Pine Crest Health Care

Based on observation, interview, and record review the facility failed to ensure the call lights in 2 out of 3 shower rooms on the second floor were functioning properly. This deficient practice has the potential to affect all 91 residents that reside on the second floor of the facility.Findings include:Facility census, dated 8/11/25, documents 91 residents residing on the third floor.On 8/11/25, at 11:08 a.m., during an observation of the second-floor shower rooms conducted with V13 (Licensed Practical Nurse/LPN), it was identified that the call lights in 2 of the 3 shower rooms were nonfunctional. V13 confirmed the issue, stating, Maintenance is working on fixing them (call lights in the showers). Any of the shower rooms can be used by any of the residents on this (second) floor. They (call lights in the showers) haven't been working since Friday (8/8/25). Yes, the call lights are important for patient safety. On 8/13/25 at 11:20am, V10 (Maintenance Director) stated that an external company had been contacted to repair the inoperative call lights in the second floor shower rooms.…

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 that handrails were secured along the resident corridors. This failure has the potential to affect 21 residents that reside within the 2400 unit.Findings include:Facility provided census documents in part that 21 residents reside within the 2400 unit.On 8/12/2025 at 9:39 AM, observed the handrail near the elevator in the 2400 unit detached from the wall and hanging down approximately 6 inches. A hole approximately 4 inches long was observed where the handrail was anchored to the wall. When pressure was applied to the bottom and top of the handrail, the handrail was loose and was able to move approximately 6 inches. V3 (Assistant Director of Nursing) observed the handrail and affirmed that the handrail was not secured to the wall. V3 stated, it (the handrail) could be tightened, I'll call maintenance.On 8/13/2025 at 10:33 AM, V2 (Director of Nursing) affirmed that the expectation of the facility is that handrails are securely affixed to the walls in case a resident needs assistance with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to have a five percent (5%) or lower medication error rate. There were 3 medication errors out of 25 medication opportunities resulting in an 11% medication error rate. This failure affected two residents (R47 and R52) of five residents reviewed for medication administration. Findings include:On 8/12/2025 at 8:30AM, observed medication administration with V20 (LPN) on the first floor of the facility. The first resident observed was R47, a [AGE] year-old female who have a diagnosis of polyneuropathy among others. V20 administered 10 medications to R47, among the medications given was:Gabapentin Oral Tablet 600 MG (Gabapentin) 1 tablet by mouth.Active physician order for R47 shows the following. Gabapentin Oral Tablet 600 MG (Gabapentin) Give 1 tablet by mouth three times a day for neuropathy; reducing dose due to weight gain. Gabapentin Oral Tablet 100 MG (Gabapentin) Give 1 tablet by mouth three times a day for neuropathy give in addition to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to revise a comprehensive care plan, failed to develop care plan with measurable goals, objectives and individualized interventions to meet the need for increased supervision in preventive interventions for one resident (R1) reviewed for elopement in the sample.Findings include:R1 medical report admission Record showed that R1 was admitted to the facility on [DATE] with diagnosis that includes but not limited to Schizophrenia, hyperlipidemia, cerebral infarction and bilateral primary osteoarthritis of knee.R1 eloped from the facility on 07/17/2025 without authorization and without facility staff being aware that R1 was missing until the V22 (family) called the facility staff on 07/18/2025 at approximately 12:30am to inform them of R1 whereabout.R1's V22 (family) with the local police department advice sent R1 to the hospital for evaluation.R1's hospital emergency room record diagnosis includes but not limited to Dementia, PTSD (Post Traumatic Stress…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe environment by using space heaters in residents' rooms; failed to ensure that four shower rooms on the first floor of the facility were clean and in good repair; and failed to maintain adequate temperature in residents' rooms and the first-floor dining room. This failure affected five (R1, R2, R3, R4 and R5) of five residents reviewed for environment. Findings include: R1 is a [AGE] year-old male who have resided at the facility since 2024, face sheet documented the following past medical history: Heart failure, essential primary hypertension, cardiomyopathy, major depressive disorder, chronic kidney disease, anxiety disorder, vascular dementia, type 2 diabetes, etc. 2/20/2025 at 9:21AM, R1 was observed in his room, awake and alert and said that he is doing okay. R1 was wearing a winter coat and wrapped himself with a blanket while sitting in a corner of the room, his room was noted to be very cold, and there were clutters…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to follow their policy for weighing residents and failed to follow physician orders to weigh resident weekly, which resulted in a 6% unplanned weight loss. This failure applied to one of one (R1) residents reviewed for weight loss. Findings include: R1 an [AGE] year-old male admitted to the facility on [DATE] with the medical diagnosis including but not limited to chronic obstructive pulmonary disease, dementia, hypertension, gait disturbances, and vasovagal syncope. According to R1's weight log found in the electronic medical record, only weights documented were for 1/04/2025, 1/10/2025 and 1/17/2025. Physician orders dated 01/09/2025 include: weekly weights for 4 weeks. R1 had no weights documented from 1/18/2025 to 2/1/2025. 02/2/2025 at 11:49AM R1's family member said, I was not notified of R1's weight loss. 02/01/2025 at 3:52PM V7 (Licensed Practical Nurse) said, I do not see weights charted after 1/17/2025 and the order says it should be done weekly.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident. This failure applied to two (R1, R2) of three residents reviewed for abuse. Findings include: R1 is [AGE] years old and have resided at the facility since 2016, past medical history includes: Disorganized Schizophrenia, type 2 diabetes, anemia, constipation, Tobacco use, elevated prostate specific antigen, vitamin D deficiency, bipolar disorder, etc. 12/09/2024 at 1:00PM, R1 was observed in his room, alert and oriented and recalled the day he had an altercation with another resident. R1 stated that R2 just walked up to him and hit him in the eye, he did not do anything to him and has never been involved in any altercation with R2 before. R2 is [AGE] years old with past medical history of Other Asthma, Alzheimer's disease with late onset, hyperlipidemia, essential primary hypertension, paranoid schizophrenia, vitamin D deficiency, bipolar disorder, unspecified dementia…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to follow their policy and procedure for mechanical lift transfers by not ensuring two staff were present while attempting to transfer a resident using the mechanical lift. This failure applied to one (R1) of three residents reviewed for accidents/hazards. Findings include: R2 is a [AGE] year-old male with a diagnoses history of COPD, Dysphagia, Partial Paralysis Following a Stroke, Morbid Obesity, Other Seizures, Weakness, Anxiety Disorder, and Mild Recurrent Major Depressive Disorder who was admitted to the facility 05/06/2022. On 11/12/2024 at 2:04 PM Observed R2 in his room sitting in his wheelchair showing no signs of injury or distress. R2 stated a while ago he had a fall while being transferred from his bed to his chair by a certified nursing assistant with the mechanical lift. R2 stated the certified nursing assistant lost her balance and the mechanical lift fell on his leg. R2 stated he did experience some pain. R2's Current Care Plan documents…

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 food was held at a safe and proper temperature before serving. This failure effect 143 residents out of 146 residents in the facility observed for food temperatures. Findings include: On 9/17/2024 at 11:50am V27 (Dietary Cook) was observed for food temperatures, the ground turkey for upstairs was at 128.6 degrees, and then reheated and temperature was at 131.0 degrees. The turkey patties temperature was at 131.2 degrees, the whipped potatoes was at 128.0 degrees, and the pasta temperature was at 126.5 degrees. On 9/17/2024 at 12:00 noon V27 said the food temperature should be holding at 160-170 degrees, I will reheat the food and take all the temperatures over. On 9/17/2024 at 12:30pm V27 (Dietary Supervisor) said all food should be held at 135 degrees before serving, I will make sure all the food is at the correct temperature before serving. Facility Policy: Policy: To ensure food safety, hot food is cooked to a minimum safe temperature and is held no lower than 135 degrees Fahrenheit. Cold food is…

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

Based on observation, interview, and record review the facility failed ensure cleanliness of washing machines and to keep the clean linens covered. The facility also failed to conduct annual test to prevent the growth of Legionella and other opportunistic waterborne pathogen in the building water system. This deficiency could affect the entire 146 residents who are using linens that are being washed in the facility and water that being used in the facility. Findings include: On 9/17/24 at 10:30AM, V10 Infection Preventionist provided copy of facility's annual Legionella test done on 5/18/23. Surveyor was referred to V1 Administrator and V11 Maintenance Director for the annual test for 2024. On 9/17/24 at 12:04PM, V11 Maintenance Director said that annual legionella test is not yet done for this year. They are only doing daily water temperature in the facility. They ordered it and waiting for the kit. Presented copy of email dated 9/17/24 indicating V1 Administrator ordering CDC Elite lab culture legionella test kit with analysis from vendor. Requested for policy. On 9/18/24 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, record review the facility failed to follow their policy in ensuring that ceiling tiles in the residents are free from watermarks or spots, and that vents in the residents' room are free from dust build up. This deficiency affects all four rooms (Rooms 205, 211, 2316, and 2210) reviewed for clean, comfortable, and homelike environment. Findings include: On 9/17/2024 between 10:30 AM and 11:30 AM, rooms 205, 211, 2210, and room [ROOM NUMBER] were observed to have brown sports on the ceiling, and vents have dust build up. On 9/18/2024 at 12:41 PM, V11 (Maintenance Director) said that the brown sports on room [ROOM NUMBER] ceiling is from water leakage from the air conditioner. At 12:49 PM, V11 said that the brown spots on the ceiling above a 211-1 bed is from a water leakage from the toilet from the room above 211-1's room, and that the brown sports on 205 ceiling is from water leakage. On 9/19/2024 at 01:00 PM, V11 said that the brown sports on room [ROOM NUMBER] ceiling is also…

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 written policies and procedures that prohibit and prevent abuse. This deficiency affects one (R19) of three residents in the sample of 29 reviewed for Abuse prevention program. Finding includes: On 9/17/24 at 11:10AM, Observed R19 up in wheelchair and able to propel himself. He is alert, oriented and response appropriately. On 9/18/24 at 9:40AM, V1 Administrator said that he is the abuse coordinator. V1 said that resident abuse screening is done upon admission. V1 said that V2 Assistant Administrator and V5 Social Service Director are responsible for screening residents for identified offender. V5 is responsible for developing abuse prevention and identified offender care plan. On 9/18/24 at 1:37PM, V5 Social Service Director (SSD) said that she is responsible for developing abuse prevention and identified offender care plan. Reviewed R19's medical records with V5 SSD. Informed V5 that R19 does not have care plan for abuse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide nail care to resident who is dependent with Activity of Daily Livings (ADL). This deficiency affects one (R103) of three residents in the sample of 29 reviewed for providing ADL care. Findings include: On 9/17/24 at 12:30PM, While observing R103 for wound care observed bilateral hand with long and dirty fingernails. Noted black/dark colored dirt under the fingernails. Showed both observation to both V9 Wound Care Nurse (WCN) and V14 CNA (Certified Nurse Assistant). Both said that CNA should provide nail during personal hygiene/shower. V9 said that R103 refused nail care but when V9 WCN asked her if they can trim her fingernails and clean it R103 agreed. Requested for policy. On 9/18/24 at 1:30PM, Follow up policy with V2 Assistant Administrator. On 9/20/24 at 11:13Am, V3 Director of Nursing said that they don't have policy on nail care. R103 is admitted on [DATE] with diagnosis listed din part but not limited to Cerebral…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to identify early signs of skin impairment and provide treatment in timely manner. The facility failed to develop care plan and implement interventions to prevention skin impairment to resident who is at high risk. The facility also failed to follow manufacturer recommendation when using low air loss mattress. This deficiency affects two (R88 and R103) of three residents in the sample of 29 reviewed for providing Quality of care. Findings include: R103 On 9/17/24 at 10:25AM, V22 Family member said R103 developed a sore on her foot that is now gangrene. R103 is not diabetic. R103 may require amputation. R103 was sent to the hospital after V22 complained to the facility. V22 said that she informed unknown CNA (Certified Nurse Assistant) about the sore couple months ago. V22 said that she has not spoken to R103's PCP (Primary Care Physician) but has spoken to wound care nurse, head nurse and administrator. On 9/17/24 at 12:30PM, Observed V9 WCN…

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 preventive measures and updates fall care plan after each fall occurrence. This deficiency affects all three residents (R13, R88 and R146) in the sample of 29 reviewed for Fall Prevention Program. Findings include: On 9/18/24 at 10:13AM, Observed R88 lying in bed not in the lowest position. On 9/18/24 at 11:58AM, Review R88's medical record with V8 Restorative Nurse/Fall Coordinator. V8 said that R88 is at high risk for falls due to multiple fall incidents. Review R88's fall incidents report for 2024 dated: 1/22, 7/18, 7/26, 7/30 and 8/26/24. All fall incidents were unwitnessed fall and rolled out from bed. All fall incidents did not have fall investigation/root cause analysis. Interventions are not changed after each fall occurrence. On 9/18/24 at 12:28PM, Rounds made to R88 with V8 Restorative Nurse. Observed R88 lying in bed not in the lowest position. V8 said that the bed should be in the lowest position for safety. V8…

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 collaborate and coordinate care by failure to ensure that resident's updated medical records are available and accessible to all interdisciplinary team (IDT) in the facility. This deficiency affects two (R88 and R113) of three residents in the sample of 29 reviewed for Hospice Services Program. Findings include: On 9/17/24 at 10:0AM, Observed R88 lying in bed. She is awake but verbally unresponsive. She is totally dependent with activity of daily living (ADL). On 9/17/24 at 12:04PM, Observed R113 lying in bed. He is awake and response to simple questions. He is totally dependent with ADLs. On 9/17/24 at 12:10PM, Review R88 and R133 hospice records in individual binders with V3 Director of Nursing and V9 Wound Care Coordinator. R88 is admitted on [DATE] with diagnosis listed in part but not limited to Benign neoplasm of the left breast, Intraductal carcinoma of left breast, Dementia. Psychosis. Active physician order sheet indicates…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their physician notification policy and did not notify the physician when a small, metal piece was found in a resident's skin/scalp. This affected one of three (R1) residents reviewed for physician notification of a change. Findings Include R1 is a [AGE] year old with the following diagnosis: developmental delay, pressure ulcer of the left heel, spastic hemiplegic cerebral palsy, and fusion of the cervical spine. A Nursing note dated 10 4/11/23 documents R1 was admitted to the facility. R1 had a wound to the left heel and bilateral anterior ankles. There was a surgical incision scar to the neck. There is no documentation on any of these days that a small metal piece was found in or on R1's skin or that the physician was notified. On 2/20/24 at 11:16AM, V3 (Guardian) stated it was brought to V3's attention that a staple was found in R1's head while R1 was being assessed by the housing nurse a couple days before discharge. On 2/20/24 at 12:30PM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their abuse policy by not preventing an incident of physical resident to resident physical attack. This affected two of four residents (R2, R3) reviewed for physical abuse. This failure resulted in R3 hitting R2 for standing close to R3 during the smoking break. Findings Include: R2 is a [AGE] year old with the following diagnosis: peripheral vascular disease, type 2 diabetes, and chronic kidney disease. R3 is a [AGE] year old with the following diagnosis: schizoaffetive disorder and schizophrenia. On 2/20/24 at 2:03PM, R3 stated R3 hit R2 in the face when out on the smoking patio. R3 reported the reasoning for hitting R3 was because R2 was getting to close to R3. R3 again began yelling at this surveyor and refused to answer any further questions on the incident. On 2/20/24 at 2:18PM, R2 stated last month R3 hit R2 in the face while they were out for smoke break on the patio. R2 reported R2 was in a wheelchair backing up in the wheel chair to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident with a history of physical and verbal aggression attended psychosocial group management. This affected one of three (R3) residents reviewed for behavior management and interventions. This failure resulted in R3 physically attacking R2 during a smoking break for standing to close. Findings Include: R2 is a [AGE] year old with the following diagnosis: peripheral vascular disease, type 2 diabetes, and chronic kidney disease. R2 R3 is a [AGE] year old with the following diagnosis: schizoaffetive disorder and schizophrenia. No observations were made asking R3 to attend the groups held by social services. On 2/20/24 at 2:03PM, R3 instantly began aggressive and started yelling at this surveyor with any questioning. R3 denied being offered to go to any groups and denied wanting to go to any groups to help manage behaviors. R3 said, They can't make me do anything. I will do what I want. Nobody wants to hear everyone talking in a group. On…

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

Based on interviews and record reviews, the facility failed to identify an acute change in a resident's respiratory condition and implement immediate effective interventions to improve respiratory status. This affected one of three residents (R8) reviewed for change in condition and assessment. This failure resulted in (R8) calling EMS (emergency medical services) 911 for assistance with difficulty breathing out of three residents reviewed for change in condition in a sample of 10. R2's oxygen saturation level was 72% when the paramedics arrived. Findings include: On 1/17/24 at 11:45am, R8 who was assessed to be alert and oriented to person, place, and time, stated that last November R8 called for CNA (certified nurse aide) to inform staff he was not feeling well. R8 stated that it took awhile before staff came to his room, so R8 called EMS 911 for his difficulty breathing. On 1/19/24 at 7:20am, V18 (nurse) stated that V18 was rounding on assigned residents and responded to R8's call light. V18 stated that upon entering R8's room, R8 stated that he couldn't breathe and that he…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their Abuse prevention policy by not immediately reporting an allegation of abuse and failing to conduct a full body exam at the time of the allegation. This failure effects one resident (R1) who has stated she was hit by a Cerified Nursing Assistant while receiving care. Findings include: R1 is an [AGE] year old woman who admitted to the facility 8/8/13 and has diagnoses that include bipolar disorder, violent behavior, and osteoporosis. Facility Reported Incident dated 8/21/23 was initiated for a Physical Abuse complaint related to R1. On 8/3/23 at 11:47AM, R1 was observed alert and oriented sitting in her room in a wheelchair, appropriately dressed and practicing art. R1 said she has experienced three instances of abuse by different staff, and she has mentioned these instances to V1 (Administrator) and nothing has been done. R1 said the most recent was about a month or so ago in August, could not remember the exact date or the name of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow individualized care plan interventions to prevent a fall. This failure affected one resident (R3) and resulted in R3 sustaining a head laceration which required treatment rendered in a hospital emergency room. Findings include: R3 is an [AGE] year old male who admitted to the facility 7/24/23 and has diagnoses that include Arthritis, Lack of Coordination, abnormal posture, reduced mobility, and contractures of the right and left knee. Facility Reported Incident dated 9/13/23 indicated that R3 was receiving incontinence care from V10 CNA (Certified Nursing Assistant) during the day shift and when V10 turned to reposition R3 to his side, the bolster (wedge pillow) which was attached to the bed, gave out and R3 fell out of the bed. R3 suffered a laceration above the eyebrow, and he was sent to the emergency room for a medical evaluation. On 10/2/23 at 10:39AM, R3 was observed lying in bed, sleeping. The bed was noted to have wedge pillows…

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

Based on observations, interviews, and record reviews, the facility failed to follow its abuse policy and prevent an resident to resident physical assault. This affected two of four (R1, R2) residents reviewed for physical assault. This failure resulted in R2 wandering into R1's room and assaulting R1 with an aluminum reaching device. Findings include: On 9/2/23 at 10:45am, R1 was observed lying in bed. R1's bed was positioned next to the window. R1's aluminum reaching device was observed on top of R1's nightstand that was next to the head of R1's bed. On 9/2/23 at 10:45am, R1 stated that R2 has come into R1's room on several occasions prior to this incident. R1 stated that on 8/8/23 R1 was lying in bed when R2 came into his room. R1 stated that R1 was yelling and screaming for R2 to get out of R1's room. R1 stated that R1 activated his call light. R1 stated that R1 threw water on R2. R1 stated that R2 then picked up R1's reaching device and was hitting R1's left hand and forearm. R1 stated that R1 raised left arm to prevent the reaching device from hitting him in the face. R1…

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

Based on observations, interviews, and record reviews, the facility failed to implement an effective plan to monitor a resident with a history of wandering. This affected one of three residents (R2) reviewed for supervision. This failures resulted in R2 wandering into R1's room unsupervised subsequently assaulting R1 with an aluminum reaching device. Findings include: On 9/2/23 at 10:15am, this surveyor observed residents sitting in an open area/dining room on the second floor. There was a CNA (certified nurse aide) supervising residents in this area. R2 was observed sitting in a chair the enclosed smaller dining room unsupervised. R2's chair was positioned facing the wall. R2 was observed extending arms touching the wall. On 9/2/23 at 10:45am, R1 was observed lying in bed. R1's bed was positioned next to the window. R1's aluminum reaching device was observed on top of R1's nightstand that was next to the head of R1's bed. On 9/2/23 at 10:45am, R1 stated that R2 has come into R1's room on several occasions prior to this incident. R1 stated that on 8/8/23 R1 was lying in bed when R2…

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 develop a written policy and procedure for disinfection of washer and dryer used in the laundry room. The facility also failed to keep washing machines free of detergent residue and grime (accumulation of dirt). This deficiency could affect the entire 128 residents who are using linens that are being washed in the facility. Findings include: On 8/8/23 at 1:05pm, Rounds made to laundry room with V4 Laundry Supervisor. V4 said that they are responsible for washing the personal clothing of residents and linens. Observed all 3 washing machines with brown stained detergent residue and grime (accumulation of dirt/filth) surrounding the machines. Only 2 washing machines currently running, the 2nd machine does not have front cover exposing the live wires. V4 said that the 3rd machine is broken. V17 Laundry Aide said that the detergent residue surrounding the washing machines are from the detergents overflowing from the top. V4 Laundry Supervisor said that the washing machine should be cleaned daily. Requested for…

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 sanitary and comfortable environment in the patio and gazebo areas. This failure has the potential to affect all 138 residents listed on the facility census. The facility also failed to ensure the washing machine is in a safe operating condition. This deficiency could affect 128 residents who are using the linens that are being washed in the facility. Findings: On 8/8/23 at 12:25 PM the patio area had grass and weeds up to 24 inches tall. The limbs on the trees are hanging down to five feet off the ground. There is trash, disposable cups and snack wrappers on the floor of the gazebo, on the floor of the patio, and throughout the grass and weeds. There are eighteen residents using the area to smoke at this time. On 8/9/23 at 1:00 PM the patio and gazebo area still have tall weeds and low hanging branches and scattered trash throughout that was observed on 8/8/23. On 8/9/23 at 4:55 PM the patio and gazebo area was observed with V1 (Administrator). The overgrown grass and weeds, and scattered trash was…

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

Based on observation, interview, and record review the facility failed to have a working call system for seven residents (R1, R18, R82, R84, R93, R112, and R129) of 17 residents reviewed for call system in the sample of 28. Findings include On 8/9/23 at 4:25 PM R112 said my call light does not work. I pull the cord, and no one comes in here. It has been that way for days. I told somebody but I don't remember who it was. The call light was in the on position. The call light over the door was very dim and was not visible from two rooms down the hall. There was no audible alarm. On 4/9/23 at 4:30 PM R112's call light non-functioning call light was reported to V17 (Receptionist). 8/10/23 at 11:40 AM The call light in R112's room was in the on position, the light over the door is dim and not visible from two rooms away . There is no audible alarm. V3 (Assistant Director of Nursing) was at the nursing station and was asked if there is a panel to indicate which call lights were activated. V3 looked around the desk and located the panel behind a row of binders. The call lights for R18 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 a safe, clean, comfortable, and homelike environment for 1 of 3 residents (R85) reviewed for residents' rights in a sample of 28. Findings Include: On 8/8/2023 at 11:45am R85 was observed in her room with the window drapes hanging down on one side. R85 said I asked the housekeeping supervisor to hang them up correctly and she never returned it looks abandoned in my room. On 8/8/2023 at 12:30pm V4(Housekeeping Supervisor) observed with the surveyor the window drapes hanging down. On 8/8/2023 at 12:40pm V4 said the curtains should not be hanging I will put them up as soon as possible. On 8/9/2023 at 10:40am V2(Assistant-Administrator) said all residents window drapes should be hanging correctly. An Order Summary Report dated 8/10/2023 indicates that R85 has a history of schizoaffective disorder, and anxiety disorder. Facility Policy: Residents rights Your rights to dignity and respect . Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality 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.

Based on interview and record review, the facility failed to follow their Incident/Accident Reports policy. Facility failed to report fall incident with injury to the Illinois Department of Public Health IDPH). This deficient practice affect one (R3) resident of three resident reviewed for fall incident in a total resident sample of 28. Findings Include: Documented on 8/4/23 at 6:48AM, reads in part: R3 observed in his room lying on the floor bleeding from right eye brow. R3 assessed with no other injuries found. Due to unwitnessed fall and being on blood thinners, R3 sent to local hospital for further evaluation. Ambulance ETA (Estimated Time of Arrival) 45 minutes. Physician Progress note dated 8/4/23 at 9:44AM, reads in part: R3 returned from ER (Emergency Room) status post fall with right eye brow laceration. R3 with 2 steri strips over laceration to right eye brow. On 8/10/23 at 11:25AM V7 (LPN) stated V7 making rounds when V7 heard R3 calling for help, went to the room and noted R3 on the floor, floor matt was in place however R3 was outside the parameter of the floor matt. R3…

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 Fall Prevention Program Policy and supervise a high risk for fall resident. This deficient practice affect one resident (R137) of three residents reviewed for fall incident in a total sample of 28 residents. Findings Include: R137 had a fall incident on 7/18/23. Nursing Progress Note dated 7/18/23 at 15:58, reads in part: R137 trying to transfer from her wheelchair to another chair and landed on bottom in dining area. R137 assessed with non-visible injuries. R137 did not hit her head witnessed by staff. On 8/10/23 at 11:03AM, V6 (LPN) stated that she was the assigned nurse for R137 that time. Denied witnessing the fall of R137 on 7/18/23. Stated that another nurse (V5) witnessed the fall of R137 in the dining room. Also stated that R137 is High risk fall. High risk for fall residents we try to keep them where we can see them. Fall risk residents we placed them in the common area. I do not recall if there was staff in the dining room at the time of R137 fall incident. On 8/10/23 at 10:50am, V5 (LPN) stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to follow the physician's order for a resident who receives oxygen therapy. This deficiency affects two (R99 and R133) of three residents in the sample of 28 reviewed for Respiratory care. Findings include: On 8/8/23 at 11:45am, Observed R99 with V14 RN, lying in bed with oxygen via nasal cannula (NC) at 4 LPM connected to oxygen concentrator. On 8/8/23 at 11:55am, Observed R133 with oxygen via nasal cannula at 9LPM connected to oxygen concentrator with humidifier. Called V12 Infection Control Coordinator and showed observation. V12 verified oxygen at 9LPM. Surveyor asked R133 if he adjusted his oxygen, R133 said that he did not adjust his oxygen. R133 said that the nursing staff is the one who provided his oxygen. On 8/8/23 at 12:20pm, V16 Hospice CNA said that she just visited R133 and provided personal care. V16 said that R133 has oxygen, but he did not check how many liters he is on. V13 said that it not part of her duty to check his…

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

Based on observation, interview and record review the facility failed to have coordinated care by ensuring that the resident's hospice medical records are available and accessible to all interdisciplinary staff in the facility. This deficiency affects one (R99) of three residents in the sample of 28 reviewed for Hospice Care Services. Findings include: On 8/8/23 at 11:40am, V9 Social Service Director (SSD) said that R99 is hospice resident. Observed R99 lying in Low air loss mattress bed with oxygen via nasal cannula. On 8/8/23 at 12:30pm, V6 LPN presented R99's hospice folder to surveyor. R99's hospice medical record in folder included: copy of the admission orders/hospice certification, IDT (Interdisciplinary team) plan of care dated 6/5/23, IDT log from 6/7/23 to 8/7/23. No hospice IDT progress notes of each visit indicating treatment provided and pertinent information related to R99's condition that is available for the IDT in the facility to access. V6 LPN said she does not know who coordinates with hospice regarding their documents for R99. On 8/10/23 at 1:22pm, V3 ADON 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.