Joliet Living & Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to investigate incidents and allegations of abuse and mistreatment of residents. This failure apples to 3 of 7 residents (R1, R2, and R7) reviewed for abuse in a sample of 7 residents. The findings include:R1 is a [AGE] year-old male with diagnoses history of Bipolar Disorder, Generalized Anxiety Disorder, and Suicidal Ideations, who was admitted to the facility 01/20/2016. On November 17, 2025 at 11:34 AM, R1 said V3 (Psychosocial Rehabilitation Services Aide) told him You're a dick, when R1 tried to apologize to V3 for a miscommunication from the day prior. R1 said he originally thought V3 was joking, however, when R1 looked at V3 and saw V3 wasn't laughing, he realized V3 wasn't joking. R1 said he reported the incident to V4 (Certified Nursing Assistant), who then informed V1 (Administrator). R1 said V3 has a military background and went on to question him about his military clothing, such as asking why R1 was wearing army clothing if he was 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect two residents from abuse by not implementing interventions regarding repeated behavioral concern and a resident complaint. This applies to 2 of 3 residents (R1 and R2) reviewed for abuse in a sample of 10. The finding includes: According to the Electronic Medical Record (EMR), R1 is a [AGE] year-old female with diagnoses including, but not limited to, mood disorder, depression, anxiety, morbid obesity, and chronic pain. The Minimum Data Set (MDS), dated [DATE], showed R1 is cognitively intact and exhibits verbally threatening behaviors on an almost daily basis. R1 also demonstrated depressive moods. The EMR of R2 showed R2 is a [AGE] year-old female with diagnoses of schizoaffective disorder, post-traumatic stress syndrome (PTSD), anxiety disorder, bipolar disorder, and morbid obesity. The MDS, dated [DATE], showed R2 is cognitively intact and experiences depressive moods. The facility incident report, dated May 28, 2025,…

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

Based on interview and record review, the facility failed to follow their water management program and identify areas where control measures are needed and assess how much of a risk those hazardous conditions pose. This affects all 88 residents residing in the facility. Findings include: The CMS (Centers for Medicare and Medicaid Services)-671 Long Term Care Facility application for Medicare and Medicaid, dated May 12, 2025, showed the total census of 88 residents. The facility's Water Management program stated the facility will do the following: 1. identify building water systems for which Legionella control measures are needed. 2. Assess how much risk the hazardous conditions in those water systems pose. On May 14, 2025 at 1:25 PM, it was requested from V1 (Administrator),V6 (Maintenance Director), V15 (Regional Maintenance) all information regarding their water management plan, Legionella, and other waterborne pathogens plan, their water management assessment, and any evidence of measures used to prevent Legionella. On May 14, 2025 3:32 PM, V1, V6, and V15 acknowledged and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to have window screens in resident's rooms. This applies to 5 of 5 residents (R30, R66, R74, R77 and R80) in the sample 18. The findings include: 1.R80's quarterly MDS (Minimum Data Set), dated March 21, 2025, showed R80 was cognitively intact. On May 13, 2025 at 9:11 AM, R80 stated the window in her room does not have a screen. On checking R80's window in her room, it did not have a screen. The window was partially (about 4 inches) opened on the right side. R80 stated she had slid the inner panel sideways as far as it would go. A wooden block at the left side was inside the ledge of the window that prevented sliding the panel to open the window further. R80 stated V6 (Maintenance Director) applied the wooden block to prevent residents from opening the window completely and jumping out. R80 stated when V6 applied the wooden block on April 23, 2025, she had told him about the missing screen, and he did nothing about it. R80 remarked it is warm at 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 record review and interview, the facility failed to provide residents or residents' representatives their written bed hold and return policy prior to hospitalization. This applies to 4 of 4 residents (R23, R38, R72, R78) reviewed for hospitalizations in the sample of 18. The findings include: 1. R38 has multiple medical diagnoses including type 2 diabetes mellitus without complications, hypothyroidism, unspecified, constipation, unspecified, extrapyramidal and movement disorder, unspecified, hypertensive heart disease without heart failure, schizoaffective disorder, bipolar type, Ogilvie syndrome, based on the face sheet. Progress notes from November 2024 to present shows that R38 was sent to the hospital multiple times for different reasons. On November 17, 2024, he was sent to the hospital for acute left lateral fracture of the 4th, 5th, 6th, and 7th rib, with 5% pneumothorax. On December 20, 2024, he was sent for abnormal result of KUB (Kidney, Ureter, Bladder) test, and on January 2, 2025, he 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 interview and record review, the facility failed to prevent resident to resident abuse. This applies to 2 of 2 (R9 and R17) reviewed for abuse in the sample of 18. The findings include: R9's face sheet shows R9 is 59 years-old, and has multiple diagnoses including paranoid schizophrenia. R9's most recent Minimum Data Sheet (MDS) assessment indicates R9 is cognitively intact. R17's face sheet shows he is 62 years-old, and has multiple medical diagnoses including unspecified schizophrenia, and generalized anxiety disorder, with a MDS assessment indicating moderately impaired cognition. R17's active care plan shows R17 has history of aggressive behavior and has exhibited verbally/physically abusive behavior related/manifested by being challenged by mental illness, ineffective coping mechanisms, poor verbal skills and inability to express self in more appropriate language. Incident report, dated May 1, 2025, at approximately 3:30 PM, documents while watching a movie in the dining/day room, V4 (Psychiatric Rehab Service Director/PRSD) witnessed R17 reaching out and touching R9'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 provide behavioral health services to residents with SMI (severe mental illness). This applies to 2 of 3 residents (R76 and R81) reviewed for behavioral health services in the sample of 18. The findings include: 1. R76 was admitted to the facility on [DATE], with multiple diagnoses including schizoaffective disorder and attention deficient hyperactivity disorder, based on the face sheet. R76 was under [AGE] years old. R76's annual MDS (Minimum Data Set), dated February 10, 2025, showed R76 is cognitively intact. The MDS showed the resident has no functional impairments in range of motion. Further review of the MDS showed R76 requires supervision with all his ADLs (activities of daily living). The same MDS showed R76's primary SMI (Serious Mental Illness) diagnosis is schizophrenia, and the resident is on antipsychotic medication. R76's PASRR (Pre-admission Screening and Resident Review) Level II, dated September 11, 2024, showed R76 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 maintain a residents room in good repair. This applies to 1 of 3 residents (R1) reviewed for physical environment. The findings include: R1 was admitted to the facility on [DATE] with multiple diagnoses which included schizoaffective disorder, attention deficit hyperactivity disorder, obesity, and tinea unguium. R1's MDS (Minimum Data Set), dated 02/10/25, showed R1 was cognitively intact. R1's Progress Note, dated 02/13/24 at 9:52 AM, showed, It was brought to writers attention that there was a hole in the wall by the resident's bed. Writer approached resident about the said behavior and incident and was educated that vandalizing facility property is not acceptable and will be held accountable. On 04/23/25 at 2:00 PM, R1 was in his room, sitting on the side of the bed. R1 was alert and oriented x3. R1 had a large piece of plywood on the wall next his bed. R1 stated he accidentally kicked the wall a year ago while he was sleeping. R1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect a resident's rights to be free of sexual and physical abuse. This applies to 3 of 4 residents (R2, R3, and R4) reviewed for sexual and physical abuse. The findings include: R2 was admitted to the facility on [DATE] with multiple diagnoses which included post-traumatic stress disorder, schizoaffective disorder, anxiety, and borderline personality disorder. R2's MDS (Minimum Data Set), dated 02/13/25, showed R2 was cognitively intact. R3 was admitted to the facility on [DATE] with multiple diagnoses which included schizoaffective disorder, post-traumatic stress disorder, anxiety, insomnia, psychoactive substance use, depression, and seizures. R3 was discharged from the facility on 04/07/25. R4 was admitted to the facility on [DATE] with multiple diagnoses which included primary insomnia, schizoaffective disorder, bipolar disorder, cannabis use. R4's MDS, dated [DATE], showed R4 was cognitively intact. The facility's 04/05/25 Report to IDPH…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to have podiatry services provide foot care and treatment. This applies to 1 of 3 residents (R1) reviewed for podiatry services. The findings include: R1 was admitted to the facility on [DATE] with multiple diagnoses which included schizoaffective disorder, attention deficit hyperactivity disorder, obesity, and tinea unguium. R1's MDS (Minimum Data Set), dated 02/10/25, showed R1 was cognitively intact. The same MDS showed R1 required supervision or touching assistance with ADL's (Activities of Daily Living). On 04/23/25 at 2:00 PM, R1 was wearing black slippers. R1's toenails on his left foot were long, black, and curled in a downward position. R1's toenails on his right foot were long. R1 stated the last time he had his toenails clipped by the podiatrist was six months ago. R1 stated he told the program manager that he needed his toenails clipped. R1 stated he was on the list to see the podiatrist in March. R1 stated the podiatrist came…

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 respect a resident's right to receive a second cup of coffee, as desired by the resident. This applies to 1 of 3 (R3) residents reviewed for resident rights in the sample of 8. The findings include: The EMR (Electronic Medical Record) shows R3 was admitted to the facility on [DATE]. R3 has multiple diagnoses including, cocaine dependence with cocaine-induced anxiety disorder, major depressive disorder, COPD (Chronic Obstructive Pulmonary Disease), cardiac arrhythmia, back pain, and suicidal ideations. R3's MDS (Minimum Data Set), dated March 5, 2025, shows R3 is cognitively intact, and requires supervision with all ADLs (Activities of Daily Living). R3 is always continent of bowel and bladder. On March 27, 2025 at 10:50 AM, R3 was sitting up in bed in his room. R3 said on March 25, 2025, he was in the dining room and wanted a second cup of coffee. R3 said, I went up to [V3] (CNA-Certified Nursing Assistant) and asked for a second cup of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect the residents' right to be free from physical abuse. This applies to 3 of 6 residents (R3, R4, and R7) reviewed for physical assault in the sample of 8. The findings include: 1. The EMR (Electronic Medical Record) shows R3 was admitted to the facility on [DATE]. R3 has multiple diagnoses including, cocaine dependence with cocaine-induced anxiety disorder, major depressive disorder, COPD (Chronic Obstructive Pulmonary Disease), cardiac arrhythmia, back pain, and suicidal ideations. R3's MDS (Minimum Data Set), dated March 5, 2025, shows R3 is cognitively intact, and requires supervision with all ADLs (Activities of Daily Living). R3 is always continent of bowel and bladder. The EMR shows R4 was admitted to the facility on [DATE]. The EMR continues to show R4 was sent to the local hospital on March 26, 2025, and has not returned to the facility. R4 has multiple diagnoses including bipolar type schizoaffective disorder, heart disease, nicotine…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow Nurse Practitioner's orders to obtain a laboratory test. This applies to 1 of 3 residents (R1) reviewed for delay of care in the sample of 8. The findings include: The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. The EMR continues to show R1 was sent to the local hospital on September 26, 2024 and diagnosed with an elevated bilirubin and low sodium level. R1 did not return to the facility. R1 had multiple diagnoses including bipolar type schizoaffective disorder, UTI (Urinary Tract Infection), abnormal gait, muscle weakness, left ulna fracture, insomnia, encephalopathy, COPD (Chronic Obstructive Pulmonary Disease), heart failure, pulmonary edema, heart disease, diabetes, myocardial infarction, and rheumatoid arthritis. R1's MDS (Minimum Data Set), dated September 6, 2024, shows R1 was cognitively intact, required setup assistance with eating, oral hygiene, showering, personal hygiene, and bed mobility, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent a resident to resident physical abuse altercation. This applies to 2 of 3 residents (R1 and R2) reviewed for physical abuse in the sample of 6. The findings include: Facility reported incident dated October 13, 2024 included as follows: R1 reported to V1 (Administrator) at 1:00 PM, that on October 13, 2024 at 9:30 AM, when R1 entered the bathroom while R2 was using it, R2 became upset and slapped R1. R1 and R2 are not roommates but share the same bathroom. R1 denied any pain or discomfort and stated that it does not hurt. Investigations initiated .Conclusions for this investigation included that facility believes that R2 had no intention to abuse R1 and was responding to internal stimuli and was surprised and upset by R1's reaction to his behaviors. R1 has diagnoses of Schizophrenia and does have delusional thoughts and ideations as well as maladaptive behaviors R1's face sheet included diagnoses of schizoaffective disorder, generalized anxiety…

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 cleanliness in the food preparation area and equipment storage. This applies to all residents in the facility for a total 92 residents. The findings include: On 06/11/2024 9:54 AM, during initial kitchen tour with V4 (Dietary Manager), two staff were preparing food for the lunch meal and snack. V5 (Cook) was wearing a hair restraint, with hair dangling to their earlobe on both sides of the face. While wearing gloves, V5 was chopping red peppers and onions. Without removing gloves, V5 went to the cooler to retrieve additional vegetables and resumed chopping. V5 did not change gloves or perform hand hygiene before she resumed chopping vegetables. V6 (Dietary Aide) was wearing a hair restraint with hair dangling to their earlobe on both sides of the face while preparing peanut butter jelly sandwiches. An air vent on the ceiling in between the food preparation area was covered with black dust build up. The floor behind the shelving, which was holding the plates, bowls, plastic storage bins, stainless…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable environment. This applies to 8 residents (R34, R72, R53, R193, R75, R59, R71, and R42) reviewed for homelike environment in a sample of 26 residents. The findings include: 1. R34's MDS (Minimum Data Set), dated 3/4/24, shows his cognition is intact. On 6/11/24 at 10:48 AM, R34 said his bathroom door gets stuck when he is trying to open or close it, and he feels like he is going to throw his back out trying to open it. R34 said when he is in the bathroom it is even worse trying to open it; he has to kick the bottom of the door to get it to open. R34 then demonstrated opening the door, and he had to pull hard on the knob, rocking his body back and forth, 3-4 times to get the door to open, and when it finally did open, it scraped against the floor making a loud noise. R34 said he mentioned the door needing to be repaired to V9 (Maintenance Director) 3-4 months ago, and V9 told him he would have to take…

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 invite 4 residents (R55, R65, R76 and R31) to their care plan meetings that were reviewed for care plans, in a sample of 26 Findings include: 1. On 06/11/24 at 2:31 PM, R55, who's cognition is intact, said he had never been invited or attended a care plan meeting. On 6/13/24 at 1:51 PM, R55's electronic health record showed no documentation for any care plan meeting or invitation to any care plan meetings. 2. On 06/11/24 at 11:23 AM, R65, who's cognition is intact, said he has never attended a care plan meeting. On 6/13/24 at 1:51 PM, R65's electronic health record showed no documentation for any care plan meeting or invitation to any care plan meetings. 3. On 06/11/24 12:43 PM, R76, who's cognition is intact, said he has never attended a care plan meeting. On 06/13/24 at 1:58 PM, R76' electronic health records did not show any documentation for any care plan meetings or invitations to any care plan meetings. On 06/13/24 at 3:01 PM, V1…

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 2. 06/12/24 at 10:13 AM, R17, who's cognition is intact, said during smoking breaks the staff will sometimes come out, and sometimes the staff stays inside. R17 said the residents light their own cigarettes. R17 said the staff leaves the lighter outside, and sometimes the lighter will come up missing, because no one is watching. R17 said the staff hardly ever gets the lighter back. 3. On 06/11/24 10:31 AM, R59, who's cognition is intact, said during smoking breaks, the staff watch from the inside, and they don't come outside at all. R59 said sometimes it is one staff monitoring, and sometimes it is 2 staff, but nobody goes outside to monitor when the residents are smoking. On 06/12/24 3:29 PM, V3 (Psych Services Rehab Director) said, The facility is short staffed, and they don't have two staff to monitor during smoking breaks. The facility's lighter will come up missing when they don't have staff to monitor during smoking breaks outside. On 06/13/24 11:18 AM, V2 DON (Director of Nursing) said staff are to go…

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 dignity and privacy for 2 residents (R17 & R71) in a sample of 26. Findings include: 1. On 06/12/24 at 10:13 AM, R17 was in her room. R17, who's cognition is intact, said she has anxiety and panic attacks, and staff will knock on her door and just walk in. R17 said the staff will not wait for her to give them permission to come in before they enter. R17 said this makes her feel like she is not respected, and she feels like she is being invaded. At 10:25 AM, V13, CNA (Certified Nurse's Assistant) knocked on the door while opening it, entered the room and said, room check. V13 entered the room without waiting for permission to enter. 2. On 06/12/24 at 09:33 AM, R71 was in her room and R71, who's cognition is intact said, Some staff will knock and come in without getting permission to come in, and some don't even knock, especially at night so you don't even have time to cover up. R71 said many of the staff have seen her naked. At 09:48 AM, V12 (Nurse) came in to R71's room to give her her medication and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain proper documentation for Advanced Directives for 3 residents (R76, R293, and R243) in a sample of 26. Findings include: 1. On [DATE] at 12:00 PM, R76's health records were reviewed. The facility's book titled Advanced Directives showed R76 was to receive CPR (cardiopulmonary resuscitation) full treatment. The document was signed on [DATE]. R76's electronic record showed his code status as DNR (do not resuscitate). R76's [DATE] physician's orders showed Do Not Attempt Resuscitation/DNR. On [DATE] at 11:25 AM, V2, DON (Director of Nursing), said the staff will use the resident's electronic health record to determine treatment when a resident goes into cardiac arrest or is found unconscious. V2 said if the electronic health record shows R76 is a DNR, and the Advanced Directives book shows R76 is a full code, the staff will not be giving him CPR. V2 said this would be against R76's wishes. The facility's Advance Directives policy, dated 3/2021,…

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 physicians' orders for 1 resident (R71), and failed to monitor 1 diabetic resident's blood glucose levels (R293) in a sample of 26. Findings include: 1. R71's electronic health records showed diagnoses including spinal stenosis, muscle weakness, and perforation of intestines. R71's 5/17/24 physician orders showed Tylenol oral tablet (acetaminophen) 1000 milligrams every four hours as needed for pain. On 06/12/24 at 9:48 AM, R71 was in her room and V12 (Nurse) gave R71 her morning medications. R71 looked at all of the medications, and informed V12 she had given her two 325mg of Tylenol instead of two 500mg of Tylenol that was ordered. V12 said she only had the 325mg of Tylenol on her cart. V12 said, I just substituted the 325mg for the 500mg. I gave 650mg instead of the 1000mg. I did not have the 1000 in the cart and I am allowed to do that. V12 then said, I am going to get her the 1000 mg now because she asked for it. R71 said,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to update the EMR (Electronic Medical Record) to include R243's medical diagnoses. Findings include: R243 was admitted to the facility on [DATE]. During review of R243's medical record, no diagnoses were noted listed in the EMR. On 6/13/24 at 12:08 PM, V2, DON (Director of Nursing), reviewed R243's EMR and did not find his diagnoses. V2 stated the admitting nurse is responsible for entering the residents' diagnoses list and the MDS (Minimum Data Set) Coordinator should have reviewed them. The resident's diagnosis list is obtained from the discharge summary or admission packet received from the hospital. If the resident needed to be sent out, we would not have a diagnoses list to provide for the transfer. The facility did not provide a policy or procedure guide for resident record updating.

Based on observation, interview, and record review, the facility failed to ensure milk and cottage cheese were stored and served at temperatures to prevent potential food- borne illnesses. This applies to 96 of 99 residents in the building. Findings include: On 9/6/23 at 3:05 PM, V3 (Dietary Manager) stated facility census is 99 residents, out of which three residents do not drink milk. 1. On 9/6/23 at 11:15 AM, V3 (Dietary Manager) stated, Milk should be stored at 41° F (degrees Fahrenheit) or less. On 9/6/23 at 11:30 AM, the thermometer inside the milk refrigerator showed a temperature of 52° F. On 9/6/23 at 11:31 AM, a carton of milk from the refrigerator was checked with a 'stick' thermometer, and it showed 50° F. On 9/6/23 at 12:45 PM, the thermometer inside the milk refrigerator showed a temperature of 54° F. On 9/6/23 at 12:46 PM, a carton of milk from the refrigerator was checked with a stick thermometer and it showed 56° F. On 9/6/23 at 2:50 PM, the thermometer inside the milk refrigerator showed a temperature of 60° F. On 9/6/23 at 2:55 PM, three cartons of milk from 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.