Aperion Care Forest Park

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow its abuse policy by failing to initiate and thoroughly investigate an allegation of resident-to-resident verbal/mental abuse. This failure affected one (R7) of two residents reviewed for abuse in a total sample of 67. Findings include:R7 is [AGE] years old, and the face sheet listed the following past medical history: blindness to left eye, essential primary hypertension, diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema bilateral, hyperlipidemia, history of falling, type 2 diabetes with other circulatory complications, etc.On 2/23/2026 at 11:32AM, R7 was observed in the dining room, awake and alert and stated that R16 has been messing with her, she reported to staff, and nothing is being done. R16 will come to her room, harassing her and telling her that he will get some people to come and beat her up. R7 said that R16 messes with her wig when she puts it on.Progress noted dated…

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

Based on interview and record review, the facility failed to obtain from an outside resource routine and emergency dental services. This failure affected one (R210) resident reviewed for dental services in the total sample of 67 residents. Findings include:R210's census list documented that R210 was admitted at the facility on 10/26/2020 and was discharged on 1/28/2026. R210's (01/05/2026 - 02/28/2026) order Recap Report documented that R1's diagnoses include but are not limited to hemiplegia (paralysis) and hemiparesis (muscle weakness), cerebral infarction, and COPD (Chronic Obstructive Pulmonary Disease). R210's (01/16/2026) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 14. Indicating R210's mental status as cognitively intact. The (02/24/2026) email correspondence with V5 (Social Services Director) documented, in part Subject: (R210) Notes. Kindly include any dental notes. The (02/24/2026) email correspondence between National Preventive solutions and V36 (Social Services Assistant) documented,…

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 light devices were placed within residents' reach. This failure affected two (R6 and R7) residents reviewed for call light devices in the total sample of seven residents.Findings include:R6's admission Record documented that R6's diagnoses (include but not limited to) pulmonary embolism, Type 2 Diabetes Mellitus, and COPD (Chronic Obstructive Pulmonary Disease). R6's (12/09/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 11. Indicating R6's mental status as moderately impaired. Section GG0130. C. Toileting hygiene, E. Shower/bathe self, F. Upper body dressing. G. Lower body dressing, H. putting on/taking off footwear: 2 - Substantial / maximal assistance. R6's (12/16/2025) care plan documented, in part Focus: I am at risk for falls and injury related to falls Risk factors: Requires assistance with ADL's, possible medication side effects, incontinence, Neuropathy, H/O (history of) Falls. Goal: I will have…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to update a resident's care plan after each fall. This failure affects one (R5) resident reviewed for care plan in the total sample of 7 residents.Findings include:R5's admission Record documented that R5's diagnoses (include but not limited to) hypertension, alcohol dependence, and osteoarthritis. R5's (01/14/2026) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 08. Indicating R5's mental status as moderately impaired.R5's (11/01/2025 - 12/31/2025) Progress notes documented that R5 had unwitnessed falls on 11/04/2025, 11/05/2025, 11/27/2025, 11/30/2025, 12/05/2025, and on 12/07/2025.R5's (01/21/2026) care plan documented, in part Focus: I am at risk for falls and injury related to falls. Risk factors: Requires assistance with ADL's, possible medication side effects, Chronic pain, OA. Goals: I will have interventions in place and reviewed as needed to address risk for fall…

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 implement their abuse prohibition policy by failing to conduct a thorough investigation for an injury of unknown origin. This failure affects one of three residents (R1) reviewed for injuries of unknown origin. As a result, R1 was noted with swelling to the right lower forearm and grimacing in pain and was transported to the local hospital and R1 was found to have sustained a right comminuted distal radial fracture with displacement, a comminuted and impacted distal ulnar fracture with displacement, and a hematoma to the right side of the head.Findings includes:R1's hospital record, dated 9/22/25, notes R1 was brought in by EMS (emergency medical services) crew. Per EMS report, R1 had fall yesterday. This morning R1 had images which showed distal radius and ulna fracture. R1 states that she remembers falling yesterday. On physical exam by emergency room physician, a small hematoma was noted to R1's right lateral head; swelling noted to right wrist with obvious deformity. The emergency room diagnoses: fall and closed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident's comfort by failing to provide a comfortable mattress resulting in R1 lying in a sunken mattress. This failure affect one of three residents (R1) reviewed for comfortable mattresses. Finding includes: R1 was observed lying on bed. R1 mattress observed sunk in. Surveyor observed 3 fans in R1's room. One fan was broken, another fan provided by the facility but not the same kind as the broken fan, the 3rd fan is the same kind as the broken fan. R1 said that his family bought him the fan and he will like the facility to refund the money. R1 is oriented and can make his needs known. R1 said that he told V3 (Maintenance Director) about his mattress not being good. R1 said that V3 said that V3 will replace it but it has not been replaced yet. R1 said that R1 told V4, Licensed Practical Nurse (LPN) about his mattress and V4 wrote it up. On 5/27/2025 at 12:30 PM, V3 (Maintenance Director) said that R1 called V3 either 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide accepted standards of clinical practice by failing to provide necessary care and services in administering necessary medications, failed to identify signs and symptoms of hypotension, and failed to notify the RN and physician before having dialysis treatment. This failure affects 1 (R2) of 3 residents reviewed for professional standards in the sample of 3. Findings include: R2 was a [AGE] year old with diagnoses including but not limited to pulmonary disease, systemic sclerosis, hypertensive heart and kidney disease, end stage renal disease, dementia, and dependence on renal dialysis. Care plan dated [DATE] reads in part, I am at risk for decreased cardiac output related to hyperlipidemia, carotid stenosis. Primary medical history of Atherosclerosis of Aorta , Cardiomegaly, MI, readmitted to the facility status post acute hospital stay, continue with interventions ([DATE]). Goal: I will maintain hemodynamic stability: No palpitations, no…

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 residents Power of Attorney for healthcare (POAH) of a fall with injury that required Emergency treatment for 1 of 3 residents (R1) reviewed for notification of change in the sample of 5. The findings include: On 2/21/25 at 9:03 AM, V7 (R1's POAH) said she was not informed of R1's fall with injury on 1/8/25 and transport to the hospital. V7 said it was days after the incident that she found out about his Dad's fall (R1) R1 was sent to the ER then sent back to the facility with an Ortho referral. V7 said she did not change her phone number, it was always working and it's the same phone number since R1 got admitted to the facility. V7 also said she works with the Chicago Police Department and there were other ways to get a hold of her. R1's change of condition eval/progress notes dated 1/8/25 by V17 (License Practical Nurse-LPN) documents, (R1) had an unwitnessed fall in his room trying to go to the bathroom by himself. R1 complained of left shoulder pain. R1 had an X-ray STAT (immediate) that show R1 had a left…

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 treatment orders were initiated for a resident with a stage 2 sacral pressure ulcer. This applies to 1 of 3 (R3) residents reviewed for pressure ulcers in the sample of 5. The findings include: R3's face sheet shows she is a [AGE] year old female admitted to the facility on [DATE]. R3's diagnoses including pressure ulcer of sacral region stage 2, chronic kidney disease, hypertension, type 2 diabetes, lymphedema, COPD, cellulitis of right lower extremity, and morbid obesity. On 2/21/25 at 10:23 AM, R3 was observed lying in her bed. V8 (Registered Nurse-RN) and V9 (Certified Nursing Assistant-CNA) provided incontinence care to R3. A protective dressing was in place to R3's sacrum. V9 said R3 has a pressure ulcer to her sacrum and is dependent on staff for cares. On 2/21/25 at 10:42 AM, V10 (Wound Nurse) said R3 was admitted to the facility with several wounds. She has a stage 2 pressure ulcer to her sacrum. On admission a skin…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record the facility failed to ensure a resident was free from significant medication errors by failing to ensure admission medications were transcribed and administered for 1 of 3 residents (R3) reviewed for medications in the sample of 5. The findings include: R3's face sheet shows she is a [AGE] year-old female admitted to the facility on [DATE]. R3's diagnoses including pressure ulcer of sacral region stage 2, chronic kidney disease, hypertension, type 2 diabetes, lymphedema, COPD, cellulitis of right lower extremity, and morbid obesity. On 2/21/25 at 1:50 PM, V2 (DON) said she was informed on 2/15/25, R3's admission was not done by nursing. She received a call from V15 (Licensed Practical Nurse) that the day shift was nurse upset. V15 reported V16 (LPN) the night shift nurse did not perform R3's admission assessment and orders. V15 said she was not going to do R3's admission and left the facility. V2 said V16 reported she was inexperienced and did not know how to admit a resident. V2…

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 discarding food products before or on expiration date affecting all 196 residents receiving food from the kitchen. The facility also failed to ensure resident refrigerators have recorded temperature logs affecting 4 of 6 (R6, R53, R140, R168) residents reviewed for resident refrigerator in a sample of 36. Findings Include: 1. On 1/14/2025 at 6:20AM, during kitchen initial tour, the container of multiple use for Flour, Thickener, and Sugar has the used by date of 9/24/2024. All containers were less than half full. V21 (Cook) said it was recently filled but forgot to change the date on the label. V21 said yesterday was the last time the content of these containers was used. On food shelves, four cartons of Mildly Thick - Nectar Consistency (46 FL OZ) were expired, three cartons with used by date of 12/3/2024 and one carton with used by 11/12/2024. V21 said all should have been removed from the shelf. On another food shelves, individually pack of hot sauce, sweet relish, tartar sauce, and horseradish…

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 resident call light is within reach. This deficiency affects 5 (R11, R102, R148, R191, R261) of 5 residents in the sample for 36 reviewed for accommodation of needs. Findings include: 1. On 1/14/25 at 7:35 AM, R148 observed in bed alert and verbal with feet touching foot board. R148 said that she could not reach her call light. Call light observed behind bedside dresser on floor. On 1/14/25 at 8:06 AM, V5 (Registered Nurse) said that call light should be kept within reach in case the resident needs assistance. V5 said the call light should not be behind dresser on the floor. R148 is admitted on [DATE] with diagnosis in part but not limited to type 2 diabetes mellitus without complications, generalized anxiety disorder, history of falling, other lack of coordination. A focused care plan for alteration in comfort indicated intervention including call light within reach dated 10/03/24. 2. On 1/15/25 at 10:42 AM, R11 observed in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement manufacturer's recommendation in using low air loss mattress to residents with multiple stage 4 and unstageable pressure ulcer. This deficiency affects all four (R5, R83, R147 and R185) residents in the sample of 36 reviewed for Wound/Pressure ulcer Prevention Management. Findings include: 1. On 1/14/25 at 7:16AM, Rounds made to R147 with V9 Nursing Supervisor. Observed R147 lying in bed with Low air loss mattress. Observed flat sheet with cloth pad over the mattress. V9 said that R147 should only have flat sheet over the mattress. R147 is admitted on [DATE] with diagnosis listed in part but not limited to Respiratory failure with hypoxia, Parkinson disease, Dementia, End stage renal disease, Multiple pressure ulcers to different body parts-sacral/buttocks, elbows, and heels. Active physician order sheet indicated Left anterior leg- clean with wound cleanser, pat dry with gauze, every Tuesday, Thursday, and Saturday and as…

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 fall preventive measures were implemented to residents who are at risk for fall and history of falls. The facility also failed to change the fall intervention with each fall incident in a timely manner. This deficiency affects all four (R147, R148, R191 and R261) in a sample 36 reviewed for Fall prevention program. Findings include: 1. On 1/14/25, at 7:02AM, Observed R191 lying in bed on high position (surveyor waistline level) with bilateral floor mat. He has right arm flexion contracture. His call light and bed control are placed on his bedside dresser, not within reach. Called V9 Nursing supervisor and showed observation made. V9 said that R191's call light should be within reach and his bed should be in the lowest position while on bed. She took the call light and placed within R191's reach. She then took the bed control and placed the resident on the lowest position. R191 is admitted on [DATE] with diagnosis listed in part but…

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 monitor self-administration medication management, medication refrigerator temperature log, and label insulin with open date and follow pharmacy/manufacturer's recommendation on discarding for one of five medication carts (3rd floor medication cart), and one of two medication room storage (2nd floor medication room) observed for medication storage and labeling. This failure also affected one of one resident (R4) reviewed for medication self-administration. Findings include: 1. On 01/14/25, at 07:15 AM, observed medication cart on 4th floor by nurse's station unlocked with medications on top of cart. On 1/14/25, at 7:20 AM, V33 (Licensed Practical Nurse) said that cart should not be left open and unattended because residents can easily access the medications. 2. On 1/15/25, at 11:05 AM, during observation with V24 (Licensed Practical Nurse) on 3rd floor medication cart and medication storage room had the following: 1. R56's opened Insulin glargine pen with open date 11/14/24. Manufacturer's storage…

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 knock on resident's doors before entering for three of 36 (R5, R62, R207) reviewed for dignity in a sample of 36. Findings include: 1. On 01/14/2025 at 10:46AM during unit rounds with V32 (Wound Care Coordinator), V32 entered R5's room without knocking. On 01/14/2025 at 10:50AM during interview with V32, V32 stated that she did not knock on the door before entering R5's room. V32 stated that she should have knocked before entering R5's room. Review of R5's care plan for abuse, neglect, exploitation, trauma revised on 11/06/2024 indicated a goal to treat R5 with respect, sensitivity, dignity, and feel safe while living in the facility. Review of R5's care plan also indicated admission date of 06/13/2023 and diagnoses of not limited to obstructive sleep apnea and age-related physical debility. 2. On 01/14/2025 at 10:47AM during unit rounds with V32 (Wound Care Coordinator), V32 entered R62's room without knocking. On 01/14/2025 at 10:50AM during interview with V32, V32 stated that she did not knock on the 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 interview and record review the facility failed to ensure a resident was free from verbal abuse for 1 of 3 residents (R68) reviewed for abuse in a sample of 36. Findings include: On 1/15/2025 at 9:40am R68 said that R93 was her roommate in December and had accused her of taking a blanket and slapped her twice then scratched her on the nose. R93 was moved to another room on the same unit which she must come pass several times a day to smoke, and other activities, a couple of days ago R93 was blocking the hallway and she asked her can she come pass, and R93 started yelling at her and said go around and don't touch my chair. On another occasion R93 noticed R68 wheeling past by the nurse's station, and yelled out profanity saying get away from me now). R68 said I am not afraid of R93 but would like her to stop yelling at me when I'm wheeling past, I don't know why R93 is still on this floor she had an issue with another roommate. R68 said she spoke with the social worker and informed her about how R93 yells at her and the social worker said, that's just how she is. On 1/16/2024…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide nail care to a dependent resident. This deficiency affects one (R55) of three residents in the sample of 36 reviewed for Activity of Daily Living (ADL) Program. Findings include: On 1/15/25 at 10:18AM, Round made with V2 Director of Nursing and V17 Assistant Director of Nursing to R55. Observed R55 lying in bed with call light within reach. She is alert and responsive but confused. Observed bilateral fingernails are long and dirty. There is black matter underneath the resident's long fingernails. V2 said that CNAs (Certified Nursing Assistant) and Nurses should provide nail care- including cleaning and trimming of fingernails to R55 as part of ADLs program. R55 is admitted on [DATE] with diagnosis listed in part but not limited to non-traumatic intracerebral hemorrhage in hemisphere, subcortical, Type 2 Diabetes Mellitus, Adult failure to thrive. Comprehensive care plan indicated she has an ADL self-care /mobility performance…

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 physician's order for oxygen administration affecting 1 of 2 (R53) residents reviewed for oxygen use in a sample of 36. Findings Include: On 01/14/25, at 8:05 AM, R53 was in bed with oxygen (O2) on per nasal cannula (NC) running at 1L per minute. Physician order checked with V4 (Licensed Practical Nurse/LPN) and indicated O2 at 2L/NC and titrate to 4L/NC. V4 said R53's oxygen should be at 2L/NC. On 1/14/2025 at 8:32 AM, V2 (Director of Nursing) said physician's orders should be followed and O2 in use signage should be posted by the door. Order Summary Report: Diagnoses: Metabolic Encephalopathy; Respiratory Failure, Unspecified with Hypoxia; Shortness of Breath; Unspecified Asthma, Uncomplicated; Heart Failure, Unspecified Order Date 12/16/2024 May start O2 at 2L/NC and titrate to 4L/NC to maintain O2 SATS above 90% PRN Care Plan: R53 use oxygen as ordered, R53 at risk for complications related to its use. Intervention: Administer oxygen as ordered. Give medications as ordered by physician. Policy 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 record review and interview the facility failed to ensure that each resident medication regimen was free from unnecessary medication for 1 of 2 resident's (R91) reviewed for unnecessary psychotropic medication in a sample of 36. Findings include: On 1/17/2025, at 12:00pm, V2, (Director of Nursing-DON), said the assistant director of nursing and the director of nursing is responsible for following up on the pharmacy recommendations. On 1/17/2025, at 12:10pm, this surveyor and V2 reviewed a consult pharmacist recommendation to prescriber document dated 10/1/2024 that indicated R91 Olanzapine 2.5 milligrams for bipolar to be discontinued to minimize somnolence. The physician response agreed and signed. A medication administration record dated October 2024, November 2024, December 2024, and January 2025 all indicated that Olanzapine 2.5mg was signed out daily by the nurse at 9am and administered to R91. An Order Summary Report dated January 16, 2025, indicates that R91 has Olanzapine 2.5 mg ordered on 9/19/2024 for unspecified dementia. Facility Policy: Psychotropic…

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 use appropriate infection control practices after using respiratory treatment and when performing high contact resident care to resident on Enhanced barrier precaution. This deficiency affects two (R83 and R261) residents in the sample of 36 reviewed for Infection control Program. Findings include: 1. On 1/14/25 at 7:12AM, rounds made with V9 Nursing supervisor to R261. Observed R261 lying on bed. He has oxygen via nasal cannula at 6 liters per minute. Observed nebulizer machine with tubing connected to nebulizer tubing mask found exposed on the floor. V9 Nursing supervisor said that nebulizer mask should be placed in plastic bag and stored in bedside drawer. R261 is admitted on [DATE] with diagnosis listed in part but not limited to hemiplegia and hemiparesis following non-traumatic intracerebral hemorrhage affecting left non-dominant side, Respiratory failure, Pleural effusion, Type 2 Diabetes Mellitus. Active physician order sheet…

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 report an allegation of resident to resident abuse for two residents (R1, R4) reviewed for abuse. Findings include: R1 is an [AGE] year-old resident admitted to facility on 2/17/2024 with medical diagnoses including but not limited to: major depressive disorder, moderate protein-calorie malnutrition, adult failure to thrive and age-related osteoporosis. R1 has a Brief Interview for Mental Status (BIMS) score of 9/15 dated 10/30/2024 which suggests moderate cognitive impairment. According to minimum data set (MDS) section GG dated 10/30/2024, R1 requires substantial/maximal assistance for shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. R1 is dependent on staff for toileting hygiene. R1 needs partial/moderate assistance for oral hygiene. R1 needs supervision or touching assistance for eating. R1 reported an allegation of abuse on 11/19/2024 that had allegedly happened 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to send a copy of the involuntary discharge notice to the ombudsman. This deficiency affects one (R9) of three residents reviewed for transfers and discharges. Findings Include: R9 is a [AGE] year-old, female, originally admitted in the facility on 07/25/24 with diagnoses of Vascular Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety; Schizophrenia, Unspecified; Bipolar Disorder, Unspecified; and Schizoaffective Disorder, Bipolar Type. MDS (Minimum Data Set) dated 07/29/24 recorded R9's BIMS (Brief Interview for Mental Status) of 9, which means moderate impairment in cognition. Involuntary transfer/discharge notice dated 11/14/24 was issued to R9 due to safety of individuals in the facility is endangered. R9's progress notes documented in part but not limited to the following: 11/14/24 8:00 AM: R9 continues behaviors and unable to redirect her. R9 hitting, throwing items, staff 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 implement an individualized and person-centered care goals and services addressing maladaptive behavior; and failed to establish appropriate activities and therapy programs for a resident diagnosed with mental disorder. This deficiency affects one (R9) of one resident reviewed for behavior and behavior management. Findings include: R9 is a [AGE] year-old female, originally admitted in the facility on 07/25/24 with diagnoses of Vascular Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety; Schizophrenia, Unspecified; Bipolar Disorder, Unspecified; and Schizoaffective Disorder, Bipolar Type. MDS (Minimum Data Set) dated 07/29/24 recorded R9's BIMS (Brief Interview for Mental Status) of 9, which means moderate impairment in cognition. Involuntary transfer/discharge notice dated 11/14/24 was issued to R9 due to safety of individuals in the facility is endangered. R9's progress notes…

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 prevention interventions for one of three (R1) residents reviewed for falls. Findings include: R1's diagnosis include but are not limited to Systolic Congestive Heart Failure, Dementia, Anxiety, Alzheimer's Disease, Hemiplegia and Hemiparesis following Cerebral infarction, Osteoarthritis, History of Falling, Glaucoma, and Blindness in One Eye. The facility's List of Incidents includes R1's falls on 8/27/24 and 9/13/24. R1's Fall Risk assessment dated [DATE] notes R1 is at risk for falls. R1's Fall Risk assessment dated [DATE] notes not at risk for falls. R1's Cognitive patterns assessment dated [DATE] identifies R1 as moderately impaired - decisions poor; cues/supervision required. R1's Functional Ability assessment dated [DATE] notes R1 requires partial/moderate assist with toileting hygiene, dressing, personal hygiene, toilet transfer and walking. The facility's Facility Reported Incident documents on 9/13/24 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 ensure two residents who roomed together were compatible. This applies to 2 of 3 (R1, R5) residents reviewed for resident rights in the sample of 8. Findings include: On 9/15/24 at 10:15AM, R1 and R5 were in their room. R1 was asked about her room being cleaned. R1 became upset and started pointing at her roommate's side of the room. R1 pointed at a hamper that had R5's clothes in it. R1 was upset and said, look at the (expletive) clothes. The plastic hamper had a plastic disposable bag inside, open at the top. The hamper was filled with what appeared to be soiled clothes. R5 was sitting on her side of the room. Both R1 and R5 started arguing. R5 said those were her clothes and her stuff. R5 asked to speak to the surveyor and R1 said she wants to talk about me. She has dementia. Look at all the (expletive) clothes. R1 continued to say, don't pay her no mind'. R5 asked again to speak to the surveyor outside of the room away from R1. R5…

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 resident rooms, and the dining room were in a clean, sanitary condition for 2 of 3 residents (R1, R3) reviewed for clean, comfortable, homelike environment in the sample of 8. Findings include: 1. On 9/16/24 at 10:15AM, R1 and R5 were in there room. R1 said they don't clean the room, and said look at the garbage. There was scattered debris on the floor that looked like food particles. The floor appeared dirty on both sides of the room with scattered paper debris on the floor. There was yellow liquid that appeared to be urine sitting in the toilet in the bathroom. On 9/16/24 at 10:30 AM, the fourth floor dining room had food and debris scattered throughout the floor. There were piles of old dried food stuff that appeared to be pushed and left along perimeter of the walls. There were dried liquid spills that were sticky when walking. All tables had pieces of food under them. Residents were in the dining room listening to music. On 9/15/24 at 11:00AM, V21 (Housekeeping) said she was assigned to the fourth…

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 physician orders for a urinalysis was completed for 1 of 3 residents (R2) reviewed for laboratory services in the sample of 8. Findings include: R2's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include dementia without behavioral disturbance, protein-calorie malnutrition, primary generalized osteoarthritis, mood disorder due to known physiological condition, primary osteoarthritis of left hip, hypertensive heart disease without heart failure, vitamin B deficiency, and hypertension. R2's electronic medical record showed a urinalysis was ordered 8/3/24 after a fall occurrence. R2's 8/6/24 Physician Progress Note showed, . Pt (patient) presents today alert, sitting in dining room & in no acute distress. Pt s/p (status post) fall without injury 8/3/24, UA ordered and not carried out at this time. Staff educated on frequent monitoring, fall and safety precautions . R2's lab results showed no urinalysis was collected…

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 residents are treated in a dignified manner by using personal cell phones while monitoring residents for 4 (R6, R8, R12, R13) of 6 residents reviewed for resident's rights in the sample of 15. Findings include: On 07/29/2024 at 10:45 AM Surveyor observed V7 (Certified Nursing Assessment) in the 3rd floor unit hallway with white earpiece talking and laughing loudly while gathering patient care items. On 07/29/2024 at 11:10 AM Surveyor interviewed V1 (Administrator) who said that staff is not allowed to be on their phones during work hours. On 07/29/2024 at 11:45 AM Surveyor observed V6 (Certified Nursing Assistant) talking on his cell phone in the 4th floor unit dining room. R6, R8, R12, and R13 were present in the dining room at this time. On 07/29/2024 at 11:47 AM Surveyor interviewed V6 (Certified Nursing Assistant) who said: I'm monitoring residents in the dining room at this time. Surveyor asked if staff is allowed to make personal phone calls during work hours, V6 (CNA) responded, We're not…

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

Based on observation, interview, and record review, the facility failed to ensure the facility is maintained in a clean and sanitary condition by failing to provide a clean, homelike environment. These failures have the potential to affect all 209 residents currently residing in the facility. Findings include: The facility census received upon survey entrance on 6/14/24, documents 209 residents in the building. The following observations were made while touring the facility on 6/14/24: At 4:30PM, on the fourth floor of the facility it was noted that the hallway floors were sticky, with black scuff marks. [NAME] color (appeared as dry liquid) was stained on the floor in front of the soiled utility/biohazard room. The fourth floor dining room walls were splattered with brown, dark spots; edges and corners of floor were noted to have dirt build up; dining room floors were sticky with dried up liquid spill stains on the floor; baseboards were dirty. At 5:03PM, elevator floor was noted to be sticky and dirty, with black marks on the floor. At approximately 5:20PM, the third floor…

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 sufficient nursing staff to meet the needs of the residents on two different floors. This failure affects 147 residents who reside on the third and fourth floors and has the potential to affect all 209 residents currently residing in the facility. Findings include: Facility census received upon survey entrance on 6/14/24, documents 209 residents reside in the building. 6/14/24 at 4:30PM, V3, Registered Nurse (RN) was asked about scheduling on the unit. R3 said there are abut 74 residents and three nurses; the schedule said five certified nursing assistants (CNA's) but there are four; normally there are five to six CNA's. V3 added that she thinks someone called off. V3 said the fourth floor unit is busy because the residents on this floor have dementia, falls, and elopement risk. V3 said, management was told about this so they are trying to pull someone from another floor. 6/14/24 at 4:47PM, V4 (CNA) said, it's a short day.…

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 their facility assessment included a thorough evaluation of the overall number of facility staff needed to ensure sufficient number of qualified staff are available to meet the day-to-day needs of the residents. This failure affects has the potential to affect all 209 residents currently residing in the facility. Findings include: Facility census received upon survey entrance on 6/14/24, documents 209 residents reside in the facility. On 6/14/24 at 4:30PM, V3 Registered Nurse (RN) was asked about scheduling on the unit. V3 said there are abut 74 residents and three nurses; the schedule said five certified nursing assistants (CNA's) but there are four; normally there are five to six CNA's. V3 stated she thinks someone called off. V3 said the fourth floor unit is busy because the residents on this floor have dementia, falls, and elopement risk. V3 said, management was told about this so they are trying to pull someone from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide showers to residents dependent on staff assist with bathing and failed to provide timely incontinence care to residents requiring staff assistance. These failures affect three of three (R4, R8, R10) residents reviewed for incontinence care. Findings include: 1. R4 is a [AGE] year-old female, originally admitted on [DATE] with medical diagnoses that include and are not limited to: diabetes, extramedullary plasmacytoma, hypertension, and major depressive disorder. R4's Minimum Data Set documents R4's Brief Interview for Mental Status (BIMS) score of 15/15, which R4 is cognitively intact. Section GG personal hygiene, shower and bathe indicate R4 requires substantial/maximal assistance from staff. R4's Care plan reads: Activities of Daily Living (ADL) self-care deficit, needs assistance in bathing and was initiated 2-9-2024, Bathe/shower two times weekly and as needed bases, rinse well, moisturize skin as needed. On 6-15-2024 at 9:35am…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a supply of resident medication was available as prescribed by the physician for 2 of 4 residents (R1, R14) reviewed for medications in the sample of 14. Findings include: 1. R1's admission Profile printed 6/9/24 shows diagnoses to include chronic pain syndrome, paraplegia, and morbid obesity. R1's 4/15/24 facility assessment shows he is cognitively intact, required as needed (PRN) pain medication, had occasional pain, and occasionally had pain that made it difficult for him to sleep. R1's Pain assessment dated [DATE] shows his pain was distressing, that he takes norco (narcotic) 10/325, and medication is what is used to relieve it. R1's care plan initiated 8/15/20, and revised on 4/25/24, shows he has potential alteration in comfort related to chronic pain syndrome and paraplegia. This care plan shows an intervention to administer analgesia as ordered. R1's Physician Orders printed 6/9/24 shows an order for Norco 10/325mg…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident received their anticonvulsant medication immediately following a hospitalization for status epilepticus (prolonged seizure activity) for 1 of 4 residents (R4) reviewed for medications in the sample of 14. Findings include: R4's Physician Order Summary printed 6/9/24 shows diagnoses to include epilepsy, unspecified, not intractable, with status epilepticus. R4's facility assessment dated [DATE] shows he is cognitively intact. R4's progress notes dated 5/28/24 at 10:55AM shows resident had two active seizures . both 5 seconds lasting .MD notified. The next entry at 11:13AM shows the resident had another active seizure lasting 5 seconds . order to send to the hospital. The 5/28/24 at 2:31PM progress note shows R4 is being admitted to [local hospital] for status epilepticus ( a seizure with 5 minutes or more continuous clinical and/or electrographic seizure activity or recurrent seizure activity without recovery between…

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, interviews, and record review, the facility failed to accurately transcribe a physician's order for pain medication and failed to follow facility's medication administration policy by not clarifying the pain medication dosage for one (R4) of two residents reviewed for medications. Findings include: On 05/24/2024 at 3:30 PM, observed V9 (Licensed Practical Nurse) at her med cart on third floor prepping pain medication for R4. R4's electronic medication administration record (eMAR) was visible on V9's (LPN) computer screen that showed an order for acetaminophen 625 milligram (mg) by mouth every six hours as needed for pain. Surveyor then observed V9 (LPN) place one tablet of acetaminophen 325 milligram (mg) onto a pill cutter and cut the tablet in half. She then placed the two halves into a plastic medication cup then placed a second plastic cup on top. At 3:32 PM, observed V9 (LPN) administer the two halves of acetaminophen to R4. After exiting R4's room, V9 returned to her med cart. Surveyor inquired as to what the dosage of acetaminophen was that she…

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 advanced directives for DNR (Do Not Resuscitate) orders and Emergency Code Blue procedures for 1 (R1) of 5 residents in the sample. Findings include: R1 was a [AGE] year old with diagnosis including Chronic Respiratory Failure with Hypoxia, Atherosclerosis of Coronary Artery Bypass Grafts, Type 2 Diabetes, Acute/chronic Diastolic Heart Failure, and Presence of Automatic (implantable) Cardiac Defibrillator. R1's POLST (Practitioner Order for Life-Sustaining Treatment) form signed by the resident on [DATE] showed resident's wishes for no CPR: Do Not Attempt Resuscitation (DNAR). On [DATE] at 11:46 AM, R1 was discovered on the floor of his bathroom without a pulse, without blood pressure, not breathing and presumed dead. V4 (LPN) the nurse who found the resident in the bathroom, yelled for help, called a code blue, and initiated CPR on R1 for an undetermined amount of time until V3 (Director of Nursing) took over and continued chest compressions.…

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 fall prevention interventions were implemented, failed to update fall prevention care plans and implement new post fall care interventions. The facility also failed to document monitoring of residents at a risk for falls. These failures affect five of five residents (R1-R5) reviewed for a history of falls with injuries on the sample list of five. Findings include: 1. R3's medical record indicated that he admitted to the facility on [DATE] and has a past medical history including Parkinson's Disease, psychotic disorder with hallucinations, dementia, lack of coordination, covid-19, osteoarthritis, unsteadiness on feet, abnormalities of gait & mobility, abnormal posture and age-related physical debility. R3's medical record documents R3's date of discharge as [DATE] to hospice. R3's Care Plan dated [DATE] indicates that R3 is at risk for falls related to falls with risk factors including R3 requires assistance with activities of daily…

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 safe storage of resident's medication by leaving medication at bedside. The facility also failed to date inhalers, eyedrops and insulin when opened and discard after 28 days. The facility also failed to refrigerate unopened eyedrops. This deficiency affects all ten residents (R47, R52, R60, R67, R123, R151, R163, R217 and R267) in the sample of 36 reviewed for Medication storage. Findings include: 1. On 11/15/23 at 10:10AM, Observed topical medication on R60's top bedside dresser. Topical medication: Nystatin topical powder 100,000 units USP labeled from (local) hospital. R60 said that she brought this medication from the hospital. The CNA (Certified Nurse Assistant) apply it under her breast after morning care. R60 said the last time the CNA applied it was yesterday after morning care. R60 showed to surveyor where the topical medication is being applied. Observed white powder under her both breasts. Called V7 LPN (Licensed Practical Nurse) and showed topical medication found at bedside. V7 said 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.

Based on observation, interview and record review the facility failed to provide privacy by not closing the privacy curtain or the room door while administering insulin for one resident (R118) of four reviewed for resident's rights in a sample of 36. Findings include: On 11/14/2023 at 11:10am V14 (Licensed Practical Nurse-LPN) was observed administering insulin subcutaneous to R118 in the abdomen while in bed with the privacy curtain open and the room door open. On 11/14/2023 at 11:12am V14 was asked what she should do before administering insulin subcutaneous. V14 said I should have pulled the privacy curtain and closed the door. On 11/15/2023 at 9:40am V3 (Director of Nursing-DON) said I expect all the staff to maintain privacy while administering any injections and the door and privacy curtain should always closed. An Order summary report dated 11/15/2023 indicates R118 have a diagnosis of Diabetes Mellitus due to underlying condition with diabetic neuropathy. A medication order for Novolog Flex pen subcutaneous inject 12 units before each meal. Facility Policy: Resident Rights…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to perform nail care and follow get up list schedule for three of five residents (R180, R95, R60) reviewed for activities of daily living (ADL) care in a sample of 36. Findings include: 1. On 11/14/2023 at 1:00PM during observation with V4 (Wound Care Nurse) and V3 (Director of Nursing), R180's left hand was observed with fingers against the palm, and R180's left 2nd digit's nail was observed pressing against the middle part of the left 4th digit with observable darkened areas on the middle part of the left 4th digit. R180's both hands were observed with long, uneven edges fingernails. On 11/14/2023 at 1:00PM, V4 said that the darkened areas observed on R180's left 4th digit were caused by the nail pressing on it. On 11/14/2023 at 1:00PM, V2 said that R180's nails should have been cut short. R180's care plan revised 09/21/2023 indicated R180 has impaired skin integrity with risk factors are present which affect healing and puts R180 at risk…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. R195 is admitted on [DATE] with diagnosis listed in part but not limited to Anoxic brain, Encephalopathy, Contractures of left and right elbow, Acute and chronic respiratory failure. Physician order sheet indicates: Skilled OT (occupational therapy) services 3-5x weeks for 41 days includes any combination of interventions including: Splint assessment and management. Care plan indicates at risk for limited range of motion related to anoxic brain damage. No interventions in placed for range of motion and splint management. Occupational Therapy (OT) evaluation and plan of treatment for certification period of 8/16/23 to 9/28/23 indicates: Goals: Patient will safely wear hand splint on and an elbow extension splint on right elbow and right wrist. OT Discharge summary dated [DATE] indicated: Discharge recommendation for functional maintenance program: Range of motion (ROM), Splint and brace program. Referred to restorative nursing. R195's restorative assessment dated [DATE] indicates: Contracture screen: Marked…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to assess and follow it's smoking safety policy for a smoking resident (R179), one of five residents reviewed for smoking in a sample of 36. Findings include: On 11/16/2023 at 12:50PM during observation, R179 was observed with shaking of his right upper extremity and noted 2 cigarettes on his bedside table. On 11/16/2023 at 12:50PM, R179 said that he is given 3 cigarettes every day in the morning, and he keeps it so he can smoke it after breakfast, lunch, and dinner. On 11/16/2023 at 1:55PM, V9 (Social Service Director) stated that residents who smoke are assessed every year to see if they can hold down their cigarette, not shaking a lot and not presenting with any behaviors like smoking in the room or unauthorized smoking area to determine if they need to be supervised or not. V9 said that R179 can smoke unsupervised. R179's Smoking Safety Risk assessment dated [DATE] indicated R179 requires supervision while smoking. R179's care plan…

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 check for gastrostomy tube (GT) placement prior to administer enteral feeding and follow physician order for enteral feeding. This deficiency affects one (R195) of three residents in the sample of 36 reviewed for Enteral/Tube feeding Management. Findings include: R195 is admitted on [DATE] with diagnosis listed in part but not limited to Anoxic brain, Gastrostomy status, Dysphagia oropharyngeal phase. Physician order sheet indicates: Jevity 1.5 at 80ml (milliliters)/hour from 10am to 6am. Total volume 1600ml. Check placement before feeding, flush and meds. Care plan indicates: GT in place and at risk for complications. Intervention: Check for tube placement and gastric contents/ residual volume per day per facility protocol and record. On 11/15/23 at 11:02AM, Observed V7 LPN (Licensed Practical Nurse) flushed 60ml of water to R195's GT without checking for tube placement. After flushing, V7 connected R195's GT to enteral feeding of Jevity…

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 keep a tracheostomy tube and an obturator at bedside for resident with tracheostomy tube. This deficiency affects one (R95) of three residents in the sample of 36 reviewed for Tracheostomy care management. Findings include: R95 is admitted on [DATE] with diagnosis listed in part but not limited to Chronic respiratory failure, Tracheostomy status, Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Physician order sheet indicates: Change tracheostomy tie one time a day every 3 days and as needed. Change disposable inner cannula two times a day and as needed. Trach care with normal saline, may use trach kit everyday shift and as needed for excessive drainage. Change trach tube everyday every 3 months on the 15th day. No order for Trach size. Care plan indicates: At risk for complications related to tracheostomy. Intervention: Keep extra trach tube and obturator at bedside. On 11/14/23 at 10:37AM, Observed…

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 policy on infection control in storing Nebulizer (Handheld breathing mask) in a plastic bag after completing breathing treatment. The facility also failed to keep the tracheostomy oxygen corrugated tubing and water collection drainage bag off the floor. The facility also failed to implement appropriate standard cleaning and disinfecting of glucometer after use. These failures have the potential to affect four residents (R72, R149 and R195) reviewed for infection control in a sample of 36 residents. Findings include: 1. On 11/17/23 at 10:45 am, R72's breathing mask was observed laying at the bedside table touching a white powdery substance and not in a plastic bag. V16 (Registered Nurse) proceeded by picking up the machine and breathing mask and placed in the R72's drawer with putting it in a bag. On 11/17/23 at 10:45 am, V15 stated that the breath mask should be in the drawer. On 11/18/23 at 10:00 am, V3 (Director of Nursing)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a reasonable suspicion of a crime was reported for 5 of 12 residents (R1, R2, R3, R9, and R12) reviewed for illegal substance possession and use on the sample list of 13. Findings include: 1. R1's [DATE] Nurses Note entered at 11:23 PM showed, Resident was found unresponsive, rapid response was initiated. 911 was called, EMTs arrived and resident was taken to [acute care hospital] . R1's [DATE] Nurses Note entered at 2:15 AM showed, Spoke to ER Nurse of [acute care hospital] resident admitted with Dx (diagnosis) Opioid Overdose. 2. R2's [DATE] Nurses Note entered at 9:16 PM showed, Resident was found unresponsive, rapid response was initiated. 911 was called, EMTs arrived and resident was taken to [acute care hospital] . R2's acute care hospital documents from his admission [DATE] through 7/1023 showed, . Chief complaint: Drug Problem, Patient was found unresponsive at nursing home. Patient denies drug or ETOH (alcohol), and patient responded to…

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

Based on observation, interview and record review the facility failed to provide clean and organized closet for resident clothing. This deficiency affects two (R1, R2) of three residents reviewed for home like environment on the sample list of five. Findings include: On 10/3/23 at 11:35AM, V9 CNA (Certified Nurse Assistant) said that R2 is in the dining room. At this time, there were soiled clothing in an open blue plastic bag inside R2's closet. There was a yellow bag on top of the tray table and V9 said that the yellow bag is clean personal clothes of R2 brought by laundry staff. V9 placed the yellow bag with clean folded clothes inside the closet with soiled clothes. V9 said that they can placed both soiled and clean clothes in the resident closet. On 10/3/23 at 11:59AM, V16 Restorative Aide/CNA said that R1 is in dialysis. At this time, R1's room had soiled linen and a disposable adult brief on the floor closer to R1's closet. Linens, gown, towels, and disposable adult brief were on top of R1's bed. R1's closet was disorganized, messy, and overflowing with clothes and had a foul…

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 prevention interventions for two of three residents (R2, R5) reviewed for falls on the sample list of five. Findings include: 1. On 10/3/23 at 8:37AM, V22 Family member said that the facility failed to provide proper fall precautions for R2. R2 is blind, high risk for falls and needs assistance for everything. V22 stated R2 has had 3 falls within 3 months with injuries. R2's last fall incident was on 9/21/23 in the evening. R2 fell off from the wheelchair, hit his face on the ground and was sent to the hospital for further evaluation. On 10/3/23 at 10:59 AM, V11 Activity Aide said that R2 is alert but confused, blind and totally dependent with ADLs (Activity of Daily Living) and transfers. V11 also stated R2 requires constant supervision. On 10/3/23 at 12:55PM, R2 was up in the wheelchair in the dining room being assisted with R2's meal by V19 CNA (Certified Nurse Assistant) said that R2 had a recent fall, and he is at high…

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

Based on observation and interview the facility failed to repair a resident's bed to ensure it was in safe operating condition. This failure affects one (R1) of three residents reviewed for safety on the sample list of five. Findings include: On 10/4/23 at 9:50AM, R1 was sitting in a wheelchair in the hallway. V23 LPN (Licensed Practical Nurse) instructed V24 Certified Nursing Assistant (CNA) and V25 CNA to transfer R1 to bed to be assessed by the wound care nurse. On 10/4/23 at 10:10AM, V25 CNA said that she cannot transfer R1 to bed because the bed control is broken, and the bed cannot be locked. V25 said she did not know that the bed is broken. V25 said R1 was already up in the wheelchair when she came in to work this morning. V16 Restorative Aide said that she worked with R1 yesterday as a CNA, but she is not aware that his bed is broken. V16 said R1 is already up in wheelchair when she came to work, and she did not transfer him to bed during her shift yesterday. V23 LPN was not aware that R1 's bed is broken, it was not endorsed to her. V23 called V7 Maintenance Director. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a resident was safely transferred by not having a two person assist when using a mechanical lift. This applies to 1 of 3 residents (R5) reviewed for safety in the sample of 9. The findings include: R5's face sheet shows she is a [AGE] year-old female with diagnosis including hemiplegia and hemiparesis following cerebral infarct affecting the right dominant side, generalized osteoarthritis, age-related debility, and need for assistance with personal care. R5's Minimum Data Set assessment dated [DATE] shows she requires extensive two person assist with transfers. On 8/11/23 at 9:25 AM, R5 was observed lying in bed. She said the staff use a lift machine to get her out of bed. She was hit in the face with the metal bar from the lift. Her right eye was swollen and bruised. It was a young girl, only one person. They don't know how to operate it. I don't want to get in the lift anymore, I might get hit in the face again. On 8/11/23 at 12:16 PM, V6 (RN)…

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

Based on observations, interviews and record reviews the facility failed to follow their dialysis cleaning and maintenance policies by not ensuring dialysis chairs are kept clean and in good repair. This failure includes 8 residents (R8, R62, R64, R74, R87, R104, R133, R188) in a total sample of 40 residents reviewed for environment and applies to all 18 residents receiving dialysis treatment in the facility. Findings include: On 12/05/22 at 11:04 AM, R104 stated all the dialysis chairs are raggedy and he has been telling them that for years. R104 stated he doesn't believe the dialysis equipment is cleaned properly. R104 stated everyone shouldn't be sick after leaving from dialysis. R104 stated he has been sick as recent as Friday and has dialysis on Monday, Wednesday, and Friday. R104 stated on Friday of last week he was sick after dialysis and has been throwing up. On 12/05/22 at 11:40 AM, R62 stated most of the dialysis chairs are broken. On 12/05/22 at11:56 AM, R133 stated the dialysis chairs are busted up and due to many issues with dialysis he would prefer to receive 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.