Pearl Of Joliet, The

Based on observation, interview, and record review, the facility failed to follow infection control and prevention practices with PPE (Personal Protective Equipment) usage.This applies to 2 residents (R9 and R1) reviewed for infection control in a sample of 30 residents.The findings include: 1.On 5/5/26 at 12:21 PM, R9 said her main concern is the effectiveness of hemodialysis as her health has been up and down in the past year. R9 was observed without a dressing covering her left chest venous access device (VAD) that is used for hemodialysis and redness at the insertion site. R9 said she has a history of MRSA (Methicillin Resistant Staphylococcus Aureus) infection of her hemodialysis site and she recently had her site changed from her right chest to her left chest. R9's MDS (Minimum Data Set) dated 4/10/26 shows her cognition is intact. There was EBP (Enhanced Barrier Precautions) signage outside room with PPE cart. On 5/5/26 at 12:35 PM, V4 (RN/Registered Nurse) entered R9's room without washing her hands or putting on gloves and pulled back the neck of R9's shirt to assess her…

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 head of bed at thirty degrees while a resident's tube feeding was infusing. This applies to 1 of 4 residents R1 reviewed for their tube feeding in a sample of 8.Findings include:On 10/15/25 at 10:33 AM, R1 was observed during care provision by V9 and V10, CNAs (Certified Nursing Assistants). While R1 was in bed, the head of the bed was in a flat position. The tube feeding of Nepro 1.8 Cal was infusing at 40 ML (Milliliters) per hour by a feeding pump. V10 CNA stated residents receiving their tube feedings only needed to have the head of bed elevated if the resident is being rolled side to side, otherwise it is ok for the resident to be flat with the tube feeding infusing.V9 CNA stated there was no problem with R1's head of bed being flat while her tube feeding was infusing if she was not being turned side to side as it may cause R1 to become sick.On 10/15/25 at 5:15 PM, V2, DON (Director of Nursing), stated the head of bed should be elevated when the tube feeding is infusing so that the 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 administer the ordered initial dose of an antibiotic. This applies to 1 of 4 residents R1 reviewed for antibiotic administration in a sample of 8.Findings include:V5, NP (Nurse Practitioner) progress note on 9/12/25 documents the plan for to treat a UTI (Urinary Tract Infection) with Levofloxacin IV (Intravenously). Levofloxacin 750 MG (Milligrams) to start on 9/13/25 and end 9/14/25. Levofloxacin 500 MG administered every 48 hours for 10 days starting 0 9/15/25 and ending on 9/25/25. Meropenem 500 MG intravenously daily for 7 days starting on 9/9/25.R1's MAR (Medication Administration Record) shows a missed administration of Meropenem 500 MG on 9/14/25 at 9am. There is no documentation for the administration of Levofloxacin 750 MG on R1's MAR on 9/13/25 or 9/14/25. V4, LPN (Licensed Practical Nurse) progress, note dated 9/14/25 at 3:25 AM, states call to pharmacy related to Levofloxacin would be delivered early in AM. A nursing progress note, dated 9/14/25 at 6:42 PM, states Levofloxacin 750 MG was not available and would…

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 maintain palatable and appetizing food temperature when serving meals. This applies to all 121 residents receiving meals from the facility. The findings include: The facility data sheet, dated August 4, 2025, documents 133 residents in the facility, with 121 receiving food from the Dietary department, and 12 residents on NPO (Nothing by mouth) status.From August 4 to August 6, 2025, R1, R4, R7, R10, R11, and R14 were observed at mealtime and interviewed about the facility's food service. R1, R4, R7, R10, R11, and R14 are assessed to be alert and oriented based on their most recent MDS (Minimum Data Set) assessments. R1, R4, R7, R10, R11, and R14 all stated the food was lukewarm or cold, and they would prefer that food be served warmer. R12 was a former resident from the facility. R12 was alert and oriented based on her last her last MDS prior to discharge. On August 4, 2025, at 1:15 PM, V17 (family member) stated R12 was always complaining to V17 the food in the facility was always served cold.On August 5,…

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

Based on observation, interview, and record review, the facility failed to follow standard infection control practices with regards to donning of gowns during provisions of care to residents who are on EBP (Enhance Barrier Precautions).This applies to 3 of the 4 residents (R1, R4, R5) reviewed for EBP in the sample of 14.The findings include: 1. On August 4, 2025, at 10:06 AM, there was an EBP signage outside R1's bedroom. V13 and V14 (Both Certified Nursing Assistants/CNA) were providing hygiene care to R1. Both staff were not wearing a gown during the provision of care. R1 is on the facility's EBP list for history of Candida Auris. 2. Face sheet shows tR4 is 77 years-old who has multiple medical diagnoses including end stage renal failure (ESRD). On August 5, 2025, at 12:51 PM, R4 was in bed receiving incontinence care. R4 has an AV (Arteriovenous) fistula in his left arm and an intravenous (IV) midline catheter in his right arm. V25 (Certified Nursing Assistant/CNA) was providing incontinence care to R4, who had a bowel movement. V25 did not wear a gown all throughout 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 complete thorough abuse investigations to ensure abuse is recognized/identified and failed to maintain proof of thorough investigations. This has the potential to affect all residents in the facility. The findings include: The facility's 2/4/2025 CMS-671 Form showed 145 residents live in the facility. 1. On 2/6/2025 at 9:06 AM, V11, CNA (Certified Nursing Assistant), stated she remembered the incident between R81 and V33 LPN (Licensed Practical Nurse) on January 10th. V11 stated she heard V33 in R81's room and holler at him to Stop that and Shut up! when V33 went in his room to pass medication. V11 stated she did not see the interaction but overheard it because V33's voice was raised. V11 stated she didn't think anyone else was around to hear it. V11's abuse allegation statement showed, On Friday evening 01/10/2025 [V33] I overheard talking to [R81] disrespectfully. The nurse hollered stop that and then told resident to shut up! Loudly. The facility's Final Report for R81's abuse allegation showed, On 01/10/2025, [V11]…

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 kitchen facility in a manner to prevent foodborne illness. This applies to 133 residents in the facility receiving dietary services. Findings include: On 02/06/25 at 12:08 PM, V17, Dietary Manager, confirmed 133 residents were being served from dietary services. 1. On 02/04/25 at 10:15 AM, the vents located over the stove cooking surface were dusty. One of two red sanitizing buckets sanitizer tested at 500 ppm (Parts Per Million). The three-compartment sink sanitizing solution tested at 500 ppm. The dishwasher was being utilized to clean dishware. The temperature sensitive strips were run through the dishwasher and did not turn black to indicate the appropriate sanitizing temperature had been achieved. During the test run the digital reading highest temperature was 99-degree Fahrenheit. V17 stated the dishwasher disinfects by temperature and should have a final rinse of 180 degrees Fahrenheit. V19, Morning Cook, stated he last filled the sanitizing sink, and it tested at 300ppm. V19 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. R46's face sheet shows an admission date of 9/8/23. R46's face sheet shows diagnoses of metabolic encephalopathy, acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity, and facial weakness following cerebral infarction. R46's MDS (Minimum Data Set), dated 12/11/24, shows a blank score for the BIMS (Brief Interview for Mental Status). R46 was triggered as moderately impaired under cognitive skills for daily decision making. R46 has impairment on both sides of his upper and lower extremities. R46's POS (Physician Order Sheet) shows the following orders: Don right rest hand splint for contracture management daily, doff at NOC (Night Shift/Nocturnal) and for hygiene, check skin integrity every shift. Apply cervical collar when up in the wheelchair, may remove for feeding, hygiene, check for redness, discomfort, and pain. R46's care plan documents he has impaired cognitive function/dementia or impaired though processes related to dementia and history of stroke. R46 has limited…

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 securely store oxygen cylinders and cleaning supplies, and failed to maintain residents bed at a safe height to minimize potential injuries from falls. This applies to 17 of 17 residents (R2, R22, R34, R35, R39, R41, R44, R50, R57, R65, R105, R110, R126, R128, R129, R138, R141) reviewed for accident hazards in a sample of 30. Findings include: 1. R44's current care plan states she is at risk for fall. Interventions include to provide R44 with a safe environment. On 02/04/25 at 01:12 PM, R44's bed and overbed table were left in a very high position. R44 stated she needed to raise her bed to reach items on her overbed table. R44 stated no one ever told her it was not safe raise her bed to the high position. On 02/04/25 at 01:20 PM, V21 LPN (Licensed Practical Nurse) stated R44's table and bed shouldn't be left in that high position as it is not safe. R44 can adjust her bed up and down herself, but not her overbed table. On 02/05/25 at 01:06 PM, R44's bed and overbed table were left in a very position. R44…

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 a resident who was self-administering medication. This applies to 1 of 1 residents (R76) reviewed for self-medication administration in a sample of 30. The findings include: R76's face sheet showed she was admitted with diagnoses including gastrointestinal hemorrhage, chronic obstructive pulmonary disease, morbid obesity, type 2 diabetes mellitus, congestive heart failure, gout, and repeated falls. R76's POS (Physician Order Sheet) showed an order dated 12/19/23 for Hemorrhoidal Rectal Ointment 0.25-14-74.9% with instructions to Insert 1 application rectally every 8 hours as needed for hemorrhoids. R76's MDS (Minimum Data Set), dated 1/6/25, showed R76 had severe cognitive impairment. On 2/4/25 at 1:21 PM, R76 had a tube of hemorrhoid cream on her bedside table. The tube showed it was a two-ounce tube of hemorrhoidal ointment with applicator, and the sticker showed it was opened January 19, 2025. R76 said she was running out of the cream and needed it to help her butt cheeks slide. R76 said she 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.

Based on observation, interview, and record review, the facility failed to place call lights within reach of residents. This applies to 3 of 3 residents (R114, R2, R44) reviewed for call lights in a sample of 30. The findings include: 1. On 2/4/25at 10:37 AM, R114 was lying in bed, and her call light was placed on the side dresser, out of reach of the resident. R114 said she was unable to use her left arm, and she would use the call light to call for help, if she could find it. R114 said if she could not find it, she would have to scream for help. On 2/6/25 at 3:43 PM, V2 (DON/Director of Nursing) said the call lights should be attached to the bed linen or wrapped around the side rail. R114's face sheet showed she was admitted to the facility with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side and weakness. R114's care plan, dated 12/22/23, showed R114 is at low risk for falls due to weakness, limited mobility, decrease strength, physical limitation, low activity tolerance [related to] hemiplegia, with 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.

Based on interview and record review, the facility failed to protect the residents' right to be free from verbal and mental abuse. This applies to 3 of 6 residents (R81, R13, R45) reviewed for abuse. The findings include: 1. R81's 10/25/2024 MDS (Minimum Data Set) showed he is moderately cognitively impaired. R81's Abuse care plan (initiated 4/29/2022 and revised 2/6/2025-during the survey) showed a problem focus as may be at risk for potential abuse [related to] behavior problem. An intervention (revised 10/17/2022) showed, If [R81] becomes increasingly agitated or upset, stop what you're doing, ensure [R81] is safe and politely leave the area . V11's (Certified Nursing Assistant/CNA) abuse allegation statement showed, On Friday evening 01/10/2025 [V33] I overheard talking to [R81] disrespectfully. The nurse hollered stop that and then told resident to shut up! Loudly. The facility's Final Report for R81's abuse allegation showed, On 01/10/2025, [V11] alleged that she felt that the facility nurse was verbally discourteous to resident. The facility nurse suspended pending…

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 report an allegation of verbal abuse to the Illinois Department of Public Health (IDPH). This applies to 1 of 6 residents (R81) reviewed for abuse in the sample of 30. The findings include: The facility's 1/10/2025 Initial Report from R81's incident showed, On 1/10/25, A [Certified Nursing Assistant (CNA)- V11] alleged that she felt that the facility nurse was verbally discourteous to resident. The facility nurse suspended pending investigation. The abuse investigation is ongoing and the final will be sent into public health within 5 business days. V11's (CNA) statement from the investigation showed .the . nurse I overheard talking to [R81] disrespectfully. The nurse hollered stop that and told resident Shut up! Loudly. On 2/6/25 at 1:25 PM, V1 (Administrator) stated she thought the initial incident report and the final incident report were reported to IDPH, but neither of the reports were sent to IDPH, even though they would have been sent on two different days. V1 added as the Abuse Coordinator, it is her responsibility,…

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 incontinent residents for toileting programs and placed multiple layers of disposable incontinence products on a resident. This applies to 1 (R32) of 3 residents reviewed for incontinence care in the sample of 30. The findings include: On 02/04/25 at 11:07 AM, R32 was being assisted with toileting by V39 (CNA/Certified Nursing Assistant). R32 was wearing a disposable incontinence brief and a second disposable incontinence pad inside of the brief. On 02/05/25 at 1:44 PM, R32 stated she continued to wear an incontinence brief with an incontinence pad inside the brief. R32 stated she wears the briefs and pads for protection. R32 stated she was not on a toileting program/schedule. On 02/04/25 at 11:07 AM, V39 stated R32 drinks a lot of coffee and water. V17 stated she requires the pad and the brief due to her urine being heavy. On 02/06/25 at 2:25 PM, V15 (Restorative Nurse) stated residents should not wear an incontinence brief and an…

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

Based on observation, interview, and record review, the facility failed to provide necessary services and care to maintain a midline intravenous (IV) catheter. This applies to 1 resident (R81) reviewed for IV catheter care in a sample of 30. The findings include: R81's Face sheet shows a diagnosis of unspecified hearing loss. On 2/4/25 at 2:25 PM, R81's right upper arm was observed with a midline intravenous catheter. The midline had a gauze underneath the transparent dressing that was saturated in serosanguinous (pink) blood. The midline dressing had no time, date, or staff member initial on it to show when the dressing was last changed or by whom, and the catheter had blood present in the tubing. R81 communicated in writing that he had the midline catheter for about a month, it was last used and flushed last month, and he could not recall the last time the dressing was changed. On 2/5/25 at 4:41 PM, V2 (DON/Director of Nursing) said the midline catheter dressing changes should be documented in either the MAR (Medication Administration Record) or the TAR (Treatment Administration…

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 completed documentation of the pharmacy's monthly MRR (Medication Regimen Reviews) recommendations with the physician / prescriber response. This applies to 2 of 5 residents (R55 and R64) reviewed for unnecessary medications in a sample of 30. Findings include: 1. The EMR (Electronic Medical Record) for R55 documents the consultant pharmacist completed MRR and referenced see report for any irregularities and or recommendations on 05/17/2024, 06/14/2024, and 09/06/2024. The facility did not provide the referenced reports or documentation of the physician's responses to the recommendations. On 02/06/25 at 01:03 PM, V3, ADON (Assistant Director of Nursing), stated, We need a better tracking system. V3 stated the pharmacist emails her the recommendations and she puts the recommendations in the physician's mailbox. She lets them know the recommendations are in their mailboxes. V3 stated she should be following up with the physicians for their recommendations. V3 stated some of the pharmacist recommendations are missing…

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 that resident's personal food items were properly stored. This applies to 1 (R45) of 3 residents reviewed for stored food in the sample of 30. The findings include: R45's Face Sheet showed she was admitted to the facility on [DATE], with multiple diagnoses which included chronic obstructive pulmonary disease, morbid obesity, major depressive disorder, acquired absence of right and left fingers, and heart failure. R45's MDS (MDS/Minimum Data Set), dated 01/05/25, showed R45 was cognitively intact. On 02/04/25 at 11:09 AM, R45 had an opened bottles of Miracle Whip (19 ounces) and horseradish sauce (12 ounces) stored in the windowsill in her room. Both bottles stated to refrigerate after opening. R45 stated she used to have a refrigerator in her room, but the company removed the refrigerator. R45 stated she has nowhere else to store her personal food items since there is no refrigerators. R45 stated she uses the condiments often. 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 wear the appropriate PPE (Personal Protective Equipment) before entering a isolation room. This applies to 1 of 4 resident (R447) reviewed for infection control in a sample of 30. The Findings include: R447's face sheet shows diagnoses of infection of amputation stump, right lower extremity, non-pressure chronic ulcer of other part of left lower leg with unspecified severity, MRSA infection, unspecified site, MRSA as the cause of diseases classified elsewhere, and acquired absence of right leg below knee. R447's POS (Physician Order Sheet) shows an order for Transmission based precautions: Contact Precautions for IV (Intravenous) Antibiotics for Wound Infection with MRSA+ culture. R447's care plans show she has MRSA. Interventions: Maintain isolation precautions as indicated and as ordered. Instruct family/visitors/caregivers to wear disposable gown and gloves during physical contact with resident. Discard in appropriate receptacle and wash hands before leaving room. On 2/4/25 at 2:00 PM, V11 (CNA-Certified…

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 utilize an antibiotic use protocol tool for residents who were placed on antibiotics. This applies to 2 of 5 residents (R27, R120) reviewed for antibiotic stewardship in a sample of 30. The findings include: On 2/6/25 at 11:24 AM, V4 (IP/Infection Preventionist) was interviewed regarding antibiotic stewardship. At 3:05 PM, V4 said they should use the tool when they suspect a resident has an infection, which should be done right away. V4 said it helps the staff to screen for infections. 1. R27's EMR (Electronic Medical Record) was reviewed with V4, and showed he was receiving Ciprofloxacin 500 MG (Milligrams) every 12 hours started on 2/5/25 and ending 2/15/25. V4 said the Infectious Disease Nurse Practitioner ordered the antibiotics on 2/4/25 at 2:48 PM. V4 said the McGeer's tool was not completed, and it should have been done. R27's face sheet showed R27 was admitted to the facility with diagnoses including urinary tract infection and encounter for fitting and adjustment of urinary device. 2. R120's EMR was reviewed 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.

Based on observation, interview, and record review, the facility failed to identify an area of possible entrapment on a resident's bed. This applies to 1 of 17 residents (R22) reviewed for safety. The findings include: On 02/04/25 at 12:34 PM, R22's bed and overbed table were left in a very high position. R22's side rails extended approximately five inches on both sides of her bed. On 02/06/25 at 10:01 AM, V15, LPN (Licensed Practical Nurse), was called to R22's bedside. R22's bed rails are too far apart from the mattress and bed frame. She could roll over and become stuck between the rails. On 02/07/25 at 01:33 PM, V2, DON (Director of Nursing), stated, Maintenance and Nursing should make sure there is not space between the bed rail and mattress. We don't want to risk anyone being injured from lying on a metal frame or becoming entrapped. The facility policy Resident Bed, dated 1/17/2025, states the facility will conduct regular inspection of all bed frames, mattress and bed rails, if any, as part of a regular maintenance program to identify areas of possible entrapment.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide information to install cameras in a resident's room. This applies to 1 of 1 resident (R2) reviewed for resident rights in a sample of 10. The findings include: The EMR (Electronic Medical Record) shows R2 was admitted to the facility with diagnoses including hemiplegia and hemiparesis of the left non-dominant side, type 2 diabetes mellitus, delusional disorders, bipolar disorders, dementia, epilepsy, low back pain, and gastroesophageal reflux disease. R2's MDS (Minimum Data Set), dated October 18, 2024, showed she was moderately impaired. R2 required moderate assistance with eating, oral hygiene, substantial assistance for upper body dressing, and personal hygiene, and was dependent on staff for shower/bathing, toileting hygiene, lower body dressing, putting on/taking off footwear. R2's progress notes, dated December 13, 2024 at 1:27 PM, showed the following, Care conference was held for (R2) on the 5th of December with family,…

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 resident with his scheduled anxiety medications, as ordered. This applies to 1 of 1 resident (R9) reviewed for pharmacy services in a sample of 10. The findings include: The EMR shows diagnoses including alcohol dependence, insomnia, chronic obstructive pulmonary disease, anxiety disorder, major depressive disorder, gastroesophageal reflux disease, hypertension. R9's MDS (Minimum Data Set), dated September 23, 2024, showed R9 was cognitively intact. R9 was independent with eating, oral hygiene, upper body dressing, and personal hygiene, required set up assistance for putting on/taking off footwear, and required supervision for lower body dressing, toileting hygiene, and shower/bathing. R9's care plan, dated July 11, 2024, showed R9 presents with signs and symptoms of anxiety that is manifested by restlessness, anxiousness, and having difficulty with sleep, thinking and concentration; related to psychiatric illness, anxiety disorder. Psychiatry will continue to evaluate and provide medication management…

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 and obtain treatment orders for a resident (R2) with known skin tears. This applies to 1 of 4 residents (R2) reviewed for quality of care. The findings include: R2's Care Plan, dated 10/02/2024, said R2 was at risk for potential impairment of the skin integrity related to fragile skin and a history of skin tears. R2's care plan showed multiple interventions including, If skin tear occurs, treat per facility protocol and notify MD . Monitor/document location, size, and treatment of skin tear . On 10/02/2024 at 11:24 AM, R2 was observed with a dressing on her right lower leg. R2 was confused and not interviewable. At 12:20 PM, V3 (Wound Care Nurse/WCN) and V4 (Wound Care Aide) were asked to assess R2's right lower leg dressing. V3 said she was not aware of R2 having active wounds. V3 said R2 had frail skin and was prone to skin tears. V3 removed R2's right lower leg dressing, and R2 had two dry scabs to her mid-shin and lower lateral areas. Then V3 noticed R2 had other dressings on her left lower leg and…

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

Based on observation, interview, and record review, the facility failed provide a clean, comfortable, homelike environment. This applies to 6 of 6 residents (R1, R2, R3, R4, R5, R6) reviewed for clean, comfortable, homelike environment in the sample of 6. The findings include: On September 25, 2024, from 9:30 AM through 2:00 PM, environmental observation was conducted. The bedroom floors of R1, R2, R3, R4, R5, and R6, were all dull and dirty, with accumulated dirt and dust debris which adhered to the floor. The floors were stained or marked with patches of dry spilled unidentified fluids. Additionally, the bedroom floors were littered with small pieces of plastics from the packaging of gowns (personal protective equipment/PPE). Interviews were conducted as well with residents and family members. R1, R4, R6, and V7 (R5's family) also said their bedroom floor was dirty and needs a thorough cleaning. On September 25, 2024, at 12:54 PM, V6 (Housekeeper) was observed cleaning R6's bedroom; it had accumulated debris of dust and other things like plastic from PPE wrapper and dry food…

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, record review, the facility failed to provide timely incontinence care, and failed to ensure a resident who requires total assistance is being assisted to get up from bed. This applies to 3 of the 6 residents (R1, R2, R3) reviewed for activities of daily living (ADL) care in the sample of 6. The findings include: 1. On September 25, at 1:15 PM, V4 (Certified Nursing Assistant/CNA) rendered incontinence care to R3, who was saturated with urine, and had a bowel movement which was pasty. The urine was dark yellow. V4 said the last time she changed R3's incontinence brief was about 9 AM. 2. On September 25, at 1:22 PM, V5 (CNA) rendered incontinence care to R2. R2's brief was saturated with urine, dark in color, he had a small bowel movement that was somewhat pasty. R2 was unable to recall when he had the bowel movement. V5 said the last time she changed R2's incontinence brief was after breakfast, about 9:00 AM. 3. On September 25, 2024, from 9:30 AM to 2:00 PM, R1 was observed resting in bed. At 1:46 PM, V4 (CNA) and V3 (Respiratory Therapist) rendered…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement a physician's order. This applies to 1 of 3 residents (R1) reviewed for having an NPO (Nothing by Mouth) order. Findings include: R1 is a [AGE] year old female admitted to the facility on [DATE], with diagnoses including bilateral cataracts. R1's 4/9/24 physician order showed, NPO from midnight. May have clear liquids until 6:30 AM: take the following medicines if taken in the morning on the day of the surgery with sip of water if taken Pepcid, amlodipine, carvedilol and quetiapine. R1's 4/12/24 Health Status progress note showed resident was scheduled for eye surgery this AM. Appointment had to be rescheduled due to patient was to be NPO and had toast this AM. Daughter is aware and spoke with management today regarding her concern. On 4/17/24 at 1:00pm, R1 said on 4/12/24, the morning of her scheduled cataract surgery, the staff fed her toast and cereal. On 4/17/24 at 11:54am, V1 (Administrator), at 9:34am V2 (Assistant Director of Nursing),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to maintain residents bed equipment. This applies to 1of 3 residents (R1) reviewed for maintenance of furnishings and equipment in a sample of 3. Findings include: R1 is a [AGE] year old female admitted to the facility on [DATE], with diagnoses including osteoarthritis, type 2 diabetes, and bilateral cataracts. On 4/16/24 at 1:46pm, the cord to R1's bed control was observed with approximately two inches of exposed wires. On 4/17/24 at 9:15am, the cord to R1's bed control was observed with 2 inches of exposed wires. V1 (Administrator) was present at this time. On 4/16/24 at 11:41am, V4 (R1's daughter) said the cord to R1's bed control had frayed wires. On 4/17/24 at 2:00pm, V1 said the bed control to R1's bed was not maintained because the cord to the bed control had exposed wires. On 4/17/24 at 10:52am, V7 (Director of Maintenance) said that he was notified on this day \R1's cord for her bed control was with exposed wires. 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.

Based on interview and record review, the facility failed to assist a resident to the bathroom with his oxygen equipment. This applies to 1 of 4 residents (R1) reviewed for transfer assistance and ADL's (Activities of Daily Living) in a sample of 4. The findings include: R1's face sheet shows the following diagnoses: other intervertebral disc degeneration, thoracolumbar region, secondary parkinsonism, COPD (Chronic Obstructive Pulmonary Disease), pneumonia, chronic respiratory failure with hypoxia, peripheral vascular disease, and age-related osteoporosis. R1's hospice physician orders from hospice (company) show R1 was placed on hospice on 1/17/24 with a diagnosis of COPD. It also shows R1 is to be on continuous oxygen 2 to 5 liters by nasal cannula. R1's MDS (Minimum Data Set), dated 2/11/24, shows R1's BIMS (Brief Interview for Mental Status) score as 15, which means he is cognitively intact. Under functional abilities and goals, R1 was assessed as a 4 for toileting hygiene which means he need supervision or touching assistance. R1 was assessed as a 4 for chair/bed to chair…

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 administer medications as ordered by the physician to a resident. This applies to 1 of 4 residents (R1) reviewed for medications in a sample of 4. The findings include: R1's face sheet documents the following diagnoses: secondary parkinsonism, COPD (Chronic Obstructive Pulmonary Disease), pneumonia, chronic respiratory failure with hypoxia, peripheral vascular disease, hypertensive heart and chronic kidney disease without heart failure, benign prostatic hyperplasia without lower urinary tract symptoms, major depressive disorder, gastro-esophageal reflux disease without esophagitis, and chronic kidney disease stage 2 (mild). R1's hospice physician orders from hospice (company) show R1 was placed on hospice on 1/17/24 with a diagnosis of COPD. R1's MDS (Minimum Data Set), dated 2/11/24, shows R1's BIMS (Brief Interview for Mental Status) score as 15, which means he is cognitively intact. Staffing sheet for Saturday March 2nd, 2024 V4 worked from 7 PM to 7 AM. R1's EMAR (Electronic Medication Administration…

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 notify a resident's POA (Power of Attorney) of a change in condition. This applies to 1 of 3 residents (R1) reviewed for notification of changes. The findings include: R1's Face Sheet showed R1 was admitted on [DATE], with diagnoses of multiple sclerosis, mild protein calorie malnutrition, moderate protein calorie malnutrition, aphasia, dysphagia, vascular dementia, convulsions, chronic pain, and muscle spasms. R1's MDS (Minimum Data Set), dated 12/15/23, showed R1 had long and short-term memory problems. The same MDS showed R1's cognitive skills for daily decision making were severely impaired and she required substantial/maximal assistance with oral hygiene. On 01/23/24 at 9:15 AM, R1 was in bed. R1 was awake and alert to name only, and did not respond when spoken to. V7 (Registered Nurse) assisted with assessment of R1's mouth. R1's front right tooth/cap was missing. R1 had a small, blackened, shaved tooth near the upper front 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide personal hygiene (Oral care, incontinence care, nail trimming, grooming, shaving, and showering) to dependent residents. This applies to 8 of 12 residents (R20, R26, R33, R38, R50, R62, R70, and R82) reviewed for activities of living (ADL) in a sample of 34. The Findings include: 1. R20 is a [AGE] year-old female, admitted on [DATE], with severe cognitive impairment as per the Minimum Data Set (MDS), dated [DATE]. On 11/28/23 at 10:38 AM, R20 was on her bed, and was observed with thick, crusty lips and tongue. R20's MDS documents R20 is dependent for oral and toileting hygiene. On 11/28/23 at 10:38 AM, V6(Registered Nurse/RN) stated, I am going to tell my nursing assistant to clean up her lips and tongue. On 11/29/23 at 11:10 AM, during sacral wound care with V7(Wound Care Nurse), R20 was observed with a heavily soaked incontinent brief with urine. The brief was observed with a light brown discoloration outside. On 11/29/23 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident using oxygen had physician orders in place for it, and failed to date and contain respiratory equipment. This applies to 4 of 4 residents reviewed (R58, R88, R103, and R318) for respiratory care and treatment in a sample of 34. The findings include: 1. R88 is a [AGE] year-old female admitted on [DATE], with mild cognitive impairment as per the Minimum Data Set, dated [DATE]. R88 has an admitting diagnosis, including COPD, pneumonia, bronchitis, and a personal history of tuberculosis. On 11/28/23 at 11:33 AM, R88 was standing at her bedroom door side with oxygen therapy via nasal cannula (with a portable oxygen tank) at three litters per minute (L/M). R88 stated, I had pneumonia and was admitted here for short term therapy. I need to use oxygen at 3 L/M. Record review on R88's Physician Order Sheet (POS) does not show any physician order for oxygen therapy to indicate the type of oxygen delivery and flow rate. On 11/29/23…

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 residents by not knocking on doors and asking permission before entering a resident's room; failed to close the door and privacy curtain before providing resident care; and failed to dress a resident properly which exposed a resident's private area. This applies to 2 of 2 residents (R14, R79) reviewed for dignity in a sample of 34. The findings include: 1. R79's face sheet shows the following diagnoses: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, difficulty in walking, not elsewhere classified, other specified arthritis, unspecified site, and spinal stenosis, site unspecified. R79's MDS (Minimum Data Set), dated 10/13/2023, documents a BIM's (Brief Interview for Mental Status) score of 12, which means she was assessed as being cognitively intact. It also shows she needs partial/moderate assistance with upper body dressing. R79's care plan (revised on 4/17/23) shows a focus of having a 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 observation, interview, and record review, the facility failed to have call lights accessible to dependent residents. This applies to 3 of 3 residents (R36, R47, and R316) reviewed for accommodation of needs in a sample of 34. The findings include: 1. R316's face sheet (11/29/23) showed that R316 had the following diagnoses of chronic obstructive pulmonary disease, atherosclerotic heart disease of native coronary artery without angina pectoris, major depressive disorder, dementia, fall, and lack of coordination. R316's Minimum Data Set (MDS), dated [DATE], showed R316's cognition was intact, is dependent with toileting hygiene and needs substantial/maximal assistance with personal hygiene. R316's care plan (initiated on 11/1/23) showed R316 has high risk for falls related to history of falls, with intervention to have call light within reach and encourage the resident to use it for assistance. On 11/28/23 at 11:37 AM, during initial tour rounds on the 1st floor, R316 was in bed in her room, watching TV.…

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 safe, comfortable, and homelike environment. This applies to 3 residents (R66, R7, and R99) reviewed for environment in a sample of 34 residents. The findings include: 1. R66's MDS (Minimum Data Set), dated 11/2/23, shows her cognition is intact. R66's Face sheet shows the following diagnoses: hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, morbid obesity, and functional quadriplegia. On 11/28/23 at 12:08 PM, an approximately 1.5 foot wide by 1.5 foot tall hole was seen in the drywall behind R66's bed, and a cracked plastic light cover was seen on the light above her bed. R66 said the hole in the wall is from the bed hitting the wall when staff pull her up in bed, and the cracked light cover happened from the overhead trapeze pole hitting the cover when staff pulled her up in bed. R66 said the cracked light happened in the last couple of days, and a piece of the plastic flew into her…

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 properly obtain a blood sample for 1 diabetic resident that required blood glucose levels prior to receiving insulin. This applies to 1 of 10 residents (R14) reviewed for glucose testing in a sample of 34. Findings include: R14 is a [AGE] year old female admitted to the facility on [DATE], with diagnoses including type 2 diabetes, dementia, legally blind, and long term use of insulin. R14 electronic medical records showed 8/17/23 physician order for Accucheck two times a day for hyperglycemia. 11/6/23 physician order showed Insulin Lispro Solution 100unit/ml sliding scale if 181 - 230 = one unit; 231 - 280 = 2 units; 281- 330 = 3 units; 331-380= 4 units; >380 or <70, contact MD, subcutaneously 2 times a day with meals. On 11/29/23 at 9:21 AM, V11 (Nurse) wiped R14's thumb with an alcohol swab, pricked her finger with a lancet and collected a drop of blood for the blood glucose meter. R14's blood glucose level showed a blood sugar of 216.…

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 foot care to meet the needs of all residents. This applies to 1 resident (R1) reviewed for foot care in a sample of 34 residents. The findings include: R1's MDS (Minimum Data Set), dated 10/11/23, shows her cognition is intact. R1's POS (Physician Order Sheet) shows an order, dated 11/10/21, stating R1 may be seen by Podiatrist. R1's EMAR for September, October, and November 2023 show completed weekly skin checks by her nurse. R1's EMR (Electronic Medical Record) shows the last podiatry visit and nail trimming took place on 12/1/21. This podiatry note shows, Care Plan: Follow up in 2-3 months or as needed for a more acute problem. On 11/28/23 at 11:56 AM, R1 said, I wish they would trim my toenails, they're long. R1 then proceeded to take off her right shoe and sock to reveal a great toe toenail that was overgrown an inch above the tip of her toe and curved to the right, digging into the top of her second toe. R1 said she did not know exactly when she saw the podiatrist last, but she remembered it 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 provide supervision for smokers with smoking materials, and failed to provide a safe environment in resident's rooms. This applies to 2 of 2 residents (R53, R413) reviewed for accidents/hazards and supervision in the sample of 34. The findings include: 1. R413's POS (Physician's Order Sheet), dated 11/03/23, showed R413 had diagnoses of dementia without behavioral disturbances, altered mental status, weakness, convulsions, chronic obstructive pulmonary disease, muscle wasting and atrophy, and unsteadiness on feet. R413's MDS (Minimum Data Set), dated 11/07/23, showed R413's cognitive skills for daily decision making were severely impaired. R413's care plan, dated 11/06/23, showed R413 had impaired cognitive function/dementia and required cues, reorientation, and supervision. No documentation found in R413's medical record showed R413 had independent smoking privileges. On 11/28/23 at 11:40 AM, R413 was in bed. A pink cigarette lighter was on the bedside table. R413 said he smokes, and the facility lets him…

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 residents' urinary catheter drainage bags were secured in a sanitary manner. This applies to 2 residents (R38, R321) reviewed for urinary catheters in a sample of 34. The findings include: 1. R38's physician's order sheet, dated 11/01/23, showed R38 had diagnoses of benign prostatic hyperplasia with lower urinary tract symptoms, spinal stenosis of lumbar region with neurogenic claudication, obstructive and reflux uropathy, anemia, low back pain, chronic kidney disease, Alzheimer's Disease, major depressive disorder, osteoarthritis, diabetes, and hypertension. R38's MDS (Minimum Data Set), dated 09/27/23, showed R38 was cognitively intact. The same MDS showed R38 required partial/moderate assistance with toileting. R38's care plan, revised 02/01/22, showed R38 had an indwelling catheter due to urinary retention. Care plan goal with target date of 01/15/24 was to alleviate and reduce further the spread of infection. On 11/29/23 at 11:32 AM, R38 was in the bed. R38's indwelling catheter with yellow urine…

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 wheelchair was in working condition to prevent the risk of falls. This applies to 1 of 3 residents (R2) reviewed for safe operating equipment. The findings include: On 11/7/23 at 11:07 AM, R2 was in her wheelchair and said her wheelchair brake was loose. R2 put her brake into the locked position and the brake fell back into an unlocked position. R2 demonstrated putting it in the locked position again and with pressure to the handrail, the brake fell out of the locked position into the unlocked position. R2 said she told the staff about the loose brake. At 1:58 PM, R2 was observed in her room, sitting in her wheelchair. R2 again demonstrated the brake not remaining in the locked position, and said she notified V8 (Maintenance Director) of the loose wheelchair brake a while ago. On 11/7/23 at 2:02 PM, V8 (Maintenance Director) was brought to R2's room and put the wheelchair brake into the locked position, which then fell back to unlocked. V8 said he needed to tighten the brake up. R2 said he…

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