Hillsboro Rehab & Hcc

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Interview and Record Review the facility failed to ensure a resident was free from abuse, from a resident with a history of prior altercations, for 1 of 6 (R4) residents reviewed for abuse in the sample of 6. Findings include: 1. R4's Face sheet documents an admission date of 12/18/2024. Diagnosis include Unspecified Dementia with Agitation, Congestive Heart Failure, Respiratory Failure, and Malignant Neoplasm of Colon. R4's Minimum Data Set, MDS, documents R4 is severely cognitively impaired. R4 requires partial/moderate assist with transfers and mobility. R4's Care Plan, dated 2/19/2025, documents R4 has been identified as a vulnerable person related to cognitive deficit. R4 has the potential for aggression related to her cognitive deficit. Interventions include R4 at times will believe she recognizes residents as people from her past and will seek them out to confront them. Staff will provide redirection to other area of facility and offer activities of her choice. R4 will have 1:1 supervision 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 interview and record review, the facility failed to prevent physical abuse from occurring for 2 of 2 residents (R2, R3) reviewed for abuse in the sample of 7. Findings include: 1.) R2's face sheet, print date of 2/19/25, documented R2 has diagnoses of Alzheimer's disease with early onset, dementia, major depressive disorder, encephalopathy, amnesia, restlessness and agitation, and personal history of traumatic brain injury. R2's MDS (Minimum Data Set), dated 12/16/24, documented R2 is severely cognitively impaired. R2's care plan, print date 2/19/25, documented R2 has the potential to become aggressive related to dementia diagnosis. R2's progress note, dated 2/8/25 at 6:21 PM, documented R2 is experiencing a change in condition. The change in condition the resident is currently experiencing is hit another resident in the common area. Writer called to the hall and informed writer that R2 had held another resident's right forearm down and hit her closed fist on the left cheek. The incident was witnessed…

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

Based on interview and record review, the facility failed to notify law enforcement of an allegation of sexual assault for 1 of 1 resident (R2) reviewed for reporting abuse in a sample of 6. Findings include: Local law enforcement report, dated 1/5/2025, documented, On 01/05/2025 at approximately 0120 hours, I, (V12, officer at local police department), was on routine patrol when my dispatch advised me of a nurse from (Regional Hospital) was needing to speak with me in reference to a sexual assault report she had just recently taken. The nurse, (V13, Sexual Assault Nurse Examiner/SANE, Registered Nurse) RN, was transferred from dispatch to my cell phone. R2's Regional hospital record, dated 1/5/2025, V13, SANE RN, documented, Writer contacted (local police department) and spoke with officer (V12, officer at Local Police Department.) Writer reported what was happening to the officer and officer gave a phone number for writer or (regional law enforcement agency) to contact him. (Regional law enforcement agency) was contacted at 1:15 am. On 1/07/2025 at 10:20 AM, V5, Admissions…

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

Based on interview and record review, the facility failed to notify the physician of abnormal blood sugars as ordered in 1 of 8 residents (R2), reviewed for pharmacy services in the sample of 8. Findings Include: R2's Medical Diagnosis Listing, undated, documents R2 has a diagnosis of Type 2 Diabetes Mellitus. R2's Physician Order Sheet documents the following order, dated 12/13/24 through 12/15/24, Novolin 70/30 Subcutaneous Suspension (70-30) 100 Units/ML (Milliliter). Inject as per sliding scale: if 80 - 100 = 7; 101 - 150 = 9; 151 - 200 = 11. Call MD (Medical Doctor) if blood sugar is greater than 200, subcutaneously in the morning. Inject as per sliding scale: if 80 - 100 = 7; 101 - 150 = 6; 151 - 200 = 8 Notify MD greater than 200, subcutaneously in the evening. R2's Blood Sugar Record documents the following: 12/14/24 at 11:08 AM, blood sugar of 215; 12/14/24 at 4:03 PM, blood sugar of 235; 12/14/24 at 8:18 PM; 12/14/24 at 9:00 PM, and 12/15/24 at 7:04 AM, blood sugar of 205. R2's record was reviewed with no documentation that R2's Physician was notified of the blood sugars…

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 wound care on 1 of 3 residents (R2), reviewed for quality of care in the sample of 8. Findings Include: R2's Medical Diagnosis Listing, undated, documents R2 was admitted to the facility with a diagnosis of Orthopedic Aftercare following a Right Femur Fracture. On 12/18/24 at 9:30 AM, wound care was observed with V3, ADON(Assistant Director of Nurses)/Wound Nurse/IPC (Infection Control Preventionist) . R2 has 3 incisions to the right hip. There was a dressing, dated 12/18/24, covering the two lower incisions. There was no dressing in place to the upper incision. All incision areas had staples in place. On 12/18/24 at 8:30 AM, R2 stated he thinks the nurses look at his hip incision, but don't put a dressing on it every day. R2's TAR (Treatment Administration Record), dated 12/2024, documents R2 has a physician's order, dated 12/12/24, to cleanse the surgical incision sites to the right hip with wound cleanser, pat dry and apply a dry dressing every shift. The TAR fails to show documentation 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, observation, and record review, the facility failed to dispose of an open multi-dose vial of Insulin after 30 days, failed to dispose of an expired bottle of stock medication, and failed to date an open vial of Tuberculin that is used by all staff and residents. This failure has the potential to affect all 93 residents in the facility. The Findings include: On [DATE] at 9:35 AM, the facility's Medication Room was checked with V7, Licensed Practical Nurse (LPN). There was one Medication Refrigerator checked with a Tuberculin (TB) Vial in the box, with a date of delivery of [DATE], was open and did not have an open date. A Lantus Insulin Pen 100Units/Milliliter (ML)/3ML was seen sitting in the fridge, with no resident name or date written on it. V7 stated, There is usually a resident label on the pen, or it should be in a plastic bag from the pharmacy with a resident name on it. On [DATE] at 9:40 AM, V7, LPN, stated, We use that TB vial for all staff and residents when needed. If I found 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, observation, and record review, the facility failed to perform proper hand hygiene and/or the changing of gloves while plating food, failed to date food when opened and/or cooked, and failed to check and maintain the temperatures of the food, including all diets (regular diets, special diets, and pureed foods) prior to serving the residents to prevent contamination and foodborne illness. These failures have the potential to affect all 93 residents living in the facility. The findings include: On 9/16/24 at 9:15 AM, during the initial tour of the kitchen, V11, Interim Dietary Manager (DM), stated, I can't find the fridge/freezer temperature logs. It's a mess, I'll look for them. Upon assessment of the kitchen, a bag of bacon was seen in the refrigerator and was dated 9/11/24 as opened, but the bag was open and not sealed. A gallon of chocolate milk, half full, was seen with no open date and an expiration date of 9/13/24. A box of cucumbers was seen in the walk-in refrigerator sitting on the floor of the refrigerator. A frozen bag of ground meat was sitting in the…

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

Based on interview and record review, the facility failed to ensure their facility assessment was updated to include all necessary components per the current standards of practice. This failure has the potential to affect all 93 residents residing in the facility. Findings include: The Facility Assessment, dated 7/11/22 - 7/10/23, did not include the following in the plan: identifying resources provide necessary care and services the residents require during both day-to-day operations and emergencies (including nights and weekends) and emergencies; evaluation of the overall number of facility staff needed to ensure sufficient number of qualified staff are available to meet each resident's needs as identified through resident assessments and care plans; pertinent information about the resident population the facility serves may include race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, preferred language, health literacy or other factors that affect access to care and health outcomes related to health equity; physical environment, equipment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff donned/doffed Personal Protective Equipment (PPE) on the COVID-19 positive hallway, in a manner to prevent cross contamination; failed to ensure residents were not exposed to staff exhibiting symptoms of COVID-19; failed to implement transmission-based precautions for residents that were COVID-19 positive who were mobile throughout the unit including the hallway and dining/day areas; failed to ensure COVID negative residents were not exposed to COVID positive residents; failed to cohort positive COVID-19 residents together and instead cohorted positive and negatives together; failed to ensure signage posted indicating a positive COVID status; failed to offer/educate COVID vaccinations for residents and staff since 2022; and failed to have a system in place to track, trend and test residents and staff during a COVID-19 outbreak. This failure has the potential to affect all 23 residents residing on the 100 hall of the facility.…

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 offer, provide, and track COVID vaccines, boosters, and immunizations. This failure has the potential to affect all 93 residents residing in the building. The Findings Include: V2, Director of Nursing (DON), is the facility's Infection Preventionist (IP), with a Certification on file dated 4/3/22. V8, Assistant Director of Nursing (ADON), is also the facility's IP with a Certification on file, dated 6/27/24. On 9/18/24 at 10:25 AM, V2 stated, Both me and (V8) are certified Infection Preventionist for this facility, but (V8) does most of the work with it. On 9/18/24 at 1:25 PM, when asked about resident Influenza and other resident vaccinations, V8 stated, We just received the Influenza vaccination this past Thursday (9/12/24). (V2) started asking residents last week and we have been asking this week as well if they want the vaccination. I will be going through each resident's medical record and checking their immunizations. If needed, I will follow up to make sure they get them. On 9/18/24 at 1:30 PM, when asked for a list…

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 Nurse Aides completed the required 12 hours of education per year. This has the potential to affect all 93 residents residing in the facility. Findings include: 1. The facility's employee files documented the following: V73, Certified Nurse Assistant, (CNA) hire date of 10/20/21. V74, CNA hire date of 8/2/2023 V75, CNA hire date of 9/1/2020 V76, CNA hire date of 1/17/2022 V73's computer education report, dated 9/1/23-9/25/23, documents V73 had 1.75 hours of education for the past year. V74's computer eduction report, dated 9/1/23-9/25/23, documents V74 had 0.5 hours of eduction for the past year. V75's computer education report, dated 9/1/23-9/25/23, documents V75 had no education hours documented for the past year. V76's computer eduction report, dated 9/1/23-9/25/23, documents V76 had 2 hours of eduction for the past year. On 9/24/24 at 3:15PM, V2, Director of Nursing, stated she is not sure how many education hours CNA's are required to complete annually. On 9/25/24 at 1:00PM, V33, Regional Director, stated she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide education, obtain consents, and administer influenza vaccine to 4 of 8 residents (R61, R77, R82, R23) reviewed for immunizations in the sample of 57. The Findings Include: 1. R61's admission Record, undated, documents R61 was originally admitted to the facility on [DATE], with diagnoses of Dementia, Sepsis, Cellulitis, Emphysema, Dysphagia, Psychotic disorder, Chronic Kidney Disease, and COVID-19. R61's Care Plan, dated 7/18/24, documents R61 is incontinent of bowel and bladder. Interventions: Check R61 for incontinence, wash, rinse and dry perineum, change clothing PRN after incontinence episodes, monitor/document for s/sx (signs/symptoms) UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. It continues R61 has C. Difficile (C-Diff). Interventions:…

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 protect residents during abuse investigations to prevent further potential abuse from occurring for 2 of 4 residents (R17, R31) residents reviewed for investigation/prevention/correct alleged violation of abuse in a sample of 57. Findings include: R31's face sheet, dated 9/24/24, documented R31 has diagnoses of COPD (Chronic Obstructive Pulmonary Disease), benign prostatic hyperplasia, muscle weakness, hyperlipidemia, PTSD (post-traumatic stress disorder), depression, hypertension, obstructive and reflux uropathy, chronic migraine, and low back pain. R31's Minimum Data Set (MDS), dated [DATE], documented R31 is cognitively intact. R31's Care Plan, print date of 9/17/24, documented R31 has a behavior problem related to cursing about his loss of independence and showing signs of frustration. R31 suffers from PTSD related to his military background. R31's care plan documented R31 will show signs of PTSD and staff interventions could include:…

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 document in the resident's Electronic Medical Record (EMR) the reason for discharge, failed to provide written documentation of the reason for discharge and resident rights to appeal the discharge to for 1 of 3 residents (R20) residents reviewed for discharge in a sample of 57. Findings include: R20's Face Sheet, dated 9/24/24, documented R20 has diagnoses of pseudarthrosis after fusion, depression, gastro-esophageal reflux disease, osteoarthritis, anxiety disorder, insomnia due to other mental disorder, chronic pain, alcohol dependence, altered mental status, hypertension, hyperlipidemia, hypokalemia, and hypomagnesemia. R20's Minimum Data Set (MDS), dated [DATE], documented R20 is cognitively intact. R20's Care Plan, print date of 9/24/24, does not document any discharge planning. R20's Progress Note, dated 9/10/24 at 10:53 AM, documented resident seems increasingly confused and agitated this morning. Resident states he's in a lot of pain and needs…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the Facility failed to ensure showers, basic grooming, and feeding assistance were provided for 2 of 24 residents (R33 and R145) reviewed Activities of Daily Living (ADLs) in the sample of 57. Findings include: 1. R145's Face Sheet, dated 9/18/2024, documents R145 was admitted to the facility on [DATE], with a diagnosis of Amyotrophic Lateral Sclerosis (ALS- also known as Lou Gehrigsdisease, is a fatal neurological disorder that causes nerve cells in the brain and spinal cord to die. This leads to muscle weakness, paralysis, and eventually the loss of the ability to breathe and control voluntary movements.) R145's Care Plan, undated, documents R145 has ADL (Activities of Daily Living) self-care performance deficit related to ALS, weakness, and osteoarthritis. R145 is totally dependent on one staff member for toilet use. On 9/17/2024 at 11:13 AM, R145 stated she has been at the Facility since 9/11/2024, and has not had a shower or a bed bath. On 9/17/24 at12:53…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the Facility failed to prevent the deterioration of pressure ulcer, the development of a new pressure, and treat pressure ulcers as order by physician for 1 of 2 residents (R85) reviewed for pressure ulcers in the sample of 57. Findings include: 1. R85's Face sheet, dated 9/19/2024, documents R85 was admitted to the facility on [DATE] with a pressure ulcer (site unspecified). R85's Minimum Data Set, dated [DATE], documents R85 has one stage 3 (full thickness tissue loss) pressure ulcer. R85's Physician's Order Sheet, dated 9/19/2024, documents, Cleanse open area to sacrum with wound cleanser, pat dry, apply sure prep to surrounding skin. Apply Calcium Alginate to wound bed only, cover with dry dressing daily and as needed. On 9/16/2024 at 11:57 AM, R85 stated he had two open areas on his buttocks. On 9/16/2024 at 1:00 PM, V8, Assistant Director of Nursing, and V36, Wound Nurse, were observed exiting R85's room. V8 stated they had changed R85's dressing to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the Facility failed to provide timely toileting and incontinent care to prevent potential urinary tract infections (UTIs) for 3 of 3 residents (R145, R85, and R23) reviewed for incontinent care in the sample of 57. Findings include: 1. R145's Face Sheet, dated 9/18/2024, documents R145 was admitted to the facility on [DATE], with a diagnosis of Amyotrophic Lateral Sclerosis (ALS- also known as Lou Gehrigsdisease, is a fatal neurological disorder that causes nerve cells in the brain and spinal cord to die. This leads to muscle weakness, paralysis, and eventually the loss of the ability to breathe and control voluntary movements.) R145's Care Plan, dated 9/18/2024, documents R145 has bowel/bladder incontinence and prefers to use a bedpan while in bed, at night. Interventions include observe pattern of incontinence and initiate toileting schedule if indicated. Offer resident toilet at same time each day resident usually has bowel incontinence (after meals).…

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 monitor and provide services for residents who verbalizes suicide threats for 1 of 1 resident (R31) reviewed for behavioral health services in the sample of 57. Findings include: R31's Face Sheet, dated 9/24/24, documented R31 has diagnoses of COPD (Chronic Obstructive Pulmonary Disease), benign prostatic hyperplasia, muscle weakness, hyperlipidemia, PTSD (post-traumatic stress disorder), depression, hypertension, obstructive and reflux uropathy, chronic migraine, and low back pain. R31's Minimum Data Set (MDS), dated [DATE], documented R31 is cognitively intact. R31's Care Plan Focus, date initiated on 11/13/23, documents (R31) has suffered a traumatic life event and declines services and intervention at this time. Related to PTSD. The Care Plan Focus, date initiated on 11/27/23, documents The resident has mood problems related to frustration of losing the independence and nursing home placement. (R31) will refuse care from staff at times. R31's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to monitor, track, and properly document microbiology organisms on infection control log, and failed to monitor and follow up for proper antibiotic use for 2 of 6 residents (R10, R61) reviewed for Antibiotic Stewardship in the sample of 57. The Findings Include: 1. R10's admission Record, undated, documents R10 was admitted to the facility on [DATE], with diagnoses of Alzheimer's disease, Dementia, Falls, and COVID-19. R10's Care Plan, dated 7/12/24, documents R10 is incontinent of bowel and bladder. Interventions: : Check frequently for incontinence, wash, rinse and dry perineum, change clothing PRN (as needed) after incontinence episodes, monitor/document/report to MD (Medical Doctor) PRN possible medical causes of incontinence: bladder infection, constipation, loss of bladder tone, weakening of control muscles, decreased bladder capacity, diabetes, stroke, medication side effects, uses briefs. It continues R10 a has an Activities of Daily Living (ADL)…

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 notify the Administrator of an allegation of abuse immediately for 1 of 3 residents (R1) reviewed for abuse in the sample of 4. Findings include: R1's admission Record, print date of 1/30/24, documented R1 was admitted on [DATE], and has diagnoses of Anxiety and Depression. R1's Minimum Data Set, dated [DATE], documents R1 is cognitively intact. R1's Health Status Note, dated 1/21/24 at 12:36 PM, documents, CNAs reported to writer that resident made accusations against a male midnight CNA that he did not recognize as a regular employee from previous shift. Resident reported to CNAs that this specific CNA made sexually inappropriate comments and touched him sexually. Writer went to resident's room to confirm story. Resident told writer a story. Writer said to confirm with Resident 'Just to be clear and to confirm. The male CNA that worked overnight made sexually inappropriate comments and touched you in an inappropriate sexual manner', (R1) responded…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prevent resident to resident physical abuse for 6 of 6 residents (R2, R3, R4, R8, R9, and R13) reviewed for abuse in the sample of 13. Findings include: 1. R2's Face Sheet documents an admission date of 3/25/22 and diagnoses to include Unspecified Sequelae of Cerebral Infarction, Hemiplegia and Hemiparesis Following Unspecified Cerebrovascular Disease Affecting Left Non-Dominant Side, and Unspecified Sequelae of Cerebral Infarction. R2's Order Summary Report, dated 11/16/23, documents an order, dated 9/26/23: Brexipiprazole 0.5 milligram (mg) one time a day by mouth related to Alzheimer's Disease, Unspecified. Another order, dated 11/16/23, documents: Brexipiprazole 1 mg one time a day by mouth related to Alzheimer's Disease, Unspecified, increasing R2's daily dose to 1.5 mg/day. R2's Minimum Data Set (MDS), dated [DATE], documents R2 has clear speech, is usually understood, and usually understands others. It documents R2 is severely…

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 the resident's environment in a clean and sanitary condition. Findings include: On 09/13/23 at 11:15 AM, inspection of the shower on the 300-hallways was done. The commode was observed to have a brown feces stain on the seat. On 09/13/23 at 11:20 AM, inspection of the shower room on the 400-hallway was done. There was a corner in the shower that had a green fuzzy substance. There was no stain noted to the commode seat in this bathroom, but the commode did have dried feces on the inside. On 09/14/23 at 9:44 AM, inspection of the shower room on the 100-hallway was done at this time. There was a green fuzzy substance noted to be along all three sides of the baseboard of the shower and there was dried brown feces on the base of the commode. On 09/14/23 at 2:25 PM, this surveyor and V1, Administrator, went to the shower room on the 100-hallway. V1 was shown the green substance along the baseboards in the shower. The commode was noted to have streaks of feces on the inside of the bowl, and there was dried…

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, observation, and record review, the facility failed to thoroughly investigate an allegation of abuse in 1 of 4 residents (R2), reviewed for abuse in the sample of 4. Findings include: R2's Face Sheet, undated, documents R2 has a diagnosis of Unspecified Depressive Episode. R2's Minimum Data Set (MDS), dated [DATE], documents R2 is cognitively intact. R2's Care Plan, dated 5/4/21, documents R2 has depression. On 8/29/23 at 7:40 AM, R2 was observed in her room. R2's hair appeared dry, was cut short about 1 inch in length, and was a dark brown/black color. R2 stated she had bought some hair dye a while back, but didn't use it because her hair was too long, and she wanted it cut before she applied the hair dye. R2 stated she (R2) cut her hair and a nurse, (unsure of name, later identified as V5, Agency Licensed Practical Nurse(LPN) didn't like it and was going to fix it and put dye on her hair. R2 stated this nurse put the dye on her hair and left it on for 2 hours; she (R2) had to get into the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prevent and contain flies, for 4 of 4 (R32, R43, R74, R134) residents, reviewed for pest control, in a sample of 34. This failure has the potential to affect all residents living in the facility. Findings include: 1. R134's Minimum Data Set, (MDS), dated [DATE], documented her cognition was intact. R134's Physicians Order Sheet, dated 08/2023, documented diagnoses of Atherosclerotic Heat Disease and Acute Respiratory Failure. On 08/17/2023 at 9:10 AM, R134 stated she has had flies in her room, and this one has been in here all day. There was a fly in her room. 2. R43's Physician Order Sheet, dated 08/2023 documented diagnosis of Displaced Intertrochanteric Fracture of Left Femur and Type 2 Diabetes. On 08/17/2023 at 9:15 AM, 2 flies were in R43's room flying around. R43 stated he has had flies in his room and they were being a nuisance to him. 3. R74's Minimum Data Set, (MDS), dated [DATE], documents R74 is moderately cognitively…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to perform timely and complete incontinent care for 6 of 6 (R6, R23, R25, R35, R49, R75) residents reviewed for incontinent care in a sample of 34. Findings include: 1. R35's Care Plan, dated 6/18/19, documents, (R35) has bladder incontinence r/t, (related to), Disease Process and Impaired Mobility. (R35) is aware of her toileting needs at times, but has incontinent episodes in between, when she states she's not aware that she is voiding, she takes a diuretic. She requires assist of one for toileting needs. (R35) uses disposable briefs, toilet frequently and change if needed. R35's MDS, dated [DATE], documents, R35 is always incontinent of bowel and bladder and totally dependent of 2-persons for toileting. On 8/17/2023 at 11:18 AM, V19, and V20, Certified Nurse Assistants (CNAs), assisted R35 with incontinent care. V19 and V20 turned R35 onto the right side and opened R35's brief, revealing a heavily soiled incontinent brief. Using a wet…

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 offer assistance to shave facial hair for 2 of 5 (R6 and R134) residents, reviewed for activities of daily living in a sample of 34. Findings include: 1. R134's Minimum Data Set (MDS), dated [DATE], documented R134's cognition was intact and she required limited assistance of 1 staff member for personal hygiene including shaving. R134's Care Plan did not have documentation regarding Activity of Daily Living, (ADL), such as shaving and bathing and the assistance she required. On 08/15/2023 at 1:47 PM, R134 had a thick patch of facial hair on neck under her chin. On 08/17/2023 at 9:10 AM, R134 facial hair remains on neck. R134 stated they have not offered to assist her to shave, she would usually shave it at home before she left for work, but she hasn't asked. R134 then covered up the hair with her hand. R134's Nursing Skin Inspection Report, dated 07/28/2023, documented she refused a shower, but did not document if her facial hair 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to perform safe transfer for 3 of 3 (R35, R36, R74) residents reviewed for transfer in a sample of 34. Findings include: 1. R35's Care Plan, dated 6/18/19, documents, (R35) has an ADL (Activities of Daily Living) Self Care Performance Deficit related to history of right foot fracture, osteoarthritis and Polyneuralgia Rheumatic. It also documents, Restorative program - Transfer Explain to resident that he/she is going to transfer from the bed to the chair. Ensure bed and w/c (wheelchair) are locked apply gait belt to resident. Verbally cue and/or assist resident to scoot to the edge of the bed. Verbally cue and/or assist resident to stand. Verbally cue and/or assist resident to turn. Verbally cue and/or assist to reach back and grab arms of chair and prior to sitting. Ensure resident is in proper position after transfer and call light is within reach. It also documents, Transfers: Extensive assist of 2 staff member, dependent upon resident…

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 the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. This has the potential to affect all 85 residents who reside in the facility. Findings include: On 8/8/23 at 3:15 PM, Nursing Staffing Schedules were reviewed with V1, Administrator. V1 stated RN staffing has been pretty good lately. While reviewing each day between July 1, 2023, and August 7, 2023, there was not an RN working in the facility for 8 consecutive hours on the following dates: 7/7/23, 7/9/23, 7/13/23, 7/22/23, 7/29/23, 8/3/23 or 8/5/23. V1 stated she has been the administrator for about six weeks now, and she has been hiring nurses, including RNs and Certified Nurse's Aides. On 8/8/23 at 4:17 PM, V1 stated they try to follow the regulations, but does not have a specific policy for RN coverage. The facility's CMS form 672 documents there are 85 residents residing in the facility at the time of the survey.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to have adequate numbers of staff to meet the needs of the residents, including adequate supervision to prevent falls. This failure has the potential to affect all 81 residents living in the facility. Findings include: On 6/29/22 at 9:50AM, V3, LPN, stated she is over the staffing of the facility, and is temporarily on call. V3 stated, They (V1, Administrator) gives me a number of staff based off of the census. V3 stated, Right now with the census, they are allowed to have 7 CNAs on day shift, 7 CNAs on evening shift, 4-5 CNAs on night shift, 3-4 nurses on days and 3 nurses on nights. V3 stated the nurses do 8 and 12 hour shifts. V3 stated they have a hard time staffing the 2pm-6pm time for nurses and CNAs. V3 stated they are open to all agencies. V3 stated she started being on-call this past Monday (6/27/22) for staffing. V3 states V1 was taking call, but he has no clinical experience, so she said she would do it temporarily. V3 stated the…

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

Based observation and interview, the facility failed to have a Registered Nurse (RN) to serve as a full-time Director of Nurses (DON). This failure has the potential to affect all 81 residents living in the facility. Findings include: On 6/21/22, 6/22/22, 6/23/22, 6/27/22, 6/28/22, 6/29/22 and 6/30/22, there was not a DON (Director of Nursing) observed in building. On 6/30/22 at 11:05 AM, V1, Administrator, stated they do not have a DON. V1 stated they do not have a policy for the DON; they follow the regulations. The Resident Census and Condition of Residents form (CMS 672), dated 6/21/22, documents that the facility has 81 residents living in the facility.

Based on observation, interview, and record review, the Facility failed to properly store and label medications, protein supplements, and tuberculosis test vials. This has the potential to affect all 81 residents in the Facility. Findings include: On 6/30/22 at 9:35 AM, the 300 Hall medication cart was inspected. The medication cart contained the following medication in the top drawer: 1. Toujeo Max SoloStar Solution Pen - Injector 300 unit/milliliter, which was dated 6/4/22, but without legible resident name. V27, Licensed Practical Nurse (LPN), stated, I think that is for (R44) because she is the only one on that medication, but I will go ahead and pitch it to be safe. The Toujeo Max SoloStar Manufacturer Instructions document, Do not share your pen(s) with other people, even if the needle has been changed. You may give other people a serious infection, or get a serious infection from them. On 6/30/22 at 9:48 AM, the 200 Hall medication cart was inspected. The medication cart contained the following in the bottom drawer: 2. Open unlabeled Pro-Stat protein supplement V41, LPN,…

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 stored and prepared in a manner which prevents potential contamination. This has the potential to affect all 81 residents living in the facility. Findings include: On 6/28/22 at 9:15 AM, in the standing refrigerator, there was a plate with three slices of meatloaf covered in plastic wrap, with no label or date. V34, Dietary Manager, stated, This is trash, and removed plate from the refrigerator. There were two gallon size plastic bags, one containing bologna and one with turkey. There was no label or date on either of the bags. V34 stated, The labels must have fallen off. They were just put in there last night. On 6/28/22 at 9:20 AM, in the standing freezer closest to the refrigerator, there was a bag of diced white meat that was tied up with no label or date. V34 stated, That is chicken. There was a box of corn dogs, with an inner plastic bag that was not tied up or dated. The corn dogs were exposed to the air. V34 stated, I put the label stickers on each shelf of the refrigerator because…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure infection control guidelines were implemented, including those to prevent and/or contain COVID-19 and other infections by: staff not wearing appropriate masks and eye protection, staff not performing hand hygiene and glove [NAME] during care, staff not sanitizing multi use surfaces 9 of 18 (R19, R24, R30, R43, R44, R50, R53, R66, R175 ) residents reviewed for infection control in a sample of 51. These failures have the potential to affect all residents in the facility. Findings include: 1. On 6/21/2022, the facility provided documentation of 1 current COVID positive, and 2 Isolation precautions due to exposure. Upon entering and exiting the facility on 6/21/22, 6/22/22, 6/23/2022, and 6/27/2022, there was no sign or posting indicating positive COVID in the facility. On 7/7/2022 at 10:35 AM, V9, Travel Corporate Nurse Manager, stated a posting is placed on the front door to alert visitors there is a COVID positive in the facility.…

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 employee an infection control preventionists to oversee the infection prevention control program. This has the potential to affect all 81 residents living in the facility. Findings include: On 6/21/22 at 9:53 AM, V1, Administrator, stated V3, Licensed Practical Nurse (LPN), was the Infection Control Preventionist (ICP). On 6/21/22 at 2:04 PM, V3, Licensed Practical Nurse (LPN), stated she was not the ICP for the facility, and was not responsible for Infection Control. V3 stated she was the ADON (Assistant Director of Nursing), and stepped down from the position. V3 stated she started the education, but did not complete it. V3 stated she helped V2, previous Director of Nursing, who was the ICP. V3 stated V3 no longer works at the facility. V3 stated she is not aware of who the Infection Control Preventionist is. On 6/21/22 at V6, Regional Nurse, provided documentation of COVID positive resident in facility, with current isolation. On 6/21/22, 6/22/22, 6/23/22, and 6/27/22, upon entry and exit to the facility, no signs or…

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 place the call light within reach of residents, and failed to follow recommendations for getting resident up as desired for 5 of 8 residents (R20, R44, R54, R72, R175) reviewed for accommodation of needs in the sample of 51. Findings include: 1. R20's Care Plan, dated 9/11/2020, documents, The resident is at risk for falls. It also documents, Be sure the call light is within reach and encourage the resident to use it for assistance as needed. It also documents, The resident has a communication problem. It continues, Ensure/provide a safe environment: Call light in reach, Adequate low glare light, Bed in lowest position and wheels locked, Avoid isolation. On 6/21/22 from 9:00 AM to 11:00 AM, based on 15 minute observation intervals, R20 remained sitting in her room in wheelchair next to the bed, with call light out of R20's reach, with the cord attached to the wall outlet. On 6/28/2022 at 11:38 AM, V44, Certified Nurse Assistant (CNA),…

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 thoroughly investigate injuries of unknown origin, and a sexual abuse allegation for 4 of 6 residents (R24, R36, R51, R66) reviewed for abuse in the sample of 51. Findings include: 1. R24's Minimum Data Set (MDS), dated [DATE], documents R24 is severely cognitively impaired, R24 requires extensive assistance of 2 staff members for bed mobility, transfers, walking in his room and on the hall, dressing, toileting and personal hygiene. R24's MDS documents R24 requires limited assistance of 1 staff member for locomotion on and of the unit. R24's MDS also documents R24 is not steady, and only able to stabilize with staff assistance during transitions and walking. R24 does not use any mobility devices, and he has not had any falls in the previous 90 days. R24's Health Status Note, dated 5/16/22 at 5:42 AM, written by V42, Registered Nurse/RN, documents, Res (Resident) scratched his nose causing a skin tear. Cleansed with wound cleanser and applied TAO…

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 assistance with grooming and hygiene, and failed to provide oral care to dependent residents for 8 of 18 residents (R5, R24, R29, R30, R43, R51, R53, R63) reviewed for Activities of Daily Living (ADL) in the sample of 51. Findings include: 1. R53's Care Plan dated 1/10/22, documents, (R53) Care/ADL Preferences: prefers to have a shower two times a week. It continues, (R53) has an ADL Self Care Performance Deficit. Interventions: requires one staff participation with bathing, requires one staff participation to dress, requires one staff participation with personal hygiene and oral care, requires two staff participation to reposition and turn in bed. R53's Minimum Data Set (MDS), dated [DATE], documents R53 is cognitively intact, and requires extensive assistance from two staff members for transfers and toilet use. R53 is totally dependent on one staff member for bathing. R53 requires extensive assistance from one staff member 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 4. R5's admission Record, print date of 6/29/22, documents R5 was admitted on [DATE], and has a Diagnosis of Dementia with Behavioral Disturbances. R5's MDS, dated [DATE], documents R5 is severely cognitively impaired, requires extensive assistance of 2 staff members for transfer, extensive assistance from 1 staff member for bed mobility, dressing and toileting, supervision for walking in room, eating and is totally dependent on one staff member for personal hygiene. This MDS also documents R5 is frequently incontinent of urine. R5's Care Plan, dated 6/5/21, documents, The resident has bladder incontinence r/t (related to) Alzheimer's Disease. Check the resident q (every) 2 hours and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episode. On 6/27/22 at 9:00 AM, R5 was assisted to his room by V37, CNA; the back of R5's pants are wet. R5 was seated in his room on his armchair. V37 walked R5 to the restroom. R5's wet pants were removed, and his incontinent brief…

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 obervation, interview, and record review, the facility failed to provide structured and meaningful activities for 6 of 6 residents (R5, R15, R29, R40, R71) reviewed for Dementia care in the sample of 51. Findings include: 1. R5's admission Record, print date of 6/29/22, documents R5 was admitted on [DATE], and has a Diagnosis of Dementia with Behavioral Disturbances. R5's MDS, dated [DATE], documents ,R5 is severely cognitively impaired, requires extensive assistance of 2 staff members for transfer, extensive assistance from 1 staff member for bed mobility, dressing and toileting, supervision for walking in room, eating, and is totally dependent on one staff member for personal hygiene. On 6/27/22 at 5:09 AM, R5 exited his room. R5 is fully dressed. R5 only has on regular socks. R5 is wandering the Memory Unit hallway. R5 is going into other residents rooms and coming back out. R5 returns to his room multiple times, and then comes back out and wanders the hall again. At this time, there are 2 CNA's, V5…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the Facility failed to ensure foods were served at safe and palatable temperatures. Findings include: On 6/28/2022 at 12:34 PM, V34, Dietary Manager, stated, We have finished making all of our trays. We get complaints about cold food now and then, but it is always hot when it leaves the kitchen. Nursing just takes a long time to pass out all of the trays. R53's Minimum Data Set (MDS), dated [DATE], documents R53 is cognitively intact. On 6/21/2022 at 9:20 AM, R53 stated, The food is usually cold by the time it gets to me in my room. R47's MDS, dated [DATE], documents R47 is cognitively intact. On 6/21/2022 at 9:45 AM, R47 stated, The food is cold by the time I get it. This hall is the last on the list so we get the food late. R21's MDS, dated [DATE], documents R21 is cognitively intact. On 6/21/2022 at 9:55 AM, R21 stated, The food is cold all the time, even when I eat in the dining room. R48's MDS, dated [DATE], documents R48 is cognitively intact. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to immediately report allegations of abuse and injuries of unknown origin to the Administrator and to the Illinois Department of Public Health (IDPH) for 3 of 6 residents (R24, R26, R66) reviewed for abuse in the sample of 51. Findings include: 1. R24's Health Status Note, dated 5/16/22 at 5:48 AM, documents, Res (Resident) scratched his nose causing a skin tear. cleansed with wound cleanser and applied TAO (Triple Antibiotic Ointment). Notified daughter (V14) and she stated that he had a scratch and she said that he probably picked that open. SBAR (Situation Background Assessment Recommendation) sent to MD (Medical Doctor) via fax awaiting on orders. R24's Health Status Note, dated 5/16/22 at 7:41 PM, documents, Skin tear to bridge of nose, purple discoloration starting inner corner RT (right) eye. No acute distress noted at this time. On 6/27/22 at 6:23 PM, V42 stated, I was the nurse working the night (R24) got the scratch. Around 5:00 AM ish, I think,…

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.