a family member on 12/24/23. Findings Include: Facility Reportable Incidents reported to IDPH in December 2023, there is no report filed for R5's allegation of injury of unknown origin On 2/7/24 at 2:45PM, V1 was asked if there was reportable done to R5 on December of 2023. V1 stated nothing was reported to V1 about abuse and bruising. Stated that the DON and the wound care team looked at it on the 12/29/23 when it was reported to them, it was not bruising it is skin pigmentation. Facility unable to provide state reportable and investigation of injury of unknown source for R5. Grievance Facility Form reviewed and noted that on 12/24/23 a concern was filed by V30 (Concern Party). Stated R5 has bruising on right shoulder, report taken by V17 (Social Service Director) on 12/24/23. On 2/8/24 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 follow their weight management policy and the recommendation of the dietician by not monitoring weekly weights for one of three (R12) residents. This failure resulted in R12 sustaining an unplanned 24.5% weight loss over three months. Findings include: R12 was admitted to the facility on [DATE] with a diagnosis of left femur fracture, dysphagia, anemia, cognitive communication deficit, and failure to thrive. On 2/8/24 at 10:46AM, V10 (Dietician) said R12 was at risk for malnutrition based on initial assessment. V10 said weights should be monitored when admitted to monitor a residents nutritional status and how they are adjusting to the facility. V10 said she recommended weekly weights x4 weeks in her notes on 12/19/23 and 1/9/24 due to weight changes. Weekly weights are important to evaluate the effectiveness of the nutritional interventions put in place. R12's dietary note 12/19/23 documents: significant weight loss in one month. Weekly…

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 interviews and record reviews, the facility failed to follow physician's order and failed to administer medication for pain. This deficient practice affect one resident (R8) of three residents reviewed for medication administration and fall incident. R8 had a fall, and complaint of right hip pain. Staff received an order for right hip and femur STAT x-ray and to give 650mg of acetaminophen for the pain. Findings Include: R8 had a fall incident on 2/7/24 upon record reviewed. Nursing notes reviewed and on 2/7/2024, Nurses Notes reads in part: R8 found on floor, full assessment completed, no signs and symptoms (s/s) of injury noted, no s/s of pain noted. Placed back in bed. Bed in lowest position. R8 had no pain after fall incident, however on the 2/7/23 (day shift), R8 complaint of right hip pain. Nurse received an order for STAT hip and femur x-ray and to give Tylenol for pain. On 2/7/2024 11:04 Nurses Notes reads in part: Writer informed NP that resident is complaining of right hip pain. NP gave orders for X-RAY of the hip and femur and to give 650mg acetaminophen for 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 follow a resident who was diagnosed with End Stage Renal Disease and dependence on renal dialysis plan of care by not transporting 1 of 3 (R3) to their scheduled dialysis treatment. This failure resulted in R3 missing one three hour treatment. Findings Include: R3 was diagnosed with End Stage Renal Disease and dependence on renal dialysis. Brief interview for mental status dated 01/08/24 documents a score of thirteen which indicate cognitively intact. Section GG (functional abilities) documents: R3 had impaired lower extremity (hip, knee, ankle, foot) on both sides and required a wheelchair. On 2/7/23 at 10:42AM, V16 (Dialysis Nurse) said, R3 was scheduled for 6:00am dialysis treatment on 12/6/23. V16 said, she called R3's nursing station to inquire about R3 who was not in dialysis. V16 said, she was informed that R3 was going to miss dialysis due to no staff available to transport R3 which was in the house/facility. On 2/7/23 at 11:09AM, V2 (DON) said, the nurse is provided with a list of residents who require dialysis…

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 interviews and record reviews, the facility failed to follow physician orders and obtain a stat x-ray of the right hip and femur within 4-6 hours. This affected one of three residents R8 reviewed for radiology. This failure resulted in delay in R8 being x-rayed post fall for over 24 hours. Findings Include: R8 had a fall incident on 2/7/24 upon record reviewed. Nursing notes reviewed and on 2/7/2024, Nurses Notes reads in part: R8 found on floor, full assessment completed, no signs and symptoms (s/s) of injury noted, no s/s of pain noted. Placed back in bed. Bed in lowest position. R8 had no pain after fall incident, however on the 2/7/23 (day shift), R8 complaint of right hip pain. Nurse received an order for STAT hip and femur x-ray and to give Tylenol for pain. On 2/7/2024 11:04 Nurses Notes reads in part: Writer informed NP that resident is complaining of right hip pain. NP gave orders for X-RAY of the hip and femur and to give 650mg Acetaminophen for the pain On 2/7/2024 12:06PM, Nurses Notes, reads in part: R8 observed with complaints of pain to R forearm at this…

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

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 tracheotomy suctioning, failed to follow physician orders to provide adequate and appropriate respiratory and tracheal suctioning consistent with professional standards of practice for 1 of 3 residents (R1) in the sample. This failure resulted in R1 not receiving sufficient suctioning to maintain tracheal airway free from mucus/phlegm and failed to conduct tracheal suctioning care by being forcibly suctioned in a harsh and non-gentle manner by the respiratory therapist who caused pain and fear to the resident. Findings include: R1 is an alert and oriented [AGE] year-old with diagnosis of tracheotomy, gastrostomy, acute and chronic respiratory failure with hypoxia, and alcoholic liver disease. On 1/5/24 at 11:48 AM, R1 was in bed watching television. Surveyor tried to interview R1, but his tracheotomy appeared gray, and phlegm filled. R1 was coughing and tried to cover the tracheal opening to talk with the surveyor…

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 administration failed to take appropriate action to ensure the safety of 1 of 3 residents (R1) in the sample. The facility administration failed to protect a resident from harmful actions inflicted by staff, failed to conduct a thorough investigation of an allegation of abuse, and failed to honor the requests of the resident to remain safe and free from harm. Findings include: On 1/5/24 at 12:30 PM V1 Administrator and Abuse Prohibition Coordinator stated, I was informed of an incident that was reported to me on Christmas day around 3 PM and for an allegation of abuse that occurred on Christmas Eve by V3 RT/Respiratory Therapist When I interviewed the RT over the phone and I suspended him on the 25th and he returned on the 31st. Surveyor asked when the resident was interviewed, V1 stated, I interviewed the resident on Christmas day. He reported that a respiratory therapist slapped him on the left-hand side and he coughed and mucus came out and 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 thoroughly investigate an allegation of sexual abuse. This affected two of three residents (R1, R2) reviewed for investigation of an allegation of sexual assault. This failure resulted in R2 not being physically assessed by facility after an allegation of sexual assault was made by R1. Findings include: R1's progress note dated 11/11/23 documents: Around 1am this writer heard resident's bathroom call light sounding. CNA immediately went to assist resident. CNA returned to nursing station stating that resident was requesting to see the nurse because he needed his butt to be examined. Both this writer and nursing supervisor who was at nursing station as well went to assess resident's request. Resident stated that he needed his butt examined because he woke up with roommate on top of him. During examination resident did not verbalize any pain. No swelling or discoloration was seen at time of examination. There was poop at anus and on bedding, R2's progress note dated 11/11/23 documents: Around 1am it was reported by roommate…

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 follow their policies to include bathing and incontinence care for residents reliant on staff for care needs. This affected six of six residents ( R1, R2, R3, R4, R15, R16) all reviewed for assistance with activities of daily living. Findings include: On 8/17/23 at 3:03 pm, R1 was observed with a white layer of flaky dried skin covering his entire scalp and long thick brown nails. R1 who was assessed to be alert and oriented to person, place, and time, said, I would like my nails cut. I get my hair shampooed once in a while. R1 could not report the last time his hair was shampooed. On 8/22/23 at 1:10 pm, R4 observed lying in bed on right side, bilateral hand splints are not on properly, both hands clenched and over the wrist area of splint. Hair observed to be greasy with scaly skin on head and face. On 8/22/23 at 12:50 pm, V10 CNA (Certified Nurse Aide) stated that V10 started working at this facility in January and works 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review this facility failed to properly prevent and/or contain the spread of Covid-19 by not following their infection control protocol to include donning and doffing the appropriate personal protective equipment prior to entering and exiting a Covid-19 isolation room, and following hand hygiene policy and procedures. This affected four of four residents (R12, R25, R29, and R30) reviewed for infection control. Findings include: On 8/30/23, R25's Covid-19 test result was positive. On 9/1/23 at 10:19 am, V62 (Nurse) was observed entering a resident's room. V62 stated to R25 I found you. V62 did not don appropriate PPE prior to entering room with a Covid-19 positive resident, R25. V62 administered medications to R25. R25 was observed lying in bed under the covers. V62 was observed exiting room. V62 did not re-direct R25 back to his Covid-19 isolation room nor perform hand hygiene. V62 was then observed entering R29 and R30's room and removing a lunch meal tray. No hand…

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 interviews and record reviews, the facility failed to notify residents' family members of positive Covid-19 infection by 5:00 pm the next calendar day following confirmed infection of Covid-19. This failure affected 9 residents (R4, R25, R26, R29, R30, R31, R32, R33, and R34) out of 20 residents positive for Covid-19 infection in a sample of 34. Findings include: On 9/12/23 at 11:00 am, V41 (Infection Prevention Nurse) stated that V41 only reports Covid-19 positive residents to the resident and resident's family. V41 stated that V41 documents in the resident's progress notes when resident's family is notified of Covid-19 positive test results. V41 stated that V41 also notifies resident's family when isolation ends. V41 stated that the Covid-19 outbreak started on 8/20/23 with the first positive case identified. Review of R4, R25, R26, R29, R30, R31, R32, R33, and R34's medical records does not note that their family members were notified of positive Covid-19 test results. Review of this facility's outbreak line testing notes: R4's test result was positive on 9/5. R25's test…

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 notify a resident's family representative with changes in sacral pressure ulcer and treatments. This failure affected one resident (R14) out of three residents reviewed for notification of change and treatments. Findings include: On 9/7/23 at 11:25 am, V48 (Wound Care Nurse) stated that when R14 was admitted to this facility in December 2022, R14 had a state guardian. V48 stated that V48 notifies the residents' representative with weekly updates and with any changes that occur, such as wound decline or development of a new wound, between weekly updates. V48 stated that during a scheduled skin check for R14, V48 noticed a new phone number listed for contact person on R14's face sheet. V48 stated that V48 does not know when family took over guardianship of R14, but as soon as V48 noticed the change, V48 started contacting the family with updates. Review of R14's medical record notes: On 2/16/23, social services received call from R14's State Guardian who reports R14's family member has been made the assigned guardian of R14.…

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 interviews and record reviews, the facility failed to follow its abuse policy and conduct a thorough investigation for an allegation of physical abuse involving two residents (R23 and R24) out of 3 reviewed for abuse in a sample of 34. Findings include: On 9/1/23 at 3:55 pm, residents were observed standing in line unsupervised waiting to go outside and smoke. On 9/6/23 at 3:50 pm, V43 (CNA (Certified Nurse Aide) Supervisor) stated that V43 was upstairs on another nursing unit at the time of the incident on 5/13/23. V43 stated that by the time V43 got downstairs, the altercation was just about over. V43 stated that he was informed that R23 stated something to R24 and R24 hit R23. V43 stated that both residents fell to the floor. V43 stated that R24 walked off and R23 was put back in wheelchair. V43 stated that V43 did not watch the video recording of the altercation. V43 stated that R23 was sent out to the hospital because R23's posterior head was split open. R23 returned to facility with staples. V43 stated that staff are assigned to monitor residents during smoke breaks.…

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 follow the physician orders to restart glaucoma eye drops for one of three residents (R12) reviewed for readmission orders after hospitalization. Findings Include: On 9/6/23 at 4:55 pm, V2 (Director of Nurses) said, R12 had multiple hospitalizations. R12's Latanprost eye drop was not reinstated as a mistake. At that time we had a lot of agency nurses working. R12's eye drops should not have been discontinued nor should they have been stopped without a doctor's orders. On 9/1/23 at 10:30 am, V31 (Pharmacy Personnel) said, R12 did not have Latanprost eye drops for three months. R12 did not have any billing issues. Every time, R12's eye drops were requested we sent them. Nurse Practitioner note dated 6/6/23 documents: Follow up to Glaucoma, patient (R12) was previously taking Latanoprost drops and was discontinued when patient had a hospital stay. Assessing need and starting treatment again today. R12's Latanprost eye drop dispensing history documents: 3/4/23 a request was made on 2/24/23 but it was a refill too soon. On…

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 reviews, the facility failed to review and revise the falls care plan to prevent or reduce the risk of falling. This affected one of three residents (R19) reviewed for plan of care review and revisions. Findings include: On 9/6/23 at 1:25 pm, V40 (MDS (Minimum Data Set) Consultant) stated that the nurse updates the fall care plans. V40 stated that the interdisciplinary team collaborates on interventions. V40 stated that any nursing department head investigating the resident's fall needs to update the resident's care plan. Review of R19's MDS (Minimum Data Set), dated 8/2/23, notes R19 with moderately impaired cognitive skills for daily decision making. R19 requires extensive assistance with bed mobility. R19 is dependent on staff for transfers, toileting, and bathing. Review of R19's medical record notes on 7/19/23, V16 RN (Registered Nurse) noted R19 was in dining area when V16 was approached by CNA (Certified Nurse Aide) stating R19 was on the floor in the dining area. R19 was noted on floor laying on buttocks. R19 is very confused and unable 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 interviews and record reviews, the facility failed to consistently monitor and implement pressure relieving interventions to prevent the development of a facility acquired pressure ulcer for one resident (R13). This failure resulted in R13 developing a stage 3 sacral pressure ulcer on 2/27/23 which worsened to a stage 4 pressure ulcer during R13's stay at this facility. In addition, the facility failed to prevent one resident (R20) who was identified as very high risk for pressure injuries from developing a facility acquired deep tissue injury for two of three residents reviewed for wound care. Findings include: On 9/6/23 at 3:00 pm, V28 (Wound Care Nurse) stated that R13's sacral pressure ulcer worsened while at this facility. V28 stated that the wound care physician will use same treatment for 14 days and then re-evaluate wound's progress. If deteriorating, will change treatment at that time. V28 stated that fecal pouches and indwelling catheters are only used with stage 3 and 4 wounds on sacrum. V28…

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.

1. Based on interview and record review, the facility failed to follow physician orders by not ensuring an urgent abdominal x-ray was completed as ordered on 7/3/23 for one resident (R14). This failure resulted in R14 having an abdominal ultrasound, not an x-ray as ordered, 48 hours later on 7/5/23. In addition, the facility failed to follow physician orders to obtain a stat doppler for one resident (R9) who was displaying signs of cyanosis in lower bilateral lower extremities for two of three reviewed for diagnostic testing. Findings include: On 9/5/23 at 2:45 pm, V5 (Nurse) stated that when the physician or nurse practitioner orders an urgent test for a resident, the nurse is expected to call the outside diagnostic imaging company. V5 stated that urgent orders need to be completed within 4 hours; this is the standard of practice. V5 stated that if not done in that time, the nurse will call the diagnostic company again. V5 stated that the nurses don't usually call the physician or nurse practitioner again until it has been 7-8 hours and testing still not done. On 9/13/23 at 9:45…

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 apply a hand splint to prevent further contracture for 4 residents (R37, R64, R72, R80) reviewed for splint application in a sample of 30 residents. Findings include: 1. During observation on 1/31/23 and 2/1/23 at 10:00 am, R80 was observed with bilateral contractures to hands with no splints applied. During an interview on 2/1/23 at 11:00 am, with V6 (RN), V6 stated that hand splints are applied by the restorative nurse. During an interview on 2/1/23 at 11:00 am, with V7 (Restorative Director), V7 stated that R80 should have hand rolls on to prevent further contracture. Facility policy titled Restorative Programming Objective. All residents will be assessed upon admission, quarterly and with any significant change of condition to determine activity of daily living level of functioning. Residents will be placed in restorative programming .these programs may include . and range of motion. Procedure: If a need for skilled therapy service is…

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

Based on observation, interview and record review the facility failed to handle oxygen safely for four (R16, R118, R48, R89) of six residents reviewed for oxygen therapy in a sample of 30. Findings include: On 01/31/2023 at 10:26 AM, during observation, R16 was observed with undated nasal cannula tubing connected to the oxygen machine. At 10:28 AM, R118 was observed with undated nasal cannula tubing connected to the oxygen machine. At 10:46 AM, R48 was observed with undated nasal cannula tubing connected to the oxygen machine. At 11:16 AM, R89 was also observed with undated nasal cannula tubing connected to the oxygen machine. On 01/31/2023 at 11:15 AM, V17 (Licensed Practical Nurse) stated that all oxygen tubings should have dates on it and must be changed weekly. On 02/02/2023 at 4:05 PM, V2 (Director of Nursing) said that it is expected that all oxygen tubings must have date on it and must be changed on a weekly basis. R16's Physician Order Report indicated admit date of 01/28/2021, diagnosis of but not limited to chronic obstructive pulmonary disease, and order for oxygen at 3…

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 appropriate hand hygiene practices and transmission-based precautions affecting five (R99, R106, R100, R196, R130) of thirteen residents observed for medication administration and transmission-based precautions in a sample of 30. Findings include: 1. On 02/02/2023 at 10:45 AM, during observation on incontinence care to R130, V14 (Certified Nursing Assistant - CNA) was observed wearing personal protective equipment (PPE) without performing hand hygiene, double gloving, touching clean linen with dirty gloves on, stepping out of the room with PPE on twice, touching the clean linen cart with dirty gloves on, and leaving the room without performing hand washing. R130's door has sign that reads Contact Plus which indicates hand hygiene, isolation gown, gloves every time you enter the room and When Leaving: remove gloves and gown and wash your hands with soap and water only. At 11:13 AM during observation, V9 (Social Service Director) was observed inside R196's room without gown and gloves on. R196's door…

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 call lights where in reach for 3 of 21 residents (R10, R20, R38) in a sample of 30 reviewed for call lights. Findings include: 1. On 1/31/2023 at 9:50 am, R38 was observed in bed with her call light hanging off the side of the bed out of reach. On 1/31/2023 at 9:55 am, V13 (Nurse/Minimum Data Set-MDS Nurse) observed with this surveyor the call light hanging on the side of the bed out of reach and said, R38's call light should be in reach of her and placed the call light in reach. On 1/31/2023 at 2:30 pm, V2 (Director of Nursing-DON) said I expect all call lights to always be in reach of the resident. A record review of the Physician Order Report dated 12/31/2022-1/31/2023 indicates R38 has a diagnosis of unspecified lack of coordination, abnormal posture, and muscle weakness. A care plan that indicates a history of falls with injury and an Approach to keep call light in place. 2. On 1/31/2023 at 9:50 am, R10 was observed in bed with the call light attached to the wall out of reach and the privacy curtain…

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

Based on observation, interview and record review the facility failed to store medication in its original container for one resident (R58) reviewed for medication storage and labeling in a sample of 30 residents. Findings include: During medication review on 2/2/23 at 9:45 am, an inhaler was observed in the second-floor medication cart with no cover to the mouthpiece, no expiration date and not in a storage bag or in the original container. During an interview with V5 (LPN), V5 stated that R58 came with the inhaler from home with no cover to the mouthpiece. V5 stated that the mouthpiece should be covered. Facility policy titled; storage of medications Objective-Drugs and biologicals shall be stored in a safe, secure, and orderly manner. Drugs and biological are stored in the container in which they are received. Transfer between containers is performed only by issuing pharmacy.