Aliya Of Glenwood

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to prepare food using methods that conserve nutritive value, flavor, and appearance; failed to serve food that was palatable, attractive, and at a safe/appetizing temperature. These failures have the potential to affect all 137 residents that consume food from the facility's kitchen. Findings include: Facility census (4/24/2026) documents 139 residents reside in the facility. Facility Diet Type Report (5/25/2026) documents 3 residents do not receive oral intake. This indicates 137 residents consume food from the facility's kitchen. R4's face sheet documents in part the following diagnoses: type 2 diabetes mellitus with neuropathy, emphysema, acute respiratory failure, radiculopathy, heart failure, and hepatomegaly. R4's minimum data set documents a brief interview of mental status (BIMS) summary score of 14, indicating R4 is cognitively intact. On 4/24/2025 at 10:46 AM, R4 explained, I've been here since around 2024. The food here is 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 prepare food in a sanitary manner, failed to ensure staff wear appropriate hair restraints, and failed to ensure the kitchen was regularly cleaned to remove dust, debris and grease to prevent growth of microorganisms. These failures have the potential to affect all 137 residents that consume food from the kitchen. Facility census (4/24/2026) documents 139 residents reside in the facility. Facility Diet Type Report (5/25/2026) documents 3 residents do not receive oral intake. This indicates 137 residents consume food from the facility's kitchen. On 4/24/2026, at 12:34 PM, a kitchen tour was conducted. Observed large black patches of stains on the ceiling tiles, old brownish grease/dirt over 30% of the wall of the area above the steam table, food debris stuck to the steam table, wrappers and debris near the drain by the steam table, broken ventilation vent with significant amounts of accumulated dust over the food preparation and dish area. These findings were observed confirmed with V1 (Administrator) and V17…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to follow their abuse policy by not investigating an incident involving alleged abuse. This deficiency affected one (R1) of three (R2, R7) residents reviewed for Abuse. R1 is an [AGE] year-old male, initial admitted to the facility 10/10/2022. R1s Minimum Data Set (MDS) dated [DATE] section C Brief Interview for Mental Status (BIMS) score is 12/15 cognitive moderately impaired. R1s medical diagnosis included, but are not limited to Chronic Respiratory Failure, disorder of the muscle, Chronic Obstructive Pulmonary Disease, Major Depressive Disorder, Asthma, Hypertension, Type 2 Diabetes, difficulty in walking, abnormal posture.On 3/18/2026 at 9:34AM, R1 stated a few weeks ago his old roommate beat him up. R1 stated he took a broken rib. R1 stated his roommate, unable to recall his name, punched him more than six times to R1s left lower chest area. R1 stated the incident occurred at nighttime. R1 stated he was angry because R1 was transferred to another…

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 review, the facility failed to follow their Staffing Policy by not having the appropriate staff available to meet the needs of the resident resulting in a resident's (R10) fall. This failure affected 1 (R1) of 3 residents reviewed for staffing.On 3/18/2026 at 11:39AM called V9 (Certified Nurse's Assistant/CNA), no answer, left a voice message.On 3/19/2026 at 10:54AM V1 (Administrator) stated the facility was staffed accordingly with eight Certified Nurse's Assistant (CNAs) to the census on 3/3/2026, but there was call offs and only had 5 CNAs.On 3/19/2026 at 9:41AM V2 states the nursing management team alternates the staffing phone for staffing call offs. V2 stated if there is a call off, the nursing management team will find coverage immediately.On 3/18/2026 at 5:18PM, V11 (CNA) stated she worked night shift 11:00PM to 7:00AM on 3/3/2026 and had 25 residents to herself and the CNAs needed more help to ensure proper nursing care was being completed for the residents, but some work was not completed. V11 stated the other two CNAs who worked the A and B…

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 complete Care plan indicating need for assistive bed devices. This deficiency affects one (R5) of three residents reviewed for Patient Centered Care plan.Findings include:On 3/2/26 at 11:55AM, R5 said that she had both bilateral side rails to use in bed for bed mobility and then had had a bed changed and did not have side rails. R5 stated she received left side bed rail placed over a week ago and has asked staff for right side bed rail to help with repositioning and to be able to scoot up in bed if needed. R5 showed surveyor that she is unable to do anything with her left arm and is able to grasp with Right hand and can't turn or reposition self without right side bed rail. On 3/4/26 at 2:21pm, V7 (Restorative Nurse) said that side rails were placed per resident request on 3/3/26. V7 said no restorative assessment was completed, but it should be completed upon admission, quarterly and as needed and same with resident care plan. On 3/5/26 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 interview and record review, the facility failed to complete restorative assessment upon admission. This deficiency affects one (R5) of three residents reviewed for Restorative nursing program. Findings include:On 3/2/26 at 11:55AM, R5 said that she had both bilateral side rails to use in bed for bed mobility and then had had a bed changed and did not have side rails. R5 stated she received left side bed rail placed over a week ago and has asked staff for right side bed rail to help with repositioning and to be able to scoot up in bed if needed. R5 showed surveyor that she is unable to do anything with her left arm and is able to grasp with Right hand and can't turn or reposition self without right side bed rail. On 3/4/26 at 2:21pm, V7 (Restorative Nurse) stated that side rails were placed per resident request on 3/3/26. V7 said no restorative assessment was completed, but it should be completed upon admission, quarterly and as needed.On 3/4/26 at 2:30PM, V2(Director of Nursing) stated that a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow facility policy on Medication Administration. This deficiency affects one (R5) of three residents reviewed for Medication Administration. Findings include:On 3/2/26 at 11:55AM, R5 stated that she has not received her pain medication (Pregabalin oral capsule 50mg) as ordered for more than 5 days and has asked staff why medication is not in the medication cart. R5 said she takes her pain medication every day in the morning and has been without it for couple of days, said she doesn't like to take her other pain medication that is an as needed basis (Hydrocodone-Acetaminophen oral tablet 5-325mg) because of constipation issues. On 3/5/26 at 10:50AM, V1 (Administrator) stated that if there is medication that is not available in the nurse's cart then the nurses are able to locate medications in the facility electronic medication dispenser to obtain medication. If there is medication that is not available in the nurse's cart. On 3/5/26 at 12:45PM, 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 upon observation, interview, and record review the facility failed to follow policy procedures, failed to implement care plan interventions, failed to ensure that dental recommendations were followed, failed to follow-up with the provider as directed, and/or failed to ensure that timely dental care was provided to three of three residents (R2, R3, R4) reviewed for dental services. These failures have the potential to affect 143 residents.Findings include:The 2/16/2026 facility census includes 143 residents.On 1/14/26, IDPH (Illinois Department of Public Health) received allegations that R2 had complaints of dental pain and the facility failed to arrange a dental appointment in a timely manner.R2's (10/18/23) Physician Order Sheets include dental care as needed. R2's (8/25/23) care plan states resident has oral/dental problems related to edentulous tooth infection/pain. Interventions: Coordinate arrangements for dental care, transportation as needed/as ordered. Monitor/document/report any signs/symptoms of oral/dental problems needing attention. R2's (9/10/25) handwritten note…

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

Based on observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that staff report malfunctioning handicap push buttons, failed to ensure that essential equipment was in safe operating condition, and failed to timely repair malfunctioning equipment. This failure has the potential to affect 143 residents residing at facility. Findings include:The 2/16/2026 facility census includes 143 residents.On 1/23/26, IDPH (Illinois Department of Public Health) received allegations that the facility front doors are not handicap accessible. The doors have not been working since August 2025.On 2/17/26 at 11:15am, surveyor inquired about facility concerns V3 (Family) stated, The main entrance handicap door doesn't work. When you press the button, it doesn't open the door. On 2/17/26 at 11:41am, surveyor inquired if the handicap push buttons (that open the front entrance doors) were working. V4 (Lead Receptionist) stated, That one's not, for a few months now (referring to the push button - adjacent the reception area) but the other one (referring…

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 protect a resident from physical resident-to-resident abuse when a resident (R12) punched another resident (R13) which resulted in a red mark on R13's face. This failure affected 1 resident (R13) of 3 reviewed for abuse. The noncompliance occurred from 10-22-25 to 11-23-25.Findings include:On 1-13-26 at 11:44 AM, R12 said he remembers having verbal and physical altercation with former R13. R12 said he hit R13 in the face and R13 hit R12 in the face. R12 said he had redness in the face (cheek) from R13's punch. R12 admits to hitting R13 in the jaw. R12 said he was transferred to the hospital and came back. R12 said he no longer wants to fight and does not want to get transferred to the hospital.On 1-13-26 at 9:50 AM, R13 said he had an altercation with former roommate R12. R13 he and R12 were yelling at each other and R12 hit him in the eye. R13 said he had redness to his eye. R13 denies hitting R12. R13 said he is safer and satisfied with the room…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, and review of facility records, there is evidence to indicate that residents' dietary preferences are not consistently followed, and this failure affected 1 resident (R7) out of 3 residents reviewed for dietary services. R7, is a [AGE] year-old male who was admitted to the facility on [DATE] to receive skilled therapy services. R7's diagnoses include but are not limited to, vertebrogenic low back pain, post-traumatic stress disorder, atrial fibrillation, chronic low back pain, depression, polyneuropathy, and presence of a cardiac pacemaker.According to the Minimum Data Set (MDS) dated [DATE], R7 had a Brief Interview for Mental Status (BIMS) score of 12, indicating intact cognitive function. The MDS further indicated no evidence of an acute change in mental status from the resident's baseline and no signs of disorganized thinking or incoherent behavior.On 1/13/2026 at 11:46 AM, R7 was observed in his room seated in a wheelchair. R7 stated that he was doing…

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

Based on observation, interview, and record review, the facility failed to follow policy and procedures, failed to implement care plans, failed to follow physician orders, and failed to ensure that ordered dressing changes were provided for four (R1, R2, R3, and R4) of four residents reviewed for dressing changes.Findings include:R1's face sheet documents and admission date of 9/22/2025 and diagnoses that include but are not limited to displaced intertrochanteric fracture of right femur, Type 2 Diabetes Mellitus, heart failure, polyneuropathy, and end stage renal disease.R1's BIMS (brief interview mental status) score, dated 9/29/25, is 12 which indicates R1's cognition is moderately impaired.R1 no longer resides at the facility. R1 was discharged on 10/09/2025.R1's care plan, dated 9/24/25, documents, in part, (R1) was admitted to the facility for a skilled stay requiring physician ordered, medically necessary services including direct therapy services, skilled nursing care, management and evaluation of the patient care plan, observation and assessment of the patient's condition…

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

Based on interview and record review, the facility failed to provide a safe environment for residents residing in the facility and failed to perform a resident inventory check for one of three residents (R2) upon admission. This failure resulted in a weapon found in R2's possession due to facility not performing an inventory check. Findings include: Facility census, dated 12/12/2025, documents 137 residing in the facility.R2's face sheet documents admission to facility 10/30/2025 with diagnoses that include but are not limited to include but are not limited to asthma, type 2 diabetes mellitus, and chronic kidney disease.R2's BIMS (brief interview mental status), dated 11/05/25 is 12 which indicates R2's cognition is moderately impaired.R2's progress note, dated 12/10/2025, documents, in part, The resident (R2) returned from hospital and was immediately complaining of his missing black bag. The writer was busy with another resident while he (R2) was out in the hall yelling for nurses to return his bag. I explained to the resident that I was unaware of any missing items and that I…

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

Based on interview and record review , the facility failed to implement their abuse prohibition policy to ensure the safety of a resident when an employee is accused of abuse and was permitted to remain in the facility, the facility also failed to ensure a resident had an initial abuse screening and initial abuse care-plan and failed to revise the care-plan for 1 of 1 resident (R3) in a sample of 5 reviewed for Abuse. Findings include:On 8/19/2025 at 10:30am R3 said that on 8/5/2025 at about 12:30am, she requested pain medication from V8 (Nurse) and that V8 said she did not have any pain medication available, and she would administer the medication when available. Upon returning to her room R3 said she overheard the nurse at the station reading her chart out loud stating, I see why her legs are burned. R3 said she felt bad and did not come out of her room anymore that night. R3 reported this to V15 (Social Service), which she was told by V1 (Administrator) that V8 would not work on this unit anymore. On 8/17/2025 at 12:30am R3 said she ask the (Certified Nursing Assistant-CNA) 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 interview and record review the facility failed to effectively monitor and treat pain for a resident with bilateral burns to lower extremities for 1 of 1 resident (R3) reviewed for pain. Findings Include:On 8/19/2025 at 10:30am R3 said that on 8/17/2025 about 12:30am she informed the (Certified Nursing Assistant-CNA) that she needed some pain medication for her legs. At about 2:30am the night shift nurse entered her room and said she did not have any pain medication available and that it would be delivered in the morning. R3 said at that time her pain level was at an 8 out of 10. On 8/21/2025 at 1:00pm, V8 (Nurse) said she was R3's night nurse on 8/17/2025, the CNA informed me that R3 wanted pain medication. I did check for pain medication and R3 did not have any, I followed up with the pharmacy and the pharmacy indicated that the medication would be delivered in the early morning. It was 2:30am at that time, I offered R3 an alternative until delivery and R3 said no. I did not ask what R3's pain level was she did not want to talk to me any longer, I should have gotten it…

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

Based on interview and record review the facility failed to ensure a resident's beta blocker medication was available for 1 of 3 residents (R1) and the facility failed to ensure that a resident's pain medication was available for 1 of 3 residents (R3) reviewed for medication administration in a sample of 5. Findings Include:On 8/19/2025 at 11:30am R1's electronic medication administration record was reviewed and the dates of 8/8-8/11/2025 Toprol XL 50mg, a beta blocker, was not administered. On 8/19/2025 at 1:45pm V4 (Nurse) said she was the nurse working on the following days of 8/8 - 8/11/2025 and that the medication was not available. V4 said she called the pharmacy and the pharmacy said they would deliver the medication as soon as possible, V4 said she should have retrieved the medication from the convenience box and did not.On 8/19/2025 at 2:00pm V2 (Director of Nursing-DON) said I expect all medications to be given to the resident's as ordered and retrieved from the convenience box if available. A resident information sheet dated 8/19/2025 indicates that R1 has a diagnosis 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 interview and record review the facility failed to implement measures for unstageable wound. This facility also failed to implement wound care treatment orders and develop a wound care plan. This deficiency affects one (R4) of three residents reviewed for Wound/Pressure Ulcer Prevention and management. Findings include: On 5/10/25 at 10:25AM, V5 (Wound Care Nurse) said that R4 sacral wound was identified on 4/28/25. V5 said that R4 had multiple co morbidities and was declining rapidly. On 05/10/25 at 1:20PM V3 (Director of Nursing) said that R4 develop a wound in facility and based on documentation it was observed on 4/26/25 by staff V6 (Certified Nurse Aide) and V7 (Licensed Practical Nurse). V3 said that residents with new skin concerns or wounds should have been notified to Nurse Practitioner or MD for treatment orders, and care plan should be updated with interventions. Treatment orders should reflect on the resident treatment administration record for wound care management. V3 said that there is 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to follow the infection control policy related to placement of isolation precaution signs and wearing of personal protective equipment before entering room and during provision of care for four (R51, R87, R99 and R107) of five residents in the sample of 41 reviewed for infection control. Findings include: 1. R87 is a [AGE] year-old, male, admitted in the facility on 01/07/25 with diagnoses of Malignant Neoplasm of Rectum; Colostomy Status; and Metabolic Encephalopathy. POS (Physician Order Sheet) dated 03/26/25 documented R87 is on contact precautions for E. coli (Escherichia coli) of sacral wound. R87's care plan dated 03/27/25 recorded: Resident has active infection of the wound - Interventions: Isolation as per physician's orders. On 04/07/25 at 10:52 AM, it was observed that a sign stating R87 is on contact isolation was posted by the door. An isolation bin containing yellow gowns, gloves and masks were stored. R87 is alert, oriented,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that nursing staff met professional standards of practice by not adequately monitoring and documenting all resident assessments, vital signs, results of blood glucose level for diabetic residents. This failure affected two (R1 and R2) of three residents reviewed for nursing care. Findings include: R1 is [AGE] years old and was admitted to the facility on [DATE]. Face sheet listed the following medical diagnosis among others: Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and affecting right dominant side, type 2 diabetes without complications, hyperlipidemia, chronic kidney disease stage 3, neurocognitive disorder with Lewy bodies, unspecified dementia severe with other behavioral disturbance, etc. Per record review, R1 was sent to the hospital on 1/6/2025 for altered mental status and unstable vital signs. On 1/6/2025 11:43:39, V9 (LPN) documented the following: Resident out with family. 1/6/2025…

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 accurately document a narcotic medication on the Medication Administration Record and only documented the medication give on the Controlled Substance Record for one out of three reviewed for medication administration in a total sample of four. Findings Include: R2 is an [AGE] year old with the following diagnosis: type 2 diabetes, stage 4 chronic kidney disease, heart failure, and neoplasm of the cerebral meninges. Due to R2's mental status only being alert to self, R2 was unable to answer any questions related to medication. On 3/4/25 at 1:19PM, V1 (Nurse) stated when any narcotic medication is administered it must be documented on the Medication Administration Record (MAR) and the Controlled Substance Sheet. V1 reported an accurate record must be kept on both the Controlled Substance Sheet and MAR because anytime any medication is administered it has to be documented on the MAR so other staff can see when medications are given. On 3/4/25 at 2:36PM,…

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 take and record food temperatures prior to serving in order to ensure meals were provided at an appetizing temperature. This failure affected five (R1, R2, R3, R4 and R7) of five residents who were reviewed for dietary services. Findings include: On 11/19/24 at 10:35am R2 and R3 were observed in their room, alert and coherent and expressed concerns about dinner being served cold on several occasions within the past week. R2 and R3 both clarified that the issue was on-going and specific to dinner. At 11:00am R4 Resident Council President said the food is often served cold when it should be warm, but people (other residents) get tired of complaining about it. At 11:30am R1 and R7 was observed alert and coherent in their bedroom. R1 and R7 expressed sometimes getting dinner that is ice cold by the time it is served in their rooms. On 11/20/24 at 12:24pm the temperature logs for Breakfast, Lunch and Dinner were reviewed with V4 Dietary Manager. During this observation, it was noted that temperatures for Dinner Service were 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not provide timely incontinence care for one resident who is dependent on staff for activities of daily living including incontinence care. This failure affected one of one resident (R1) reviewed for incontinence care who developed moisture associated skin dermatitis. Findings include: R1 is [AGE] years old, admitted to the facility 2/7/24 and has diagnoses that include but are not limited to Peripheral Vascular Disease, Chronic atrial fibrillation, and Diabetes Mellitus with Diabetic Neuropathy. According to the Minimum Data Assessment, R1 was assessed as unable to ambulate (walk), is frequently incontinent of bowel and bladder function and requires physical assistance from nursing staff to perform hygiene related to incontinence care. On 11/19/24 at 11:35am R1 was observed alert and coherent in bed. R1 expressed a tone of frustration regarding the lack of responsiveness from nursing staff when R1 uses the call light in order to receive care.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to have physician ordered pain medication available for administration for a resident experiencing pain. This failure applies to one (R1) of four residents reviewed for pain management. Findings include: R1 is [AGE] years old, admitted to the facility 2/7/24 with diagnoses that are not limited to peripheral vascular disease, Type II Diabetes Mellitus, Diabetic Neuropathy, Opioid Dependence and Hypertension. According to Minimum Data Set (9/13/24) R1 is cognitively intact, frequently experiences pain with a score of eight out of ten on the pain scale and pain occasionally affects R1's sleep. R1's Physician's Order Sheet reviewed includes an active order since admission for Oxycodone 10-325mg (milligrams) give one tablet by mouth every eight hours as needed for Pain. R1's care plan initiated on 3/5/24 documents, Focus: I have pain/potential for pain related to multiple wounds, status post toe amputation, PVD (peripheral vascular disease). Intervention:…

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 account for the usage, disposition, and reconciliation of all controlled medications. This deficiency affects all 4 (four) medication carts reviewed for Controlled Substance reconciliation. Findings include: On 6/11/24 at 6:12AM, Checked A unit medication cart with V7 Registered Nurse. Observed shift change narcotic count form marked May unit C /D cart C wing. V7 verified that this is A unit narcotic medications binder. The shift changes narcotic count form listed count monitoring beginning June 9 and June 10, missing June 1 to 8, 2024. Noted missing shift nurses' signatures on 6/9 and 6/10/24. V7 said she does not know; this is how she received it. V7 and surveyor search the binder but unable to find the narcotic medication reconciliation for June 1 to June 8. V7 said she did not count the narcotic medications when she arrived to work at 11:30pm, the 3-11 shift nurse already left. V7 said that the off going and on coming nurses should count the narcotic medications. Count narcotic medications with V7.…

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 medications are stored safely, securely, and properly following manufacturer/supplier recommendations. This deficiency affects all two (2) medication storage rooms reviewed for Medication Storage. Findings include: On 6/11/24 at 6:23AM, Checked medication storage room for Unit A and B with V7 Registered Nurse (RN). Observed Medication refrigerator unlocked. V7 said that medication refrigerator should be always locked. Observed 1 carton of thickened dairy. V7 said that she does not know who placed the carton of thickened milk inside the refrigerator. V7 said that no food should be placed inside the medication refrigerator. On 6/11/24 at 6:31AM, Checked medication cart and count controlled substance/narcotic medications. Observed R25's lorazepam 2mg /ml (milligram/milliliter) concentrate bottle inside the locked drawer inside the medication cart. The medication labeled keep refrigerated. On 6/11/24 at 7:21AM, Checked medication storage room for Unit C and D with V9 RN. Observed Medication refrigerator…

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 perform hand hygiene during medication administration in between residents, failed to disinfect medical equipment such as pulse oximeter and Blood pressure (BP) machine after each resident use, and failed to disinfect glucometer properly as manufacturer recommendation. The facility also failed to implement enhanced barrier precaution (EBP) during intravenous ( IV) medication administration to resident with central line. The facility also failed to store the nebulizer mask in a plastic bag. This deficiency affects all 7 residents (R5, R16, R22, R31, R39, R68 and R77) in the sample of 26 reviewed for infection control during medication administration. Findings include: On 6/11/25 at 7:30AM, V8 Registered Nurse (RN) prepared medication for R22. V8 about to go to R22's room to administer his medication when she saw R31 propelling himself on wheelchair in the hallway, she asked R31 to stop as she placed the pulse oximeter to his left index finger and instructed him to wait for her. Then she went to R22 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 record review and interview the facility failed to ensure immunization documentation for 5 of 5 residents (R13, R17, R40, R55, R71) reviewed for immunization administration. Findings include: On 6/13/2024 at 11:00AM, V3 (Infectious Preventionist) provided immunization record of R13, R17, R40, R55, and R71. Record revealed (R13, R17, R40, R55, R71) did not received pneumonia vaccine as evidenced by lack of documentation in the immunization record. On 6/13/2024 at 01:00PM, V3 stated vaccine should be offered on admission. When vaccine is given, documentation on resident immunization record should be completed. Facility Policy: Guideline: Infection Control Program - General Manual: Nursing Review Date: 2/2024 General: The facility is committed to ensuring that all appropriate infection and control measures are in place as determined by State and Federal Regulations as well as CDC (Centers for Disease Control) recommendations and guidance. Policy: c. Ensure that all residents and staff are offered and encouraged to receive immunizations as recommended by CDC and State and…

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

Based on observation, interview and record review, the facility failed to provide privacy during wound care treatment for 1 of 2 residents (R5, R40) observed for wound treatment in a sample of 26. Findings include: On 6/12/2024 at 09:50AM, V19 (Wound Nurse) observed for wound care treatment including dressing changed of R40's left heel. V19 prepared supplies needed and proceeded to R40's room. R40's door was not closed, and privacy curtain was not drawn the entire time treatment was performed. R40 is visibly seen in the hallway during treatment. On 6/12/2024 at 10:00AM, V19 stated she should have closed R40's door during treatment to provide privacy. On 6/12/2024 at 11:15AM, V2 (Director of Nursing/DON) stated staff is expected to close the door and curtain drawn when providing care to residents, including all treatment performed to maintain privacy. On 6/12/2024 and 6/13/2024, Privacy Policy related to treatment procedure was requested on multiple occasions to V1 (Administrator), V2 (DON), and V16 (Nurse Consultant) and facility was not able to provide. admission Record: Diagnosis…

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 perform criminal history background checks within 24 hours of admission for three of five residents (R118, R322, R323) reviewed for criminal history background check in a sample of 26. Findings include: 1. On 06/12/2024 at 10:50AM during record review, R118 was noted with admission date of 05/14/2024 and Criminal History Information Response Process was initiated on 06/11/2024. On 06/11/2024 at 12:45PM during interview with V24 (Admissions Director), V24 stated that criminal background checks should be done within 24 hours of admission. On 06/13/2024 at 11:40AM during interview with V1 (Administrator), V1 stated that criminal background checks should be done within 24 hours of admission but because the facility staff did not have access to request Criminal History Information Response Process they were not able to do it within 24 hours for R118. Review of R118's order summary report printed 06/13/2024 indicated admission date of 05/14/2024. Review of R118's Criminal History Information Response Process indicated dated 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 provide care and maintain hygiene for the resident's nails for 1 of 7 residents (R98) in a sample of 26. Findings include: On 6/11/24 at 10:30AM, Observed R98 with long dirty fingernails, R98 said he would like is fingernails to be cut down, R98 said that the staff does not cut them. On 6/11/24 at 10:32AM, Informed V12 (Licensed Practical Nurse) of above observation, V12 said that R98 sometimes refuses getting his fingernails cut. On 6/13/24 at 12:54PM, V2 (Director of Nursing) said that nail care should be provided to the residents, the nails should be cut and cleaned as needed by the CNA's (Certified Nursing Assistants). V2 said if the resident refuses, then the staff should notify the nurse so that a refusal care plan can be added. V2 said that the staff should follow the nail care facility policy. Review of R98 medical records. R98 admitted on [DATE] R98 is alert and verbal, with diagnosis listed in part but not limited to Primary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to accurately complete smoking assessment to a resident who smokes and formulate care plan for smoking safety. The facility also failed to initiate fall investigation and update fall care plan. This deficiency affects two (R46, R55) of five residents in the sample of 26 reviewed for Smoking Safety. Findings include: On 6/11/24 at 8:31AM, V11 said that R55 is a smoker. On 6/11/24 at 9:30AM, Observed R55 lying in his room. He said that he smokes daily. He said that he needs assistance when he goes to smoke. R55 is admitted on [DATE] with admitting diagnosis listed in part but not limited to Diabetes Mellitus type 2, Fractured of right toe, Osteoarthritis, Dependence of Renal dialysis. Smoking assessment dated [DATE] indicated that he is not smoking. No care plan formulated for safety smoking. Smokers list as of 6/11/24 given by V2 Director of Nursing (DON) indicated that R55 is included in the list of residents who smokes. On 6/12/24 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 administer medication as ordered by physician. This deficiency affects two (R5 and R54) of three residents in the sample of 26 reviewed for Significant medication error. Findings include: On 6/11/24 at 8:07AM, V9 RN (Registered Nurse) prepared IVPB (Intravenous piggy bag) medication of Meropenem 50mg /100ml (milligrams/milliliter)0.9% NS (sodium chloride) infused for 1 hour every 8 hour for R5. Observed signage posted at the door indicating EBP (Enhanced barrier precaution). V9 donned gloves and entered the room with the medication. R5 has central intravenous line with double lumen on right chest. V9 primed the IVPB antibiotic. V9 cleansed the blue colored lumen from the central line, flushed the lumen with 10ml NSS (normal saline solution), attached the IVBP medication and set it at dial flow regulator at 200 rates. V9 said that the IVBP medication should infused for 1 hour. R5 is re-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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to obtain physician order for resident on hospice care and failed to access hospice staff documentation of visit to ensure coordinated care and communication. This deficiency affects one (R71) of three residents in the sample of 26 reviewed for Hospice care management. Findings include: On 6/11/24 at 8:31AM, V11 said that R71 is on hospice care. On 6/11/24 at 9:20AM, Observed R71 sleeping in bed with bilateral floor mat on side on the bed. R71 is admitted on [DATE] with diagnosis listed in part but not limited to Dementia without behavioral disturbance, Benign neoplasm of pituitary gland. Active physician order indicates no order of hospice evaluation or hospice care. Review R71's hospice binder by the nursing station. Noted hospice nurse and CNA (certified Nurse Assistant) visit log from 5/1/24 to 6/11/24 but cannot find documentation/ notes in the binder. On 6/12 24 at 9:30AM, Informed V2 DON (Director of Nursing) that R71 is on hospice…

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 aid with dressing, incontinent care, and provide clean linen in a timely manner to a resident identified as dependent for needing assistance with Activities of Daily Living (ADL) for 1 of 3 resident's (R2) reviewed for ADL care. Findings include: On 5/9/2024 at 11:57am R2 was observed in bed leaning over to the left side. No gown or clothing on, in a soiled incontinent brief and with soiled bed linen. On 5/9/2024 at 11:58am R3 is R2 roommate and is alert and oriented times three. R3 said R2 is always leaning and that no one assists him with his meals. His clothing is always dirty, smells of the urine and feces and they never give him fresh water. On 5/9/2024 at 12:00 pm V3 (Nurse) said R2 is confused and I really don't know him well. The Certified Nursing Assistant-CNA is with another resident. I will find another CNA to assist R2 he should be dressed and cleaned up and not leaning to the side. On 5/9/2024 at 12:05pm V4 (Certified Nursing Assistant - CNA) said R2 is confused, I make my rounds every two hours.…

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 window screens were free of damage/holes for 14 of 14(R8-R20) windows reviewed for environment. Findings includes: On 12/7/23 at 11:39AM, V5 (maintenance) was observed by R1's room in the hallway with a window screen observed with a hole in the bottom corner of the screen approximately 4x 4 inch. V5 confirmed that the screen was removed from R1's room. V5 said he was told to exchange out the screens and started today because of the weather being nice. At this time, no other screens had been replaced and R1's was the first one. When asked why R1's room which was in the back of the facility in the middle of wing was being replaced first, V5 said he just decided to start there. A tour was conducted with V5 around the facility to observe for any further damage to the screens. The following windows were observed with screen damaged for R8-R20. On 12/13/23 at 10:51Am, V5(maintenance) said he checks the building every day and was unable to recall when he observed the screens to be damaged. V5 said he does 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to provide sufficient nursing staff to provide daily care needs for dependent residents. This failure applies to three of seven residents (R2, R4 and R6) reviewed for staffing and has the potential to affect all 116 residents in the facility. Findings include: Facility census provided documents there are currently 116 residents in the building. On 11/27/2023 at 11:40 AM R2 stated the night shift staff don't answer call lights and don't do anything. R4 is a [AGE] year-old male with a diagnosis history of Dementia with Agitation, Muscle Wasting and Atrophy, Low Back Pain, and Heart Failure who was admitted to the facility 05/02/2023. On 11/28/2023 at 11:12 AM observed a strong urine smell in the hallway of R4's room. Observed R4 lying in his bed in his room appearing to be well groomed. Observed R4's room smelled strongly of urine. R4 stated he needs assistance with using the bathroom. On 11/28/2023 at 11:15 AM V8 (Certified 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 that nursing staff were provided with training to ensure that Certified Nursing Assistants had the required competencies and skills to provide service to residents with special care needs. This failure affected two (R3 and R7) of seven residents reviewed for special care. Findings include: 1.) R3 is [AGE] years old and has resided at the facility since 2/01/2023, with past medical history including, but not limited to Paraplegia, Type 2 diabetes without complication, colostomy status, acquired absence of left leg above knee, neuromuscular dysfunction of bladder, ataxia following other cerebrovascular disease, pain, major depressive disorder, hypertensive chronic kidney disease, Kidney failure, benign prostatic hyperplasia, etc. 11/28/2023 at 11:30AM, observed wound care for resident with V5 (Licensed Practical Nurse/LPN) and V7 (Wound Care Tech) and noted a large area of excoriation on the residents back left tight with some whitish substance,…

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 the facility failed to have a Registered Nurse (RN) on duty for a least eight consecutive hours a day, 7 days a week. This has the potential to affect all 113 residents. Findings include: On 11/7/23 at 1:14PM V13 (Vice President of Regional Operation) said that V1 (Administrator) is responsible for submitting the staffing summary report through Payroll Base Journal. V13 said last quarter report submitted for April to June 2023, they got cited for non-compliance. V13 presented copy of plan of correction submitted. V13 said that V5 (Scheduling Coordinator) does the staffing schedules for both nurses and CNAs (Certified Nursing Assistants). V2 (Director of Nursing/DON) oversees it. They use agency if needed but most of the time the staff picked up extra hours. On 11/7/23 at 1:53PM V2 (DON) said that they have a census of 113 residents. For unit A&B 7-3 and 3-11 shift, they have 2 nurses and 4 CNAs while for 11-7 shift, they have 1 nurse and 2 nurses. For unit C & D 7-3 shift, they have 2 nurses and 5 CNAs, 3-11 shift they have 2 nurses and 4 CNAs and 11-7…

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 its Abuse Prevention and Reporting policy by not providing a resident secure environment free from verbal abuse for 3 of 4 residents (R5, R7 and R8) reviewed for abuse in a sample of ten. Findings include: The 9/12/2023 incident report for R5 indicated that V24 (Licensed Practical Nurse/LPN) was verbally inappropriate to her (R5) for requesting assistance and using the call light at 2am, saying I know your family complains a lot but you're not going to keep putting on this call light. On 11/7/2023 1:15pm R8 said that she thought V24 would have been fired by now she yells at the residents for using the call light at night, I did not report it because my daughter talked to her and I'm not afraid of her. On 11/7/2023 at 1:30pm R7 said that on 11/5/2023 V24 entered her bedroom between 1:30am and 2:30am and began yelling saying that she was irritating and if she keeps up with the call light, she will document her psychotic behavior and she had to wait for the (Certified Nursing Assistant/CNA) staff for assistance. 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.

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 residents with a history of multiple falls. This deficiency affects two (R1 and R2) of three residents reviewed for Fall Prevention Management Program. Findings include: 1.) On 11/7/23 at 11:32AM, R2 was lying in bed in the high position. R2 is alert and responsive, but with garbled speech. R2 has bilateral above the knee amputations. No bedside commode. No anti-slip material to his wheelchair seat. On 11/7/23 at 11:40AM, V10 (Certified Nursing Assistant/CNA) said that she is assigned to R2. Showed V10 the observation of R2's bed in high position. V10 said that R2 is not at risk for falls but his bed should be in the lowest position. V10 took the bed remote control located by the foot part of the bed and adjusted the bed to the lowest position. V10 said that R2 does not use floor mat nor anti-slip material on his wheelchair seat. On 11/8/23 at 9:57AM, V16 (CNA) said that she is the CNA assigned…

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 implement the physician's order to provide therapy services to a resident who has a decrease in functional mobility. This deficiency affects one (R3) of three residents reviewed for specialized rehabilitation services. Findings include: On 11/07/2023 at 10:15 AM, R3 was lying in bed. R3 said that he has not received any physical therapy since admission to the facility. On 11/9/2023 at 1:00 PM, V26 (Physical Therapy Assistant/PTA) said that R3 was evaluated for physical and occupational therapy treatment. V26 said that the facility sent the result of the evaluation to Veteran Administration for approval of services, but no approval has been received. V6 said that R3's primary doctor should have been notified if R3 was not receiving the rehabilitation services as ordered. V26 said that the director of the physical therapy department is the person that will notify R3's primary doctor regarding R3 not receiving rehabilitation services as ordered. V26 said…

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