Pearl Of Hinsdale, The

Based on observation, interview, and record review, the facility failed to properly label, date, seal, and store food items in the kitchen. This applies to all resident that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The Facility Resident Census and Condition of Residents (Form CMS-Centers for Medicare and Medicaid Services-672) dated 10/15/24 documents the total census was 138 residents. On 10/15/24 at 11:33 AM, V12 (Dietary Manager) said there are 3 NPO (Nothing by Mouth) residents and the rest of the residents eat from the facility kitchen. On 10/15/24 starting at 10:24 AM, the facility kitchen was toured. Starting at 10:37 AM, V13 (Regional Dietary Manager) was present for the tour. The following was found: At 10:53 AM in walk-in cooler #1: 1. 2 large pork roasts, no label and no date 2. 5- 10 pound packages of 73% lean and 27% fat ground beef with best before or freeze by date of 10/9/24. V13 (Regional Dietary Manager) said the staff told her the ground beef was thawed a couple days ago. The meat was all completely thawed and there 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 properly contain and cover garbage in the facility kitchen to control fruit fly population. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The Facility Resident Census and Condition of Residents (Form CMS-Centers for Medicare and Medicaid Services-672) dated 10/15/24 documents the total census was 138 residents. On 10/15/24 at 11:33 AM, V12 (Dietary Manager) said there are 3 NPO (Nothing by Mouth) residents and the rest of the residents eat from the facility kitchen. On 10/15/24 at 10:24 a large black garbage can was observed uncovered in the main kitchen area with at least 2 fruit flies seen flying above the garbage can. On 10/15/24 at 11:19 AM in the Dish Room, a large black garbage can was seen uncovered with food debris in it and swarms of an estimated 10-20 fruit flies flying around it. No staff were doing dishes in the dish room at that time, the room was not occupied and garbage can was left with food in it, uncovered. V13…

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

Based on observation, interview, and record review, the facility failed to implement fall precaution interventions for residents at risk for falls. This applies to 3 of 3 residents (R5, R103, and R87) reviewed for accidents and supervision in a sample of 28. 1. R103 admitted to the facility with diagnoses of osteoarthritis of both knees, methicillin resistant staphylococcus aureus, morbid obesity, heart failure, lymphedema, hypotension, sleep apnea, chronic kidney disease, and hypertension. R103 current care plan states she is at risk for fall interventions include staff to assess the physical environment, device including furniture bed to ensure that they don't pose a safety hazard. Bed in a safe level position based on residents needs / risks. R103 MDS (Minimum Data Set) dated 9/28/24 shows she is dependent on staff for transfers and uses a manual wheelchair for mobility. On 10/15/24 at 11:08 AM, R103 was lying in bed with the bed and over-bed table in the highest position. R103 stated her bed was left in that position after her brief was changed. On 10/16/24 at 04:07 PM, R103 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, record review, and interview, the facility failed to complete accurate post-dialysis weights for residents on dialysis treatments. This applies to 5 of 7 residents (R41, R49, R91, R107, and R138) reviewed for dialysis in a sample of 28. Findings include: The dialysis service policy titled Monitoring and documentation pre, during, and post-treatment, dated 06/2018, in part, showed that the post-dialysis assessment would include post-dialysis weight. The registered nurse will do the post-dialysis assessment before the resident is discharged from the treatment area, and a copy of the completed dialysis communication form will be given to the unit staff after the resident's dialysis treatment. On 10/16/2024 around 11:00 AM, V21 (Registered Nurse dialysis) said staff either check the post weight at the dialysis unit or some time at the unit by the Certified Nursing Assistants, and staff let V21 know to complete the dialysis communication report, and then V21 provides the dialysis communication…

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 ADL (Activities of Daily Living) care for 3 residents (R87, R123, & R65) who are dependent on care for daily living in a sample of 28. The findings include: 1. On 10/15/24 at 11:19 AM, R87 was observed with long fingernails, about 1/4 inch over nailbed and a brownish blackish substance under the nails, and R87's legs were observed with dry flaking skin. At 12:15 PM V25 CNA (Certified Nurses' Assistant) brought R87 his lunch tray but did not offer to clean his hands or assist in cleaning them before serving him his food. On 10/17/24 at 10:23 AM, R87's fingernails were observed long and with a brownish colored substance under the nails. R87's 8/21/24 ADL care plan showed that R87 has an ADL self-care performance deficit related to an impaired balance, decreased strength and endurance, weakness, decreased cognitive and communication skills secondary to stroke with residual deficits with diagnoses including altered Mental Status, CHF…

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 appropriately store and secure medications and biologics safely for 2 residents (R19 & R93) who were reviewed for medication storge in a sample of 28. Findings include: 1. On 10/15/24 at 01:38 PM 1 unopened package of albuterol sulfate 0.5% 2.5 mg / 0.5ml (milligram/milliliter), 1 albuterol sulfate 0.5% 2.5mg/0.5ml vial, not in the package, and 1 white pill in a medication cup was observed on R19's overbed side table. R19 said that the nurse had left the pill for her, and she did not know what the medication was for. Then R19 swallowed the pill. R19 said that the nurse leaves the albuterol sulfate for her every day, and she does the treatments herself. On 10/16/24 at 12:03 PM, a record review was done of R19's electronic health record, and it did not show any order to have medications at bedside, an assessment for self-medication, or an order to self-medicate. On 10/17/24 at 02:22 PM V3 ADON (Assistant Director of Nursing) said that R19 should not have medications left at her bedside because R19 doesn't have…

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

Based on observation, interview and record review the facility failed to assure residents were not served food items to which they had allergies or sensitivities and follow up on a resident's food preferences. This applies to 2 of 4 residents (R40 and R30) reviewed for food concerns in a sample of 28. Findings include: 1. R40 admitted to the facility with diagnoses that includes atrial fibrillation, cognitive communication deficit, pneumonitis due to inhalation of food and vomit, anemia, anxiety, bipolar disorder and celiac disease. R40's MDS (Minimum Data Set) dated 7/27/24 indicates she has moderate cognitive impairment. R40's current diet order is general diet regular texture, regular consistency, gluten free / restricted. R40's current care plan states she has bowel incontinence related to celiac disease. R40 has a nutritional problem related to celiac disease. Interventions include to provide and serve diet as ordered. On 10/15/24 at 12:35 PM, R40's lunch meal ticket read: allergy red dye, gluten / wheat. Main menu vegetarian / vegan option, green peas, no sub found for apple…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow its Enhanced Barrier Precautions (EBP) Guidelines and isolation policy by staff not wearing gowns during incontinent care for an EBP resident and having visitors visiting contact isolation residents without having gloves or gown. The facility also failed to maintain effective hand hygiene during resident care. This applies to 3 of 3 residents (R51, R80, and R87) reviewed for infection control practices in a sample of 28. The findings include: 1. R80 is a [AGE] year-old female admitted on [DATE]. As per the Minimum Data Set (MDS) dated [DATE], her cognition is intact. On 10/15/24 at 11:29 AM, R80's entry door was observed with an EBP sign to wear gloves, gown, and mask to provide high-contact resident care activities. On 10/15/24 at 11:35 AM, the writer observed V27 (Certified Nursing Assistant / CNA) and V28(CNA) providing incontinent care without wearing a gown as per the EBP sign posted on the entry door. On 10/15/24 at 11:44 AM,…

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 maintain residents' bed equipment. This applies to 2 residents (R87 & R123) reviewed for maintenance of furnishings and equipment in a sample of 28. The findings include: 1. On 10/15/24 at 11:28 AM, R87 was observed in his bed and his bed control had about 2 inches of exposed wires. On 10/17/24 at 10:11 AM, R87 was observed in his bed and his bed control was observed with about 3 inches of exposed wires. On 10/17/24 at 02:16 PM V3 ADON (Assistant Director of Nursing) said that R87's bed control should not have exposed wires because it is a safety issue. V3 said that it is her expectation for staff to report it. 2. On 10/15/24 at 12:23 PM, R123 was in his bed, and he said that his bed control has not worked since he was moved into the room [ROOM NUMBER] weeks ago and he reported it. V25 CNA (Certified Nurse's Assistant) said that she reported it the day before, and the Friday before that. R123 said that the bed can only be adjusted by 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 observation, interview, and record review, the facility failed to assist a resident (R1) needing assistance with eating during meal services. This applies to 1 of 3 residents (R1) reviewed for feeding assistance. The findings include: R1's EMR (Electronic Medical Record) showed R1 had multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, dysphagia, cognitive communication deficit, esophagitis, gastrointestinal hemorrhage, diabetes type 2, chronic kidney disease stage 4, and hypertension. R1's MDS (Minimum Data Set) dated 6/5/2024 showed R1 had moderate cognition impairment. R1's Order Summary Report dated 8/31/2024 showed R1 had an active order for 1:1 feed due to increased weakness initiated on 8/27/2024. On 8/31/2024 at 12:55 PM, R1 was in bed with her bedside table positioned in front of her with her lunch. R1 was not being assisted or supervised during her meal. R1 had her eyes closed and appeared very fatigued. R1 had food debris on her left lower lip area. R1 also had food in her mouth and 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 ensure pressure ulcer recommendations and pressure ulcer treatments were completed as ordered. This applies to 1 of 3 residents (R1) reviewed for pressure ulcers. The findings include: R1's EMR (Electronic Medical Record) showed R1's diagnoses include diabetes type 2, neuropathy, unstageable pressure ulcer to the sacrum, left heel diabetic ulcer, hemiplegia, and hemiparesis following cerebral infarction affecting the left non-dominant side. R1's 8/16/2024 MDS (Minimum Data Set) showed R1 had moderate cognition impairment. R1's MDS showed R1 was dependent on staff with toileting and required substantial to maximal staff assistance with bed mobility. R1's MDS also showed that R1 was at risk for pressure ulcers and had a stage 3 pressure ulcer present on admission. On 8/31/2024 at 11:52 AM, R1 was lying on her backside in bed, underneath her was a mechanical lift sling. At 2:20 PM, V10 (Wound Care Nurse/WCN) said R1 had an unstageable…

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 properly label and date intravenous fluid bag/tubing and timely administer physician ordered intravenous antibiotics as ordered for a resident (R1) with an infection. This applies to 1 of 3 residents (R1) reviewed for intravenous medications. The findings include: R1's EMR (Electronic Medical Record) showed R1 had multiple diagnoses including an unstageable pressure ulcer to the sacrum and a left foot diabetic ulcer. R1's Order Summary Report dated 8/31/2024 showed an order Vancomycin 1gm every 24 hours Pharmacy to dose at bedtime for Elevated WBC (white blood cell) To start after PICC (peripherally inserted central catheter) line insertion, with a start date of 8/30/2024. R1's document titled Professional Nursing Services, document showed R1 had a right brachial midline inserted at 3:40 PM on 8/30/24 for antibiotic treatment. R1's MAR (Medication Administration Record) report dated 8/31/2024 showed R1's initial scheduled dose for 8/30/2024 at 9 PM was not administered. R1's lab result dated 8/28/2024 showed…

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 residents with a clean, comfortable, home-like interior. This applies to 3 residents (R4, R7, R8) reviewed for sanitary and home-like environment. The findings include: 1. R4 is a [AGE] year-old male admitted on [DATE] with moderate cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. On 7/9/24 at 9:35 AM, R4 was in his second-floor room with a mild urine smell. R4 stated, They showered me this morning. There were dirty clothes on the floor and feces on the shower floor. The shower room was filthy and terrible. They clean my room, but not thoroughly. They never clean my room walls. 2. On 7/9/24 at 9:50 AM, the second-floor common shower room was observed with V4 (Licensed Practical Nurse/LPN) and was found with used gloves and dirty clothes inside the bathtub. V4 stated the dirty clothes and used gloves shouldn't be deposited in the bathtub. The facility presented the linen management policy revised on 5/18/24…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an alleged threat of harm made by a nurse toward a resident at the facility. This applies to 1 of 4 residents (R1) reviewed for abuse in a sample of 24. The findings include: Face sheet, dated 3/25/24, shows R1 was admitted to the facility on [DATE] and R1's diagnoses included polyneuropathy, spondylosis, regional pain syndrome, and osteoarthritis. On 3/20/24 at 1:55 PM, R1 stated late one night she was trying to turn her wheelchair around in her room and bumped the footboard of her roommate's bed. R1 stated V3 (Licensed Practical Nurse) entered her room and asked what R1 was doing. R1 stated she told V3 she was trying to turn around and accidentally bumped her roommate's footboard. R1 alleged V3 responded by saying it was no accident and if R1 bumped it again she would be harmed and harmed real bad. R1 stated she wanted to call the police because she felt threatened. On 3/20/24 at 9:30 AM, V1 (Former Administrator) stated R1 alleged V3…

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 check food temperatures after cooking food, before the start of meal service, and halfway through service to ensure safe temperatures were held to prevent foodborne illnesses. This applies to all 132 of 134 residents eating from the kitchen. Two residents were nothing by mouth or fed by gastrostomy tube. The findings include: On 12/28/23 at 11:44 AM, V4 (Dietary Manager) said the kitchen staff had started the meal service for lunch. V4 said the staff are checking the temperatures when the food is cooked. V4 also said he hosted monthly Culinary Council meetings, which nine to ten residents attended, and the residents mentioned the food was cold. 1. On 12/28/23 at 11:20 AM, V5 (Family Member) said the food at the facility was cold and did not look appetizing. V5 said the food was really bad quality. V5 said she had to bring R1 breakfast, lunch, and dinner for the three weeks R1 remained at the facility. The EMR (Electronic Medical Record) showed R1 was admitted to the facility with diagnoses including abnormalities of gait…

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 serve portion sizes of entrees as per the facility's planed menu. This applies to all residents residing in the facility receiving regular consistency diets. The findings include: Facility Menu Extension, dated Tuesday, 9/19/23, shows the roasted turkey served at lunch was to be served as a 3 ounce portion to all residents receiving diets other than Mechanical soft, Pureed, and Vegetarian. On 9/18/23 at 11:30 AM during lunch service, V8 (Cook) was plating portions of sliced turkey with tongs onto resident lunch plates. The portions of turkey appeared to weigh less than three ounces. At 11:47 AM, a test plate of sliced turkey entree was plated and the turkey portion was weighed with V7 (Corporate Food Service Manager). The portion of turkey weighed 2.25 ounces. V7 stated the turkey portions being served should weigh a total of three ounces. On 9/18/23 at 11:55 AM, V6 (Food Service Manager) stated the turkey portions served to residents at lunch should have been served as 3 ounce portions. 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 observation, interview and record review, the facility failed to provide pureed diets in a consistency per the facility's policy. This applies to 12 of 12 residents (R2, R10, R19, R26, R32, R35, R44, R60, R77, R333, R335, R336) reviewed for for pureed consistency diets. The findings include: Facility Diet Type Report, dated 9/19/23, shows the following residents received pureed consistency diets at the facility: R2, R10, R19, R26, R32, R35, R44, R60, R77, R333, R335, and R336. On 9/18/23 at 11:35 AM, V8 (Cook) had the lunch pureed food items set up in the steamtable for lunch service. The pureed turkey was sampled and tasted lumpy with pieces of unpureed turkey left in the mixture. On 9/18/23 at 11:55 AM, V6 (Food Service Manager) stated purees should be a smooth consistency, no lumps, no particles and easy to swallow. Facility document Pureed Diet, dated 7/2019, shows pureed food items must be in a form like mashed potatoes/custard/strained cream soups and contain no lumps and require no biting/chewing. Facility document Characteristics and Procedures for Consistency…

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 a resident's room was clean and without a strong smell of urine. This applies to 1 resident of 1 resident (R40) reviewed for homelike environment in a sample of 24. Findings include: On 9/18/2023 at 11:41AM, R40's room was noted with a strong smell of urine, and the floor area by R40's bed was noted to be dirty and sticky. On 9/19/2023 at 3:10PM, R40's room was noted with a strong urine odor. The odor could be smelled in the hallway outside the room. The floor of the room near the head of the bed was noted to be wet with urine. There was wet and crusty paper towels and tissues noted on the floor near the wastebasket. A urinal about ¾ filled was noted hanging on the wastebasket. On 9/18/23 at 11:41 AM, R40 stated he urinates a lot because he is on a lot of diuretics. R40 stated he has to change his shorts a lot because they get wet with urine. On 9/19/23 03:15 PM, R40 stated that the facility is short staffed here. It takes time to get them to answer the call light to empty his urinal or clean. He tries…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to assess and provide treatment for an open skin blister for R93 and failed to follow a physician's order for an urology appointment for R36. This applies to 2 residents of 2 residents (R36, R93) reviewed for skin treatment and physician appointments from the total sample of 24. The findings include: 1. Face sheet showed that R93 is 79 years-old who has multiple medical diagnoses which include Alzheimer's disease, peripheral vascular disease, and cerebrovascular disease. The Significant Change of Status Minimum Data Set (MDS) dated [DATE] indicates that R93 is cognitively impaired. She is totally dependent with toileting and hygiene. The same MDS documented that she has lesions on her body. On 9/19/23 at 3:29 PM, V18 and V19 (Certified Nursing Assistant/CNA) provided incontinence care to R93. The incontinence brief was saturated with urine with some blood stains in the brief. There was a fresh wound in the upper lateral side of the right…

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

Based on observation, interview and record review, the facility failed to implement elopement prevention interventions for resident identified at risk for elopement as per the facility policy. This applies to 1 of 1 residents (R104) reviewed for elopement in a sample of 24. The findings include: Face sheet, dated 9/20/23, shows R104's diagnoses included Alzheimer's disease, cognitive communication deficit, anxiety, insomnia and depression. MDS (Minimum Data Set), dated 9/5/23, shows R104 was severely cognitively impaired and exhibited wandering behaviors during the assessment period. Progress note, dated 9/5/23 shows, Patient alert and oriented x1. Was very confused in the afternoon and agitated. [One] occurrence of trying to escape. Refused medications in the morning. Able to administer buspirone in the afternoon. Continuing to monitor. Progress note, 9/5/23, shows R104 had a facility departure alert system device placed on her left wrist and the floor staff were updated. R104's elopement risk care plan, dated 9/6/23, showed R104's elopement concerns included being a new admission…

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 incontinence and catheter care in a manner that would prevent urinary tract infection (UTI). This applies to 3 of 4 residents (R3, R93, R117) reviewed for perineum and catheter care in the sample of 24. The findings include: 1. Face sheet showed that R3 is [AGE] year old who has multiple medical diagnoses which include hemiplegia and hemiparesis due to embolism of left middle cerebral artery, hemiplegia and hemiparesis following other cerebrovascular disease affecting right dominant side, and history of falling. On 9/19/23 at 2:47 PM, V17 (Certified Nursing Assistant/CNA) rendered incontinence care to R3 who was wet with urine. V17 cleaned R3 from front to back by wiping R3's frontal perineum twice in downward stroke in the outer labia, she proceeded to clean the back peri-area, then she put a new disposable brief to R3. V17 did not open labia and groins to clean inner corners of these areas. 2. Face sheet showed that R117 is [AGE]…

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

Based on observation, interview and record review the facility failed to assess intravenous midline catheter site and complete dressing changes in a timely manner. This applies to 1 resident of 1 resident (R126) reviewed for PICC (peripherally inserted central catheter)/midline in a sample of 24. The findings include: Face sheet showed that R126 is 66 years-old who has multiple medical diagnoses which include abscess of liver, hepatic encephalopathy, and sepsis. On 9/18/23 at 12:33 PM, R126 was observed in his room with a midline catheter on his left arm with a dressing dated 9/8/23. R126 stated that the midline dressing was changed once since his admission in the facility. The treatment administration record (TAR) dated September 2023 indicated to assess the PICC/midline catheter site by measuring the arm circumference and length of the exposed PICC/midline every PICC/midline change, on admission and every 7 days. The same TAR also showed that the PICC/midline dressing was changed on 9/1/23, and 9/8/23. The next scheduled date was supposed to be 9/15/23. The TAR for 9/15/23 was not…

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

Based on interview and record review, the facility failed to provide a pneumococcal vaccine to a resident who consented to receive the pneumococcal vaccine. This applies to 1 of 5 residents (R61) reviewed for pneumococcal vaccine administration in a sample of 24. The findings include: On 9/19/23 at 01:44 PM, V4 (IP/Infection Preventionist) provided vaccine administration records for R61. V4 said history and vaccine consents were taken during the admission process and consent was received to administer vaccines. On 9/20/23 at 01:01 PM, V4 said she was unable to find documentation about why R61 did not receive the pneumococcal vaccine. V4 said R61 was able to and should have gotten the pneumococcal vaccine. R61 was admitted to the facility with diagnoses including dysphagia, low back pain, chronic pain, and schizoaffective disorder. R61's MDS (Minimum Data Set) dated 8/9/23 showed R61 had severe cognitive impairment. R61 required supervision for transfers, eating, dressing, toileting, and personal hygiene. R61 required extensive assistance for bed mobility. The facility'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 observation, interview and record review, the facility failed to serve palatable meals to facility residents. This applies to all 127 residents receiving oral diets at the facility. The findings include: Facility document, dated 8/16/23, shows the facility census on 8/10/23 was 131 residents and there were 4 residents with diet orders of NPO (Nothing By Mouth). 1. MDS (Minimum Data Set), dated 5/12/23, shows R1 was cognitively intact. On 8/10/23 10:30 AM, R1 stated, The food is unacceptable! R1 stated he asks for substitutions for poor tasting menu items but the kitchen does not provide him the substitutions on his tray. On 8/15/23 at 12:01 PM, R1 stated he was told by facility staff he was losing weight. R1 stated he knew he was losing weight because his pants were lose. R1 stated he felt he was losing weight because they were not sending him food he could eat. R1 stated if they would send palatable food, he would eat it. R1 stated the facility began giving him a nutritional supplement which he did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to serve residents the lunch menu as planned. This applies to 14 of 14 residents (R1, R3, R4, R9, R10, R12-R14, R19, R20, R22, and R24-R26) reviewed for facility menus in the sample of 28. The findings include: Facility Menu Extension, dated Thursday, 8/10/23, shows all diets (except Dysphagia Mechanical Soft) were to receive pasta salad, and all diets (except Cardiac, Finger Foods, and Gluten Free) were to receive blueberry cobbler for dessert. 1. On 8/10/23 during lunch service at the facility, the following residents were not served food items as planned on the facility menu: R3 (Regular Diet), R12 (Regular Diet) R13 (Cardiac Diet), R14 (Regular Diet), and R20 (Regular Diet) were not served the pasta salad at lunch. R19 (Regular Diet), R20 (Regular Diet) R22 (Regular Diet), R24 (Mechanical Soft / No Added Salt Diet), R25 (Regular Diet) were not served the blueberry cobbler at lunch. 2. MDS, dated [DATE], shows R1 was 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.

Based on observation, interview, and record review, the facility failed to serve residents double portions of protein servings at meals per physician orders. This applies to 5 of 5 residents (R10, R12, R16, R17, and R27) reviewed for prescribed therapeutic diets in a sample of 28. The findings include: 1. Care plan, dated 7/19/23, showed, [R12] has the potential for nutritional problems as evidenced by patient with diagnoses gout, dysphagia, chronic obstructive pulmonary disease, dementia, calorie protein malnutrition, low body mass index. R12's Order Summary Report dated 08/14/2023 showed an order dated 5/08/2023, for double protein at all meals. R12's lunch menu ticket on 8/10/2023, showed R12 was to be served double protein. On 8/10/2023 during lunch service at the facility, R12 was served only one tuna melt sandwich. R12 stated, It's not enough! R12 stated he was supposed to be provided double protein servings at meals per his physician order. R12 stated, I have to ask for it. 2. R16's Order Summary Report dated 08/14/2023 showed an order dated 8/16/2023, for double protein 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.