Country Health

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility repeatedly failed to follow a physician order to discontinue the administration of a medication, for one of five residents (R69) reviewed for unnecessary medications on the sample list of 31.Findings include:R69's Minimum Data Set, dated [DATE] documents R69's Brief Interview of Mental Status score as three out of a possible 15, indicating severe cognitive impairment.R69's Medication Administration Sheet (MAR) dated 9/1/25- 9/30/25 documents: Nuedexta (can cause excessive drowsiness), Oral Capsule 20-10 MG (Dextromethorphan HBr-Quinidine Sulfate), Give 1 capsule by mouth every morning, and at bedtime for the diagnoses of Pseudobulbar Disease (neurological disorder, uncontrolled laughter, crying and involuntary movements). This Physician order documents to start R69's Nuedexta 11/19/2024. R69's MARs for May, June, July, and August also documents R69 received Nuedexta every morning and at bedtime.R69's Quarterly Medication assessment dated [DATE]…

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 pharmacy instruction for the safe administration of physician ordered medication, for two of eight residents (R66 and R78) reviewed during medication observation. These failures resulted in three errors out of 29 opportunities for a 10.39 percent medication administration error rate. Findings include:R66's Minimum Data Set (MDS) dated [DATE] documents R66's Brief Interview of Mental Status (BIMS) score as 10 out of a possible 15, indicating moderate cognitive impairment.R66's current Physician Order Sheet (POS) documents the following: R66 is on a regular diet with regular-texture food and thin-consistency liquids, which indicates R66 does not have difficulty chewing.The same POS documents 15 oral medications scheduled for administration during the morning medication pass. The oral medications include:Potassium Chloride Crystal, ER (Extended Release) 20 mEq tablet, give three tablets by mouth each morning, andAspirin EC (Extended…

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 respond to a resident grievance in a timely manner, for one of four residents (R58) reviewed for grievances in the group meeting, on the sample list of 31.Findings include: On 09/22/2025 at 10:30 am - 11:50 am during the resident group meeting. R58 sat in a wheelchair without a shoe on her left foot. R58 stated she had filed a grievance by sending a letter to V1, Administrator within the last month. R58 stated I haven't been able to wear a shoe, because of a toe ulcer, I have had for about a year. I saw a podiatrist, at an outside the facility four to six months ago. The corn was removed, and my pinky toe never healed. I still can't wear a shoe and the Administrator never responded to the letter.On 9/24/25 at 3:25 pm V1, Administrator provided an undated, handwritten grievance letter from R58. V1 confirmed the letter had been written by R58, and was given to V1, Administrator within the last several weeks. V1 also confirmed she had not put this grievance on her grievance log and therefore had not followed up…

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

Based on interview and record review the facility failed to report an injury of unknown origin to the administrator and the state survey agency for one of one resident (R6) reviewed for abuse in the sample list of 31. Findings include: The facility's Abuse Prohibition Policy dated 8/25/25 documents injuries of unknown origin will be immediately reported to the administrator and the administrator will notify the Illinois Department of Public Health (IDPH). R6's Emergency Department Note dated 8/15/25 at 5:27 PM documents R6 presented with shortness of breath and chest discomfort described as constant pressure that worsens with inspiration. R6's Chest Computed Tomography (CT) dated 8/5/25 at 7:18 PM documents Likely acute/recent T10 compression fracture with approximately 25% central vertebral body height loss. Other chronic compression fractures are demonstrating similar height loss relative to the CT from 10/20/2022. R6's Hospital admission History and Physical dated 8/5/25 documents R6's hospital admission diagnoses included Acute/recent T10 fracture and neurosurgery was consulted…

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 investigate an injury of unknown origin for one of one resident (R6) reviewed for abuse in the sample list of 31. Findings include:The facility's Abuse Prohibition Policy dated 8/25/25 documents injuries of unknown origin will be immediately reported to the administrator and will be investigated. R6's Emergency Department Note dated 8/15/25 at 5:27 PM documents R6 presented with shortness of breath and chest discomfort described as constant pressure that worsens with inspiration. R6's Chest Computed Tomography (CT) dated 8/5/25 at 7:18 PM documents Likely acute/recent T10 compression fracture with approximately 25% central vertebral body height loss. Other chronic compression fractures are demonstrating similar height loss relative to the CT from 10/20/2022. R6's Hospital admission History and Physical dated 8/5/25 documents R6's hospital admission diagnoses included Acute/recent T10 fracture and neurosurgery was consulted for further evaluation. R6's Neurosurgery Note dated 8/5/25 documents R6 has a T10 compression…

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 revise a care plan with fall interventions for one of 18 residents (R4) reviewed for care plans in the sample list of 31. Findings include:The facility's policy titled Care Plan Process with the revision date of 11/2017 documents a comprehensive person-centered care plan shall be developed and implemented to meet the resident's preferences and goals., and address the resident's medical, physical, mental and psychosocial needs, while honoring resident rights to choice All plans of care must be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly assessment.Review of incident report reported to Illinois Department of Public Health on 5/30/25 at 7:50 AM documents R4 sustained a fall on May 30, 2025 at 7:50 AM. R4 was observed sitting in front of her recliner chair, legs extended out, and head resting on the foot of the chair. R4 stated I fell out of this chair right here. R4 complained of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to prevent cross-contamination during catheter care for one of two residents (R53) reviewed for urinary catheter care on the sample list of 31. Findings Include:R53's Medical Diagnoses List dated May 20, 2025 documents R53 is diagnosed with Infection and inflammatory reactions due to indwelling urethral catheter and Retention of urine.R53's Minimum Data Set (MDS) dated [DATE] documents R53 has severe cognitive impairment, uses a wheelchair, is always incontinent of bowel, and is dependent on staff for toileting, hygiene, and transfers.R53's Care Plan dated 7/29/25 documents R53 has an indwelling Foley catheter.On 9/22/25 at 11:15 a.m., V27, Certified Nursing Assistant (CNA), wearing a personal protective gown, donned gloves and placed a basin of water on the bedside table, which also contained washcloths and towels. V27 placed a washcloth in the water, wrung out the excess water, and proceeded to wash R53's inner right thigh with 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 monitor and record weights and meal intakes for one of three residents (R45) reviewed for weight loss in the sample list of 31. Findings include: On 9/21/2025 12:34 PM R45 was in her room eating lunch which consisted of peanut butter and jelly sandwich, cheese puffs, root beer float pie, and high protein ice cream. At 12:59 PM R45 was finished eating and lying in bed. R45 ate one or two bites of the sandwich and cheese puffs, half of the pie, and all of the ice cream. On 9/22/2025 at 11:51 AM V23 R45's Family stated R45's weight loss began in the Spring and R45 also was very sick with Norovirus. V23 stated R45 was getting nutritional shakes, but had a hard time keeping anything down. V23 stated the facility has kept the physician informed and R45 has continued to lose more weight. V23 stated R45 has dementia related to a traumatic brain injury that occurred four years ago and eating is something that R45 doesn't remember. V23 stated R45…

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 change the oxygen tubing and humidifier bottle for one (R63) of three residents reviewed for respiratory care on the sample list of 31. Findings include:R63's Facility Census documents R63 was admitted to the facility 4/1/23 and has the following medical Diagnosis; Obstructive Sleep Apnea, and Symptoms and Signs Involving the Circulatory and Respiratory system. R63's Physicians Order Sheet dated 3/27/25 documents oxygen clean filter on concentrator, change the water bottle, nasal cannula and bag on concentrator weekly and as needed. When in use. The facility's Oxygen Administration policy dated 1/15/25 documents to change nasal cannulas, tubing, and humidifiers weekly and label with the date, and store oxygen cannula or mask in a plastic bag when not in use.On 9/21/25 at 9:17 AM R63's oxygen concentrator bottle was dated 8/27/25 and R63's oxygen tubing was not dated. R63's Continuous Positive Airway Pressure machine (CPAP) was connected to the oxygen concentrator and tubing. R63 was sitting in R63's recliner…

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 accurately transcribe hospital discharge orders resulting in a significant medication error for one of five residents (R6) reviewed for unnecessary medications in the sample list of 31.Findings include:R6's Hospital Discharge Orders dated 8/13/25 document to administer Eliquis (blood thinner) 10 milligrams (mg) by mouth twice daily for two more days through 8/14/25, then give 5 mg by mouth twice daily starting on 8/15/25 at 9:00 AM. These orders include a hand written notation that these orders were reviewed with V20 Nurse Practitioner on 8/13/25 and V20 signed these orders 8/15/25. R6's August 2025 Medication Administration Record documents R6's Eliquis orders were incorrectly transcribed, with both the 10 mg and 5 mg orders implemented together, and R6 received 15 mg on the evening dose on 8/13/25 and 15 mg twice daily on 8/14/25. There is no documentation that the facility identified this medication error. On 9/22/25 at 2:46 PM V2 Director of Nursing confirmed R6's Eliquis order was transcribed incorrectly.On 9/23/25 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.

Based on interview and record review, the facility failed to develop and implement a person-centered comprehensive care plan for elopement risk and the use of a departure alert system. This failure affects two (R1 and R3) of three residents reviewed for supervision in the sample list of three. Findings include: The facility Exit Seeking list dated April 2025 documents R1 and R3 as exit seeking. 1. A Progress Note dated 4/3/25, documents R1 found wandering near door at approximately 10pm with door alarming. Further documents R1 assisted back to bed and departure alert system placed around right ankle. R1's Care Plan (current) does not document R1 as an elopement risk or R1's use of a departure alert system until 4/29/25. R1's Physician Orders (current) documents the following order dated 4/29/25: check placement and functionality of departure alert system daily in evening. R1's Exit Seeking/Wandering Assessments dated 10/15/24 and 4/7/25 documents R1 is at risk for exit seeking/wandering. R1's Behavioral Notes dated 8/29/24, 12/28/24, 3/1/25 and 4/13/25 documents R1's wandering…

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 one staff assistance to prevent a fall for one (R1) of three residents reviewed for accidents in the sample list of five. Findings include: R1's Facility Census documents R1 was admitted to the facility on [DATE] and has the following medical diagnosis, Malignant Neoplasm of Endometrium, Chronic Pain Syndrome, Weakness, Overactive Bladder, Age-Related Osteoporosis, GERD, Encounter for Palliative Care and Anemia. R1's Minimum Data Set (MDS) dated [DATE] documents R1's Brief Interview for Mental Status (BIMS) score 8, moderate cognitive impairment, needs substantial/maximum assistance with Activities of Daily Living. R1's Care Plan dated 8/17/23 documents R1 is at risk for falls due to limited physical mobility related to chronic pain syndrome and Osteoarthritis. Interventions. Transfers: R1 transfers with one staff assist/gait belt and rolling walker. R1's Health Status Note dated 4/1/25 at 7:33pm documents V4 Certified Nursing Assistant notified…

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 develop, implement, measure, act on or analyze a performance improvement program project in the last twelve months. This failure has the potential to affect all 85 residents who reside in the facility. Findings include: The facility provided long term care facility application for Medicare and Medicaid dated 10/20/24 documents 85 residents reside in the facility. The facility provided Quality Assessment Performance Improvement Policy dated 12/8/23 documents that the facility quality program will enable a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality in the facility while involving all caregivers in practical and creative problem solving. Additionally, the policy documents that a systematic approach to determine underlying causes of problems, and development of corrective actions that will be designed to effect changes at the facility level to prevent quality of care, quality of life or safety problems and to facilitate and monitor the effectiveness of its 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 interview and record review the facility failed to store, handle, and launder linens that were potentially exposed to scabies. This failure has the potential to affect all 85 residents who reside in the facility. The facility also failed to follow enhanced barrier precautions for two (R4, R39) of six residents reviewed for enhanced barrier precautions from a total sample list of 44 residents. Findings include: 1.) The facility provided undated Scabies/Crusted Norwegian Scabies infection control policy documents that scabies are infectious diseases of the skin. Transmission occurs from brief skin to skin contact with items such as bedding, clothing, furniture, rugs carpeting, floors and other items that can become contaminated with skin scale and crusts shed by a person with Scabies. To avoid reinfestation, bedding and clothing used by residents with scabies would be collected and transported in plastic bag an emptied directly into the washer to avoid contaminating other surfaces and items. Machine wash and dry using the hot water and high heat cycle temps in excess of 122…

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

Based on observation, interview, and record review the facility failed to administer medications timely and according to physician's orders and manufacturer's instructions for four (R17, R61, R42, R4) of seven residents reviewed for medication administration in the sample list of 44. These failures resulted in eight medication errors out of 25 opportunities, a 32% medication error rate. Findings include: 1.) On 10/21/24 at 10:36 AM V5 Registered Nurse (RN) stated V5 is behind on the morning medication pass, and there are still morning medications that need to be given. On 10/21/24 at 10:59 AM V5 stated V5 still has scheduled morning medications that need to be administered. On 10/21/24 at 10:51 AM V5 administered R17's medications which included Lantus insulin 15 units, Macrobid (antibiotic) 100 milligrams (mg), Tylenol 650 mg, and Metoprolol Tartrate (cardiac medication) 25 mg. V5 did not prime the Lantus insulin pen prior to administration. R17's October 2024 Medication Administration Record (MAR) documents to administer Lantus 18 units daily at 8:00 AM starting on 10/9/24,…

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 maintain resident's furniture in a clean manner for two of 24 residents (R74, R61) reviewed for clean, comfortable, homelike environment in the sample list of 44. Findings include: On 10/20/24 at 9:36 AM, there is a light tan fabric chair in the sitting area of R74 and R61's room. This chair has dark brown stains and light brown stains on at least half of the seat of the chair. On 10/23/24 at 3:56 PM, V13 Housekeeping Supervisor stated that they clean resident's chairs in the resident's rooms every once in awhile. V13 stated that she just had most of them cleaned by an outside company a few months ago. V13 stated she was not aware that the chair in R74 and R61's sitting area was stained. On 10/23/24 at 9:05 AM, R74 and R61's chair had been removed from the sitting area in their room. On 10/23/24 at 9:07 AM, V28 Housekeeper stated that she does not know what happened to their chair. On 10/23/24 at 9:27 AM, V13 confirmed R74 and R61's sitting room chair was stained with what she thought was coffee. V13 stated 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 observation, interview and record review the facility failed to ensure a resident was free from restraint by not having a Physician's Order, a signed consent form for a restraint and to complete restraint reduction attempts. This affects one of one resident(R74) reviewed for restraints in the sample list of 44. Findings include: On 10/20/24 at 10:14 AM and 12:51 PM, R74 was in his wheelchair and had a lap cushion across the front of his lap. On 10/21/24 at 9:35 AM and 10:43 AM, R74 was in his wheelchair and had a lap cushion on his lap. R74's diagnosis list documents diagnoses including Unspecified Dementia, Unspecified Severity with Mood Disturbance, Muscle Weakness, Polymyalgia Rheumatica and Muscle Wasting and Atrophy. R74's Physician's Orders dated 10/21/24 do not document an order for the use of a soft lap cushion as a restraint nor as a therapeutic intervention. R74's Care Plan dated 10/7/24 documents R74 utilizes a lap cushion as a comfort device. This Care Plan documents R74 is able to place and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement hearing devices and develop a care plan for hearing loss for one (R39) of one resident reviewed for communication in the sample list of 44. Findings include: R39's Minimum Data Set, dated [DATE] documents R39 has minimal difficulty hearing when using hearing aide/device and R39 has moderate cognitive impairment. R39's admission nursing assessment dated [DATE] documents R39 uses left and right hearing aides. R39's Care Plan dated 10/10/24 documents R39 is hard of hearing and only uses one hearing aide to the right ear. There is no documentation that R39's care plan addressed R39's hearing loss and hearing aide use prior to 10/10/24. R39's Concern Form dated 10/15/24 documents R39's family reported R39's left hearing aide has been missing since Sunday (10/13/24) and the right hearing aide was also missing. This form documents the right hearing aide was found on 1016/24, the facility will replace R39's hearing aide, and an…

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 check and record gastric residual volume to verify gastrostomy tube placement, and administer and record water flushes and enteral feeding amounts for one (R39) of one resident reviewed for gastrostomy tube in the sample of 44. Findings include: On 10/20/24 at 8:58 AM R39 was lying in bed asleep with Osmolite 1.5 Cal (calorie) infusing at 60 milliliters (ml) per hour via gastrostomy tube (g-tube). The mechanical pump also contained a bag of water and was set to infuse 200 ml of water every four hours. On 10/21/24 at 10:27 AM V5 Registered Nurse stated R39's feeding pump is set to administer a certain amount of feeding, and it stops infusing and beeps when it has reached the set amount. V5 stated if the pump is shut off early it is documented, but we don't record the total volume infused. On 10/21/24 at 2:24 PM V5 checked R39's g-tube placement by inserting 20 ml of air via syringe and listening with a stethoscope. V5 dissolved each medication (which were already crushed prior to observation) that was in three…

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 label, store, and change oxygen and nebulizer tubing for three (R17, R39, R84) of three residents reviewed for respiratory care in the sample of 44. Findings include: 1.) On 10/20/24 at 9:55 AM R17 was asleep in his room. The undated and uncovered oxygen tubing was on top of R17's bed and connected to the oxygen concentrator. R17's Physician Order dated 9/30/24 documents titrate oxygen via nasal cannula to keep saturation above 90 %. There is no order to routinely change R17's oxygen tubing and there is no documentation in R17's medical record that R17's oxygen tubing is routinely changed. R17's ongoing oxygen saturation log documents R17 used oxygen on 13 days between 9/23/24 and 10/21/24. 2.) On 10/20/24 at 9:00 AM R39's undated and uncovered nebulizer mask and tubing was on R39's night stand and connected to a nebulizer machine which had splatters of a brown substance. R39's October 2024 Medication Administration Record (MAR) documents R39 receives Aformoterol Tartrate 15 micrograms per 2 milliliters (ml)…

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 infection control measures to prevent the spread of COVID-19 (Human Coronavirus Infection) by failing to stock isolation carts with N95 masks, ensure isolation signage was posted, and ensure staff discarded personal protective equipment (PPE) upon leaving COVID-19 positive resident rooms. The facility also failed to complete COVID-19 symptom monitoring for residents having COVID-19. These failures affect five (R1, R2, R4, R5, R6) of six residents reviewed for infection control in the sample list of eight. Findings include: The facility's COVID-19 Testing and Response Plan dated 9/1/24 documents monitor for clinical worsening including assessing for symptoms and vital signs for every four hours for COVID-19. This policy documents to discard respirator or mask and a new one should be applied after caring for a COVID-19 positive resident. The facility's General Approaches to Infection Prevention and Control Standard and Transmission-Based Precautions for Communicable Disease policy dated 10/17/22…

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 (R2) was not subjected to physical abuse by (R1). R2 is one of 4 residents reviewed for abuse. Findings include: R1's Facility Census documents R1 was admitted to the facility on [DATE] and has the following medical diagnoses: Hospice, Alzheimer's Disease, Dementia, Protein Calorie-Malnutrition, Hyperlipidemia, Chronic Kidney Disease Stage 3, Muscle Weakness, Dysphagia, Nonexudative Age Related Macular Degeneration, HTN, Disorders of Bone Density, Personal History of Other Venous Thrombosis and Embolism, GERD, Insomnia, Personal History of Pulmonary Embolism, Long Term Use of Anticoagulants, Adhesive Capsulitis of Left Shoulder, Wandering Disorders, Localized Swelling Mass and lump Upper Limb and Pre-glaucoma. R1's Minimum Data Set (MDS) dated [DATE] documents R1's Brief Interview for Mental Status (BIMS) score 99, severe cognitively impairment. R1's Care Plan dated 3/14/24 documents R1 exhibits moods/behaviors as evidenced by…

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

Based on interview and record review the facility failed to prevent misappropriation of medications for five (R1, R2, R3, R4 and R5) of five residents reviewed for misappropriation of medications from a total sample list of five residents reviewed. Findings include: The facility provided Resident Care Policy and Procedure Regarding Abuse and Neglect, Involuntary Seclusion, Exploitation, Misappropriation of Resident Property, Injuries of Unknown Origin and Social Media policy dated 3/15/18 documents that Misappropriation of Resident Property is the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident belongings or money without the resident's consent. No person shall misappropriate or steal any resident's property. Any person who becomes aware of any alleged misappropriation or theft of resident property shall report the incident to the Administrator immediately. On 2/27/24 at 3:06PM, V8 (Registered Nurse/RN) said When I began my shift on 2/12/24 I was counting narcotics with the off-going nurse and some of the people's narcotic numbers were…

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 abuse policy by employing a nurse with a history of disciplinary action on their license. This failure affects five (R1, R2, R3, R4 and R5) of five residents reviewed for abuse on the sample of five residents. Findings include: The facility provided Resident Care Policy and Procedure Regarding Abuse and Neglect, Involuntary Seclusion, Exploitation, Misappropriation of Resident Property, Injuries of Unknown Origin, and Social Media dated 3/15/18 documents that the facility will not knowingly employ individuals or otherwise engage individuals who have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. This includes individuals who have findings entered into the State Nurse Aide Registry or those who have had disciplinary action in effect against his or her professional licenses by a state licensure board as a result of a finding of abuse, neglect, exploitation, mistreatment of resident or misappropriation of resident property. V3 (Agency Registered…

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 dispose of narcotics as directed by their policy. This failure has the potential to affect one (R1) of five residents reviewed for medication disposal on the sample list of five. Findings include: The facility Medication Disposal Policy dated 2/2021 documents that unused, unneeded, or expired controlled medication tablets and capsules should be removed from the outer packing and placed into a commercially available controlled drug denaturing kit. R1's physician order dated [DATE] documents an order for Oxycodone-Acetaminophen (Narcotic) Oral Tablet 2.5/325 milligram dated [DATE] with instructions to give one tablet by mouth every 4 hours as needed for moderate pain to severe pain for 3 days. The order was discontinued on [DATE]. R1's Controlled Drug Receipt/Record/Disposition Form documents V3 (Agency Registered Nurse) signed out R1's discontinued Oxycodone 2.5 milligrams/325 milligrams on [DATE] at 8:00AM and 1:00PM and on [DATE] at 7:00AM, 11:30AM 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 ensure quarterly Quality Assurance (QA) meetings included all required committee members. This failure affects all 81 residents residing in the facility. Findings include: The facility's Quality Assurance Performance Improvement (QAPI) policy dated as reviewed 3/30/23 documents the QAPI program will use a systematic approach to identify underlying causes of problems, develop corrective actions to create changes in order to prevent quality of care, quality of life and safety problems, and monitor the effectiveness of these changes. The QA meetings will be held at least quarterly and lists the Medical Director/Designee, Administrator, Director of Nursing (DON), Infection Prevention & Control Officer, Consulting Pharmacist, Minimum Data Set/Care Plan Coordinator/Restorative Nurse, Business Office Manager, Social Services Director, Activity Director, Certified Dietary Manager, Environmental Services Director, and Housekeeping/Laundry Supervisor as committee members. The facility's QA Quarterly Meeting sign in sheet 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to timely administer pneumococcal vaccines to ensure residents are up to date with pneumococcal vaccinations for five (R52, R12, R44, R64, R45) of seven residents reviewed for immunizations in the sample list of 36. Findings include: The facility's Pneumococcal Pneumonia Vaccination Policy dated April 2022 documents incidents of pneumococcal pneumonia will be reduced by administering pneumonia vaccines to residents who are at high risk or [AGE] years old or older and refers to the Pneumococcal Vaccination in Adults algorithm for the time frames of dose administration. The algorithm documents that pneumococcal vaccination is recommended for anyone over the age of 65. If the patient has no prior pneumococcal vaccination, then administer Prevnar20 or Vaxneuvance. If the patient previously had Pneumovax23 without Prevnar13, then administer Prevnar20 or Vaxneuvance. If the patient previously had Prevnar13 with/without Pneumovax23, then Prevnar20 or Vaxneuvance…

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 assess two of two residents (R47, R58) reviewed for safe self-administration of medication in the sample list of 36. Findings Include: The facility's policy Self-Administration of medications reviewed 12/05 states if the resident wishes to self-medicate, the interdisciplinary team (IDT) must assess the resident's cognitive, physical, and visual abilities. 1.) On 9/12/23 at 9:50AM, R47 was in bed finishing breakfast. There was a pill cup with several pills on the bed side table. R47 dumped the pills in R47's mouth and swallowed them with water. R47 stated the nurse leaves my pills here so I can take them after I eat. On 9/12/23 at 10:00AM V6 (Registered Nurse/RN) stated I left (R47's) medication so (R47) could take it after (R47) was finished eating. I thought I could just keep an eye on (R47) from the hall. At the time R47 was observed taking (R47's) medication, V6 was at the nurse's station where she had no view of (R47). On 9/11/23 V2 (Director of Nursing/DON) stated (R47) is not on a self-medication program.…

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 complete pressure ulcer risk assessments, routinely assess pressure ulcers, update a care plan to include a pressure ulcer and new pressure relieving interventions, and ensure a pressure ulcer was covered with a dressing for resident's wounds. This failure affects three of seven residents (R61, R10, R77) reviewed for pressure ulcers in the sample list of 36. Findings include: The facility's Wound and Ulcer Policy and Procedure revised 1/10/18 documents the Braden Scale will be used to determine the resident's risk for developing pressure ulcers and preventative measures may include addressing pressure, moisture, friction, and shearing. This policy documents Braden Assessments are completed upon admission, then weekly for four weeks, and then monthly thereafter. This policy documents residents who are at moderate and high risk will have care planned approaches, wounds assessments will be documented in the resident's medical record at least…

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 complete fall investigations, develop, and implement fall interventions for one of three residents (R77) reviewed for falls in the sample list of 36. Findings include: The facility's Fall Assessment and Management Policy with a revised date of April 2019 documents, Interventions will be based on the fall risk assessment and the circumstances surrounding the risk for injury or actual injury of fall. R77's Care Plan documents diagnoses including Restless Legs Syndrome, Insomnia, Obstructive Sleep Apnea, Dizziness and Giddiness, Muscle Wasting and Atrophy and Muscle Weakness. The Care Plan dated 5/17/23 documents R77 is at high risk for falls and has had actual falls r/t (related to) Confusion, Incontinence, Psychoactive Drug Use and unaware of safety. This Care Plan documents R77 had falls on 5/16/23, 6/5/2023, 6/11/2023, 6/16/2023, 7/17/2023, 7/23/2023, 8/19/2023, 8/24/2023, 9/6/2023 and 9/10/2023. There is no investigation for the fall on 6/16/23 and the investigation for the 9/6/23 fall is incomplete. On 9/12/23 at 2:52…

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 secure R24's catheter and failed to provide R24 with hygienic perineal care during catheter care and failed to prevent R77's catheter from dragging on the floor for two of two (R24, R77) residents reviewed for catheter care and urinary tract infections from a total sample list of 36. Findings include: 1.) The facility provided Catheter Care/Incontinent Care Policy dated 8/1/2005 documents that after giving pericare (perineal care) and before starting catheter care, make sure and wash hands and obtain new supplies. If the resident is incontinent of bowels, rectal care may be given before performing incontinent or catheter care. Make sure to obtain new supplies and wash your hands. Catheter care is given every shift by the CNA (Certified Nursing Assistant) trained in the procedure. Cleanse downward from top to bottom giving care to cleanse the catheter when applicable. Incontinent care will be given with each episode of incontinence. R24's…

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 maintain a gastrostomy (G-tube) site in a clean sanitary manner for one resident (R38) of one resident reviewed for gastrostomy tubes in a sample list of 36. Findings Include: The facility's policy Enteral/ Tube Feeding Policy dated 2/26/15 states Routine care such as cleansing the healed insertion site and provision of oral hygiene may be performed by non-licensed staff under the supervision of licensed staff following facility procedure. This policy also states, To discourage the transmission of infection, residents receiving tube feedings will receive daily hygiene and skin care to site utilized for feeding. R38's Current physician's orders includes an order to Monitor stoma for cleanliness. Clean as needed. Resident (requires) two caregivers for cleaning care, make sure to talk (R38) through care and reassure (R38) that it will not hurt every day shift related to Dysphagia. On 9/11/23 at 11:57 AM R38's feeding tube disc was caked with crusty brown secretions. R38 was lying flat in bed. R38's lower teeth…

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.